Medicine

to Clinical
86 An Insider's Guide Rib crowding/intercostal widening:
Stand behind the patient and place the fingers in the
s simultaneouslyon both sides as shown
intercostal spaces:
inFigure 3D.29.
separation of the fingers
Observe for the
Rib crowding
Intercostal widening
Bilateral Unilateral Bilateral
Unilateral

Atelectasis
Interstitial Pneumo- Emphysema
lung thorax
Collapse Pleural
Fibrosis
disease
Fibrosis effusion
Pneumonec
(bilateral)
tomy

Fig. 3D.28: Demonstration of vocal fremitus.

Vocal fremitus
Increased Decreased
Consolidation Pleural effusion
I Large cavity I Pneumothorax
I Bronchopleural fistula Fibrosis
Collapse
Asthma
Emphysema
Thick pleura
Tactile fremitus:
These are palpable adventitious sounds
It could be coarse crepitations or rhonchi. Fig. 3D.29: Examination of rib crowding.
Friction fremitus: These include palpable pericardial rub or
pleural rub (e.g., dry pleurisy).
Tenderness:
Over intercostal spaces Over ribs Over spines
Empyema I Rib fracture I Spinal injury
Malignant Potts
Pleurisy
Malignant deposits in the disease
mesothelioma ribs Paget's
Pneumothorax disease
Tietze's syndrome Collapse
(costochondritis) vertebra
Pneumonia
Pulmonaryabscess Over sternum
Hepatic abscess Due to
Pulmonary enbolism
leukaemia/
Pulrnonary infarction
infiltration Fig. 3D.30: Demonstration of percussion of anterior chest.
Herpes zoster before
appearance of eruption
Intercostal muscle pain Percussion (Lower Respiratory Tract)
Recent injury to the
chest
Preferably done in sitting position, supine position isSneeeded
fordemonstrating shifting dullness.
Detection of subcutaneous emphysema:
Spongy crepitant feeling on palpation Position of patient for
1. Injury to chestwall Anterior chest (Fig,percussion:
3D.30): with
hands

2. Pneumothorax
by his side Sits up
straight
" Axilla (Fig. 3D.31): h e a da n d
3. Rupture of esophagus
place over the back Raise the arm
of head
Over the
 Respiratory System Examination
87
Posterior of chest (Fig. 3D.32): Sits up with hands Direct Indirect
crossed and placed over the opposite shoulders. percussion
Auscultatory percussion
percussion
Rules of Percussion Directly over By percussing Was first described by
the bony Over the Laennec and used to
1. Direction of percussion: Always percuss from resonant structures like
to non-resonant area. pleximeter delineate the size of organs
clavicle finger with the by placing the stethoscope
2. Pleximeter is usually the middle phalanx of middle plexor/plessor directly above the structure
finger of left/nondominant hand and is firmly placed to be outlined, followed
on the surface while rest of fingers are slightly lifted off. by percussion from the
3. Plexor/plessor (percussing finger) is middle finger of periphery towards the organ
the right/dominant hand. of interest
4. The movement of the plexor hand should be sudden and Direct percussion (Fig. 3D.33):
originating from the wrist. Percuss the middle third of the clavicle with plexor
5. The pleximeter must be kept parallel to the border to be finger.
percussed. Stretch the skin over the clavicle using the left hand as
6. Percuss around 2-3 times over each area. shown in Figure 3D.33.
7. Percussion has to be heard as well as felt. Normally middle third of the clavicle is resonant whereas
8. Always percuss the identical areas of chest for the medial and lateral thirds are dull (because of muscles
comparison. attached).
9. The distance between the pleximeter finger and the ear
should preferably be maintained. Impaired note Heard in apical fibrosis
Dullnote Mass lesion like pancoast tumor
Types of percussion Widening of zone of Heard in pneumothorax or
Heavy percussion Light percussion resonance emphysema
Posterior part of chest Anterior part of chest and abdomen
Flicking percussion: Flicking using thumb and finger-- done
for percussion of the abdomen, cardiac border and to check
for metallic note of pneumothorax.
Guarino's method of auscultatory percussion:
Examined with patient sitting up and examiner facing the
back of the patient.
Place the stethoscope around 3 cm below the last rib in
the scapular line as shown in Figure 3D.34.
Now percuss with the free hand (by finger flicking or with
pulp of the finger) along 3 or more parallel lines from
the apex of each hemithorax perpendicularly downward
towards the base to note the dullness.
Lung Resonance
Normal:
Vesicular resonance
Fig. 3D.31: Demonstration of percussion of axillary area. Front of chest more resonant

Fig. 3D.32: Demonstration of percussion over the posterior chest. Fig. 3D.33: Demonstration of direct percussion over the clavicle.
 Clinical Medicine
88 An Insider's Guide to
Qualitative types
Normally seen chest of infants or
in
Cracked pot during the act of crying child
resonance
Pathological lung cavity with
communication with bronchus
due to
sudden expulsion of. air form the cavity
to bronchus

Artificially imitated by beating clasped

hands over the knee

Low pitched hollow note

Amphoric Normally seen in trachea and cheek
distended with air
73 cm
Pathologically seen in pneumothorax
and large cavity

Bell tympany
High pitched metallic or tympanic note
Seen in massive pneumothorax
Place coin on affected side of chest
and percuss with another coin while
Fig. 3D.34: Guarino's method of auscultatory simultaneously auscultating the back
percussion in pleural effusion.
Lesion >5 cm from chest wall or <2-3 cm in size will not Dullness in presence of fluid in lung
alter the percussion note. Straight line dullness Hydropneumothorax
Abnormal types of percussion notes Pleural effusion
S-shaped curve of Ellis
Quantitative Qualitative
Tympanic note Crackpot 5-7-9 rule:
Subtympanic note Amphoric The upper border of liver dullness is at 5th intercostal space
Hyper-resonant note Bell tympany (ICS) in midclavicular line, 7th ICS in the midaxillary line and
Impaired note 9th ICS in the scapular line.
Dull/woody dull note
I Stony dull note Topographical percussion of lung
Quantitative types
Apicalpercussion:
Kronigs isthmus: It is a band of resonance in the
Tympanic note It is a drum-like note
Normally seen over the stomach, supraclavicular area bounded anteriorly by the posterior
intestine-Traube's space border of the clavicle, medially by the neck muscles,
Inchest-superficial cavity, posteriorly by the anterior border of trapezius,extended
subcutaneous emphysema (metallic laterally till the acromioclavicular joint.
tympanicnote) Stand behind the patient, place the pleximeter finger
Subtympanic It is Boxy quality over the neck and percuss from lateral to medial as
(skodaic) note Seen just above pleural effusion shown in Figure 3D.35.
Hyper-resonant Intermediate between normal and
note tympanic note
Bilateral-emphysema
Unilateral-pneumothorax,
compensatory emphysema
Large bullae
Impaired note Airless areas (fibrosis, collapse)
Dull note Consolidation
Thick pleura
Flat dulI Can be elicited by percussing over the
thigh
Seen in pleural effusion
Stony dullness Pain over the pleximeter finger with
resistance felt by plexor
Large pleural effusion
Large solid tumnor
Fig. 3D.35: Percussion of apical area (Kronig's
isthmus
 Respiratory System Examination 89

On percussion there is dull zone medially and laterally,

and only middle part is resonant.
Dullness in this area suggests apical tuberculosis,
Pancoast tumor or apicalfibrosis.
The zone of resonance may be widened in emphysema or
apical pneumothorax.

Tidal percussion:
Tidal percussion isa measure of diaphragmatic excursion
Itis used to differentiate whether the causes of dullness
are above the diaphragm (subpulmonic effusion) or
below (subphrenic collections)
With patient in, percuss the right side of the chest from
above downwards till you get the liver dullness.
Normally, it is in 5th intercostal space. Fig. 3D.37: Percussion of Traube's space.
Ask the patient to take a deep inspiration and hold his Shifting dullness:
breath.
Itis classically described for hydropneumothorax. It can also
Now percuss the same area be demonstrated in pleural effusion.
Normally, dullness moves down by1-2interCostal spaces
as shown in Figure 3D.34. Steps:
Tidal percussion is negative in right-sided subpulmonic Percuss the anterior chest in sitting position, from above
effusion,diaphragmatic paralysis. downward to get upper border of dullness. You will get a
In emphysema, since the lung is already fully expanded level of straight line dullness perpendicular to long axis of
tidal percussion will be negative (Figs. 3D.36A and B). body as shown in Figure 3D.38A. Mark this level.
Percussion of Traube's space (Fig. 3D.37): Now, make the patient lie down in opposite lateral
position/normal side (for around 5 minutes in case of
It is asemilunar space in the left anterior chest bounded by: hydropneumothorax and around 30 minutes in case of
Above by 6th rib
pleural effusion). Percuss over the affected side and note
Below by left costal margin
Laterally by anterior axillary line. the change in the straight line dullness which will now be
parallel to long axis of body as shown in Figure 3D.38B.
Shifting dullness may be absent in case of empyema or
Normal Traube's Tympanic note
space percussion
loculated pleural effusion.
Obliteration of Collapsed lung
Left sided pleural effusion
Traube's space Pericardial effusion
Massive splenomegaly
Enlarged left lobe of the liver
Full stomach or fundic mass Hyper-resonant
note
Upward shift of Left diaphragmatic paralysis
Traube's space Left lower lobe collapse or fibrosis Air fluid level

Dull note

Hyper-resonant
note
Air fluid level

Dull note

Collapsed lung

A B
Figs. 3D.36A and B: Demonstration of tidal percussion:
(B) Inspiration (Note the change in liver dullness from (A) Expiration;
B

inspiration).
expiration to Figs. 3D.38A and B:Right hydropneumothorax:
(A) Sitting position; (B) Left lateral position.
 90 Clinical Medicine
An Insider's Guide to
Special findings in percussion:
Special finding Clinical condition
Shifting dullness Hydropneumothorax
S-shaped Pleural effusion (moderate)
curve of Ellis
(Damoiseau's 3
curve)
Obliteration of Pleuraleffusion (left sided)
Traube's space
1
Grocco's triangle Boundaries of Grocco's triangle:
(Fig. 3D.39) Medially: The mid-spinal line from the 2
(Paravertebral level of the effusion to the level of the
triangle of tenth dorsal vertebra
dullness) Below: Ahorizontal line extending
outwards from the tenth dorsal vertebra
along the lower limit of lung resonance Fig. 3D.39: Special findings in percussion:
(1) Effusion (
Laterally: A
curved line connecting these Rauchfuss-Grocco triangle, (3) Garland triangle,
two lines
Auscultation (Lower Respiratory Tract)
Clinical condition:
Seen over the back of the chest, on the
opposite side of effusion in moderate to Position of patient:
massive pleural effusions Front Sittingor standing
Garland's Small area of resonance next to the spine In upright Back Preferably sitting and leaning
triangle (Fig. found in patients with large unilateral position forward with neck flexed and arms
3D.39) pleural effusions crossed in front
Lower relaxed part of the lung in
moderate or large pleural effusion is In recumbent Back Turn the patient sideways or slip
tympanic or subtympanic position the steth underneath the patient
William's Description: Breathing advice:
tracheal Area of tympanyover the first or second
resonance intercostal space, close to sternum
Ask the patient to breathe through the mouth. If not
Seen in: cooperating ask the patient to count numbers or cough
I Patch of consolidation or fibrosis successively and then observe during deep inspiration.
interposed between the trachea or a A quiet room and a stethoscope are needed when
major bronchus and the chest wall examining the patient with the intent of auscultating their
Referred to as'pulled trachea syndrome" breath sounds.
in fibrotic apical tuberculosis Thediaphragm of the stethoscope should be used tor tuie
Wintrich's sign Description: assessment
Percussion note over an area during The examination should not be conducted over clothing
inspiration appears clearer and higher
pitched with the mouth open than with of any kind, regardless of how thin that clothing may be: t
it closed
should be done in such a manner that the stethoscope hä
direct contact with the skin.
Seen in:
Lungcavity communicating with a
bronchus, pneumothorax or mediastinal
Normal physiology of breath sounds:
tumor Mechanism of sound production
Gerhardt's sign Description: In larger airways (pharynx, large
I Percussion note over an area appears airways of trachea and lung) In smaller airways
lower pitched with the patient recumbent Sounds are generated due to Higher frequencies are lost due
than with him standingor sitting turbulence they travel
Seen in: to dampening when airway[
from higher to smaller
Lung cavity containing both fluid and air
They are the source of sound and
Friedreich's sign Description: They are just flter sounds
Percussion note over an area becomes not the source of sound
higher in pitch during forced inspiration Sound frequencies are of range Sound frequencies are of range
than during expiration 200-2,000 Hz 200-400Hz
Seen in: Heard over the upper sternum Heard over most other areds
Lung cavity
of lung
 Respiratory System Examination 91

Mode of production Due to in and out movement of air

Grading of breath sound intensity through narrow aperture of glottis
Absent breath sounds
Graphical
Barely audible breath sound representation

2 Faint but definitely audible breath sound

3 Normal breath sound A

4 Louder than normal breath sound

Graphical representationof breath sounds a. Tubular phase of inspiration
Upstroke Inspiratory element b. ABSENT
Downstroke Expiratory element c. Expiration
Length Duration or timing Type of bronchial breathing
Thickness Loudness or intensity Tubular Amphoric Cavernous
Angle between upstroke Pitch of respiratory sound High-pitched sounds Low-pitched Low-pitched
and downstroke made with Lower the angle higher is the at the bronchioles bronchial sound with a
a vertical line pitch are conducted to the breathingwith peculiar hollow
chest wall without high-pitched quality, e.g, cavity
Types of normal breathing modification, e.g. overtones
Vesicular breathing Most areas of chest I Consolidation producing a
Tracheal/bronchial Larynx Above thelevel of metallic quality,
breathing Trachea pleural effusion e.g.
Between C7 to T3 Massive pericardial I Open
Bronchovesicular Anteriorly 1st and 2nd intercostal space effusion (Ewart's pneumothorax

Posteriorly between the scapula sign) due to

bronchopleural
Vesicular breath sounds fistula
Characteristics Rustling or breezy quality Large
Longer duration of inspiratory phase communicating
(which includes both tubular and cavity
alveolar phase)
Higher pitch of inspiratory sound Bronchovesicular breath sounds (also known as vesicular
1:E= 2-3:1 breath sounds with prolonged expiration)
Absence of pause between Iand E Characteristics Intermediate in character between vesicular
Distribution Most of chest and bronchial breath sounds
Louder: Infraclavicular, axillary and Expiratory phase is louder, longer, higher
Intensity pitched than inspiratory, or hollow
infrascapular areas
Diminished: Lower margins of lung character

and over the scapular areas Distribution Upper part of sternum

Distension and separation of alveolar
Up to 3rd/4th dorsal spines between scapula
Mode of production At times over the lung apices particularly on
walls by the in rushing current of air
right side
Graphical Mode of Usually seen when air containing lung tissue is
representation
production interposed between a large bronchus and the
B C
chest wall-thus combining the characteristics
of both vesicular and bronchial breath sounds
Graphical Tubular phase of
A representation inspiration
a. Tubular phase of inspiration Alveolar phase
b. Alveolar phase of inspiration of inspiration
Expiration
c. Expiration
A C

Tracheal (bronchial) breath sounds

Characteristics I Character is aspirate or guttural It is the hallmark auscultatory finding of obstructive lung disease
Expiration in longer like chronic obstructive pulmonary disease and asthma
Expiration is louder
Expiration has high pitch Diminished Intensity of breath sounds
Defect in transmission
I:E = 1:1 Defect in production Pleural effusion
There is a pause between inspiration Bronchialobstruction
and expiration (due to absence of Pneumothorax
Emphysema Thickened pleura
alveolar phase) Respiratory muscle paralysis
Thick chest wall
Distribution Larynx
Trachea Fibrosis
 to Clinical Medicine
92 An Insider's Guide

Adventitious Sounds (Flowchart 3D.1) sounds.

showing adventitious
Flowchart 3D.1: Algorithm
Adventitious
sounds

Discontinuous
Continuous

Pleural rub
High-pitched Low-pitched Crepitations
(wheeze) (rhonchi)

Mechanism of crepitation:
Continuous adventitious sounds:
Bubbling sounds produced by passage of air through
Lasts for more than 250 ms 1. accumulated secretions.
Sinusoidaland musical in quality 2. Sudden snapping opening of successive small airways
Mechanism of production of sound: Important
prerequisite for the production of wheeze is airflow when airflow is through it.
limitation. Narrowing of airways along with increased Fine crepitations
Coarse crepitations
intrathoracic pressure results in airflow limitation Due to snapping opening of Due to bubbling sounds
producing sinusoidal oscillations. successive small airways produced by passage of
For example: Wheeze and rhonchi. air through accumulated
secretions
Wheeze Rhonchi Low-pitched (loud)
High pitched (soft)
High-pitched sounds Low-pitched sounds Smaller airways Larger airways
400 Hz 150-200 Hz Heard during inspiration and
Heard during inspiration
Hissing/shrillquality (sibilant) Snoring quality (sonorous) expiration
Predominantly arise from Usually produced when air Not modified by coughing Modified by coughing
smallairways obstruction moves through tracheobronchial Not palpable Palpable
passages in the presence of
mucus or respiratory secretions
For example For example
1. Indux crepitations (initial 1. Redux crepitations
Classification of wheezes/rhonchi: stages of pneumonia) (resolution phase of
1. Monophonic or polyphonic 2. Pulmonary edema (early pneumonia)
2. Inspiratory or expiratory phase) 2. Pulmonary edema (late
3. Interstitial lungdisease phase)
Monophonic Polyphonic 4. Asbestosis 3. Bronchiectasis
Single tones Diffuse, multiple tones, both phases 5. Hypersensitivity pneumonitis
Due to local pathology Due to dynamic compression 6. Sarcoidosis
4. Lung abscess
5. Bronchitis
producing bronchial 1. COPD
obstruction 2. Bronchialasthma Inspiratory crepitations Expiratory crepitations
1. Tumor 3. Tropicalpulmonary eosinophilia Early Acute bronchitis
2. Foreign body aspiration ReduX crepitations
4. Hypersensitivity pneumonitis Chronic bronchitis (Resolution phase of
3. Bronchostenosis 5. Eosinophilic pneumonia Mid Bronchiectasis
4. Mucous plug pneumonia)
6. Churg-Strauss syndrome Resolving phase of Pulmonary edema
5. Lymph node pneumonia
Compression Late
(late phase)
Interstitial lung disease Bronchiectasis
Sequential inspiratory wheeze: Asbestosis Lung abscess
Series of sequential but not overlapping inspiratory Early pneumonia I Bronchitis
sounds or occasionally a single sound, resulting from Pulmonary edema
opening of airways which had become abnormally Few named crepitations
apposed during previous expiration. Coarse leathery
Occur in deflated areas of lung and are heard in lung Bronchiectasis
crepitations
fibrosis, mainly fibrosing alveolitis. Velcro crepitations
Interstitial lung disease
Posture induced
Discontinuous Adventitious Sounds (Rales/ crackles Appearance of fine crackles while changing
of posture (sitting tosupine or supine wi
Crepitations/Crackles) passive leg elevation), Ausculate in
These are discontinuous/intermittent, explosive, posterior axillary line in the 8th, 9th and
10th intercostal spaces of
nonmusical and harsh in quality after 3 minute

Mainly inspiratory (can be in expiratory or both). Supine position, It indicates ischemic heart
disease with heart failure
Contd..
 Contd.. Variationsof vocal resonance
Post-tussive Crepitations which are not present Bronchophony ncrease in loudness as wellas clarity of the
crepitations normally but appear after a bout of Sound
cough. Seen in early pneumonia, early Seen in:
tuberculosis and lung abscess Consolidation
Tracheal Rales Usually heard over the trachea or lungs Just above level of pleural effusion
(Death Rattle) in seriously illpatients who are unable to On spine up to T4
cough out their respiratory secretions
Aegophony Selected amplification of high frequency
Stridor: sounds. "E" is heard as "A"
" High-pitched whistling or grating sound which is Seen in:
produced by upper airway obstruction. Consolidation (it is the auscultatory sign of
It is louder over the neck than the chest wall. consolidation)
Mode of production:
Indicates extrathoracic upper airway obstruction (like I Due to interposition of a thin layer of fluid
vocal cord paralysis, supraglottic growths, etc.) between the lung and chest wall, allowing
It usually seen during inspiration, however, can be seen in transmission of overtones but damping off
expiration in intrathoracic tracheobronchial obstruction. lower fundamental tones, or
Pleural rub: Due to partialcompression of lung tissue
underneath the upper part of effusion,
It is harsh discontinuous, localized, nonmusical,
altering the normal relationship between
superficial grating sound due torubbing of the inflamed bronchiand lung parenchyma and thus
pleural surfaces against each other. reinforcing high-pitched nasal sounds
It is heard in both phases of respiration and disappearson Whispering When the whispered sound in the chest wall is
holding the breath. pectoriloquy heard clearly and distinguishably as if uttered
directly into the external ear
Causes: Seen in:
Dry pleurisy I Fairly large cavity in the lung
Consolidation communicating with the bronchus
Infarction Massive ordiffuse consolidation of lung
tissue overlying or adjacent to a bronchus
Differences between pleural rub and crepitations:
Pleural rub Crepitations Other Auscultatory Features
Both inspiratory and expiratory nspiratory/expiratory or both Post-tussive suction:
phases It is a sign of superficial collapsible cavity seen in active
Localized to smallarea Widespread tuberculosis. When you auscultate a cavernous bronchial
May clear after coughing
breathing (which indicates a cavity), ask the patient to cough.
No change after coughing Asuction sound will be heard if the cavity collapses.
Pressure on stethoscope No effect
increases the sound Prerequisites for post-tussive suction:
Associated with pleuritic chest No pain or tenderness Superficial cavity
pain and local tenderness Thin-walled cavity
Has to be communicating with bronchus
Vocal resonance: Surrounding lung should be normal.
Make the patient sit
Place the stethoscope firmly on the chest wall Succussion splash (Hippocrates succussion):
Ask the patient to speak "one-one-one" or "ninety nine" It is seen in hydropneumothorax
repeatedly First percuss and get the air fluid level in hydropneu
mothorax
Comparecorresponding areas anteriorly, in axilla and
Keep the diaphragm at the air-fluid level
posteriorly. Hold the opposite shoulder of the patient and shake
Increased vocal resonance
vigorously as shown in Figure 3D.40.
Vocal resonance Tinkling or splashing sound will be heard.
Increased Decreased Other conditions like large cavity with fluid, diaphragmatic
Consolidation Pleural effusion hernia can also produce succussion splash.
Coin test:
Large cavity Pneumothorax
Bronchopleural fistula Fibrosis High-pitched metallic or tympanic note
Collapse Place one coin flat on affected side of chest (posteriorly/
Asthma anteriorly) and percuss with another coin perpendicularly
Emphysema on it, while simultaneously auscultating from the opposite
Thick pleura direction of the same affected side as shown in Figure 3D.41.
Note: In upper lobe fibrosis, VR is increased due to the pulled trachea. Seen in massive pneumothorax/hydropneumothorax.
 Clinical
An Insider's Guide to H amman's mediastinal crunch:

Loud cracking or clicking sound heard in the 3rd to 5th

intercostal spaces nearthelefttsternal border: synchronous
with the heartbeat.
It is the sign of mediastinal emphysema (pneumo.
mediastinum) or can
also be seen in left-sided
pneu-
mothorax.

Forced expiratory time (FET):

It is a simple inexpensive and sensitive bedside test to
detect airflow obstruction.
Instruct the patienttto inhaleup to the total lung
and then blow it as fast and complete as possible
capacity
Place the bell of stethoscope in suprasternal notch .
time the audible expiration.
value less than 5 seconds indicates FEV1/FVC more
Fig. 3D.40: Demonstration of succussion splash. than 60%, whereas FET more than 6sec indicates FEVI|
FVC less than 50%.

Summary of fndings in pleural effusion based on the severity

Moderate Massive
Mild effusion effusion (300 effusion
Finding (<300 m) 1,500 mL) (>1,500 mL)
Tachypnea No Present Signifcant
Chest Normal Decreased on Significantly
expansion the effected decreased on
side the effected
side
Tactile fremitus Normal Decreased Absent

Breath sounds Vesicular Decreased Absent or

Fig. 3D,41: Demonstration of coin test. bronchial
Contralateral Absent Absent
Scratch sign: Present
trachealor
Used for diagnosis of pneumothorax mediastinal
Patient sitting, place the diaphragm of the stethoscope in shift
the midpoint of sternum or spine Bulging No
" Scratch the chest wall from mid axillary
line towards the intercostal Sometimes Present
sternum on either side. Spaces
Sound will be louder on the side of pneumothorax.
Egophony No
Yes Yes