Respiratory system 09

A.A. Stokhof and A.J. Venker-van Haagen

already been done in the general examination. Then, to

Chapter contents evaluate the respiratory sounds, we return to the
description in the history, although abnormal respiratory
9.1 History 63 sounds are sometimes clearly recognized during the
9.1.1 Symptoms 63 examination. Then comes the external examination of
9.1.2 Living conditions 65 the nose and sinuses, followed by examination of the
9.1.3 Past history 65 larynx and trachea, and then finally the thorax.
9.2 Physical examination 65
9.2.1 Respiratory movements and sounds 65 9.1 History
9.2.2 Nose and frontal sinuses 65
In focusing the history on the respiratory system, we use
Introduction 65 the same approach as for the general history (Chapter 6).
Nose 66 Further questions are asked about the symptoms
Frontal sinuses 67 reported by the owner. More detailed questions are
Nasopharynx 67 then asked about other symptoms associated with
Oropharynx 67 the respiratory system, such as nasal discharge,
9.2.3 Larynx and trachea 67 sneezing, additional sounds, coughing, sputum,
gagging or retching, and labored respiration. After
Technique 67
this, additional specific questions are asked about the
9.2.4 Thorax 68 situation in which the patient is living and any
Thoracic wall 69 previous illnesses in the patient or its relatives. We
Technique 69 go into these aspects of the history as follows.
Respiratory movements 69
Bronchi, lungs, and pleura 69
9.1.1 Symptoms
Auscultation 69
Technique 71 Nasal discharge is often associated with one or more of
the other signs given above. The owner is asked
Percussion 72
whether the nasal discharge is from one or both
Technique 72
nostrils and whether it is continuous or only occurs at
9.3 Notation 73 certain times (e.g., mainly in the morning when the
9.4 Further examination 74 dog awakens, or mainly when the dog goes outside), or
only occurs when the dog sneezes. Questions about the
description of the exudate must be asked in layman’s
terms, such as watery, mucus, pus, or blood.
If the screening examination has led to formulation of a A stridor is a respiratory sound that can be heard at
problem and a diagnostic plan that includes examination some distance from the animal and keeps recurring; it is
of the respiratory system, the first step is to further focus of fairly constant amplitude and frequency. A narrowing
the history on this system. The second step is to observe (stenosis) in the upper airways can lead to such an
the respiratory movements, although this has usually acceleration of the air stream that the Reynolds value
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(} 4.1.4) is exceeded and strong turbulence develops.
The stridor is named after the location of the
obstruction, such as a nasal stridor, pharyngeal stridor,
or laryngeal stridor. The location of the obstruction also
determines the sound. For example, sniffing is
characteristic of nasal stridor, snoring is characteristic of
a pharyngeal stridor, and a soft ‘sawing’ sound typifies a
laryngeal stridor. In a few breeds of dogs, selective
breeding for brachycephalic characteristics has led to
various types of stridor. The tooting sound of a collapsed
trachea is expiratory, while the sounds mentioned above
can be inspiratory or both inspiratory and expiratory,
depending on the severity of the obstruction. A stridor
of the nose or nasopharynx disappears as soon as the
animal begins to breathe through the mouth. In very
severe nasal obstruction the animal does this
spontaneously, but often keeps alternating with attempts
to breathe through the nose. In a mild stenosis the
stridor is only heard during and shortly after exercise.
Sneezing is one of the two reflexes that protect the
respiratory system against injury. Stimulation of
subepithelial receptors in the nose triggers the sneezing
reflex.1 The stimuli include inflammation or products of
inflammation, foreign bodies, and tumors. In addition
to sneezing, which everyone recognizes, there is another
sound that occurs in the dog and which is called
‘reverse sneezing’. This occurs as a result of stimulation
of the mucosa of the nasopharynx, leading to a spasm
of the pharyngeal muscles, which hinders the passage of
air to the larynx. The dog (it occurs chiefly in the dog)
makes an inspiratory snoring sound and at the same
time shows all the signs of severe dyspnea. The
pharyngeal spasm can be interrupted by reflex
swallowing, which can be brought about by massaging
the throat or by obstructing the nostrils until the dog
swallows. Reverse sneezing occurs without warning in
otherwise healthy animals and episodes can last from
seconds to minutes. If there is irritation or inflammation
of the mucosa in the nose and nasopharynx, the
frequency can increase to several times per day.
Coughing is the second important reflex by which the
respiratory system protects itself against injury. The
reflex can occur via stimulation of the airways
anywhere from the larynx to the larger bronchi.2 After
a deep inspiration the intrathoracic pressure is
increased (sometimes to 20 kPa!) by closure of the
glottis and contraction of the thoracic and abdominal
muscles. This is followed by an abrupt decompression,
by opening the glottis and driving out the respiratory
gas, together with any sputum that may be present.3
The frequency, severity, and character of the stimulus is
determined by (1) the nature of the causative lesion, (2)
the presence of sputum, and (3) any complicating
factors such as pain or reduced ventilation capacity.
The following types of cough can be distinguished,
according to the site of the stimulation:
64
1 A cough that is started by stimulation of the
larynx usually occurs episodically, is often heavy,
and is sometimes associated with gagging or
retching, a tendency to vomit, and sometimes the
coughing up of a little mucus or saliva.
2 A cough that is due to a process in the trachea is a
loud, explosive cough that often has the
characteristics of a bark.
3 Stimulation of the bronchi can result in various
kinds of coughing. In the acute phase the pattern is
not easy to differentiate from a cough due to
tracheitis. When much mucus and pus are
produced, the cough has a wet and rough character.
The tracheal cough—and even more so the bronchial
cough—are above all dry and nonproductive in the
acute phase and then associated with the coughing up
of sputum in the chronic phase. In taking the history
an attempt is made to describe the cough in terms of
frequency, duration, strength, whether it is painful, the
production of sputum, the probable localization of the
cough stimuli, and the time of occurrence (excitement,
time of day, change of environment).
Sputum is the substance in the airways that is
transported by coughing. In the dog and the cat we
are seldom well informed by the history about its
character (serous ¼ watery, mucous, purulent ¼ pus,
mucopurulent ¼ mucus and pus) or the amount, because
the coughed-up material is usually swallowed
immediately. In by far the majority of cases it is only on
the basis of the nature of the cough (productive or
nonproductive) that one can form an impression about
the presence or absence of sputum. Sputum is coughed
out only when coughing itself so stimulates the pharynx
that the animal begins gagging or retching so severely
that swallowing does not occur. The owner can describe
the nature of the sputum with the help of questions
about its color, stringiness, and odor. Account must be
taken of the frequent mixing with saliva and the possible
addition of material from the digestive tract. In acute
lung edema there may be not only coughing of serous
sputum but also serous discharge via the nasal openings,
with the formation of air bubbles at the nostrils. The
discharge can have a pinkish-red color due to the
presence of some blood. Damage to the blood vessels
can lead to the production of sputum that is blood-red.
Dyspnea (labored or difficult breathing) is
characterized by forced respiratory movements,
whereby auxiliary respiratory muscles are activated.
When the history is being taken it must first be
determined whether the dyspnea is acute and recurring
or chronic and continuous. In cases of acute dyspnea it
is certainly necessary to also ask about the conditions
under which this difficult breathing recurs and whether
there are any accompanying signs (e.g., stridor).
Owners do not always find it easy to distinguish
 Physical examination

between panting (thermal or nervous polypnea) and nasal openings are often small (Fig. 9.1), which can
dyspnea. Questions about the depth of the breathing cause respiratory difficulties.
can help here. A chronic dyspnea is sometimes clearly
The nose of dogs and cats is largely filled with richly
recognizable to the owner and the examiner when the
vascularized conchae. A bullous extension of the ventral
animal is at rest. In other cases the signs occur only
concha (plica alaris), which proceeds craniolaterally into
during exercise (dyspnea of exertion). In the latter case
the nasal ala, divides the incoming air over the dorsal,
one must be aware that owners do not always
medial, and ventral nasal passages. Most of the air is
recognize the difference between the rapid development
turned ventromedially toward the largest passage, the
of fatigue during exercise and the loss of interest in
ventral nasal passage (ventral nasal meatus). It is only via
exercise. The latter is an apathy, for which there need be
this passage that a tube can be passed (hence also
no cardiopulmonary problem. It is also possible that the
ventromedially) into the esophagus for artificial feeding
animal does not want to continue exercising because of
(Fig. 9.2).4 Caudally the ventral nasal passages are fairly
difficulties in locomotion. By asking questions about the
wide and they pass through the oval openings (the
character of breathing following apparent respiratory
choanae) to the nasopharynx. This area is dorsal to the
difficulty, about the development of auxiliary respiratory
caudal part of the hard and the soft palate (Fig. 9.2).
movements, and about the way the animal was walking,
we usually succeed, on the basis of the history, in Of the paranasal sinuses the maxillary sinus is actually a
differentiating among these forms of what an owner lateral extension or recess of the nasal cavity and only
sometimes calls reduced endurance. on the medial side of the caudal part is it bordered by
bone (Fig. 9.3). Hence this sinus is not considered
9.1.2 Living conditions separately but rather as part of the nasal cavity. The
frontal sinus lies in the frontal bone and varies
Here we are concerned with questions about what is
markedly in form and size due to the great variety in
required of the animal (such as strenuous physical
skull shapes that occur in the dog.
training), its contacts with other animals (possible
These very briefly described structures form the first
transmission of infectious disorders), and whether it is
part of the passages to the site of gas exchange, the
allowed outdoors without observation (increased chance
of trauma).

9.1.3 Past history

Information about all previous disorders can be of great
importance in connection with interpretation of the
findings. This ranges from illnesses, wounds, and injuries
by automobiles to surgery that has been performed. The
same applies to any known disorders of the respiratory
system in the relatives of the patient or in the breed.

9.2 Physical examination

9.2.1 Respiratory movements and sounds
Evaluation of the respiratory movements has been Fig. 9.1 Lateral and rostral views of the nose of a dolichocephalic dog
(left) and a brachycephalic dog (right).
described in the general examination (} 8.3.1). The
respiratory sounds have been described in the general
impression (Chapter 7) and in the above discussion of the
history.

9.2.2 Nose and frontal sinuses

Introduction
The shape of the nose is determined by a solid bony
structure and a moveable cranial part having a
cartilaginous skeleton. The flat front surface of the
nose is the nasal plane. There is a small groove down
the middle (the philtrum). The nasal openings (nostrils
or nares) are bordered laterally by wings (nasal alae). Fig. 9.2 Section of the head of a cat, in which a tube has been passed
In brachycephalic breeds the nose is very short and the via the ventral nasal passage into the esophagus.
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Fig. 9.3 Skull of a dog, in which the locations of the maxillary sinus
and frontal sinus are shown. The cranial part of the maxillary sinus,
which is not bordered by bone medially, is shown by a dotted line.
lungs. But in addition, these upper airways have a
number of other functions:
– They warm and humidify the inspired air.
– They protect against inspired particles that are
irritating or infectious. The nose contributes to this
by the sneezing reflex and the turbulent air stream
over a richly vascularized mucous membrane.
This is covered by a sticky secretion having
bactericidal properties, that is passed to the
esophagus by ciliated epithelium.
– They enable detection of odors by the olfactory
nerve ends, half of which lie in the ethmoidal
conchae. The perception of diverse odors is
facilitated by the interior structure of the nasal
cavity. The convoluted conchae create a variety of
turbulent air streams that result in an uneven
distribution of odorant molecules and thereby
selective exposure of olfactory receptors.5
– The upper airways facilitate emission of heat in the
form of heat of vaporization. In the dog and cat
the lateral nasal gland plays an important role in this
at high environmental temperatures, by increasing
the secretion of fluid at an exponential rate.6 During
thermal polypnea most of the air is inspired via the
nose and expired via the mouth.7 Hence the inspired
air is rapidly saturated with moisture on the large
mucosal surface in the nose and then expired via the
mouth. This prevents the warmth and moisture in
the expired gasses from being released again to the
nasal mucosa. In addition, this form of panting has
a constant frequency, which corresponds to the
resonance frequency of the respiratory movements,
thereby much reducing the energy expenditure for
these activities.8
Nose
After evaluation of the shape of the nose as a whole, the
following are examined in sequence:
– Nasal stridor. Under quiet conditions, listen very
close to the animal’s nose with its mouth closed. If
there is a stridor resulting from a too-narrow nasal
opening (brachycephalic breeds), the tone of the
stridor can be changed by moving the nasal alae
laterally.
66
Fig. 9.4 Testing the airflow through a nasal passage by use of a fluff of
cotton. The cotton is held at a steady distance from the nasal opening
by resting the hand against the bridge of the dog’s nose.
– Expired air. The symmetry of the air stream is
examined by watching the movement of a small
fluff of cotton held before each nostril (Fig. 9.4).
At the same time, the odor of the expired air
should be noted (for nasal fetor).
– Nasal discharge. In healthy animals there is
sometimes a drop of serous fluid. Abnormal
discharges may be mucoid, purulent, mucopurulent,
ichorous (rotting), or hemorrhagic. Episodic flow of
pure blood is a nosebleed or epistaxis. Occasionally
during vomiting or regurgitation some material from
the digestive tract may be discharged through the
nasal passages. If milk or other food comes directly
out of the nostrils of a puppy while it is eating, the
palate may not be fully closed. Any material that
remains in the nasal passages or nasal openings may
dry out and can hinder the passage of the air stream.
– Nasal plane. In most animals the nasal plane is
slightly moist and, depending on the distribution
of pigment over the body, it may or may not be
pigmented (Fig. 9.5). In some completely healthy
dogs the nasal plane is almost always dry. In other
animals the nose appears to become dry when
there is reduced secretion by the tear glands and
the salivary glands.
– Nasal openings. Attention should first be given to
the width of the nasal openings and the moveability
of the nasal alae. The plica alaris described above
prevents direct examination of the nasal passages
with the naked eye. By slight lateral displacement
of the nasal ala only the entrance of the ventral
nasal passage can be inspected. Further inspection
can be accomplished with the aid of an otoscope
or rhinoscope, under anesthesia.
– Palate. By opening the animal’s mouth one obtains
a view of the ventral wall of the nasal passages and
thus of any deformities that result from processes in
the nose. At the same time, abnormalities may be

Fig. 9.5 The nasal plane in two dogs. Left: a moist nasal plane with its characteristic irregular surface. Right: a dry nasal plane, smeared with dried
vomitus (also present in the hair around the mouth).
seen in the mouth (e.g., involving the canine teeth)
which can be the cause of a disorder in the nose.
Frontal sinuses
The frontal sinus is inspected and palpated to detect
possible swelling, pain, or crepitation. The frontal sinus
is surrounded on all sides by bone and thus percussion
produces a slightly hollow tone. When the sinus is filled
with fluid or tissue the tone can be slightly damped. This
is best detected if the change is unilateral and the
percussion tones on the left and right are compared.
Percussion is performed by tapping on the frontal bone
bilaterally with the forefinger or middle finger (Fig. 9.6).
Nasopharynx
Examination of the nasopharynx must be performed
completely under anesthesia. Only then is it possible to
reach the caudal part via the mouth and to inspect the
area with optical instruments and mirrors. As noted
above, the nasopharynx can also be reached by a tube
or an optical instrument introduced via the ventral
nasal passage. The retropharyngeal lymph node is
palpated as described in } 8.2.6.
Oropharynx
The respiratory and digestive tracts cross here and so this
area is inspected during the examination of both systems.
Fig. 9.6 Percussion of the right frontal sinus of a dog.
Physical examination
The mouth is opened and the base of the tongue is
depressed (Fig. 9.7) so that the tonsils, hard palate, and
soft palate can be inspected. Sometimes even the glottis
can be seen. Usually this area can only be examined
adequately when the animal is anesthetized.
9.2.3 Larynx and trachea
The larynx reaches to the base of the tongue and the soft
palate and it lies ventral to the atlas. This mostly
cartilaginous structure is about six centimeters long in a
medium-sized dog. Caudally it joins the trachea, a
cartilaginous tube with an interior diameter slightly
smaller than that of the larynx. Cranial to the larynx
lies the hyoid apparatus, which is attached dorsally
to the skull and acts as a suspensory mechanism for
the tongue and the larynx. Parts of the hyoid apparatus
can be palpated cranial to the larynx between the
mandibles.
The examination consists of inspection and palpation.
Inspection is performed with attention to possible
deformities in the throat and neck regions. Palpation
serves to detect possible deformities and to determine
sensitivity to pressure.
Under normal conditions the larynx is palpable in the
throat area and the transition from larynx to trachea—
marked by an abrupt change to a somewhat smaller
diameter—can be felt easily. The trachea can be
followed to the thoracic inlet. In dogs that are not
especially brachycephalic, the base of the tongue can
be retracted far enough forward during inspection of
the pharynx (Chapter 11) to reveal the cranial part of
the larynx. If further internal examination is necessary,
it must be carried out under anesthesia with a
laryngoscope and a bronchoscope.
Technique
The throat and neck are inspected with the neck stretched
slightly forward and upward. In this position palpation
can be performed by placing one hand around the larynx
(without pressing!) and then moving it caudally.
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Fig. 9.7 Oropharynx of a healthy dog. Opening the mouth without pressing on the base of the tongue (left) provides a view at the transition from
the hard palate to the soft palate. By pressing the base of the tongue downward and forward (right), the caudal part of the soft palate (somewhat long
in this dog) can be inspected, together with the epiglottis and the tonsillar fold. The method for opening the mouth is described in detail in Chapter 11.
Note: Few dogs tolerate this inspection without anesthesia and in cats anesthesia is always required.

The pressure sensitivity of the trachea is examined 9.2.4 Thorax

by applying slight pressure at three locations: just before
the thoracic inlet, at the midpoint of the cervical trachea,
and at the level of the first tracheal rings. The pressure
should be just sufficient to cause a slight deformation
of the trachea. After this kind of deep palpation, always
pause slightly (at least until the next expiration) to see
if a cough follows (not normal!). Finally the larynx is
also palpated. This is left until last because usually the
larynx in dogs and cats is more sensitive to pressure
than the trachea and because even in healthy animals a
cough may be stimulated by this palpation. If a laryngeal
or tracheal stridor is suspected but there is some
doubt about the localization, then brief and light
pressure can be applied to the larynx and to various
places along the trachea. A change in tone of the stridor
usually gives more certainty about the location of the
obstruction.
The objectives of examination of the thorax are:
– observation of the respiratory movements by
inspection
– detection of abnormalities in the thoracic wall by
inspection and palpation
– detection of abnormalities in the structure and
function of the bronchi, lung tissue, and pleura by
auscultation and percussion
Good examination of the thorax requires some familiarity
with the anatomy. The following remarks refer to the
superficial anatomy of the thorax and cranial abdomen
(Fig. 9.8) and to the branching of the bronchi and the
divisions of the lung lobes (Fig. 9.9).
Examination of the first ribs and most cranial parts of
the cranial lung lobes is partly or completely prevented

68 Fig. 9.8 Structures in the thorax and cranial part of the abdomen of the dog seen from the left and from the right.

LA
Fig. 9.9 Diagram of the lung lobes and bronchial tree in dogs and cats
viewed in the ventrodorsal direction (LA = accessory lobe of the right
lung).
by the musculature of the front legs. In order to count
intercostal spaces as reference points, we begin in the
most caudal (twelfth) intercostal space. Keep in mind
that just behind the front leg the thorax is covered,
especially dorsally, by the serratus, scalenus, and
latissimus dorsi muscles.
On the right side the lung field is bordered caudally by
the liver, which lies against the diaphragm, while on the
left the stomach forms most of the caudal border. The
ventral part of the thorax is largely filled by the heart.
Nevertheless, the lungs on both sides reach nearly to
the sternum as very thin extensions of the cranial lobes
(Fig. 9.8). The left lung is divided into two lobes, the
cranial one being further divided into a cranial and a
caudal part. The right lung consists of four separate
lobes. As a result, the left and right bronchial branching
also differs markedly. In Figure 9.9 it can be seen that
the right main bronchus gives off three branches, while
on the left there is one large branch that further divides
into branches for the cranial and caudal parts of the
cranial lobe. The bronchus of the right middle lobe is
directed quite ventrally.9 This has the consequence
that, especially in mucopurulent bronchitis, mucopus
accumulates primarily in this lobe and can result in
complete obstruction of the bronchus.
Thoracic wall
This examination consists of evaluating the shape of the
thorax and looking for abnormalities.
Physical examination
The shape of the thorax varies markedly among different
breeds. Especially among racing and hunting dogs there are
breeds whose thorax is very deep dorsoventrally. When
these dogs lie on the sternum they easily develop pressure
sores. In other breeds the form of the thorax is much less
laterally compressed and especially in the English bulldog
the thorax is almost cylindrical or even dorsoventrally
flattened. Pups generally have a much more cylindrical
thorax than do adult dogs.
The examination for abnormalities of the thoracic
wall is, in this examination of the respiratory system,
only concerned with those related to respiration. Those
only affecting the skin are dealt with in Chapter 15.
Hence we are concerned here with subcutaneous or
deeper lesions that can be the cause or result of
abnormalities of the pleura or lungs.
Technique
Examination of the thoracic wall is carried out by
looking at the shape and symmetry of the thorax from
above and slightly to one side. Then the superficial
layer of the wall is palpated from behind, with one
hand on each side. Attention is given to the presence of
any difference in temperature, pain, and/or crepitation.
If a local abnormality is found, it is examined in more
detail (} 4.1.2). Next, the ribs and the strength of the
intercostal muscles are examined. The ictus cordis is
palpated on the right and the left, followed by deeper
palpation to detect any areas of pain or of crepitation.
Respiratory movements
See } 8.3.1.
Bronchi, lungs, and pleura
These structures are examined by auscultation and
percussion. Some fundamental aspects of these techniques
have been explained in Chapter 4.
Auscultation
The sounds heard by auscultation may be extrathoracic,
pleural, or bronchopulmonary in origin. Extrathoracic
sounds can be caused by such things as movement of
the stethoscope tube over the hair, or muscle trembling.
Pleural movements can also produce sounds. They
occur in pleuritis when there is little fluid production
(pleuritis sicca). This is called ‘pleural rubbing’ and
resembles the sound of walking on hard snow (‘snow
crunching’).10 However, it is seldom if ever heard in
dogs and cats, because in these species pleuritis is
usually exudative rather than fibrinous.
Bronchopulmonary sounds may be inaudible (no
sound), weaker than expected (weak respiratory sound),
of normal loudness and only during inspiration (normal
respiratory sound), or louder than expected and including
the beginning of expiration (enhanced respiratory sound).
Finally, the respiratory sounds may be similar to those 69
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RESPIRATORY SYSTEM

heard over the trachea, in which inspiration and expiration

are alike (bronchial respiration).
The movement of respiratory gasses is only audible if
there is some turbulence. The development of turbulence
is very much dependent on the diameter of the airway
and the speed of the air stream (see also } 4.1.4) and
therefore above all the respiratory frequency. In large
dogs with a normal respiratory frequency, turbulence is
present down to about the bifurcation of the trachea.
Peripheral to this the stream of the respiratory gasses is
laminar and thus no respiratory sound is produced.
The reason is that towards the periphery the total
diameter of the air passages continuously increases; the
velocity of the stream of the respiratory gasses is
therefore very slight. There are no indications that the
soft tissues of the peripheral airways or the alveoli are
able to produce vibrations of an audible frequency if
Fig. 9.10 These are the locations on a medium-sized dog (15–30 kg)
they are subject to gradual pressure changes.11 where one can hear normal respiratory sounds (n), bronchial
If the respiratory frequency increases then the limit of respiratory sounds (b), and heart sounds (h).
turbulence extends to the first branches of the main
bronchi. In smaller animals the usually somewhat higher
respiratory frequency and the small diameter of the
also be heard on the thoracic wall. One then hears
airways leads to respiratory sounds that under normal
respiratory sounds which are similar to the sounds that
conditions can be heard over a relatively large area. In
can be heard over the large air passages (trachea) and
contrast, in larger dogs with a relaxed respiration there
these are called bronchial respiratory sounds. We must
are often almost no audible respiratory sounds at the
remember that in smaller animals this type of
level of the caudal lobes.
respiratory sound is heard in the cranial part of the
The transmission of sound from the larger air passages
thorax even under normal conditions (Fig. 9.10).
to the thoracic wall is determined by the acoustic
During rapid respiration (including thermal
impedance (density of the material  speed of the
polypnea) the turbulence is so intensified and the
sound) of the intervening tissues. If the impedances are
borders of turbulence are extended so far peripherally
quite similar, as when an infiltrated lung lies against the
that respiratory sounds with a bronchial character are
thoracic wall, a large part of the sound is transmitted.12
heard far caudally. In lung disorders in which there is
When there is a large amount of gas-containing lung
active expiration as the result of obstruction of the
tissue between the source of the sound and the thoracic
peripheral bronchi or bronchioles, a very clear expiratory
wall, a large part of the sound is reflected back from the
sound is heard. In such an expiration the intrathoracic
pleural surface. When the lungs and thoracic wall are
pressure rises so much that the central bronchi and the
separated by gas or fluid in the pleural space, sound
trachea are narrowed enough to cause turbulence.
transmitted through the lung is reflected back when it
reaches the lung surface, with the result that no Under pathologic conditions other sounds can be heard
respiratory sound reaches the thoracic wall. in addition to the respiratory sounds. After many years
The respiratory sound is audible over the trachea of dispute10,13,14 about the terminology, two types of
throughout the respiratory cycle. It is also audible on rhonchi (rhonchus is Greek for snoring sound) are now
the cranial part of the thoracic wall, certainly in distinguished.11,14
smaller animals, but as one moves caudally along the Musical rhonchi. These are sounds with a peeping or
thoracic wall, the expiratory sound in particular wheezing character. They occur in patients with
becomes softer and sometimes falls away completely. obstructive lung diseases that result in active expiration.
This situation, in which a fairly constant respiratory They can sometimes be heard at a distance. Partly via the
sound is heard during inspiration but dies away during Venturi effect (} 4.1.4), the larger airways sometimes
expiration, is called the normal respiratory sound. become so narrowed that the opposing walls almost come
Inspiration is an active process and expiration is into contact. They begin to vibrate between the open
passive. During expiration the speed of the respiratory (inspiration) and almost closed (expiration) state and
gasses decreases such that peripherally there is no thus produce one musical tone. The tone is low if a large
longer a sound that is still audible on the thoracic wall. and soft mass is in vibration and high if the vibrating
As noted above, infiltration of the lung can lead to tissues are light and stiff. Such a ‘peep’ can sometimes
better transmission, such that expiratory sounds can occur during inspiration, if the bronchus is not adequately
70
 Physical examination

open during inspiration because of a persisting stenosis,

such as may be caused by a foreign body or tumor in the
bronchus.
Nonmusical rhonchi. These are short crackling
sounds (crepitation) at the end of inspiration,
sometimes continuing to the beginning of expiration.
They occur in areas that are not adequately filled with
respiratory gasses but are infiltrated with fluid. It was
for a long time supposed that these sounds were the
result of an excess of fluid in the airways. Now,
however, there are good grounds for assuming that
they are caused by the abrupt opening of previously
closed bronchioles.15 Because of the very rapid change
in the pressure, turbulence suddenly occurs in the
bronchioli. In addition, the explosive equalization of Fig. 9.11 Auscultation of the left side of the thorax. The auscultation
the gas pressure brings the adjacent walls of the air sites are shown by the dots.
passages into vibrations, which results in the sound.
The interstitial accumulation of fluid affects the not hard, one can avoid the disturbing sound of hair
elastic properties of the lung and causes the closure of scratching on its diaphragm.
bronchioles. This also explains why nonmusical In order to detect even small localized lesions, the
rhonchi sometimes recur directly after an episode of diaphragm or the cup of the stethoscope is placed on
heavy coughing, at exactly the same point in the at least five locations on each side. At two-thirds of the
respiratory cycle and with the same rhythm as before. height of the thorax the eighth, sixth, and fourth
A series of moist rhonchi can result from the opening intercostal spaces are auscultated, and at one-third of
of different bronchioles one after another and/or from the height the sixth and fourth intercostal spaces are
the opening of the same bronchioles time after time. used (Fig. 9.11).
It is possible that sputum in the larger bronchi can
cause such sounds, but it seems likely that narrowing For auscultation of the left side of the thorax it is best
also contributes. Narrowing of a large bronchus can be to stand at an angle on the left side behind the animal
the result of inadequate cartilaginous support16,17 or (Fig. 9.12) and hold the stethoscope with the left hand
the sagging inward of the membranous part of the against the thoracic wall. The right hand can help to
bronchus. At the beginning of inspiration the walls of hold the animal in position. To auscultate on the right
the bronchus remain slightly in contact (perhaps in side it is best to be positioned on the right side, holding
part via a little sputum) and then open up as the lung the animal with the left hand. At each auscultation site,
expands and the intrathoracic pressure decreases. the examiner should listen to at least two respiratory
In addition to muscle trembling, vocal sound can also cycles, concentrating fully on the inspiration and the
interfere with auscultation. Vocal sounds are weakened expiration in order to determine the type and intensity of
and filtered through the lung and thoracic wall, just the respiratory sound. In addition, a search is made for
like the respiratory sounds and other sounds. Low the occurrence of other sounds and if any are detected,
frequency sounds are especially well transmitted. the type, number and location are recorded.
Auscultation can also be hindered by groaning of the
patient. In cats, purring makes lung auscultation
completely impossible. Purring occurs via frequent
alternating activity of the diaphragm and the intrinsic
laryngeal muscles.18 A stridor in the upper airways can
also often be heard over the entire lung field and can
prevent auscultation of the lungs.
Borborygmi are not heard in the lung field under
normal conditions.

Technique
It is very important to perform auscultation in a quiet
room. The patient should be allowed to relax as much
Fig. 9.12 Lung auscultation in a dog. The researcher is positioned on
as possible, for muscle tension causes a quite disturbing the side of the auscultation sites and keeps contact with the animal with
humming sound. By pressing the stethoscope firmly but his other hand.
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Percussion in order to avoid differences between left and right in

In contrast with the percussion of an air-filled barrel,
percussion of the thorax only produces a slight resonance.
The vibrations are quickly deadened by the structures of
the thorax. The pitch and above all the intensity of the
sound are very much determined by the elasticity and
thickness of the thoracic wall. This explains the fairly
large variation in percussion tones obtained with different
shapes of thorax and from animals in different states of
nutritional condition. In animals with a thin thoracic wall
the percussion tone sounds definitely more hollow than it
does in animals with a thick thoracic wall. Nevertheless,
in the individual animal sounds of such differing tone
value can be produced that it is possible by percussion to:
– determine the borders of the lungs
– obtain an indication of whether the amount of gas
in the underlying structures is increased or
decreased
the tension of the thoracic musculature.
Both sides of the thorax are percussed along three vertical
and three horizontal lines (Fig. 9.14). First, the caudal
border of the lung field is determined on the basis of
three horizontal lines equally spaced over the thoracic
wall. In many animals these lines are found to be at (1)
the midpoint of the scapula, (2) the shoulder joint, and
(3) the midpoint of the humerus. It is advisable to begin
percussion on the right side, because there the caudal
border is usually clearly determined by the damping of
the sound by the liver. As noted earlier, the stomach is on
the left side and it often contains some gas, which can
make determination of the lung border difficult.

Technique
The examiner presses slightly against the standing
animal and bends over in such a way as to be able to
percuss on the other side (Fig. 9.13). Depending on the
size of the patient and the height of the examination
table, the animal may or may not be placed on the
table. It is not very satisfactory to attempt percussion
with the animal lying down, because the underlying
table will also resonate. However, the condition or the
type of animal (cat) may not allow a standing position
to be maintained and so percussion may have to be
performed with the animal lying on its sternum. The
animal is positioned in such a way that the entire Fig. 9.14 The percussion lines are shown with the caudal and ventral
spinal column as seen from above forms a straight line, limits of the lung field.

Fig. 9.13 Percussion of the wall of the thorax by a left-handed person using the finger-finger method and using the percussion hammer and
plessimeter.
72

For the vertical percussion lines the front leg is moved
forward so that the cranial part of the thorax is
covered somewhat less by the triceps muscle. In spite
of this, the percussion area in small animals is quite
small. Hence in the area cranial to the sixth intercostal
space, one to three lines are percussed, depending on
the size of the animal, to determine the ventral border
of the lung field (¼ absolute damping by the heart).
In a healthy animal a slightly dull (muscle) tone is heard
along the top horizontal line. Caudally the tone becomes
a hollow (lung) tone, which makes it possible to define
the border (tenth intercostal space) of the abdomen,
which produces a damped tone, especially on the right
side. During percussion along the middle horizontal
line a muscle tone is only heard directly behind the
triceps muscle. Caudal to this a full lung tone is
produced, which makes the caudal border (eighth
intercostal space) easy to define. Especially on the left
side, the relative damping of the sound by the heart
affects percussion along the lowest horizontal line,
where definition of the caudal border of the lungs
(sixth intercostal space) is already difficult because the
stomach does not give a clearly deadened tone.
Percussion along the vertical lines first produces a
muscle tone dorsally and then a full lung tone, which
gradually becomes damped in the lower half of the
thorax because of the relative damping by the heart.
Here the lungs are only a thin covering over the heart,
especially on the left. Depending on the size of the
patient, the lower border of the lung percussion field is
found to be 1.5 to 4.5 cm above the sternum, in the
form of the absolute damping by the heart. However,
Table 9.1 Overview of findings by inspection/palpation, auscultation, and percussion in some abnormalities of the lungs and
pleura (see also Chapters 4, 8, and 10). (This table is meant to stimulate thinking about the basis for the findings;
it is not meant to be memorized)
condition inspection/palpation
Liquothorax in Usually no abnormalities except forced
dogs bilateral; respiratory movements. Breathing is often
in cats pendulous.
sometimes
unilateral
Pneumothorax Trauma may have caused local lesions
usually (swelling, skin defect, subcutaneous
bilateral emphysema). Breathing is usually
pendulous.
Diaphragmatic Pendulous respiration. Change in location of
hernia often the ictus cordis: weak on the side of the
unilateral hernia and enhanced on the contralateral
side; it may also be shifted cranially.
Lung infiltrate As in liquothorax.
often unilateral
Notation
the absolute damping can lie a little higher in dogs
with a deep thorax than in those with a more rounded
thorax. During percussion one should pay attention to
possible reactions of the patient, such as coughing,
and/or pain reactions.
Some authors are of the opinion that percussion of
the thorax has little or no diagnostic value in dogs and
cats.19,20 This is primarily based on the argument that
most dogs and cats are too small for this purpose.20
Along with many others, we have the experience that
serious intrathoracic abnormalities (liquothorax,
pneumothorax, and diaphragmatic hernia) can be
characterized in dogs and cats by physical examination
(Table 9.1). In large dogs some examiners find it better
to use a percussion hammer and plessimeter (Fig. 9.13)
to generate a sound that can be interpreted. In small
dogs and in cats the thoracic wall is much thinner than
in large dogs, and usually the finger-finger method
produces an adequate percussion sound.
An overview of possible thoracic abnormalities that
can be found is presented in Table 9.1. The table lists
global characteristics that may be observed by physical
examination in some of the conditions of the lungs and
pleura.
9.3 Notation
The form on the DVD can be used to record findings in
a way that provides an overview. Drawings are included
on which to mark the results of auscultation and
percussion. Both the location of various sounds and the
borders of the lung percussion field can be shown on
the drawings.
auscultation percussion
Very few or no respiratory sounds ventrally The percussion sound is dampened
in thorax. Heart sounds can also be ventral to the (horizontal) fluid
dampened. Usually enhanced respiratory surface. Above it the resonance is
sounds dorsal to the (horizontal) fluid line. normal or increased.
Respiratory sounds weak or inaudible Increased resonance, especially
despite forced respiratory movements. dorsally. Enlargement of the
Heart sounds are audible and unaffected. percussion field caudally but caudal
limits are difficult to identify.
Heart and lung sounds decreased on the Decreased resonance on the side of
side where intestines are located and the hernia, but if a gas-filled stomach
enhanced on the contralateral side. is herniated into the thorax, the
resonance can be increased.
Enhanced respiratory sounds (bronchial Decreased resonance in the affected
respiratory sounds) in the area where the area.
infiltrate reaches the thoracic wall. If the
bronchus is closed, the lung sounds are
weak.
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RESPIRATORY SYSTEM
9.4 Further examination
If further examination of the respiratory system is
necessary, there are several possibilities, at progressively
higher levels of practice:
– white blood cell count and differential
– radiographic examination, aspiration from the
thorax, bacteriologic examination, rhinoscopy
with otoscope, laryngoscopy
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