Conducting Respiratory

System Examination
DR. MWABUSILA(MD).
Learning Objectives
 By the end of this session, students are expected to
be able to:
 Identify common symptoms and conditions of the
respiratory system
 Describe the techniques for conducting respiratory
system examination (inspection, palpation, percussion,
auscultation)
 Demonstrate skills in examining conducting the
respiratory system examination
Common Symptoms and Conditions of the
Respiratory System

 Common symptoms of the respiratory system include the following:

 Chest pain
 Shortness of breath (dyspnoea)
 Wheezing
 Cough
 Blood streak sputum (haemoptysis)

 If during history a client complains of one or more of these symptoms,

you know that there is a problem of the respiratory system that needs
to be identified.
 These symptoms may originate from different conditions which
examination through inspection, palpation, percussion or auscultation
may bring about clues.
Techniques for Conducting Respiratory System
Examination: Inspection of the Chest

 The normal chest is bilaterally symmetrical and elliptical in cross-section.

 The chest may be destroyed by disease of the ribs or spinal vertebrae as well as by
underlying lung diseases.
 Kyphosis (forward bending) and Scoliosis (Lateral bending) may cause asymmetry of
the chest.
 See if there is any previous surgical or traumatic scarring or tattoos

 Inspect for masses or lumps

 Pectus excavatum – sternum sunken into the chest.

 Pectus carinatum – sternum protruding from the chest.

 Movement of the chest, normal chest moves with respiration and it moves equally on
both sides
PECTUS EXCAVATUM
PECTUS CARINATUM
Signs of Respiratory Distress That Can Be Inspected

 Cyanosis – person turns blue centrally or peripherally

 Chest in drawing

 Accessory muscle use

 Diaphragmatic Paradox – the diaphragm moves

opposite of the normal direction on inspiration,
suspect flail segment in trauma.
CHEST WALL INDRAWING
Techniques for Conducting Respiratory System Examination:
Palpation of Chest

 Locate the mediastinal position by locating the position of

the trachea
 Identify apex beat

 Examine chest expansion

 Perform tactile vocal fremitus (TVF)

 Palpate any part of the chest and identify pathological defect

 In recent injury palpate for pain and tenderness

POSITION OF TRACHEA
CHEST EXPANSION
Findings from Palpation
 Asymmetrical chest expansion may be detected during
palpation
 The mediastinum may be pushed away from the affected
side by:
 Pleural effusion
 Pneumothorax
 Empyema
 Haemopneumothorax

 The mediastinum may be pulled to the affected side by:

 Lung fibrosis
 Lung collapse
Findings from Palpation
cont…
 Tactile vocal fremitus is detected by palpation (but this
is not a commonly used routine examination technique)
 Vocal fremitus is the perception of vibrations produced
by sound on the chest wall. They are reported as
normal, increased or reduced. Note that anything
which hardens the lungs substance, such as
consolidation in Pneumonia or Tuberculosis will
increase the vocal fremitus
 Pneumothorax, or fluid in the pleural cavity, will reduce
the vocal fremitus.
Techniques for Conducting Respiratory System
Examination: Percussion of Chest

 Percussion of chest means a gentle tapping of the chest wall

 Middle finger strikes the middle phalanx of the other middle

finger. The right and left sides of the chest are compared during
percussion
 Effective percussion requires consistent practice

 The middle finger of the left hand is placed on the part percussed
and the back of middle phalanx is stuck by tip of the right middle
fingers. The movement should be at the wrist rather than at the
elbow.
Findings from Percussion
 Normal chest finding is a resonant percussion note

 Dullness indicates consolidation as in pneumonia

 Stone dullness indicates fluid stimulated by percussion

off a wall made of bricks
 Hyper resonance (as can be detected by percussing
the inflated cheek) suggests a presence of excess air
in the lung (pneumothorax, Chronic broncho asthma)
 Percussion over the precardium area is dull (cardiac
dullness)
Techniques for Conducting Respiratory System Examination:
Auscultation of the Chest

 Here we use a stethoscope to detect the sounds transmitted

in large airways. The structure of the lung will affect the way
in which these sounds are perceived by the ears.
 Breath sound is a normal if it is a vesicular sound.

 Broncho breathing sound suggests consolidation or fibrosis.

 The sounds of broncho breathing is generated by turbulent

airflow in large airways and similar sounds can be heard in
healthy patients by listening over the trachea.
AREAS FOR AUSCULTATION
Findings from Auscultation
 Vocal resonance

 If you ask the patient to pronounce some syllables

and auscultate the vibrations on the chest wall, what
you hear is called vocal resonance. It is louder in
conditions which the lungs are hardened
(consolidation) and reduced in pleural effusion and
lung collapse.
Findings from Auscultation
cont…
 Crackles may represent opening of small airways and
alveoli. They may be normal at the lung base if they
clear on coughing or a few deep breaths.
 Basal crackles are classical features of pulmonary
congestion with left ventricular failure. They may be
more diffuse in pulmonary fibrosis
 By listening the breath sound, one can assess the
quantity of the air being drawn in the lungs. It is
usually reported as normal, reduced, or absent air
entry
 Reflection
 What things should be reported when inspecting the
chest in respiratory examination?
 What lung conditions which may displace
mediastinum away from the lesion?
 Explain the basic principles of chest examination.
 Respiratory examination is carried out by comparing the two sides
(left and right) at each point of examination.
 Perform systemic respiratory examination by following these
principles (IPPA):
 Inspection

 Palpation

 Percussion

 Auscultation

 Respiratory distress can be seen when there is central or peripheral

cyanosis, intercostals in drawing and the use of accessory muscles.
 References
 Bickley, L.S. (2008) Bates’ Guide to Physical
Examination and History Taking. (10th ed.)
Philadelphia, USA: Lippincott Williams & Wilkins.
 DK Images. Health and Beauty: Medical Examination.
Retrieved March 14, 2010 from:
www.dkimages.com/.../Medical-Examination-04.html
 Swash. M. & Glynn, M. (2007). Hutchison’s Clinical
Methods. (22nd ed.) London: Saunders.
 Swash, M. (2002). Hutchison’s Clinical Methods (21st
ed.) London: Saunders.