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Respiratory Examination
Introduction

W - Wash your hands.

I Introduce yourself (full name and role). Greet the patient with their title and
surname, and check you are using their preferred form of address.
P - Permission. Explain that you wish to perform a respiratory examination and obtain
consent for the examination.
E - Expose the necessary parts of the patient. Ideally the patient should be undressed
from the waist up taking care to ensure the patient is not cold or unnecessarily
embarrassed.
R Reposition the patient. In this examination the patient should be supine and
reclined at 45 degrees.

Peripheral Examination
End of the Bed
The position of the patientFirst look at the patient from the end of
the bed for signs of breathlessnesss or distress. Those with extreme
pulmonary dysfunction will often sit up-right. In cases of real distress, they
will lean forward, resting their hands on their knees in what is known as the tri-
pod position.

It is also important to look at the surrounding environment for sputum pots,

nebulisers, peak-flow meters, inhalers or oxygen tubing.
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Breathing through pursed lips, often seen in cases of emphysema.

Ability to speak. At times, respiratory rates can be so high and/or work of
breathing so great that patients are unable to speak in complete sentences. If this
occurs, note how many words they can speak (i.e. the fewer words per breath, the
worse the problem!).

Hands
Look at the hands for clubbing, tar staining and peripheral cyanosis.
Examine for tremor and a carbon dioxide retention flap.
Palpate the radial pulse to calculate heart rate. At this time also assess respiratory rate and
determine the pattern of breathing.

Face
Look at the patients eyes and face for signs of Horners syndrome or lupus pernio.
Inspect the conjunctivae for anaemia.
Look at the lips and tongue for central cyanosis
Lie the patient at 45 degrees and assess JVP.
Palpate the cervical, supraclavicular and axillary lymph nodes.
Examination of the chest

Review of Lung Anatomy:

Understanding the pulmonary exam is greatly enhanced by recognizing the relationships
between surface structures, the skeleton, and the main lobes of the lung. Realize that this
can be difficult as some surface landmarks (eg nipples of the breast) do not always maintain
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their precise relationship to underlying structures. Nevertheless, surface markers will give
you a rough guide to what lies beneath the skin. The pictures below demonstrate these
relationships. The multi-colored areas of the lung model identify precise anatomic segments
of the various lobes, which cannot be appreciated on examination. Main lobes are outlined
in black. The following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper
Lobe; RML = Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.
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Inspection
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1.look for chest deformity while you are examining the patient
anteriorly or spine deformity posteriorly.
These may arise as a result of chronic lung disease (ex.emphysema), occur
congenitally, or be otherwise acquired. In any case, they can impair a patient's
ability to breathe normally.
a. Barrel chest: chest wall increased anterior-posterior , Associated with emphysema
and lung hyperinflation

b. Pectus excavatum: sternum sunken into the chest

c. Pectus carinatum - sternum protruding from the chest
d. Kyphosis: Causes the patient to be bent forward

e. Scoliosis: Condition where the spine is curved to either the left or right

2.look for skin ,scars , dilated vessels , respiratory distress signs

Skin eruption e.g Herpes zoster
Nodules (inflammatory, metastatic, lipoma, neurofibroma)
Subcutaneous emphysema
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Purpuric spots, Vascular spiders, Bruises

Prominent blood vessels (arterial in coarctation of aorta and venous in
SVC obstruction)
Scars (previous operation, trauma, sterneotomy)
Discharging sinuses
Lesions of the breasts and enlargement of axillary LNs

.Signs of respiratory distress-

. Pursed-lip breathing - COPD (used to increase end expiratory pressure)

. Accessory muscle use (scalene muscles)

. Diaphragmatic paradox - the diaphragm moves opposite of the normal direction

on inspiration

. Any degree of asymmetry or asynchrony of chest expansion

3. Look for respiratory movement:

In female ,it is thoracoabdominal with chest predominant movement.

In male , it is abdominothoracic movement

4. Use of accessory muscles of breathing:

Intercostal indrawing , supraclavicular or intercostal retraction.

PALPATION:

Place the entire palm of each hand first on the superior portion of both
hemithoraces and then, gently though firmly, move the hand inferiorly to just
below the twelfth rib. Repeat the process moving laterally and subsequently
anteriorly; search for rib deformities, nodules, and areas of tenderness. In the face
of a history of chest discomfort, ask the patient to point to the area(s) of greatest
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discomfort. Palpate the area with increasing firmness in an attempt to elicit

tenderness and to assess if this maneuver reproduces the patient's symptoms.

1. Trachea:
The trachea should be checked to see if it is in the normal
central position. This means the distance between the trachea
and the sternomastoid muscles should be equal on both sides.
Slight displacement of the trachea to the right is fairly common
in healthy people. Palpate the trachea by placing a finger
either side of the trachea and judging whether the distance
between it and the sternomastoid tendons are equal on both
sides. Before doing this warn the patient that this might be
slightly uncomfortable.

Tracheal deviation is indicative of mediastinal displacement to one side, which

can be due to:
The trachea is pushed away to other side:
1. pneumothorax large volume of air in the pleural space
2. Pleural effusion Large volumes of fluid in the pleural space
Trachea is pulled by apical collapse , fibrosis or tumour while it is pushed to
other side by air or fluid if large.

Cricosternal distance
Measuring the cricosternal distance can help determine if the patient is
hyperventilating. A distance of less than three of the patients finger-breadths
indicates hyperventilation, usually evident as a visible descent of the trachea
during inspiration (tracheal tug) (Ford et al, 2005).

2.APEX BEAT:
It is the lower most , outer most ,most forceful pulsation.
It is important to check the line, space and character.
Position of the apex beat can confirm or exclude mediastinal displacement (Ford et al,
2005). This is not a reliable sign if there is cardiomegaly (Epstein et al, 2003).

3.CHEST EXPANSION:
Chest expansion must be assessed to determine the depth and quality of movement on each
side of the chest. Both sides should be assessed for symmetry. The symmetry and degree of
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chest expansion can be more accurately evaluated by observing chest movement than by
palpating the chest wall (Ford et al, 2005).

Palpation of Respiratory Movements

1. Respiratory movements in the infraclavicular regions

2. Respiratory movements at the costal margins
3. Respiratory movements of the lower ribs posteriorly

Signifacance of reduced respiratory movements

Unilateral reduction of chest wall movements:

Pleural effusion/empyema
Pneumothorax
Pulmonary collapse
Pleural or parenchymatous pulmonary fibrosis
Bilateral reduction of chest wall movements:
Bronchial asthma
Emphysema
Diffuse pulmonary fibrosis
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Method:
Assess chest expansion by putting the fingers of both your hands as far round the chest as
possible and then bring your thumbs together in the midline . Ask your patient to take a deep
breath and observe whether the distance moved is the same for both thumbs.
Your hands should lift symmetrically outward when the patient takes a deep breath .
Asymmetric lung expansion, as occur when anything fills the pleural space (e.g. air or fluid),
may then be detected as the hand on the affected side will move outward to a lesser degree.
thumbs typically separate by approximately 2 to 3 cm.ANT= 2 LEVELS ,POST= 3 LEVELS

4.TACTILE VOCAL FREMITUS:

.Comparison is mandatory in chest examination.

.The anatomical land marks to use are:
Anteriorly= mid-clavicular line
Laterally= mid-axillary line
Posteriorly=above scapula , parascapular paraspinal, below scapula
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Physiological idea:

Normal lung transmits a palpable vibratory sensation to the chest wall

as it is a good conductive media for sound.
How to do?
This palpable vibratory sensation is called fremitus. It can be detected by placing the
ulnar aspects of both hands firmly against either side of the chest while the patient says
the words "Ninety-Nine whilst physician sense with ulnar aspect of hand for changes in
sound conduction. This maneuver is repeated until the entire posterior thorax is covered.
The bony aspects of the hands are used as they are particularly sensitive for detecting
these vibrations.
Palpate for tactile vocal fremitus by placing the edge or flat of your hand on the chest and
asking your patient to say ninety nine or forty-four.

. Increased TVF
Consolidation
Cavitation
Collapse with patent main bronchus

.Decreased TVF

Thick chest wall

Pleural effusion
Collapse
Pleural fibrosis
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Pneumothorax

4. Percussion

. Press The last 2 phalanges of your left middle finger firmly on the patient's back on the
area to be percussed and raise the second and fourth fingers off the chest surface; otherwise,
both sound and tactile vibrations will be blunted.

.Middle finger right strikes the middle phalanx of the other middle finger.. Use a quick,
sharp wrist motion, Allow your hand to swing freely at the wrist (like a catcher throwing a
baseball to second base) to strike the finger in contact with the chest wall with the tip of the
third finger of the other hand. The best percussion site is between the proximal and distal
interphalangeal joints.

.When percussing any one spot, 2 or 3 sharp taps should suffice.

. After you have percussed the left chest, move your hands across and repeat the same
procedure on the right side.

. Percuss the posterior, lateral, and anterior chest wall in such a manner that the long axis
of the percussed finger is roughly parallel to the ribs. Compare one side to the other.

.In general percussion in 5 or so different locations should cover one hemi-thorax.

.If you detect any abnormality on one side, it's a good idea to slide your hands across to the
other for comparison.
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Cut your nails

Percussion :Anterior Chest

1. Start percussion by tapping directly in the middle of both clavicles.

2.. Percuss from side to side and top to bottom using the pattern shown in the
illustration away from bones and midline.

3. Compare one side to the other looking for asymmetry.

4. Note the location and quality of the percussion sounds you hear.

5. The finger on the chest should always be placed in the intercostal space, and there is no
need to percuss more heavily than is necessary as this can be distressing for the patient.

6. Normal dullness is caused by liver on right midclavicular line6th , heart on left

midclavicular line4th intercostals space ,and
Spleen on left midaxillary line 9th,10th,11th.
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Percussion: Posterior Chest

In general, percussion is limited to the posterior lung fields.
Ask the patient to cross their hands in front of their chest, grasping the opposite
shoulder with each hand. This will help to pull the scapulae laterally, away from
the percussion field.
Avoid bones and midline-Work down the "alley" that exists between the scapula
and vertebral column.
Percuss from side to side and top to bottom using this pattern. Omit the areas
covered by the scapulae.
Compare one side to the other looking for asymmetry.
Note the location and quality of the percussion sounds you hear.
Find the level of the diaphragmatic dullness on both sides.
you will develop a sense of where the normal lung should end by simply looking at
the chest.
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A. What is "Speed percussion" ?

It help to accentuate the difference between dull and resonant areas. During
this technique, the examiner moves their left (i.e. the non-percussing) hand at a
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constant rate down the patient's back, tapping on it continuously as it

progresses towards the bottom of the thorax. This tends to make the point of
inflection (i.e. change from resonant to dull) more pronounced.

B. What is Diaphragmatic Excursion?

1. Find the level of the diaphragmatic dullness on both sides.
2. Ask the patient to inspire deeply.
3. The level of dullness (diaphragmatic excursion) should go down 3-5cm symmetrically.
4. Decreased or asymmetric diaphragmatic excursion may indicate paralysis or
emphysema.

C. Tidal percussion:

1. It is used to differentiate supra-diaphragmatic from infra-diaphragmatic dullness.

2. While the patient seated find the upper level of dullness
3. Ask the patient to take deep inspiration and to hold it then percuss again.
4. If the note becomes resonant infra-diaphragmatic cause.
5. If there is no change of the note supra-diaphragmatic cause as pleural effusion.

THE PURPOSE:
The purpose of percussion is to determine if the area under the percussed finger
is air filled (sounding resonant like a drum), fluid filled (a dull sound) or solid (a flat
sound). If the normal air-filled tissue has been displaced by fluid (e.g. pleural
effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion
will generate a deadened tone. Alternatively, processes that lead to chronic (e.g.
emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space,
respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion.

Stony dull------ 1. pleural effusion

2. pleural fibrosis
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Dull impaired percussion note

1. Consolidation pneumonia, cancer, embolism

2. Collapse

Auscultation:
Keys to performing a sensitive yet thorough exam:

o Explain what you're doing (" why) before doing it .

o Expose the minimum amount of skin necessary .
o Examining lungs of female patients:
Expose the chest only to the extent needed. For lung exam, you can
listen to the anterior fields by exposing only the top part of the breasts .`

Enlist patient's assistance, asking them to raise their breast to a position

that enhances your ability to listen to the heart
o Don't rush, act in a callous fashion, or cause pain
o PLEASE... don't examine body parts thru gown as:
It reflects Poor technique
You'll miss things
You'll lose points on scored exams .

Anatomical areas to remember :

.Lower lobes occupy the bottom 3/4 of the posterior fields

.Right middle lobe heard in right axilla

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.Lingula in left axilla

. Upper lobes in the anterior chest and at the top 1/4 of the posterior fields.

This can be quite helpful in trying to pin down the location of pathologic processes that may
be restricted by anatomic boundaries (e.g. pneumonia).

Technique of Auscultation

The chest is ausculted with the diaphragm

1. Put on your stethoscope so that the ear pieces are directed away from you.
Adjust the head of the scope so that the diaphragm is engaged. If you're not
sure, scratch lightly on the diaphragm, which should produce a noise. If not,
twist the head and try again. Gently rub the head of the stethoscope on your
shirt so that it is not too cold prior to placing it on the patient's skin.

2. While the patient relaxed and breathes normally with mouth open, auscultate the
lungs, making sure to auscultate the apices and middle and lower lung fields
posteriorly, laterally and anteriorly.
3. The upper aspect of the posterior fields are examined first. Listen over one spot and
then move the stethoscope to the same position on the opposite side and repeat. This
again makes use of one lung as a source of comparison for the other.
4. The entire posterior chest can be covered by listening in roughly 4 places on each side.
Of course, if you hear something abnormal, you'll need to listen in more places.
5. Alternate and compare both sides at each site.
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6. Listen to at least one complete respiratory cycle at each site.

7. First listen with quiet respiration. If breath sounds are inaudible, then have him take
deep breaths.
8. The lingula and right middle lobes can be examined while you are still standing
behind the patient.
9. Then, move around to the front and listen to the anterior fields in the same fashion IF
NOT STARTED BY IT. This is generally done while the patient is still sitting upright.
Asking female patients to lie down will allow their breasts to fall away laterally, which
may make this part of the examination easier

A few additional things worth noting.

1. Ask the patient to take slow, deep breaths through their mouths while you are
performing your exam. This forces the patient to move greater volumes of air
with each breath, increasing the duration, intensity, and thus detectability of
any abnormal breath sounds that might be present.
2. Sometimes it's helpful to have the patient cough a few times prior to beginning
auscultation. This clears airway secretions and opens small atelectatic (i.e.
collapsed) areas at the lung bases.
3. If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative
states, etc.), auscultation can be performed while the patient is lying on their
side.
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What can you expect to hear?

Note the intensity of breath sounds and make a comparison with the opposite side.
Assess length of inspiration and expiration. Listen for a pause between inspiration,
expiration and the quality of pitch of the sound
Also compare the intensity of breath sounds between upper and lower chest in
upright position. Compare the intensity of breath sounds from dependent to top lung
in the decubitus position.
.Note the presence or absence of adventitious sounds.

IN SUMMARY;
1. EQUALITY OF ENTRY OF BREATHING SOUNDS IN BOTH SIDES
2. TYPE OF BREATHING
3. ADDED SOUNDS CREPITATION,RHONCHI,PLEURAL RUB

IN NORMAL LUNG
The normal breath sounds heard over the lung are vesicular breathing.
The vesicular breathing is heard over the lungs, lower pitched and softer than
bronchial breathing. Expiration is shorter (I > E) and there is no pause between
inspiration and expiration.
The breath sounds are symmetrical and louder in intensity in bases compared to
apices in erect position and dependent lung areas in decubitus position.
No adventitious sounds are heard.
The breath sounds heard over the tracheobronchial tree are called bronchial
breathing.
The only place where tracheobronchial trees are close to chest wall without
surrounding lung tissue are trachea, right sternoclavicular joints and posterior right
interscapular space. These are the sites where bronchial breathing can be normally
heard. In all other places there is lung tissue and vesicular breathing is heard.
The bronchial breath sounds have a higher pitch, louder, inspiration and expiration are
equal and there is a pause between inspiration and expiration.

A prolonged expiratory phase (E > I) indicates airway narrowing, as in:

Bronchial asthma.
Chronic bronchitis
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Bronchial breathing may be heard in pathological conditions as:

Consolidation
Collapse with patent large airways
Compressed lung by a large pl effusion or a tension pneumothorax
Pulmonary fibrosis
Cavitation

Voice Transmission Tests: are only used in special situations. All these tests become
abnormal in consolidation to confirm bronchial breathing. They include
Bronchophony
Whispered Pectoriloquy
Egophony

Voice sounds- Bronchophony

1. Ask the patient to say "ninety-nine or 44 in arabic several times in a normal voice.
2. Auscultate several symmetrical areas over each lung.
3.The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called
bronchophony

Whispered Pectoriloquy

1. Ask the patient to whisper "ninety-nine or 44 in arabic several times.

2. Auscultate several symmetrical areas over each lung.
3.You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is
referred to as whispered pectoriloquy.

Egophony
1. Ask the patient to say "ee" continuously.
2. Auscultate several symmetrical areas over each lung.
3. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as
"E -> A" or egophony.
4. Egophony (British: Aegophony) is an increased resonance of voice sounds heard when
auscultating the lungs, often caused by lung consolidation and fibrosis.
5. It is due to enhanced transmission of high-frequency noise across fluid, such as in
abnormal lung tissue, with lower frequencies filtered out. It results in a high-pitched
nasal or bleating quality in the affected person's voice.
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Adventitious sounds

Crepitations: types
Rhonchi: sibilant and sonorous
Pleural rub

Wheezes are whistling-type noises produced during expiration (and sometimes

inspiration) when air is forced through airways narrowed by bronchoconstriction,
secretions, and/or associated mucosal edema. As this most commonly occurs in
association with diffuse processes that affect all lobes of the lung (e.g. asthma and
emphysema) it is frequently audible in all fields. In cases of significant
bronchoconstriction, the expiratory phase of respiration (relative to inspiration)
becomes noticeably prolonged. The greater the difference, the worse the obstruction.
Occasionally, focal wheezing can occur when airway narrowing if restricted to a single
anatomic area, as might occur with an obstructing tumor or bronchoconstriction
induced by pneumonia. Wheezing heard only on inspiration is referred to as stridor
and is associated with mechanical obstruction at the level of the trachea/upper
airway. This may be best appreciated by placing your stethescope directly on top of
the trachea.

Note when the wheezes occur and if there is a change after a deep breath or cough. Also
note if the wheezes are monophonic (suggesting obstruction of one airway) or polyphonic
(suggesting generalized obstruction of airways).
Conditions:
asthma
CHF
chronic bronchitis
COPD
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pulmonary oedema

Rales (a.k.a. crackles) are scratchy sounds that occur in

association with processes that cause fluid to accumulate within
the alveolar and interstitial spaces. The sound is similar to
that produced by rubbing strands of hair together close to your
ear. Pulmonary edema is probably the most common cause, at least
in the older adult population, and results in symmetric
findings. This tends to occur first in the most dependent
portions of the lower lobes and extend from the bases towards
the apices as disease progresses. Pneumonia, on the other hand,
can result in discrete areas of alveolar filling, and therefore
produce crackles restricted to a specific region of the lung.
Very distinct, diffuse, dry-sounding crackles, similar to the
noise produced when separating pieces of velcro, are caused by
pulmonary fibrosis, a relatively uncommon condition.
Crepitations are present in all sorts of conditions, and really
are non-specific. Crepitations are usually divided into 'coarse'
and 'fine', and may occur during inspiration or expiration

Auscultation over the same region should help to distinguish between these possibilities, as
consolidation generates bronchial breath sounds while an effusion is associated with a
relative absence of sound. Similarly, fremitus will be increased over consolidation and
decreased over an effusion. As such, it may be necessary to repeat certain aspects of the
exam, using one finding to confirm the significance of another.
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The mechanical basis of crackles: Small airways open during inspiration and collapse
during
expiration causing the crackling sounds. Another explanation for crackles is that air
bubbles
through secretions or incompletely closed airways during expiration.
Conditions:
ARDS
asthma
bronchiectasis
chronic bronchitis
consolidation
early CHF
interstitial lung disease
pulmonary oedema

Pleural Rub
Pleural rubs are creaking or brushing sounds produced when the pleural
surfaces are inflamed or roughened and rub against each other. They may be
discontinuous or continuous sounds.
They can usually be localized a particular place on the chest wall and are
heard during both the inspiratory and expiratory phases.
Conditions:
pleural effusion
pneumothorax

3 types of lesions