Badanie fizykalne układu oddechowego | Respiratory Examination

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“Posture”: “Postawa”, “Tripod position”: “Pozycja trójnoga”, “Labored breathing”: “Wysiłek oddechowy”, “Accessory muscles”: “Mięśnie pomocnicze oddechowe”, “Cyanosis”: “Sinica”, “Shape of the chest”: “Kształt klatki piersiowej”, “Pectus excavatum”: “Klatka piersiowa lejkowata”, “Pectus carinatum”: “Klatka piersiowa kurza”, “Barrel-shaped chest”: “Beczkowata klatka piersiowa”, “Dyspnea (shortness of breath)”: “Duszność (utrudnione oddychanie)”, “Acute dyspnea”: “Ostra duszność”, “Chronic dyspnea”: “Przewlekła duszność”, “Pulmonary embolism”: “Zatorowość płucna”, “Pneumothorax”: “Odma opłucnowa”, “Interstitial lung disease”: “Śródmiąższowa choroba płuc”, “Cough”: “Kaszel”, “Productive cough”: “Kaszel mokry (produktywny)”, “Dry cough”: “Kaszel suchy”, “Hemoptysis”: “Krwioplucie”, “Tuberculosis”: “Gruźlica”, “Bronchiectasis”: “Rozstrzenie oskrzeli”, “Lung cancer”: “Rak płuca”, “Wheezing”: “Świsty oddechowe”, “Chest pain”: “Ból w klatce piersiowej”, “Pleuritic pain”: “Ból opłucnowy”, “Pleuritis”: “Zapalenie opłucnej”, “Pulmonary edema”: “Obrzęk płuc”, “Clubbing”: “Pałeczkowatość palców”, “Tachypnea”: “Przyspieszone oddychanie (tachypnoe)”, “Bradypnea”: “Spowolnione oddychanie (bradypnoe)”, “Abdominal breathing”: “Oddychanie brzuszne”, “Thoracic breathing”: “Oddychanie piersiowe”, “Mixed breathing”: “Oddychanie mieszane”, “Breathing patterns”: “Wzorce oddechowe”, “Kussmaul breathing”: “Oddychanie Kussmaula”, “Cheyne-Stokes respiration”: “Oddychanie Cheyne’a-Stokesa”, “Biot’s breathing”: “Oddychanie Biota”, “Eupnea”: “Oddychanie prawidłowe (eupnoe)”, “Hyperpnea”: “Hiperwentylacja (hiperpnoe)”, “Apnea”: “Bezdech (apnoe)”, “Signs of respiratory distress”: “Objawy niewydolności oddechowej”, “Pursed-lip breathing”: “Oddychanie przez zaciśnięte usta”, “Chest expansion”: “Rozprężanie klatki piersiowej”, “Atelectasis”: “Niedodma płucna”, “Pleural effusion”: “Płyn w jamie opłucnej”, “Lung collapse”: “Zapadnięcie płuca”, “Vocal fremitus”: “Drżenie głosowe”, “Consolidation”: “Zagęszczenie miąższu płuc”, “Obstructive lung disease”: “Choroba obturacyjna płuc”, “Tracheal deviation”: “Przemieszczenie tchawicy”, “Tension pneumothorax”: “Odma prężna”, “Percussion”: “Opukiwanie”, “Comparative percussion”: “Opukiwanie porównawcze”, “Lung resonance”: “Odgłos opukowy płuc”, “Hyper-resonance”: “Nadmierny odgłos opukowy”, “Lung apices”: “Szczyty płuc”, “Respiratory mobility”: “Ruchomość oddechowa”, “Auscultation”: “Osłuchiwanie”, “Stethoscope placement”: “Pozycjonowanie stetoskopu”, “Normal breath sounds”: “Prawidłowe szmery oddechowe”, “Tracheal breathing”: “Oddychanie tchawicze”, “Bronchial breathing”: “Oddychanie oskrzelowe”, “Bronchovesicular”: “Szum oskrzelowo-pęcherzykowy”, “Vesicular breathing”: “Oddychanie pęcherzykowe”, “Pathological breath sounds”: “Patologiczne szmery oddechowe”, “Crackles (rales)”: “Trzeszczenia”, “Fine crackles”: “Drobne trzeszczenia”, “Coarse crackles”: “Grube trzeszczenia”, “Inspiratory wheezes”: “Świsty wdechowe”, “Expiratory wheezes”: “Świsty wydechowe”, “Stridor”: “Świst krtaniowy (stridor)”, “Inspiratory stridor”: “Świst wdechowy”, “Expiratory stridor”: “Świst wydechowy”, “Biphasic stridor”: “Świst dwufazowy”, “Sonorous wheezes”: “Świsty niskotonowe”, “Pleural friction rub”: “Tarcie opłucnowe”, “Muffled breath sounds”: “Przytłumione szmery oddechowe”, “Absent breath sounds”: “Brak szmerów oddechowych”, “Phonation”: “Fonacja”, “Pneumonia”: “Zapalenie płuc”, “Chronic obstructive pulmonary disease (COPD)”: “Przewlekła obturacyjna choroba płuc (POChP)”, “Asthma”: “Astma”, “Fibrosis”: “Zwłóknienie”, “Neoplasm”: “Nowotwór”, “Emphysema”: “Rozedma płuc”, “Tumor”: “Guz”, “Rhonchi”: “Rzężenia grubobańkowe”, “Respiratory mobility evaluation”: “Ocena ruchomości oddechowej”, “Pleural abnormalities”: “Nieprawidłowości opłucnej”, “Mucus accumulation”: “Nagromadzenie śluzu”, “Respiratory rhythm”: “Rytm oddechowy”, “Anterior lung fields”: “Przednie pola płucne”, “Posterior lung fields”: “Tylne pola płucne”, “Lateral lung fields”: “Boczne pola płucne”, “Pulmonary fibrosis”: “Zwłóknienie płuc”, “Bronchitis”: “Zapalenie oskrzeli”, “Pleural effusion boundaries”: “Granice płynu w jamie opłucnej”, “Upper lung disease”: “Choroby górnych partii płuc”, “Pulmonary metastases”: “Przerzuty do płuc”, “Conducive”: “Sprzyjający”, “COPD”: “Przewlekła obturacyjna choroba płuc (POChP)”, “Sternum”: “Mostek”, “Protrusion”: “Wypukłość”, “Acute”: “Ostry”, “Chronic”: “Przewlekły”, “Sputum”: “Plwocina”, “Gastroesophageal reflux”: “Refluks żołądkowo-przełykowy”, “Obstruction”: “Zablokowanie”, “Inflammation”: “Zapalenie”, “Pleuritic”: “Opłucnowy”, “Pleurisy”: “Zapalenie opłucnej”, “Exacerbated”: “Zaostrzony”, “Peripheral cyanosis”: “Sinica obwodowa”, “Chronic hypoxia”: “Przewlekła hipoksja”, “Sepsis”: “Sepsa”, “Diaphragmatic”: “Przeponowy”, “Stroke”: “Udar”, “Heart failure”: “Niewydolność serca”, “Diabetic ketoacidosis”: “Kwasica ketonowa cukrzycowa”, “Fever”: “Gorączka”, “Narcotic overdose”: “Przedawkowanie narkotyków”, “Sleep apnea”: “Bezdech senny”, “Labored”: “Wysiłkowy (oddech)”, “Shallow breathing”: “Płytkie oddychanie”, “Fremitus”: “Drżenie głosowe”, “Effusion”: “Wysięk”, “Dullness”: “Stłumiony odgłos opukowy”, “Boundaries”: “Granice”, “Intermittent”: “Przerywany”, “Vocal cord dysfunction”: “Dysfunkcja strun głosowych”, “Tracheal inflammation”: “Zapalenie tchawicy”, “Foreign body”: “Ciało obce”, “Epiglottitis”: “Zapalenie nagłośni”, “Retropharyngeal abscess”: “Ropień zatchawiczny”, “Chronic bronchitis”: “Przewlekłe zapalenie oskrzeli”, “Vocal cord palsy”: “Porażenie strun głosowych”, “Mucus buildup”: “Nagromadzenie śluzu” }; // Normalize keys in the dictionary const normalizedWordsToTooltip = {}; for (const [key, value] of Object.entries(wordsToTooltip)) { const cleanedKey = key.replace(/(.*?)/g, ”).trim(); // Remove anything in parentheses normalizedWordsToTooltip[cleanedKey.toLowerCase()] = value; } function processNode(node) { if (node.nodeType === Node.TEXT_NODE && node.nodeValue.trim()) { let content = 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Szacowany czas lekcji: 18 minut
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Observation

Observation is the initial step of the pulmonary exam – focus on the patient’s posture, chest shape, respiratory patterns, and any signs of respiratory distress.

Posture and General Appearance

  • Posture: A forward-leaning posture, known as the tripod position, is commonly adopted by patients with conditions like COPD or asthma to reduce respiratory effort.
  • General appearance: Look for signs of respiratory distress, such as labored breathing, use of accessory muscles, or cyanosis (bluish discoloration of the skin).

Shape of the Chest

Evaluate the chest for any structural abnormalities

  • Pectus excavatum: Inward sunken appearance of the sternum.
  • Pectus carinatum: Protrusion of the sternum outward.
  • Barrel-shaped chest: Increased anterior-posterior diameter, often seen in patients with chronic obstructive pulmonary disease (COPD).

Respiratory Conditions

Observation of the respiratory system provides crucial insights into both localized and systemic health. Respiratory symptoms and signs can be manifestations of underlying systemic diseases, infections, allergic reactions, or environmental exposures.

  • Dyspnea (Shortness of Breath): Dyspnea is a common indicator of respiratory distress. It may be acute or chronic and is seen in conditions like asthma, chronic obstructive pulmonary disease (COPD), pneumonia, and heart failure. Acute dyspnea often suggests infections, pulmonary embolism, or pneumothorax, while chronic dyspnea is typical of conditions like COPD or interstitial lung disease.
  • Cough: A persistent or acute cough can reflect various respiratory conditions. A productive cough, characterized by sputum production, is often seen in infections such as pneumonia or bronchitis, while a dry cough may indicate asthma, viral infections, or gastroesophageal reflux. Hemoptysis (coughing up blood) suggests more serious conditions like tuberculosis, lung cancer, or pulmonary embolism.
  • Wheezing: Wheezing is a high-pitched sound caused by narrowing of the airways, commonly associated with asthma, COPD, or bronchitis. It often indicates obstruction or inflammation in the lower airways and may be triggered by allergens, infections, or irritants.
  • Chest Pain: Respiratory-related chest pain often stems from pleuritic causes, such as pleurisy, pulmonary embolism, or pneumonia, and is exacerbated by breathing or coughing. It is crucial to differentiate respiratory chest pain from cardiac or musculoskeletal sources.
  • Cyanosis: Bluish discoloration of the skin or mucous membranes indicates hypoxemia (low blood oxygen levels) and is often a sign of severe respiratory distress, seen in conditions like COPD, asthma, or severe pneumonia. Central cyanosis (around the lips and tongue) usually reflects more severe oxygen deprivation than peripheral cyanosis (fingers and toes).
  • Clubbing: Clubbing of the fingers or toes is a sign of chronic hypoxia and is often seen in respiratory conditions such as lung cancer, interstitial lung disease, or bronchiectasis. It is characterized by the rounding and enlargement of the nail beds.
  • Use of Accessory Muscles: In patients with respiratory distress, the use of accessory muscles (neck and shoulder muscles) during breathing is often observed. This indicates increased work of breathing, commonly seen in severe asthma, COPD exacerbations, or respiratory failure.
  • Tachypnea (Rapid Breathing): Tachypnea is an abnormally rapid breathing rate and is a non-specific sign of respiratory or metabolic distress. It is observed in a wide range of conditions, including pneumonia, sepsis, or pulmonary embolism.

Breathing Patterns

  • Abdominal breathing: Diaphragmatic involvement where abdominal muscles are more engaged.
  • Thoracic breathing: More involvement of chest muscles with limited diaphragmatic movement.
  • Mixed breathing: A combination of both abdominal and thoracic breathing patterns.

Respiratory Rate and Rhythm

  • Respiratory rate: Normal is 12–20 breaths per minute in adults. Note any bradypnea (rate < 12) or tachypnea (rate > 20).
  • Rhythm: Evaluate for irregularities:
    1. Kussmaul breathing: Deep and rapid breathing, often seen in diabetic ketoacidosis or metabolic acidosis.
    2. Cheyne-Stokes respiration: Cyclic pattern of gradual increase and decrease in breathing, followed by periods of apnea, often seen in stroke or heart failure.
    3. Biot’s breathing: Irregular breathing with periods of apnea, typically associated with severe brain injury.

Types of breathing 

Type of BreathingDescriptionAssociated Conditions
EupneaNormal, unlabored breathing at a regular rate.Normal condition
DyspneaDifficulty breathing or shortness of breath.Heart failure, pulmonary embolism, anxiety
HyperpneaIncreased depth of breathing to meet metabolic demands.Exercise, anemia
TachypneaRapid, shallow breathing.Pneumonia, fever, heart failure
BradypneaAbnormally slow breathing rate.Narcotic overdose, brain injury
ApneaAbsence of breathing.Sleep apnea, cardiac arrest

Signs of Respiratory Distress

  • Dyspnea: Difficulty breathing, often associated with labored, shallow breathing.
  • Cyanosis: A bluish tint to the skin or nails, indicating inadequate oxygenation.
  • Pursed-lip breathing: A breathing technique commonly seen in patients with COPD, allowing them to control the rate of exhalation and maintain open airways.
  • Use of accessory muscles: Recruitment of neck and intercostal muscles indicates increased respiratory effort, often seen in severe respiratory distress.

Palpation

Palpation helps assess the movement of the chest wall and identify abnormalities that may not be visible on inspection.

Chest Expansion

  • Place your hands on the patient’s back with your thumbs touching at the midline.
  • Ask the patient to take a deep breath and observe the symmetry of chest expansion. Asymmetry may suggest conditions like atelectasis, pleural effusion, or lung collapse.

Vocal Fremitus

  • Place your hands on the patient’s chest or back and ask them to repeat a phrase such as “ninety-nine”, “blue balloons” or “czterdzieści cztery”.
  • Feel for the vibrations transmitted through the chest wall. Increased fremitus may indicate consolidation (as in pneumonia), while decreased fremitus suggests effusion, pneumothorax, or obstructive lung disease.

Tracheal Deviation

  • Palpate the trachea to assess its position. A deviation from the midline may suggest a tension pneumothorax or large pleural effusion.

Percussion

Percussion in lung examination involves rhythmically tapping the chest wall using the middle finger of one hand to strike the distal interphalangeal joint of the opposite hand. This technique is applied systematically across the anterior, posterior, and lateral lung fields to assess resonance. Abnormal sounds, such as dullness or hyper-resonance, can indicate lung pathologies like consolidation, pleural effusion, or pneumothorax.

Comparative Percussion

  • Systematically percuss the anterior, posterior, and lateral chest to compare resonance across both lung fields.
  • Normal lung tissue produces a resonant sound, while dullness suggests consolidation, effusion, or atelectasis.
  • Hyper-resonance indicates air trapping, as seen in pneumothorax or emphysema.

Detailed Percussion

  • Lung apices: Percussion over the upper lung areas to evaluate for pneumothorax or upper lung disease.
  • Lower lung boundaries: Percuss to define the lower margins of the lung fields and assess for pleural effusion or other abnormalities.
  • Respiratory mobility: Evaluate the movement of the lungs during inhalation and exhalation by percussing the lung borders and noting their shift with breathing.

Auscultation

Preparation: Ensure a quiet environment and ask the patient to sit comfortably with their chest exposed for clear stethoscope placement.

Stethoscope Placement: Place the diaphragm of the stethoscope firmly on the chest wall, systematically covering anterior and posterior regions, as well as upper, middle, and lower lung fields, for a thorough respiratory assessment.

Normal Breath Sounds

SoundDescriptionNormal Location
Tracheal BreathingLoud and high-pitchedHeard over the neck
Bronchial BreathingLoud and high-pitched. Expiratory sounds last longer.Heard over large airways (sternum)
BronchovesicularIntermediate intensity and pitch. Inspiratory and expiratory sounds are equal.Heard over 1st and 2nd intercostal spaces
Vesicular BreathingLower-pitched, rustling sounds. Inspiratory sounds last longer than expiratory.Heard over both lung fields

Note: In clinical practice, we primarily focus on bronchial breathing and vesicular breathing. These two types of breath sounds are the most clinically significant when distinguishing between normal and pathological respiratory states.

Pathological Breath Sounds

Pathological breath sounds are abnormal sounds heard during auscultation of the lungs and airways. They can indicate a range of respiratory conditions and are critical for diagnosing and assessing lung pathologies. These sounds include crackles, wheezes, stridor, sonorous wheezes (rhonchi), pleural friction rub, and muffled or absent sounds. 

Crackles (Rales)

Type of SoundDescriptionAssociated Conditions
Fine CracklesDiscontinuous, intermittent, high-pitched sounds heard during inspiration.Pneumonia, pulmonary fibrosis, pulmonary edema
Coarse CracklesLow-pitched, louder sounds heard during both inspiration and expiration.Bronchiectasis, chronic bronchitis

Wheezes

Type of SoundDescriptionAssociated Conditions
Inspiratory WheezesHigh-pitched sound caused by airway narrowing outside the chest wall.Vocal cord dysfunction, tracheal inflammation, foreign body
Expiratory WheezesHigh-pitched sound due to airway narrowing within the chest wall, typically heard during expiration.Asthma, COPD, chronic bronchitis

Stridor

Type of SoundDescriptionAssociated Conditions
Inspiratory StridorHigh-pitched, musical sound from turbulent airflow during inspiration.Epiglottitis, retropharyngeal abscess
Expiratory StridorHigh-pitched, musical sound occurring during expiration, often due to lower airway obstruction.Asthma, COPD
Biphasic StridorHigh-pitched sound during both inspiration and expiration, indicative of glottic obstruction.Foreign body, vocal cord palsy

Sonorous Wheezes (Rhonchi)

Type of SoundDescriptionAssociated Conditions
Sonorous Wheezes (Rhonchi)Low-pitched, snoring-like sounds, often associated with mucus accumulation and may be heard with crackles.Bronchitis, pneumonia, or conditions with mucus buildup

Pleural Friction Rub

Type of SoundDescriptionAssociated Conditions
Pleural Friction RubDiscontinuous, low-pitched sound heard in both inspiration and expiration, resembling the sound of rubbing sandpaper.Pleuritis, fibrosis, or neoplasm

Muffled or Absent Sounds

Type of SoundDescriptionAssociated Conditions
Muffled or Absent SoundsReduced or absent breath sounds, often indicating a serious underlying issue like air or fluid accumulation around the lung.Emphysema, pneumothorax, pleural effusion, tumor