Explain respiration system examination in detail
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Respiratory System Examination
The physical examination of the respiratory system is the cornerstone of clinical diagnosis and uses four classic techniques: inspection, palpation, percussion, and auscultation. A thorough history supplements these findings. Below is a structured, detailed account.
1. General Principles
Physical examination of the chest should be performed with:
- The patient sitting comfortably, sufficiently undraped to expose the entire thorax
- Privacy, warmth, good lighting, and a quiet atmosphere (essential for auscultation)
- Comparison of both sides at every step - symmetry is the guiding principle
The examination begins the moment the clinician sees the patient. As Murray & Nadel's Textbook of Respiratory Medicine notes, "88% of all diagnoses in primary care were established by taking a thorough medical history and performing a complete physical examination."
2. History (Pre-Examination)
Before laying hands on the patient, note:
- Symptoms: cough (productive/dry), dyspnea, wheeze, hemoptysis, pleuritic chest pain
- Timing and progression: acute vs. chronic
- Occupational/environmental exposures: asbestos, dust, smoke
- Tobacco use: leaf stains on teeth/fingers, characteristic odor on hair/clothing are visible clues
- Other odors: foul-smelling breath suggesting anaerobic lung abscess; ketone odor in diabetic ketoacidosis
3. Inspection
General Appearance from the Foot of the Bed
Even before touching the patient, observing from a distance provides critical information:
- A visible lag in expansion on one side localizes pleural effusion, pulmonary consolidation, or a paralyzed diaphragm
- Visible accessory muscle use (sternocleidomastoid, scalenes) indicates increased work of breathing
Chest Shape and Symmetry
| Finding | Association |
|---|---|
| Barrel chest (increased AP diameter) | Emphysema/COPD |
| Kyphoscoliosis | Restrictive lung disease |
| Pectus excavatum (funnel chest) | Can compress heart/lungs |
| Pectus carinatum (pigeon chest) | Chronic childhood asthma, Marfan syndrome |
| Surgical scars or chest wall defects | Previous thoracic surgery |
Respiratory Pattern
Several classic ventilatory patterns provide immediate diagnostic clues:
- Slow, deep breaths: severe airflow obstruction (COPD, asthma)
- Rapid, shallow breaths: restrictive processes (interstitial lung disease, kyphoscoliosis, pleural effusion)
- Paradoxical inward abdominal movement during inspiration (in supine position): respiratory muscle weakness or diaphragmatic paralysis
- Cheyne-Stokes breathing: alternating apnea and hyperpnea - heart failure, CNS disorders
- Kussmaul breathing: deep, sighing breaths - metabolic acidosis (e.g., diabetic ketoacidosis)
Rate and Depth
- Normal respiratory rate: 12-20 breaths/min in adults
- Tachypnea (>20/min): fever, hypoxia, acidosis, anxiety, pain
- Bradypnea (<12/min): CNS depression, opioid use
Peripheral Signs (Inspect Hands, Face, Neck)
| Sign | Description | Association |
|---|---|---|
| Clubbing | Increased nail-fold angle (>180°), loss of diamond window | IPF, bronchiectasis, lung carcinoma, cyanotic heart disease |
| Cyanosis (central) | Bluish discoloration of lips and tongue | Severe hypoxia (SaO2 <85%) |
| Cyanosis (peripheral) | Bluish fingertips | Poor perfusion |
| Pursed-lip breathing | Patient exhales through pursed lips | COPD (auto-PEEP mechanism) |
| Superior vena cava syndrome | Puffy face/neck/eyelids, dilated neck/shoulder veins | Lung carcinoma (>80% of cases) |
| Horner syndrome | Unilateral ptosis, miosis, anhidrosis | Pancoast (pulmonary sulcus) tumor |
| JVP elevation | Raised jugular venous pressure | Cor pulmonale, heart failure |
4. Palpation
Palpation confirms and extends findings from inspection.
Trachea
- Assessed in the suprasternal notch with the index finger
- Tracheal deviation toward the affected side: collapse/atelectasis, fibrosis
- Tracheal deviation away from the affected side: tension pneumothorax, large pleural effusion
- Tracheal tug (downward pull during inspiration): severe hyperinflation (COPD)
Chest Expansion
- Hands placed symmetrically over each hemithorax, thumbs meeting at the midline
- Both sides should expand equally and symmetrically
- Unilateral reduction: pleural effusion, pneumothorax, consolidation, fibrosis, splinting due to pain
Vocal/Tactile Fremitus
The patient says "one, two, three" (or "ninety-nine") while the examiner's palms or the ulnar edges of the hands are moved systematically from apex to base over both hemithoraces:
| Fremitus | Cause |
|---|---|
| Increased | Consolidation (pneumonia) - enhanced sound transmission |
| Decreased/absent | Pleural effusion, pneumothorax, pleural thickening, bronchial obstruction |
Other Palpation Findings
- Point tenderness over ribs: fracture, metastasis, pleuritis
- Subcutaneous crepitus (emphysema): crackling feel under the skin - air leak
- Fluctuant areas: empyema necessitans
- Cervical rib: palpable bony abnormality above clavicle
- Subcutaneous calcinosis: seen in systemic sclerosis
- Palpable pleural friction rub: felt over inflamed pleural surfaces
- Supraclavicular lymph nodes: enlargement suggests lung malignancy or infection
5. Percussion
Percussion was introduced by Auenbrugger (based on sounding beer barrels to determine fluid levels) and remains a valuable diagnostic tool.
Technique
- The pleximeter finger (usually middle finger of non-dominant hand) is placed flat on the chest wall
- The plexor finger (middle finger of dominant hand) strikes the distal interphalangeal joint of the pleximeter with a quick, uniform, flicking wrist motion
- The striking finger is quickly withdrawn to avoid damping the sound
Normal Percussion Note
- Over air-containing normal lung: resonant
- Over liver: dull/flat (used as a reference)
Abnormal Percussion Notes
| Note | Quality | Cause |
|---|---|---|
| Resonant | Normal hollow sound | Normal lung |
| Hyperresonant | Louder/lower-pitched than resonant | Emphysema (generalized), pneumothorax (localized) |
| Tympanitic | Drum-like, very loud | Tension pneumothorax, large pneumothorax |
| Dull | Short duration, reduced intensity, higher pitch | Consolidation (pneumonia), pleural effusion |
| Stony dull/flat | Completely non-resonant | Large pleural effusion (below the fluid level), solid tumor |
Three Zones over Pleural Effusion
Percussing a large pleural effusion reveals three distinct zones:
- Normal resonance - above the fluid
- Dullness - in the middle (fluid level)
- Flatness - when completely within the fluid
Diaphragmatic Excursion
- Percuss the posterior chest from above downward during quiet breathing, then during full inspiration
- Normal excursion: 3-5 cm (reduced in COPD, paralyzed diaphragm)
6. Auscultation
Auscultation with a stethoscope (Laennec's invention, 1816) examines both the quality and the presence of adventitious sounds.
Normal Breath Sounds
| Sound | Location | Character | Note |
|---|---|---|---|
| Vesicular (normal breath sounds) | Peripheral lung | Soft, low-pitched; inspiration > expiration | Generated by turbulent flow in lobar/segmental bronchi; "vesicular" is a misnomer (alveoli are silent) |
| Bronchial | Over trachea/larynx | Loud, high-pitched; expiration = inspiration or expiration > inspiration, with a gap | Heard normally over trachea only |
| Bronchovesicular | 1st/2nd intercostal spaces anteriorly; between scapulae posteriorly | Intermediate quality | Normal at these locations |
Changes in Intensity
| Change | Cause |
|---|---|
| Globally reduced | Emphysema (airflow impaired), bilateral pleural effusion, obesity |
| Unilaterally reduced/absent | Pleural effusion, pneumothorax, main bronchus obstruction, hemothorax |
| Focally reduced | Large bulla, collapse, large mass |
| Increased/harsh (bronchial breathing) | Consolidation, atelectasis, compressed lung (above effusion) |
Prolonged Expiration
- Inspiratory phase is normally audible longer
- Prolonged expiration (expiration > inspiration): airway obstruction (asthma, COPD)
Adventitious (Abnormal) Breath Sounds
These are classified as discontinuous or continuous:
Discontinuous Sounds: Crackles
| Type | Timing | Quality | Cause |
|---|---|---|---|
| Fine crackles | Mid-to-late inspiration | Soft, high-pitched, short duration ("Velcro-like") | Opening of collapsed distal airways (atelectasis, pulmonary fibrosis, early pulmonary edema) |
| Coarse crackles | Early inspiration or expiratory | Loud, low-pitched, longer duration | Secretions in larger airways (COPD, bronchiectasis, pneumonia); may change after coughing |
Continuous Sounds (>250 ms)
| Sound | Frequency | Quality | Cause |
|---|---|---|---|
| Wheeze | High-pitched (≥400 Hz) | Hissing/musical | Airway narrowing by spasm, mucosal thickening, or obstruction (asthma - diffuse; tumor - focal) |
| Rhonchi | Low-pitched (<200 Hz) | Snoring/gurgling | Secretions or liquid in large airways; often clears with coughing |
| Stridor | High-pitched | Predominantly inspiratory, heard best over neck | Extrathoracic upper airway obstruction (anaphylaxis, epiglottitis, croup) - needs urgent attention |
Pleural Friction Rub
- Creaking, leathery sound heard on both inspiration and expiration
- Does not change with coughing
- Caused by inflamed pleural surfaces rubbing together
- Heard in: pleuritis, pulmonary embolism (with infarction), pneumonia adjacent to pleura
Vocal Resonance (Auscultation of Voice Sounds)
The patient says "one, two, three" or "ninety-nine" while the stethoscope is moved over the chest:
| Sign | Technique | Finding | Significance |
|---|---|---|---|
| Bronchophony | Say "ninety-nine" | Voice sounds louder and clearer than normal | Consolidation, atelectasis, compressed lung |
| Aegophony (Egophony) | Say "E" | Heard as "A" through stethoscope | Most prominent when consolidation and effusion coexist; also lobar pneumonia |
| Whispered pectoriloquy | Whisper "one, two, three" | Whispered sounds heard abnormally clearly | Same significance as bronchophony - consolidation |
| Reduced vocal resonance | Normal speech/whisper | Voice sounds muffled or absent | Pleural effusion, pneumothorax, obstruction |
7. Summary of Classic Examination Patterns
| Condition | Inspection | Trachea | Expansion | Fremitus | Percussion | Breath Sounds | Added Sounds |
|---|---|---|---|---|---|---|---|
| Consolidation | - | Central | Reduced ipsilateral | Increased | Dull | Bronchial | Fine crackles, bronchophony, egophony |
| Pleural Effusion | Lag | Deviated away (if large) | Reduced ipsilateral | Reduced/absent | Stony dull | Absent/reduced (bronchial above fluid) | Pleural rub (early) |
| Pneumothorax | Lag | Deviated away (tension) | Reduced ipsilateral | Reduced/absent | Hyperresonant/tympanitic | Absent/reduced | None |
| COPD/Emphysema | Barrel chest, pursed lips, accessory muscles | Central | Bilaterally reduced | Reduced | Hyperresonant | Reduced, prolonged expiration | Wheeze, rhonchi |
| Asthma (attack) | Accessory muscles, tachypnea | Central | Reduced | Reduced | Resonant/hyperresonant | Reduced, prolonged expiration | Diffuse wheeze |
| Fibrosis (IPF) | Clubbing | Central | Bilaterally reduced | Normal or increased | Resonant | Reduced | Fine inspiratory crackles ("Velcro") |
| Collapse/Atelectasis | - | Deviated toward | Reduced ipsilateral | Reduced | Dull | Reduced/absent or bronchial | - |
| Bronchiectasis | Clubbing | Central | Normal or reduced | Normal | Resonant | Coarse crackles | Coarse crackles, rhonchi |
Sources
- Murray & Nadel's Textbook of Respiratory Medicine (2-Volume), Examination of the Chest, Chapter 18
- Fishman's Pulmonary Diseases and Disorders (2-Volume Set), Chapter 27
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