CLINICAL EXAMINATION

OF

RESIPRATORY SYSTEM
 Examination under 04 Headings
Clinical examination of respiratory system Involves examination of
lungs and trachea. It is ideally done with subject comfortably lying in
the bed or examination couch at an angle of 45 degree and
supported by a pillow. It is carried under the following headings :
Inspection: means naked eye examination. The subject is not to
be touched.
Palpation: means feeling with the hand. Findings of inspection are
confirmed by palpation.
Percussion: means to strike. The examiner strikes the chest- wall
with his finger and the sound elicited gives information regarding
the condition of lungs.
Auscultation: means to hear and is done with the help of
stethoscope.
 PRE-REQUISITES

The subject should be comfortable,

The examination should be carried out in a well lit
room.
Expose the whole chest.
Be gentle with the subject.
Always stand on the right side of the subject.
First we look for some particular signs in GPE that
are relevant to the Respiratory System:
Voice of the subject should be noted
Pallor or paleness seen in lower palpabral
conjunctiva. It indicates anemia.
Cyanosis.
Clubbing.
Lymph nodes: Neck and supraclavicular region
should be examined for any enlarged lymph nodes.
Accessory muscles of respiration (sterno-cleido-
mastoid and alae nasae may be working in severe
breathlessness).
 SYSTEMIC EXAMINATION OF CHEST
Inspection: Subject is examined in good light striped up to the waist and we
have to examine the chest (resp. System) from all sides.
1. Look for any obvious scar from previous surgery/ trauma
2. Any visible lumps within the skin.
3. Any lesion in the skin itself.
4. Shape and symmetry of Chest: Normally shape of chest is bilaterally symmetrical
and elliptical in cross section. This means transverse diameter > than the antero-
posterior diameter.
5. Movement of chest
6. Depth of Respiration
7. Rhythm
8. Types of respiration.
9. Expansion of chest
10. Examination from side
11. Examination from back
 Abnormalities of shape & symmetry

I). Disease of Rib Cage

 Pigeon shaped chest:-the sternum is unduly prominent and project
beyond the plane of the front of abdomen. Chest is triangular in
cross section. It is seen in rickets.
 Harrison’s sulcus:- a transverse groove which begins at the level of
xiphi sternum & passes outwards & downwards. It is seen in rickets.
II). Disease of spinal vertebrate;-
a) Kyphosis:- forward bending of vertebral column backward
convexity of spine leading to shortening of chest and undue
prominence of sternum.
b) Scoliosis is lateral bending of the vertebral column.
c) a & b together are known as kyphoscoliosis.
d) Lordosis This is backward bending of vertebral column.
 Underlying lung diseases.
III).

a) Barrel shaped chest: Seen in chronic airway obstruction

(emphysema, asthma). AP diameter of the chest increases. Chest
is fixed in full inspiration position. Ribs are set less obliquely than
normal.
b) Unilateral fibrosis / or unilateral apical flattening: Generally
secondary to TB and produce flattening on the affected side.
 5. Movements of chest: count the rate i.e frequency of breathing
by observing abdominal wall movement in one minute. Normally
all parts of chest moves equally during respiration.
 Normal rate of breathing is 12- 16 breaths per minute.
Decreased rate of respiration is known as Bradypnea. Similarly,
increased rate of respiration is known as Tachypnea.

 
 CAUSE OF FAST BREATHING

I. PHYSIOLOGICAL causes
• Exercise
• Nervousness
• Hypoxia
• Hysteria
• Newborn, infant & Children
• Gender: Rate of respiration is higher in women
II. Pathological causes: Hypoxic conditions due to
pulmonary and cardiac causes.
Bradypnea is seen in CNS depression (Narcotic Overdose)
(6) Depth of Respiration:- look whether breathing is shallow or
deep . Normally it should be neither too deep nor too shallow.
• If shallow it is associated with hypoxia or hunger of air
(asthma)
• If deep it may be because of uraemia or brain damage.
(7) Rhythm: Normally it should be even and regular i.e duration
in between two successive breaths is same . Inspiration is
followed by expiration with out any detectable pause (gap) and
there is a pause (gap) at the end of expiration. Duration of
inspiration appears longer that expiration.
• Irregular breathing: occur in obstructive diseases.
• Chyne stokes breathing: there is alternate period of apnoea
and hyperventilation. It is seen in Brain damage and also in
some normal people during deep sleep.
(8). Type of respiration : Both thorax and abdomen move during
respiration. Normally it is abdomino-thoracic in males and thoraco-
abdominal in females.
Thoracic movements are more marked in:
 Pregnancy
 Intra abdominal tumours (like tumour of GIT)
 Peritonitis (inflammation of GIT) etc.
 (9). Expansion of chest:
Note about equality of expansion of the two sides of the chest. Chest
expansion can be measured using a measuring tape around the chest at
the level of nipples. In healthy persons chest may expand up to 5-8 cms.
Diminished expansion may occur when underlying lung is diseased such as
 Emphysema
 Pleural suffusion
 Pneumothorox
 Consolidation
 
(10). Examination from sides:
Ask the subject to raise his arms and keep them on his head and examine
right and left side by observing them continuously.
(11). Examination from Back Examine the contours from back . Note the
scapular prominence, supra scapular area, infra scapular area & supra and
infra spinous regions. Also note about the outline of various muscles of this
region.
PALPATION: is confirmation of findings of inspection by palms and fingers.
 Note the temperature with dorsum of your hand on both sides.
 Lymph nodes in the supra clavicular fossa, cervical region and axilla should
be palpated.
 Palpate any part of chest which presents palpable obvious swelling or of
which patient complains for pain.
 Position of trachea: Feel the rings of trachea in supra sternal notch.
Normally trachea lies at centre or may slightly deviated towards right side.

 
 
 METHODS FOR PALPATION OF TRACHEA:
Two finger method : Place the two fingers in supra sternal notch
leaving trachea free in between the fingers and see whether the
spaces are equal on both sides of trachea
Three finger method : most commonly used method . Place
middle finger on trachea , index and ring finger on both sides of
sternocleidomastoid (muscle on either side of the trachea)
If trachea is deviated, less space is found on the side of deviation.
Trachea will be pushed away from affected sides as seen in case
of:
 Severe pleural effusion.
 Pneumothroax
 Large tumours,
Trachea may be pulled towards affected sides as in case of fibrosis
 (V) Position of apex beat: the lowest and outermost point
of cardiac pulsation. Normally it lies 9 cms away from the
mid sternal line or 1cm medial to mid clavicular line left
5th ICS.
To locate the apex beat first place the palm of your right
hand on the precardium
Feel the apex beat and then bring your middle finger over it.
Finally locate it with the tip of middle finger and identify
the intercostals space.
Displacement of the apex beat with out the displacement of
trachea may be due to:
• Scoliosis.
• Enlargement of left ventricle.
• Deformity of chest.
(VI) Expansion of Chest We have to palpate and confirm whether the chest
expands symmetrically with respiration. In this, examiner faces towards the
subject and places finger tips of both sides on either side of lower rib cage so
that tips of thumbs meet in the midline in front but not touching the chest.
Then, a deep breath by the subject will increase the distance between the
thumbs and indicate the degree of expansion. If one thumb remains closer to
midline, this is confirmation of decreased expansion of that side.
(VII) Tactile Vocal Fremitis or Vocal Fremitis:- it is a specialized method of
palpation where the ulnar border is placed over the intercostal spaces of
subject and he is asked to repeat words 1, 1, 1-9, 9, 9 or Ram Ram i.e words
with nasal twang.
Procedure is repeated on corresponding areas of chest on both sides.
Vocal Fremitis is increased in :-
Consolidation of lung or when there is a large cavity in the lung
Vocal fremitis is decreased in :-
Bronchial obstruction & Thickened pleura
Vocal fremitis is absent when Lung is separated from the chest wall by pleural
effusion or pneumothorax.
IMPORTANT LANDMARK OR REVELANT ANATOMY
The two lung are housed within the thoracic cage . Right lung has three
lobes: upper, middle and lower; divided by major and minor
interlober fissures. Left Lung has two lobes divided by major inter-
lobar fissure.
Major interlober fissure can be represented by a line starting from
second thoracic spine posteriorly and extending obliquely downward
& forward to reach 6th costochondral junction anteriorly. It
corresponds to upper border of lower lobe.
Minor interlober fissure is on the rt. side. Its surface marking is by a
horizontal line drawn from sternum at the level of 4th costal cartilage
to meet the first line of major inter lobar fissure. Between the two
lines lies the middle lobe of the right lung.
Anterior aspect of the chest is occupied by the upper lobe on left side
and by upper and middle lobes on left side .Most of the back of the
chest is occupied by the lower lobes of the lungs on either side. In
the axillary area , parts of all three lobes are accessible.
Bifurcation of Trachea
On the anterior wall it corresponds with the sternal
angle, also known as Angle of Lewis and on the
posterior side it corresponds to the inter
vertebral disc between 4th and 5th thoracic
vertebrae.
Angle of Lewis is a transverse bony ridge at the
junction of sternum and manubrium.
The ribs are counted from above downward as the
2nd costal cartilage articulates with the sternum at
this point.
IMPORTANT SIGNS AND SYMPTOMS:-
Cough: It may be dry or productive if it is productive we have to
look for amount, colour , watery or frothy and also the time at
which it occurs and its duration and also about the character of
sound produced during the act of coughing.
Dyspnea (Breathlessness) :It is a unpleasant awareness of the
respiratory efforts. It may be present at rest or on exertion. It may
also be associated with posture of the subject.
Hemoptysis: It is coughing out of blood in sputum. It is an important
sign of TB or carcinoma of lung.
Wheezing: The patient must be asked if any sound comes from lungs
during breathing.
Pain: could be from the muscles or the Skelton of chest. Pain due to
lung disease comes from pleura.
Fever:
Clubbing of fingers:
Cyanosis (bluish colouration) which may be Central
or peripheral
Before examining also ask the patient about
relevant family history and occupational history.
Occupational history is important for respiratory
diseases i.e. workers of rubber and plastic
industries, wood workers, exposure to pollen or
dust may lead to bronchial asthma
Workers who are exposed to asbestos for long
periods may develop mesothelioma.
Percussion :Is the procedure employed for setting up artificial
vibrations in the tissues by means of a sharp tap usually delivered
with the fingers.
Methods of percussion :
Middle finger of left hand is used to bear the stroke and is k/as
Pleximeter finger . This finger is placed firmly on the organ to be
percussed.
Back of middle phalanx of pleximeter finger is struck with the help
of middle finger of rt. hand k/as Percussing finger or Plexor finger
The movement of percussing finger should be at wrist and not at the
elbow. The percussing finger should be so bent that when the
blow is delivered the terminal phalanx is at rt angle to metacarpal
bones and strike the pleximeter finger perpendicularly.
As soon as blow has been given , the percussion finger must be
lifted.
Steps of percussion
Beginning in front, percussion starts on supra clavicular
area. Tap slightly and directly without pleximeter finger
on most prominent point on each clavicle.
Corresponding areas on either side should be carefully
percussed. It is sufficient to percuss 3-4 areas on
anterior aspect of chest , 3-4 areas posteriorly and 2-3
areas in axillary region.
While examining the back subject’s arms should be
folded across the chest and hands resting on opposite
shoulders.
For percussing over axilla, the subject holds his hands on
the back of head.
Observe the quality of sound elicited.
Three types of note are produced
Resonant Note When the air filled cavity subdivided
by numerous septa into a number of small
chambers is set into vibration, a characteristic
resonant note is produced and there is
characteristic feeling in pleximeter finger. Such
condition prevails in healthy lungs.
Hyper resonant note: It occurs in pneumothorax,
When pleural cavity contains air and the lungs are
collapsed towards hilum.
Impaired Note Or Diminished resonance
It occurs when pleura are thickened or when underlying lung is more
solid than the usual.
* A Dull note occurs in case of thickened pleura or in case of
consolidation of lungs and at basis of both lungs in cases of heart
failure.
* Stony dullness that means completely dull note with a peculiar
sense of résistance in percussing finger. It is characteristic finding in
pleural effusion .
* During percussion a comparison of percussion note should be made
out on both sides to map out limits of lungs, resonance particularly
at the apices, at the base and area of cardiac dullness. The lower
limit of lungs is determined by percussion from above downwards
with pleximeter finger in intercostal space and parallel to
diaphragm.
* Lower border of rt. Lung lies over liver and its exact location is best
made anteriorly by light percussion.
* It lies at the level of 6th ICS in the mammary line, 8th
ICS in mid- axillary line and 10th ICS in mid-scapular
line.
6th ICS: -----mammary line
8th ICS: -----mid axillary line
10th ICS: -----mid scapular line
---- Lower border of left Lung overlaps the stomach, so
there is a change from resonant note to hyper-
resonant note/ tympanic note.
----Posteriorly there is dullness of various solid organs
which is below the left lung
----- Anteriorly area of cardiac dullness lies on left side
from 2nd to 5th ICS.
Abnormalities of percussion.
(1) Increase in resonance /hyper-resonant note.
Seen in –
* Pneumothorax
* Large cavities.
* Emphysema
(ii) Decrease in resonance /hypo-resonant note heard when
pleura is thickened and it does not allow sound in the
cavity to be transmitted to chest wall. It is seen in
* Pleural effusion
* Consolidation
* Heart failure
In case of heart failure it is seen in lower border of lung
because of pulmonary oedema.
AUSCULTATION:
Before using stethoscope for auscultation one should listen
the patient’s breathing. Audible breathing at rest can be an
important sign of airway diseases (due to narrowing and
secretions), breathing can be audible in certain other
conditions like:
 The breathing sound may be Stertorous (snoring like) in
coma.
 Gasping, grunting and sighing (in exercise, pain, fear, grief).
 Wheezing – Usually louder during expiration as in asthma.
 Hissing – Kaussmaul’s breathing as in acidosis of diabetes
and uremia.
 Stridor – Tracheal inflammation.
In auscultation we use stethoscope for hearing various breath
sounds. Diaphragm is kept on chest wall and we listen to
sounds conducted along the tubes. Three observations must
be made:
1st observation: Type or character of breath sounds whether
vesicular or bronchial.
2nd observation: Intensity of sounds whether diminished or
absent.
3rd observation: added or adventitious sounds like
crepitations, rhonchi (Wheeze), pleural rub.
Character of vocal resonance:
Auscultation is done all over the lungs, front, axillarry region
and back. Sounds on corresponding points on two sides are
compared. Patient is asked to take deep breath with open
mouth .
Vesicular breath sounds:
(i) Are produced by passage of air in medium and large
bronchi. Breath sounds get filtered and attenuated
while passing through millions of air filled alveoli
before reaching the chest wall. These sounds are heard
both during expiration and inspiration.
(ii) The inspiratory sound is low pitched or rustling in
character and is always longer than expiratory sound.
(iii) Expiratory sound is softer and shorter follows without a
pause and heard during early part of expiration.
(iv) Normally breathing over most areas of chest is
vesicular and most typically so in the axillary and
infrascapular region.
 expiration
expiration
inspiration
inspiration

VESICULAR BREATH SOUNDS

BRONCHIAL BREATH SOUNDS
Bronchial breath sounds :
Originate probably in the same medium and large bronchi and replace the
vesicular sound when the lung tissue between them and chest wall becomes
airless as a result of consolidation (pneumonia, TB, Carcinoma, fibrosis)
There is no filtration and attenuation of sound because they pass directly
from bronchi to diseased lung tissue instead of passing through air filled
alveoli.
(i) Bronchial breath sounds are loud, clear, hollow or blowing in character and
of high frequencies.
(ii) The inspiratory sounds become inaudible just before the end of inspiration
while the expiratory sound is heard throughout expiration. Thus the sounds
are loud and clear, the inspiratory and expiratory sounds being of equal
duration separated by distinct pause.
(iii)The bronchial type of breathing resembles that heard over trachea. In
children the breath sounds are harsher and are described as puerile
breathing..i.e. Inspiration is loud and harsh
 
Bronchial breath sound can be heard over trachea, larynx, apex of rt. Lung ,
infra clavicular and lower cervical vertebrae and mid scapular region.
 COMPARISON BETWEEN BRONCHIAL AND
VESICULAR BREATH SOUNDS
VESICULAR BREATH SOUNDS
• ORIGIN
In the larger airways but
when the normal healthy
lung is present between the
airways and the chest wall.
• CHARACTER
Low pitch rustling sounds.
There is no gap or pause
between the end of inspiration
and the beginning of expiration
. Inspiration sound is fairly
intense and heard twice as long
as the expiratory sound.
BRONCHIAL BREATH SOUNDS
It also originates from the same larger
airways but when the lung between
these airways and the chest walls is
airless ( as in consolidation ,
fibrosis , cavity or collapse of lungs).
High frequency and harsh sound.
There is a gap between the end of
inspiration and the beginning of
expiration. The expiratory sound
has more whistling character than
inspiratory sound. It lasts for most
of the expiratory phase and is of
the same duration as that of
inspiration
SITES
It is heard all over the healthy • It is heard over the trachea
lungs and most typically in and portion of lungs where
the axillary region and bronchus is patent and air is
infrascapular regions . not entering the alveoli.
Intensity of breath sounds i.e. Loudness of breath
sounds.
May be normal, increased or decreased.
It is decreased in:
 -Pleural effusion
-Emphysema
-Bronchopneumonia
-Pneumothorax
Vocal Resonance: It refers to the sounds heard over
the chest during the act of phonation when subject
repeats words like one –one, nine –nine with nasal
twang.
Intensity depends on----
 Loudness
 Depth of sound
 Conductivity of sound
Vocal resonance of normal intensity conveys an impression of sound
produced near chest piece of stethoscope. If it is increased, then it seems
to come from ear piece of stethoscope and is called Bronchophony (TB,
Pneumonia , Resonating cavities)
Vocal resonance is decreased in conditions like emphysema, pleural
effusion ,pneumothorax and pleural thickening etc.
Vocal resonance is markedly increased when it appears to be near the ear
piece of stethoscope, this is described as Bronchophony.
Bronchophony is heard over consolidation of lung such as pneumonia, TB or
other resonating cavities all over Lung apex
Further, increase in vocal resonance (we ask the person to whisper), if the
words became clear and seen to be spoken right into the listener’s ear.
This is described as whispering pectoriloquy. This occurs in proximity of
trachea with larger bronchus, consolidation and cavity in the Lungs.
 ADDED SOUNDS
I. PLEURAL RUB: Is characteristic of pleural inflammation. It is
rubbing sound produced because of friction between two
layers of inflamed pleura. It is mainly produced during
inspiration and sound resembles sound produced by
movement of diaphragm over smooth surface of lungs.
II. Wheeze or Rhonchi: These are prolonged uninterrupted
musical sounds produced during expiration due to narrowing
of airways which is characteristic of bronchial asthma.
III. Crepitations /moist sound (Crackling sounds): They are
discontinuous bubbling or crackling sounds produced by the
passage of air through fluid in the small airways and all
alveoli. They may be fine or coarse. If you rub your hair
between your thumb and finger near your ear, the sound
produced resembles fine crepitations.
 OBSERVATIONS:
On Inspection:
1. Shape and symmetry of chest:-Elliptical, Bilaterally symmetrical.
2. Movements of chest:-equal on both sides
3.Rate of respiration :-14 breaths /minute
4. Depth of Respiration:-Normal
5. Rhythm:-Regular
6.Expansion of chest:-5cm
7.Type of Respiration:-Abdomino- thoracic

On palpation:
1. Position of Trachea:- Centrally placed
2. Position of apex beat:-9cm lateral to mid sternal line in left 5th ICS
3. Expansion of chest:-Equal on both sides
4. Vocal Fremitus :- Equal on both sides.
 
On Percussion:
I. Type of percussion note: Resonant on both sides
II. Intensity of percussion note: Normal on both sides
III. Lung Boundaries:
Right Lung Left Lung

Mid Clavicular 6th ICS 6th ICS

Mid axillary 8th ICS 8th ICS

Mid scapular 10th ICS 10th ICS

Para sternal 11th ICS 11th ICS

Apex 2cm above clavicle 2cm above clavicle

On Auscultation:
I. Intensity of breath sounds: Normal and equal on
both sides
II. Character of Breath sounds: Vesicular on both
sides
III. Vocal resonance: Equal on both sides
IV. Added sounds: Absent on both sides