EXAMINATION OF RESPIRATORY SYSTEM

GENERAL EXAMINATION
INSPECTION
• Shape – Normal / Abnormal.
• Respiratory movement – Rate, Rhythm, Depth (abnormal types), Chest expansion,
Trachea, Apex beat.
PALPATION
• Lymph nodes.
• Tenderness.
• Chest expansion.
• Trachea.
• Apex ,VF.
PERCUSSION
• Auscultation – Breath sound (Intensity, Character, Differences)
• Added sound – Ronchi, Crepitation, Pleural rub.
 GENERAL EXAMINATION
• Physique.
• Voice.
• Breathlessness (BP, Pneumonia < 60mg DBP)
• Clubbing.
• Cyanosis & pallor.
• Intercostal recession.
• Use of accessory respiratory muscles – In dyspnoea, sternocleidomastoid,
platysma, pectoral muscles – elevation of sho with inspiration & aid respiration by
increase chest expansion (COPD)
• Lymph node – Ask the patient to sit down & stand behind him. Palpate one side of
neck at a time using fingers of one hand.
• Size & consistency – rubbery (Hodgkin’s lymphoma).
• Fixity
• Tender
• Discrete / Matted (TB)
• Lips & tongue for central cyanosis which almost always indicates poor
oxygenation of blood by lung. Peripheral cyanosis is due to poor peripheral
perfusion.
• A breathless patient may be using the accessory muscles of respiration
(Sternocleidomastoid), alae nasi.
• Voice – Hoarse (Damage to LRLN)
• Wheezing – Loudest on expiration.
• Stridor – Inspiratory noise.
 INSPECTION
SHAPE
• Normal chest is B/L symmetrical & elliptical in cross section.
• It may become asymmetrical by disease of lungs or bony cage (Rib/Vertebrae).
• Abnormal form of chest:---
• Pigeon chest – Elliptical with prominent sternum (Rickets).
• Scoliosis – Lateral bending of vertebral column.
• Kyphosis – Forward bending.
• Kyphoscoliosis – Tubercular spine.
• Barrel shape chest – AP diameter increase.
• Harrison sulcus – Groove running horizontally from the sternum outwards in the
lower part of chest.
• Funnel chest – Marked depression in lower end of sternum.
APPEARANCE
• Any scars from previous surgery, lumps, any lesion, flattening, over inflation.
• MOVEMENT OF CHEST
• Normally movements are equal on both sides.
• If movement is diminished in one side - likely to be side on which there is an abnormality.
• VENOUS PULSATION
• Venous pulse in the neck should be inspected.
• A raised venous pressure is usually indicative of right heart failure.
• Obstruction of SVC (Malignancy in upper mediastinum).
• TYPES OF RESPIRATION
• Abdominal – Males, Children.
• Thoracic – Female.
RESPIRATORY RATE & RHYTHM
• Regular / Irregular.
• Normal rate – 14 to 16 breaths / min.
• Rate faster – Tachypnoea (Children & old age).
• Dyspnoea – Breathlessness.
• Apnoea – Cessation of respiration.
• Cheyne – Stokes breathing.
• Alternate period of apnea & hyperventilation seen in LVF (e.g. Brain damage,
Voluntary hyperventilation)
• Kussmaul – Metabolic acidosis, Increased rate.
PALPATION

• Palpation – Feeling.
• Chest – Upper, Middle, Lower. (Front & back)
• Lymph node:-- Supraclavicular fossae, Cervical region, Axillary region.
• If they enlarged this may be due to spread of malignant disease from chest.
• Swelling & tenderness:--
• Patient may complain of pain.
• Feel gently as pressure may increase pain.
• Important in musculoskeletal pain.
Chest expansion:--
• Face the patient & place the fingertips of both hands on either side of the lower rib
cage, so that the tips of the thumb meet in the midline in front of – but not
touching the chest.
• A deep breath by the patient will increase the distance between the thumbs &
indicate the degree of expansion.
• If one thumb remains closure to the midline, this suggest diminished expansion on
that side.
• Normal – 4 to 8 cm.
• Tape 0 mark in middle just below the nipple. Breath in & out as deeply as
possible. Several reading as initial efforts are often shallower than subsequent
ones.
Trachea & heart
• Feel the trachea by putting the 2nd & 4th finger of the examining hand on each edge of
sternal notch & use the 3rd finger to assess whether the trachea is central or deviated to one
side.
• A slight deviation of trachea to right may be found on healthy people.
• Displacement of cardiac impulse without displacement of trachea may be due to scoliosis.
• Congenital funnel depression of sternum.
• Enlargement of left ventricle.
• In the absence of these condition, a significant displacement of cardiac impulse or trachea
or both – suggest shifting of mediastinum due to disease of lungs or pleura.
• Mediastinum may be pushed away from affected side by pleural effusion &
pneumothorax.
• Fibrosis & collapse – Pull the mediasternum towards the affected side.
Vocal fremitus
• The patient is asked to repeat a phase such as ninety nine.
• The examining hand feels distinct vibration when this is done.
• The flat of the hand, including the finger tips is far more sensitive / ulnar border on
intercostal space – B/L.
• It investigates how vibration generated in larynx or large airway – trachea – bronchi –
bronchiole to alveoli – chest wall – palm of subject.
• VF normal or equal on both sides.
• Increased VF – Consolidation.
• Reduced VF – Pleural effusion.
 PERCUSSION
• It is the procedure employed for setting up artificial vibrations in a tissue by
means of a sharp tap usually delivered with finger.
• Percussion is done for determining condition of the underlying tissue, lungs,
pleura, borders of the lung.
• Place the palm of your left hand on the chest, with your finger slightly separated.
• Remove the percussing finger quickly , so the note generated is not dampened.
• To percuss the upper posterior chest, ask the patient to fold their arm across the
front of their chest, thereby moving the scapula laterally.
• Don’t percuss the midline as this produces a dull note from the solid st. of the
thoracic spine & paravertebral musculature.
• If the organ lie superficially percussion should be light.
• If lies deep – Heavy percussion.
• Heavy percussion is done by using 2 or several fingers without any intermediate
fingers.
• Percussion of axilla – Hands on head.
• The subject should ordinarily be sitting up comfortably on a relaxed manner.
• Middle finger of left hand (pleximeter finger) is placed on the part to be percussed
& pressed firmly against it.
• The back of the distal interphalangeal joint is then struck with the tip of the
middle finger of the right hand.
• The movement should be at the wrist rather than at the elbow.
• The percussing finger is bent, so that at its terminal phalanx is at right angle & it strikes the other finger
perpendicularly.’
• No single point should be percussed more than twice.
• It should be carried out from more resonant to dull areas.
• It should be parallel to the edge of organ.
• Both the sides are compared by alternate percussion on both sides.
• To start with clavicles should be lightly percussed directly on either side (medial third as percussing laterally
is dull over the shoulder muscle).
• Percussion in the usual manner started along the………
• Mid clavicular line upto 6th ICS.
• Mid axillary line upto 8th ICS.
• Back axillary line upto 10th ICS.
• The normal degree of resonance varies between individuals.
• Also in different parts of chest in same individual.
• Being most resonant below the clavicles anteriorly & scapula posteriorly.
• Where the muscles are relatively thin, least resonant over the scapula.
• Front – Right side liver dullness starts from 4th/5th ICS.
• Left side – Cardiac dullness from 2nd & 3rd ICS to 5th ICS.
• Increase resonance: Pneumothorax.
• Decrease resonance: Thickened pleura, Pleural cavity having fluid (Stony dull)..
 AUSCULTATION
• Listen the chest with diaphragm.
• By auscultation – Breath sound, VR, Added sound.
• Breath sound: Ask the patient to take deep breaths in & out through he mouth.
• 1st demonstrate, then check visually that they are doing it while you listen to the chest.
• BS have…..
• Intensity – Normal / Reduced / Increased.
• Quality – Vesicular / Bronchial.
• Sitting position is ideal.
• When auscultation at back, the patient is asked to lean forward, flex the head & cross
the arms infront.’
• The patient is asked to breath deeply through open mouth.
• Axillary & infrascapular – Breathing over most areas of chest is vesicular & most
typically in these areas.

Normal bronchial BS –
• Trachea, Larynx – Harshes & louder than over decreased lung.
• Interscapular region & apex – Near to surface (Trachea & bronchi).
• Right infraclavicular.
• Lower cervical vertebrae.
• Breath sounds probably originate from turbulent airflow in large airway.
Vesicular breathsound
• Intensity of inspiration is greater than that of expiration.
• Duration of inspiration is greater than expiration.
• No gap between inspiration & expiration.
• Rustling in character.
• Low pitch (200 – 300 cps)
• Site – All, axillary, infrascapular.
• Origin – LA, but normal healthy lung between airway & chest wall.
Bronchial breath sound.
• Intensity of expiration is greater than that of inspiration.
• Duration of expiration is greater than inspiration.
• Definite gap between inspiration & expiration.
• Blowing or aspirate in character.
• High pitch, High frequency more than 500 cps.
• Site – Trachea.
• Origin – Lungs & between airways chest wall is airless in consolidated, fibrosis &
collapse.’
 Vocal Resonance
• Auscultatory counterpart of VF.
• Subject is asked to say continuously resonant words, the VR is examined on the
sides simultaneously by putting the stethoscope over the chest both front & back.
• Region wise –
• Infra clavicular
• Mammary
• Infra mammary
• Axillary & infra axillary
• supra scapular, inter scapular & infra scapular.
• VR of normal intensity & conveys the impression of being produced at
the chest piece of stethoscope.
• Increased VR
consolidation.
• Whispering pecterioloquy – words become clear & seem to be spoken
right into listener’s ear.
• Decreased VR
• Pleural effusion.
• Pneumothorax.
• Added sounds: Abnormal sound arise in lung or pleura.
• From lungs – Wheezes, Ronchi, crackles [coarse(rales), Fine(crepitation)]
• Wheeze – High pitched whistling sound / musical sound louds in
expiration. Exp – Bronchial asthma.
• Crackles – Short explosive sounds often described as bubbling or clicking.
• At the beginning of inspiration – COPD.
• Late inspiratory – Interstitial fibrosis.