Respiratory system examination comprehensive notes
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Respiratory System Examination - Comprehensive Notes
Based primarily on Murray & Nadel's Textbook of Respiratory Medicine and Goldman-Cecil Medicine
1. OVERVIEW
Physical examination of the chest uses four classic techniques performed in this sequence:
- Inspection
- Palpation
- Percussion
- Auscultation
Optimal conditions: privacy, warmth, good lighting, and a quiet room. The patient should be adequately undressed to expose the entire thorax, typically sitting upright.
2. GENERAL INSPECTION (from a distance)
Begin the moment you first see the patient. Note:
a) General Appearance
- Level of distress, use of accessory muscles
- Ability to speak in full sentences
- Posture (tripod position in severe obstruction)
- Nutritional status and cachexia (suggests malignancy or COPD)
- Mental status changes (CO2 retention - "CO2 narcosis")
b) Chest Shape and Symmetry
| Deformity | Association |
|---|---|
| Barrel chest | COPD, emphysema (AP:lateral ratio approaches 1:1) |
| Kyphoscoliosis | Restrictive lung disease, cor pulmonale |
| Pectus excavatum (funnel chest) | Usually cosmetic; severe cases restrict lung expansion |
| Pectus carinatum (pigeon chest) | Chronic childhood asthma, Marfan syndrome |
| Harrison's sulcus | Horizontal groove at level of diaphragm attachment; childhood respiratory disease |
c) Breathing Pattern
Several classic patterns of ventilation:
| Pattern | Description | Cause |
|---|---|---|
| Eupnea | Normal (12-20 breaths/min) | - |
| Tachypnoea | >20 breaths/min | Hypoxia, fever, pain, anxiety |
| Bradypnoea | <12 breaths/min | Opiates, CNS depression |
| Cheyne-Stokes | Waxing-waning with apnoeic pauses | Heart failure, CNS lesions, high altitude |
| Biot's (ataxic) | Irregular without pattern | Medullary brainstem damage |
| Kussmaul | Deep, rapid, labored | Metabolic acidosis (DKA) |
| Apneustic | Prolonged inspiratory cramp | Pontine lesion |
d) Use of Accessory Muscles
- Sternocleidomastoid, scalene, trapezius: activated in obstructive disease
- Intercostal retraction: indicates increased work of breathing
- Paradoxical chest movement (chest sinks inward on inspiration): diaphragm paralysis or flail chest
e) Peripheral Signs (Inspect the Hands, Face, Neck)
Hands:
- Clubbing - loss of the normal angle between the nail and nail bed (Schamroth's sign); seen in bronchogenic carcinoma, chronic suppurative lung disease (bronchiectasis, abscess), cyanotic heart disease, fibrosing alveolitis, mesothelioma
- Peripheral cyanosis - bluish discoloration of fingers/nail beds
- Tar staining - tobacco leaf stains on teeth, lips, fingers
- Asterixis (flapping tremor) - CO2 retention
- Wasting of intrinsic hand muscles - Pancoast tumour (T1 involvement)
Face and Lips:
- Central cyanosis - bluish discoloration of tongue and mucous membranes; indicates SaO2 <85%
- Anaemia - pallor of conjunctivae
- Horner's syndrome (ptosis, miosis, anhidrosis) - Pancoast tumour, mediastinal mass
Neck:
- Elevated JVP - right heart failure, COPD with cor pulmonale, SVC obstruction
- Lymphadenopathy - malignancy, sarcoidosis, infection
- Tracheal position (see Palpation below)
3. PALPATION
a) Trachea
- Palpate with a single finger in the suprasternal notch
- Normally midline
- Displaced toward the lesion: collapse, lung fibrosis, pneumonectomy
- Displaced away from the lesion: large pleural effusion, tension pneumothorax, large mass
- Fixed/immobile trachea: mediastinal fibrosis or malignant infiltration
b) Chest Expansion
- Place both hands flat on the posterior chest with thumbs meeting at the midline (or anterior chest)
- Ask the patient to take a deep breath
- Normally symmetric; thumbs should move 5-6 cm apart
- Reduced unilaterally: consolidation, effusion, pneumothorax, collapse on that side
- Reduced bilaterally: COPD, bilateral fibrosis, neuromuscular disease
c) Vocal (Tactile) Fremitus
- Place the ulnar aspect of both hands (or palms) on the chest wall
- Ask the patient to say "one-two-three" or "ninety-nine"
- Feel for transmitted vibration and compare symmetrically
| Finding | Cause |
|---|---|
| Increased fremitus | Consolidation (pneumonia) - enhanced sound transmission through solid tissue |
| Decreased fremitus | Pleural effusion, pneumothorax, emphysema, obesity (impaired transmission) |
| Absent fremitus | Large effusion, complete collapse with blocked airway |
d) Other Palpation Findings
- Subcutaneous emphysema: crepitant crackling sensation under the fingers (air in subcutaneous tissue - pneumothorax, tracheobronchial injury)
- Bony tenderness: rib fractures, malignant deposits
- Cervical rib: palpable supraclavicular mass
- Fluctuant area: empyema necessitans (pus tracking through chest wall)
- Apical impulse / heaves: cor pulmonale; in severe COPD, best felt subxiphoid
4. PERCUSSION
Technique
- Place the middle finger of the non-dominant hand (pleximeter) firmly on the chest wall, parallel to ribs
- Strike the middle phalanx sharply with the middle finger of the dominant hand (plexor)
- Free, easy, uniform stroke - predominantly felt, not just heard
- Compare symmetrical areas systematically
Percussion Notes
| Note | Quality | Normal Location | Pathological Cause |
|---|---|---|---|
| Resonant | Hollow, low-pitched, long | Normal lung | - |
| Hyperresonant | Booming, louder than normal | Normal lung in children | Emphysema, pneumothorax |
| Tympanitic | Drum-like, higher frequency | Stomach/bowel | Tension pneumothorax, large cavity |
| Dull | Short, high-pitched, thud-like | Liver, heart | Consolidation, pleural effusion (upper zone), collapse |
| Stony dull (flat) | Very dull, no resonance | No normal location | Massive pleural effusion (below the fluid level) |
Key Clinical Correlation:
With a large pleural effusion, three zones are detected on percussion:
- Above the fluid: normal resonance
- At the fluid level: dullness
- Below (at base): stony flat
Useful Percussion Tests
- Liver dullness: normally begins at right 5th intercostal space mid-clavicular line; if absent - emphysema (hyperinflation pushes liver down)
- Cardiac dullness: if absent - emphysema
- Traube's space (LUQ): tympanic normally; dullness suggests splenomegaly or left-sided effusion
5. AUSCULTATION
Use the diaphragm of the stethoscope (high-pitched sounds). Listen at multiple symmetrical locations systematically - apex to base, anterior and posterior.
Normal Breath Sounds
| Sound | Location | Character |
|---|---|---|
| Bronchial (tubular) | Over trachea and main bronchi | Loud, high-pitched, hollow; expiration longer than or equal to inspiration; gap between I and E |
| Bronchovesicular | Over main bronchi; 1st and 2nd intercostal spaces | Intermediate quality; I = E in duration |
| Vesicular | Over peripheral lung | Soft, low-pitched, rustling; inspiration longer than expiration (I:E = 3:1); no gap |
Bronchial breathing heard peripherally = pathological, suggests consolidation or collapse with patent airway
Added (Adventitious) Sounds
Crackles (formerly "rales")
- Fine crackles (late inspiratory): brief, high-pitched, discontinuous sounds like rubbing hair near the ear; caused by sudden opening of small airways
- Causes: pulmonary fibrosis (cryptogenic fibrosing alveolitis), pulmonary oedema (early), pneumonia
- Coarse crackles (early inspiratory or expiratory): lower-pitched, bubbling, gurgling sounds; caused by secretions in larger airways
- Causes: bronchiectasis, COPD with secretions, pulmonary oedema (later)
Wheezes (formerly "rhonchi")
- Polyphonic (multiple pitches): diffuse airway obstruction; characteristic of asthma during an attack
- Monophonic (single pitch): fixed obstruction of a single airway; suggests carcinoma, foreign body, or mucus plug
- Inspiratory wheeze (stridor): high-pitched, audible at the neck; indicates upper airway/extrathoracic obstruction (laryngeal oedema, croup, foreign body)
Pleural Friction Rub
- Creaking, leathery sound during both inspiration and expiration (sometimes only one phase)
- Caused by roughened, inflamed pleural surfaces rubbing together
- Heard in: pleurisy, pulmonary embolism with infarction, mesothelioma
- Does NOT disappear with coughing (distinguishes from crackles)
- May be heard even in the presence of pleural effusion (shape change of thickened pleura)
Voice-Transmitted Sounds
| Test | Technique | Normal | Abnormal (Consolidation) |
|---|---|---|---|
| Vocal resonance | Patient says "ninety-nine"; listen | Muffled, indistinct | Increased, clearer - "bronchophony" |
| Whispering pectoriloquy | Patient whispers "one-two-three"; listen | Barely audible, indistinct | Whispered words heard clearly and distinctly |
| Egophony | Patient says "eeeee"; listen | "eeeee" sound | Sounds like "aaaay" (E-to-A change) |
All three reflect increased sound transmission through consolidated lung (as in lobar pneumonia). Egophony is also heard at the top of a pleural effusion where the lung is compressed.
6. CLINICAL PROFILES OF COMMON CONDITIONS
| Condition | Trachea | Expansion | Fremitus | Percussion | Breath Sounds | Added Sounds |
|---|---|---|---|---|---|---|
| Consolidation (Pneumonia) | Central | Reduced ipsilateral | Increased | Dull | Bronchial breathing | Fine crackles, bronchophony, egophony |
| Pleural Effusion | Central (small); pushed away (large) | Reduced ipsilateral | Absent/reduced | Stony dull | Reduced/absent (bronchial at top of effusion) | Pleural rub (if pleurisy); egophony at top |
| Pneumothorax | Central (small); pushed away (tension) | Reduced ipsilateral | Absent/reduced | Hyperresonant | Absent/reduced | None |
| Lobar Collapse (with blocked bronchus) | Pulled toward | Reduced ipsilateral | Absent | Dull | Absent | None |
| Lobar Collapse (with patent bronchus) | Pulled toward | Reduced | Increased | Dull | Bronchial | None |
| Emphysema/COPD | Central | Reduced bilaterally | Reduced | Hyperresonant, loss of liver/cardiac dullness | Reduced vesicular, prolonged expiration | Wheeze, coarse crackles |
| Pulmonary Fibrosis | Central | Reduced bilaterally | Normal/increased | Normal | Normal, or bronchial | Fine, late inspiratory crackles (basal) |
| Asthma (attack) | Central | Reduced bilaterally | Normal/reduced | Normal or hyperresonant | Prolonged expiration | Polyphonic wheeze |
| Bronchiectasis | Central | Normal or reduced | Normal | Normal | Normal | Coarse crackles, bronchophony |
7. EXTRAPULMONARY SOUNDS
- Stridor: high-pitched continuous sound from turbulent flow in the extrathoracic (upper) airway; louder during inspiration; causes include epiglottitis, croup, foreign body, laryngeal oedema, tracheal stenosis - potentially life-threatening
- Hamman's sign (mediastinal crunch): crunching or clicking sound with each heartbeat; caused by pneumomediastinum
- Succussion splash: splashing sound with patient movement; suggests hydropneumothorax
8. STRUCTURED APPROACH SUMMARY
A systematic bedside approach:
- Wash hands, introduce, position (sitting upright)
- General inspection from end of bed (distress, colour, breathing pattern, body habitus, equipment like inhalers, O2, sputum pots)
- Hands (clubbing, cyanosis, tar staining, asterixis, wasting)
- Arms (pulse rate and rhythm, pulsus paradoxus - >10 mmHg drop in systolic BP during inspiration, suggests severe asthma or cardiac tamponade)
- Face (central cyanosis, anaemia, Horner's syndrome, pursed lip breathing)
- Neck (JVP, tracheal position, lymphadenopathy, accessory muscle use)
- Chest - Inspection (shape, deformities, scars, chest movement symmetry, intercostal recession, chest drains)
- Chest - Palpation (confirm trachea, apex beat, expansion, vocal fremitus)
- Chest - Percussion (all zones, anterior and posterior, compare sides)
- Chest - Auscultation (breath sounds quality, added sounds, vocal resonance)
- Complete (check for ankle oedema, peak flow, oxygen saturations, request CXR and spirometry)
9. IMPORTANT MNEMONICS
IPPA = Inspection, Palpation, Percussion, Auscultation
Causes of DECREASED chest expansion (unilateral):
- Pneumothorax
- Pleural effusion
- Pneumonia/consolidation
- Post-lobectomy/pneumonectomy
- Pulmonary fibrosis (unilateral)
Causes of CLUBBING in respiratory:
- BLASTC: Bronchiectasis, Lung abscess, Asbestosis/fibrosing alveolitis, Suppurative lung disease (empyema), Tumour (bronchogenic carcinoma), Cyanotic heart disease (not strictly respiratory but often tested)
SHIFT of trachea:
- Pushed away: effusion, tension pneumothorax
- Pulled toward: collapse, fibrosis, pneumonectomy
Sources: Murray & Nadel's Textbook of Respiratory Medicine, 2-Volume; Goldman-Cecil Medicine; Barash Clinical Anesthesia, 9e
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