Explain me about clinical examination of respiratory system
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respiratory system clinical examination inspection percussion auscultation
I now have comprehensive content from Murray & Nadel's Textbook of Respiratory Medicine. Let me compile a thorough, well-organized answer.
Clinical Examination of the Respiratory System
A systematic respiratory examination follows the classic sequence: History → General Inspection → Vital Signs → Examination of the Chest (Inspection → Palpation → Percussion → Auscultation) → Extra-pulmonary findings.
1. History & Symptom Assessment
Before touching the patient, a structured history directs the examination.
Key Symptoms
| Symptom | Clues |
|---|---|
| Dyspnea | Timing (acute vs. chronic), position (orthopnea, platypnea, bendopnea), triggers |
| Cough | Duration, character (dry/productive), hemoptysis |
| Wheezing | Episodic vs. continuous, nocturnal |
| Chest pain | Pleuritic vs. dull |
| Sputum | Color, amount, consistency |
Qualitative descriptors of dyspnea help localize pathology:
- "Air hunger / can't get enough air" → increased respiratory drive (hypercapnia, acidosis)
- "Tightness" → bronchospasm, stimulation of irritant receptors
- "Work/effort" → mechanical load on ventilatory pump
Timing:
- Acute → asthma, pulmonary edema, PE, mucus plugging
- Intermittent → exercise-triggered; think COPD, asthma, ILD, heart failure
- Chronic at rest → severe end-stage COPD, heart failure, neuromuscular disease
Positional variants:
- Orthopnea — lying flat worsens dyspnea (left heart failure, pulmonary vascular congestion)
- Platypnea — sitting up worsens dyspnea (AV malformations at lung base, hepatopulmonary syndrome)
- Bendopnea — bending over triggers dyspnea (central obesity, heart failure)
Murray & Nadel's Textbook of Respiratory Medicine
2. General Inspection & Vital Signs
Vital Signs
| Sign | Interpretation |
|---|---|
| Tachypnea | Increased respiratory drive; not necessarily hyperventilation |
| Pulsus paradoxus > 10 mmHg | Increased airway resistance or reduced respiratory compliance (in absence of tamponade) |
| Kussmaul breathing | Deep, mildly rapid breathing — severe metabolic acidosis (increases efficiency by reducing VD/VT ratio) |
| SpO₂ (pulse oximetry) | Now considered a 5th vital sign; assess at rest and with activity |
Breathing Pattern from the Bedside
- Accessory muscle use (sternocleidomastoid, scalenes) → increased respiratory drive, airway obstruction, or diaphragm weakness
- Paradoxical abdominal motion → respiratory muscle weakness
- Abdominal rounding on exhalation (outward periumbilical + inward lateral abdomen) → acute pulmonary edema — thought to generate intrinsic PEEP to reduce LV afterload
3. Inspection of the Chest
| Finding | Significance |
|---|---|
| Barrel chest | Hyperinflation (COPD, emphysema) |
| Hoover sign | Inward motion of lower lateral rib cage on inspiration → hyperinflation; flattened diaphragm pulls ribs inward |
| Kyphoscoliosis | Restrictive ventilatory defect from chest wall deformity |
| Pectus excavatum/carinatum | May restrict lung expansion |
| Tracheal deviation | Away from tension pneumothorax; toward collapse/fibrosis |
| Prominent accessory muscles | Chronic increased work of breathing |
| Cyanosis (central) | SpO₂ < ~85%; check tongue and lips |
| Clubbing | Lung cancer, bronchiectasis, ILD, cystic fibrosis |
Standard positioning: posterior chest auscultation with patient seated and upper torso exposed
4. Palpation
Tracheal Position
- Central = normal
- Deviated away from lesion → tension pneumothorax, large pleural effusion
- Deviated toward lesion → lobar collapse, post-pneumonectomy fibrosis
Chest Expansion
- Place both thumbs at the costal margin posteriorly; thumbs should separate symmetrically on deep inspiration
- Reduced unilateral expansion → pneumonia, effusion, pneumothorax, or pleural thickening on that side
- Reduced bilateral expansion → COPD, diffuse fibrosis
Tactile Vocal Fremitus (TVF)
- Place the ulnar border of the hand on the chest; ask patient to say "99" or "one-one-one"
- Increased TVF → consolidation (solid lung transmits vibration better)
- Decreased TVF → pleural effusion, pneumothorax, emphysema (air/fluid between lung and chest wall dampens transmission)
5. Percussion
Technique
- Place the middle finger of the non-dominant hand flat against an intercostal space; strike sharply with the tip of the dominant middle finger
Percussion Notes
| Note | Quality | Cause |
|---|---|---|
| Resonant | Hollow, low-pitched | Normal aerated lung |
| Hyper-resonant | Drum-like | Pneumothorax, emphysema |
| Dull | Thud-like, high-pitched | Consolidation, collapse |
| Stony dull | Extremely flat | Pleural effusion |
Diaphragmatic Excursion
- Percuss down the posterior chest from resonance to dullness on full inspiration, then full expiration
- Normal excursion: ~4–6 cm
- Reduced excursion → diaphragm palsy, hyperinflation, or elevated hemidiaphragm
Murray & Nadel's Textbook of Respiratory Medicine — "Percussion can be used to identify pleural effusions and motion of the diaphragm."
6. Auscultation
This is the most information-rich part of the chest examination.
Anterior (2nd ICS mid-clavicular) and posterior (upper T4–T5 and lower T9–T10) stethoscope positions for systematic auscultation
Normal Breath Sounds
| Sound | Where heard | Character |
|---|---|---|
| Vesicular | Most of lung fields | Soft, low-pitched; inspiratory > expiratory; no gap |
| Broncho-vesicular | 1st–2nd ICS anteriorly, between scapulae | Intermediate |
| Bronchial | Over trachea/manubrium | Loud, high-pitched; expiratory ≥ inspiratory; gap between I and E |
Added (Adventitious) Breath Sounds
| Sound | Mechanism | Clinical Significance |
|---|---|---|
| Crackles (fine) | Sudden opening of collapsed small airways | Pulmonary fibrosis, early heart failure; "like pulling Velcro apart" |
| Crackles (coarse) | Secretion movement in large airways | Bronchiectasis, pneumonia |
| Wheeze | Rapid airflow through narrowed airways | Asthma, COPD, foreign body |
| Rhonchi | Turbulence from secretions in large airways | Bronchitis, COPD; clears with cough |
| Stridor | Extrathoracic/large airway obstruction | Upper airway obstruction (laryngeal edema, croup) |
| Pleural rub | Inflamed pleural surfaces rubbing | Pleuritis (creaking leather sound, heard in both I and E) |
Murray & Nadel's — "Auscultation may reveal diminished or absent breath sounds (pleural effusion, pneumothorax, bullous emphysema), wheezes (increased airway resistance), crackles (diminished lung compliance), and rhonchi (turbulence from airway secretions)."
Vocal Resonance
- Ask patient to say "99" while auscultating
- Bronchophony → sounds louder and clearer over consolidation
- Egophony (AE change) → patient says "EEE," heard as "AYY" over consolidation/effusion border (goat-like quality)
- Whispering pectoriloquy → whispered words heard clearly over consolidation
7. Extra-Pulmonary Signs
| Finding | Association |
|---|---|
| Clubbing | Lung cancer, bronchiectasis, ILD, CF, mesothelioma |
| Central cyanosis | Severe hypoxemia |
| Peripheral edema + JVP elevation | Cor pulmonale, heart failure |
| Loud P2 | Pulmonary hypertension |
| Erythema nodosum | Sarcoidosis, TB |
| Raynaud phenomenon | Scleroderma → ILD |
| Skin changes | Connective tissue diseases associated with ILD |
| Horner syndrome | Pancoast tumor (apical lung cancer) |
| Lymphadenopathy | Lymphoma, sarcoidosis, malignancy, TB |
8. Classic Examination Patterns: Summary Table
| Condition | Inspection | TVF | Percussion | Breath Sounds | Added Sounds |
|---|---|---|---|---|---|
| Consolidation | Reduced expansion | ↑ | Dull | Bronchial | Crackles, egophony |
| Pleural effusion | Reduced expansion | ↓ | Stony dull | Absent/reduced | Pleural rub (at margins) |
| Pneumothorax | Reduced expansion | ↓ | Hyper-resonant | Absent | None |
| COPD/Emphysema | Barrel chest, Hoover sign | ↓ | Hyper-resonant | Reduced | Wheeze, prolonged expiration |
| Asthma (acute) | Accessory muscle use | Normal | Normal/↑ | Reduced | Polyphonic wheeze |
| Pulmonary fibrosis | Clubbing, cyanosis | Normal/↑ | Dull | Reduced | Fine end-inspiratory crackles |
| Collapse | Trachea deviated toward | ↓ | Dull | Reduced/absent | None |
Key Principles
- Always examine systematically — compare left and right at every level before moving lower
- Link physical signs to pathophysiology — understand why each sign occurs (transmission of sound, air/fluid interface, airway mechanics)
- Vital signs are part of the examination — tachypnea, SpO₂, and use of accessory muscles convey critical physiologic information
- Dyspnea can only be quantified by the patient — clinicians frequently underestimate its severity; always ask the patient to rate it
Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume Set (9780323655873)
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