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Examination of the Chest / Respiratory System

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1. General Assessment (Before Examining the Chest)

• 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.

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2. INSPECTION

Chest Shape and Deformities

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.

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3. PALPATION

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)

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.

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4. PERCUSSION

Technique

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

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5. AUSCULTATION

Breath Sounds

Added (Adventitious) Sounds

Vocal Resonance Techniques

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6. Summary: Classic Examination Findings in Common Respiratory Conditions

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7. Peripheral Signs to Examine

• 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).

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Stethoscope Placement for Breath Sounds

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The Three Normal Breath Sounds and Where to Place Your Stethoscope

1. Bronchial (Tubular) Breath Sounds

• Loud, harsh, high-pitched
• Expiration is longer, louder than inspiration (ratio approximately 1:2)
• There is a distinct pause/gap between inspiration and expiration
• Sounds like breathing through a snorkel or "Darth Vader" breathing

If you hear bronchial sounds anywhere else in the lung fields - that is ABNORMAL and indicates consolidation (pneumonia), where sound travels through solid lung directly to the chest wall.

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2. Bronchovesicular Breath Sounds

• Intermediate pitch and intensity - between bronchial and vesicular
• Inspiration and expiration are equal in duration (1:1 ratio)
• No pause between the two phases

If heard in peripheral lung fields, this is also abnormal.

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3. Vesicular Breath Sounds

• Anterior chest: apices, upper and lower lung fields (away from the sternum)
• Posterior chest: all lung fields below the interscapular region
• Lateral chest: axillary regions bilaterally
• Right middle lobe and left lingula: heard anteriorly only (these zones are not accessible from the back)

• Soft, low-pitched, gentle "rustling" or "breezy" quality
• Inspiration is longer than expiration (ratio approximately 3:1)
• Expiration fades out quietly - no sharp end
• No gap/pause between phases

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Visual Summary

ANTERIOR CHEST                    POSTERIOR CHEST
─────────────────────             ─────────────────────
     BRONCHIAL                          BRONCHIAL
   (trachea/manubrium)              (C7 to T3, back of neck)

  BRONCHOVESICULAR                  BRONCHOVESICULAR
(1st–2nd ICS, near sternum)       (between scapulae, T3–T5)

    VESICULAR                           VESICULAR
  (all other areas)               (all other areas below)

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Practical Technique: How to Auscultate

1. Use the diaphragm of your stethoscope for breath sounds (it detects higher-frequency sounds better than the bell).
2. Patient position: seated upright if possible, breathing slowly and deeply through the mouth.
3. Pattern: use a stepladder (zigzag) pattern - listen at one spot, then the mirror image on the opposite side, then move down. This lets you compare left vs. right at each level.
4. Sequence: Start posterior (most lung surface accessible), then anterior, then lateral (axillary).
5. Listen for at least one full cycle (one inspiration + one expiration) at each spot.
6. Cover at least 3 levels posterior, 2 levels anterior, and the axillae on both sides.
7. Don't forget to specifically listen anteriorly for the right middle lobe and left lingula - you cannot hear these from the back.

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Quick Rule to Remember

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