Inspection

Respiratory Rate:

• Normally, it is 14 to 18/min (in adult).
• Increased rate of respiration is called tachypnoea (.20). Usually, it is faster in children, slower in the elderly.
•  Increased depth of respiration is called hyperpnoea.

Causes of tachypnoea (increased rate of respiration):

1. Physiological: Anxiety, fear, exercise or exertion.

2. Pathological:

• Respiratory causes: bronchial asthma, pneumonia or other respiratory infections, pulmonary embolism, COPD.
  
• Cardiac causes: acute anterior myocardial infarction, acute left ventricular failure.
  
• Others: Fever, metabolic acidosis (diabetic ketoacidosis, lactic acidosis and renal failure), hysterical conversion reaction (HCR) and cerebrovascular disease (CVD).

Causes of reduced respiratory rate:

• Sleep.
• Depression of respiratory centre (by narcotic drugs such as morphine, in some CVD).

Abnormal Breathing:

1. Kussmaul’s breathing (air hunger): It is characterized by deep, sighing, rapid respiration at

regular rate due to stimulation of respiratory centre. Causes are (due to metabolic acidosis):

• Diabetic ketoacidosis.
•  Renal failure.
• Occasionally in severe respiratory failure and hepatic failure.

2. Ataxic breathing (Biot breathing): Characterized by irregular respiration in timing and depth. It indicates brain stem damage (due to CVA and head injury).

3. Cheyne–Stokes breathing: Cyclical variation in the depth of respiration characterized by gradual deepening of respiration till a maximum is attained, followed by gradual diminished respiration till a period of apnoea occurs (apnoea alternates with hyperpnoea). It is due to diminished sensitivity of respiratory centre to CO2. The cycle may last for 2 min. Causes are:

• Acute LVF (or severe heart failure).
• Coma due to any cause.
• Brain damage due to head injury and cerebral haemorrhage.
• Narcotic drug poisoning.
• Sometimes, at high altitude.

4. Apneustic breathing: Characterized by a post-inspiratory pause in breathing. It indicates pontine damage.

5. Paradoxical breathing: If abdomen sucks inward during inspiration. It indicates diaphragmatic paralysis.

Shape of the Chest (Deformity or Asymmetry):

1. Asymmetry: Whether any kyphosis, scoliosis, lordosis, flattening of chest.

2. Pigeon chest (pectus carinatum): It is localized prominence, outward bowing of sternum and costal cartilage. Causes are:

• Congenital.
• Ricket.
•  Marfan’s syndrome.
•  Homocystinuria.
• Repeated respiratory infection in childhood (causing strong diaphragmatic contraction as the
• thorax remains pliable).
• Bronchial asthma since childhood.
• Osteogenesis imperfecta.

3. Pectus excavatum (funnel chest, saucer or cup): It is the localized depression at the lower end of sternum or rarely depression of whole length of the body of sternum and of costal cartilage attached to it. It does not usually cause any problem. Rarely, it may cause lung and cardiac problems (pulmonary hypertension and cor pulmonale). Causes are:

• Congenital (common cause).
•  Ricket.
•  Marfan’s syndrome.
• Homocystinuria.
•  Osteogenesis imperfecta.

4. Harrison sulcus: It is a groove directed outward and slightly downward from the sternum in the lower part of the chest anteriorly, along the line of attachment of diaphragm (due to indrawing of ribs). Causes are:

•  Chronic bronchial asthma since childhood.
•  Ricket.

5. Barrel-shaped chest: Antero-posterior diameter of the chest is increased than the transverse diameter, ribs look more horizontal, intercostal spaces appear full, chest remains like full inspiration, subcostal angle .90° (normally 90° or less). It is detected by placing two hard boards, one on the front and another on the back of the chest and measure the distance between these two for antero-posterior diameter (normal ratio of A:P diameter is 5:7). Causes are:

•  Emphysema.
•  Severe chronic asthma.

6. Rickety rosary: It is the prominent swelling at the costo-chondral junction due to rickets.

7. Flail chest: It occurs in multiple fractures of ribs and sternum. There is paradoxical inward movement of chest during inspiration.

8. Thoracoplasty: In this procedure, some ribs are resected on one side of the chest to achieve permanent collapse of the lung. Usually one side of the upper part of the chest is depressed. Previously, it was done to treat pulmonary tuberculosis (before the development of chemotherapy).

Reduction of Movement of Chest:

Any respiratory disease is associated with reduction or restricted movement of chest on the affected

side. Causes are:

1. Unilateral:

• Pleural effusion.

• Pneumothorax.

• Collapse.

• Fibrosis.

• Consolidation.

2. Bilateral:

• COPD (especially in emphysema).

• Diffuse bilateral pulmonary fibrosis.