Dedicated Pulmonology / Respiratory Textbooks

Supporting Books with Strong Respiratory Content

Respiratory System Examination

1. GENERAL INSPECTION (Before You Touch)

a) General Appearance

• Level of distress, ability to speak in full sentences (inability = severe dyspnea)
• Nutritional status, body habitus (obesity can restrict breathing)
• Use of accessory muscles (sternocleidomastoid, scalene muscles) - suggests increased work of breathing
• Patient's posture (e.g., tripod position in COPD/asthma)

b) Hands and Peripheries

• Clubbing - loss of the normal angle at the nail bed (Schamroth's sign). Seen in:
  • Chronic lung disease (bronchiectasis, lung abscess, fibrosing alveolitis)
  • Malignancies (lung cancer)
  • Congenital heart disease with right-to-left shunts
  • NOT seen in COPD (important negative)
• Peripheral cyanosis - bluish discoloration of fingertips/toes. Distinguish from acrocyanosis (poor circulation)
• Nicotine staining on fingers/teeth/lips
• Asterixis (flapping tremor) - CO2 retention in type 2 respiratory failure
• Fine tremor - beta-2 agonist use

c) Face and Mouth

• Central cyanosis - bluish discoloration of the tongue/buccal mucosa (arterial hemoglobin saturation ≤80%, PaO2 <50-52 mmHg)
• Pursed-lip breathing - seen in COPD, helps maintain positive airway pressure
• Odors: ethanol, ketones (diabetic ketoacidosis), foul (anaerobic lung abscess), sweet/fruity (Pseudomonas infection)

d) Eyes

• Horner's syndrome (ptosis, miosis, anhidrosis) - Pancoast tumor (apex of lung) compressing sympathetic chain
• Plethora/suffused eyes - CO2 retention

e) Neck

• Raised JVP - cor pulmonale, right heart failure secondary to lung disease
• Tracheal position - assessed from front; deviation suggests mediastinal shift

f) Respiratory Rate and Breathing Pattern

2. INSPECTION OF THE CHEST

Shape and Symmetry

• Barrel chest - increased AP diameter; AP:transverse ratio approaches 1:1; seen in emphysema/COPD (hyperinflation)
• Pectus excavatum (funnel chest) - sternal depression
• Pectus carinatum (pigeon chest) - sternal protrusion; seen after childhood asthma
• Kyphosis - anterior curvature of spine
• Scoliosis - lateral curvature
• Kyphoscoliosis - both; can cause restrictive ventilatory defect
• Ankylosing spondylitis - rigid chest, reduced expansion

Scars and Deformities

• Thoracotomy scars
• Drain site scars
• Radiation skin changes

Chest Wall Movement

• Symmetry of movement during breathing
• Reduced movement on one side suggests:
  • Pneumonia/consolidation
  • Pleural effusion
  • Pneumothorax
  • Collapse/atelectasis

3. PALPATION

a) Trachea

• Place finger in suprasternal notch - trachea should be central
• Tracheal deviation TOWARD lesion: collapse/atelectasis, pulmonary fibrosis
• Tracheal deviation AWAY from lesion: large pleural effusion, tension pneumothorax

b) Chest Expansion

• Place hands on either side of the lower chest, thumbs together in midline
• Ask patient to take a deep breath
• Normal: symmetrical expansion, thumbs separate equally by ~5 cm
• Reduced on one side: consolidation, effusion, pneumothorax, collapse

c) Vocal (Tactile) Fremitus

• Place palm or ulnar border of hand on chest wall
• Ask patient to say "one, two, three" or "ninety-nine"
• Feel for vibrations; compare side to side from apex to base

d) Other Palpation Findings

• Point tenderness - rib fracture, costochondritis
• Subcutaneous emphysema - crepitus on palpation (air under skin); trauma, pneumothorax
• Fluctuance - empyema necessitans (pus tracking through chest wall)
• Cervical ribs - bony abnormalities
• Palpable cardiac heave - in severe COPD, right ventricular heave may be felt at the subxiphoid area (as hyperinflated lungs displace the heart)

4. PERCUSSION

Technique

• Place the middle finger of the non-dominant hand (pleximeter) firmly on the chest wall
• Strike it sharply with the middle finger of the dominant hand (plexor) - a quick, wrist-driven motion
• Compare percussion note side to side, moving from apex to base
• The note is predominantly felt as much as heard

Normal Percussion Note: Resonant

1. Normal resonance above the fluid
2. Dullness at the fluid level
3. Stony dullness at and below fluid

Percussion Sites

• Anterior chest: clavicles (percuss directly), 2nd, 4th, 6th intercostal spaces
• Posterior chest: suprascapular fossae, between scapulae, below scapulae
• Axillae bilaterally
• Liver dullness (lower right, starting from resonant to dull)
• Cardiac dullness (left, 2nd-5th ICS)

5. AUSCULTATION

Technique

• Use diaphragm of stethoscope for most lung sounds (higher pitched)
• Use bell for lower-pitched sounds
• Ask patient to breathe slowly and deeply through an open mouth
• Listen in same systematic pattern as percussion - compare side to side

Normal Breath Sounds

Breath Sound Intensity

• Reduced/absent breath sounds: pleural effusion, pneumothorax, emphysema, collapse (with blocked bronchus)
• Increased breath sounds: consolidation with patent airways

Adventitious (Added) Sounds

Crackles (Crepitations)

• Fine crackles: high-pitched, brief, end-inspiratory, like pulling Velcro apart
  • Causes: pulmonary fibrosis, early pulmonary oedema, pneumonia
• Coarse crackles: low-pitched, early inspiratory or expiratory
  • Causes: bronchiectasis, COPD, secretions; may clear with coughing
• Mechanism: sudden opening of collapsed small airways, or movement of secretions

Wheeze (Continuous Sound)

• Expiratory wheeze (polyphonic): multiple pitches simultaneously = diffuse airway obstruction (asthma, COPD)
• Inspiratory stridor (monophonic): single high-pitched sound = upper airway or large airway obstruction (croup, foreign body, tumour)
• Fixed monophonic wheeze: same site, always present = local obstruction (tumour, foreign body)
• Dominant frequency >400 Hz; caused by airway wall flutter at critical flow velocity

Rhonchi

• Low-pitched continuous sounds (~200 Hz)
• Caused by fluid film rupture and airway wall vibration
• May clear with coughing
• Sometimes called "low-pitched wheeze"

Pleural Rub

• Scratchy, creaking, leathery sound (like walking on fresh snow)
• Heard in both inspiration and expiration
• Does NOT disappear with coughing
• Cause: inflamed visceral and parietal pleura rubbing (pleuritis, pulmonary embolism, pneumonia at periphery)

Voice-Generated Auscultatory Signs (over consolidated/solid lung)

6. SUMMARY TABLE: Examination Findings in Common Conditions

7. COMPLETING THE EXAMINATION

• Check oxygen saturation (SpO2) with pulse oximetry
• Check peak expiratory flow rate (PEFR) in suspected asthma
• Examine the cardiovascular system (JVP, cardiac heave, peripheral oedema for cor pulmonale)
• Check for lymphadenopathy (cervical, supraclavicular - lung malignancy, sarcoidosis)
• Check temperature chart and sputum if available
• Review chest X-ray and spirometry if available

1. General Inspection - hands (clubbing, cyanosis), face (central cyanosis, Horner's), JVP, breathing pattern
2. Chest Inspection - shape (barrel, pectus), symmetry, movement, scars
3. Palpation - trachea position, chest expansion, vocal fremitus, tenderness
4. Percussion - resonant / dull / stony dull / hyper-resonant
5. Auscultation - breath sounds (normal vs. bronchial), added sounds (crackles, wheeze, rub), voice sounds (bronchophony, egophony, pectoriloquy)
6. Summary table - key findings in pneumonia, effusion, pneumothorax, collapse, COPD, asthma, IPF, bronchiectasis