Clinical Examination of the

Respiratory System
Pandian M
Dept of Physiology
DYPMCKOP
 SLO
• Materials
• Symptoms
• Examination of Resp. Sys:-
– Inspection
– Palpation
– Percussion &
– Auscultation
• Examination of chest
 Materials :
• Stethoscope, measuring tape and 2 cardboards

Symptoms:-
• Pain in chest, fever, cough – dry or expectoration,
blood in sputum (haemoptysis), breathlessness
(dyspnoea), bluish discoloration of nails (cyanosis)
.
Examination of Resp. Sys:-
• It’s starts right from examination of Nose, Oral cavity
and Throat
 Examination
• Inspection
• Palpation
• Percussion &
• Auscultation
 Examination of chest
• Position of subject:-
– sitting position.
• Inspection:
1. Shape of the chest
2. Movements of the chest
1. sitting Position
– Size and shape – normal is bilaterally symmetrical,
elliptical in cross section, transverse diameter greater
than A-P dia., subcostal angle is 90 ̊ (more acute in males )
– Significance : size and shape get altered in different
diseased condition, e.g.
Rickets
emphysema
Lateral bending Forward bending
 Movements of chest
• Observation from foot end of bed tangentially or sitting position and note
following points:-
Rate & Rhythm during quiet resp.
• 12 – 18 breaths/ min, regular.(mostly observing abdominal wall)
• In children Resp.Rate is higher
a) Causes of fast & shallow breathing (Tachypnoea) are : exercise,fever,
nervousness, hypoxia.
b) Causes of slow breathing are: brain damage.
Expansion of chest – whether expansile & symmetrical (use tape )
{diminished or asymmetrical seen in - pneumothorax,
collapse,consolidation, emphysema, pleural effusion}
Types of breathing
• Abdomino thoracic
• Thoracico – abdominal
Accessory muscles of resp – working or not
Position of trachea (Trial’s sign)
 Position of apex beat

Position of apex beat get displaced in diseases of

lungs or pleura
 Palpation
Confirm the finding of inspection
1. Size and shape
a. Symmetrical (or) asymmetrical
b. A-P diameter (measure by two cardboard)
c. Transverse diameter (measure by two cardboard)
Circumference is – at the end of Inspiration (normal )
at the end of Expiration (normal )
For Circumference expansion how to
measure
 Movements / Expansion of chest
• Sitting position :- for front and back
For Apical expansion
Position of Trachea
Position of Trachea
• The trachea may be pushed away from the affected
side by : pleural effusion or pneumothorax.

• The trachea may be pulled towards the affected side

by fibrosis or collapse of the lung.
Position of apex beat
• Apex beat may be displaced due to : scoliosis,
enlargement of LV.

• Displacement of the mediastinum by disease of lungs or

pleura.
 Tactile Vocal Fremitus (TVF )
• The detection, by palpation of tactile perception of
vibration that are communicate to the chest wall – from
the larynx via bronchi and lungs during the act of
phonation is referred to as TVF.
• For TVF the subject repeat the word like ninety nine
or one bcoz of nasal twang, then the examining hand
perceives distinct vibrations.
• Determine whether the vibration in corresponding
areas on two identical sides of chest approximately
equal intensity or not
Tactile Vocal fremitus (TVF)
TVF in front
i. TVF is ↑sed when the lung is consolidated or
contains large cavity near surface.

ii. TVF is ↓sed when the corresponding bronchi

are obstructed .

iii. TVF is totally absent when the lung is

separated from chest wall by pleural effusion
or pneumothorax
Percussion
 Place the palm of your left hand on the chest, with your fingers
slightly separated .
 Press the middle finger of your left hand firmly against the
chest, aligned with the underlying ribs over the area to be
percussed.
 Strike the centre of the middle phalanx of your left middle
finger with the tip of your right middle finger, using a loose
swinging movement of the wrist and not the forearm.
 Remove the percussing finger quickly so the note generated is
not dampened.
 Percuss the lung apices by placing the palmar surface of your
left middle finger across the anterior border of the trapezius
muscle, overlapping the supraclavicular fossa and percussing
downwards.
 Percuss the clavicle directly over the medial third, as percussing
laterally is dull over the shoulder muscles.
• To percuss the upper posterior chest ask patients to
fold their arms across the front of their chest,
thereby moving the scapulae laterally.
• Do not percuss near the midline, as this produces a
dull note from the solid
• structures of the thoracic spine and paravertebral
musculature. Map out abnormal
• areas by percussing from resonant to dull.
AREAS ON THE CHEST WALL
for PERCUSSION
• AREAS ON THE CHEST WALL

• Anteriorly: Supraclavicular, Clavicular,

Infraclavicular, Mammary and Inframammary.

• Laterally: Axillary and Infra-axillary.

• Posteriorly: Suprascapular, Scapular,

Infrascapular and Interscapular.
Lower border of Right lung:-
• In the anterior aspect, the lower right border of the
lung extends upto the 6th rib in the mid clavicular line
• 8th rib in the mid axillary line and
• 10th rib in the mid scapular line
Lower border of Left lung:-
• Anterior aspects its overlaps by stomach
• 8th rib in the mid axillary line overlaps by spleen
• 10th rib in the mid scapular line
• Increase in resonance ( or hyperresonance) –
pneumothorax & lung collapsed towards the
hilum.

• Reduction in resonance (dullness to

percussion) – pleura is thickened, pleural
caviy contains fluid (stony dullness)
Types of breath sounds:
air entry, present or not, equal or not
1. Vesicular breath sounds
2. Bronchial breath sounds:
• Vesicular breath sounds – Produced by movement of air in
and out of normal lung tissue.
• Sounds are rustling of leaves
• Heard all over the chest wall.
• Duration and intensity of inspiration are more than that in
expiration.
• There is no gap/pause between inspiration and expiration.
• Most typically heard in the axillary and infrascapular region.
• Low pitched with frequencies between 200 – 600 Hz.
• Bronchial breath sounds:
• The sound originates in larger airway and is transmitted
directly to the chest wall without passing through the
lung tissue.
• This is heard sometimes in interscapular region T1 to
T4 and resembles the sound over the trachea.
• Sounds are hollow, tubular, blowing in nature.
• Duration and intensity of expiration is more than
inspiration.
• There is a gap/ pause between inspiration and
expiration.
• They are high pitched with frequencies above 600 Hz.
• Heard in pathological conditions like cavity and
Auscultation
 Added sounds
• Rhonchi / Wheeze:- prolonged uninterrupted
musical sounds, particularly heard during exp
(bronchial asthma and bronchitis)
• Crepitations / crackles:- short, explosive
sounds often described as bubbling or clicking
noises.(pneumonia, TB, bronchitis), they may
be fine or coarse.
• Pleural rub:- pleural inflammation,
creaking/rubbing character
 Vocal resonance
• Sounds heard over various parts of the chest
during the act of speech
• Vocal resonance is auscultatory equivalent of TVF.
• The same laws govern the mode production,
transmission, elicitation and abnormalities as
seen in TVF.
• Each point examined on one side of the chest
should be at once compared with corresponding
point on other side.
• VR ↑sed
• VR markedly ↑sed Bronchophony
• Further ↑sed in VR called Whispering
pectoriloquy
– Consolidation
• VR is either abolished or much diminished in
cases of – pleural effusion, pneumothorax,
emphysema.
 References
• Text book of Medical Physiology
– Guyton & Hall
• Hutchinson Clinical Methods
• Practical Physiology Manual
– A.K. Jain, C.L. Ghai, G.K. Pal
• Net source for pictures
THANK YOU . .
.