NOTES IN RESPIRATORY
SYSTEM EXAMINATION
BY
DR. SHAHAB SHAIKH
Examination of the Respiratory System
Inspection:
Co mf o rta b le a t re st . . . . ?
B re a t h le ss . . . .?
Cya n o sis . . . . . ? ,
1 . Che s t w a l l a ppea ra nc e:
a . S ha pe

No rm a lly E llip so id

B a rre l Ch e st - Hyp e re xp a n sio n (A -P d ia me t e r in crea sed )
e g. CO P D
b. S ymme tr y
c . S c a rs / Les i ons
d. De formi t y:

P e c tus c a ri na tum – st e rnu m b u lge s f o rwa rd s (‘p ige o n ch e st
d ef o rm it y’)

P e c tus e x ca va tu m – st e rnu m ca ve s in wa rd s (Fu n n e l ch e st
d ef o rm it y)
P e c tus c a ri na tum
P e c tus e x ca va tu m
 K yphos i s is a n e xa gge ra t e d an t e rio r cu rva t u re of t h e
sp in e
 S c ol i osi s is an e xa gge ra t e d la te ra l cu rva t u re of th e sp in e
2 . Che s t w a l l move me nt :
a . E x pa ns i on
b. S ymme tr y of mo ve me nt
c . P a ra doxi c al move me nt : Ph re n ic ne rve p a ra lysis, Fla il ch e st
3 . Br e a thi ng:
a . Re s pi ra tor y ra te :

RR co u n t ed af t e r dive rt in g a t t e n t io n as if p re t en d in g to
t a ke Pu lse

T a ch yp n o ea is a re sp ira t o ry ra t e > 15 / m in a nd is cau sed
b y in cre a se d ve n t ila t o ry d rive a s in f eve r, a st h ma an d CO P D, o r
re d u ced ve n t ila t o ry ca p a cit y a s in p ne u mo n ia, pu lm on ary
o e de ma an d int e rst it ia l lu n g d ise a se .

A slo w re sp ira t o ry ra t e can o ccu r in asso cia t io n wit h
o p io id t o xicit y, h yp o t h yro id ism , ra ised in t ra cra n ia l p re ssu re ,
h yp o t h a lam ic le sion s, an d h yp e rca p nia .
b. Re s pi ra tor y de pt h
c . Re s pi ra tor y Rh yt hm
d. T ype of re s pi ra ti on:

Norma l

Kus s a mul: Hyp e rve n t ila t ion wit h d e ep , sigh in g
re sp ira t io n s (Kü ssm a u l re sp ira t ion ) is a re spo n se t o t he re d u ce d
a rt e ria l p H in m et ab o lic a cid o sis. T h is ca n o ccu r in a cut e re na l
f a ilu re , la ct ic a cido sis, d iab e t ic ket oa cid o sis an d in sa li cyla t e
a n d m et h an o l p o iso n in g. T h e p at ie n ts a p pe a r to ha ve 'a ir
h u n ge r'.

Che yne s trok e : Ch e yn e -S t o ke s b reat h in g, o r pe rio d ic
re sp ira t io n , is ch a ra ct e rize d b y a p e rio d of in cre a sin g ra t e an d
d e p th of b rea t h in g f o llo we d b y d im in ish in g re sp ira t o ry e f f o rt an d
ra t e , u su a lly e n d ing in a p e riod of a pn o ea o r h yp op n oea . T h e
cycle t h e n re pe a t s. Th is p at t e rn of b re a t h in g re la t e s to a n
a lt e re d se n sit ivit y of t he re sp irat o ry ce n t re to chem ica l co n t ro l
a n d d e la y in circu la t io n t im e b et we e n t h e lu n g a nd
ch e mo re cep t o rs. I t is se e n mo st f re qu e n t ly in st ro ke invo l vin g
t h e b ra in ste m, a nd in se ve re ca rd iac f a ilu re . Ho we ve r, it m a y b e
n o rma l d u rin g sle ep in th e e ld e rly.
e . Us e of a cc e ss or y mus c l es : T h e se inclu d e th e
st e rn o cle ido ma st o id s, p lat ysm a an d pe ct o ra l m u scle s . Use of
a cce s so ry m u scle s is ch a ra cte rist ic of p a t ie n t s wit h COP D wh o
h a ve h yp e rinf la t ed lu n gs.
5 . Ne c k re gi on:
a . P os i ti on of Tra c he a
Ca us e s of trac hea l de vi a ti on
Tow a rds the s i de of the l ung l e s i on

Up p e r lo be o r lun g co lla p se

Up p e r lo be f ib ro sis

P n e umo n e ctom y
Aw a y from the s i de of the l ung l esi on

T en sio n p ne um o tho ra x

Ma ssive p le u ra l ef f u sio n
b. S upra c la vi c ul a r fos s a e
c . V i s i ble pul sa ti on , J V P
d. L ymph node s
PALPATION:
1 . Te nde rne ss
2 . Te m pe ra ture
3 . P os i ti on of Tra c he a : Use on e o r t wo f in ge rs in sup ra st e rn a l no t ch !
4 . Che s t E x pa ns i on:

B o t h sid e s of th e th o ra x sh o u ld e xp an d e qu a lly d u rin g tid a l a nd
m a xim a l in sp irat ion .

Re d u ced e xp a n sion o n o ne sid e in d ica t e s a b no rm a lit y o n th a t sid e ,
e . g. p le u ra l ef f u sion , lu n g o r lob a r co lla p se , p n eum o th o ra x a n d
u n ila t e ra l f ib ro sis.

B ila t e ra l re du ct io n in ch e st wa ll m o ve m en t is co mm on in a d va n ced
CO P D a n d d if f u se p u lmo n a ry f ib ro sis
5 . Ta c ti l e V oc al Fremi tus :

T a ct ile vo ca l f re m it u s is t he t ran sm issio n of vo ice so u nd s f rom
ce n t ra l a irwa ys t o t h e ch e st wa ll. I t is in cre a sed b y so lid lu n g,
p ro vid e d t he a irwa ys su p p lyin g t h a t pa rt of t h e lu n g a re p a t en t .

I t is im po rt an t to de cid e wh e t he r a rea s f ou n d t o b e d u ll t o
p e rcu ssio n sh o w in cre a sed t a ct ile vo ca l f rem it u s (su gge st in g
co n so lid at io n o r f ib ro sis) o r re d u ce d t a ct ile vo ca l f rem it u s
(su gge st in g f lu id or co lla p se )

Du rin g a sse ssm ent of ta ct ile vo ca l f re m it u s, it is con ve n t io na l t o
a sk t he pa t ie nt t o sa y 'n in e t y -n in e '. I n o th e r lan gu a ge s, o t he r
n u mb e rs o r p h ra ses a re u se d . (T he in t e nt io n is t o p ro du ce a n a sa l
'o i' so u nd ).
6 . Ap e x be a t l oc a li za ti on :
 De via t io n of th e card ia c a pe x b e a t ind ica t e s sh if t of th e lo we r
m e d ia st in um .
 Disp la ce me n t of the ca rd ia c im pu lse wit h o u t d e via t io n of t h e
t ra ch e a is u sua lly d u e t o lef t ve n t ricula r e n la rge me n t b ut ca n a lso
o ccu r in sco lio sis, kyp h o sco lio sis, o r se ve re p e c t u s e xca va t u m .
 T he ca rd ia c a pe x b e a t ma y b e d if f icu lt t o lo ca lize in ob e sit y,
p e rica rd ia l ef f u sion , po o r lef t ve n t ricu la r f u n ct io n o r p at ie n t s wit h
lu n g h yp e rin f la t io n a s in CO P D.
Percussion:
I d e a l site s f o r p e rcu ssio n a re a s sh own b e lo w
The sounds heard in different condition are as mentioned:
Type
Condition
R es onant
Norm al l ung
H yp err esonant
P neum ot horax
P ul m onar y consol i d at i on
Dul l
P ul m onar y col l aps e
S evere pul m onar y fi brosi s
'S t on y dul l '
P l eural effusi on
Auscultation:
 T he st et h o sco pe wa s in ve n t e d b y a Fre n ch ph ysicia n , La e nne c, in
1 8 19 .
 A u scu lt at e b o th sid e s a lte rn a te ly, co m p a rin g f ind in gs ove r a la rge
n u mb e r of e qu iva le n t p o sit io n s t o e nsu re t ha t lo ca lize d a b no rma lit ie s
a re n ot m isse d .
 T yp e s of so un d s on e m a y b e e xp e ct ed t o h ea r:
 Re s pi r a tor y (nor ma l ) s ounds
o V e s ic ul a r s ounds
o Bronc hi a l s ounds
A )-Vesicular sounds
Lower pitched, rustling
Softer relatively
Inspiration longer & Expiration shorter
No Gap between Insp & Exp sounds
Normally heard in lung parenchymal region
(peripheral thorax)
B )- Bronchial sounds
Higher pitched, hollow or blowing quality
Louder relatively
Inspiration & Expiration equal
Gap present between Insp & Exp sounds
Normally heard only along tracheobronchial
tree (central thorax)
B ro n ch ia l so u nd s c a n be f o u nd in p erip h e ra l re gio n wh e n e ve r n o rm a l lu ng
t issu e is re p la ce d b y u n if o rm ly co n duct in g t issu e , wh e t he r t h ro u gh
c ons ol i da ti on , fi bros i s o r c ol la ps e .

Ad ve nti ti ous ( Add e d) s ounds :
Wheezes / Rhonchi
Musical sounds produced by air passing through
narrowed airways. e.g. asthma.
Non-musical sounds mainly heard during inspiration
caused by:
1) Reopening of occluded small airways. e.g.
Crackles (Crepititions)
fibrosing alveolitis and pulmonary edema
2) Air bubbling through secretions.
e.g. bronchiectasis
Leathery or creaking sounds produced by movement of
roughened pleural surfaces. E.g. pleurisy caused by
Pleural Friction rub
pneumonia, pulmonary infarction. Usually associated
with pleural pain.
 voc a l r e s ona nc e : Fin a lly, a sse ss vo ca l re so na n ce b y askin g t h e pa t ie nt to
sa y 'o n e , on e , o ne '. I n th e n o rm a l lu ng a wh isp e re d n ote will n o t b e he a rd
b u t o ve r co n so lid at e d lun g, a s in p neu m on ia , t h e so un d is t ra n sm it t ed
p ro d u cin g 'w hi s peri ng pe c tori l oqu y' .
SPIROMETRY:
•
Ba s i c s pi rome tr y te rmi nol og y
1 . Ti da l vol ume (TV ): vo lu me of a ir in ha le d o r e xh a le d in o n e n o rm a l
b re a t h.
2 . I ns pi ra tor y re s e rve vol ume (I RV ): m a xim a l am ou n t of a ir t h a t
ca n be in ha le d f o llo win g a n o rm a l inha la t io n.
3 . E x pi ra tor y re s e rve vol ume (E RV ): m a xim a l vo lu m e of a ir t h a t
ca n be e xh a led f o llo win g a n o rma l e xh a la t ion .
4 . I ns pi ra tor y Ca pa c i t y (I C): m a xim a l am o un t of a ir a su b je ct can
in h a le f o llo win g a n o rma l e xh a la t ion .
5 . V i ta l ca pa ci t y (V C ): ma xim a l am o un t of a ir th a t a sub ject ca n
e xh a le af te r a m a xim a l in ha la t ion .
6 . Re s i dua l vol ume (RV ): vo lu m e of a ir re m a in in g in lu n gs af t e r
m a xim a l e xh a la t ion .
7 . Func ti ona l re si dua l ca pa c i ty (FRC) : vo lu me of a ir lef t in lu n gs
af t e r a n o rm a l e xh a la t io n.
8 . Tota l l ung c a pa c it y (TLC ): t o t a l vo lu m e of a ir t he lu n gs ca n h o ld .
NO RM AL R ANG E :
VARIOUS RESPIRATORY SIGNS & UNDERLYING PATHOLOGY
Shape of the Chest
Symmetry of the Chest
Respiratory rate
Mode of Breathing
Trachea
Reduced Chest
Expansion
Breathing Sounds
Vocal Resonance
Pigeon-shaped
Barrel-shaped
Asthma in childhood
Rickets
Emphysema
Forward Bending
Lateral Bending
Kyphosis
Scoliosis
Increased
Decreased
Fever
Acute Pulmonary Infections
Pleural Pain
Bronchial Asthma
Pulmonary Edema
Repiratory Failure
Thoracic
Abdominic
Abdominal pain
Ascites
Gaseous Distension of the
Intestines
Large Ovarian Cyst
Pregnancy
Ankylosing Spondylitis
Pleural Pain
Intercostal Paralysis
Pushed
Pulled
Pleural Effusion
Pneumothorax
Supramediastinal Mass
Pulmonary Consolidation
Lung Collapse
Pulmonary fibrosis
Bilateral
Unilateral
Bronchial Asthma
Emphysema
Pulmonary fibrosis
Pleural Effusion
Pleural thickening & fibrosis
Pulmonary Collapse Pulmonary
Consolidation
Pneumothorax
Diminished Vesicular
Bronchial Breathing
Emphysema
Pleural effusion/thickening
Thick Chest wall
Pneumothorax
Lung Collapse when large
bronchi occluded
Pulmonary Consolidation
Large Superficial Lung Cavity
Pulmonary Fibrosis
Lung Collapse when large
bronchi patent
Increased
Decreased
Pulmonary Consolidation
Lung Collapse when large
bronchi patent
Pleural Effusion
Pneumothorax
Lung Collapse when large
bronchi occluded