Short notes of Respiratory rate examination inspection palpation percussion auscultation in brief
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Respiratory Examination: Short Notes
Respiratory Rate
Normal values:
- Adults: 12-20 breaths/min
- Children: higher (up to 40/min in neonates)
Abnormal patterns:
- Tachypnea - rate >20/min; seen in pneumonia, pulmonary embolism, heart failure, fever, anxiety
- Bradypnea/Hypopnea - rate <12/min; seen in CNS depression, opioid use
- Cheyne-Stokes - cyclical crescendo-decrescendo pattern with apnoeic periods; seen in heart failure, CNS disease
- Kussmaul - deep, rapid, laboured; seen in metabolic acidosis (diabetic ketoacidosis)
- Biot's - irregular with apnoeic periods; seen in meningitis, raised ICP
- Apnoea - cessation of breathing
Tachypnea out of proportion to fever is an early sign of childhood pneumonia. The respiratory rate is the most sensitive vital sign for detecting respiratory compromise - Harrison's Principles of Internal Medicine, 22e
1. INSPECTION
What to look for:
General:
- Distress, use of accessory muscles (sternocleidomastoid, scalenes, intercostals)
- Three-to-four word dyspnea (patient cannot complete a sentence - sign of severe impairment)
- Central or peripheral cyanosis (indicates >5 g/dL deoxyhaemoglobin)
- Clubbing of nails (seen in IPF, cystic fibrosis, lung cancer, bronchiectasis)
Chest wall:
- Shape deformities: pectus excavatum, barrel chest (increased AP diameter in COPD/hyperinflation), flail chest
- Spinal deformities: kyphosis, scoliosis (cause restrictive pattern)
- Intercostal retractions (children in respiratory distress)
- Chest lag - one side moves less than the other (consolidation, effusion, pneumothorax)
- Symmetry of chest wall expansion
Breathing pattern:
- Pursed-lip breathing (COPD)
- Prolonged expiratory phase (early obstruction - even before wheeze develops)
- Paradoxical movement
Common findings by disease (Inspection):
| Disorder | Inspection Finding |
|---|---|
| Asthma (acute) | Hyperinflation, accessory muscle use |
| Pneumothorax | Lag on affected side |
| Pleural effusion | Lag on affected side |
| Atelectasis | Lag on affected side, volume loss |
| Pneumonia | Possible lag/splinting on affected side |
- Textbook of Family Medicine 9e; Harrison's Principles of Internal Medicine 22e
2. PALPATION
Purpose: Confirm inspection findings; assess fremitus and chest expansion.
Tracheal position:
- Normally midline
- Deviated toward affected side: collapse/atelectasis, fibrosis
- Deviated away from affected side: large pleural effusion, tension pneumothorax
Chest expansion:
- Place thumbs at the midline over the lower posterior chest, fingers grasping lateral rib cage
- Ask patient to take a deep breath - thumbs should move apart equally
- Reduced unilaterally: effusion, consolidation, pneumothorax, fibrosis
Tactile (vocal) fremitus:
- Ask patient to say "99" or "one-one-one" while palpating
- Increased fremitus: consolidation (fluid-filled alveoli transmit vibration better)
- Decreased/absent fremitus: pleural effusion, pneumothorax, emphysema, bronchial obstruction
Subcutaneous emphysema:
- Crepitus on palpation - air in subcutaneous tissue; seen in barotrauma, tension pneumothorax
Apex beat/mediastinal shift can also be confirmed by palpation.
Common findings by disease (Palpation):
| Disorder | Palpation Finding |
|---|---|
| Asthma (acute) | Impaired expansion, decreased fremitus |
| Pneumothorax | Absent fremitus |
| Pleural effusion | Decreased fremitus; trachea shifted away |
| Atelectasis | Decreased fremitus; trachea shifted toward |
| Pneumonia | Increased fremitus |
- Harrison's Principles of Internal Medicine 22e; Textbook of Family Medicine 9e
3. PERCUSSION
Technique: Middle finger of one hand placed on chest wall, struck by middle finger of the other.
Normal note: Resonant over lung fields
Percussion notes and their meaning:
| Note | Sound | Cause |
|---|---|---|
| Resonant | Normal hollow sound | Normal lung |
| Hyperresonant/Tympanitic | Drum-like, higher than normal | Pneumothorax, emphysema (air-trapping) |
| Dull | Thud-like, less resonant | Consolidation (pneumonia), pleural effusion, lung fibrosis |
| Stony dull/Flat | Extremely dull | Large pleural effusion |
Diaphragm excursion:
- Percuss down the posterior chest to find where resonance changes to dullness (upper border of liver/diaphragm)
- Ask patient to breathe in and out; mark the difference (normal ~4-6 cm)
- Reduced excursion: effusion, hyperinflation, diaphragm palsy
Common findings by disease (Percussion):
| Disorder | Percussion Note |
|---|---|
| Asthma (acute) | Hyperresonance, low diaphragm |
| Pneumothorax | Hyperresonant or tympanitic |
| Pleural effusion | Dullness or flatness |
| Atelectasis | Dullness or flatness |
| Pneumonia | Dullness |
- Textbook of Family Medicine 9e; Harrison's Principles of Internal Medicine 22e
4. AUSCULTATION
Technique: Listen over upper, middle, and lower lung fields posteriorly AND over apices and mid-fields anteriorly. The right middle lobe and left lingula are only heard anteriorly.
Normal Breath Sounds
| Type | Character | Normal Location |
|---|---|---|
| Vesicular | Soft, breezy; inspiration longer than expiration; continuous | Peripheral lung fields |
| Bronchial (tubular) | Loud, hollow; expiration longer than inspiration; pause between phases | Over trachea/upper sternum |
| Bronchovesicular | Mixed quality | 1st and 2nd intercostal spaces anteriorly, interscapular region posteriorly |
- Note: Bronchial breath sounds heard in the peripheral lung = pathological (consolidation)
- Prolonged expiratory phase is an early sign of airway obstruction, even before wheezing develops
Added (Adventitious) Sounds
Crackles (rales):
- Discontinuous, clicking/bubbling sounds
- Caused by alveolar sacs popping open
- Fine crackles (end-inspiratory): pulmonary oedema (bases), IPF (described as "Velcro being ripped apart")
- Coarse crackles: early consolidation, bronchitis
- Crackles in IPF have no egophony; crackles in pneumonia do have egophony
Wheeze:
- Continuous, musical/sibilant sound - airway narrowing
- Polyphonic: multiple-sized airways involved (asthma, COPD)
- Monophonic: single-sized airway (endobronchial tumour, foreign body)
- Expiratory wheeze = asthma; also seen in cardiac asthma (LVF with peribronchial oedema)
Rhonchi (Sonorous ronchi):
- Low-pitched, continuous, snoring quality - medium-sized airway obstruction (secretions)
- Acute: bronchitis; Chronic: COPD, bronchiectasis
- Typically clear with coughing
Pleural friction rub:
- Leathery/grating sound; heard in both inspiration and expiration; does not clear with coughing
- Cause: pleuritis (pneumonia, PE, connective tissue disease)
Vocal Resonance (Transmitted)
- Ask patient to say "99" and listen
- Bronchophony: increased, louder transmission - consolidation
- Egophony: "EEE" heard as "AAA" - consolidation (e.g., pneumonia); NOT in pleural effusion (except just above effusion border)
- Whispered pectoriloquy: whispered words transmitted clearly - consolidation
- Decreased vocal resonance: effusion, pneumothorax, emphysema
Common findings by disease (Auscultation):
| Disorder | Auscultation Finding |
|---|---|
| Asthma (acute) | Prolonged expiration; inspiratory + expiratory wheeze |
| Pneumothorax | Absent breath sounds |
| Pleural effusion | Absent breath sounds |
| Atelectasis | Absent breath sounds |
| Pneumonia | Bronchial breath sounds; bronchophony; pectoriloquy; crackles |
| COPD/Emphysema | Quiet chest, decreased breath sounds; prolonged expiration |
| Pulmonary oedema | Fine bibasal crackles; wheeze (cardiac asthma) |
| Interstitial fibrosis | Fine bibasal Velcro crackles |
- Textbook of Family Medicine 9e; Harrison's Principles of Internal Medicine 22e
Quick Summary Table: Classical Patterns
| Condition | Inspection | Palpation | Percussion | Auscultation |
|---|---|---|---|---|
| Consolidation | Lag | Increased fremitus | Dull | Bronchial BS, crackles, bronchophony |
| Pleural effusion | Lag, trachea away | Decreased fremitus | Stony dull | Absent BS |
| Pneumothorax | Lag, trachea away | Absent fremitus | Hyper-resonant | Absent BS |
| Atelectasis | Lag, trachea toward | Decreased fremitus | Dull | Absent BS |
| Asthma | Hyperinflation, accessory muscles | Impaired expansion | Hyperresonant | Wheeze, prolonged expiration |
| COPD/Emphysema | Barrel chest, pursed lips | Decreased expansion | Hyperresonant | Decreased BS, wheeze |
| Fibrosis | Reduced expansion | Reduced expansion | Dull | Fine Velcro crackles (bases) |
Sources:
- Harrison's Principles of Internal Medicine 22e (2025, McGraw Hill) - Physical Examination section
- Textbook of Family Medicine 9e - Diagnostic Tools in Pulmonary Medicine
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