Inspection for shape and movement of the chest

Looking from above (standing behind the patient), over the shoulders or the upper part of the chest.If standing or sitting is not possible for the patient, inspect the chest in Iying down position, patient lies absolutely straight in the bed in supine position) inspect from the

• Top.
• Foot end of the bed.
• The sides in profile.
• Head end.
• Back (try to turn the patient to any one side).

The following are the points to note :

1. Any deformity, fullness or depression (i.e. shape of the chest), apical impulse etc.
2. Back (winging of the scapula, drooping of the shoulder, kyphoscoliosis, gibbus. skin changes).
3. Whether both the sides of the chest arc moving simultaneously and symmetrically.
4. Classically  winged scapula is found in paralysis of nerve to serratus anterior (C 6 ,7) and sometimes in facio-scapulo-humeral muscular dystrophy.
5. Assessment of the expansion of the upper lobes is better achieved by inspection
6. From behind the patient, looking down at the clavicles during moderate respiration.
7. Equal on both sides - normal
8. Reduced movement on one side -  pleural disease ,pulmonary disease
9. Bilaterally reduced movement - in emphysema.

Assessment of position of Trachea

Trail's sign

Shift of trachea produces prominence of sternal head of sternocleidomastoid on the side to which the trachea is shifted. It is called Trail's sign.

The pretracheal fascia encloses the clavicular head of stemomastoids muscle on both sides. When the trachea is shifted to one side, the pretracheal fascia covering the stemomastoid muscle on that side relaxes, producing the clavicular head more prominent on the side of tracheal deviation.

Causes of tracheal shift
Pleural disease - Shift to opposite side

• Pleural effusion
• Pneumothorax

Pulmonary disease-Shift to same side

• Fibrosis and collapse of lung

Goiter - Shift of trachea to opposite side.

Position of the Trachea and Trail's sign

Where do you beat in clavicular percussion ?

• This is a direct percussion (clavicle acts as pleximeter  finger): percussion is done by right middle finger.
• Over the most prominent part of clavicle, or
• Over the medial I /3 rd ol the clavicle, just lateral to its expanded medial end.
• During percussion, stretch the overlying skin downwards with the left thumb so that the percussing finger does not slip over the clavicle. It is a light percussion.

What are the areas of the percussion of lung ?

Percussion of Anterior chest wall

• Clavicle: Direct percussion is used and percussion is done within the medial l/3rd of the clavicle 
• Supraclavicular region (Kronig's isthumus)
• Infraclavicular
• Second to sixth intercostal spaces. However the percussion note in this area cannot be compared due to relative cardiac dullness on the left side.

Percussion of Lateral Chest Wall

• From the fourth to seventh intercostal spaces lateral chest wall is percussed

Percussion of Posterior Chest Wall

• Suprascapular (above the spine of the scapula)
• Interscapular region
•  Infrascapular region up to the eleventh rib.

Features of pulmonary and systemic circulation

Features of pulmonary circulation

It is a low pressure system

Because it only needs to pump  blood to the top of the lungs.

If it is high pressure, then  following Starling forces, the fluid  would flood  the lungs.

Advantages of Pulmonary Circulation being a Low Resistance system

• Accommodates more blood as a person shifts from the standing to the lying position.
• High compliance allows the vessel to dilate in response to modest increase in Pulmonary arterial pressure.
• Pulse pressure in the pulmonary circulation is rather low

Pressures in the pulmonary system
Right Ventricle:

Systolic= 25 mmHg

Diastolic= 0-1 mmHg,

Pulmonary artery:

Systolic= 25 mmHg

Diastolic= 8 mmHg

Mean Pulmonary arterial pressure= 15 mmHg.

Pulmonary Vein:

Averages about 5 mmHg

Pulmonary capillaries:

7 mm Hg

Left atrium:

Averages 2 mmHg

It is a low resistance system

• Only 1/10th of the resistance of the systemic circulation
• Arterioles have less smooth muscle, veins are wider & shorter& pulmonary vessel walls are thinner. 

Pulmonary vasculature has High compliance

• Accommodates 5 L of blood  (same as the systemic circulation)
• Accommodates shifts of blood more  quickly e.g. when a person shifts from  a standing to a lying position

Features of systemic circulation

Systemic circulation is a High pressure system

Because it needs to send blood to the brain even when standing & to the tip of en elevated fingertip.

Systemic circulation has High resistance

Because of increased smooth muscle in the  arterioles & the  metarterioles. 

Systemic circulation has Low compliance

Because of resistance  offered by the arterioles  and the metarterioles

Causes of chestpain in clinical practise

Types of chest pain observed in clinical practise are:
Restrosternal pain
Pleuritic pain
Acut onset chest pain
Chest pain with dyspnea 
Causes of chest pain with circulatory collapse or syncope

• Acute myocardial infarction.
• Tension pneumothorax.
• Pulmonary' thromboemlxilism
• Dissectlon of aorta.
• Cardiac tamponade.
• Acute pancreatitis.
• Upper gastro intestinal bleeding.

Causes of Retrosternal chest pain

Retrosternal chest pain  causes are given below

• Ischaemic heart disease.
• Oesophagitis or diffuse oesophageal spasm.
• Acute dry percardltis.
• Acute mediastinitis.
• Diaphragmatic hernia.
• Aneurysm of the aorta.
• Dissecting aneurysm.
• Psychogenic.

Causes of upper retrosternal Pain

It is a momentary pain which increases in intensity on coughing and subsides when the cough becomes productive. This is seen in acute tracheitis.

Mid or Lower Retrosternal Pain in mediastinal disease

Character resembling cardiac pain, radiate to neck and arms, unrelated to exertion.

This pain is constrictive in character and may be present in:

• Acute mediastinitis
• Mediastinal tumour
• Mediastinal emphysema
• Reflux esophagitis
• Achalasia cardia.

Causes of chest pain with breathlessness :

Following are the causes of chest pain with breathlessness

• Spontaneous pneumothorax.
• Acute myocardial infarction-Occurs in middle aged or aged persons ,characterised by  retrosternal pain with radiation to left hand, associate with  drenching sweat and shock. Breathlessness with signs of heart failure may occur.
• Acute pulmonary thromboembolism - Sudden onset of chest pain  with dyspnoea, haemoptysis and circulatory collpase develop. Tachycardia, right ventricular gallop rhythm, loud P2 are the clinical sign present.There is  normal resonant note on percussion over the chest. History of prolonged recumbency or signs of thrombophlebitis may be noted.
• Dissection of aorta -  Abrupt onset of chest pain with dyspnoea  and will mimick acute myocardial infarction with pain referred to the back. There is discrepancy between carotid pulses difference in BP in two arms, arrhythmia and features of acutely developing aortic regugitation. Dissection  of aorta occur more commonly in  Marfans  syndrome, hypertension, coarctation  and pregnancy
• Acute dry pleurisy (specially from consolidation) - Dyspnoea is not so common in this situation but chest pain is present. Pleural Friction rub is audible and no sign of pneumothorax can be detected.
• Massive collapse of the lung -There will be history of aspiration of foreign body .Mediastinalshifting is noted towards the side of collapse. Impaired resonance note on percussion. Breath sound is diminished vesicular or absent.
• H/O trauma can also produce chest pain with dyspnea. Point of tenderness may be detected. Normal resonant note on percussion.Typical findings of pneumothorax are lacking.
• Psychogenic condition can also produce chest pian with dyspnea

What is Stridor?

Stridor can be laryngeal or tracheal in origin
Laryngeal stridor
High pitched crowing sound better heard during inspiration
Causes of laryngeal stridor are

• Foreign body
• Laryngeal spasm
• Edema
• Infection
• Tumor
• Bilateral vocal cord paralysis.

Tracheal stridor
It is a low pitched sound best heard in inspiration.
Croaking inspiratory sound or continuous sound increased by coughing, associated with inspiratory dyspnoea and indrawing of the suprasternal notch.
Causes of tracheal stridor are

• Obstruction of the tracheal lumen by tumor or foreign body.

Inspection of respiratory system

Inspection of  upper and lower Respiratory tract 

Position of Trachea

Apical impulse

Displacement of apical impulse is seen in push and pull of the pleuropulmonary disease

Inspection  for shape and movement of the chest

Normal shape of  Chest

Abnormal shape of chest

Crowding of ribs

Patient should be in sitting or standing posture

Crowding of ribs should be made out from the back

Standing behind the patient by sliding the fingers along the lower intercostal spaces on either sides and comparing them

Drooping of the shoulder

Supraclavicular and Infraclavicular fossa

Supraclavicular and Infraclavicular fossa hollowing is seen following 

• Fibrosis 
• Collapse of the lung, 
• Malnutrition

Unilateral flattening of the chest

It is seen in 

• Fibrosis 
• Collapse of lung

Spinal Deformity

Movement of the Chest-It is described in terms of rate, rhythm ,equality and type of breathing.

The skin over the chest wall 

The skin over the chest wall is examined for the following:

• Engorged veins and subcutaneous nodules seen in sarcoid and malignancy
• Intercostal scar  are drained pleural effusion, empyema or pneumothorax
• Discharging sinuses is seen in Tuberculosis
• Empyema necessitans in which there is an intercostal swelling is seen close to the sternum.
• Metastatic nodule
• Swelling due to empyema necessitans.

Presence of Veins over the chest wall

In superior vena caval syndrome look for presence of distended veins over the chest wall 

If the obstruction to SVC occur above the level of azygos vein, collateral venous circulation on the anterior surface of chest wall is less prominent as the intercostal veins drain into the azygos vein.

If the obstruction to SVC is at or below the level of azygos vein, collateral veins on the chest become prominent as these collaterals carry blood caudally to the IVC.

Common causes of intercostal suction

Following are the common causes of intercostalsuction

• Foreign body wiihin larynx or trachea.
• Diphtheria.
• Oedema of the glottis (in anaphylaxis).
• COPD.
• Bronchiolitis (in infants and children).
• Bilateral diaphragmatic palsy.

Observation on inspection of back in respiratory system 

What are the abnormal shape of chest?

Normal chest is symmetrical and elliptical in cross section.The following abnormalities are noted in shape of chest
Flat chest 
The anteroposterior to transverse diameter ratio is 1 : 2
Present in  fibrothorax
Barrel shape chest
The anteroposterior to transverse diameter ratio is 1:1
Seen in physiological states like infancy and old age and in pathological states like COPD (emphysema).
Pectus Carinatum or Pigeon chest
It is the forward protrusion of the sternum and adjacent costal cartilage
It is seen in

• Childhood respiratory disease like asthma 
• Rickets
• Marfan's syndrome 

Pectus excavatum or Funnel chest or cobbler's chest
This is the exaggeration of the normal hollowness over the lower end of the sternum.
It is a developmental defect.
Due to displacement of heart the apex beat is shifted further to the left and the ventilatorv capacity of the lung is restricted
This is found in marfan syndrome.
Thoracic kyphoscoliosis reduce ventilatory capacity of lung
Harrison's sulcus
It is due to the indrawing of ribs to form symmetrical horizontal grooves above the costal margin, along the line of attachment of diaphragm due the hyperinflation of lung,
It is due to the hyperinflation of the lungs and the strong contraction of the diaphragm contraction

• Occurs in chronic respiratory disease in childhood-Childhood asthma 
• Rickets 
• Blocked nasopharynx due to adenoid enlargement

Rachitic and scorbutic rosary
It is the beed like enlargement of costochondral junction in rickets and scurvy
Scorbutic rosary: It is the sharp angulation, with or without beading or rosary formation, of the ribs, arising as a result of backward displacement or pushing in of the sternum,
Scorbutic rosary is painful
Teitz disease
It is characterised by congenital costochondral prominence.
Other abnormalities are
Abnormalities in shape of chest
1.Droopingof shoulder
2.Hollowing of supra/infradavicular fossae is seen in
Fibrosis
Bulging of chest wall Seen in  Mass lesion, Empyema
3.Crowding of ribs
Patient should be in sitting or standing posture
Crowding of ribs should be made out from the back
Standing behind the patient by sliding the fingers along the lower intercostal spaces on either sides and comparing them

Normal shape of Chest

• Normal chest is bilaterally symmetrical without undue elevation or depression,
• Truncated cone-shaped  with transverse diameter > anteroposterior diameter and vertical is the highest ,elliptical in cross section.
• The normal anteroposterior to transverse diameter ratio is 5 : 7. 
• The normal subcostal angle is 90°. 
• It is more acute in males than in females.
• Both the sides of the chest move simultaneously and symmetrically

Look for the following in inspection of chest:

Drooping of the shoulder 

Crowding of ribs

Patient should be in sitting or standing posture

Crowding of ribs should be made out from the back

Standing behind the patient by sliding the fingers along the lower intercostal spaces on either sides and comparing them

Supraclavicular and Infraclavicular fossa

Supraclavicular and Infraclavicular fossa hollowing is seen following 

• Fibrosis 
• Collapse of the lung, 
• Malnutrition

Flattening of chest

Unilateral flattening of the chest

It is seen in 

• Fibrosis 
• Collapse of lung

The skin over the chest wall is examined for the following:

• Engorged veins and subcutaneous nodules seen in sarcoid and malignancy
• Intercostal scar  are drained pleural effusion, empyema or pneumothorax
• Discharging sinuses is seen in Tuberculosis
• Empyema necessitans in which there is an intercostal swelling close to the sternum.
• Features of systemic fungal infection
• Metastatic nodule
• Swelling due to empyema necessitans.

Kyphoscoliosis

Kyphosis (forward bending of the spine) and Scoliosis (lateral bending of the spine).

Drooping of the shoulder

How to detect the drooping of shoulder?

Ask the patient to stand with the face away from the examiner

• Identify the level difference of the tips of both shouders
• Distance between the inferior angle of scapula and the midspinal line is noted
• Note the prominence of the inferior angle of the scapula
• If any two of the above are positive the patient has a drooped shoulder
• In drooping the following findings are noted
• Lower end of scapula is at a lower level
• Spine - scapular distance is reduced
• Medial border of scapula is more prominent on the affected side

Causes of drooping

• Fibrosis
• Collapse
• Trapezius paralysis

Mechanism of drooping in Fibrosis

It is due to decreased expansion of the lung producing disuse atrophy of the muscles & irreversible bone changes.

Minimum time for drooping to develop in fibrosis is 6 months

Mechanism of drooping in Collapse

Drooping is due to disuse atrophy,it is partially reversible

This is due to volume loss of the lung

Drooping takes only 6 weeks in collapse whereas it takes 6 months in fibrosis because the lung function is totally lost acutely in collapse and gradually in fibrosis

Pseudodrooping

Drooping correctable on stooping forward is called as pseudodrooping

Causes are

• Congenital scoliosis 
• Pleurisy-Due to muscle spasm.
• Empyema-Due to toxic myositis

Drooping vs Pseudodrooping

Drooping                                                                    Pseudodrooping

Convexity to the opposite side of lung disease        Convexity may to be either side

Not correctable on stoopirfg forwards or walking    Correctable on stooping forwards or walking

Causes of Reversible drooping

• Pleurisy
• Empyema
• Collapse with removal of obstruction

Causes of Irreversible drooping 

• Fibrosis

Examination of the Respiratory System

Inspection ot upper Respiratory tract
Examination of Oral cavity

• Oral hygiene
• Dental caries
• Oral thrush
• Tonsils.

Examination of Nose

• Deviated nasal septum
• Nasal polyps may be seen in- Wegener's granulomatosis, allergic asthma, ABPAS ,cystic fibrosis.

Examination of Pharynx

• Postnasal drip
• Lymphoma deposits.

Inspection of Lower Respiratory Tract
All the findings in the clinical examination should be compared on both sides in the following areas:

• Supraclavicular area
• lnfraclavicular area
• Mammary region
• Axillary region
• Infraaxillary region
• Suprascapular region
• Interscapular region
• Infrascapular region.

Assessment of Respiratory System

Physical Examination

Inspection

• posture, shape, movement, dimensions of chest,flared nostrils, use of accessory muscles, skin color, and rate, depth, & rhythm of respiration

Palpation

• respiratory excursion, masses, tenderness

Percussion

• flat, dull, resonant, hyperresonant sounds

Auscultation

• breath sounds, voice sounds, crackles, wheezes

Observation on inspection of back in respiratory system

Inspection of back (in respiratoty system or CVS) is always done in standing position if the condition of the patient permits.This is to avoid undue obliquity.

One should look for the following

• Kyphosis (look from sides in profile).
• Scoliosis.
• Drooping of the shoulder (signifies apical fibrosis or collapse).
• Winging of the scapula (long thoracic nerve palsy or spinal deformity).
• Whether the inferior angle of scapula on both sides are at the same level or not.
• Interscapular area (spino-scapular distance) you should compare between two sides of chest.
• Gibbus is an acute angulation in the spine commonly due to caries spine
• Ankylosing spondylitis (stiff and immobile spine)—may produce restrictive lung disease.
• Crowding of rib is examined both in the front as well as the back.
• Skin condition—Scar, sinus, herpes zoster, local oedema, venous prominence, arterial pulsation(Suzman s sign), pigmentation, deformity after thoracic operation,example  thoracoplasty etc. 
• Movement—Whether both the sides are moving simultaneously and symmetrically, or not

What is hyperventilation?

Hyperventilation means deep rapid breathing as in

• Acidosis
• Upper brainstem lesion,
• Hypoxia
• Hysteria
• Salicylate poisoning.

Tachypnea is respiratory rate > 22/min.
Bradypnea is respiratory rate < 10/min.

Differentiation between pulmonary and cardiac causes of Dyspnoea

Dyspnoea due to pulmonary aetiology has the following features

• Cough with expectoration precedes dyspnoea.
• Wheeze or stridor.
• Pleuritic chest pain.
• Pyrexia.
• Seasonal variation.
• Weight loss.
• Cyanosis (++ or +++).
• Progression over many years.
• Response to oxygen, bronchodilalors.
• Absence of obvious cardiac disease.

Dyspnoea due to cardiac aetiology has the following features

• PND and orthopnoea.
• Dyspnoea precedes cough with expectoration.
• Associated angina, syncope, palpitation: hypertension.
• Rapid progression of symptoms.
• Little or no cyanosis {+).
• Response to diuretics and digoxin.
• Physical signs of cardiac disease.