Examination of the respiratory system: history, pectoral fremitus

Examination of the
respiratory system: history,
pectoral fremitus,
bronchophonia, hemoptoe,
Dr. Gabriella Szőcs, Dr. Zoltán Szabó
Universitiy of Debrecen
Institute of Medicine
Anamnesis - history
History of present illness – presenting
Family diseases
History of past illness
Occupation history
Social history
Drug use - tobacco!
Respiratory system:
Respiratory muscles
CO2 ↔ O2: passive
Presenting complaints
Constitutional symptoms (e.g., fever, weight
loss, fatigue, night sweat etc.)
Shortness of breath, dyspnea
Sputum eg .: Blood-streaked sputum
Chest pain
Breathing is largely an automatic act, controlled in
the brain- stem and mediated by the muscles of
respiration. The dome-shaped diaphragm is the
primary muscle of inspiration.
When it contracts, it descends in the chest and
enlarges the thoracic cavity. At the same time it
compresses the abdominal contents, pushing
the abdominal wall outward. Muscles in the rib
cage and neck expand the thorax during
inspiration, especially the parasternals, which
run obliquely from sternum to ribs, and the
scalenes, which run from the cervical vertebrae
to the first two ribs.
During inspiration, as these muscles contract,
the thorax expands. Intrathoracic pressure
decreases, drawing air through the
tracheobronchial tree into the alveoli, or distal
air sacs, and expanding the lungs. Oxygen
diffuses into the blood of adjacent pulmonary
capillaries, and carbon dioxide diffuses from
the blood into the alveoli.
Chest – abdominal breathing
Inspiration: -9 Hgmm pressure in pleural cavity –
p ↓ air gets into the lungs
Inspiration: shorter, exspiration: longer
Breathes: 16-20/min
500 + 2000 + 1500 + 1500 = 5500 cm3 – total
Central respiratory system: stimulated by CO2
blood CO2 increase – stimulation, decrease inhibition
Normal breathing
Normal breathing is quiet and easy—barely
audible near the open mouth as a faint whish.
When a healthy person lies supine, the
breathing movements of the thorax are relatively
In contrast, the abdominal movements are usually
easy to see. In the sitting position, movements of
the thorax become more prominent.
During exercise and in certain diseases, extra
work is required to breathe, and accessory
muscles join the inspiratory effort.
The sternomastoids are the most important of
these, and the scalenes may become visible.
Abdominal muscles assist in expiration.
Respiration is influenced by:
Acidosis: increases, decreases the
stimulation of the central respiratory
Hypoxia: stimulation
Severe resp. acidosis results in stimulation
of respiratory center by hypoxia, and not
CO2 cc. of blood.
Shortness of breath (dyspnea)
Breathes/min, depth, rythm
Respiratory accessory muscles
Patient’s position
Dyspnea can be physiological: eg.:
physical exercise
Changes in the frequency and
depth of respiration
Polypnoe (eg.: hysteria)
Superficial respiration
Deep respiration (Kussmaul)
Periodic resp. Eg.: Cheyne-Stokes
Usage of respiratory accessory
Neck (m.sternocleidomastoideus)
M.serratus, m. trapezius, mm. pectorales
Abdominal muscles assist in expiration.
Nasal respiration eg.: pneumonia, sepsis
Orthopnoe – most severe cardiac dyspnoe:
patient has to be at a sitting position to breathe
Gasping: poisonings, agony: rare sudden
Shortness of breath (dyspnoe; dyspnea)
Clinical forms:
cardiac dyspnea
Stenosis of upper respiratory tract
Weekness of respiratory muscles
Respiratorc dyspnea
Toxic state: acidosis
Diseases of the central nervous system
Oxigen pressure ↓ in the air
Abnormality of oxigen transport (anaemia)
Shortness of breath (dyspnea)
Inspiration dyspnea
Stenosis of upper respiratory tract
Weekness of respiratory muscles
Exspiration dyspnea
Mixed – cardiac + respiratory + anaemia
etc. – most common form
Respiratory dyspnea
Chest deformity, muscle weekness
Stenosis of upper respiratory tract
Respiratory surface ↓(pneumonia,
diaphragm relaxation, ptx, hydrothorax,
tumor etc)
In clinical practice: 2 main reasons
of dyspnea
Cardiac dyspnea: cardiac failure
Respiratory dyspnea: diseases of the
respiratory system
Very often it is combined: cardioresp.
Productive – improductive
Respiratory inflammation
Bronchitis (bronchiectasia, pneumonia etc)
Pleural diseases
Mediastinal diseases
Cardiac decompensation
Pulmonary infarction
Foreign body
Nervous cough
Reflux disease
Differentiation between certain
forms of dyspnoe
Upper airway stenosis: low frequency of
breathing, inspiratory dyspnoe, stridor
Lower airway stenosis (eg. asthma): it is hard to
exhale, deep breathing
Decrease of airway surface: frequent, superficial
breathing, cyanosis.
Cardiac dyspnoe: frequent, superficial breathing,
cyanosis, difficulties of both inspiration and
Quantity - quality
Pharynx: clear, mucous
Bronchitis: mucous, purulent
Asthma: clear, viscosus
Pneumonia: mucous, purulent, rusty
colored, fresh blood
Pulmonary oedema: foamy white
Bronchiectasia, abscessus: 3 layers –
Lung cancer: bloody
Lung infarction bloody-mucous
Chest pain
of chest pain or chest
discomfort raise the specter of heart
disease, but often arise from structures in
the thorax and lung as well.
Sources of chest pain
The myocardium
The pericardium
The aorta
The trachea and large bronchi
The parietal pleura
The chest wall, including the musculoskeletal
system and skin
The esophagus
Extrathoracic structures such as the neck,
gallbladder, and stomach.
Chest pain
Sharp, increased with inspiration
Neural compression
intercostal nerves, plexus brachialis
Ptx, embolism!
Pectoral fremitus (vocal tactile fremitus)
palpable vibration on the chest
Bronchophonia (vocal resonance)
Abnormal transmission of sounds from the
lung or bronchi detected by auscultation
caused by a solidification of lung tissue
around the bronchii (lung cancer, fluid in the
alveooli, pneumonia, wide bronchii