Presented by:Ruba Awni

Saleh Mayyas

Supervised by:Dr. Esam Al-Khasib

Objectives Structure of the respiratory system History hints Physical exam of respiratory system * inspection * palpation * percussion * auscultation Cancers related to the respiratory system

At the end of this lecture, the students will be able to:

1- Identify the structure of the respiratory system2- Locate the thorax landmarks: anteriorly,

posteriorly, and laterally3- Recall major hints in obtaining complete

history of respiratory system4- Demonstrate the steps of respiratory physical

examination5- Differentiate between normal and abnormal

findings in respiratory physical examination6- Relate the physical examination to the

oncology science

Upper airway: nose, pharynx, larynx, & trachea

Lower airway: right lung (3 lobes) and left lung (2 lobes) air exchange occurs in alveoli

Thoracic cavity: rib cage, muscles, & diaphragm

Anterior Thorax: Suprasternal notch sternum, costal angle (90 degrees or less), midsternal, midclavicular, and anterior axillary line

Posterior Thorax: vertebral line, and scapular line

Lateral Thorax: anterior axillary line Midaxillary line, and posterior axillary line

SOB Dyspnea (difficulty breathing) Orthopnea (difficulty breathing lying down) Angina (chest pain), asthma, bronchitis,

pneumonia Chest pain with breathing Client or family hx. of lung disease, TB, or

cancer Smoking hx. Environmental Exposure

1- Cough:* Do you have cough?* How long have you had it?* How often do you cough?* Do you cough any sputum? * Cough up any blood?* How do you describe your cough: hacking,

dry, congested, bubbling?* What makes cough better\worse?* What treatments for cough you tried?

1- Cough:* Continuous throughout the day: acute

respiratory infection* Afternoon/evening: occupational irritants* Night postnasal drip, sinusitis * Early morning chronic smoking* Characteristics: Mycoplasma pneumonia: hacking, Early HF: dry, Croup: barking, Bronchitis and pneumonia: congested

2- Sputum* White or clear mucoid: colds, bronchitis, viral

infections* Yellow or green: bacterial infection* Rust colored: TB, pneumococcal pneumonia * Pink, frothy: pulmonary edema, or side effects

of anticholinergic medications

3- Shortness of breath:* Have you ever had SOB? How severe it was?

How long?* Is it affected by position? (orthopnea)* Does it occur at specific time of day or night?

(nocturnal dyspnea)* Is it associated with night sweats? (diaphoresis)* Associated with chest pain, bluish lips, wheezing

sound? (cyanosis)* Episods related to food, pollen, animal, season?

(asthma attacks)* What do you try once having SOB?

4- chest pain with breathing:* PQRST

5- Past history of respiratory infections:* Any unusually frequent or severe colds? * Any family history of allergies, TB, or

asthma?

6- Smoking history:* Do you smoke? How much? For how long? * Did you ever think to quit smoking? What

was helpful? What was not?* What activities do associate with smoking?

7- Environmental Exposure:* Any environmental conditions that affect

your breathing?* Where do you work?* Do you use protective measures at work?

8- Self-care Behaviors:* underwent recent TB skin test, CXR,

pneumonia or influenza immunization?

Stethoscope Small ruler marked in centimeters Marking pen Alcohol swab

Chest for shape & configuration Ratio of AP to transverse (1:2) Costal angle with 90 degrees Watch for the development of neck muscles Scapulae located symmetrically on each

hemithorax Development of abdominal muscles should be

appropriate for age, weight, gender, and athletic condition

The position at which person takes breath (relaxed)

Skin color should be consistent with person’s genetic background (check also lips and nailbeds)

Assess for skin lesions

Look for relaxed facial expressions No retraction or bulging of interspaces should

occur on inspiration Accessory muscles are not being used unless

after heavy exercise Respiratory rate within the normal limit in

relation to age

Skeletal deformities may limit the thoracic cage excursion

1- scoliosis: S-shaped 2- Kyphosis: exaggerated

curvature of thoracic & posterior curvature of

lumbar spine the thoracic spine

3- pectus excavatum: 4- pectus carinatum:

Sunken sternum and forward protrusion

adjacent cartilage of the sternum(Funnel Breast) (Pigeon chest)

Costal angle>90 degrees: barrel chest Hypertrophy of abdominal muscles: chronic

emphysema Hypertrophy of neck muscles: COPD COPD patients usually sit in tripoid position Pallor or cyanosis indicate tissue hypoxia Clubbing of nails with chronic respiratory

disease Cutaneous angiomas (spider nevi) associated

with liver disease or portal HTN Tense, strained facies occurs with COPD

Interspace retraction: obstruction of the respiratory tract or atelectasis

* bulging is due to trapped air at expiration as in emphysema or asthma

• The use of accessory muscles accompany acute airway obstruction or massive atelectasis

• Tachypnea, bradypnea, hyperventilation, hypoventilation are problems associated with respiratory rate and depth

Abnormal respiration patterns:1- Kussmaul’s respirations: * a type of hyperventilation * exaggerated deep, rapid breathing * normal with exercise * abnormal with Aspirin overdose, pain, fever, hysteria, cardiac and/or respiratory disease

2- Cheyne-Strokes respirations: regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea.

3- Biot’s respiration: irregular pattern characterized by varying depth & rate of respirations followed by periods of apnea

* associated with intracranial pressure & respiratory compromise

* Palpate each rib & interspace for tenderness

1- Symmetric chest expansion• Unequal expansion with marked

atelectasis, pneumonia, and thoracic trauma

2- Tactile Fremitus:• Fremitus is palpable vibrations (sounds generated

from the larynx and transmitted to chest wall through patent bronchi and lung parenchyma)

• Decreased fremitus can result from obstructed bronchus, pleural effusion, pneumothorax, or emphysema

• Increased fremitus accompanies consolidation of the lung (e.g.: lobar pneumonia)

• Pleural friction fremitus felt with inflammation of the pleura

• Rhonchal fremitus with thick bronchial secretions• Crepitus: coarse crackling sensation palpable over

the skin surface (subcutaneous emphysema following thoracic injury or surgery)

Palpate the anterior chest wall for tenderness Symmetric chest expansion * a lag in expansion could indicate atelectasis,

pneumonia, or postoperative guarding

Purpose: To determine boundaries or organs (lungs) Make side to side comparison all the way over

the lung Start at the apices the band across the tops of

both shoulders), then percuss the interspaces Make a side-to-side comparisons (5 cm

intervals) Resonance: clear, long, low-pitched sound

that predominates normal adult healthy lung

Hyperresonance: lower-pitched, louder, longer than resonance heard at full inflation indicating emphysema (too much air)

Flatness: * absolute dullness, short feeble, high-

pitched * heard over muscles & organ masses

Tympany: * loud, well-sustained, musical sound,

drum-like * heard over air-filled stomach, distended

abdomen

Diaghragmatic excursion:• Ask pt to “exhale and hold”, percuss down the

scapular line until resonance becomes dullness on both sides, put a mark there

• Now ask pt to “take a deep breath and hold, percuss from the marked point down until resonance changes to dullness (3 – 5 cm)

Purpose: assess breath sounds anteriorly,

posteriorly, & laterally assess for abnormal sounds

Techniques: Use diaphragm of stethoscope Listen for normal sounds first Instruct client to take slow, deep breaths Listen to inspirations & expirations

1- Bronchial: High-pitched, & loud, short during inspiration & longer during expiration, harsh or hollow

Heard over trachea & larynx2- Bronchovesicular: Medium-pitched,

equal during inspiration & expiration Heard over major bronchi (1st & 2nd

interspaces at both sides of sternum anteriorly, and between scapulae posteriorely)

3- Vesicular: Low-pitched, breezy, & soft, long during inspiration & short during expiration

Heard over peripheral lung fields

1- Rales (Crackles): On inspiration-sticky (mucus secretions) air

passages open & Inspired air meets secretions in large bronchi & trachea

Late inspiration-restrictive diseases (pneumonia, pulmonary edema, & CHF)

Early inspiration-obstructive diseases (bronchitis, asthma, & emphysema)

Pulmonary fibrosis-heard louder & closer to stethoscope, usually do not change location, common in long-term COPD

2- Sibilant Wheeze: Air passes through constricted airway High-pitched, musical sound primarily on

expiration Acute asthma, chronic emphysema3- Sonorous Wheeze: Air passes through constricted airway Low-pitched snoring or moaning sound Primarily during expiration May clear with coughing Bronchitis, & single obstructions

4- Stridor: Air passes through constricted airway A harsh honking wheeze with severe

bronchospasm Croup, swallowing object which gets

caught in airway5- Pleural Friction Rub: Secondary to rubbing of 2 inflamed

surfaces, Pleuritis Low-pitched, dry, grating sound during

inspiration & expiration More superficial than crackles

1- Bronchophony:• Pt repeats “ninety nine” as you auscultate over

the chest wall.• Normally sounds are muffled & unclear, if clear,

expect pathology (increased lung density)2- Egophony: if “eeeee” sound is heard as

“aaaaaaaa” consolidation or pleural effusion3- Whispered pectoriloquy: whispered “one-

two-three” heard clear and distinct with even minimal consolidation (normally heard faint and muffled)

The major histological types of respiratory system cancer are:

Small cell lung cancer Non-small cell lung cancer Other lung cancers (carcinoid, Kaposi’s sarcoma, 

melanoma) Lymphoma Head and neck cancer Pleural Mesothelioma, almost always caused by

exposure to asbestos dust.

● A type of highly malignant cancer that most commonly arises within the lung, although it can occasionally arise in other body sites, such as the cervix and prostate.

● Small cell carcinomas are smaller than normal cells. Some researchers identify this as a failure in the mechanism that controls the size of the cells

● Treatment usually involves chemotherapy, radiation, with little role of surgery

● In a significant number of cases, small cell carcinomas can produce ectopic hormones, including adrenocorticotropic hormone (ACTH) and anti-diuretic hormone (ADH). Ectopic production of large amounts of ADH leads to syndrome of inappropriate production of anti-diuretic hormone (SIADH).

Lambert-Eaton myasthenic syndrome (LEMS) is a well-known paraneoplastic condition linked to small cell carcinoma

 any type of epithelial lung cancer other than small cell lung carcinoma

As a class, NSCLCs are relatively insensitive to chemotherapy, compared to small cell carcinoma. When possible, they are primarily treated by surgical resection with curative intent; although chemotherapy is increasingly being used both pre-operatively and post-operatively

Types:◦ Adenocarcinoma of the lung◦ Squamous cell carcinoma of the lung◦ Large cell lung carcinoma

Does screening for lung cancer save lives?

Screening is the use of tests or exams to detect a disease in people without symptoms of that disease. For example, the Pap test is used to screen for cervical cancer. Because lung cancer usually spreads beyond the lungs before causing any symptoms, an effective screening test for lung cancer could save many lives.

For many years, doctors have tried to see if a test to find lung cancer early would save lives. Studies of 2 possible screening tests, chest x-ray and sputum cytology, did find that these tests detected lung cancers at an early stage, but neither test helped patients live longer. This is why major medical organizations have not recommended routine screening with these tests for the general public or even for people at increased risk, such as smokers. Recently, though, a different lung cancer screening test has been shown to help lower the risk of dying from this disease.

About 5% of lung cancers are of rare cell types, including carcinoid tumor,lymphoma, and others

Mesothelioma is a rare form of cancer that develops from transformed cells originating in the mesothelium, the protective lining that covers many of the internal organs of the body. It is usually caused by exposure to asbestos

Bickley L, Szilagyi P, Bate’s Guide to Physical Examination and History Taking, ninth edition

Carolyn Jarvis, Physical Examination & Health Assessment, fourth edition

Yarbro C.H, Wudjcik D, Gobel B.H, Cancer Nursing,( seventh edition, 2011)

www.cancer.org

http://en.wikipedia.org