Physical Examination of the Respiratory System

Observation and Inspection

If a patient presents with specific symptoms, you’re able to tailor your history taking and physical exam to focus on
specific organ systems.

So what are some symptoms that might point to a respiratory problem?

1. Runny, blocked nose and sneezing

2. Cough
3. Chest pain
4. Shortness of breath (dyspnea)
5. Wheezing
6. Swollen feet/ankles (peripheral edema)

KEY QUESTIONS: Do you smoke? (determine pack years). Ask about home and work (occupational hazards).

When approaching the patient, you should take note of the shape of the patient’s chest. You want to look for any
deformities of the thorax, while also paying attention to the rate and rhythm of breathing. Are they using accessory
muscle to help with respiration? Are the diaphragm (abdomen) and thorax moving in the correct way?
INSPECTION & AUSCULTATION:
While inspecting, it is important to try and visualize the structures that lie beneath. If there is a deformity, what parts of
the lung may be affected?
Surface Anatomy: Because of how the lobes of the lung are shaped, it is important to have a good idea of their
positioning relative to the surface anatomy when trying to perform a proper respiratory physical exam. The right lung
has 3 lobes, while the left lung has only 2. Why? Bc heart is on the left = only 2 lobes.
You want to ensure you listen over each lung quadrant, so know the borders of the lobes anteriorly and posteriorly.
[DEMO]
Begin on one side, listen, and auscultate same region on othe side → use patie t’s anatomy for comparison. You want
to auscultate the apex and lobes of the lungs. Have a quiet space, need to be able to hear.

PROPER ETIQUETTE = GIVE CLEAR INSTRUCTIONS TO PNT

HIGH YIELD: LUNG FISSURES

● Right Lung
○ Oblique Fissure: T post → th i id
a . → th i id lav.
○ Middle Fissu e: th i a t → th i
(mid ax.)
● Left Lung
○ O li ue Fissu e: T post → th i id
clav.)
Starting ANTERIORLY:
● Apex: above the clavicle, ask patient to breath normally
and listen for 1-2 breaths. Listen to the same spot on
other side.
● Superior lobe: Right + Left: 2nd IC space at the
midclavicular line. Use the angle of louis to find this
spot.
● Middle lobe: right side, 4th IC space
● Inferior lobe: R + L: for the lower lobes, listen in the mid
axillary lines in the 6th IC space.
● Posteriorly: You can only auscultate the superior and
inferior lobes. Good trick is to have pnt raise arms and
place hand on head. Scapula can delineate the upper
and lower lobes. (T3 to 5th IC)
[NOTE: CLinically, you’ll start posteriorly, then anteriorly listen to middle lob and proceed to heart PE. If you hear
something, then do a full anterior exam]
What do you WANT to hear?
BREATH SOUNDS:
1. Inspiratory and expiratory sounds are equal.
Some abnormal sounds:
Narrow or obstructed airways:
● Rhonchi: continuous low pitched, rattling lung sounds, often resembles snoring. Often OBSTRUCTIVE cause,
seen in COPD, pneumo, cystic Fibrosis.
● Wheezes: continuous noise, constriction of bronchioles, see in asthma and bronchitis. (musical quality, high
pitched)
Others
● Crackles/Rales: discontinuous, smaller airways, fluid in lungs . Seen in CHF, pneumo.
● Rubs (sounds like rubbing hair): usually discontinuous, Pleural friction rubs are low-pitched, grating, or creaking
sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on
inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To
determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his
breath briefly. If the rubbing sound continues, it is a pericardial friction rub because the inflamed pericardial
layers continue rubbing together with each heartbeat - a pleural rub stops when breathing stops.
[DEMO]
PERCUSSION:
A controlled blow that sets up a vibration in tissue. The vibration is transmitted differently if underlying tissue is air or
fluid filled or solid. Air filled = resonant or tympanic sounds.
Leave on finger on the chest wall (called the pleximeter, surface being struck)
Strike finger with one or two fingers. Is the sound dull or resonant?
→ Test skills: t o i , a d the i IC spa e. The ib will make a duller sound, good to hear difference.
RATE & RHYTHM:
As you listen and discuss symptoms with Pnt, you can assess the rate and rhythm of breathing.
● How long should you try and watch for? 30 secs
● What’s a normal RR? About 12, +/= 4 breaths per minute in an adult. (count for 30 secs, x2)
○ Infants 30-60
○ Kids: 20-30
● Tachypnea (abnorm. Rapid breathing) = >20
○ Tachypnea can be caused by a number of conditions. Chronic conditions like asthma, lung disease,
anxiety, or obesity can lead to tachypnea. It may also be caused by acute conditions like pulmonary
embolism (blood clots in lungs), choking, heart failure, shock, or heatstroke. Lung infections can also
cause tachypnea.
● Bradypnea = < 8
○ One of most common: Narcotics (ex. Benzos, opioids), hypothyroidism (cushing’s). Also pulmonary
obstructions, increased intracranial pressure, obesity, alcohol consumption, and cardiogenic shock.
RESP PATTERN:
● Usually it’s rhythmic and regular, with insp to exp ratio being 1:2
● Prolonged expiration can suggest underlying OBSTRUCTIVE impairment
● Rapid shallow breathing (1:1) suggest restrictive impairment.
● Abnormal Sounds:
○ Cheyne-Stokes breathing (gradual increase in resp. rate, decrease, increase, rhythmic),
■ Sign of Heart Failure. (Also sign of central sleep ap ea, da age to esp e te s i the ai → T
IPAP)
○ Kussmaul breathing (sounds like you just ran): It is a form of hyperventilation, which is any breathing
pattern that reduces carbon dioxide in the blood due to increased rate or depth of respiratio → e . I
metabolic acidosis.
○ Abdominal paradox: diaphragm goes down and thorax expands in normal breathing. If thorax goes out
and abdomen in, sign of diaphragmatic dysfunction (possibly paralysis)

OTHER SIGNS ON PE:

Signs of resp distress can include tachypnea. Is there accessory muscle use when breathing?
T ipod positio : sig of esp dist ess → the t ipod positio opti izes the e ha i s of espi atio taki g adva tage of
the accessory muscles of the neck and upper chest to get more air into the lungs.
Nasal fla i g? → Ca i di ate esp dist ess, diffi ult eathi g.
Unable to complete a full sentence on a single breath?
Cyanosis? Bluish discoloration of the skin, bc of low oxygen lvls in blood. Peripheral remains in hands and feet, whereas
central cyanosis you see discoloration in the core, around lips and tongue. Can indicate a ventilatory prob leading to
[poo lood o ge atio i the lu gs → e p eu o, PE, COPD.
Clubbing? Lose normal angle of nail bed-to-finger. Clubbing can be seen with lung cancer, bronchiectasis as well as some
indolent pulmonary infections. It can also be seen in a few extra-throracic conditions. Interstitial lung disease
(restrictive). It is NOT seen in COPD*
Back to Symptoms (time permitting):
1. Runny, blocked nose, sneezing.
Pathophysiology: inflammatory response in airways (could be infectious or not)
Ask about: duration, timing, provoking and palliating factors (exposure to infection, allergens, travel)

2. Cough
a. Forced expiration interrupted with repeated closure of glottis: generates high pressures
b. 5th most common complaint seen by GPs in an office
c. Duration – the two week paroxysms of whooping cough (acute< 3 wks; chronic > 3 wks)
Timing – Just since starting an ACE inhibitor or just at night from aspiration of gastric acids or occurring
every meal secondary to stroke
d. P and P – Induced by exercise or by cold air in asthma or made better by cold air in bronchiolitis
e. Associated Symptoms – Blood in urine of vasculitis or const’l sx
f. Sputum: Volume; Dry – ILD; Mucoid – Asthma, tumors; Yellow-green purulent – Bronchiectasis; pink
frothy – pulmonary edema; Bloody in TB, Neo, PE, bleeding disorders, acute bronchitis, Rust-colored -
pneumococcal pneumonia; Foul-smelling – Lung abscess; think of GERD; post-viral URI; post-nasal drip
g. Occupational / Toxic - Silo-filler’s lung disease (NO2), or Bleomycin chemo or tobacco
h. Other systems provoking cough?: Aspiration from a neuromuscular disorder in the oropharynx e.g.
Myasthenia gravis or stroke or polymyositis

3. Chest pain: OPQRST

a. Ass’d Symptoms:
b. Leg swelling and pleuritic chest pain – PE
c. Shaking chills & pleuritic chest pain – Pneumococal pneumonia
d. Other systems that can provoke chest pain –
e. Cardiac, GI (biliary, esophageal), Pericardial, Neuropathic
4. Shortness of breath (dyspnea)
a. Onset and duration – Sudden as in pneumothorax or insidious as in ILD
b. Palliation by rest or by sitting up or provocation by activity or lying down
c. Ass’d symptoms: Chest pain; Functional status & exercise tolerance!! NYHA; MRC: 1
(strenous ex); 2 (hill); 3 (more slowly); 4 (< 100yds); 5 (with ADLs)
d. Affect on ADL’s: Avoid walking up Metro steps or on the flat, missing school or work or special
events.
e. Other systems that can provoke dyspnea: Anemia of any cause; Thyroid
f. Alarm symptoms: acute/pleuritic and unilateral

5. Wheezing (narrowing airways)

a. Onset and duration: Infectious, running out of puffers, endobronchial tumor, exposure to
carpets / dust.
b. Palliation and provocation: Puffers help.
c. Affect on ADL’s: Stopped playing sports etc.
d. Other systems that can provoke wheezing: Cardiac -> CHF

6. Swollen feet/ankles (peripheral edema)

a. Swollen feet, ankles
b. Hemoptysis
c. Snoring
d. Change in color (e.g. cyanosis)
e. Voice change
f. Constitutional symptoms
g. Previous and/or last CXR