Respiratory System Physical Examination Objectives

Goal:  After learning the prescribed information, learning the prescribed respiratory exam and practicing it frequently, the student should be able to identify and describe pathology associated with respiratory system in any given patient.

1.         Be able to describe the components of the Respiratory Exam, and when and why portions are done.

Chapter 12

Janelisa Review Respiratory Focus Sheet and Swartz Chapter 12.

2.         Review the anatomy and physiology of the respiratory system.  Given a diagram or model be able to identify the surface landmarks and imaginary lines (e.g., the axillary and midclavicular lines.)

Pages 316-320

Janelisa  Review Swartz 316-320.

3.         Describe normal changes with age that are seen in the respiratory system. (Swartz pages 736 and 743)

Anonymous Bates page 252

-Capacity for exercise decreases

-Chest wall becomes stiffer & harder to move

-Resp. muscles weaken & lungs lose elastic recoil

-Speed of breathing out with maximal effort diminishes

-Skeletal changes may accentuate dorsal curve of thoracic spine, producing kyphosis & increasing the anteroposterior diameter of chest.  This results in “barrel chest”.

Stephen. Shwartz. Pg. 736/743

A loss of elasticity in the pulmonary septa and atrophy of the alveoli cause a coalescence of the alveoli, with a reduction in the vital capacity and oxygen diffusion.

There are decreases in forced vital capacity and expiratory flow rate.

A degeneration of bronchial epithelium and mucous glands increases the susceptibility of infections.

Skeletal changes also contribute to a decrease in vital capacity. (kyphoscoliosis)

Janelisa Swartz 736 A loss of elasticity in the pulmonary septa and atrophy of the alveoli cause a coalescence of the alveoli, with a reduction in vital capacity and oxygen diffusion. There are decreases in forced vital capacity and expiratory flow rate. A degeneration of bronchial epithelium and mucous glands increases the susceptibility to infections, and skeletal changes lead to a decrease in vital capacity.

4.         Identify the normal resting rate of respiration in an adult.

Page 329

Anonymous Bates page 253

-Norm resp. rate is:  14-20 times a minute.

Stephen.

10-14 breaths per min. as stated in the book, although 16 is more common in my practice as a nurse.

Janelisa Swartz  329 The normal adult takes about 10-14 breaths a minute.

5.         Define "stridor," and identify what condition it suggests when heard.

Page 326

Anonymous Bates pg. 253

Stridor- A chiefly inspiratory wheeze, suggests airway obstruction in the larynx or trachea.  

Stephen. Shwartz. Pg. 326 and Tabers

Stridor is a harsh type of noisy breathing and is generally associated with obstruction of a major bronchus that occurs with aspiration.

Tabers. …resembling the blowing of wind.

Janelisa Swartz 326 Stridor is a harsh type of noisy breathing and is generally associated with obstruction of a major bronchus that occurs with aspiration.

6.         Identify several conditions that may cause abnormal retraction of the interspaces during inspiration.

Anonymous  Bates pgs. 254 & 264

Retraction is most apparent in the lower interspaces.  Supraclavicular retraction is often associated.  Conditions include:  Severe asthma, COPD, or upper airway obstruction.

Greg R.  Bates, p. 221.  During inspection check for abnormal retraction of the interspaces during inspiration.  Retraction is most apparent in the lower interspaces.  Supraclavicular retraction is often associated.  Causes of abnormal retraction include severe asthma, COPD, or upper airway obstruction. 

Deb B./Bates, pg. 230

           Severe asthma, COPD, or upper airway obstruction 

7.         Identify a condition that may cause unilateral diminution or delay in chest expansion.

Anonymous

Causes of unilateral decrease or delay in chest expansion include chronic fibrotic disease of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, and unilateral bronchial obstruction.

Bates, pg. 255

Greg R.  Bates, p. 221.  Unilateral impairment or lagging of respiratory movement suggests disease of the underlying lung or pleura.  Swartz p. 331-Localized pulmonary disease may cause one side of the chest to move less than the opposite side.   

Deb B/Bates,pg.230

            Underlying disease of lung or pleura 

8.         Define "fremitus."

Anonymous

Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall when the patient speaks.  To detect fremitus use either the ball or bony part of the palm at the base of the fingers or the ulnar surface of you hand to optimize the vibratory sensitivity of the bones in you hand.  Ask the patient to repeat the words “ninety-nine” or “one-one-one”.  If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.  

Bates, pg. 255

Greg R.  Swartz p.331.  Speech creates vibrations that can be heard when one listens to the chest & lungs – Vocal fremitus.  When you palpate the chest wall while an individual is speaking, these vibrations can be felt and are termed – tactile fremitus. 

Deb B/Bates,pg.222

            Fremitus is palpable vibrations transmitted through the bronchopulmonary tree to chest wall when pt. speaks 

9.         Identify several conditions which cause decreased or absent fremitus.

Anonymous Bates, pg. 255

Causes of decreased fremitus include an obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening), air (pneumothorax), or an infiltrating tumor; and also a very thick chest wall.

Greg R.  Swartz p. 331-332.  Excess fatty tissue on the chest, air or fluid in the chest cavity, or overexpansion of the lung causes tactile fremitus to be diminished.  Specific causes include; Unilateral- pneumothorax, pleural effusion, bronchial obstruction, atelectasis (incomplete expansion of lung tissue); Bilateral- COPD, Chest wall thickening (muscle, fat).   Bates p. 222-Fremitus is decreased or absent when the voice is soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded.  Causes include on obstructed bronchus; COPD; separation of the pleural surfaces by fluid (pleural effusion), fibrosis (pleural thickening); air (pneumothorax), or an infiltrating tumor; and also a very thick chest wall. 

Deb B/Bates, pg.222

            Obstructed bronchus, COPD, separation of pleural surfaces by fluid, fibrosis, infiltrating tumor, or very thick chest wall 

10.       Identify a condition that causes increased fremitus.

Anonymous

Fremitus is increased when transmission of sound is increased, as through the consolidated lung of lobar pneumonia.

Greg R.  Swartz. P. 331-2.  Conditions that increase the density of the lung and make it more solid, such as consolidation, increase the transmission of tactile fremitus, e.g. pneumonia.  See also Bates’ p. 240.

Deb B/Swartz,pg. 331

           Conditions that increase density of the lung and make it more solid, such as consolidation, increase transmission of fremitus.

11.       Identify several conditions that cause dullness on percussion over normally resonant lung areas.

Anonymous

Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath you percussing fingers.  Examples include: Lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue or tumor.

Bates, pg. 259

A.T. Bates p.225.

Lobar pneumonia, pleural effusion (pleural accumulation of serous fluid), hemothorax (blood), emphema (pus), tumor (fibrous tissue).

EChing, Swartz P333

As the lung fill with fluid and become more dense, as in pneumonia, resonance is replaced by dullness.

Bates, 3^rd ed, P142

Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space.

12.       Identify two possible causes of generalized hyperresonance.

Anonymous

1)  emphysema (hyperinflated lungs)

2)  asthma

A.T. Bates p. 225.

Hyperrresonance heard over hyperinflated areas, emphysema, asthma.

EChing, Swartz P333

Hyperresonance has been applied to the percussion note obtained from a lung with decreased density, such as that found in emphysema.

Bates, 3^rd ed, p142

Hyperresonance is heard over the hyperinflated lung of emphysema.

13.       Identify two possible causes of unilateral hyperresonance.

Anonymous

1)  a large pneumothorax

2)  a large air-filled bulla in the lung

A.T. Bates p. 225.

Unilateral hyperresonance suggests a large pneumothorax, or an air filled bulla.

14.       Describe the physical exam technique for diaphragmatic excursion and the significance of abnormal findings.

Anonymous

Start just above expected level of diaphragm as observed during quiet respiration.  Percuss progressively downward until dullness replaces resonance. Check this level laterally and near the hemithorax.

Abnormal findings may indicate pleural effusion or a high diaphragm as in atelectasis or diaphragmatic paralysis.

A.T. Swartz p. 334.

Have the patient take a deep breath and hold it.  Percuss the right side of the chest to the lowest area of resonance.  When the sound becomes dull the diaphragm is reached and the liver is percussed as a dull sound.  Then have the patient exhale and hold it.  Repeat percussion on the right side, again dullness indicates the diaphragm and the liver.  Mark the difference.  The excursion between inhalation and exhalation is 4-5 cm.

EChing, Swartz P334

Patient is asked to take a deep breath and hold it.  Percussion at the right lung base determines the lowest area of resonance, which represents the lowest level of the diaphragm.  Below this level is dullness from the liver.  The patient is then instructed to exhale as much as possible, and the percussion is repeated.  With expiration, the lung contracts the liver moves up, and the same area becomes dull – that is, the level of dullness moves upward.  The difference between the inspiration and expiration levels represents diaphragmatic motion, which is normally 4 – 5 cm.  In patients with emphysema, the motion is reduced.  In patients with a phrenic nerve palsy, diaphragmatic motion is absent.

15.       Understand the differences between vesicular, bronchovesicular, and bronchial breath sounds on the basis of:  

            a. duration of inspiration and expiration

            b. normal locations                                                                

Anonymous- Bates pp. 261

 Anonymous

Vesicular          Bronchovesicular          Bronchial

Duration:          Inspiration        Inspiration about           Expiration

                  longer than        = to expriation              longer than

                                     expiration                                 inspiration

Normal Location:          Over most of         1^st and 2^nd ant.              Over the

                  lungs                 interspaces and       manubrium, if

                                    between scapulae         at all.

A.T. Swartz p. 335-336.

      Vesicular- long inspiratory, short expiratory.  Most lung fields, picture shows these sounds in the bases.

      Bronchovesicular- inspiratory = expiratory.  Heard beween 1^st and 2^nd ICS’s anteriorly and between the scapula posteriorly.  These areas are over the carina and the mainstem bronchi.

            Bronchial-Expiratory is louder and longer than inspiratory.  Heard over the manubrium.  Definite pause between the 2 phases. 

EChing, Swartz P335-336

Vesicular breath sounds are the soft, low-pitched sounds heard over most of the lung fields.  The inspiratory is much longer than the expiratory, which is also much softer and frequently inaudible.

Bronchovesicular breath sounds are a mixture of bronchial and vesicular sounds.  The inspiratory and expiratory are equal in length.  Normally heard only in the first and second interspaces anteriorly and between the scapulae posteriorly.

Bronchial breath sounds are loud and high pitched and sound like air rushing through a tube.  The expiratory is lounder and longer than the inspiratory.

16.       Identify several possible causes of decreased breath sounds.

Anonymous- Bates pp. 262

Breath sounds may be decreased when air flow is decreased (as by obstructive lung disease or muscular weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax or emphysema).  When patients do not breathe deeply enough or when they have a thick chest wall, as in obesity, breath sounds may remain diminished.

Anonymous

      -A decrease in air flow as in obstructive lung disease or muscular weakness.

      -Poor sound transmission as in pleural effusion, pneumothorax or emphysema.

Paul, Schwartz pg 341

• Asthma

• Emphysema

• Pneumothorax

• Pleural effusion

• Atelectasis

• Adult Respiratory Distress Syndrome (ARDS)

17.       Define "adventitious" sounds and give examples.

Anonymous

These are abnormal breath sounds heard when listening to the chest as a person breaths. These may be rhonchi (wheezes), crackles (rales), or pleural friction rubs. They do not include sounds produced by the muscle activity in the chest wall or friction of the stethoscope on the chest.

Anonymous Bates 252/63/67/72/74/75 

Added sounds occurring in a place other than the usual one.

Crackles or rales: discontinuous non-musical sound

Wheezes: high-pitched, hissing or thrills

Rhonchi: low pitched snoring quality

Vince B. Bates pg 228

            Any added sounds superimposed of usual breath sounds (crackles, wheezes, rales, rhonchi); leads to diagnosis of cardiac and pulmonary conditions.

Paul, Schwartz pg 338

Adventitious sounds are abnormal sounds heard during auscultation and include:

• Crackles

• Wheezes

• Rhonchi

• Pleural rubs

18.       Explain why the sitting position and pursed lip breathing are often preferred by persons with severe chronic obstructive lung disease.

Anonymous Merck Manual, pg 573-574

The patient with end-stage COPD is often a dramatic sight--standing before a counter leaning forward with arms outstretched and weight supported on the palms. The accessory respiratory muscles of the neck and shoulder girdle are in full use. Expiration often occurs through pursed lips. The chest appears overinflated, often with paradoxic indrawing of the lower interspaces. Cyanosis may be present.

 Morning headache may indicate hypercapnia. Hypercapnia with more severe hypoxemia, sometimes with erythrocytosis, is common in end-stage disease. Weight loss occurs in some patients.

Sitting down would be similar. The patient is sitting down, leaning forward, with palms on knees, holding chest upright while using accessory respiratory muscles to assist in breathing. Pursed lips when exhaling helps create a “positive pulmonary pressure,” helping to force more O2 across the alveolar sacs and into the blood.

Anonymous Bates 263

“Tripod position” Persons with severe COPD may prefer to sit leaning forward, with lips pursed during exhalation and arms supported on their knees or the table to breath easier.

Vince B Swartz pg 327.

            The sitting position increases the pleural space and allows for more expansion of lungs needed to gain more oxygen.  The pursed lip breathing increased the effort of breathing so that accessory muscles are used to expand the chest wall.

Paul’s Small Brain

Pursing the lips causes an increased intrathoracic pressure. The tri-pod and sniffing position help Facilitate air passage through the airways.

19.       Describe the importance of displacing the right breast when percussing the anterior chest.  What condition may be missed if this is not done?

Anonymous Bates pg 266

The dullness of right middle lobe pneumonia, typically occurs behind the right breast.  Unless you displaced the breast, you may miss the abnormal percussion note.

Vince B. Bates pg 232

            The dullness of right middle lobe pneumonia typically occurs behind the right breast.  Unless you displace the breast, you may miss this abnormal percussion note.

20.       Identify the effect of emphysema on percussion for cardiac dullness, liver border, and diaphragm level.

Anonymous Bates pg 266

A lung affected by COPD often displaces the upper border of the liver downward.  It also lowers the level of diaphragmatic dullness posteriorly.

Vince B. Bates. pg 231/232

            Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies te pleural space.  The hyperresonance of COPD may totally replace cardiac dullness.  A lung affected by COPD oftendisplaces the upper border of the liver downward.  It may lower  the level of diaphragmatic dullness posteriorly.

Paul, Schwartz pg 334

With expiration, the liver moves up, the level of dullness moves upward and diaphragmatic level moves, but in patient with emphysema, the motion is reduced.

21.       Identify the potential significance of a slowed expiratory phase, as measured by a forced vital capacity maneuver.

Anonymous Bates pg 268

A forced expiration time of six or more seconds suggest obstructed pulmonary disease.

Brent K.  PFT handout

A slowed expiratory phase could suggest obstructive disorders such as asthma, emphysema, or chronic bronchitis, in addition to restrictive disorders. 

Fassil   Bates’  pg. 233

Forced expiratory time assesses the expiratory phase of breathing, which is typically slowed in obstructive pulmonary disease.  

22.       Describe or recognize these different types of breathing and their causes: normal, tachypnea, hyperventilation, Kussmaul breathing, bradypnea, Cheyne-Stokes, ataxic, sighing respiration, and obstructive breathing.

Anonymous Bates pg 269

Normal:      The respiratory rate is about 14 to 20 per minute in normal adults and up to 44 per minute in infants.

Tachypnea: Rapid shallow breathing has a number of causes, including restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

Hyperpnea, Hyperventilation: Rapid deep breathing has several causes, including exercise, anxiety, and metabolic acidosis.  In the comatose patient, consider infarction, hypoxia, or hypoglycemia affecting the midbrain or ponds.

Kussmaul breathing: Is deep breathing due to metabolic acidosis.  It may be fast, normal in rate, or slow.

Bradypnea: Slow breathing may be secondary to such causes as diabetic coma, drug induced respiratory depression, and increased intracranial pressure.

Cheyne Stokes breathing: Periods of deep breathing alternate with periods of apnea (no breathing).  Children and aging people normally may show this pattern in sleep.  Other causes include heart failure, uremia, drug induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or diencephalon).

Ataxic breathing (Biot’s breathing): Ataxic breathing is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods.  Causes include respiratory depression and brain damage, typically at the medullary level.

Sighing respiration: Breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome – a common cause of dyspnea and dizziness. Occasional sighs are normal.

Obstructive breathing: In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to airflow.  Causes include asthma, chronic bronchitis, and COPD.

Brent K. Bates Pocket Guide 176

Types of breathing:

Normal - 14 -20 per min. in adults; in infants up to 40 per min.

Tachypnea - rapid shallow breathing that has many causes, including restrictive lung disease and pleural pain.

Hyperventilation - rapid deep breathing.  Causes include exercise, anxiety, metabolic acidosis, or brainstem injury.

Kussmaaul breathing - due to metabolic acidosis is deep but rate may be fast, slow, or normal.

Bradypnea - slow breathing due to diabetic coma, drug induced respiratory depression, increased intracranial pressure.  

Cheyne-Strokes - Rhythmically alternating periods of hyperpnea and apnea.  May be normal during sleep but also acompanies brain damage, heart failure, uremis, and respiratory depression.

Ataxic Biot’s breathing - unpredictable irregularity of depth and rate.  Caused from brain damage and respiratory depression.  

Sighing breathing - breathing punctuated by frequent sighs.  When associated with other symptoms, it suggests hyperventilation syndrome.

Obstructive disorders - asthma, emphysema, and chronic bronchitis.

Fassil     Bates’ pg. 93

•        Normal breathing is quiet and easy-barely audible near the open mouth as a faint whish. Norma  rate is 14-20 breaths per min ( Bates’  pg. 93 & 215)

•        Tachypnea: abnormal increase in respiration , rapid shallow breathing. Causes include restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

•        Hyperventilation: rapid deep breathing has several causes including exercise, anxiety, and metabolic acidosis. In comatose patient, consider infarction, hypoxia, or hypoglycemia affecting the midbrain or pons.

•        Kussmaul breathing is deep breathing due to metabolic acidosis. It may be fast, normal in  rate , or slow.

•         Bradypnea: slow breathing may be secondary to such causes as diabetic coma, drug-induced respiratory depression, and increased  ICP.

•        Cheyne-stokes breathing: periods of deep breathing alternate with periods of apnea. Children and aging people may show this pattern in sleep. Other causes include heart failure, uremia, drug-induced respiratatory depression, brain damage.

•        Ataxic breathing (Biot’s breathing): is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for periods. Causes include respiratory depression and brain damage, typically at madullary level.

•        Sighing respiration: breathing punctuated by frequent sighs should alert you to the possibility of hyperventilation syndrome – a common cause of dyspnea and dizziness. Occasional sighs are normal.

•        Obstructive breathing: In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.

23.       Describe or recognize the various deformities of the thorax and their causes:  normal, barrel chest, flail chest, funnel chest (pectus excavatum), pigeon chest (pectus carinatum), and thoracic kyphoscoliosis.

Anonymous

Normal:  Thorax in adult wider than it is deep.

Barrel chest:  Increased anteroposterior diameter; normal during infancy and often seen in normal aging and chronic obstructive pulmonary disease (COPD).

Flail chest:  In trauma, if multiple ribs are fractured, paradoxical movements of thorax may be seen, i.e., injured area caves inward on inspiration and moves outward on expiration.

Funnel chest (pectus excavatum):  Characterized by a depression in the lower portion of the sternum.  Compression of heart and great vessels may cause murmurs.

Pigeon chest (pectus carinatum):  Sternum displaced anteriorly, increasing the anteroposterior diameter; costal cartilages adjacent to protruding sternum are depressed.

Thoracic kyphoscoliosis:  Abnormal spinal curvatures and vertebral rotation deform chest.  Distortion of underlying lungs may make interpretation of lung findings very difficult.

Brent K.  Swartz 329

Barrel chest is an increase in the anteroposterior diameter with the chest tending to equal the lateral diameter.  Seen in advanced chronic obstructive disease.

Flail chest is a chest configuration in which one chest wall moves paradoxically inward during respiration.  Can be a result of multiple rib fractures.

Funnel chest or pectus excavatum is a depression of the sternum that can produce a restrictive lung problem if the depression is significant.  Patients may also have abnormalities of the mitral valve, especially mitral valve prolapse.

Pigeon chest or pectus carinatum results from a anterior protrusion of the sternum.  Does not cause any ventilation problems.

Thoracic kyphoscoliosis results in an abnormal anteroposterior diameter and lateral curvature of the spine that severely constricts chest and lung expansion.

Fassil      Bates’ pg. 239

•        Normal adult: the thorax of the normal adult is wider than it is deep. Its diameter is larger than its anteroposterior diameter.

•        Barrel chest: has an increased anteroposterior diameter. This shape is normal dring infancy, and often accompanies normal aging and COPD.

•        Traumatic Flail chest: If multiple ribs are fractured, paradoxical he movements of the thorax may be seen. A descent of the diaphragm decreases intrathoracic pressure on inspiration, the injured area caves inward; on expiration, it moves outward.

•        Funnel chest: is characterized by depression in the lower portion of the sternum. Compression of the heart and great vessels may cause murmurs.

•        Pigeon chest: the sternum is displaced anteriorly, increasing the anteroposterior diameter. The costal cartilages adjacent to the protruding sternum are depressed.

•        Thoracic Kyphoscoliosis:  abnormal spinal curvatures and vertebral rotation deform the chest. Distortation of the underling lungs may make interpretation of lung findings very difficult.

24.       Define bronchophony, egophony, and whispered pectoriloquy, and identify the conditions they are associated with.

Anonymous Bates p. 263, 271

Note:  Normal voice sounds transmitted through chest are muffled and indistinct.  When lung tissue loses air (ex. lobar pneumonia, pulmonary edema, hemorrhage), high-pitched sounds are transmitted much better, making words louder and clearer.

Bronchophony:  Louder, clearer voice sounds (as when pt. says “ninety-nine”)

Egophony:  Patient saying “ee” is heard as “aa” (E-to-A change).  Sound is nasal.

Whispered pectoriloquy:  Louder, clearer whispered sounds.  (Normally, whispers may not be heard at all.).

Brent K. Swartz  340

Bronchophony is the increased transmission of spoken words heard in the presece of consolidation of the lungs.  The pt. is asked to say “99” while the examiner listens to the chest.  Bronchophony is present when the words are louder that normal.  

Egophony is when a spoken word such as “eee” is heard through the lungs with increased intensity but takes on a nasal quality which will be heard as “aaa” instead of “eee”.  

Whispered pectoriloquy is the intensification of a whispered word in the presence of lung consolidation.  Have the pt. whisper 1-2-3.  Normally, these high pitched wispers would not be heard unless consolidation is present. 

Fassil    Swartz  pg 339-340

•        Bronchophony: is the increased transmission of spoken words heard in the presence of consolidation of the lungs. The patient is asked to say “ninety-nine” while the examiner listens to the chest. If bronchophony is present, the words will be transmitted louder than normally.

•        Whispered pectoriloquy: is the term for the intensification of whisperd word heard in the the presence of consolidation of the lung. The patient is instructed to whisper “one-two-three” while the examiner listen to the area suspected of having consolidation. If consolidation is present, the transmission of the spoken words will be increased, and the words will be clearly heard.

•        Egophony: is said to be present when the spoken word heard through the lungs is increased in intensity and takes on a nasal or bleating quality. The patient asked to say ‘eeee’ while the examiner listens to an area in which consolidation is suspected. If egophony is present, the “eeee” will be heard as “aaaa”.

25.       Describe or define these adventitious lung sounds and their causes: crackles, wheezes and rhonchi, stridor, pleural rub, and mediastinal crunch.

Anonymous

Crackles result 1) from a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration or 2) as air bubbles flow through secretions or lightly closed airways during respiration.  Crackles can be fine or hoarse.  Late inspiratory crackles are usually fine, fairly profuse, repeat themselves from breath to breath, and causes include interstitial lung disease (such as fibrosis) and early congestive heart failure (CHF).  Early inspiratory crackles are often coarse, relatively few in number, and causes include chronic bronchitis and asthma.  Midinspiratory crackles and expiratory crackles are heard in bronchiectasis.

Wheezes & rhonchi occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure.  Can be heard at the mouth and through the chest wall.  Can be inspiratory, expiratory, or both.  Causes generalized throughout the chest include asthma, chronic bronchitis, COPD, and CHF.  In severe-obstructive pulmonary disease, wheezes may disappear which should not be mistaken for improvement.  Localized wheezes suggest partial obstruction of a bronchus as by a tumor or foreign body.  Rhonci suggest secretions in the larger airways.

Stridor is a wheeze that is entirely or predominately inspiratory.  It is often louder in the neck than over the chest wall.  It indicates a partial obstruction of the larynx or trachea, and demands immediate attention.

Pleural rub are creaking sounds that are caused by inflamed and roughened pleural surfaces that grate against each other as they are momentarily and repeatedly delayed by increased friction.  Heard on inspiration and expiration and are confined to small area of chest wall.

Mediastinal crunch is a series of precordial crackles synchronous with the heartbeat, not with respiration.  Best heard in left lateral position.  It is due to mediastinal emphysema.

Anonymous Bates p. 262; sound diagrams and mechanisms explained p. 272

Crackles:  Discontinuous crackling sounds are intermittent, nonmusical, and brief.

Late inspiratory crackles suggest interstitial lung disease (fibrosis) or early congestive heart failure (CHF).

Early inspiratory crackles suggest chronic bronchitis or asthma.

Midinspiratory and expiratory crackles are heard in bronchiectasis but not diagnostic.

Wheezes and rhonchi:  More continuous, musical sounds.  Wheezes are higher pitched; hissing or shrill quality.  Rhonchi are lower pitched; snoring quality.

Causes: asthma, chronic bronchitis, COPD, CHF.  Persistent, localized wheeze may indicate partial obstruction by tumor or foreign body.

Rhonchi suggest secretions in the larger airways.

Stridor:  A wheeze that is entirely or predominantly inspiratory; often louder in the neck over chest.  Indicates partial obstruction of the larynx or trachea, an urgent condition.

Pleural rub:  Inflamed and roughened pleural surfaces grating against each other produce creaking sounds; sometimes so numerous they merge into apparent continuous sound.  Typically, rub confined to small area, heard in both inspiration and expiration.

Mediastinal crunch:  Series of precordial crackles synchronous with the heart beat, not with respiration; best heard in left lateral position.  Due to mediastinal emphysema (pneumomediastinum).

Bent K.  Swartz 338

Crackles are short, discontinous, nonmusical sounds heard mostly during inspiration.  Also known as rales or crepitation, they are a result of the opening of collapsed distal airways and alveoli.  Causes include: bronchitis, respiratory infections, pulmonary edema, atelectasis, fibrosis, and congestive heart failure.

Wheezes are continuous, musical, high pitched sounds heard mostly on expiration.  They are produced by airflow through narrowed bonchi.  Causes include asthma, pulmonary edema, bronchitis and CHF.

Stridor is a harsh type of noisy breathing and is generally associated with obstruction of a major bronchus that occurs with aspiration.

A pleural rub is a grating sound produced by motion of the pleura.  Best heard at the end of inspiration and at the beginning of expiration.  Sounds like creaking leather.  Caused by pneumonia, neoplastic cells, or pulmonary infarction.

Mediastinal crunch ???

Fassil     Bates’  pg. 241

•        Crackles: have two leading explanations (1) They result from a series of tiny explosions when small airways, deflating during expiration, pop open during inspiration . This mechanism explained the late inspiratory crackles of interstitial lung disease and early CHF. (2) Crackles result from air bubbles flowing thru secretions or lightly closed airways during respiration.

•        Wheezes occur when air flows rapidly thru bronchi that are narrowed nearly to the point of closure. Causes include asthma, chronic bronchitis, COPD and CHF.

•        Rhonchi suggest secretions in the larger airways. In chronic bronchitis, wheezes and rhonchi often clear with coughing.

•        Stridor: is a wheeze that is entirely or predominantly inspiratory. It is often louder in the neck than over the chest wall. It indicates a partial obstruction of the larynx or trachea and demands immediate attention.

•        Pleural rub: inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction. These movements produce creaking sounds known as a pleural rub.

•        Mediastinal Crunch: is a series of precorial crackles synchronous with heart beat not with respiration. Best heard in the left lateral position, it is due to mediastinal emphysema.    

26.       Learn the physical signs associated with the following  conditions, be able to identify the typical findings for percussion, tactile fremitus, breath sounds, and adventitious sounds that you would expect to find.

                   chronic bronchitis

                  left-sided heart failure

                  lobar pneumonia (consolidation)

                  atelectasis, pleural effusion

                  pneumothorax, emphysema

                  bronchial asthma

Anonymous

Anonymous

                                Percussion              Tactile Fremitus          Breath sounds   Adventitious sounds

Chronic Bronchitis: resonant                   normal                          normal                      none

L side heart failure: resonant                            normal               normal                    late inspiraory crackes

Lobar Pneumonia:   dull over airless area   bronchophny             bronchial             late inspir. crackles

Atelectasis:             dull over airless area    absent                         decreased          none

pleural effusion:     dull over fluid               decreased                     decreased          none

pneumothorax:        hyperresonant               decreased                 decreased              none

emphysema:          diffusely hyper reso.       decreased                  decreased              none

bronchial asthma:  normal to resonant          decreased                wheezes                 wheezes and possible crackles

Sung K, Barkauskas, p.334-9 and Swartz, p. 341 

27.       Identify the components of a "normal" respiratory examination.

28.       Given a patient with a respiratory complaint, be able to perform a proper respiratory examination and identify any abnormalities found.