The respiratory system

History of the patient with respiratory system

disorders

1.Data connected with age:

In childhood, acute infections of the respiratory
airways are more frequent;
Tuberculosis is more frequent with teenagers (the
first bacillary infection);
Bronchic asthma, bronchiectasia, chronic
bronchitis, pneumonia, bronchopulmonary cancer are
more frequent with adults;
Pulmonary emphysema, bronchopulmonary cancer,
bronchopneumonia are more frequent with the elderly.
2. Data connected with gender:

Chronic bronchitis, bronchiectasia, pulmonary

emphysema, broncho-pulmonary cancer are more
frequent in men.

Bronchic asthma, pulmonary embolism (secondary

to thrombophlebitis), tuberculosis are more frequent in
women.
3. Data connected with profession:

Pneumoconiosis is more frequent with miners.

Silicosis and silicotuberculosis are more frequent
with people working in cement factories.
Bronchitis, bronchic asthma and pneumoconiosis
are more frequent with people working in textile
industry.
Respiratory diseases are more frequent with people
working in glass industry, with furnace workers and
with people working in agriculture.
Professional exposure to azbest can favorise
pulmonary fibrosis.
Instrumental musicians are more exposed to
4. Family history:
some diseases, such as bronchic asthma, chronic
bronchitis, pulmonary emphysema, bronchiectasia
or pulmonary cancer can manifest more often in
individuals with genetic predisposition.
allergic bronchic asthma is usually present in
individuals with history of allergy in their family
(allergic rhinitis, Quincke edema)
Cystic fibrosis is hereditary transmitted
(autosomal recessive)
5. Past medical history:
infectious diseases in childhood, such as measles
or whooping cough, can complicate with pneumonia
or bronchopneumonia;
untreated whooping cough can lead to
bronchiectasia in 10-20% of cases;
childhood rickets can lead to thoracic
deformation and then to chronic respiratory failure;
diphtheria or influenza can lead to respiratory
insufficiency by croup or pseudo-croup (obstruction
of the glota by false membranes);
repeated acute bronchitis develop into chronic
bronchitis
History of the first tuberculosis infection, other
tuberculosis lesions, suggest the possibility of
relapse (reactivation).
Pulmonary tuberculosis can develop into
hemothorax or can determine pleural effusion,
empyema.
Chronic bronchitis and pulmonary emphysema
can evolve into a chronic obstructive pulmonary
disease and then into chronic cor pulmonale;
Pneumonia can complicate with pleural effusion
and if the cure is vicious it can lead to pahipleuritis
or pleural simphises.
The traumas of the thorax can develop into
hemothorax and pneumothorax.
Diabetes mellitus creates favorable conditions
for the onset or aggravation of pulmonary
tuberculosis.
Mitral stenosis, because of stasis in the lungs
and pulmonary hypertension can determine
haemoptysis.
6. Social history
Chronic alcoholism, carential alimentation,
overcrowded living conditions decrease the
capacity of defense of the body and favours
pulmonary tuberculosis
House dust, animal fur, pollen from the
apartment plants can trigger an asthma crisis
Smoking can lead to chronic bronchitis and
amplifies the risk of lung cancer
Pollution from the large urban, industrial
centers favourise acute and chronic bronchitis
and can also trigger asthma crisis
7. History of the present illness
The onset of respiratory diseases can be acute,
super-acute or perfidious (insidious).
Acute onset:
pneumonia; ex: pneumococcal
pneumonia shiver, fever, chest pain, dry cough
followed by expectoration of rusty sputum.
acute bronchitis
influenza
pleural effusion
some forms of tuberculosis
Super-acute onset (brutal):
pulmonary embolism
pneumothorax (violent chest pain,
accentuated dyspneea)
Perfidious onset (insidious, slowly):
chronic bronchitis
bronchopulmonary cancer
bronchiectasia
pulmonary emphysema
some forms of pulmonary tuberculosis.
 General Symptoms
Fever
mild fever: pleural or pulmonary tuberculosis,
broncho-pulmonary cancer
intermittent (suppuration, tuberculosis)
recurrent (cavitary tuberculosis)
irregular (chronic pulmonary suppuration)

Shiver
single, solemn shiver (with a maximum
duration of 1/2h) in lobar pneumonia;
repeated and intense shiver (tuberculosis,
abcesses, pleuritis).
 Sweat
all feverish pulmonary diseases;
during night time in tuberculosis.
Anorexia and loss of weight
tuberculosis
broncho-pulmonary cancer
bronchopulmonary suppuration.
 Local symptoms
Chest pain
It is a subjective manifestation;
The pain may be connected with the thorachic
wall, the vertebral column, the pleura, the heart and
the large vessels, esophagus, mediastinum or with
abdominal organs.
It may be felt as a diffuse, violent pressing, burn or
constriction.
1.Parietal causes
-Zona zoster: vesicular eruption on the intercostal
nerve tract, surrounded by a red erythema, preceded
and followed by intense pain
-Dermatomiositis: polymorf eruption associated with
a rough, painful edema of the muscles in that area.
- Cellulitis: inflammation of the adipose tissue,
accompanied by edema.
- Trichinosis: helminthiasis characterized by fever,
eosinophilia and thoracic pain; the final diagnosis is
made by muscle biopsy.
- Thoracic trauma: rib fractures chest pain associated
with polypneea and bone crepitations.
- Diseases of the mammary gland: mastitis, breasts
cysts, breast cancer.
- Osteitis and periostitis (lues, tuberculosis).
- Intercostal neuralgia : pain in Valleix points (located
along the intercostal area paravertebral, axillar,
parasternal).
- Tietze syndrome : painful tumefaction of the condro-
costal joints of the ribs 1 and 2, and more rarely ribs 3
and 4; usually the disease is unilateral.
2. Vertebro-medular causes
- Vertebral tuberculosis (Potts disease)
- Spine cancer (progressive pain), osteomyelitis;
spondylosis
- Hernia of an intervertebral disc (compression of the
nerve in the conjugation hole)
- Tabes (chronic luetical meningitis involving the
posterior root of the spinal nerves with painful crisis)
3. Respiratory causes
Characteristics of the pain
- felt like a dagger in the thorax
- stronger during respiratory movements,
coughing and pressing
- on the involved side, the respiratory
movements are superficial and the patient will lay
down on the opposite side.
Causes
- Dry pleurisy or pleuritis: lancinating, sharp, unilateral
pleuritic pain which is felt over the involved area. The
patient will lay down on the opposite side in order to
avoid pressure on the involved side. The pleuritic pain
disappears when the pleural effusion appears.
- Pleural effusion: the patient will lay down on the
involved side to permit the uninvolved side to have an
more amplified inhaling.
- Purulent pleurisy: violent pleuritic pain and a very
sensitive hemithorax. The patient will lay down on the
opposite side.
- Diaphragmatic pleurisy: very violent pleuritic pain,
sometimes unbearable, located at the diaphragmatic-
costal insertion and affecting the intercostal and the
phrenic nerve; sometimes the pain can radiate in the
abdomen;
phrenic neuralgia is characterized by hyper
sensitivity when pressing the following areas:
- scalen spot (between the 2
sternocleidomastoidian ends)
- parasternal points
- diaphragmatic button (at the junction
of the middle of the breast bone with the extension of the
- Interlobal pleurisy: chest pain along the lung cleavage
(scarf pain)
- Pneumothorax: very violent, dagger-like sensation,
associated with anxiety, cyanosis, dyspneea, weak and
frequent pulse, diminished vesicular sounds and
characteristic modifications on the chest x ray.
- Lobal pneumonia: localised in the nipple region, lasting 2-
3 days and then disappearing;
- Pulmonary embolism: strong, violent pain, like a dagger,
dyspneea, cough, cyanosis, tachycardia, lypothymia and
syncope.
- Pulmonary cancer: progressive pain, which in advanced
stages becomes unbearable, doesnt respond to common
medication; the site depends on the size and location of the
-Pancoast Tobias syndrome (syndrome of the
pulmonary peak):
malignant tumor of the lung apex which
infiltrates the nervous plexues and the large vessels.
asthenia, anorexia, subfeverishness, dry cough,
hemoptysis, cyanosis
it can be associated with Claude Bernard-
Horner Syndrome (enophtalmia, miosis resulting from
cervical sympathic compression).

4. Cardiovascular causes
- Pain usually appear in the precordial and
retrosternal area: chronic ischemic cardiopathy,
exertional and decubitus angina pectoris, myocardial
infarction, dissecting aortic aneurysms, pericarditis.
.
6. Abdominal causes
Phrenic abscess; inflammation of the colon
flectures; billiary lithiasis, spleen diseases.

7. Mediastinal causes
Mediastinitis, mediastinal tumors are associated
with cyanosis, rain coat edema, collateral circulation.
 Dyspneea

Definition
difficult breathing
the main symptom of a respiratory insufficiency
its manifestations are objective and subjective
subjective: thirst for air and objective: forced
respiratory movements
Classification
a)Depending on frequency
- polypneea (tachypneea) an increase in the
respiratory frequency per minute
- bradypneea: a decrease in the respiratory
frequency per minute
Normal frequency: 16-18/min.
b) Depending on amplitude:
- hyperpneea: an increase in the breathing
amplitude
- hypopneea: a decrease in the breathing
amplitude
c) Depending on the phase of respiration
- inhaling dyspneea
- exhaling dyspneea
- mixted dyspneea
d)Modifications in the respiratory rhythm:
Cheyne-Stokes breathing
Kussmaul breathing
Biot breathing
e) Depending on conditions of appearance
- exertional dyspneea
- rest dyspneea
f) Depending on timing and onset
- paroxysmal dyspneea (bronchic asthmatic crisis,
cardiac asthma, acute pulmonary edema, left heart failure)
- vesperal dyspneea (it appears in the evening left
ventricular failure)
- acute dyspneea (upper respiratory ways
obstruction, acute pneumopathies, pneumothorax,
pulmonary infarction, acidosis)
- dyspneea with a slow evolution (chronic
inflammation of the respiratory ways, pulmonary tumors,
pulmonary emphysema)
 Accelerating rhythm dyspneea -Polypneea
(tachypneea)
- physiological (emotions, physical exercise)
- pathological
a) feverish conditions when the high
temperature of the circulating blood excites the respiratory
centers
b) diseases which lead to a decrease in the
amplitude of respiratory movement (intercostal neuralgies,
costal fractures, cifoscoliosis, respiratory muscles
paralysis)
c) diseases which lead to a decrease of the
lungs breathing area (pulmonary embolism, pulmonary
edema, pleural effusions, pneumonia, pulmonary tumors)
d) large bleedings, CO intoxication
e) diseases of the cardio-vascular system
f) intraabdominal processes that limit the
diaphragmatic excursions (ascites, tumors)
 Thining out rhythm dyspneea- Bradypneea
It may be:- inhaling, exhaling, mixed .
a)Inhaling bradypnoea: decrease in the upper respiratory
ways calibre, leading to obstructive ventilatory disturbances.
Causes
- internal obstacles: the vocal cordes paresis, croup,
pseudocroup, glotic oedema, laryngeal tumours.
- external compression: neighbouring tumours,
mediastinal tumours
Accessory inhaling muscles are involved and this leads to
an ortopneea and a prolonged and deep inhaling
accompanied by a sound that is called pathological wheezing.
In severe obstruction, in spite of the effort, only a small
quantity of air comes in, therefore the inter-alveolar pressure
is lower than the atmospheric pressure, phenomenon that
leads to the retraction of the tissue parts during inhaling; this
is called draught.
b) Exhaling bradypneea - an obstacle stops the evacuation
of the intrapulmonary air, creating a whistling sound
called wheezing.
Causes : - bronchic asthma in crisis
- chronic obstructive pulmonary disease (chronic
bronchitis and pulmonary emphysema).
Typical example: asthma in crisis- sudden onset,
frequently at night, suffocating sensation, prolonged
exhaling, ortopneea, associated with anxiety, cyanosis.
Initially, dry cough, then mucous sputum, pearl-like
aspect.
The mechanism of bronchic obstruction in asthma: edema,
bronchospasm, hypersecretion.

c) Mixed bradypneea: tracheal disorders (tumors).

 Dyspneea with modifications in the respiratory rhythm
a)Cheyne-Stokes breathing
- respiration with a progressive increased frequency; a
superficial breathing which goes to a maximum limit, then the
respiratory movements progressively thin out to a complete
apneea of 5 - 20 seconds, after that the cycle is repeated.
- mechanism: decrease in the excitability of the respiratory
centers, phenomenon which produces apneea, followed by a
loading with CO2 of the blood, which determines a reactivation
of the respiratory centers with a progressive hyperpneea in
order to eliminate the CO2 excess in the blood through the
alveolar air.
- causes: cerebral atherosclerosis, cerebral tumours and
hemorrhages, meningitis, left ventricular failure, during
profound sleep in elderly.
b) Kussmaul breathing
- deep and noisy breathing with a frequency of 9
10 breathings per minute, followed by apneea
- causes: agony, diabetic acidosis, uremic and
hepatic coma, methanol intoxication.
c) Biot breathing
- irregular type of breathing
- irregular and unpredictable rate, rhythm, and
depth, usually slow rate
- causes: agony, cerebral tumours, meningitis,
vascular diseases that affect the respiratory center.
 Coughing
The coughing reflex
- is a normal defense mechanism of the
lungs that protects them from foreign bodies and excessive
secretions.
- has the following components: starting
point, centripetal ways, centers, centrifugal ways.
The starting point: the coughing areas located in the
tracheal crossroad and big bronchi. The receptors can be
stimulated by inflammatory, mechanic, chemical, thermal,
psychic stimulii.
Centripetal ways - sensitive branches of the
pneumogastrical, trigeminal and glosopharyngeal nerve.
Coughing center is located in the rahidian bulb.
Centrifugal ways are: spinal marrow, motor rahidian nerves
which lead the activity of the respiratory muscles.
Coughing can be:
productive of sputum because of hypersecretion:
- in acute tracheo- bronchitis, broncho-
pneumonia and pneumonia, bronchiectasia,
tuberculosis, abcesses.
- more frequently in the morning and it
appears more often when changing the attitude.
- the secretion irritates the coughing areas
and leads to the expectoration of the sputum.
- the patients suffering from bronchiectasia
experience a chronic morning expectoration of a great
amount of sputum called bronchial toilet.
dry coughing: it is a cough without expectoration
with a different timbre. It appears in laryngitis, in the
early stages of acute bronchitis or tuberculosis,
pneumothorax, mediastinal tumors, pulmonary cancer,
Particular forms:
Slow cough, progressive in adults and elderly is
believed to result from intrabronhial tumors.
The methalic like timbre and very noisy cough
results from irritation or paralysis of reccurent
nerve.
Emetizant coughing a very intense cough, that
triggers the vomiting reflex appears in
whooping cough, severe tuberculosis.
In pulmonary infarction - rebel cough,
productive of adherent, viscous sputum with
hemopthysis.
Epiglottal diseases cause barking - like cough.
Accidents caused by coughing:
Bleedings (epistaxis, hemoptysis, meningeal bleeding)
Spontaneous pneumothorax (rupture of the alveolas next to
the pleura)
Rib fractures
Involuntary loss of urine in elderly
Hernias, genital prolapse

Expectoration
- consists of the oral elimination of pathologic secretions
accumulated in the respiratory ways, during the coughing
process
- the product of expectoration is the sputum
Sputum results from:
mucous and serous gland secretions which
develop in inflammation and bronchic asthma.
exudation :inflammation of the aveolas and of the
bronchi which appears in pneumonia and broncho-pneumonia.
transudation which appears in acute pulmonary
edema and in congestive heart failure
blood resulting from pulmonary distruction
foreign bodies
saliva
nasal pharyngeal secretions
pathological collections in the pleura, mediastinum
or subdiaphragmatic collections which open in the respiratory
ways (vomica)
The sputum has a great diagnostical value:
Rusty, brownish sputum appears in lobal pneumonia.
Cranberry jelly - like sputum appears in the
pulmonary cancer.
Rich, purullent sputum appears in bronchiectasia.
Fetid sputum appears in pulmonary abscess and
gangrene.
Macroscopically we describe the quantiy, aspect, colour, smell.
a) The quantity depends on the nature of the pathological
process, the evolution of the disease, the intensity of the cough
and the efficiency of the treatment.
- rich sputum :bronchiectasia, pulmonary
tuberculosis, abscess, pulmonary gangrene, acute pulmonary
edema, purulent pleurisy, hydatic cyst which opens in the
respiratory ways
- reduced sputum: early stages of acute
tracheobronchitis, early stage of tuberculosis, bronchic asthma
Vomica
represents the sudden and rich expectoration
resulting from the opening in the airways of a collection
situated in the pulmonary parenchyma (pulmonary abcess,
cavitary tuberculosis, hydatic cyst), pleura (purulent
pleurisy) or the neighbouring organs (subphrenic or
mediastinal abcess).
it is preceded and accompanied by coughing
it can be massive, medium and low; unique or
fractionary; purulent or spring water like.
Massive vomica appears in large pulmonary abcesses,
purulent pleurisy, hydatic cyst and is associated with
cyanosis, asphyxia sensation, anxious facies.
b)The aspect
- mucous sputum: viscous, adherent, well aired, formed
from the mucine of the secreating glands.
appears in: acute bronchitis, bronchic
asthma, pneumonia, early pulmonary tuberculosis; in bronchic
asthma, at the end of the crisis it presents small, opalescent
sediments, called pearled expectoration , accompanied by
spiral filaments called Curschmanns spirals.
- muco-purulent sputum: yellowish or greenish blend of
mucus and pus. It appears in: acute bronchitis, pneumonia,
broncho-pneumonia, bronchiectasia, cavitary pulmonary
tuberculosis.
- purulent sputum: yellow-greenish cream - like sputum.
It appears in chronic bronchitis, bronchiectasia, pulmonary
abcess, cavitary pulmonary tuberculosis. In case of vomica,
this will consist of pus.
- serous sputum: transparent, white - pink foaming
sputum. It appears in pulmonary edema, left ventricular
 - sero-muco-purulent sputum: a blend of serosity, pus
and mucus. It appears in fetid bronchitis, pulmonary gangrene
and is characteristic for bronchiectasia. This sputum has four
layers: foaming, serous, muco-purulent and purulent (rough-
grained).
- pseudo-membrane like sputum: liquid part in which
solid bodies float; very rich in fibrine that coagulates and
forms pseudo membranes: diphteric croup, pseudo membrane
like chronic bronchitis
- sanguinolent sputum: blend of mucous, serous,
purulent secretions in which variable quantities of blood
appear. It appears in pneumonia, acute pulmonary edema,
bronchopulmonary cancer, pulmonary gangrene.
c) The colour:
white (mucous secretion), yellow-greenish (purulent
secretions), pinky (serous secretion), reddish (hemoptoic
secretions), rusty, brownish sputum (lobal pneumonia)
 - red, adherent sputum (pulmonary infarction)
- cranberry jelly - like sputum (broncho-pulmonary
cancer)
- brownish sputum (pulmonary gangrene)
- black sputum in people working in coal mines.
d) The smell
It does not usually smell.
The sputum can have a fetid smell in bronchiectasia,
pulmonary abcess, pulmonary gangrene.
 Hemoptysis
elimination of blood at the level of the respiratory system.
mechanism: breakage or ulceration of a vessel;
blood diapedesis at the surface of the pulmonary
alveolas or in the bronchi.
the differential diagnosis is made with posterior epistaxis,
stomatorahia, hematemesis.
the blood in hemoptysis is red, rutilant, aired, partially
uncoagulable, covered by a thick layer of sputum. This appears
in patients who have suffered of respiratory diseases before.
the blood in hematemesis comes from a patient suffering
from a digestive disease, is coagulated and unaired
hemoptysis is accompanied by a retrosternal warming
sensation, diziness, respiratory uneasiness, cough.
the patient is pale, anxious, experiencing cold sweat,
dyspneea, tachycardia, lipothymia.
large hemoptysis are lethal by asphyxia and shock.
Causes:
- Respiratory diseases: pulmonary tuberculosis, broncho-
pulmonary cancer, bronchiectasia (repeated haemoptysis),
pulmonary abcess and gangrene, acute tracheo-bronchitis (it
appears in violent cough), thoracic traumas, hydatic cyst,
pulmonary infarction, traumas.

- Extra respiratory diseases: mitral stenosis (by

pulmonary hypertension), arterial hypertension, aortic
aneurism opening in the respiratory ways (lehal usually),
bleeding disorders, vicariant hemoptysis (during the menstrual
periods in women with hyperfoliculinemia).
 THE PHYSICAL EXAMINATION OF THE
RESPIRATORY SYSTEM
General examination - The Attitude
In pleuritis the patient takes the position of contralateral
decubitus antalgic position.
In pleurisy the patient takes the position of homolateral
decubitus antidyspneeal position.
In bronchic asthma, acute pulmonary edema, massive
pneumothorax, the patient takes the ortopneea position
In bronchiectasia, the patient will lay on the same side as the
bronchial dilatation thing which will disfavour the secretions
drainage to the coughing areas - an anticoughing position,
patients suffering from dyspneea caused by respiratory diseases,
present a modification in mobility determined by the severity of the
dyspneea:
- in case of moderate dyspneea the patient will move
normaly.
- in case of severe dyspneea there appears a breathing
 Facies

vultuos facies - in pneumonia the facies is of a strong

red colour, with shining eyes because of the fever.
the doll face (phtysical beauty) - in tuberculosis -
pale face and red cheeks, which is more accentuated on the
tuberculose lung side.
a pale face with an earth - like hue in pulmonary
suppuration (bronchiectasia, pulmonary abcess, pulmonary
gangrene).
infants suffering from bronchopneumonia - the beating
of the nasal wings.
inequality of pupils in malignant tumor of the
pulmonary apex.
cyanotic, bloated face with raincoat edema in superior
vena cava compression syndrome (compression by a
mediastinal tumour, important adenopathies - pulmonary
 Ocular Modifications In Respiratory Diseases
iridocyclitis involves modifications at the level of the
anterior pole of the eye. It appears in pulmonary tuberculosis,
sarcoidosis.
modifications which belong to Pancoast-Tobias
syndrome are typical for the pulmonary cancer of the peak
(lung peak)
- pains in the shoulder
- the atrophy of the hand
- the swelling of the supraclavicular area on the
affected side.
- Claude-Bernard-Horner syndrome involves
three ocular signs:
the narrowing of the palpebral slit,
enophtalmia (plugged ocular globe)
myosis.
 Teguments, Mucous Membranes

generalised cyanosis of central type - obstructions of

the upper or lower respiratory ways, pleuro-pulmonary
pathologic processes which reduce the ventilation area
localised cyanosis of peripheral type in patients
experiencing compressive mediastinal process
red-violet coloured skin, especially on the face in
chronic sufferings such as emphysema, pulmonary sclerosis
with secondary polyglobulia
paleness after severe hemophysis
eruptions that can be linked to respiratory diseases:
- labium herpes appears frequently in pneumonia
- erythema nodosum hypodemic nodules of red
violet colour, located exclusivelly on the shank, with pressure
sensitivity; they appear in sarcoidosis, primo-infection
tuberculosis
 Collateral circulation: raincoat edema secondary to
superior vena cava obstruction is associated with superficial
circulation (venectasia) on the anterior and lateral side of
thorax, especially in the superior area.

Nails
Clubbing fingers are present in the following respiratory
diseases:
pulmonary tuberculosis
broncho pulmonary cancer
bronchiectasia
pulmonary supuration, pulmonary sclerosis
empyema
 The Subcutaneous Cellular Tissue
generalised edema (anasarca) appears in cardiopathy,
nephrotic syndromes; liquid is present also in the pleural
cavity - hydrothorax.
raincoat edema appears in the obstructions of the superior
vena cava by an expanding mediastinal process
Quincke edema and bronchic asthma are both allergic
processes in which the target organ is different.
In Quincke edema the target is on the tegumentary and
subcutaneous cellular tissue, while in bronchic asthma it is at
the bronchiole level.
This is why there appear allergic symptoms.
The Physical Examination of the Upper Respiratory Ways

The nostrils:
The most important thing to be observed is the nasal
obstruction. The patients will breath orally, this being a
very important aspect, because the air is warmed and
purified in the nose.
The nasal voice:
In order to determine the obstruction examiners ask the
patient to breathe nasally while pressing alternatively
the nostrils. The nature of the obstacle will be
determined with the nasal speculum.
The sinuses:
They can be the source of an inflammation which may
result in a frontal headache. It is termed sinusitis. If
vivid sensitive reaction results when pressure is applied,
acute sinusitis is suggested.
 The Physical Examination of the Trachea

It is accessible only in the first segment.

The palpation:
The examiner is situated in front of the patient; he
introduces his finger in the jugular fosseta and he
palpates the tracheal rings in order to identify them
and to determine their consistency and the position of
the trachea.
The pleural pulmonary pathologic processes can deviate
the trachea.
The timus pushes the trachea on the opposite side.
The adherences pull the trachea on the same side
 The Physical Examination of the Thorax

1.INSPECTION
Teguments for colour, scars of previous heart or lung
surgery; swellings, marks and spots on the skin (eruptions,
collateral circulation, edema)
Thorax conformation (normal, deformed)
Respiratory type
The frequency and amplitude of the respiratory movements
Modification of the thorax during respiration
-
Thoracic teguments examination
- vesicles in the intercostal area suggests zona
zoster.
- tiny vein dilatation on the top of the thorax in
pulmonary peaks tuberculosis.
- located edema with a bucket appears in deep
suppurations (empyema).
 Thorax conformation
Normal:
the xiphoid angle is of ninety degrees
the antero-posterior diameter is smaller than the
transversal one.
the vertebral column has a very slight curve with an
anterior concavity (physiological ciphosis).
the supraclavicular and subclavicular fossi are not
encaved nor protruding.
the ribs are bent anteriorlly and downwards.
Thoracic deformations:
bilateral (symmetrical and asymmetrical)
unilateral.
a) Bilateral Symmetrical Deformations
The emphysematous thorax: The thorax is dilated and rigid
like a barrel (always while inhaling) with an antero-
posterior diameter bigger or equal to the transversal one;
The ribs are horizontal, the supra and subclavicular areas
protrude; Xyphoid angle is larger than ninety degrees, and
the respiratory movements are very weak.
The paralytic thorax: The antero-posterior diameter is smaller
than the transversal one; The xyphoid angle is under ninety
degrees, the supra/subclavicular areas are deepened. Most
of the cases are congenital, but it can be secondary to
tuberculosis.
The conoid thorax: The lower part of the thorax is very dilated
due to a hepato or splenomegaly or an ascitis.
The adenopatic thorax: The ganglion growth results in the
dilatation of the upper part of the thorax..
Pectus excavatum (funnel chest) = localized depression of the
lower end of the sternum or depression of the whole length of
the sternum.

Pectus carinatum (pigeon chest) = a localized prominence of

the sternum and adjacent costal cartilages often accompanied
by indrawing of the ribs to form symmetrical horizontal
grooves ('Harrison's sulci') above the costal margin, caused by
severe and poorly controlled childhood asthma, osteomalacia
and rickets.

The rickety thorax: Appears in the rickets, the sternum is

protruded, the thorax seems twisted laterally; along the
sternum, thickenings develop, which are called costal rosary.
b) Bilateral Assymetrical Deformation
They are determined by the modifications of the vertebral
column
Kyphosis represents the curving of the column in a sagitta
plan, with a forward concavity. When it is very accentuated it is
called guibus (huntch back).
Lordosis the concavity is posterior.
Scoliosis lateral deformation of the column.
These modifications appear as a result of rickets, vertebral
tuberculosis, vicious position of the body in childhood.

c) Unilateral Deformations
-Retraction: pachypleuritis, massive atelectasis (the lack of air
in the thorax), extensive pulmonary fibrosis.

- Protruding or distension thorax: massive

pleurisy,pneumothorax, massive intrathoracic tumors.
 Respiratory type
Normal:
In men the breathing is performed using the lower
part of the thorax and the abdomen.
In women the respiration is performed using the
upper part of the thorax.
Pathological:
Men breathe with the upper thorax in case of the
existance of pleuro-pulmonary processes of the basis
(pleurisy, pneumonia) or abdominal tumours, ascitis,
uni/bilateral diaphragmal paralysis.
Women breathe with the lower side of the thorax in case of
pathological processes that interest the upper part of the
thorax or in rib fractures at this level.
The frequency and amplitude of the respiratory movements
Normal both hemithorax participate simetrically, equal to the
respiratory movements.
- frequency: 16-18 resp/min
- the amplitude depends on frequency (low when high
frequency and viceversa)
Pathological:
- amplitude is reduced - bilateral in the case of bilateral
pulmonary emphysema.
- unilateral if a main bronchi is
obstructed and the lung does not receive air, pachypleuritis,
massive pleural collections, intercostal neuralgia
Modification of the thorax during respiration
Expansion during exhaling : general expansion in emphysema
localised expansion empyema in
which the pus creates a fistula and passes in the subcutaneous
tissue during exhaling
Retraction during inhaling (supraclavicular fossae, intercostal
Extreme increases in inspiratory work of breathing - negative
pleural pressure: may be manifested by inspiratory retraction of the
suprasternal or supraclavicular notches or the intercostal spaces.
 2. PALPATION
Technique:
- patient in sitting position, the thorax uncovered, hands
on the knees, head flected anteriorlly, shoulders down.
- applying the palmary side of the hands simmetricaly
on the thorax from upward-downward, on the anterior, the
posterior and lateral side of the thorax
Palpation is used to assess the following:
-Teguments temperature, humidity, elasticity
- Areas of tenderness, bone crepitation (rib fractures)
- Reveals the presence of chest wall edema,
subcutaneous emphysema
- Symmetry of chest excursion
- Tactile fremitus
 Palpate for Tenderness
With your fingers, firmly palpate any chest areas where tenderness is
experienced by the patient. A complaint of chest pain may be
related only to local musculoskeletal disease and not to disease of the
heart or lungs.
Evaluate Posterior Chest Excursion
The examiner can determine the degree of symmetry of chest
excursion by placing his or her hands flat against the patients back
with the thumbs parallel to the midline at approximately the level of
the 10th ribs and pulling the underlying skin slightly toward the
midline.
The patient is asked to inhale deeply, and the movement of the
examiners hands is noted.The hand movement should be symmetric.
Reduced expansion - on one side indicates:
pleural effusion, lung collapse, pneumothorax, unilateral fibrosis.
- bilateral reduction in chest
wall movement is common in advanced COPD and diffuse pulmonary
fibrosis.
A, Placement of the examiners hands during normal expiration.
B, Placement ofthe examiners hands after normal inspiration
 Evaluate Tactile Fremitus

Speech creates vibrations that can be felt when the examiner

palpates the patients chest wall.
Sound is conducted from the larynx through the bronchial tree to
the lung parenchyma and the chest wall.
These vibrations are termed vocal fremitus, pectoral fremitus,
tactile vocal fremitus.
Tactile fremitus provides useful information about the density of
the underlying lung tissue and chest cavity.
Ask the patient to pronounce 33 (romanian patient) or 99,
while palpating symmetrical regions from the pulmonary apex
to the basis.
a) Increased tactile fremitus:
- consolidation of the pulmonary parenchyma (pneumonia,
pulmonary tuberculosis, pulmonary infarction, tumors);
conditions: permeability of the bronchi and the consolidation
superficially situated
- presence of pulmonary cavities (cavitary tuberculosis,
drenated abcess, empty hydatic cyst, bronchyectasia)

b)Decreased tactile fremitus

Partial obstruction of the bronchi: foreign body, tumor,
secretions
Interposition between the lung and the chest wall of a
medium that makes difficult the propagation
- moderate pleural effusion
- partial pneumothorax
- pahipleuritis
 Chest wall thickening (muscle, fat)
Laringeal diseases: vocal cords paresis, laringitis

c) Abolished tactile fremitus

Complete obstruction of the bronchi or compression by
tumors, adenopathies
Massive pleural effusion, massive pneumothorax
 3. PERCUSSION

The percussion of the respiratory system consists

of provoking vibrations in organs and tissues by the
repeated knocking on the surface of the body in order
to estimate on acoustic basis the physical condition of
the organs.
The initiators of this technique are Auerburger
(1722 -1809) and Pioline.
The last one used a digital-digital percussion (the
indirect method), in which one of the fingers acts as a
pleximeter and the other one acts as a hammer.
The obtained sounds must be analysed taking into
account the following: intensity, tonality, timbre .
 Percussion over a structure containing air within a tissue,
such as the lung, produces a resonant, high amplitude, lower
pitched note.
Percussion over a solid organ, such as the liver, produces a
dull, low-amplitude, short duration note sound without
resonance.
Percussion over a hollow air-containing structure, such as the
stomach, produces a tympanic, high-pitched, hollow-quality
note.
Technique:
- the examiner places the middle finger of one hand firmly
against the patients chest wall, parallel to the ribs in an
intercostal space
- the tip of the right middle finger of the other hand strikes a
quick, sharp blow on the left finger on the chest wall.
- the motion of the striking finger should come from the wrist
 Pulmonary resonance
The maximum intensity is on the anterior side, in the 2 3
intercostal areas.
At the percussion of the breast bone, a resonant sound can
be heard in the superior third part. The breast bone acts here as
pleximeter.
Pulmonary resonance is closely linked with:
- the physical condition of the vibrating organ or of the tissue.
- the shape and the resilience of the thorax (infants show a more
intense pulmonary resonance than adults do)
- the quantity and the pressure of the pulmonary air and the
extension of the surface vibrating by means of the power of the
percussion.
For example: at moderate percussion there is a surface of 2 - 5
cm vibrating and 5 - 7 cm depth.
This means that there will be discovered by percussion those
pleuro-pulmonary lesions that are accessible as depth and those
that influence the quantity or the pressure of the intrapulmonary
Percussion can be: a). Comparative
b). Topographical
a). The percussion of several anterior and posterior symmetric
areas
b). The delimitation by percussion of two different organs. (e.
g. the inferior side of the lung from the liver, the inner side
of the lung form the spleen).
The inferior limits of the pulmonary resonance (5 - 6 - 6 - 7
- 10)
- parasternal, the superior edge of the 5th rib;
- medioclavicular, the inferior limit of the 6th rib;
- axillar, the 7th rib;
- posterior, the 10th spinal vertebra
On the right it leaves space for the hepatic dullness, while on
the left, from the 4th rib to the 6th, the pulmonary
resonance is replaced by cardiac dullness.
From the 6th rib downwards, the stomach is situated and there
a tympanic sound will be obtained.
Laterally, on the left side, from the 9th rib down, the spleen
 Evaluate Diaphragmatic Movement

Percussion is also used to detect diaphragmatic movement.

The patient is asked to take a deep breath and hold it.
Percussion at the right lung base helps determine the lowest
area of resonance, which represents the lowest level of the
diaphragm.

Below this level is dullness from the liver. The patient is then
instructed to exhale as much as possible, and the percussion
is repeated.

With expiration, the lung contracts, the liver moves up, and
the same area becomes dull; that is, the level of dullness
moves upward.
Pathological situations:
a) the lowering of the inferior edge of the pulmonary
resonance:
pulmonary emphysema (alveolary distension)
bronchic asthma during crises (hyperinflation)
bronchiolitis
b) the ascending of the inferior edge of the pulmonary
resonance:
- unilateral: pleurisy, hepathomegaly, splenomegaly,
diaphragmatic hernia.
- bilateral: ascitis, severe meteorism, advanced
pregnancy
c) the diminished or abolished active mobility
- bilateral: pulmonary emphysema, generalised
peritonitis.
- unilateral: pleural effusion (exudate), pahipleuritis,
tumours
Dulness appears in:
- modifications in the thoracic wall- obesity, tumours
- the interposition of a non-containing air medium
between the lung and the thoracic wall
- pulmonary parenchyma without air (pneumonia,
pulmonary infarction, tuberculosis, atelectasis, pulmonary
cancer, pulmonary abcess, hydatic cyst).
Pleural diseases with dullness
a) The exudative pleurisy
- dullness depends on the quantity of pleural liquid
- when effusion exceeds 200 ml, we have subdullness
combined with dulness in the inferior pulmonary region
- in moderate pleurisy, the superior limit of the dullness
draws a curved line called the Damoiseau line
- when the liquid is abundant, the superior edge is a
horizontal line
- the pleural effusion compresses the neighbouring parenchyma,
resulting in its relaxation in the pleurisy proximity area; the
result of the percussion is called skodism (tympanic sound)
- the massive pleural effusions displace the adiacent organs (the
heart, the mediastinum)
- if the healing process is defective, the pleural layers get thick,
leading to persistent dulness or subdullness

b) Hydrothorax (transudate)
-Appears in heart failure, renal syndromes (nephrotic)
-The presence of a small quantity cannot be proven by
percussion
-Usually bilateral
Differential between pleurisy and hydrothorax
in pleurisy the superior limit of dullness is not changed
by the patient position because of the adherences
the adiacent organs are not dislocated in hydrothorax if
bilateral
c) Hemothorax the presence of blood in the pleura (thoracic
trauma, costal fractures, pleural puncture, aorta aneurysm
broken in the pleura, bleeding disorders)
d) Pneumo or pio pneumothorax the presence of air in the
pleura
- the air entrance is
acompanied by germs which leads to inflammation, with the
appearance of a pleural effusion; suprainfection leads to
piopneumothorax
e) Pleural tumours (benignant or malignant)
They influence dullness on a limited region
At this level, the vocal fremitus is abolished and a respiratory
immobility of the affected hemithorax is experienced
In malignant tumours, a pleural effusion appears.
f) Pleural thickening, pahipleuritis
- They determine costal and mediastinal retractions, scoliosis
abolished vocal fremitus, dullness, respiratory silence.
Pulmonary diseases with dullness
a) Infiltrating processes lobal pneumonia, bronchopneumonia
pulmonary tuberculosis, pulmonary infarction, pulmonary
tumours.
Pneumonia
-Very abundant exudation that fills the involved alveolas and
generates dullness + augmentative vocal fremitus
- The pneumonic lobe generates compression on the
neighbouring lobe, which will be relaxed, determining skodism
- The dullness is not as resistant as in pleurisy

Pulmonary tuberculosis
- Over 50% of cases are located apically and subapically

Pulmonary infarction
-It generates dullness if the infarcted area is superficial

Pulmonary tumours
-A tumour is a compact tissue without air
- They generate variable dullness or subdullness with great
Pulmonary cavities
(tubeculose cavities, abcess, pulmonary gangrene, hydatic cyst)

-If they have a liquid content and if they are superficial

situated, they generate dullness
- After the evacuation of the liquid, tympanism is obtained

b)Atelectatic processes the dullness appears when air is

completely reabsorbed.

The pulmonary hyperresonance

-Intermediary sound between resonance and tympanism
-Bilateral hyperresonance:
emphysema
bronchic asthma in crisis
acute pulmonary edema
Localised pulmonary hyperresonance
in the vicinity of massive infiltrations, large pulmonary
tumours, pleural effusions
abdominal diseases that move upward the diaphragm
(hepatosplenomegaly, ascites, tumours)
The tympanic sound
- Bronchiectasia
- Pulmonary cavity: tuberculosis, abcess, pulmonary
gangrene, pulmonary hydatic cyst
 4. THE AUSCULTATION
The tubar murmur and the vesicular breath represent the
fundamental breathing. The respiratory system comprises
fundamental breathing and added sounds.

The tubar murmur

It can be obtained by the mouth modelling for the
pronunciation of the letters h, and g, accompanied by
deep inhaling and exhaling.
It has high intensity and tonality.
When exhaling the tubar murmur lasts longer, it is more
intense, and has a lower tonality.
During the deep breathing, the tubar murmur intensity is
higher.
Tubar murmur will only be heard by auscultation on the
larynx, trachea, breast bone and scapulo-vertebral area
between D1 -D4.
 The air circulating in a tube can generate a sound only
if there is a sudden stricture or dilation of the tube.
The physiological stricture that determines the
appearance of the tubar murmur is situated at the level of
the glota (the narrowest portion of the larinx, situated at
the level of the vocal cords).
The diameter of the glotal oriffice is larger when
inhaling and narrower when exhaling; thats why the
tubar murmur is more intense when exhaling.

Normally in the other areas of the respiratory system the

tubar murmur is not percepted, being replaced by a soft
sound, called the vesicular breath.
 The vesicular breath

It is formed at the level of bronchioli and alveoli and it

is a bronchiolo-alveolar sound.
It is a soft, vacuuming, aspirative, permanent sound.
It can be obtained by the mouth modelling for the
pronunciation of the letters a, b, f, v,
accompanied by slowly inhalation.
It can also be percepted during exhaling, but it has a
shorter duration. The duration of the sound, regarding
the inhaling/exhaling ratio is 3/1.
The area of auscultation for the vesicular breath is
represented by the whole thoracic surface, except for the
areas where we can ascultate the normal tubar murmur.
The vesicular breath intensity depends on the following
factors:
- the amplitude of the respiratory movements (in case of
superficial breathing, the vesicular breath is diminished;
in case of deep breathing, the vesicular breath is stressed)
- the thorax architecture (in case of thin thorax the
vesicular breath is stressed; in obese the vesicular breath
is diminished)
- the auscultation area (in anterior regions and the
thorax base the vesicular breath is more intense than in
the posterior region).
- the patients age (in children the thoracic wall is thin
and the glotal oriffice is narrowed; therefore the vesicular
breath will be more intense).
 Modifications of the Vesicular Breath
1. hardened vesicular breath
2. diminished vesicular breath
3. abolished vesicular breath
4. prolonged exhaling vesicular breath
5. staccato vesicular breath

1. Hardened vesicular breath

In this case the vesicular breath has high intensity and
rough timbre.
It appears in:
- those cases of dyspneea which rise the respiratory
debit and which give more speed to the breathed air.
- bronchiolitis: the tumefied bronchic mucous
membrane makes the new pathological stricture to express
itself by a stressed vesicular breath.
- a healthy lung if it is in a compensatory over-activity
If one lung or one lobe does not function, the healthy part
will make more ample respiratory movements and the
vesicular breath will harden.

2. Diminished vesicular breath

- patients who have a superficial breathing (because of
pain caused by costal fractures, pleuritis)
- obstacle at the level of the upper respiratory ways
which decreases the respiratory debit (pseudo-croup,
croup, tumours, foreign bodies, glottis edema)
- the partial narrowing of a main bronchia leads to a
diminishing of the vesicular breath but only on the area
tributary to that bronchia (partial obstruction by
bronchopulmonary cancer, foreign bodies)
- bilaterally diminished vesicular breath: pulmonary
emphysema.
3. Abolished vesicular breath (respiratory silence)
- massive pleural effusions
- massive pneumothorax
- massive pneumonia
- pahipleuritis
- the upper respiratory ways are completely obstructed
(tumours, foreign body, external compression)

4. Prolonged exhaling vesicular breath

- the inhaling and the exhaling ratio becomes equal or is
reverted (the exhaling takes longer than the inhaling)
- It appears in bronchic asthma
bronchiolitis
pulmonary emphysema.
 5. Staccato vesicular breath
- Normally the vesicular breath is continuous
- In pathological conditions, it becomes discontinuous,
interrupted by short breaks.
- Causes:
intense pain during the respiratory movements
- intercostal neuralgia
- costal fractures
- pleuritis
inflammatory processes that affect the bronchi
permeability (intrabronchial circulation of the air is
discontinuous)
neurosis
 The pathological tubar murmur

It is formed at the level of the glotal oriffice, like the

physiological tubar murmur.
It is perceived, due to pathological situations, outside of
the normal auscultation areas (larinx, trachea, sternum
manubrium, interscapulovertebral).
In these situations, the vesicular breath is replaced by
the tubar murmur.
The fluid sonorous waves in the glotal oriffice propagate
to the thoracic wall.
Normally, they are blurred and anihilated by the normal
pulmonary tissue.
 When the pulmonary parenchyma loses its air consistence
(inflammation, atelectasis), the physical conditions for the unaltered
propagation of vibrations from the glotal orifice to the thoracic wall
are satisfied.
The propagation of these vibration is possible only when the
respiratory ways are perfectly permeable.
Their obstruction may stop the propagation of vibrations,
resulting in a respiratory silence.

If the condensed pulmonary tissue is situated in the center and it

is surrendered by normal parenchima, tubar murmur cannot
propagate towards the thoracic wall.
This means that the tubar murmur will be perceived when the
condensed pulmonary tissue is superficially situated and the access
ways are permeable.
Conditions that lead to the appearance of the pathological
tubar murmur
Condensation of the pulmonary tissue

The presence of pulmonary cavities

a) The tubar murmur in condensation conditions of the

pulmonary parenchima.
Lobal pneumonia in the phase of condensation
In case of massive pneumonia, the alveolar exudate floads
the bronchia, which will stop the propagation of the
bronchic sonorous vibrations and will determine a
respiratory silence.
In central pneumonia, the pneumonic block is centrally
situated and it is surrounded by normal pulmonary
parenchyma which stops the transmission of the tubar
murmur.
Tuberculosis in its infiltrative form
Pulmonary infarction
Pulmonary atelectasis
b) The cavernous tubar murmur
Pathological tubar murmur perceived by auscultation on
cavities.
- the access bronchi must be permeable.
- the cavity must be emptied of content
- the cavity must be superficial
- the cavity must be large enough (the diameter must be of at
least 5cm)
- the cavity is surrounded by dense pulmonary tissue
The sonorous vibrations propagate themselves unmodified to
the level of pulmonary cavity where they are modified because
the cavity acts as a resonance box.
The resulting tubar murmur has high intensity and low, very
grave tonality. This is what we call cavernous or cavitary
murmur.
The caverns can be:
- tuberculose cavity
- hydatic cyst opened in the bronchi
- excavated pulmonary abcess
- excavated pulmonary cancer
- bronchiectasia.
c) The amphoric sound
It is a sound with a very grave tonality and a special
timbre.
-The cavity must be larger than 6 cm
-The walls of the cavity must be smooth, elastic
-The cavity has to be surrounded by dense pulmonary
tissue
-Superficially situated
-The cavity communicates with the access bronchi throw a
narrow orifice
The tubar murmur in pleural syndrome
The pathological tubar murmur is conditioned by two
pathological processes:
1. the presence of a pulmonary condensing process
superficially situated
2. the presence of a not very abundant pleural effusion
It is present in a pneumonia complicated with a pleurisy.
In case of abundant pleurisy we will notice respiratory
silence.
 THE ADDED SOUNDS
They can appear in alveolas, bronchi or pulmonary excavations and
are called rales (wheezes and crackles).
Others appear in the pleural cavity and they are called pleural rub.
The rales
They prove the presence of a pathological secretion moved by the
air flow.
They are perceived better if the patient breathes orally.
They are influenced by coughing.
There are two types of rales: dry rales and humid rales.
Dry rales (wheezes)
-Caused by the presence of a viscous secretion in the bronchi
-These secretions create endobronchial strictures, which generate
sonorous rales as the air passes throw them.
There are 2 types of dry rales:
The rales in the bronchi with a big calibre have lower
tonality. They are called monophonic rales (wheezes). They
resemble snoring sounds.
The rales in the bronchi with a small calibre have a
sharper tonality. They are called polyphonic rales (wheezes)
and they resemble the sound of the wind blowing.

The dry rales can be auscultated in both phases of respiration.

During inhaling the first rales heard are the monophonic ones,
than the polyphonic.
During exhaling, the order is viceversa.
They appear in: -acute bronchitis
-chronic bronchitis
-bronhic asthma
-bronchiectasia
 Humid rales (crackles)
1. crepitations
2. bubbling crackles
3. cavernous crackles
1.Crepitations
- sounds similar with those resulting from salt thrown
in the fire.
- they can be reproduced: a tress of hair rubbed near
the ear pavilion.
- are determined by a viscid secretion adherent to the
alveolar walls
- the air enters the alveolus at the end of inhaling
phase, it suddenly relaxes the alveolar walls and generates
crepitations.
- they can be heard better after coughing
- they can be heard only while inhaling
Crepitations are present in:
lobal pneumonia:
- the crackles which appear in the first phase are
called inducing crepitations
- the crackles which appear in the resorbtion phase of
pneumonia are called returning crepitations
acute pulmonary edema
pulmonary infarction
tuberculosis
after haemoptysis
heart insufficiency (stasis crepitations)
prolonged dorsal decubitus (the crepitations disappear after
few deep inhalings). They are called decubitus crepitations.
2. Bubbling crackles.
humid rales which resemble the crepitations but they are
bigger, inequal, discontinuous, and are heard during both
respiration phases.
they are very mobile and they modify between two
examinations
determined by a liquid secretion moved by the inhaled air
they sound like blowing in a glass of water with a straw.
There appear air bubbles.
three types of bubbling crackles (depending on the calibre
of the bronchi ):
thick crackles
middle crackles
smooth crackles (they are also called subcrepitant rales
and they resemble the classical crackles with the difference that they
can be heard in both respiratory phases) .
The subcrepitant crackles appear in
acute pulmonary edema
bronchiolitis
bronchopneumonia
lobal pneumonia
3. The Cavernous Rales.
- are generated by the presence of a liquid in a cavity which
communicates widely with the drainage bronchi.
- they can be perceived during both respiratory phases
- present in :
cavitary tuberculosis
pulmonary absses
evacuated hydatic cyst
bronchiectasia

The Pleural Rub

In case of pleuritis, a layer of fibrine covers the pleura resulting in

a rough surface.
The rub between parietal and visceral pleura in dry pleurisy leads
to a rub noise which resembles the rubbing of a piece of leather or
of silk.
Characteristics:
- discontinuity, intermittence
- circumscribed surface
- it can be heard during both respiratory phases, but it is heard
better during inhaling.
- it becomes more ample if the patient breathes deeply
- it is not modified by coughing, allowing a differential diagnosis
from rales
- it is modified in case of pressure with the stethoscope
 Pleural syndromes

1. Pleuritis (dry pleurisy)

-Represents an inflammation of the pleura, without
exudation in the pleural cavity
-Local symptoms: chest pain- increased in deep inspiration
dry cough
-Local signs: pleural rub
reduced respiratory movements

2. Pleural effusion (pleurisy)

Exudate- inflammation: local cause
(pleuropulmonary) and other diseases
Transudate- heart failure, cirrhosis, nephrotic sdr
 Exudative pleurisy
General symptoms: fever, shivers
Local symptoms: chest pain, dry cough, dyspneea.
Local signs: depend on the volume of the collection.
Inspection:
attitude: patient in lateral decubitus on the same side as
the pleural effusion
immobility of the affected hemithorax
deviation of the mediastinum (displaced trachea, displaced
apexian beat)
Palpation
diminished or abolished vocal fremitus
Percussion
subdullness/dullness, more pronounced at the base
Auscultation
diminished/abolished vesicular breath
 Pleural puncture
Indication
Diagnosis
confirming the presence of liquid, the nature of the liquid (etiology)
- pleural byopsy
Therapy
-Evacuation (thoracocentesis)
-Administration of drugs
Contraindications
-Severe altered general status
-Thoracic wall infections
-Hydatic cyst suspicion
-Bleeding diathesis
Tehnique
-Sitting position, the thorax uncovered, the superior limb on the same side
elevated
-Repeat the percussion to establish the site where the puncture will be
made in full dullness, on the posterior axillary line, on the superior
margin of the inferior rib
-Sterile conditions assured by before inserting the needle clean skin with
- Local anesthesia
- The needle inserted perpendicular on the skin
- Aspiration of the pleural liquid
Accidents:
- Lesions of the intercostal vessels or nerves
- Pneumothorax
- Pulmonary edema when evacuating a large quantity (more than
1000ml )
Pleural liquid is analysed for protein, glucose, LDH, microbiology,
cytology, pH.
Analysis of pleural fluid helps differentiate transudate from exudate
(Rivalta reaction)
Characteristics of the exudate:
- high total fluid/serum protein ratio (>0.5)
- pleural LDH (lactic dehidrogenase) > 2/3 of the normal upper
limit
- pleural/serum LDH activity ratio > 0.6.
Exudate: bacterial pneumonia, malignancy, viral infections,
collagen vascular diseases.
Transudate: left ventricular failure, cirrhosis, pulmonary
embolism, nephrotic syndrome.