DIAGNOSIS PENYAKIT PARU

dr Indah Rahmawati, SpP Blok Respirasi, 04-03-14

PENDAHULUAN
Kelainan pada jaringan paru, pleura atau dinding toraks perubahan sifat fisik pemeriksaan fisik (tanda penyakit) 1. Bentuk / ukuran toraks

2. Pergerakan
3. Penghantaran getaran

BENTUK/UKURAN TORAKS

Volume jaringan paru berkurang

Atelektasis, Fibrosis, Schwarte

Volume jaringan bertambah

Emfisema, efusi pleura, pneumotoraks Volume jaringan paru tetap Konsolidasi

PERGERAKAN
Pergerakan dinding toraks menurun 1. Ggn otot pernapasan (poliomyelitis) 2. Tahanan ddg toraks me (obesitas) 3. Pengembangan paru me (fibrosis, atelektasis) 4. Penekanan jaringan paru (efusi, tumor, pneumotoraks) 5. Hiperinflasi jaringan paru

PENGHANTARAN GETARAN
Suara timbul dari getaran NADA ditentukan oleh frekuensi, panjang dan diameter saluran napas semakin perifer makin kecil/pendek nada tinggi INTENSITAS (kekerasan) ditentukan oleh energi untuk timbulkan suara & frekuensi menurun bila lewat pergantian medium getaran dipantulkan/diresorbsi sedikit diteruskan SIFAT/KUALITAS SUARA bernapas, bicara, berbisik

PEMERIKSAAN DASAR PARU

INSPEKSI PALPASI PERKUSI AUSKULTASI

INSPEKSI
Bentuk/ukuran toraks
Pelebaran vena (SVCS), spider naevi, Ginekomasti, posisi trakhea

Otot bantu napas, tulang iga, sela antar iga, posisi dan bentuk tulang, napas cuping
Tipe dan frekuensi napas Jari tabuh/gada, pembesaran kelenjar limfe

Lymph node enlargment

Trachea position

Pectus Carinatum

Pectus Excavatum

Abnormal Finding
Skin and soft tissue Puncture sites and Scars (Thoracentesis, FNAB, Chest tube, Surgical scars) Prominent collateral veins (SVC syndrome) Swelling (Recent thoracentesis, Empyema, Mesothelioma, Empyema necessitatis, Cystic hygroma) Erythema (Empyema) Warmth (Empyema) Tenderness ( Empyema, Rib and chest wall lesions ) Subcutaneous nodules (Metastasis)

TUBERKULOSIS

Respiratory Rate and Pattern of Breathing

To evaluate one of the vital signs. Method Of Exam The patient should not be aware that you are counting his respiratory rate. Count the RR while pretending to take the patient's pulse. Note the rate, pattern and comfort of respiration. Normal: Resting rate : 10-14 per min., regular with no apparent discomfort.. Chest wall and abdomen expand during inspiration and is symmetrical. Periodic deep breathing (Sighs) < 5/ minute.

Abnormal Finding
Minor changes in rate and rhythm of respiration occur due to anxiety and while it may represent an abnormality, it may not be significant. Rate : <10/min: Bradypnea: (Narcotics, raised intracranial tension, myxedema) >20/min: Tachypnea: (Interstitial, vascular and multitude of diseases, anxiety)

Abnormal Finding
Pattern : Cheyne-stokes breathing Periodic breathing------> Cyclical increase and decrease in depth of respiration (CHF, Cerebrovascular insufficiency) Kussmaul breathing Slow deep breathing: (Ketoacidosis) Biot's breathing: Totally irregular with no pattern:(CNS injury) Sighs Periodic deep breathing: : (Anxiety state)

Abnormal Finding
Pattern Abdominal paradox: Instead of simultaneous chest and abdominal expansion with inspiration abdomen retracts while chest expands: (Diaphragmatic paralysis) Thoracic paradox: On the side of unstable chest wall hemithorax retracts while the normal side expands with inspiration: (Flail chest) Pursed lip breathing: With lips pursed patient controls expiration slowly: (Obstructive lung disease) No abdominal component : ( Acute abdomen) No thoracic component: (Pleurisy, Chest wall pain, Ankylosing spondylitis)

Abnormal Finding
Discomfort Labored breathing: (Heart and Lung diseases) Orthopnea: Unable to assume supine position because of worsening shortness of breath: (CHF, Diaphragmatic paralysis, SVC syndrome, Anterior mediastinal mass) Platypnea: Unable to erect position because of worsening shortness of breath, more comfortable in supine position (Pulmonary spiders in cirrhotic)

Chest: Observation
To evaluate chest wall and symmetry of hemithorax . To assess negative pressure in the pleural space Method Of Exam Stand either at foot end or by the head end and observe the symmetry of hemithorax. Inspect the chest all around with the patient in sitting position. Observe the intercostal space, supraclavicular fossa and tracheal movement during quiet respiration. Examine the skin and soft tissue.

Trachea Position
To evaluate the position of the upper mediastinum Method Of Exam 1. Position yourself in front of the patient and note the position of the thyroid cartilage. 2. Inspect for the symmetry of clavicular insertion of both sternomastoids. 3. Tracheal Position: Gently bend the head to relax the sternomastoids. By inserting your finger between the trachea and sternomastoid, assess and compare the space on either side. Normal: Trachea is slightly tilted to right.

Abnormal Finding
Tracheal deviation ----> E/ the diseases of : Lung Pleural Mediastinal Chest wall Lung : Pull: ( Loss of lung volume) Atelectasis Fibrosis Agenesis Surgical resection Push: (Space occupying lesions) Large mass lesions

Abnormal Finding
Pleura Push: Pneumothorax Pleural effusion Pull: Pleural fibrosis Mediastinal masses and thyroid tumors Kypho-scoliosis

EFUSI PLEURA

PNEUMOTORAKS

KANKER PARU

Chest: Observation
To evaluate chest wall and symmetry of hemithorax . To assess negative pressure in the pleural space Method Of Exam Stand either at foot end or by the head end and observe the symmetry of hemithorax. Inspect the chest all around with the patient in sitting position. Observe the intercostal space, supraclavicular fossa and tracheal movement during quiet respiration. Examine the skin and soft tissue.

Abnormal Finding
Chest asymmetry Kyphoscoliosis Larger hemithorax : (Pneumothorax, Pleural effusion) Smaller hemithorax: (Atelectasis, Pleural fibrosis, Agenesis of Lung) Increased pleural negative pressure: Unilateral (airway obstruction) or bilateral (COPD, DIF, Asthma) Intercostal and supraclavicular fossa retraction Downward movement of trachea with quiet inspiration

Chest Expansion
To assess overall chest expansion with inspiration. To identify the side of abnormality Method Of Exam Overall chest expansion: Take a tape and encircle chest around the level of nipple. Take measurements at the end of deep inspiration and expiration.

Chest Expansion
Method Of Exam Symmetry of chest expansion: Have patient seated erect or stand with arms on the side. Stand behind patient. Grab the lower hemithorax on either side of axilla and gently bring your thumbs to the midline. Have patient slowly take a deep breath and expire. Watch the symmetry of movement of the hemithorax. Simultaneously, feel the chest expansion. Place your hands over upper chest and apex and repeat the process. Next, stand in front and lay your hands over both apices of the lung and anterior chest and assess chest expansion.

Cyanosis of nail beds

Clubbing of the digits

JARI TABUH

PALPASI
Getaran suara (fremitus vokal) Intensitas me pada jaringan paru padat (konsolidasi) sifat selective transmitter hilang getaran tinggi dihantarkan Intensitas me pada atelektasis, efusi atau pneumotoraks, obesitas

Voice transmission
Method Of Exam Patient to say "99" "1, 2, 3" or "E" Each time you lay your hands or listen All around the chest and compare : Dorsal surface of your fingers or ulnar surface of your hand (tactile fremitus) Listen with diaphragm (vocal resonance)

PERKUSI
Perkusi timbulkan getaran dinding dada menjalar ke parenkim paru

Jumlah udara > normal hipersonor

Jumlah jaringan padat > normal redup

Lungs: Percussion
To assess the amount of air in lung. To assess movement of the diaphragm Proper Technique 1. Hyperextend the middle finger of one hand and place the distal interphalangeal joint firmly against the patient's chest. 2. With the end (not the pad) of the opposite middle finger, use a quick flick of the wrist to strike first finger. 3. Categorize what you hear as normal, dull, or hyperresonant.

Percussion
resonance or hyperresonant
hyperinflated lungs (emphysema) pneumothorax

Diaphragmatic excursion
diaphragm normally moves about 3-4 cm and less in COPD and neuromuscular diseases

AUSKULTASI
SUARA NAPAS SUARA TAMBAHAN SUARA BISIK SUARA PERCAKAPAN

SUARA NAPAS
Aliran udara saat bernapas sebabkan putaran & benturan getaran suara via lumen dan dinding bronkus Alveoli sebagai selective transmitter menahan getaran frekuensi tinggi Vesikuler (normal) I > E tanpa putus Bronkial E > I ada suara terputus

 Vesikuler menguat anak, orang kurus (bilateral) Vesikuler melemah pneumotoraks, efusi, obstruksi trakea Bronkhial terdengar pada paru yang konsolidasi, kompresi dg bronkus terbuka

Auscultation

SUARA TAMBAHAN
Suara tambahan dari paru (ronki = crackle) Sekret saluran napas, penyempitan lumen atau terbukanya alveoli yang kolaps Suara tambahan dari pleura Akibat gesekan pleura yang kasar, jelas saat inspirasi Suara tambahan dari mediastinum Pneumomediastinum (terputus, seirama napas dan denyut jantung)

SUARA RONKI
1. 2. 3. Ronki basah (suara terputus) Inspirasi RB kasar (sekret banyak di sal nps besar) RB sedang (sekret di sal nps kecil/sedang) RB halus/krepitasi (terbukanya mendadak alveoli yang kolaps/terisi eksudat) Ronki kering ( tidak terputus) Ekspirasi 1. Nada rendah (sonourous) obstruksi saluran napas besar 2. Nada tinggi (sibilan = wheeze) obstruksi sal napas kecil

SUARA BISIK (PECTORILOQUE)

Tidak ada getaran pita suara, nada tinggi Jelas terdengar di laring, semakin ke bawah semakin lemah/kabur, di jaringan paru tidak terdengar Konsolidasi/atelektasis kompresi dgn bronkus terbuka jelas, keras, nada tinggi dengan fase ekspirasi panjang

SUARA PERCAKAPAN (BRONKOFONI)

Ucapkan kata : 1, 2, 3 atau 9 berulang Jelas terdengar di laring, semakin ke bawah semakin lemah/kabur, di jaringan paru tidak terdengar Bronkofoni positip (jelas) Bronkofoni negatif (tidak jelas) Egofoni (bronkofoni dg kualitas suara nasal)

Abnormal Finding
Decreased: (Pleural effusion, Pneumothorax, Atelectasis, Mass) Increased: (conditions giving bronchial breathing) Bronchophony: (Normal) Whispering pectoroliquy ( Normal ) Qualitative: Egophony

Bronchopony Normal

Whispering

Normal

Egophony

Auscultation
Normal lung sounds: Tracheobronchial or bronchial Loud, coarse, tubular High pitch, there is gap Tubulent gas flow Normal at over upper trachea or over manubrium Abnormal in perifer if there is consolidation (infiltrat in alveoli) Inspiration < or = expiration)

 Bronchovesicular
softer, less coarse intermediate airways Medium pitch Normal sound over carina area and between upper scapulae Abnormal in perifer if there is consolidation Inspiration = expiration (1:1)

 Vesicular
softest, smooth Low pitch Inspiration > expiration ( 3:1) laminar gas flow largest surface area Normal sound over most of lung

Adventitious lung sounds

Crackles or rales short, intermittent sounds air passing through fluid in the small airways air suddenly opening up ateletatic lung units decreased reduced transmission and intensity of sounds when compared to normal sounds in the same area
e.g., hyperinflated lungs, pleural effusion, obese

Crackles

Fine crackles

Coarse crackles

Absent no lung sounds noticeable e.g., pneumothorax, pneumonia

Wheezing high pitched, continous sound heard normally on exhalation associated with narrowed airways
bronchospasm, bronchoconstriction, mucosal edema, foreign body obstr

Rhonchus
low pitched, continuous sound associated with excessive secretions in the airways which narrows the lumen of large airways tends to clear with coughing

Stridor
hoarse sound heard on inspiration common post extubation because of tracheal swelling and edema causing narrowing of the upper airway treated with racemic epinephrine, its alpha effects reduce mucosal swelling

Bronchial
Tubular or tracheal sounds which are transmitted from the trachea through consolidation at the bases Sounds transmit better through solid than air Egophony: E to A Whispered pectoriloquy: 99 Bronchophony: patients words are heard clear through consolidation, but muffled in normal lungs

Pleural friction rub

Creaky or grating sounds as the patient breathes in and out similar to old leather when it is bent to and fro Related to inflamed or irritated pleural surface
pleurisy from pneumonia is common

References
1. Mangunnegoro H. Pemeriksaan Jasmani Paru 2. Luckman, Sorensens. Assesment of respiratory disorders. In:Medical-Surgical Nursing. A Psychophysiologic approach. Manila; C&E Publishing CO; 2000.p.913-40 3. UCSD School of Medicine and VA Medical Center, San Diego, California. A Practical Guide to Clinical Medicine. The Lung Exam. Available at : http://medicine.ucsd.edu/clinicalmed/lung.htm . Accessed January 10th , 2006. 4. Murray JF. History and physical examination. In: MurrayNadel. Textbook of respiratory medicine.3rd ed. Philadelphia; WB. Saunders Company:2000.p.585-605