Physical Examination in
Respiratory System
Zhao Li, M.D.
1
Skeletal landmarks
Sternal angle
Spinous process
subscapular angle
xiphoid
Intercostal space
Costalspinal angle
2
Anterior imaginary lines and
landmarks
Suprasternal fossa
Infraclavicular fossa
Supraclavicular fossa
Sternal line
Sternal angle
Anterior midline
Parasternal line
Midclavicular line
epigastric angle
3
Lateral imaginary lines
Posterior axillary line
Anterior axillary line
Midaxillary line
4
Posterior imaginary lines and
landmarks
Suprascapular region
Scapular region
Interscapular region
Infrascapular region
Scapular line
Posterior midline
5
Anterior view of lobes
6
Posterior view of lobes
7
Right lateral view of lobes
8
Left lateral view of lobes
9
Thoracic deformity
Pectus excavatum
Barrel chest
Kyphosis
10
Inspection(1)
1. Respiratory movement

Abdominal breathing: male adult
and child

Thoracic breathing: female adult
11
Inspection(2)
2. Respiratory rate: 16-18 f/min

Tachypnea: >20 f/min

Bradypnea: <12 f/min
12
Inspection(2)

Shallow and fast
 respiratory
muscular paralysis, elevated
intraabdominal pressure, pneumonia,
pleurisy

Deep and fast
 Agitation,

intension
Deep and slow
 Severe
metabolic acidosis (Kussmaul’s
breathing)
13
Inspection (3)
3. Respiratory rhythm
 Cheyne-Stokes’ breathing
 Biot’s breathing
_____Decreased excitability of respiratory center
 Inhibited breathing
 Sudden cessation of breathing due to chest pain
 Pleurisy, thoracic trauma
 Sighing breathing
 Depression, intension
14
Palpation
 Thoracic expansion

Massive hydrothorax, pneumonia,
pleural thickening, atelectasis
 Vocal fremitus (tactil fremitus)
 Pleural friction fremitus

Cellulose exudation in pleura due to
pleurisy

Holding breathing
disappeared

Tuberculous pleurisy, uremia, pulmo
embolism
15
Percussion
16
1. Method



Mediate
 Pleximeter: distal inter-phalangeal
joint of left middle finger
 Plexor: right middle finger tip
Immediate
Order
 Up to down, anterior to posterior
17
2. Affected factors

Thickness of thoracic wall

Calcification of costal cartilage

Hydrothorax

Containing gas in alveoli

Alveolar tension

Alveolar elasticity
18
3. Classification





Resonance
 Normal
Hyperresonance
 Emphysema
Tympany
 Cavity , pneumothorax
Dullness
 Hydrothorax, atelectasis
Flatness
 Massive Hydrothorax, massive atelectasis
19
4. Normal sound
Lung’s sound in percussion
 Resonance
 Slight dullness in some areas (upper, right,
back) due to thickness of muscles and
skeletons
20
4. Normal sound
Border of lungs in percussion
 Apex of lungs




Anterior border


Kronig’s isthmus: 5cm in width
Narrow: TB, fibrosis
wider: emphysema
absolute cardiac dullness area
Lower border



6th, 8th, 10th intercostal space in midclavicular line,
midaxillary line, scapular line, respectively
Downward: emphysema
Upward: atelectasis, intraabdominal pressure increased
21
4. Normal sound

Shifting range of bottom of lung
Along the scapular line
Shifting range
of
bottom of lung
To percuss bottom of lung, marking
6-8 cm
To ask the pat. to inspire deeply and hold
To percuss bottom of lung, marking

To ask the pat. to expire deeply and hold

To percuss bottom of lung, marking
To measure the dist. between upper and lower lines
Decreased: emphysema,
atelactasis, fibrosis, pulmo.
edema, pneumonia
Detected impossibly: pleura
adhesion, massive
hydrothorax, pneumothorax,
diaphragmatic paralysis 22
5. Abnormal sound
 Dullness, flatness, hyperresonance or
tympany appear in the area of supposed
resonance.
 Unchanged sound (resonance)

The depth of the lesion > 5 cm

The diameter of the lesion  3 cm

Mild hydrothorax
23
5. Abnormal sound
Dullness or flatness
 Decreased containing gases in alveoli

Pneumonia

Atelectasis?

TB

Pulmo. embolism

Pulmo. edema

Pulmo. fibrosis
24
5. Abnormal sound
Dullness or flatness
 No gases in alveoli
 Tumor
 Pulmo. Hydatid (肺包虫)
 Pneumocystis (肺囊虫)
Non-liquefied lung abscess
 Others
 Hydrothorax


Pleural thickness
25
5. Abnormal sound
 Hyperresonance

Emphysema
 Tympany

Pneumothorax

Large cavity (TB, lung abscess, lung cyst)
 Amphorophony (空瓮音)

Large and shallow cavity with smooth wall

Tension pneumothorax
26
5. Abnormal sound
 Tympanitic dullness (浊鼓音)

Decreased tension and gases in alveoli
Atelectasis
Congestive
or resolution stage
of pneumonia
Pulmo. edema
27
5. Abnormal sound
 Special areas
on percussion
in moderate
hydrothorax
Garland’s triangle area
(tympanitic dullness)
Damoiseau’s curve
Grocco’s triangle area
(dullness)
28
Auscultation
29
Order of auscultation
30
Sound of auscultation
1. Normal breath sound
2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance (语音共振)
5. Pleural friction rub
31
1. Normal breath sound
 Tracheal breath sound
Bronchial
 Bronchial breath sound
 Larynx, suprasternal fossa,
around 6th, 7th cervical
vertebra, 1st, 2nd thoracic
vertebra
Bronchovesicular
 Bronchovesicular breath
sound

1st, 2nd intercostal space
beside of sternum, the level
of 3rd, 4th thoracic vertebra
in interscaplar area, apex of
lung
 Vesicular breath sound
 Most area of lungs
Bronchial
Bronchovesicular
32
2. Abnormal breath sound
 Abnormal vesicular breath sound
 Abnormal bronchial breath sound
 Abnormal bronchovesicular breath sound
33
Abnormal vesicular breath sound(1)
1)
2)
Decreased or disappeared
 Limited movement of thoracic wall
 Respiratory muscle weakness
 Obstruction of airway
 Compressed atelectasis
 Hydrothorax or pneumothorax
 Abdominal diseases: ascites, large tumor
Increased
 Increased movement of respiration
 Exercise, fever, anemia, metabolic
acidosis, compensation (single lung)
34
Abnormal vesicular breath sound (2)
3) Prolonged expiration
___ uncompleted obstruction and / or
decreased alveolar elasticity

Bronchitis

Asthma

emphysema
35
Abnormal vesicular breath sound (3)
4) Cogwheel breath sound
 TB
 Pneumonia
5) Coarse breath sound
____ not smooth in airway due to swollen or
exudation
 bronchitis
 Early stage of pneumonia
36
Abnormal bronchial breath sound
(tubular breath sound)
 Bronchial breath sound appears in the area
where vesicular breath sound is supposed to
appear because of increased sound
transmission or resonance.
Consolidation:
lobar pneumonia
(consolidation stage)
Large
cavity: TB, lung abscess
Compressed
atelectasis: hydrothorax,
pneumothorax
37
Abnormal bronchovesicular
breath sound
 Bronchovesicular breath sound appears in
the area where vesicular breath sound is
supposed to appear.
 The lesion is relatively smaller, deeper or
mixed with normal lung tissue.
bronchopneumonia
TB
Early stage of lobar pneumonia
Upper area of hydrothorax
38
3. Adventitious sound
 moist Crackles
 Rhonchi (wheezes)
39
Moist crackles
Mechanism
During inspiration, air flow passes thin
secretion in the airway to rupture the
bubbles, or to open the collapse of
bronchioli due to adhesion by secretion.
40
Characteristics of crackles
1. Adventitious sound
2. Intermittent
3. Appeared in phase of inspiration or early
expiration
4. Constant in site
5. Unchanged in character
6. Medium and fine crackles exist meantime
7. Less or disappeared after cough sometimes
41
Classification of moist crackles(1)
 According to intensity of the sound
1.
Loud moist crackles
2.
Slight moist crackles
42
Classification of moist crackles(2)
 According to diameter of the airway crackles
appeared
1.
Coarse: trachea, main bronchi, or cavity
Bronchiectasis,
pulmo. edema, TB, lung
abscess,
coma (wheezy phlegm, 痰鸣)
2.
Medium: bronchi
bronchitis,
bronchopneumonia
43
Classification of moist crackles(3)
3.
Fine: bronchioli

Bronchiolitis, Pneumonia, pulmo. congestion,
pulmo. embolism
4.
Velcro:

5.
Interstitial lung disease
Crepitus:

Bronchiolitis, alveolitis, early pneumonia
(congestion),
elder subject, pat. lying in bed for long time
44
Site of crackles
Local: local lesion
 Pneumonia
 TB
 Bronchiectasis
2. Both bases
 Pulmo. congestion
 Bronchopneumonia,
3. Full fields
 Acute pulmo. Edema
 Severe bronchopneumonia
1.
45
Rhonchi (wheezes)
Mechanism
The turbulent flow is formed in trachea, bronchi or
bronchioli due to airway narrow or incomplete
obstruction.
Causes
 Congestion
 Secretion
 Spasma
 Tumor
 Foreign subject
 Compression (lymph node, mediastinal tumor)
46
Characteristics of rhonchi
1. Adventitious sound
2. High pitch
3. Dominance in phase of expiration
4. Variable intensity, character, site or spread
5. Wheezing (appeared in main bronchi)
47
Classification of rhonchi
1. Sibilant (哨笛音，高调)

Bonchioli, smaller bronchi
2. Sonorous (鼾音，低调)

Trachea, main bronchi
48
Site of rhonchi
1. Both fields



Asthma
Chronic bronchitis
Acute left heart failure (cardiac asthma)
2. Local site


Tumor
Endobronchial TB
49
Vocal resonance
Increased sound transmission due to
changed density of lung tissue
 Bronchophony (支气管语音）
Consolidation
 Pectoriloqny (胸语音)
 Massive consolidation
 Egophony (羊语音)
 Upper area of hydrothorax
 Whispered (耳语音)
 Consolidation
Increased density

of lung tissue:
50
Consolidation vs Atelectasis
Pleural friction rub
1. Cellulose exudation in pleurisy (rough pleura)
2. Area of auscultation
inferolateral thoracic wall (maximal shifting area
of lung)
3. Friction rub disappeared if holding breath
4. Friction rub appeared both breath and heart beat:
mediastinal pleurisy
5. Causes
 Tuberculous pleurisy
 Pulmo. embolism
 Uremia
 Pleural mesothelioma

51
Main symptoms and signs in
common respiratory diseases
52
Labor pneumonia
53
Symptoms
 Chill
 Continued fever: 39-40ºC
 Chest pain
 Tachypnea
 Cough
 Rusty sputum
54
Signs (1)
 General signs

Acute facial features, blushing (颜面潮红)

Nares flaring (dyspnea)

Cyanosis

Tachycardia

Simple herpes around lips
55
Signs (2)
 Congestion stage

Decreased movement of respiration in affected
area

Increased vocal fremitus

Dullness

Crepitus
56
Signs (3)
 Consolidation stage

Obviously increased vocal fremitus (resonance)

Dullness or flatness

Abnormal bronchial breath sound (tubular
breath sound)

Pleural friction rub
 Resolution

Moist crackles
57
Chronic bronchitis with
emphysema
58
Symptoms
 Chronic productive cough
 White mucous sputum or pus sputum
(infection)
 Usually exacerbation in winter
 Morning cough
 To last more than 3 months
 Exertional dyspnea
 Breathlessness (dyspnea)
 Chest depress
59
Signs
 Barrel chest
 Movement of respiration
 Vocal fremitus
 Hyperresonance
 The lower border of lungs downward
 Shifting range of bottom of lung
 Cardiac dullness area
 Decreased vesicular breath sound
 Prolonged expiration
 Moist crackles and/or rhonchi (acute episode)
60
Bronchial asthma
61
Symptom
 Expiratory dyspnea with wheezing
62
Signs
 Expiratory dyspnea with wheezing
 Orthopnea
 Cyanosis
 Severe sweat
 Decreased movement of respiration
 Decreased vocal fremitus
 Hyperresonance
 Rhonchi in full fields of lungs
63
Hydrothorax
(pleural effusion)
64
Symptoms
 Dry cough
 300ml: no obvious symptoms
>500ml: breathlessness, chest depress
 Chest pain


Disappeared with growing of pleural effusion
Reappeared with the fluid decreasing
 Affected side lying
 Dyspnea, orthopnea, palpitation
 The symptoms of underlying disease
65
Signs
(Moderate to massive effusion)
 Tachypnea
 Limited movement of affected side
 Costal interspaces of affected side are wider
 Trachea shifts to opposite side
 Decreased vocal fremitus
 Dullness or flatness
 Decreased or disappeared vesicular breath sound
 Decreased or disappeared vocal resonance
 Pleural friction rub
 Abnormal bronchial breath sound in upper area of
the fluid
66
Pneumothorax
67
Symptoms





Sudden chest pain
Dyspnea
Forced sitting position
Unaffected side lying
Dry cough
 Tension pneumothorax
 Progressive dyspnea
 Severe sweat
 Tyckycardia
 Tension, agitated
 Cyanosis
 Respiratory failure
68
Signs
 Costal interspaces in affected side are wider
 Limited movement of affected side
 Decreased or disappeared vocal fremitus
 Trachea and heart shift to opposite side
 Tympany
 Vesicular breath sound decreased or
disappeared
69