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Respiratory System Examination - Short Notes

Respiratory Rate

• Normal adult rate: 12-20 breaths/min
• Tachypnea = elevated rate; seen in pneumonia, pulmonary embolism, sepsis, metabolic acidosis
• Hypopnea/bradypnea = depressed rate; seen in CNS depression, opioid overdose
• Pulse oximetry should be measured alongside RR - many patients with respiratory disease have hypoxemia at rest or with exertion
• Inability to complete a sentence in conversation = sign of severe impairment requiring urgent evaluation

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Inspection

• Look for signs of respiratory distress: nasal flaring, pursed lip breathing
• Accessory muscle use - sternocleidomastoid, scalenes - indicates increased work of breathing
• Chest wall deformities: barrel chest (COPD), pectus excavatum, severe kyphoscoliosis (causes restrictive physiology)
• Breathing pattern: rate, rhythm, depth, symmetry of chest expansion
• Cyanosis - seen when >5 g/dL of deoxyhaemoglobin; peripheral vs central
• Clubbing - seen in cystic fibrosis, IPF, lung cancer
• Tracheal position: deviation suggests pneumothorax or large effusion
• Cheyne-Stokes, Kussmaul, Biot's breathing patterns should be noted

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Palpation

• Tactile (vocal) fremitus: vibration felt when patient says "99"
  • Increased = consolidation (pneumonia) - sound conducts better through solid tissue
  • Decreased/absent = pleural effusion or pneumothorax - fluid/air blocks transmission
• Chest expansion: place thumbs at midline over lower posterior chest, grasp lateral rib cage - thumbs should separate equally on deep inspiration; asymmetry indicates unilateral ventilation disorder
• Subcutaneous emphysema (crepitus on palpation) = sign of barotrauma or pneumothorax
• Tracheal position: confirm with fingertip in suprasternal notch

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Percussion

• Technique: middle finger of non-dominant hand placed on chest; struck by middle finger of dominant hand (pleximeter-plexor method)
• Normal findings: resonant over lung fields, dull over liver/heart
• Abnormal findings:

• Diaphragm excursion: assessed by percussing from resonant to dull on full inspiration vs expiration (normal ~5 cm)
• In decreased breath sounds: percussion helps distinguish effusion (dull) from pneumothorax (hyper-resonant)

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Auscultation

Normal Breath Sounds

Added (Adventitious) Sounds

• Wheeze - high-pitched, musical; expiratory; sign of airway obstruction (asthma, COPD, pulmonary edema - "cardiac asthma")
• Rhonchi - low-pitched, snoring; obstruction of medium-sized airways with secretions; clears with coughing; seen in bronchitis, bronchiectasis, COPD
• Stridor - high-pitched inspiratory wheeze, heard over neck; sign of upper airway obstruction (epiglottitis, foreign body, croup)
• Crackles (Rales) - sign of alveolar disease:
  • Fine crackles ("Velcro ripping") = interstitial fibrosis (IPF)
  • Coarse/wet crackles = pulmonary edema (basal), pneumonia
  • Crackles in pulmonary edema are more prominent at the bases
• Pleural rub - leathery, creaking sound; in-and-expiration; inflamed pleural surfaces

Special Auscultatory Signs

• Egophony: patient says "EEE" but "AH" is heard through stethoscope - indicates consolidation (pneumonia); absent in IPF
• Bronchophony/Whispered pectoriloquy: increased transmission of spoken/whispered voice = consolidation
• Absent/diminished breath sounds: emphysema (diffusely quiet), pneumothorax or effusion (focal absence)

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Quick Clinical Summary Table

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Respiratory System Examination — Short Notes (Normal Findings & Technique Only)

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1. Respiratory Rate

• Counted by observing chest wall movement for a full 60 seconds (or 30 sec × 2)
• Best counted without the patient's knowledge (patients unconsciously alter breathing when aware)
• Normal adult rate: 12–20 breaths/min
• Note: rate, rhythm, and depth together
• Recorded as part of vital signs alongside pulse, BP, and temperature

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2. Inspection

Position & Environment

• Patient seated upright or at 45°, chest fully exposed
• Adequate lighting

What to Observe

• Level of consciousness, ability to speak in full sentences
• Nutritional status, body habitus

• Elliptical cross-section, anteroposterior (AP) diameter less than transverse diameter (AP:transverse ≈ 1:2)
• Slight outward slope of ribs downward from spine

• Skin: scars, sinuses, dilated veins
• Symmetry of both sides at rest

• Both sides of the chest rise and fall equally and symmetrically
• In males: predominantly abdominal/diaphragmatic breathing
• In females: predominantly thoracic breathing
• Smooth, effortless, regular rhythm
• No use of accessory muscles at rest (sternocleidomastoid, scalenes, intercostals)
• No intercostal, subcostal, or supraclavicular recession at rest

• Regular and even
• Normal I:E ratio approximately 1:2 (inspiration shorter than expiration)

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3. Palpation

Steps in Order

• Stand in front of patient
• Place index finger gently in the suprasternal notch
• Normally, trachea sits central, equidistant from both clavicular heads

• Place both hands flat on the anterior chest with thumbs meeting at the midsternal line
• Ask patient to take a deep breath
• Thumbs should separate equally by approximately 5 cm
• Confirms symmetric bilateral expansion

• Place both hands over the lower posterior chest, thumbs approximated at the midline along the spine
• Grasp the lateral rib cage
• On deep inspiration, thumbs separate symmetrically
• Assesses symmetry and degree of chest wall movement

• Use the ulnar border of the hand or the base of the fingers
• Ask patient to repeat "99" or "one-one-one" in a deep voice
• Feel vibrations systematically at apex, middle, and base on both sides
• Compare side-to-side at each level
• Normal finding: equal, moderate vibration felt bilaterally
• Normally slightly more prominent at the right apex (closer to trachea)

• Gentle anteroposterior and lateral compression of the chest
• Used in trauma assessment
• Normal: slight, elastic spring with no focal pain

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4. Percussion

Technique

• Pleximeter finger: middle finger of non-dominant hand placed firmly on chest wall, parallel to ribs, other fingers lifted off
• Plexor finger: middle finger of dominant hand — strike the middle phalanx of pleximeter with a sharp, quick, flicking wrist movement
• Strike 2 times at each location, then move on
• Always compare left vs right at the same level

Systematic Approach

• Begin at apices (percuss over the supraclavicular fossae)
• Move down in steps of ~5 cm, comparing sides at each level
• Percuss anterior, lateral, and posterior chest walls
• At least 3 levels per side posteriorly

Normal Percussion Note

• Resonant over all lung fields
• Cardiac dullness — left parasternal, 3rd–5th intercostal space
• Hepatic dullness — right lower chest, below 6th rib in the mid-clavicular line
• Gastric tympany — left lower chest (Traube's space)

Diaphragm Excursion (Liver/Lung Border)

• Percuss down the right posterior chest from resonance to dullness on full expiration, mark it
• Repeat on full inspiration, mark it
• Normal excursion: ~5 cm (3–7 cm)

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5. Auscultation

Technique

• Use the diaphragm of the stethoscope (pressed firmly on skin)
• Patient breathes in and out through the open mouth, slightly deeper than normal
• Listen for one full breath cycle (one inspiration + one expiration) at each spot
• Compare side-to-side at the same level

Systematic Sequence

• Auscultate apex → middle → base, anterior and posterior
• Posterior auscultation gives best access to lower lobes
• At least 5–6 positions per side posteriorly

Normal Breath Sounds

Vocal Resonance (Normal)

• Ask patient to say "99" or "one-one-one"
• Sound is heard as muffled, indistinct murmur through the stethoscope normally
• Equal bilaterally
• Normal: voice sounds are not clearly transmitted through healthy air-filled lung

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Summary of Normal Findings