Examination of chest , respiratory system

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Examination of the Chest / Respiratory System

A systematic clinical examination of the respiratory system follows four classical steps: General/Systemic assessment → Inspection → Palpation → Percussion → Auscultation, with added consideration of peripheral signs.

1. General Assessment (Before Examining the Chest)

Before touching the chest, observe the whole patient:

Respiratory rate: Normal is 12-20 breaths/min. Tachypnea indicates increased drive to breathe. Note that tachypnea alone does not confirm alveolar hyperventilation (rate AND tidal volume both matter).
Oxygen saturation (SpO₂): Now considered a vital sign; assess at rest AND with exertion.
Pulsus paradoxus: A fall in systolic BP >10 mmHg on inspiration. Suggests severe asthma, COPD, or pericardial disease.
Inability to speak in full sentences: Indicates increased respiratory drive or reduced vital capacity.
Work of breathing: Supraclavicular retractions and use of accessory muscles (sternocleidomastoid, scalenes) indicate increased airway resistance or decreased respiratory compliance.
Tripod position: Patient sitting leaning forward with hands braced on knees - sign of severe respiratory distress.
Kussmaul breathing: Very deep breathing with mild tachypnea - classic of severe metabolic acidosis.
Cyanosis: Central (tongue, lips) vs. peripheral - assess for hypoxemia.
Clubbing of fingers: Associated with lung cancer, bronchiectasis, IPF, cyanotic heart disease.
Anaemia: Pale conjunctiva - anaemia reduces O₂ delivery and causes dyspnea.

2. INSPECTION

Chest Shape and Deformities

Finding	Significance
Barrel chest (AP:lateral diameter ~1:1)	Emphysema, chronic air trapping
Pectus excavatum	Funnel chest - may restrict lung expansion
Pectus carinatum	Pigeon chest - chronic childhood asthma or rickets
Scoliosis / kyphosis	Restrictive lung disease
Harrison's sulcus	Horizontal groove along lower ribs - chronic childhood asthma

Breathing Pattern

Symmetry of chest movement: Asymmetric expansion suggests unilateral disease (e.g., pneumothorax, pleural effusion, consolidation, fibrosis on the reduced side).
Hoover sign: Inward (paradoxical) motion of the lower lateral rib cage on inspiration - characteristic of severe COPD/emphysema due to diaphragmatic flattening.
Paradoxical abdominal movement: Abdomen moves inward on inspiration (instead of outward) - suggests diaphragmatic weakness or paralysis.
Abdominal rounding on exhalation: Seen in acute pulmonary edema - thought to generate intrinsic PEEP to reduce LV afterload.
Accessory muscle use: Neck and upper chest muscles recruited in obstruction or restriction.
Intercostal recession: Seen in severe airflow obstruction or reduced lung compliance.
Pursed-lip breathing: Seen in COPD - self-generates PEEP to prevent dynamic airways collapse.

Respiratory Rate and Rhythm

Cheyne-Stokes: Crescendo-decrescendo breathing with apnoeic pauses - seen in heart failure, neurological disease.
Biot's breathing: Irregular pattern with apnoeic pauses - serious brainstem injury.
Apnoeustic breathing: Prolonged inspiratory cramp - pontine lesion.

3. PALPATION

The role of palpation is more limited than in other systems but provides valuable information:

Tracheal Position

Central: Normal.
Deviated away from the affected side: Tension pneumothorax, large pleural effusion (pushes trachea away).
Deviated toward the affected side: Lobar collapse, lung fibrosis (pulls trachea toward).

Chest Expansion

Place both thumbs together at the midline over the lower posterior chest, fingers grasping the lateral rib cage.
Ask patient to take a deep breath.
Normally, thumbs separate symmetrically by 5 cm.
Reduced unilateral expansion: Pneumothorax, pleural effusion, consolidation, collapse on that side.
Reduced bilateral expansion: COPD, bilateral fibrosis, bilateral pleural disease.

Tactile Vocal Fremitus (TVF)

Ask the patient to say "99" (or "one-one-one") while palpating symmetrical areas:

TVF	Significance
Increased	Consolidation (sound transmitted better through solid tissue)
Decreased	Pleural effusion, pneumothorax, emphysema, obstruction (fluid/air between lung and hand reduces transmission)

Other Palpation Findings

Subcutaneous emphysema (crepitus under skin): Barotrauma, pneumomediastinum, surgical emphysema after chest trauma.
Tenderness: Rib fracture, costochondritis, pleurisy.
Apex beat position: Displacement gives clues to mediastinal shift.

4. PERCUSSION

Technique

Use the middle finger of the non-dominant hand as the pleximeter, placed firmly against the chest wall. Strike sharply with the tip of the middle finger of the dominant hand (plexor).

Normal Findings

Resonant over normal aerated lung.
Dull over the liver (right lower chest), cardiac dullness (left lower sternal border), stony dull over solid tissue.
Diaphragmatic excursion: Percuss from resonant to dull, down the posterior chest, to estimate the level and movement of the diaphragm. Normal excursion is about 3-5 cm.

Percussion Notes and Their Meaning

Percussion Note	Cause
Dull / Stony dull	Pleural effusion (stony dull), consolidation (dull), collapse
Hyper-resonant	Pneumothorax, emphysema
Resonant	Normal aerated lung
Tympanitic	Large pneumothorax, large air-filled cavity

5. AUSCULTATION

This is the most information-rich component of respiratory examination.

Breath Sounds

Sound	Description	Significance
Vesicular	Soft, low-pitched; inspiration longer than expiration; no gap between phases	Normal peripheral lung
Bronchial	Loud, high-pitched; expiration as long as or longer than inspiration; gap between phases	Consolidation, lung collapse with patent airway
Bronchovesicular	Intermediate	Normal over the mainstem bronchi
Diminished/Absent	Reduced or no breath sounds	Pneumothorax, pleural effusion, emphysema, severe obstruction

Added (Adventitious) Sounds

Sound	Character	Cause
Wheeze (expiratory)	Musical, high-pitched, continuous	Airway obstruction - asthma, COPD, cardiac asthma
Polyphonic wheeze	Multiple simultaneous pitches	Diffuse small airway obstruction (asthma)
Monophonic wheeze	Single fixed pitch	Single airway narrowed (e.g., endobronchial tumour)
Stridor	High-pitched, inspiratory, heard over neck	Upper airway obstruction (croup, epiglottitis, foreign body, tracheal stenosis)
Crackles (rales) - fine	Short, high-pitched, velcro-like; heard in late inspiration	Pulmonary fibrosis (IPF), early pulmonary oedema
Crackles - coarse	Low-pitched, bubbly; early inspiration	Pneumonia, pulmonary oedema, bronchiectasis
Rhonchi	Continuous low-pitched, snoring quality	Secretions in medium airways - bronchitis, bronchiectasis
Pleural rub	Creaking, leathery, biphasic	Pleuritis (pneumonia, PE, connective tissue disease)

Vocal Resonance Techniques

Test	How to Perform	Increased (Consolidation)	Decreased (Effusion/Pneumothorax)
Vocal resonance	"Say 99" while auscultating	Louder, clearer	Quieter, muffled
Whispered pectoriloquy	"Whisper 99" while auscultating	Whisper heard clearly (consolidation)	Not transmitted
Egophony	Patient says "EEE"; over consolidation it sounds like "AHH"	Positive in pneumonia	Normal says "eee"
Bronchophony	"Say 99" - louder version of vocal resonance	Enhanced over consolidation	Reduced

6. Summary: Classic Examination Findings in Common Respiratory Conditions

Condition	Trachea	Expansion	TVF	Percussion	Breath Sounds	Added Sounds
Normal	Central	Equal	Normal	Resonant	Vesicular	None
Consolidation (Pneumonia)	Central	Reduced same side	Increased	Dull	Bronchial	Crackles, bronchophony, egophony
Pleural Effusion	Away (large)	Reduced same side	Decreased	Stony dull	Absent (diminished)	Pleural rub (if exudate)
Pneumothorax	Away (tension)	Reduced same side	Decreased	Hyper-resonant	Absent	None
Lobar Collapse	Toward	Reduced same side	Decreased	Dull	Absent / Bronchial	None
Emphysema/COPD	Central	Reduced bilaterally	Decreased	Hyper-resonant	Diminished	Wheeze, prolonged expiration
Asthma (acute)	Central	Reduced bilaterally	Normal/Decreased	Resonant	Diminished	Polyphonic wheeze
Fibrosis (IPF)	Central	Reduced bilaterally	Increased	Dull	Bronchial / vesicular	Fine velcro crackles (bibasal)
Bronchiectasis	Central	May be reduced	Normal	Resonant	Vesicular	Coarse crackles, rhonchi

7. Peripheral Signs to Examine

Always look beyond the chest:

Hands: Clubbing, peripheral cyanosis, tar staining, asterixis (CO₂ retention flap), fine tremor (salbutamol).
Face: Central cyanosis (tongue), Horner syndrome (apical lung tumour - Pancoast), SVC obstruction (facial swelling, dilated veins, plethora).
Neck: Tracheal position, JVD (cor pulmonale), lymphadenopathy (sarcoid, lymphoma, malignancy), scalene/SCM use.
Lower limbs: Pedal oedema (cor pulmonale, bilateral if symmetric; DVT/PE if asymmetric), erythema nodosum (sarcoidosis).

Sources: Harrison's Principles of Internal Medicine 22nd Ed. (2025) | Murray & Nadel's Textbook of Respiratory Medicine

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