Stigmata of Chronic Obstructive Pulmonary Disease (Stanford Medicine 25)

This Stanford Medicine 25 video was created in conjunction with Stanford's AIM lab teaching the examination of the spleen.

The Stanford Medicine 25 is a Stanford School of Medicine initiative to teach and promote the bedside physical exam. Here you will find videos teaching bedside physical exam techniques.

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[Philosopheraptor]

1. Tripod position
Allows the scalene muscle (an accessory muscle of the neck) to yank the rib cage & aid in its expansion. Also, sitting forwards pushes the abdominal contents upwards, increasing the curvature of the diaphragm and improving its effectiveness. The tripod position optimizes the mechanics of respiration by taking advantage of the accessory muscles of the neck and upper chest to get more air into the lungs. With the position of the arms secure, contraction of the pectoralis results in elevation of the anterior wall of the chest.

The tripod position may be seen in cases of pericarditis as well since leaning forward tends to alleviate the chest pain of pericarditis.


2. Dahl’s sign (or thinker’s sign)
Dermatitis (hyperpigmentation & hyperkeratosis or thickening) on the thighs from prolonged resting of the palms on the thighs while in the tripod position.
COPD patients tend to sit forwards with their arms resting on their thighs (tripod position), leading to chronic erythema of the skin at the points of contact. Over time,  hemosiderin released from RBCs trapped in the skin causes a brown discoloration of said skin.


3. Flaring of the ala nasi
4. Pursed-lip breathing – Lips pursed during exhalation in order to prolong the expiratory phase and reduce air trapping.
5. Hollowing (cupping) of the supraclavicular fossa
6. Hollowing of the subclavicular fossa
7. Sternocleidomastoid muscle (SCM) hypertrophy
8. Inspiratory descent of the trachea
9. Descent of the laryngeal prominence (Adam’s Apple) during inspiration caused by the flattened diaphragm pulling on the taut pericardial sac &, thus, the trachea during contraction.


10. Prominent sternal angle of Louis
11. Exaggerated thoracic kyphosis
12. Increased anteroposterior diameter of the chest (barrel chest)
13. Harrison's sulcus
Hourglass appearance of the lower thoracic cage (subcostal grooves forming on the patient’s sides) as the diaphragm pulls the rib cage in as it contracts during inspiration.


14. Obtuse subcostal angle
– a normal subcostal angle is acute (< 90°).

15. Hoover’s sign
Narrowing of the subcostal angle (which should normally widen) upon inhalation due to the inward pull on the rib cage by the flattened diaphragm as it contracts in a horizontal fashion.

[shahbazalikhawaja]

the signs that he talked about in the video are

stooped posture or tripod position
dahl's sign which is dermatitis of thighs because of resting your hands on the thighs too long for maintaining stooped posture
alar flaring
pursed lips while exhaling
hypertrophy of the sternocleidomastoid muscle
tracheal decent with inspiration
cupping of supra clavicular fossae
very prominent angle of louis
barrel chest
thoracic kyphosis
subcoastal angle widening
hour glass apperance of lower throacic cage (harrisons sulcus)
hoovers sign (narrowing of sub coastal angle with each diapragmatic contraction)

[hectorhere]

Wow probably the most informative video on COPD

[AylaFMD]

Thanks for clearing up the reasoning behind the tracheal tug maneuvre could not find it anywhere

[Tholius]

You have fantastic clinical education videos, and the physician in these videos explains things well. My suggestion is to either illustrate these signs with a real patient, or pause the video and show these signs when mentioned

[mohdil]

You keep us maintain our hope on getting proper clinical education. Many thanks to your efforts.

[rumit]

Awesomely informative. Thanks for posting these valuable videos for all to learn.

[richard-dfpr]

these videos are great hope more are made

[murtikaab]

suggestion ; when doctor tels example sing harrison sulcus its important to put image at the sides of the video

[DisabilityExams]

Nice video, but why not demonstrate with an actual COPD patient?

[mansir]

Why is there supraclavicular and infraclavicular hollowing in emphysema??

[ashisparajuli]

i would like to learn more that it is a obstructive disease

[arunkhatri]

Tracheal tug and inspiratory tracheal descent is so confusing can u plz explain it more ...

[PawelSmerdjakow]

Can these elevations on the patient be classified as keloids?

[oscargallardo]

thx good video is good to learn this i have been a send hand smoker sense i was born, i have trade smokering but it did not like the feeling that the nikitin gave so i said that not for me. thx

[dr_ricahontas]

Which books can we find these in? Or is just many years of experience and reading.

[steenystuff]

I have all these. Quite obviously too. I'm a 5'5" woman and will be 58 next month. I can slowly walk about 10 yds without oxygen, and maybe 50 yds slowly with oxygen. I'm on 2lts oxygen for min 16 hours a day. I weigh about 98lb (never weighed more than about 115lb). I found out I had COPD about 10 years ago. I'd love to know how long I've got left?

[dr.maidulislam]

Can any one please summarize all the signs of obstructive pulmonary disease

[dc.pentrumesteri]

Too bad I can't understand I'm from Romania with this severe mixed chronic bronchitis disease

[mason]

I'm just here for the hot guy lol