Inspection in a Patient with Bronchiectasis

• General Appearance:
  Patient may appear chronically ill, with evidence of weight loss or muscle wasting in advanced cases.

• Hands:
  Look for digital clubbing, a classic sign in bronchiectasis, especially in long-standing disease.

• Face and Mouth:
  Check for central cyanosis (bluish lips/tongue) indicating hypoxemia, and signs of chronic respiratory distress.

• Chest:

  • Shape: Chest is usually normal in shape, but may show mild deformities if disease is severe or longstanding.

  • Symmetry: Inspect for symmetry of chest movement. In localized or severe disease, reduced movement may be seen over the affected area.

  • Chest Movements: Observe for reduced or asymmetrical chest expansion, particularly in the lower zones (where bronchiectasis is often most pronounced).

  • Trachea and Apex Beat: Usually central, but may be displaced in cases with significant volume loss or fibrosis.

  • Other Findings:

    • Look for surgical scars (from previous interventions), dilated veins (rare), sinuses, or evidence of previous chest drains.

    • Note any intercostal indrawing or use of accessory muscles in severe disease.

    • Crowding of ribs, supraclavicular hollowing, or infraclavicular flattening may be seen if there is significant volume loss.

• Respiratory Effort:
  Observe for tachypnea, use of accessory muscles, alar flaring, or pursed-lip breathing in advanced or exacerbated cases.

• Bedside Clues:
  Sputum pot with copious, purulent, often foul-smelling sputum may be present, reflecting the hallmark productive cough of bronchiectasis.

Summary of Key Inspection Findings in Bronchiectasis:

• Digital clubbing

• Copious sputum production (often visible at bedside)

• Possible central cyanosis

• Reduced chest movement over affected areas

• Signs of chronic illness (weight loss, muscle wasting)

• Chest wall deformities or scars in advanced/treated cases

Inspection of the Respiratory System in a Patient with COPD

• General Appearance:
  The patient may appear thin, with muscle wasting, and may adopt a “tripod” position (leaning forward, supporting themselves with their arms) to ease breathing. Signs of respiratory distress such as tachypnea and pursed-lip breathing may be present.

• Hands and Face:
  Look for peripheral cyanosis (bluish discoloration of lips and fingers) due to hypoxemia. Nicotine staining may be seen on the fingers. Clubbing is generally absent in COPD but may be present if there is co-existing bronchiectasis or lung cancer.

• Chest Shape:
  The chest is often barrel-shaped (increased anteroposterior diameter). Intercostal spaces may appear widened.
  There may be supraclavicular hollowing and flattening of the infraclavicular region in severe cases.

• Symmetry and Movement:
  Observe for reduced chest expansion, often bilaterally and symmetrically. In advanced disease, lower chest movement may be particularly diminished.

• Trachea and Apex Beat:
  The trachea is usually central unless there is significant lung volume loss or hyperinflation. The apex beat may be difficult to localize due to hyperinflated lungs.

• Accessory Muscles:
  Prominent use of accessory muscles of respiration (sternocleidomastoid, scalene) is common, especially during exacerbations.

• Other Findings:

  • Intercostal indrawing (recession) may be seen during inspiration.

  • Alar flaring (nostril flaring) may be present in severe respiratory distress.

  • Look for surgical scars (from previous interventions), dilated veins, or chest wall deformities.

  • Cyanosis and evidence of right heart failure (pedal edema, raised JVP) may be seen in advanced cases.

• Bedside Clues:
  Presence of inhalers, nebulizers, or oxygen equipment at the bedside.

Inspection – Pleural Effusion

• Shape of the chest:
  The affected side may appear full or bulged, especially in the lower and lateral aspects.

• Symmetry:
  Asymmetry may be seen with the affected side appearing larger or more prominent.

• Position of trachea:
  Trachea may be shifted to the opposite (contralateral) side in large effusions.

• Apex beat:
  Apex beat may not be visible or may be shifted away from the side of effusion.

• Chest movement in all areas:
  Chest movement is reduced or absent over the affected side, particularly in the lower zones.

  • Supraclavicular: Usually normal

  • Infraclavicular: May be reduced on the affected side

  • Mammary: Reduced on the affected side

  • Inframammary: Markedly reduced or absent on the affected side

  • Axillary: Reduced on the affected side

  • Infraaxillary: Reduced on the affected side

  • Suprascapular: Usually normal

  • Infrascapular: Reduced on the affected side

  • Interscapular: May be reduced on the affected side

• Dilated veins, scars, sinuses:
  Dilated veins may be seen in chronic or large effusions. Scars may indicate previous interventions (e.g., chest tube). Sinuses are rare.

• Crowding of ribs:
  Ribs may appear more widely spaced over the effusion due to underlying fluid.

• Supraclavicular hollowing:
  Usually not present.

• Infraclavicular flattening:
  May be present in massive effusion.

• Drooping of shoulder:
  May be seen on the affected side in long-standing cases.

• Usage of accessory muscles of respiration:
  May be increased if the patient is in respiratory distress.

• Alar flaring:
  May be present in severe respiratory distress.

• Intercostal in-drawing:
  Usually absent over the area of effusion; may be seen above the level of the effusion due to increased work of breathing.

Inspection – Pneumonia

• Shape of the chest:
  Usually normal; rarely, mild fullness or flattening over the affected area in severe or lobar pneumonia.

• Symmetry:
  Chest is generally symmetrical, but movement may be reduced on the affected side or area.

• Position of trachea:
  Usually central. Tracheal shift is uncommon unless there is massive consolidation or associated effusion/collapse.

• Apex beat:
  Usually not visible or displaced.

• Chest movement in all areas:
  Chest movement is reduced over the affected area (commonly one lower zone).

  • Supraclavicular: Normal

  • Infraclavicular: Normal

  • Mammary: Normal or slightly reduced if upper lobe involved

  • Inframammary: May be reduced if lower lobe involved

  • Axillary: May be reduced on affected side

  • Infraaxillary: May be reduced on affected side

  • Suprascapular: Normal

  • Infrascapular: May be reduced on affected side

  • Interscapular: May be reduced if consolidation is posterior

• Dilated veins, scars, sinuses:
  Not seen in uncomplicated pneumonia.

• Crowding of ribs:
  Usually absent; may be seen in associated collapse.

• Supraclavicular hollowing:
  Not present.

• Infraclavicular flattening:
  Not present.

• Drooping of shoulder:
  Not seen.

• Usage of accessory muscles of respiration:
  May be present if the patient is in respiratory distress.

• Alar flaring:
  May be seen in children or severe cases.

• Intercostal in-drawing:
  May be seen in severe pneumonia, especially in children.

Summary:
On inspection, pneumonia typically presents with a normal chest shape, possible reduction of movement over the affected area, and use of accessory muscles or intercostal in-drawing in severe cases. Trachea and apex beat are usually central, and no dilated veins, scars, or sinuses are seen.

Inspection – Lung Cavity

• Shape of the chest:
  May be normal or show localized flattening or retraction over the affected area, especially if the cavity is chronic and associated with fibrosis.

• Symmetry:
  Asymmetry may be seen if there is significant volume loss or retraction on the affected side.

• Position of trachea:
  Trachea may be central or pulled towards the side of the cavity if there is associated fibrosis and volume loss.

• Apex beat:
  Apex beat may not be visible or may be shifted towards the affected side in cases of significant volume loss.

• Chest movement in all areas:
  Chest movement is reduced over the affected area, most commonly in the upper zones (supraclavicular, infraclavicular, mammary, suprascapular, infrascapular).

  • Supraclavicular: Reduced on affected side

  • Infraclavicular: Reduced on affected side

  • Mammary: May be reduced on affected side

  • Inframammary: Usually normal

  • Axillary: May be reduced if cavity is extensive

  • Infraaxillary: Usually normal

  • Suprascapular: Reduced on affected side

  • Infrascapular: May be reduced if cavity is large and posterior

  • Interscapular: May be reduced if upper lobe is involved

• Dilated veins, scars, sinuses:
  Old surgical scars (from previous interventions such as thoracoplasty or drainage) may be present. Sinuses may be seen in chronic cases with empyema necessitans. Dilated veins are uncommon.

• Crowding of ribs:
  Crowding of ribs may be seen over the affected area due to volume loss.

• Supraclavicular hollowing:
  May be present on the affected side, especially in chronic upper lobe disease.

• Infraclavicular flattening:
  May be present on the affected side.

• Drooping of shoulder:
  May be seen on the affected side in long-standing cases with significant fibrosis and volume loss.

• Usage of accessory muscles of respiration:
  May be increased if the patient is in respiratory distress.

• Alar flaring:
  Usually not present unless in severe distress.

• Intercostal in-drawing:
  May be seen over the affected area due to fibrosis and volume loss.

Summary:
On inspection, a lung cavity may present with localized flattening or retraction, reduced chest movement in the upper zones, possible supraclavicular hollowing, infraclavicular flattening, crowding of ribs, and old surgical scars. Tracheal and apex beat deviation towards the affected side may be seen in chronic cases with fibrosis and volume loss. Accessory muscle use and intercostal in-drawing may be present if there is significant respiratory compromise.

Inspection – Pulmonary Fibrosis

• Shape of the chest:
  The chest may show flattening or retraction, especially in the lower zones. In advanced cases, the affected side may appear smaller.

• Symmetry:
  Asymmetry may be seen if fibrosis is more marked on one side, with reduced chest movement over the affected area.

• Position of trachea:
  The trachea may be shifted towards the side of fibrosis in cases of significant volume loss.

• Apex beat:
  The apex beat may not be visible or may be shifted towards the affected side.

• Chest movement in all areas:
  Chest movement is generally reduced, especially in the lower zones and over the affected side.

  • Supraclavicular: May be normal or reduced

  • Infraclavicular: May be normal or reduced

  • Mammary: May be reduced

  • Inframammary: Reduced

  • Axillary: Reduced

  • Infraaxillary: Reduced

  • Suprascapular: May be normal or reduced

  • Infrascapular: Reduced

  • Interscapular: Reduced

• Dilated veins, scars, sinuses:
  Scars may be present from previous interventions (e.g., chest drain). Dilated veins and sinuses are uncommon.

• Crowding of ribs:
  Crowding of ribs may be seen over the affected area due to volume loss.

• Supraclavicular hollowing:
  May be present, especially in upper lobe fibrosis.

• Infraclavicular flattening:
  May be seen on the affected side.

• Drooping of shoulder:
  May be present on the affected side in long-standing fibrosis.

• Usage of accessory muscles of respiration:
  May be seen in advanced disease or during respiratory distress.

• Alar flaring:
  Usually not present unless the patient is in severe respiratory distress.

• Intercostal in-drawing:
  May be seen in advanced cases due to increased work of breathing.

Summary:
Inspection in pulmonary fibrosis typically reveals a flattened or retracted chest (especially in the lower zones), reduced and asymmetrical chest movement, possible tracheal and apex beat shift towards the affected side, crowding of ribs, supraclavicular hollowing, infraclavicular flattening, and sometimes scars from previous interventions. Accessory muscle use and intercostal in-drawing may be observed in advanced disease.

General Inspection

Q1. What are the main points to look for during inspection of the chest in a respiratory case?
A: Shape of the chest, symmetry, position of trachea, apex beat, chest movement in all areas, presence of dilated veins, scars, sinuses, crowding of ribs, supraclavicular hollowing, infraclavicular flattening, drooping of shoulder, use of accessory muscles, alar flaring, and intercostal in-drawing.

Bronchiectasis

Q2. What are the typical inspection findings in a patient with bronchiectasis?
A: Digital clubbing, possible cyanosis, normal or mildly deformed chest shape, reduced movement in the lower zones (especially infrascapular and infraaxillary), possible old surgical scars, and sputum pot with copious purulent sputum.

Q3. Why is clubbing seen in bronchiectasis?
A: Due to chronic hypoxia and long-standing suppurative lung disease.

Pleural Effusion

Q4. What inspection findings suggest pleural effusion?
A: Fullness or bulging of the affected hemithorax, asymmetry, reduced or absent chest movement on the affected side, possible tracheal and apex beat shift to the opposite side, crowding of ribs, and in chronic cases, drooping of the shoulder or dilated veins.

Q5. Why is chest movement reduced in pleural effusion?
A: Because the fluid in the pleural space restricts lung expansion on the affected side.

Pneumonia

Q6. What do you expect to find on inspection in a case of pneumonia?
A: Usually normal chest shape, but reduced movement over the affected area, use of accessory muscles or intercostal in-drawing in severe cases, and generally central trachea and apex beat.

Q7. Why is chest movement reduced over the affected area in pneumonia?
A: Due to local consolidation and inflammation, which restricts lung expansion.

Lung Cavity

Q8. What inspection findings are seen in a patient with a lung cavity?
A: Localized flattening or retraction, reduced movement in the upper zones, possible supraclavicular hollowing, infraclavicular flattening, crowding of ribs, old surgical scars, and tracheal/apex beat deviation towards the affected side if there is fibrosis.

Q9. Why might there be supraclavicular hollowing in lung cavity disease?
A: Due to volume loss and fibrosis, especially in upper lobe disease.

Pulmonary Fibrosis

Q10. What are the main inspection findings in pulmonary fibrosis?
A: Flattened or retracted chest (especially lower zones), reduced and asymmetrical chest movement, tracheal and apex beat shift towards the affected side, crowding of ribs, supraclavicular hollowing, infraclavicular flattening, and sometimes scars from previous interventions.

Q11. Why does the trachea shift towards the side of fibrosis?
A: Due to volume loss and contraction of the affected lung tissue.

Accessory Muscles and Other Signs

Q12. When do you see use of accessory muscles during inspection?
A: In conditions causing increased work of breathing, such as severe COPD, asthma exacerbation, advanced fibrosis, or respiratory distress of any cause.

Q13. What is intercostal in-drawing and when is it seen?
A: It is the inward movement of intercostal spaces during inspiration, seen in severe airway obstruction or increased negative intrathoracic pressure.

General Integration

Q14. How do you differentiate between volume loss and volume gain on inspection?
A: Volume loss (fibrosis, collapse) shows flattening, retraction, rib crowding, and shift of trachea/apex beat towards the lesion. Volume gain (effusion, pneumothorax) shows fullness, bulging, rib spacing, and shift away from the lesion.

Q15. Why is it important to inspect the entire chest in all zones?
A: Because different diseases affect different areas (e.g., fibrosis often lower zones, cavities upper zones, effusion lower lateral), and comparing all zones helps localize and characterize pathology.