Clinical Signs Flashcards
What are the surface markings for respiratory examination?
Lower borders of lungs
Anterior: 6th rib
Lateral: 8th rib
Posterior: 10th rib
Angle of scapula
T7 vertebra
Normal inspiration: diaphragm movement + elastic recoil of lungs
Accessory muscle breathing - increased inspiratory effort
- Muscles (5): sternocleidomastoid, scalene, trapezius, internal intercostal and abdominal muscles
Physiology:
1. Stressors (reduced O2, increased CO2) stimulates brainstem to increase respiratory effort by activating accessory muscles
2. Raising of ribs and sternum increases intrathoracic volume and negative intrathoracic pressure, resulting in pressure gradient and greater inspiratory volume
Conditions associated with accessory muscles use:
1. COPD / asthma
2. Pneumonia
3. Pneumothorax
4. Pulmonary embolism
5. Heart failure
Bradypnoea in adult is less than 12 breaths per minute
Mechanisms of bradypnoea
1. Central respiratory drive depression - brain injury, raised ICP, opiate overdose
2. Respiratory nerve dysfunction - motor neuron disease
3. Respiratory muscle dysfunction - muscle tiredness in respiratory failure, myasthenia gravis
4. Respiratory compensation to metabolic alkalosis
Conditions associated:
1. Drugs - opiates, benzodiazepines, barbiturates, anaesthesia
2. Respiratory failure
3. Brain injury and raised ICP
4. Hypothyroidism
5. Alcoholism
6. Hypothermia
7. Uraemia
8. Metabolic alkalosis
Tachypnoea in adult is above 20 breaths per minute
Mechanisms of tachypnoea:
1. Central chemoreceptors in medulla and peripheral chemoreceptors in aortic arch and carotid body monitors for change in body systems
- O2 drop, CO2 rise, acidosis -> activates respiratory systems to increase RR and tidal volume
What is palmar asterixis?
What are the causes of palmar asterixis?
Arms extended, wrist dorsiflexed
- Flapping tremor at the wrist, MCP or hip joint
- Brief, rhythmless, low frequency (3-5Hz)
- Due to interruption of muscle tone or posture from neurochemical imbalance causing CNS dysfunction
Causes of palmar asterixis
1. Type 2 respiratory failure (CO2 retention flap)
2. Hepatic and renal failure (metabolic encephalopathy)
3. Hypovolaemia
4. Electrolyte abnormalities (hypokalaemia, hypomagnesaemia)
5. Drugs (alcohol, barbiturate, phenytoin, primidone, clozapine)
6. Wilson’s disease (wing beating tremor)
7. Focal brain lesion (in rostral midbrain tegmentum)
What are the respiratory causes of clubbing?
Interstitial lung disease
Cancer
Mesothelioma
Bronchiectasis
Cystic fibrosis
Lung abscess
Empyema
Tuberculosis
What are the causes of palmar erythema?
- Chronic liver disease
- Hyperdynamic circulation
- CO2 rentention
- Thyrotoxicosis
- Pregnancy - Rheumatoid arthritis
- Haematological - polycythaemia, leukaemia
What are the causes of asymmetrical chest expansion?
- Reduced compliance - Pneumonia, pleural effusion
- Flail chest - detached ribs susceptible to negative intrathoracic pressure, sucked inwards on inspiration
- Foreign body
- Pneumothorax, haemothorax
- Diaphragm paralysis
- Musculoskeletal deformities (kyphoscoliosis)
- Neuropathy - GBS affecting diaphragm contraction
- Localised pulmonary fibrosis
What is barrel chest (hyperinflated chest)?
Ratio of AP to lateral chest diameter > 0.9
(Normal: 0.7 - 0.75)
Conditions associated:
1. Chronic bronchitis
2. Emphysema
3. Normal in elderly
Mechanism of barrel chest
1. Loss of lung architecture in emphysema causes:
a. Loss of elastic recoil
b. Increased compliance, premature lung collapse and gas trapping leading to airway hyperinflation
- Chronic higher lung volume inspiration results in chest wall remodelling
What is pigeon chest (pectus carinatum)?
Skeletal prominence of chest from outward bowing of sternum and costal cartilages
Conditions associated:
1. Familial
2. Chronic respiratory disease
3. Rickets
4. Marfan syndrome
What is funnel chest (pectus excavatum)?
Congenital chest wall deformity with several ribs and sternum abnormalities producing concave appearance
Conditions associated:
1. Congenital disorder
2. Diaphragmatic hernia
3. Marfan syndrome
Hoover’s sign
Paradoxical inspiratory retraction of rib cage and lower intercostal spaces on inspiration
- Diaphragm overstretching, on contraction at inspiration causes inward movement (instead of outward)
Conditions associated:
1. Obstructive airway disease - asthma, COPD, emphysema
2. Chest hyperinflation
Harrison’s sulcus/grove and rickety rosary
Depression of lower ribs above costal margin at area of attachment of diaphragm
(Marker of chronic underlying process)
Associated with:
1. Rickets
2. Severe asthma in childhood
3. Cystic fibrosis
4. Pulmonary fibrosis
What are the common causes of unilateral lung lesion?
- Collapse
- Consolidation
- Effusion
- Fibrothorax
- Pneumothorax
- Pneunomectomy or lobectomy
- Pulmonary fibrosis
What are the common causes of bilateral lung lesions?
- Asthma, COPD
- Bronchiectasis
- Effusion
- Interstitial lung disease
How do you properly examine for tracheal deviation?
Head in neutral position, not turned to either side
Middle finger on trachea in suprasternal notch
Index finger and ring finger on tendons of sternocleidomastoid
Palpate trachea, then either side of it
Draw finger down trachea to determine direction of travel
Normal: central or very slightly deviated to the right
What condition causes tracheal deviation towards lesion?
What condition causes tracheal deviation away from lesion?
Deviate towards lesion
- Collapse
- Fibrosis, fibrothorax
- Lobectomy or pneumonectomy
Deviate away from lesion
- Effusion
- Pneumothorax
What is tracheal tug?
Downward displacement of thyroid cartilage during inspiration
- Accessory muscle use in respiratory distress pulls thyroid cartilage down rhythmically
Conditions associated:
1. COPD (Campbell’s sign)
2. Arch of aorta aneurysm (Oliver’s sign)
What are the causes of abnormal percussion note?
- Dullness
- Hyperresonance
Dullness: dampening of resonance sound
1. Reduced airspaces: consolidation, collapse
2. Pleural thickening
3. Pleural effusion (stony dullness)
4. Raised hemidiaphragm due to phrenic nerve injury or hepatic lesion (dullness from liver)
Hyper-resonance: better transmission
1. Pneumothorax
2. COPD (hyperinflated lungs)
Human voices are low frequency sound
Lung tissues filter out low frequency sounds and transmit high frequency sounds
Consolidated lung tissues lose ability to filter and thus transmit both low and high frequency sounds effectively
Air, fluid, fat and increase tissue mass from tumour reduce transmission of low frequency sounds and thus muffled and less audible
How do you perform tactile fremitus?
What causes increase, and reduced vibration?
Place hands on the chest and ask patient to speak “ninety-nine”
- Vibration felt is the transmission of low frequency voice
Increased vibration: consolidation (pneumonia)
Reduced vibration: air, fat, fluid, tumour (COPD, pneumothorax, pleural effusion)
Vocal resonance for normal voice is slightly muffled and difficult to understand
Increased vocal resonance (bronchophony, or whispering pectoriloquy) occurs in consoslidation
Reduced vocal resonance occurs in pneumothorax, pleural effusion
Normal (vesicular) breath sound
- Low pitched, soft (air filled alveoli filters out low frequency sounds)
- Inspiratory portion longer than expiratory with no pause in between phases
Bronchial breath sound
- Loud, harsh, high-pitched (diseased alveoli unable to filter sounds)
- Expiratory phase longer than inspiratory, with pauses in between
Conditions associated:
1. Normal over trachea
2. Pneumonia
3. Pleural or pericardial effusion (heard above the effusion)
4. Atelectasis
5. Tension pneumothorax
Reduced breath sound occurs in:
1. Low flow states - poor inspiration, elderly
2. Airway collapse - no flow
3. Gas trapping - COPD, emphysema
4. Low transmission state - obesity, pleural effusion, pneumothorax
5. Lobectomy, pneumonectomy
Describe this breath sound
Coarse crepitations
- Non-continuous, explosive popping sound, occurs with larger airways
Associated with:
1. Bronchiectasis
2. Infection - pneumonia, IECOPD, IEBA
3. Pulmonary oedema
4. Lung cancer
Describe this breath sound
Fine crepitations
- Non-continuous, fine velcro sound, occurs in late inspiratory, due to smaller airways opening
Associated with: interstitial lung disease, lung fibrosis
Describe this breath sound
Pleural friction rub
- Grating sound on inspiration and expiration due to inflammation with roughening and rubbing of pleural surfaces
Associated with:
1. Pneumonia
2. Pulmonary infarct (embolism)
3. Trauma
4. Haemothorax
5. Metastasis
6. Connective tissue diseases - RA, SLE
7. Uraemia
8. Radiation
9. Asbestosis
Stridor is a loud intense monophasic sound with constant high pitch over extrathoracic airways
- Inspiratory (supraglottic lesion)
- Expiratory (tracheobronchial lesion)
- Biphasic (subglottic to tracheal ring)
Sudden severe narrowing and drop in pressure/flow velocity closes the airway
Associated with:
1. Foreign body obstruction and aspiration
2. Croup
3. Peritonsillar abscess
4. Laryngomalacia
5. Subglottic stenosis
6. Vocal cord dysfunction
7. Laryngeal haemangioma
8. Tracheomalacia, bronchiomalacia (expiratory)
9. Epiglottitis
Wheeze is a continual high pitched musical sound at the end of inspiration or start of expiration
(end inspiratory to expiratory wheeze)
Airway narrowing increases airflow velocity, causing oscillation and vibration of airway walls producing acoustic waves.
Severe obstruction produces longer and higher pitched wheeze
Conditions associated:
1. Asthma / COPD - polyphonic wheeze
2. Bronchitis, bronchiolitis
3. Foreign body aspiration (stridor)
4. Bronchial tumour - monophonic wheeze
5. Cardiac induced wheeze
