Respiratory System Examination

• Presented By –
Prof.Dr.R.R.Deshpande
(M.D in Ayurvdic
Medicine & M.D. in
Ayurvedic Physiology)
• www.ayurvedicfriend.c
om
• Mobile – 922 68 10 630
• professordeshpande@g
mail.com
9/18/2016 Prof.Dr.R.R.Deshpande 1
 Respiratory System Examination
• Respiratory system problems are very
common on medical pracrice
• Examples are Rhinitis, Pharyngitis, Tonsillitis,
Laryngitis, Bronchitis, Pneumonia, Bronchial
Asthama ,Bronchieactasis ,Emphysema,
Tuberculosis
• In India Tuberculosis is very common in India

9/18/2016 Prof.Dr.R.R.Deshpande 2
 Respiratory System Exam – By
Prof.Dr.R.R.Deshpande

9/18/2016 Prof.Dr.R.R.Deshpande 3
 Respiratory System Examination
• This examination is better to be done in sitting
position
• Examination of back side of chest is equally
important
• Many respiratory diseases occur on back side
• Examination is divided into 2 parts
• 1) Upper Respiratory system Examination
• 2) Lower Respiratory system Examination
9/18/2016 Prof.Dr.R.R.Deshpande 4
 Examination of
Upper Respiratory Tract
• 1) Nose

• 2) Oral cavity

• 3) Throat

• 4) Larynx

9/18/2016 Prof.Dr.R.R.Deshpande 5
 Examination of chest
• 1) Inspection

• 2) Palpation

• 3) Percussion

• 4) Auscultation

9/18/2016 Prof.Dr.R.R.Deshpande 6
 Examination of upper Respiratory Tract

• 1) Examination of two nostrils by torch light &

lifting tip of nose
• See the Nasal septum ( DNS = Deviated Nasal
Septum)
• Look for mucous membrane ,any discharge (
watery, mucoid, muco purulent )
• Discharge – white, yellow ,green ( yellow or
green discharge suggests infection & may
need Antibiotics) ,any blood
9/18/2016 Prof.Dr.R.R.Deshpande 7
Examination of Upper respiratory Tract

9/18/2016 Prof.Dr.R.R.Deshpande 8
 Examination of Nose with Torch

9/18/2016 Prof.Dr.R.R.Deshpande 9
 Examination of upper Respiratory Tract

• 2) Oral cavity & Pharynx –

• Ask the patient to open the mouth & say ‘Aaa’
• Examine ,Tongue,Teeth, Gums, Cheek,
Pharyngeal wall ,Tonsillar fossae ,position of
Uvula, Pharyngeal arches
• Look for redness, secretions ,any patch present
on this mucous membrane
• Look for Leucoplakia ( pre malignancy condition)
• Look for whitish patches of Diptheria

9/18/2016 Prof.Dr.R.R.Deshpande 10
Examination of oral cavity by Torch

9/18/2016 Prof.Dr.R.R.Deshpande 11
 Examination of upper Respiratory Tract

• 3) Examination of Larynx by 2 ways

• Direct Laryngoscopy

• Indirect Laryngoscopy

9/18/2016 Prof.Dr.R.R.Deshpande 12
 Examination of Chest
• Sitting position

• Hands on waist

9/18/2016 Prof.Dr.R.R.Deshpande 13
 Inspection of chest
• 1) Size & Shape – Symmetrical
• 2) Type or act of Respiration –Abdominal
,Thoracic
• 3) Count RR
• 4) Check Chest Expansion with deep breathing
• 5) Position of Trachea
• 6) Look Apex Beat
• 7) Note Accessory Muscles
9/18/2016 Prof.Dr.R.R.Deshpande 14
 Inspection of chest
• 1) Size & shape
• Symmetrical or asymmetrical
• Convexity on both side
• Transverse diameter > AP diameter
• Barrel shaped Chest – TD = AP diameter (
Emphysema)
• Pigeon Chest – TD < AP diameter ( Bronchial
Asthama ,COPD)

9/18/2016 Prof.Dr.R.R.Deshpande 15
 Look for symmetry of chest

9/18/2016 Prof.Dr.R.R.Deshpande 16
 Abnormal Chest
Barrel Chest Pigeon Ches

9/18/2016 Prof.Dr.R.R.Deshpande 17
 Type or Act of Respiration
• 2) Type or Act of Respiration –

• Abdominal or Thoracic
• If abdominal protrudes forward during
inspiration & going back in expiration – This is
abdominal breathing & seen in males

9/18/2016 Prof.Dr.R.R.Deshpande 18
 In males – Look for
Abdominal Respiration

9/18/2016 Prof.Dr.R.R.Deshpande 19
 Inspection of chest
• 3) Count RR by seeing the movement of
abdomen for 1 min

• Normal RR = 14 to 18 per min

9/18/2016 Prof.Dr.R.R.Deshpande 20
 Count Respiratory rate

9/18/2016 Prof.Dr.R.R.Deshpande 21
 Inspection of chest
• 4) To check the chest expansion –
• Ask the patient to do deep inspiration &
expiration
• There should be equal expansion on both
sides.This means equal quantity of air is going
in both the lungs
• Observe the movement from back .Observe
the movement of scapulae on both sides

9/18/2016 Prof.Dr.R.R.Deshpande 22
 Look for symmetrical Expansion of Scapulae

9/18/2016 Prof.Dr.R.R.Deshpande 23
 Inspection of chest
• 5) Position of Trachea
• Observe the head of sternomastoid muscle
• It should be equally prominent on both sides,
which indicates that Trachea is in central
• In different diseases Trachea can be pulled on
one side or push on other side
• 6) Look for Apex beat – 5th left Intercostal
space ,in mid clavicular line
9/18/2016 Prof.Dr.R.R.Deshpande 24
 Position of Trachea – Look heads of
Sternomastoid muscle

9/18/2016 Prof.Dr.R.R.Deshpande 25
 Look for Apex beat

9/18/2016 Prof.Dr.R.R.Deshpande 26
 Inspection of chest
• 7) Note Accessory muscles ,
• if any are dominant or vigorously acting like
• Alai Nasi in Pneumonia in children or
• Sternocleidomastoid in severe attack of
Bronchial Asthama
• Normally accessory muscles are not prominent

9/18/2016 Prof.Dr.R.R.Deshpande 27
 Look for movements of Alai nasi

9/18/2016 Prof.Dr.R.R.Deshpande 28
 Look for movements of
Accessory muscles of Respiration

9/18/2016 Prof.Dr.R.R.Deshpande 29
 Palpation of chest
• 1) Measurement of Chest ( Card board & Tape)
• 2) Expansion by Circumference ( By Tape ,at
nipple level)
• 3) Palpation of Chest Expansion ( Thumb
movement)
• 4) Position of Trachea
• 5) TVF ( Tactile Vocal Fremitus)

9/18/2016 Prof.Dr.R.R.Deshpande 30
 Palpation of chest
• Palpation – feeling with palm
• 1) Measurement of chest with Tape & card
boards – Transverse & Antero posterior diameter
• 2) Expansion is measured in form of
circumference of chest with tape at nipple level –
during expiration & then after deep inspiration
• Chest expansion is expected about 5 cm after
deep inspiration

9/18/2016 Prof.Dr.R.R.Deshpande 31
 Measuring Antero posterior Diameter of Chest

9/18/2016 Prof.Dr.R.R.Deshpande 32
 Measuring Antero posterior Diameter of Chest

9/18/2016 Prof.Dr.R.R.Deshpande 33
 Measuring Transverse Diameter of chest

9/18/2016 Prof.Dr.R.R.Deshpande 34
 Measuring circumference of chest
after deep Inspiration

9/18/2016 Prof.Dr.R.R.Deshpande 35
 Palpation of chest
• 3) Palpation of respiratory movements or
chest expansion

• 1) From front
• 2) Then from Back
• 3) & also Apices of Lungs

9/18/2016 Prof.Dr.R.R.Deshpande 36
 Palpation of respiratory movements
• 3 a ) Keep your palms ,at nipple level & ask subject to
do deep inspiration & expiration .
• Ask the patient ,to turn his face laterally ( To avoid
droplet contamination to doctor)
• Thumbs are moving away on both sides equally ,it
means expansion of chest is equal on both sides ,it
means equal quantity of air is going on both sides
• 3 b ) Now ask the patient to turn on back side .Keep
hands at mid scapular region .Here also thumb should
move equal distance on both sides
• This suggests that Air Entry is bilaterally equal(AEBE)
9/18/2016 Prof.Dr.R.R.Deshpande 37
Chest Expansion – Equal on both sides

9/18/2016 Prof.Dr.R.R.Deshpande 38
Chest expansion equal on both sides –
from posterior side

9/18/2016 Prof.Dr.R.R.Deshpande 39
 Palpation of respiratory movements
• 3 c) Examination at apices is also important because -
• TB mainly occurs at Apex of lungs
• For examination of Apex keep 4 fingers on shoulder
& thumb in mid portion of scapulae
• Ask the patient to do deep inspiration & Expiration
• Upward movement of forefingers or shoulder will
be equal on both sides ,which can be felt by fingers
• This is Palpation of chest for respiratory movements

9/18/2016 Prof.Dr.R.R.Deshpande 40
 Chest expansion –equal at Apex

9/18/2016 Prof.Dr.R.R.Deshpande 41
 Confirm Position of Trachea
by Palpation
• 4) Position of Trachea –
• Put Index & middle fingers ,above the
manubrium sternum & in between
sternomastoid muscle

• If depth for finger is equal on both sides then

Trachea is in center or middle

9/18/2016 Prof.Dr.R.R.Deshpande 42
 Trachea is in central –
confirmed by palpation

9/18/2016 Prof.Dr.R.R.Deshpande 43
 TVF ( Tactile Vocal Fremitus) –
Physics Principle
• 5) TVF –Tactile Vocal Fremitus
• Sound waves travel faster & louder in solid medium as
compare to fluid or air medium
• Subject is asked to say 1-1-1 or 9-9-9
• These words are having nasal twang ,so better
appreciated for sound waves
• With ulnar border of palm ,we palpate chest for
vibration
• In solid medium – TVF is increased
• In Air or Liquid medium – TVF is decreased or reduced

9/18/2016 Prof.Dr.R.R.Deshpande 44
 Tactile Vocal Fremitus – Say 9-9-9

9/18/2016 Prof.Dr.R.R.Deshpande 45
 TVF
• TVF is examined at supra mammary ,mammary & Infra
mammary region
• Asking the patient to take hands on head ,TVF is
examined in Infra axillary region
• Ask the patient to turn back & keep the hands on
shoulder & keeping neck down .So that scapulae
spread apart
• Palpate at supra scapular, Inter scapular & Infra
scapular
• In consolidation – TVF increases
• In Pleurisy & Pneumothorax – TVF decreases

9/18/2016 Prof.Dr.R.R.Deshpande 46
 Tactitile Vocal Fremitus in Axillary
area

9/18/2016 Prof.Dr.R.R.Deshpande 47
 Tactile Vocal Fremitus –
Back side of chest

9/18/2016 Prof.Dr.R.R.Deshpande 48
 Percussion of chest
• 1) From front ,back, infra axillary area

• 2) Identical intercostal space is percussed on

left & right side & percussion note is
compared

• 3) Normally all over chest ,resonant note is

obtained ,except the area of cardiac dullness
9/18/2016 Prof.Dr.R.R.Deshpande 49
 Percussion of chest

9/18/2016 Prof.Dr.R.R.Deshpande 50
Percussion of chest in Axillary area

9/18/2016 Prof.Dr.R.R.Deshpande 51
 Percussion of chest
from back side of chest

9/18/2016 Prof.Dr.R.R.Deshpande 52
 Auscultation of chest
• 1) From front,back & infra axilary area
• 2) Identical intercostal space is Auscultated on
left & right side & findings are compared
• 3) Air Entry ( Quantity check)
• 4) Type of Breathing ( Quality check)
• 5) Adventitious sounds
• 6) Vocal Resonance ( VC)

9/18/2016 Prof.Dr.R.R.Deshpande 53
 Auscultation of Chest

9/18/2016 Prof.Dr.R.R.Deshpande 54
 Auscultation of chest
• Ask the patient to do deep breathing & put the
stethascope on intercostal spaces
• 1) If Intensity of sound is same on both sides ,it
indicates equal air entry on both sides (AEBE = Air
Entry Bilaterally equal ) – Mammary, Axillary
• Supra scapular ,Inter scapular & Infra scapular

• 2) By Type of breathing ,we check quality of sound

9/18/2016 Prof.Dr.R.R.Deshpande 55
 Difference in ---
• In Air Entry we compare –Intensity of sounds
on both the sides

• In Type of Breathing ,we concentrate on

Quality of sound ,that we are hearing

9/18/2016 Prof.Dr.R.R.Deshpande 56
 Auscultation in Axillary area

9/18/2016 Prof.Dr.R.R.Deshpande 57
 Type of breathing
• a) Vesicular breathing – Rustling of leaves (
Distension & collapse of alveoli make vesicular
sound) Vesicular breathing indicates air is entering in
thousands of alveoli. They are expanding & collapsing
during expiration
• b) Bronchial breathing --- heard on Trachea .It is like
blowing of air through pipe
• 3) If vesicular breathing is replaced by bronchial
breathing ,indicates that part of lung is not
functioning normally like in Pneumonia
9/18/2016 Prof.Dr.R.R.Deshpande 58
 Adventitious sounds
• 3) Adventitious sounds

• a) Whistling sounds –Rhonchi – heard in

Bronchial Asthama ,Bronchitis

• b) Bubbling sound or Crepitus – heard in

Pneumonia ,Pulmonary oedema ,CCF

9/18/2016 Prof.Dr.R.R.Deshpande 59
 Auscultation on back side of chest

9/18/2016 Prof.Dr.R.R.Deshpande 60
 Vocal Resonance
• 4) VR = Vocal Resonance

• 1) Principle is similar to as TVF

• Sound waves travel faster & louder in solid
medium as compare to fluid or air medium
• Ask the patient to say 9 – 9 – 9 & Auscultate
chest on intercostal space on both sides

9/18/2016 Prof.Dr.R.R.Deshpande 61
 Investigations
• All these clinical findings are corelated with
Investigations like
• 1) X ray chest PA view
• 2) Sputum Examination for AFB
• 3) Bronchoscopy
• 4) Lung Function Tests by Spirometry

9/18/2016 Prof.Dr.R.R.Deshpande 62
 Please see also Videos
• Copy ,Paste Link as URL
• Examination of Respiratory System – Part 1 --
By Prof.Dr.R.R.deshpande –
• https://youtu.be/iYitUoIxTIA
• Examination of Respiratory System – Part 2 --
By Prof.Dr.R.R.deshpande –
• https://youtu.be/liKgZjqtnY0

9/18/2016 Prof.Dr.R.R.Deshpande 63
 Prof.Dr.R.R.Deshpande
• Sharing of Knowledge

• FOR

• Propagating Ayurved

9/18/2016 Prof.Dr.R.R.Deshpande 64