Algorithm and respiratory parameters
Inspection is carried out in two phases: during quiet breathing and during deep breathing. The physician pays attention to the ratio of inspiration to expiration duration, as well as the rate and depth of respiratory movements.
- Tachypnea: rapid and shallow breathing. May be a sign of restrictive processes (fibrosis, pulmonary edema) or meningeal irritation.
- Bradypnea: decreased respiratory rate (12 or fewer cycles per minute), often associated with mechanical compression of the brainstem or toxic depression of the respiratory center.
- Inspiratory dyspnea: difficult, noisy inspiration (stridor). Indicates narrowing of the trachea, larynx, or large bronchi (foreign body, edema).
- Expiratory dyspnea: prolonged expiration involving accessory muscles (neck, intercostal spaces). Typical of small airway obstruction (asthma, COPD).
Chest shapes
The shape of the chest is based on the patient's constitution, though chronic pathological processes can alter it.
- Paralytic chest: an extreme degree of the asthenic type (flattened and narrow chest). Forms during prolonged sclerosing processes (fibrosis, shrinking of the lungs or pleura).
- Barrel chest (emphysematous): acquires features of the hypersthenic type, but with a sharp increase in the anteroposterior diameter ("visually resembling a barrel"). The ribs become horizontal, the subcostal angle becomes obtuse, and chest excursion decreases. The mechanism is associated with the loss of lung elasticity and hyperinflation in emphysema.
Skeletal deformations also occur: rachitic ("pigeon chest"), funnel chest (pectus excavatum), and scaphoid chest. Spinal curvatures, such as kyphoscoliosis, can disrupt the topography of the thoracic organs and lead to the development of cor pulmonale.
Assessment of symmetry
Normally, both halves of the chest should participate in the act of breathing synchronously and symmetrically. Asymmetry is an important diagnostic criterion indicating a localized pathological process:
- Bulging (increased volume of one hemithorax): accompanied by smoothing of the intercostal spaces. Occurs during fluid accumulation in the pleural cavity (pleurisy, hydrothorax) or air (pneumothorax), as well as massive tissue consolidations (large tumors, extensive pneumonia).
- Retraction (depression): the affected side is reduced in volume and lags during breathing. This is a consequence of connective tissue proliferation (adhesive processes) or obstructive atelectasis (collapse of a lobe due to bronchial occlusion by a tumor or foreign body).
Extrapulmonary manifestations on inspection
During the objective examination, obligatory assessment includes the forced posture (e.g., lying on the affected side to limit pain in pleurisy) and skin manifestations:
- Central cyanosis: a baseline marker of hypoxemia in pneumonia or COPD. A distinctive feature of pulmonary cyanosis is that it is "warm," as hypercapnia dilates peripheral vessels.
- Specific rashes: Herpes labialis/nasalis is a frequent companion of pneumonia. Erythema nodosum (Erythema nodosum) in the form of dense, color-changing nodules on the shins is a characteristic sign of sarcoidosis.
- Clubbing (Hippocratic fingers): thickening of the terminal phalanges ("drumstick fingers") and specific nail deformation ("watch-glass nails"). They occur in chronic suppurative processes (abscess, bronchiectasis) and bronchogenic carcinoma.
Briefly: answers to topical questions
What topographical vertical lines are identified on the chest surface for percussion and auscultation?
To accurately describe the localization of pathological processes and organ projections on the thoracic wall, the following conventional vertical lines are used:
- Anterior median line (linea mediana anterior) — from the jugular notch down the middle of the sternum.
- Sternal lines (lineae sternales) — along the margins of the sternum.
- Parasternal lines (lineae parasternales) — midway between the sternal and midclavicular lines.
- Midclavicular line (linea medioclavicularis) — drawn vertically through the midpoint of the clavicle.
- Anterior axillary line (linea axillaris anterior) — runs along the anterior fold of the axilla.
- Midaxillary line (linea axillaris media) — runs through the apex of the axilla.
- Posterior axillary line (linea axillaris posterior) — runs along the posterior fold of the axilla.
- Scapular line (linea scapularis) — drawn through the inferior angle of the scapula.
- Paravertebral line (linea paravertebral) — runs midway between the scapular line and the spinous processes.
- Posterior median line (linea mediana posterior) — corresponds to the projection of the spinous processes of the thoracic vertebrae.
What pathological breathing rhythms (periodic breathing) can be detected during patient inspection?
Diagnostics distinguish four main types of pathological breathing, often associated with CNS lesions or severe metabolic disorders:
- Kussmaul breathing — uniform cycles characterized by slow, deep, and noisy inspiration followed by an enhanced expiration.
- Grocco's breathing — wave-like variation in breathing depth from weak and shallow to deeper and back, but without pauses (apnea) between the waves.
- Cheyne-Stokes respiration — periodic breathing with a period of apnea, after which the depth of inspirations increases to a noisy maximum and then gradually decreases.
- Biot's respiration — alternation of uniform, rhythmic, and deep respiratory movements with periods of apnea.
To quickly recall the causes of asymmetry: "Plus-volume" (fluid, air, massive infiltration) causes bulging. "Minus-volume" (atelectasis, sclerosis, adhesions) pulls tissues inward and causes retraction.
Class and exam questions
Why is pulmonary cyanosis called "warm"?
In respiratory failure, carbon dioxide accumulates, causing peripheral vasodilation. Because of this, unlike in cardiac pathology, the extremities remain warm.
How to differentiate small and large airway obstruction by the type of dyspnea?
When small bronchi are narrowed, it is difficult for the patient to exhale (expiratory dyspnea). If large airways, the larynx, or the trachea are blocked, inspiration will be difficult and noisy (inspiratory dyspnea).
What is clubbing (Hippocratic fingers)?
This is a change in the distal extremities: nails acquire a "watch-glass" shape, and phalanges thicken like "drumsticks." The symptom indicates long-standing pulmonary pathology (chronic suppuration, cancer, fibrosing alveolitis).
What else to study on this topic
- Pathogenesis of pulmonary cyanosis: shunting and impaired diffusion capacity
- Peripheral cyanosis in superior vena cava syndrome
- Development of cor pulmonale and edema syndrome
- Mechanisms of respiratory center regulation (role of hypoxia and hypercapnia)
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