CLINICAL EXAMINATION

OF THE
RESPIRATORY SYSTEM
By,
Dr.Prajwal
Different Lines
Vertebra prominence
 Sternal angle and ICS
Suprasternal Notch

Sternal Angle
1. 2nd Rib joins
2. Arch of Aorta(beginning and
the end)
3. Trachea bifurcates into the
two bronchi
4. Pulmonary trunk bifurcation
5. Left recurrent laryngeal nerve
looping under the arch of the
aorta
6. Azygous Vein draining into
the superior vena cava.
7. Thoracic duct emptying into
the left subclavian vein
Lung fissure and Borders
 Lung fissure and Borders
Horizontal fissure (Minor interlobar fissure)

T2

Oblique fissure (Major interlobar fissure)

EXAMINATION OF THE
RESPIRATORY SYSTEM
Upper Respiratory Tract Lower Respiratory Tract

1) General Examination (RS)

2) Examination of the Chest
 1)General Examination
Pallor Temperature
Icterus Pulse
Cyanosis Respiratory Rate
Clubbing BP
Edema JVP
Lymphadenopathy
Pallor (Anemia)
The pallor of anemia is best seen in the
mucous membranes of the conjunctivae, lips
and tongue and in the nail beds

Anaemia may occur when there is

a. Haemoptysis
b. Excessive sputum production and protein
loss
c. Loss of appetite leading to malnutrition
Cyanosis
This is a blue discoloration of the skin and mucous membranes caused
by increased concentration of reduced hemoglobin (5g/dl)

Central cyanosis may result from the reduced arterial oxygen saturation
caused by cardiac or pulmonary disease. Intracardiac or extracardiac
shunting.

Impaired pulmonary function

a. Alveolar hypoventilation
b. Ventilation—Perfusion mismatch
c. Impaired oxygen diffusion.
Clubbing
Bulbous enlargement of the distal portion
of the digit due to increased subungual soft
tissue.
Grading of Clubbing

Grade I Positive nail bed fluctuation

Grade II Obliteration of the Lovibond angle
Grade III Parrot beak / Drumstick appearance
Grade IV Hypertrophic osteoarthropathy.
Pulmonary and Thoracic Causes
a. Bronchogenic carcinoma (rare in adenocarcinoma)
b. Metastatic lung cancer
c. Suppurative lung disease
1. Bronchiectasis
2. Cystic fibrosis
3. Lung abscess
4. Empyema
d. Interstitial lung disease
e. Longstanding pulmonary tuberculosis
f. Chronic bronchitis
g. Mesothelioma
h. Neurogenic diaphragmatic tumour
i. Pulmonary AV malformation
j. Sarcoidosis.
Hypertrophic Osteoarthropathy

It is a painful swelling of the wrist, elbow, knee, ankle,

with radiographic evidence of sub-periosteal new bone
formation. It can be familial or idiopathic.

common disorders that can produce it are:

a. Bronchogenic carcinoma
b. Cystic fibrosis
c. Neurofibroma
d. A-V malformation.
Lymphadenopathy
Scalene lymph node enlargement
1. Large and fixed in secondary involvement from a
primary lung malignancy
2. Hard and craggy, matted, with or without sinus
formation in healed and calcified tuberculous
lymphadenopathy.
Blood Pressure
Pulsus Paradoxus
 Systolic blood pressure normally falls during quiet inspiration in
normal individuals.
 Pulsus paradoxus is defined as a fall of systolic blood pressure of
>10 mmHg during the inspiratory phase.
 severe acute asthma or exacerbations of chronic obstructive
pulmonary disease.
 Examination of the Neck Veins
Jugular Venous Pulse
COPD/cor pulmonale
Bilateral non-pulsatile
SVC obstruction
Massive right sided pleural effusion
 2) Examination of the Chest
 Inspection
 Palpation
 Percussion
 Auscultation
The subject should be examined in the Standing or Sitting position in an
erect, and in good light.
All the findings in the clinical examination should
be compared on both sides in the following areas:

1. Supraclavicular area
2. Infraclavicular area
3. Mammary region
4. Inframammary region
5. Axillary region
6. Infra-axillary region
7. Suprascapular region
8. Interscapular region
9. Infrascapular region.
Inspection
 Inspection for Position of trachea
 Inspection for Symmetry of Chest
 Inspection for Chest wall abnormalities
 Inspection for Movement of the Chest
 Inspection for Apex beat
 Inspection for Dilated and engorged veins
 Inspection for Surgical or any Scars or Sinuses
Inspection for Position of trachea
Trail’s sign: It is the undue prominence of the clavicular head of
sternomastoid on the side to which the trachea is deviated.

Position of Apex Beat

The apex beat is shifted to the side of mediastinal shift.
Inspection for Symmetry of Chest
 Normal chest is symmetrical and elliptical in cross section.
The normal antero-posterior to transverse diameter ratio
(Hutchinson’s index) is 5 : 7.
 The normal subcostal angle is 90°. It is more acute in
males than in females.
AP

AP:T = 5:7
Look for the following:
1. Drooping of the shoulder
2. Hollowness or fullness in the supraclavicular and infraclavicular fossa
3. Crowding of ribs
4. Kyphosis (forward bending of the spine)
5. Scoliosis (lateral bending of the spine).
Inspection for Chest wall abnormalities
1. Flat chest: The antero-posterior to transverse diameter ratio is 1 :
2.
Seen in pulmonary TB and fibrothorax
2. Barrel chest: The anteroposterior to transverse diameter
ratio is 1 : 1.
Seen in physiological states like infancy and old age and in
pathological states like COPD (emphysema)
3. Pigeon chest (Pectus carinatum) : It is forward protrusion of
sternum and adjacent costal cartilage,
seen in Marfan’s syndrome, in childhood asthma and rickets
4. Pectus excavatum (funnel chest, cobbler’s chest)
It is the exaggeration of the normal hollowness over the
lower end of the sternum. It is a developmental defect.
The apex beat shifted further to the left and the ventilatory
capacity of the lung is restricted.
It is seen in Marfan’s syndrome
5. Harrison’s sulcus: It is due to the indrawing of ribs to form
symmetrical horizontal grooves above the costal margin, along the line of
attachment of diaphragm

occurs in chronic respiratory

disease in childhood,
childhood asthma, rickets and
blocked nasopharynx due to
adenoid enlargement
6. Scorbutic rosary: It is the sharp
angulation, with or without beading or
rosary formation, of the ribs, arising as
a result of backward displacement or
pushing in of the sternum,
e.g. Vitamin C deficiency.

7. Rickety rosary: It is a bead like

enlargement of costochondral junction,
e.g. rickets
Spinal Deformity
Kyphoscoliosis : It is a disfiguring or
disabling deformity of the spine, producing a
shift of the apex beat. It reduces the
ventilatory capacity of the lung and
increases the work of breathing.
Inspection for Movement of the Chest
It is described in terms of rate, rhythm, equality and type of breathing
Rate
• The normal respiratory rate in relaxed adults is 14-18
breaths per minute
• The type of breathing in women is thoraco-abdominal
and in men is abdomino-thoracic
• The ratio of pulse rate to respiratory rate is 4 : 1.
Tachypnoea: It is an increase in respiratory rate more
than 20 per minute(Adult). Conditions causing tachypnoea
are:
a. Nervousness
b. Exertion
c. Fever
d. Hypoxia
e. Respiratory conditions
i. Acute pulmonary oedema
ii. Pneumonia
iii. Pulmonary embolism
iv. ARDS
v. Metabolic acidosis
Bradypnoea: It is a decrease in the rate of respiration.
Conditions causing bradypnoea are:
a. Alkalosis
b. Hypothyroidism (myxoedema)
c. Narcotic drug poisoning
d. Raised intracranial tension.

Hyperpnoea: It is an increase in depth of respiration.

Conditions causing hyperpnoea are:
a. Acidosis
b. Brainstem lesion
c. Hysteria.
Rhythm
Inspiration: It is an active process brought about by the
contraction of the external intercostal muscles and the
diaphragm
Expiration: It is a passive process and it depends upon
elastic recoil of the lungs.
Accessory muscles of inspiration are the scaleni,
trapezius and pectoral muscles.
Accessory muscles of expiration are abdominal
muscles and latissimus dorsi.
Abnormal Breathing Patterns
Abnormal breathing patterns may be regular or irregular

Regular abnormal breathing patterns

a. Cheyne-Stokes breathing: It is characterised by hyperpnoea
followed by apnoea.
It occurs in cardiac failure, renal failure, narcotic drug
poisoning and raised intracranial pressure

b. Kussmaul’s breathing: It is characterised by increase in rate and

depth of breathing.
It occurs in metabolic acidosis and pontine lesions.
Irregular abnormal breathing patterns
a. Biots breathing: It is characterised by apnoea between several
shallow or few deep inspirations. It occurs in meningitis
b. Ataxic breathing: It is characterised by irregular pattern of
breathing where both deep and shallow breaths occur randomly. It
occurs in brainstem lesions

c. Apneustic breathing: It is characterised by pause at

full inspiration, alternating with a pause in expiration,
lasting for 2 to 3 seconds. It occurs in pontine
lesions
Palpation
 Palpation for Apex Beat (Position and Character)
 Palpation for Position of trachea
 Palpation for Measurement of the Chest Expansion
 Palpation for Assessing of Chest Expansion
 Palpation for Vocal fremitus (VF)
 Palpation for Direction of flow in veins
 Palpation for Tender points
Palpation for Position of trachea
The position of the trachea is confirmed by slightly flexing the neck
so that the chin remains in the midline.
The index finger is then inserted in the suprasternal notch and the
tracheal ring is felt.
Slight shift of trachea to the right is normal
Measurement of the Chest Expansion

The expansion of the chest should be measured with a tape

measure placed around the chest just below the level of the
nipples/inferior angle of scapula.
 Chest circumference in full expiration
 Chest circumference at full inspiration
 Chest expansion
 Right/Left Hemithorax

Normal expansion of the chest is 5-8 cm

In severe emphysema, it is less than 1 cm
General Restriction of Expansion
a. COPD
b. Extensive bilateral disease
c. Ankylosing spondylitis
d. Interstitial lung disease
e. Systemic sclerosis (hide bound chest).

Asymmetrical Expansion of the Chest

a. Pleural effusion
b. Pneumothorax
c. Extensive consolidation
d. Collapse
e. Fibrosis.
In all these above conditions, diminished
expansion occurs on the affected side.
Assessing Symmetry of Chest Expansion

upper thoracic expansion

anterior thoracic expansion

posterior thoracic expantion

Palpation for Vocal fremitus (VF)
 It is a vibration felt by the hand when the patient is
asked to repeat ninety-nine or one-one-one, by putting
the vocal cord into action.
 Identical areas of the chest are compared on both sides.
 It is felt with the flat of the hand or with the ulnar
border of the hand for accurate localization.
 It is increased in consolidation.
 It is decreased in pleural effusion
Tenderness over the Chest Wall

It may be due to:

1. Empyema
2. Local inflammation of parietal pleura, soft tissue and
osteomyelitis
3. Infiltration with tumor
4. Non-respiratory cause (amoebic liver abscess).
Percussion
 Percussion for the Lung fields
Cardinal Rules of Percussion

a. The pleximeter: The middle finger of the examiner’s left hand should
be opposed tightly over the chest wall, over the intercostal spaces. The
other fingers should not touch the chest wall. Greater pressure should be
applied over a thick chest wall to remove air pockets
b. The plexor: The middle or the index finger of the examiner’s right
hand is used to hit the middle phalanx of the pleximeter
c. The percussion movement should be sudden, originating from the
wrist. The finger should be removed immediately after striking to avoid
damping
d. Proceed from the area of normal resonance to the area of impaired or
dull note, as the difference is then easily appreciated
e. The long axis of the pleximeter is kept parallel to the border of the
organ to be percussed.
Anterior Chest Wall
Clavicle: Direct percussion is used and percussion is
done within the medial 1/3rd of the clavicle

Supraclavicular region (Kronig’s isthumus):

It is a band of resonance 5-7 cm size over the
Supraclavicular fossa. The percussion is done by
standing behind the patient and the resonance of the Direct percussion—clavicle

lung apices is assessed by this method.

Second to sixth intercostal spaces. However, the percussion

note cannot be compared due to relative cardiac dullness on
the left side.

Liver dullness can be percussed from the right 5th rib

downwards in the midclavicular line.
Lateral Chest Wall
Fourth to seventh intercostal spaces.
Liver dullness can be percussed from the right 8th rib
downwards in the midaxillary line.

Posterior Chest Wall

a. Suprascapular (above the spine of the scapula)
b. Interscapular region
c. Infrascapular region up to the eleventh rib.
Liver dullness can be percussed from the right 10th rib
downwards in the midscapular line.
Tidal Percussion
 This is done to differentiate upward enlargement of liver or
subdiaphragmatic abscess from right sided parenchymal or pleural
disorder.
 If on deep inspiration, the previous dull note in the fifth right
intercostal space on the mid clavicular line becomes resonant, it
indicates that the dullness was due to the liver, which had been
pushed down by the right hemidiaphragm with deep inspiration.
 If the dullness persists on the other hand, it indicates underlying
right sided parenchymal or pleural pathology, in the absence of
diaphragmatic paralysis.
Shifting Dullness
This is done to demonstrate the shift of fluid in hydropneumothorax.
The immediate shift of fluid can be demonstrated by the dull area
percussed in the axilla in the sitting posture, becoming resonant on
lying down on the healthy side.
Auscultation
 Auscultation for Breath Sounds
 Auscultation for Vocal Resonance
Listen with the patient relaxed and breathing deeply
through his open mouth.
Auscultate each side alternately, comparing findings over a
large number of equivalent positions to ensure that you do
not miss localised abnormalities.
Listen:
■ anteriorly from above the clavicle down to the sixth rib
■ laterally from the axilla to the eighth rib
■ posteriorly down to the level of the 11th rib.
■ Assess the quality and amplitude of the breath sounds.
Identifyany gap between inspiration and expiration, and
listen for added sounds.
Avoid auscultation within 3 cm of the midline anteriorly or
posteriorly, as these areas may transmit soundsdirectly from
the trachea or main bronchi.
Vesicular breath sounds
 low pitched, rustling in
nature
 produced by attenuating and
filtering effect of the lung
parenchyma.
 Duration of the inspiratory
phase is longer than the
expiratory phase in a ratio of
3 : 1.
 There is no pause between
the end of inspiration and the
beginning of expiration.
Bronchial breath sounds
 It is loud and high pitched,
with an aspirate or guttural
quality.
 It is produced by passage of
air through the trachea and
large bronchi
 The duration of inspiration is
shortened whereas that of
expiration is prolonged or
equal
 There is a pause between
inspiration and expiration.
Types of Bronchial Breathing
a. Tubular
b. Cavernous
c. Amphoric.
Added sounds
Added sounds are abnormal sounds that arise in the lung itself or in the
pleura.
The added sounds most commonly arising in the lung are best referred
to as wheezes and crackles.
Pleural rub is a “creaking” or “rubbing” sound produced by friction
between the two layers of inflamed and roughened pleura.

NEW Terms OLD Terms Definations

coarse crackles râles non-musical, interruptedshort,
fine crackles crepitations explosive sounds often described as
bubbling or clicking.
wheezes rhonchi Continuous musical sounds
associated with airway narrowing.
Vocal resonance is the detection of vibrations transmitted to the
chest from the vocal cords as the patient repeats a phrase, usually the
words ‘ninetynine’
assess the quality and amplitude of vocal resonance.
Types
a. Bronchophony: Voice sounds appear to be heard near the earpiece
of stethoscope and words are unclear, e.g. consolidation, cavity
communicating with a bronchus,
b. Aegophony: Voice sound has a nasal or bleating quality. On saying
‘E’, it will be heard as ‘A’ (E to A sign),
e.g. consolidation, cavity.
c. Whispering pectoriloquy: The patient is asked to whisper words at
the end of expiration, and this whispered voice individual syllables
are recognised clearly,
e.g. pneumonic consolidation, cavity communicating with a bronchus
Name: Examination of RS
Age:
Sex:
Address:
Occupation:

1) General Physical Examination:

Young patient moderately built and moderately nourished, well oriented to
time place and person, conscious and cooperative
Pallor Temperature
Icterus Pulse
Cyanosis Respiratory Rate
Clubbing BP
Edema JVP
Lymphadenopathy
3) Examination of the Chest

Inspection:
 Trachea appears Central in Position
 Shape of the chest is elliptical, Bilaterally symmetrical
 Movement of the chest is equal on both sides and normal
 Respiratory Movement
 Rate : 14 – 18 Breaths per minute
 Rhythm : Regular
 Depth : Normal
 Type : Abdominothoracic / Thoracoabdominal
 Accessory muscles of Respiration not in use
 No skeletal deformity seen
 Apical impulse not seen/seen at Left 5th ICS medial to MCL
 No dilated or engorged veins present
 No scars or swelling or other visible pulsations seen
Palpation:
 Apical Impulse felt at Left 5th ICS medial to MCL and is of
Normal Character
 Trachea centrally Placed (slightly deviated to right side)
 Expansion of the chest is normal and symmetrical, expansion
is more at the base compared to apex and sides of chest
 Measurement of the Chest Expansion
 Transverse Diameter : ___cm
 Anteroposterior Diameter : ___cm
 Right/Left Hemithorax : ___cm
 Chest circumference in expiration : ___cm
 Chest circumference at full inspiration : ___cm
 Chest expansion : ___cm
 No tenderness present
 Vocal fremitus (VF)
Area Right
Supraclavicular area
Infraclavicular area
Mammary region
Inframammary region
Axillary region
Infra-axillary region
Suprascapular region
Interscapular region
Infrascapular region
Left
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Percussion:
Area Right Left
Supraclavicular area Resonant Resonant
Infraclavicular area Resonant Resonant
Mammary region Resonant Dullness
Inframammary region Dullness(5th ICS onwards) Dullness
Axillary region Resonant Resonant
Infra-axillary region Resonant Resonant
Suprascapular region Resonant Resonant
Interscapular region Resonant Resonant
Infrascapular region Resonant Resonant
Auscultation
 Breath Sounds
Area Right Left
Supraclavicular area Vesicular Vesicular
Infraclavicular area Vesicular Vesicular
Mammary region Vesicular Vesicular
Inframammary region Vesicular Vesicular
Axillary region Vesicular Vesicular
Infra-axillary region Vesicular Vesicular
Suprascapular region Vesicular Vesicular
Interscapular region Vesicular Vesicular
Infrascapular region Vesicular Vesicular
 No added Sounds
  Vocal Resonance (VR)
Area Right
Supraclavicular area
Infraclavicular area
Mammary region
Inframammary region
Axillary region
Infra-axillary region
Suprascapular region
Interscapular region
Infrascapular region
Report: Examination of the respiratory system of the subject is clinically normal
Left
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides
Equal on both sides