Techniques of examination of the thorax and lungs

Dr. Szathmári Miklós Semmelweis University First Department of Medicine 27. Sept. 2011.

Inspection of the thorax

• •

Observe:

– the shape of chest • Deformities – the respiratory movement

Importance:

– The deformities influence • The percussion sounds • The breathing and the circulation • The diagnostic importance of asymetry – The decrease of the respiratory movement is the most important sign of the disease of chest/lung

Inspection of the thorax

• Shape of the chest –

Normal adult thorax:

–

Barrel chest:

diameter.

is wider than it is deep. increased anteriorposterior –

Funnel chest:

of the sternum. depression in the lower portion –

Pigeon chest:

the sternum is displaced anteriorly, increasing the AP diameter.

–

Thoracic kyphoscoliosis:

abnormal spinal curvatures and vertebral rotation deform the chest.

Dorsal kyphosis and barrel chest

Inspection of the thorax

• Abnormal retraction of the interspaces during inspiration (severe asthma, COPD or upper airway obstraction).

• Inspection of movement of chest wall during inspiration (unilateral impairment or delay of respiratory movement suggests disease of the underlying lung or pleura.

Palpation of the chest 1.

•

Assessment of respiratory expansion:

– Place your thumbs about at the level of and parallel to the 10th ribs, your hand grasping the lateral rib cage – Slide your hands medially a bit in order to raise loose skin folds between thumbs and spine – Ask the patient to inhale deeply – Watch the divergence of your thumbs during inspiration and feel for the range and symmetry of respiratory movement

Palpation of the chest 2.

Tactile fremitus

patiens speaks – refers to the palpable vibrations transmitted through the bronchopulmonary system to the chest wall when the • Palpate and compare symmetrical areas of the lungs • Use the ulnar surface of your hand. Ask the patient to repeat ninety nine or „harminchárom”.

• If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.

Pleural rub

• Normal pleural surfaces move smoothly and noiselessly against each other during respiration • When pleural surfaces become inflamed, they move jerkily as they are repetedly delayed by increased friction.

• The sounds may be discrete, but sometimes are so numerous that they merge into an apparently continuous sound. It is localized to a relatively small area of the chest wall

Palpation of the thorax

• • •

intercostal tenderness

:over inflammed pleura. Bruises over a fractured rib.

chest expansion:

decreased expansion in case of pleural effusion, lobar pneumonia, chronic fibrotic disease of the underlying lung

tactile fremitus

: Decreased pectoral fremitus is in case of pleural effusion or pleural thickening or PTX.

Other bony landmarks on the chest wall

• Posteriorly, with the fingers of one hand, press inward and up against the lower border of the rib cage you can identify the 12th rib • The

inferior angle of the scapula

lies approximately at the level of the

7th rib

• When the patient flexes the neck forward, the most prominent process is usually that of the

7th cervical

Percussion of the thorax

• While the patient keeps both arms crossed in front of chest, percuss the thorax in symmetrical locations from the apices to the lung bases • Dullness: when fluid or solid tissue replaces air-containing lung (pneumonia) or occupies the pleural space (effusion, fibrous tissue, tumor) • Generalized hyperresonance: emphysema, asthma.

• Unilateral hyperresonance (or tympanic sound): pneumothorax

Identify the level of the diaphragma

• Percuss in steps downward until dullness clearly replaces resonance.

• Movement of diaphragma: the distance between the levels of dullness on full expiration and on full inspiration (normally 5-6 cm)

Normal position of the diaphragma

– Paravertebraly at the level of X-XI. thoracic spinous process – In the scapular line at the level IX. rib – In the midaxillary line at the level VIII. rib – In the medioclavicular line (on the right side) at the level of VI. rib.

Normal movement of the diaphragma

– On full inspiration 5-6 cm in the scapular line

Abnormal positions of diaphragma

• Bilaterally deeper position: – Emphysema, asthma, – Decreased intraabdominal pressure • Unilaterally deeper position: – pneumothorax • Bilaterally higher position: – Increased intraabdominal pressure – Pleural effusion on both side • Unilaterally higher position: – Diaphragmatic paralysis – Unilateral pleural effusion – Intrabadominal abnormality (subphrenic abscess, splenomegaly)

Abnormal breathing sounds

1. Louder vesicular breathing

: during childhood, forced breathing

2. Faint alveolar breathing

: – Emphysema, – Pleural thickening, pleural effusion, – Pneumothorax – Atelectasis (absortion of the air from the alveoli because of a plug in a mainstream bronchus)

3. Bronchial breathing replaces the normal vesicular sounds when lung tissue loses its air

: • Pneumonia (the alveoli fill with fluid)