Respiratory system examination with image all details given in simple language
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🫁 Respiratory System Examination - Complete Guide (Simple Language)
The respiratory examination is done in 4 steps in order:
Inspection → Palpation → Percussion → Auscultation
The patient should sit upright, chest fully exposed, arms slightly forward (so shoulder blades don't block the upper lung fields).
🔍 STEP 1 - INSPECTION (Looking)
You look carefully at the patient before touching them. Start from the end of the bed.
A) General Look / Hands
| What to Look For | What It Means |
|---|---|
| Clubbing - rounded, bulging fingertips | Chronic lung disease (bronchiectasis, lung cancer, fibrosis) |
| Cyanosis - blue/purple color of lips or fingers | Low oxygen in blood |
| Peripheral cyanosis - blue fingers/toes only | Poor blood flow to extremities |
| Central cyanosis - blue lips and tongue | Serious: low oxygen in the whole blood |
| Asterixis (flapping tremor of hands) | CO₂ retention - seen in COPD |
| Tar staining on fingers | Smoker |
| Fine tremor of hands | Could be side effect of salbutamol (bronchodilator) |
B) Face and Neck
| What to Look For | What It Means |
|---|---|
| Central cyanosis - blue tongue/lips | Low blood oxygen |
| Pursed lip breathing | Trying to slow exhalation - seen in COPD |
| Nasal flaring (especially in children) | Increased effort to breathe |
| Trachea position - feel if it is central | Deviated trachea = pulled toward collapse, pushed away by pleural effusion/pneumothorax |
| Raised JVP (neck veins bulging) | Right heart failure from lung disease |
| Use of accessory muscles (neck/shoulder muscles during breathing) | Breathing is very hard work |
Simple rule for tracheal deviation:
- Pulled TOWARD the problem = lung collapse / atelectasis
- Pushed AWAY from the problem = pleural effusion / tension pneumothorax
C) Chest Wall
| What to Look For | What It Means |
|---|---|
| Barrel chest - chest is round and puffed out (AP diameter increased) | Air trapped in lungs - emphysema / chronic COPD |
| Kyphoscoliosis - curved/bent spine | Can reduce breathing capacity |
| Pectus excavatum - sunken sternum ("funnel chest") | Chest wall deformity |
| Pectus carinatum - protruding sternum ("pigeon chest") | Chest wall deformity |
| Intercostal indrawing - skin between ribs sucks in | Severe breathing difficulty |
| Scars (e.g., surgical, drain sites) | Previous surgery, procedures |
| Dilated veins on chest | SVC obstruction |
| Breathing pattern - rate, depth, symmetry | Is one side moving less? (= problem on that side) |
| Respiratory rate (normal adult: 12-20/min) | Fast = tachypnoea; Slow = bradypnoea |
✋ STEP 2 - PALPATION (Touching/Feeling)
A) Chest Expansion
Place both hands on the patient's chest (posterior - back) with thumbs meeting at the midline. Ask them to take a deep breath.
- Normal: Both hands move equally outward
- Reduced on one side: That side has a problem (effusion, consolidation, pneumothorax)
B) Tactile Vocal Fremitus
Place the flat of your hand (or thenar eminence) on the chest wall. Ask patient to say "99" repeatedly. Feel the vibration.
| Finding | What It Means |
|---|---|
| Increased fremitus | Sound conducts better - lung is solid (consolidation/pneumonia) |
| Decreased fremitus | Something blocks sound - fluid (effusion) or air (pneumothorax) between lung and chest wall |
C) Tracheal Position
Place index and middle fingers either side of the trachea above the sternal notch. The trachea should sit centrally.
- Deviation = abnormal (see table above)
D) Other
- Tenderness of chest wall - costochondritis, rib fractures
- Crepitus (crackling feeling under skin) = subcutaneous emphysema (air under skin)
🥁 STEP 3 - PERCUSSION (Tapping)
Technique: Place the non-dominant middle finger flat on the chest wall. Strike it sharply with the tip of the dominant middle finger. Compare left side with right side symmetrically. Work from top to bottom.
| Percussion Note | Meaning |
|---|---|
| Resonant ✅ | Normal air-filled lung |
| Hyper-resonant (hollow/drum-like) | Too much air - emphysema, pneumothorax |
| Dull | Solid/dense tissue - consolidation (pneumonia), lung collapse (atelectasis) |
| Stony dull (very flat, like percussing a thigh) | Fluid in pleural space = pleural effusion |
| Tympanic | Air-filled hollow organ |
Also percuss for:
- Diaphragm level - normally at 6th rib anteriorly; reduced excursion means air-trapping or raised diaphragm
- Compare both sides - any asymmetry is significant
🔊 STEP 4 - AUSCULTATION (Listening with stethoscope)
Technique: Use the diaphragm of the stethoscope placed directly on skin. Ask patient to breathe deeper than normal through the mouth. Listen in a ladder pattern - top to bottom, comparing left and right sides. Do this both front (anterior) and back (posterior).
A) Normal Breath Sounds
| Sound | Where Heard | Character |
|---|---|---|
| Vesicular | Over most of both lungs | Soft, rustling; heard mostly in inspiration, fades in expiration |
| Bronchial | Over trachea / large airways | Harsh, louder; expiration as long as inspiration |
| Bronchovesicular | Near main airways | Mix of both |
⚠️ Bronchial breathing heard over peripheral lung = abnormal = consolidation (pneumonia)
B) Abnormal / Added Breath Sounds
| Sound | Description | Causes |
|---|---|---|
| Crackles (Rales) | Short, popping/crackling sounds | Fluid in small airways; pneumonia, pulmonary edema, fibrosis |
| Fine crackles | Soft, high-pitched, like velcro tearing | Pulmonary fibrosis, early pulmonary edema |
| Coarse crackles | Louder, bubbly, lower-pitched | Bronchiectasis, pulmonary edema |
| Wheeze | Musical, high-pitched, continuous | Airway narrowing - asthma, COPD |
| Rhonchi | Lower-pitched, snoring sound | Mucus in larger airways - clears with coughing |
| Stridor | Harsh, high-pitched sound on inspiration | Upper airway obstruction (croup, foreign body, epiglottitis) - urgent! |
| Pleural rub | Grating/creaking, like leather rubbing | Pleural inflammation (pleuritis) - two inflamed pleural surfaces rubbing |
| Reduced/absent breath sounds | Quieter than normal on one side | Effusion, collapse, pneumothorax, obesity |
C) Vocal Resonance
Ask the patient to say "99" while you listen with the stethoscope.
| Finding | What It Means |
|---|---|
| Increased (louder voice sounds) | Consolidation - sound transmits better through solid lung |
| Decreased (muffled, quieter) | Pleural effusion - fluid blocks transmission |
| Whispering pectoriloquy - whispered "99" heard clearly | Consolidation (very specific) |
| Aegophony - "ee" sounds like "ay" | Consolidation or just above a pleural effusion |
📊 Common Conditions - Summary Table
| Condition | Expansion | Percussion | Breath Sounds | Vocal Resonance | Trachea |
|---|---|---|---|---|---|
| Normal | Equal both sides | Resonant | Vesicular | Normal | Central |
| Pneumonia (Consolidation) | Reduced on affected side | Dull | Bronchial + coarse crackles | Increased | Central |
| Pleural Effusion | Reduced on affected side | Stony dull | Reduced/absent | Reduced | Pushed away |
| Pneumothorax | Reduced on affected side | Hyper-resonant | Reduced/absent | Reduced | Pushed away (tension) |
| Lung Collapse (Atelectasis) | Reduced on affected side | Dull | Reduced/absent | Reduced | Pulled toward |
| Asthma/COPD | Equal but reduced | Hyper-resonant | Prolonged expiration + wheeze | Normal | Central |
| Pulmonary Fibrosis | Reduced | Dull | Fine crackles (bibasal) | Normal | Central |
🎬 Video References
Watch clinical demonstrations of percussion and auscultation:
Hear real lung sounds (wheeze, crackles, stridor, vesicular):
Quick Memory Aid - Order of Examination
I - Inspection (Look - general, hands, face, neck, chest)
P - Palpation (Feel - expansion, fremitus, trachea)
P - Percussion (Tap - resonant/dull/stony dull/hyper-resonant)
A - Auscultation (Listen - breath sounds, added sounds, vocal resonance)
Sources: Chest Examination - NCBI Bookshelf, Pulmonary Examination - Medscape, S Das Manual on Clinical Surgery (13th ed.), Washington Manual of Medical Therapeutics
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