Respiratory examination quiz part 1

Flatness is a short sound found on percussion over muscles. Dullness is a longer sound found over fluid filled cavities. Hyperresonance is found over emphysematous lung and tympany is a longer sound typical of a large single gas filled structure such as bowel. (link)

Breath sounds are normally longer in inspiration than expiration, usually reduced by endobronchial obstruction, are harsher in bronchial breathing and have a dry,early – mid inspiratory, crackling nature in pulmonary fibrosis. Crepitations of pulmonary oedema are wet sounding.  (link)

The normal forced expiratory time is < 3 seconds. Values higher than this indicate airway obstruction (link).

A normal person should be able to count to 15. If unable to do so, this indicates poor respiratory reserve. (link)

Whispering pectoriloquy and increased tactile fremitus are less reliable signs of collapse than comparative dullness to percussion. The effect of collapse on breath sounds is variable, depending on whether the bronchus is obstructed or not. The trachea will be displaced to the ipsilateral side only if the collapse is large.(link)

Increased tactile fremitus and whispering pectoriloquy may occur, but are less common than crackles on auscultation. Breath sounds are more likely to be bronchial in nature, than absent and hyperinflation would not be expected to occur. (link)

Abnormal comparative percussion is most likely in pleural effusion.Increased tactile fremitus and bronchial breathing may be present if there is collapse above the effusion, but are less reliable findings. A pleural rub would not be expected and tracheal displacement to the contralateral side only occurs with very large effusions. (link)

The right oblique fissure runs slightly posteriorly to the left, which may help to identify it on the lateral CXR. The pleura may protrude slightly inferiorly to the costal margin on the right side, but not on the left (this is why the left xiphisternal region is suitable for pericardiocentesis). The pleural reflection follows the left border of the sternum until the 4th CC then deviates to almost the midclavicular line by the 6th CC.

False ribs articulate with the 7th costal cartilage. The nipple is males is in the 4th ICS in the midclavicular line. Cervical ribs are present in < 1% of the population and lumbar ribs are much less common that cervical ribs. The apex of the pleura extends up to 2cm into the supraclavicular fossa, hence may be damaged with wounds or procedures in this area.

This is why intercostal catheter placement in the supine patient should occur at a high level.

This is why intercostal catheter insertion should occur in the anterior axillary line or posterior to the mid axillary line.

Silicosis predominantly involves the upper lobes. (link)

Asbestosis predominantly involves the lower lobes. (link)