PhysicalExaminationinRespiratorySystemJuanchen,ph.D.Anteriorimaginarylinesandlandmarkscostovertebralangle

InfraclavicularfossaAnteriormidlineSuprasternalfossaSupraclavicularfossaSternallineParasternallineMidclavicularlineLateralimaginarylinesAnterioraxillarylineMidaxillarylinePosterioraxillarylinePosteriorimaginarylinesandlandmarksScapularlinePosteriormidlineInfrascapularregionInterscapularregionSuprascapularregionBordersofLungsuperiorlungmarginistopofthelunginferiorlungmarginisinthe6thribsregionatmidclavicularline8thribsregionatmidaxillaryline10thribsregionatscapularline.AnteriorviewoflobesObliqueinterlobarfissureplaininterlobarfissurePosteriorviewoflobesRightlateralviewoflobesLeftlateralviewoflobesInspectionChestwall:veins,skinThorax:shape,sizeTheratiooftheanteroposterior(AP)diameterAPdiameterdecreases:long-termdisordersAPdiameterincreases:barrelchestBreast:location,shapeThoracicdeformityKyphosisBarrelchest

ThoracicdeformityInspectionRespiratorymovementAbdominalbreathing:maleadultandchildThoracicbreathing:femaleadultRespiratoryrate:16-20f/minTachypnea:>24f/minBradypnea:<12f/minShallowandfastrespiratorymuscularparalysis,elevatedintraabdominalpressure,pneumonia,pleurisyDeepandfastAgitation,intension

DeepandslowSeveremetabolicacidosis(Kussmaul’sbreathing)inspectionThreedepressionsign:

Therespiratorymusclescontractwithinspirationdepressionsinthesuprasternal

fossa,thesupraclavicular

fossaeandtheintercostalspacesappearsinobstructionoftheupperairwaysuchastrachealforeignbodyandtrachealcarcinomaInspiratory

despneadelayedinspirationobstructionoftheupperairway

ExpiratorydespneadelayedexpirationCOPDasthmaemphysema

InspectionRespiratoryrhythm

Cheyne-Stokes’breathingBiot’sbreathing_____DecreasedexcitabilityofrespiratorycenterInhibitedbreathingSuddencessationofbreathingduetochestpainPleurisy,thoracictraumaSighingbreathingDepression,intensionPalpationThoracicexpansionMassivehydrothorax,pneumonia,pleuralthickening,atelectasisVocalfremitus(語音震顫)location,areaPleuralfrictionfremitusCelluloseexudationinpleura--increasedHoldingbreathingdisappearedPercussion1.MethodMediateDirectpercussion:TappingthechestwiththepalmarofhandsIndirectpercussion:Pleximeter:distalinter-phalangealjointofleftmiddlefingerPlexor:rightmiddlefingertipOrderUptodown,anteriortoposterior2.AffectedfactorsThicknessofthoracicwallHydrothoraxContaininggasinalveoliAlveolartensionAlveolarelasticity

3.ClassificationResonanceNormalHyperresonanceEmphysemaTympanyCavityorpneumothoraxDullnessHydrothorax,atelectasisFlatnessMassiveHydrothorax4.NormalsoundLung’ssoundinpercussionResonanceSlightdullnessinsomeareas(upper,right,back)duetothicknessofmusclesandskeletons4.NormalsoundBorderoflungsinpercussionApexoflungsUpperlungmargin:5cminwidthNarrow:TB,fibrosiswider:emphysemaAnteriorborderabsolutecardiacdullnessareaLowerborder6th,8th,10thintercostalspaceinmidclavicularline,midaxillaryline,scapularline,respectivelyDown:emphysemaUp:atelectasis,intraabdominalpressuregoesup4.NormalsoundsShiftingrangeofbottomoflung

6-8cmShiftingrangeofbottomoflungAlongthescapularlinePercussingbottomoflung,markingAskingthepat.toinspiredeeplyandholdPercussingbottomoflung,markingAskingthepat.toexpiredeeplyandholdPercussingbottomoflung,markingMeasuringthedist.betweenupperandlowerlinesDecreased:emphysema,atelactasis,fibrosis,pulmo.edema,pneumoniaDetectedimpossibly:pleuraadhesion,massivehydrothorax,pneumothorax,diaphragmaticparalysis

5.AbnormalsoundDullness,flatness,hyperresonanceortympanyappearintheareaofsupposedresonance.Unchangedsound(resonance)Thedepthofthelesion>5cmThediameterofthelesion3cmMildhydrothorax5.AbnormalsoundDullnessorflatnessDecreasedcontaininggasinalveoliPneumoniaAtelectasis?TBPulmo.embolismPulmo.edemaPulmo.fibrosisNogasinalveoliTumorNon-liquefiedlungabscessOthersHydrothoraxPleuralthickness5.AbnormalsoundHyperresonance

EmphysemaTympanyPneumothoraxLargecavity(TB,lungabscess)Auscultation

OrderofauscultationListeningproceduresandtechniquesListencarefullytothepatientsbreathingwithoutstethoscope.Warmingthestethoscopeandapplyingitfirmlytothechestwall.Orderthepatienttobreathewithhismouthopenalittle,deeperandfasterrespirationthannormalAskingpatienttowhisperninety-ninetonotethevocalresonanceWhatyoumustdoduringauscultationDeterminewhetherthebreathsoundsareequalonbothsidesAscertainthecharacterofthebreathsoundsDetectanyaddedsoundsComparedthevoicesoundsoverdifferentpartofthelungSoundofauscultationNormalbreathsoundAbnormalbreathsoundAdventitioussoundVocalresonance(語音共振)1.NormalbreathsoundTrachealbreathsound

BronchialbreathsoundLarynx,suprasternalfossa,around6th,7thcervicalvertebra,1st,2ndthoracicvertebraBronchovesicularbreathsound1st,2ndintercostalspacebesideofsternum,thelevelof3rd,4ththoracicvertebraininterscaplararea,apexoflungVesicularbreathsoundMostareaoflungsBronchovesicularBronchialBronchialBronchovesicular2.AbnormalbreathsoundAbnormalvesicularbreathsoundAbnormalbronchialbreathsoundAbnormalbronchovesicularbreathsoundAbnormalvesicularbreathsound(1)DecreasedordisappearedLimitedthoracicexcusionRespiratorymuscleweaknessObstructionofairwayHydrothoraxorpneumothoraxAbdominaldiseases:abdominaltumorIncreasedMovementofrespirationincreasedCompensatoryincreasedvesicularbreathingforaffectside.Abnormalvesicularbreathsound(2)ProlongedexpirationBronchitisAsthmaemphysemaCogwheelbreathsoundTBPneumoniaCoarsebreathsoundEarlystageofbronchitisorpneumoniaAbnormalbronchialbreathsound

(tubularbreathsound)BronchialbreathsoundappearsinsupposedvesicularbreathsoundareaConsolidation:lobarpneumonia(consolidationstage)Largecavity:TB,lungabscessCompressedatelectasis:hydrothorax,pneumothorax

AbnormalbronchovesicularbreathsoundBronchovesicularbreathsoundappearsinsupposedvesicularbreathsoundareaThecausesarecombinationofsmallerconsolidationandnormalairfilledlungtissueOccurinbronchopneumonia,TB,Lobarpneumonia3.Adventitioussound(moist)CracklesRhonchi(wheezes)PleuralfrictionrubMoistcrackles

Mechanism

Duringinspiration,airflowpassesthinsecretionintheairwaytorupturethebubbles,ortoopenthecollapseofsmallairwayswithsecretion.CharacteristicsofcracklesAdventitioussoundIntermittentAppearedinphaseofinspirationorearlyexpirationConstantinsiteUnchangedincharacterLessordisappearedaftercoughClassificationofcracklesAccordingtointensityofthesoundLoudmoistcracklesSlightmoistcracklesAccordingtodiameteroftheairwaycracklesappearedCoarse:trachea,mainbronchi,orcavityBronchiectasis,pulmo.edema,TB,lungabscess,comaMedium:bronchibronchitis,pneumoniaFine:smallairwaypneumoniavelcro:alveolaralveolitis,earlypneumonia(pulmo.Congestion),eldersubject,pat.bedrestforlongtimeSiteofcracklesLocal:locallesionPneumonia,TB,bronchiectasisBothbases(twosides)Pulmo.edema,bronchopneumonia,chronicbronchitisFullfields(fromtoptolow;fromlatertomiddle)Acutepulmo.edema,severebronchopneumonia,chronicbronchitiswithsevereinfectionRhonchi(wheezes)Mechanism

Theturbulentflowisformedintrachea,airwaynarroworinco