PHYSIOLOGY LECTURE PRESENTATIONS BY - DR SHAHAB PhD, MD

Respiratory System

Physiology

ByDr. SHAHAB

SHAIKHLecture : Clinical Examination of RS•••••••••••••••••••••••••••••

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PhD MD

Physiology lecture presentations by - DR SHAHAB PhD, MD

The Doctor

Physiology lecture presentations by - DR SHAHAB PhD, MD

Respiratory System Physiology

Clinical Examination of RS

Inspection Palpation Percussion Auscultation

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection

• Comfortable at rest . . . . ?• Breathless . . . .?• Cyanosis . . . . .?• Chest wall appearance:• Chest wall movement:• Breathing:• Neck region:

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection• Chest wall appearance:

– a. Shape• Normally Ellipsoid• Barrel Chest - Hyperexpansion (A-P diameter

increased) eg. COPD

– b. Symmetry– c. Scars / Lesions– d. Deformity:

• Pectus carinatum –sternum bulges forwards (‘pigeon chest deformity’)

• Pectus excavatum –sternum caves inwards (Funnel chest deformity)

Physiology lecture presentations by - DR SHAHAB PhD, MD

InspectionPectus Carinatum Pectus Excavatum

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection

• Chest wall movement:– a. Expansion– b. Symmetry of movement– c. Paradoxical movement:

• Phrenic nerve paralysis • Flail chest

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection

• Breathing:– Respiratory rate:– Tachypnoea is a respiratory rate > 16/min and is

caused by increased ventilatory drive as in fever, asthma and COPD, or reduced ventilatory capacity as in pneumonia, pulmonary oedema and interstitial lung disease.

– A slow respiratory rate can occur in association with opioid toxicity, hypothyroidism, raised intracranial pressure, hypothalamic lesions, and hypercapnia.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection

• Breathing:– Respiratory depth– Respiratory Rhythm– Type of respiration:

• Normal• Kussamul: Hyperventilation with deep, sighing

respirations (Küssmaul respiration) is a response to the reduced arterial pH in metabolic acidosis. This can occur in acute renal failure, lactic acidosis, diabetic ketoacidosis and in salicylate and methanol poisoning. The patients appear to have 'air hunger'.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection• Breathing:

• Cheyne stroke: Cheyne-Stokes breathing, or periodic respiration, is characterized by a period of increasing rate and depth of breathing followed by diminishing respiratory effort and rate, usually ending in a period of apnoea or hypopnoea. The cycle then repeats. It is seen most frequently in stroke involving the brain stem, and in severe cardiac failure. However, it may be normal during sleep in the elderly.

– Use of accessory muscles: These include the sternocleidomastoids, platysma and pectoral muscles. Use of accessory muscles is characteristic of patients with COPD who have hyperinflated lungs.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Inspection

• Neck region:– Position of Trachea

• Causes of tracheal deviation– Towards the side of the lung lesion

» Upper lobe or lung collapse » Upper lobe fibrosis » Pneumonectomy

– Away from the side of the lung lesion» Tension pneumothorax » Massive pleural effusion

– Supraclavicular fossae– Visible pulsation, JVP– Lymph nodes

Physiology lecture presentations by - DR SHAHAB PhD, MD

Palpation

• Tenderness• Temperature• Position of Trachea:• Chest Expansion:• Tactile Vocal Fremitus:• Apex beat localization:

Physiology lecture presentations by - DR SHAHAB PhD, MD

PalpationPosition of Trachea: Use one or two fingers in supra sternal notch !

Physiology lecture presentations by - DR SHAHAB PhD, MD

Palpation

• Chest Expansion:– Both sides of the thorax should expand equally

during tidal and maximal inspiration.– Reduced expansion on one side indicates

abnormality on that side, e.g. pleural effusion, lung or lobar collapse, pneumothorax and unilateral fibrosis.

– Bilateral reduction in chest wall movement is common in advanced COPD and diffuse pulmonary fibrosis

Physiology lecture presentations by - DR SHAHAB PhD, MD

Palpation• Tactile Vocal Fremitus:

– Tactile vocal fremitus is the transmission of voice sounds from central airways to the chest wall. It is increased by solid lung, provided the airways supplying that part of the lung are patent.

– It is important to decide whether areas found to be dull to percussion show increased tactile vocal fremitus (suggesting consolidation or fibrosis) or reduced tactile vocal fremitus (suggesting fluid or collapse)

– During assessment of tactile vocal fremitus, it is conventional to ask the patient to say 'ninety -nine'. In other languages, other numbers or phrases are used. (The intention is to produce a nasal 'oi' sound).

Physiology lecture presentations by - DR SHAHAB PhD, MD

Palpation• Apex beat localization:

– Deviation of the cardiac apex beat indicates shift of the lower mediastinum.

– Displacement of the cardiac impulse without deviation of the trachea is usually due to left ventricular enlargement but can also occur in scoliosis, kyphoscoliosis, or severe pectus excavatum.

– The cardiac apex beat may be difficult to localize in obesity, pericardial effusion, poor left ventricular function or patients with lung hyperinflation as in COPD.

Physiology lecture presentations by - DR SHAHAB PhD, MD

PercussionIdeal sites for percussion are as shown below

Physiology lecture presentations by - DR SHAHAB PhD, MD

PercussionThe sounds heard in different condition are as mentioned:

Type ConditionResonant Normal lung

Hyperresonant Pneumothorax

DullPulmonary consolidationPulmonary collapseSevere pulmonary fibrosis

'Stony dull' Pleural eff usion

Physiology lecture presentations by - DR SHAHAB PhD, MD

Auscultation• The stethoscope was invented by a French

physician, Laennec, in 1819.• Auscultate both sides alternately, comparing

findings over a large number of equivalent positions to ensure that localized abnormalities are not missed.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Auscultation• Respiratory (normal) sounds

– Vesicular sounds– Bronchial sounds

Vesicular soundsLower pitched, rustling

Softer relativelyInspiration longer & Expiration

shorterNo Gap between Insp & Exp

soundsNormally heard in lung

parenchymal region (peripheral thorax)

Bronchial soundsHigher pitched, hollow or

blowing qualityLouder relatively

Inspiration & Expiration equalGap present between Insp &

Exp soundsNormally heard only along

tracheobronchial tree (central thorax)

Physiology lecture presentations by - DR SHAHAB PhD, MD

Auscultation• Adventitious(Added) sounds:

Wheezes / Rhonchi Musical sounds produced by air passing through narrowed airways. e.g. asthma.

Crackles (Crepititions)

Non-musical sounds mainly heard during inspiration caused by: 1) Reopening of occluded small airways. e.g.

fibrosing alveolitis and pulmonary edema2) Air bubbling through secretions.

e.g. bronchiectasis

Pleural Friction rub

Leathery or creaking sounds produced by movement of roughened pleural surfaces. E.g. pleurisy caused by pneumonia, pulmonary infarction. Usually associated with pleural pain.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Auscultation• vocal resonance :

– assess vocal resonance by asking the patient to say 'one, one, one'. In the normal lung a whispered note will not be heard but over consolidated lung, as in pneumonia, the sound is transmitted producing 'whispering pectoriloquy'.

Physiology lecture presentations by - DR SHAHAB PhD, MD

Respiratory FindingsVARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGY

Shape of the Chest Pigeon-shaped Barrel-shaped

Asthma in childhoodRickets

Emphysema

Symmetry of the Chest Forward Bending Lateral Bending

Kyphosis Scoliosis

Respiratory rate Increased Decreased

FeverAcute Pulmonary InfectionsPleural PainBronchial AsthmaPulmonary Edema

Repiratory Failure

Physiology lecture presentations by - DR SHAHAB PhD, MD

Respiratory FindingsMode of Breathing Thoracic Abdominic

Abdominal painAscitesGaseous Distension of the IntestinesLarge Ovarian CystPregnancy

Ankylosing SpondylitisPleural PainIntercostal Paralysis

Trachea Pushed Pulled

Pleural EffusionPneumothoraxSupramediastinal MassPulmonary Consolidation

Lung CollapsePulmonary fibrosis

Reduced Chest Expansion Bilateral Unilateral

Physiology lecture presentations by - DR SHAHAB PhD, MD

Respiratory FindingsBreathing Sounds Diminished Vesicular Bronchial Breathing

EmphysemaPleural effusion/thickeningThick Chest wallPneumothoraxLung Collapse when large bronchi occluded

Pulmonary ConsolidationLarge Superficial Lung CavityPulmonary FibrosisLung Collapse when large bronchi patent

Vocal Resonance Increased Decreased

Pulmonary ConsolidationLung Collapse when large bronchi patent

Pleural EffusionPneumothoraxLung Collapse when large bronchi occluded

PHYSIOLOGY LECTURE PRESENTATIONS BY - DR SHAHAB PhD, MD

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