---

Clinical Examination of the Respiratory System

---

Overview & Patient Positioning

---

I. INSPECTION

A. General Inspection (from the end of the bed)

• Distress, tachypnoea, use of accessory muscles (sternocleidomastoid, scalenes, trapezius)
• Inability to complete a full sentence in one breath (severe obstruction)
• Cachectic habitus — suggests malignancy or COPD

Fishman's: "Patients with severe airflow obstruction often take slow, deep breaths, whereas rapid and shallow breaths are often seen with restrictive processes, such as interstitial lung disease or kyphoscoliosis."

---

B. Inspection of the Hands & Periphery

• Grade I: Loss of angle between nail and nailbed (Lovibond angle >180°)
• Grade II: Increased curvature of nail
• Grade III: Drumstick appearance
• Grade IV: Hypertrophic pulmonary osteoarthropathy (periosteal new bone, wrist/ankle pain)

• Tachycardia → infection, PE, hypoxia
• Pulsus paradoxus (>10 mmHg drop in systolic BP on inspiration) → severe asthma, cardiac tamponade. Palpated as apparent disappearance of radial pulse on deep inspiration.

---

C. Inspection of the Face

Fishman's: "The discoloration is most apparent in the lobes of the ears, the cutaneous surfaces of the lips, and the nail beds. In patients with dark skin, the mucus membranes and the retina are important sites to examine for cyanosis."

---

D. Inspection of the Neck

• Elevated JVP → cor pulmonale, right heart failure from chronic lung disease
• Non-pulsatile, non-compressible distension → SVC obstruction (malignancy)

---

E. Inspection of the Chest Wall

• Bilateral reduction: COPD, bilateral pleural disease
• Unilateral reduction (lag): pneumothorax, pleural effusion, pneumonia, phrenic nerve palsy, fibrosis

Fishman's: "A visible lag in expansion of one side of the thorax localizes a pleural effusion, pulmonary infection, or paralyzed diaphragm."

• Thoracotomy scar, VATS ports, drain sites, radiotherapy tattoo marks
• Subcutaneous emphysema (crepitus on inspection/palpation)

• Distended collateral veins flowing upwards → SVC obstruction
• Flowing downwards → IVC obstruction

• Intercostal recession (indrawing): increased work of breathing
• Subcostal/supraclavicular recession: severe distress

---

II. PALPATION

A. Tracheal Position

Fishman's: "The position of the trachea determined by palpation in the suprasternal notch may be helpful in detecting a lateral displacement of the upper mediastinum."

B. Lymph Nodes

C. Chest Expansion (Quantitative)

D. Vocal Fremitus (Tactile Fremitus)

E. Pleural Rub (Palpable)

F. Subcutaneous Emphysema

G. Apex Beat & Cardiac Shift

• Apex displaced laterally/inferiorly → cor pulmonale, right ventricular dilatation
• Right ventricular heave palpated in parasternal region → pulmonary hypertension

H. Hoover Sign (Palpation)

Fishman's: "Hoover sign may be useful in disclosing a unilateral lag in motion of one side of the chest due to pleuritis or a pleural effusion... elicited by comparing the displacement from the midline during a patient's deep inspiration of the examiner's hands, each placed lightly over one hemithorax, with thumbs touching beneath the xiphoid."

---

III. PERCUSSION

Technique (Mediate Percussion)

Percussion Notes — Spectrum

Sites to Percuss

• Right heart border (3rd–5th ICS parastemal)
• Liver dullness (5th ICS right MCL, normally)
• Left cardiac dullness
• Traube's space (normally tympanic — LLQ costal margin; dull if effusion or splenomegaly)

Special Tests

Percussion Findings in Common Conditions

---

IV. AUSCULTATION

Technique

A. Breath Sounds

• Soft, low-pitched, rustling (like wind in trees)
• Inspiration > expiration; no silent interval
• Heard over most of the normal lung
• Generated by turbulent airflow in larger airways, transmitted to periphery through lung parenchyma

• Loud, high-pitched, tubular/hollow quality (like blowing air through a tube)
• Expiration ≥ inspiration; distinct silent gap between I and E phases
• Heard normally only over the trachea/large airways
• In the periphery, they indicate transmission of tracheal sounds through consolidated (solid) lung
• Causes: lobar pneumonia (consolidation), large pulmonary infarction, fibrosing alveolitis (sometimes), cavities with pneumonia around them

• Intermediate quality; I = E; no silent gap
• Normal over right 1st–2nd ICS anteriorly (near right main bronchus) and between scapulae posteriorly
• Abnormal elsewhere

• Pneumothorax (no conducting medium)
• Pleural effusion (fluid attenuates sound)
• COPD/emphysema (reduced airflow + hyperinflation)
• Obesity, muscular chest wall
• Complete bronchial obstruction (collapse behind)

B. Added Sounds (Adventitious Sounds)

1. Crackles (Crepitations, Rales)

• High-pitched, brief, non-musical
• Like Velcro tearing or rubbing hair between fingers near the ear
• Heard in: end-inspiratory phase
• Mechanism: sudden opening of previously collapsed small airways/alveoli (alveolar recruitment)
• Causes: pulmonary fibrosis (fine, end-inspiratory, bibasal, "Velcro crackles"), pulmonary oedema (early), pneumonia

• Low-pitched, bubbling, longer duration
• Early inspiratory or pan-inspiratory
• Mechanism: air moving through secretions in large airways
• Causes: bronchiectasis, COPD with mucus, resolving pneumonia, pulmonary oedema (late/severe)

2. Wheeze (Rhonchi)

• Musical, high-pitched (or low-pitched) sounds, predominantly expiratory (may be biphasic)
• Mechanism: rapid airflow through a narrowed airway creating oscillation of airway walls
• Types:
  • Polyphonic wheeze (multiple tones simultaneously): diffuse airway narrowing → asthma, COPD
  • Monophonic fixed wheeze (single tone, same character throughout cycle): single large airway obstruction → bronchial carcinoma, foreign body
  • Inspiratory wheeze = stridor when heard without stethoscope (see below)
• Absent wheeze in severe asthma = silent chest (ominous sign — insufficient airflow to generate wheeze)

3. Stridor

• High-pitched, inspiratory (predominantly) monophonic sound
• Audible without a stethoscope, louder on inspiration
• Indicates upper airway or large central airway obstruction
• Causes: laryngeal oedema (anaphylaxis, croup), epiglottitis, foreign body, tracheal compression (goitre, mediastinal mass), tracheal stenosis, bilateral vocal cord palsy

4. Pleural Friction Rub

• Creaking, grating, or leather-rubbing sound (like new shoe leather)
• Heard in both inspiration and expiration, does not change with coughing
• Localised (in one area of the chest)
• Mechanism: roughened inflamed visceral and parietal pleurae rubbing together
• Causes: pleurisy (viral, bacterial), pulmonary infarction, mesothelioma, adjacent pneumonia
• Disappears if effusion develops (separates the pleural surfaces)

C. Vocal Resonance

---

Summary Comparison Table — Bedside Findings

---

V. COMPLETE SEQUENCE — SYSTEMATIC APPROACH

1. Wash hands, introduce, consent, position patient at 45°
2. End-of-bed inspection: general, respiratory pattern, distress
3. Hands: clubbing, cyanosis, tremor/flap, pulse, staining
4. Arms/face: BP (paradoxus if suspected), eyes (Horner, pallor), mouth (central cyanosis, voice quality), JVP
5. Neck: trachea position (look → palpate), lymph nodes, accessory muscles
6. Chest inspection: shape, scars, veins, chest wall movement, symmetry
7. Palpation: trachea (confirm), expansion (anterior upper + posterior lower), TVF (compare sides)
8. Percussion: systematically anterior → lateral → posterior; diaphragm level; shifting dullness if relevant
9. Auscultation: breath sounds, added sounds, vocal resonance; anterior → lateral → posterior
10. Complete: check ankles for oedema (cor pulmonale), examine sputum if available, temperature chart

---

Key Eponyms & Signs

---

---

Clinical Examination of the Respiratory System — Complete Reference

---

ADDITIONS & COMPLETIONS TO INSPECTION

Clubbing — Expanded Grading

Washington Manual: "Clubbing is not a feature of COPD alone, so its presence should prompt an evaluation for other conditions, especially lung cancer."

---

Chest Deformities — Images

---

Respiratory Pattern — Additional Types

---

ADDITIONS TO PALPATION

Tracheal Deviation — Expanded

• Tension pneumothorax (emergency — trachea + mediastinum pushed; hypotension + absent breath sounds)
• Large pleural effusion (>1000 mL usually required for detectable shift)
• Large mediastinal mass

• Lung fibrosis (ipsilateral volume loss pulls trachea)
• Complete lung collapse (atelectasis) — ipsilateral pull
• Pneumonectomy — trachea pulled toward the operated side
• Fibrothorax

• Tracheal tug (Oliver's sign): Downward tug of larynx/trachea synchronous with heartbeat; aortic aneurysm. Also used to mean downward tug on inspiration in severe COPD hyperinflation.
• Fixed midline trachea despite large effusion → suggests malignant fixation of mediastinum (e.g., malignant mesothelioma, lymphoma).

---

Chest Expansion — Detailed Measurement

• Hands placed on anterior chest, thumbs at sternal angle (angle of Louis, 2nd rib junction)
• Examiner's fingers curved around the upper ribs laterally
• Normal: 3–5 cm separation of thumbs

• Most important and most sensitive
• Hands on posterior lower chest at T10; thumbs lifted off the skin (do not press), meeting at midline
• Patient takes full breath in — thumbs diverge symmetrically
• Normal: 5–8 cm; record as "5 cm bilaterally equal" or note asymmetry

---

Vocal Fremitus — Complete Method

---

PERCUSSION — EXPANDED

Kronig's Isthmus (Apical Percussion)

Liver Dullness & Traube's Space

• Raised → hepatomegaly, right lower lobe collapse, right phrenic nerve palsy, subphrenic abscess
• Low → emphysema (hyperinflation pushes diaphragm down)

• Dull → left pleural effusion (most common clinical use), splenomegaly, gastric outlet obstruction

Diaphragmatic Excursion — Technique in Detail

1. Patient seated or standing; ask to breathe in fully and hold
2. Percuss down posteriorly (paravertebral line) until dullness begins — mark this point
3. Ask patient to breathe out fully and hold
4. Percuss upward until resonance changes back to dullness — mark again
5. Measure the distance between the two marks
6. Repeat on the other side

• Right side: hepatomegaly, right lower lobe collapse, right phrenic nerve palsy, right-sided subphrenic abscess
• Left side: left phrenic nerve palsy (Pancoast, aortic aneurysm, mediastinal tumour), gastric distension

Percussion in Pleural Effusion — Key Signs

1. Stony dullness (dullest note in medicine) over the effusion
2. Upper border is concave (Ellis-Damoiseau line): dullness highest in the axilla, lower medially and laterally → creates a curved upper border
3. Shifting dullness (>300–500 mL)
4. Aegophony at the upper border of the effusion
5. Traube's space obliterated for a left effusion
6. Tracheal and mediastinal shift away (large effusion >1000 mL)

---

AUSCULTATION — EXPANDED

Systematic Auscultation Map

Harrison's 22e: "Areas of alveolar filling have increased whispered pectoriloquy as well as transmission of larger-airway sounds (i.e., bronchial breath sounds in a lung zone where vesicular breath sounds are expected)."

---

Rhonchi vs Wheeze — Clarification

Harrison's 22e: "Wheezes can be polyphonic, involving multiple different size airways (e.g., asthma), or monophonic, involving one size airway (e.g., bronchogenic carcinoma)."

Harrison's 22e: "Rhonchi are a manifestation of obstruction of medium-sized airways, most often with secretions... Chronic rhonchi suggest bronchiectasis or COPD."

---

Crackles — Detailed Classification

Harrison's 22e: "Crackles in pulmonary edema are generally more prominent at the bases. Interestingly, diseases that result in fibrosis of the interstitium (e.g., IPF) also result in crackles that sound like Velcro being ripped apart."

Harrison's 22e: "Although some clinicians make a distinction between 'wet' and 'dry' crackles, this distinction has not been shown to be a reliable way to differentiate among etiologies."

---

Vocal Resonance — Complete Assessment

Harrison's 22e: "Egophony is the auscultation of the sound 'AH' instead of 'EEE' when a patient phonates 'EEE.' This change in note is due to abnormal sound transmission through consolidated parenchyma and is present in pneumonia but not in IPF."

---

DISEASE-SPECIFIC EXAMINATION FINDINGS — DETAILED

1. COPD / Emphysema

Washington Manual: "On inspection, pursed lip breathing, barrel chest secondary to hyperinflation, use of accessory muscles of respiration, and central and peripheral cyanosis can be present... Auscultation in severe COPD may expose prolonged (i.e., >6 seconds) breath sounds on a maximal forced exhalation and decreased breath sounds."

2. Lobar Pneumonia (Consolidation)

3. Pleural Effusion

4. Pneumothorax

5. Pulmonary Fibrosis (IPF/Fibrosing Alveolitis)

6. Bronchiectasis

7. Asthma (Acute)

8. Lung Carcinoma — Examination Findings

• Monophonic fixed wheeze or stridor (proximal airway involvement)
• Signs of lobar collapse (atelectasis distal to obstruction)
• Signs of consolidation (post-obstructive pneumonia)

• Pleural effusion signs
• Pleuritic chest pain; pleural rub

• Cervical/supraclavicular lymphadenopathy (Virchow's node — left)
• Superior vena cava obstruction: non-pulsatile JVP, facial plethora, cyanosis, distended chest veins, Pemberton's sign

• Horner syndrome (Pancoast — stellate ganglion invasion)
• Wasting of small hand muscles (Pancoast — T1 root compression)
• Clubbing + hypertrophic pulmonary osteoarthropathy
• Signs of metastasis: hepatomegaly, bony tenderness, neurological signs (brain mets)

---

COMPLETE INTEGRATION TABLE — ALL FINDINGS

---

ADDITIONAL CLINICAL TESTS DURING EXAMINATION

Forced Expiratory Time (FET)

• Normal: <3 seconds

• 6 seconds = significant airflow obstruction (COPD, severe asthma)

• Washington Manual: "Auscultation in severe COPD may expose prolonged (i.e., >6 seconds) breath sounds on a maximal forced exhalation."

Peak Expiratory Flow Rate (PEFR)

Pulsus Paradoxus (Measured)

Harrison's 22e: "Pulsus paradoxus is an ominous sign in a patient with obstructive lung disease, as it is associated with significant negative intrathoracic (pleural) pressures required for ventilation and impending respiratory failure."

Pemberton's Sign

Six-Minute Walk Test (6MWT)

---

NORMAL ANATOMY OF LUNG LOBES — SURFACE MARKINGS

• Upper lobe: above horizontal fissure (4th rib anteriorly, 4th ICS)
• Middle lobe: between horizontal and oblique fissures (4th–6th rib anteriorly; right axilla)
• Lower lobe: below oblique fissure (6th rib MCL to T10 posteriorly); dominates the posterior chest

• Upper lobe (+ lingula): above oblique fissure; dominates anterior chest
• Lower lobe: below oblique fissure; dominates posterior chest
• Lingula: equivalent of right middle lobe; 3rd–5th ribs anteriorly, left MCL

• Posteriorly, nearly all audible sounds below the scapulae = lower lobes
• Anteriorly above nipple = upper lobes (right) and upper + lingular (left)
• Right middle lobe and lingula best heard in the right and left axillae respectively

---

EXAMINATION OF SPECIAL SITUATIONS

Patient in Respiratory Distress (ABCDE Approach)

• Do not fully undress before calling for help
• Assess SpO₂ immediately (normal ≥94%, target 94–98%)
• Look for: stridor → upper airway; silent chest + wheeze history → severe asthma; absent unilateral breath sounds + haemodynamic instability → tension pneumothorax

Intensive Care / Ventilated Patient

• Chest inspection for asymmetric rise (mainstem intubation)
• Auscultate bilaterally immediately after intubation
• Percuss for pneumothorax (hyper-resonance) if acute deterioration

Paediatric Patient

• Respiratory rate faster (neonates 40–60/min; 2 years 25–35; 10 years 20–25)
• Subcostal recession more prominent (pliable chest wall)
• Grunting = alveolar atelectasis (intrinsic PEEP)
• Stridor more common (laryngomalacia, croup, epiglottitis)

---

FINAL SYSTEMATIC CHECKLIST

RESPIRATORY EXAMINATION — STRUCTURED SEQUENCE

1. PREPARATION
   □ Wash hands, introduce, consent, chaperone if needed
   □ Expose patient to waist; seated at 45° or upright
   □ Adequate lighting

2. END-OF-BED INSPECTION
   □ General appearance, distress, cachexy
   □ Respiratory rate, pattern, depth
   □ Accessory muscle use
   □ Pursed-lip breathing, paradoxical breathing
   □ Oxygen, nebulisers, inhalers, sputum pots

3. HANDS & ARMS
   □ Clubbing (grade + Schamroth test)
   □ Peripheral cyanosis
   □ CO₂ flap (asterixis) — wrists extended 30 sec
   □ Fine tremor
   □ Tar staining
   □ Radial pulse (rate, rhythm, character)
   □ Bounding pulse (CO₂ retention)
   □ Pulsus paradoxus (if indicated — >10 mmHg)
   □ BP

4. FACE & NECK
   □ Central cyanosis (lips, tongue)
   □ Plethora vs pallor (conjunctivae)
   □ Horner syndrome (ptosis, miosis, enophthalmos)
   □ JVP (height, waveform)
   □ Pemberton's sign (if mediastinal mass suspected)
   □ Cervical/supraclavicular lymphadenopathy

5. TRACHEA
   □ Visual midline assessment
   □ Palpate tracheal position (suprasternal notch)
   □ Tracheal tug (Oliver's sign if vascular cause)

6. CHEST INSPECTION
   □ Shape: barrel, pectus, kyphoscoliosis, Harrison's sulci
   □ Symmetry of chest wall
   □ Scars (thoracotomy, VATS, chest drains, radiotherapy marks)
   □ Dilated chest wall veins (direction of flow)
   □ Chest wall movement — symmetry and degree
   □ Intercostal recession

7. PALPATION
   □ Upper zone expansion (anterior)
   □ Lower zone expansion (posterior, most important)
   □ Tactile vocal fremitus — all zones bilaterally
   □ Subcutaneous emphysema
   □ Apex beat position
   □ Right ventricular heave (parasternal)
   □ Pleural rub (palpable)
   □ Hoover's sign

8. PERCUSSION
   □ Apices (Kronig's isthmus)
   □ Anterior: 2nd ICS downward bilaterally
   □ Left → right comparison
   □ Cardiac dullness boundaries
   □ Posterior: systematic from apices to bases
   □ Lateral axillary lines
   □ Liver dullness (right MCL, 5th ICS)
   □ Traube's space (left)
   □ Diaphragmatic excursion (4–6 cm normal)
   □ Shifting dullness (if effusion suspected)

9. AUSCULTATION
   □ Breath sound character (vesicular vs bronchial vs ↓)
   □ Inspiration: expiration ratio
   □ Forced expiratory time (normal <3 s)
   □ Added sounds: crackles (timing, type, distribution)
   □ Wheeze (polyphonic vs monophonic, timing)
   □ Stridor
   □ Pleural rub
   □ Vocal resonance (ninety-nine)
   □ Whispering pectoriloquy
   □ Aegophony (E→A change)
   □ Anterior → lateral → posterior comparison

10. COMPLETION
    □ Ankle oedema (cor pulmonale)
    □ Temperature chart, SpO₂, PEFR if available
    □ Sputum: colour, consistency, volume, odour
    □ CXR if available — comment systematically
    □ Thank patient, help redress
    □ Summarise findings

---