Physical Examination in

Respiratory System

Dr. Zheng Jinxu

Affiliated Hospital
of Jiangsu University
Physical examination

Physical examination is a
fundamental examining method, it
is proceeded by the sense organs
such as eyes, ears, nose and
hands or simple tools –
stethoscope.
The basic methods of
physical examination

1 inspection
2 palpation
3 percussion
4 auscultation
 Physical Exam Steps
§ General examination
§ Mediastinal position
§ Chest expansion
§ Lung resonance
§ Breath sounds
§ Adventitious sounds
§ Voice transmission
 General Examination
§ Respiratory rate
§ Pattern of breathing
§ Cyanosis
§ Clubbing
§ Weight
§ Cough
§ Hospital setting
§ Effort of ventilation
§ Shape of thorax
 Inspection
1. General
Ø barrel, pigeon, rib recession, clubbing.
2. Respiratory movement
Ø Abdominal breathing: male adult and child
Ø Thoracic breathing: female adult
Ø paroxysmal breathing,etc.
3. Respiratory rate: 16-18 f/min
Ø Tachypnea: >20 f/min
Ø Bradypnea: <12 f/min
Ø Shallow and fast
¡ respiratory muscular paralysis, elevated
intraabdominal pressure, pneumonia, pleurisy
Ø Deep and fast
¡ Agitation, intension
Ø Deep and slow
¡ Severe metabolic acidosis (Kussmaul’s breathing)
 Inspection
4. Respiratory rhythm
§ Cheyne-Stokes’ breathing
§ Biot’s breathing
Decreased excitability of respiratory center
§ Inhibited breathing
Ø Sudden cessation of breathing due to chest pain
¡ Pleurisy, thoracic trauma
§ Sighing breathing
Ø Depression, intension
Clubbing
§ In clubbing, there is widening of the lateral
diameter of terminal portion of fingers and toes
giving the appearance of clubbing.
§ The angle between the nail and skin is greater
than 180.

§ The periungual skin is stretched and shiny.

Clubbing fingers
 Palpation
§ Thoracic expansion
Ø Anterior, Posterior and Axillae
Ø Massive hydrothorax,
pneumonia, pleural thickening,
atelectasis
§ Pleural friction fremitus
Ø Cellulose exudation in pleura
due to pleurisy
Ø Tuberculous pleurisy, uremia,
pulmo embolism
Lymph nodes
Ø cervical chain, post auricular, axillae
Vocal fremitus (tactil fremitus)
Ø *Vocal resonance “99” – stethoscope
Ø *Vocal Fremitus “99” – hands
Ø - Ask the patient to whisper "ninety-nine" several times,
Ø Increased fremitus indicates fluid in the lung (pneumonia).
Ø Decreased fremitus indicates sound transmission obstructed by
chronic obstructive pulmonary disease (COPD), fluid outside the
lung (pleural effusion), air outside the lung (pneumothorax), etc.
Percussion
 Method

§ In-direct or mediate percussion

§ Direct or immediate percussion

 Method
§ In-direct or mediate
percussion
the palmar surface of the
left long finger is firmly
pressed onto the body
surface, as a pleximeter,
only the distal phalanx
should touch the wall. as a
plexor, the tip of the right
long finger strikes a sharp
blow on the distal
interphalangeal joint of
the pleximeter finger
 Method
§ Direct percussion
when you elicit sound by striking the body
surface directly with your fingers, hand, or
reflex hammer, the procedure is called
direct or immediate percussion
PERCUSSION
2. 注意事项 ON CHEST -- anterior
3. 叩诊的体位及顺序
PERCUSSION ON CHEST -- posterior
 Classification
Ø Resonance
¡ Normal
Ø Hyperresonance
¡ Emphysema
Ø Tympany
¡ Cavity or pneumothorax
Ø Dullness
¡ Hydrothorax, atelectasis
Ø Flatness
¡ Massive Hydrothorax
 Normal sound

§ Lung’s sound in percussion

§ Resonance
§ Slight dullness in some areas (upper,
right, back) due to thickness of muscles
and skeletons
 Abnormal sound
§ Hyperresonance
Ø Emphysema
§ Tympany
Ø Pneumothorax
Ø Large cavity (TB, lung abscess, lung cyst)
§ Amphorophony (空瓮音)
Ø Large and shallow cavity with smooth wall
Ø Tension pneumothorax
 Abnormal sound
§ Tympanitic dullness
Ø Decreased tension and gas in alveoli
¡ Atelectasis
¡ Congestive or resolution stage of
pneumonia
¡ Pulmo. edema
 Abnormal sound
Dullness or flatness
§ Decreased containing gas in alveoli
Ø Pneumonia
Ø Atelectasis?
Ø TB
Ø Pulmo. embolism
Ø Pulmo. edema
Ø Pulmo. fibrosis
§ No gas in alveoli
Ø Tumor
Ø Pulmo. Hydatid (肺包虫)
Ø Pneumocystis (肺囊虫)
Ø Non-liquefied lung abscess
§ Others
Ø Hydrothorax
Ø Pleural thickness
 content
§ Definitive percussion of the chest

§ Abnormal percussion notes

Definitive percussion of the chest
§ In the examination of the thorax,definitive
percussion is employed to outliness of the
heart,the spleen,the upper border of the
liver,and the lumbar muscles below the lung
bases.
 Percussion of the lung apices
§ The patient must be sitting or standing

§ The apices of the lungs normally extend

slightly above the clavicles, producing a
band of resonance over each shoulder

§ The narrowest part, termed the kronig

isthmus, lies on the shoulder top
 Percussion of the lung apices
§ width:4-6cm
kronig isthmus
narrow：
Pulmonary tuberculosis
flatness
Pulmonary fibrosis
wider ：
pulmonary emphysema

Shifting
range

kronig isthmus
Percussion of the anterior lungs
§ If the patient is in the supine position, the
patient’s arms should be slight abducted

§ If the patient is in the sitting or standing

position, the patient’s arms should rest on
his hips
Percussion of the anterior lungs
§ Starting under the
clavicles, compare the
percussion sound from
each interspace
sequentially with that
from the contralateral rib dullness

region. work
downward to the flatness Traube
region of hepatic semilunar
space
dullness on the right
and the traube Percussion of the anterior lungs
semilunar space on the
left
Percussion of the anterior lungs
§ The entire anterior region should be resonant,
except for the area of cardiac dullness
Dullness in anterior region enlarge:
cardiac dilatation
pericardial effusion
aortic aneurysm
pulmonary hilar lymph node enlarged
Dullness in anterior region narrow:
pulmonary emphysema
Percussion of the posterior lung
§ The patient is in the sitting or standing
position. the patient’s arms are folded in
front and requested to pull his shoulders
forward (hump the shoulders), with the
spine slightly anteflexed
Percussion of the posterior lung
§ Percussion of each hemithorax is begun at
the top, working downward to compare
symmetrical regions sequentially. the zone
of resonance ends inferiorly at about the
9th to 10th rib.
(10th)
Percussion of the posterior lung bases

§ During quiet respiration, the inferior lung

edges are at about the 9th rib on the left and
the 8th interspace on the right
§ After the lung bases have been located
during quiet respiration, mark the level,
and have the patient inspire deeply and
hold his breathwhile you percuss the level
after descent 6-8cm
 Shifting range of bottom of lung
Along the scapular line

s marking
Percussing bottom of lung,
Shifting range of
bottom of lung
Asking the pat. to inspire deeply and hold

6-8 cm
Percussing bottom of lung, marking

Asking the pat. to expire deeply and hold

n Decreased: emphysema, atelactasis,
fibrosis, pulmo. edema, pneumonia
Percussing bottom of lung, marking
n Detected impossibly: pleura adhesion,
massive hydrothorax, pneumothorax,
Measuring the dist. between upper and lower lines diaphragmatic paralysis
 Border of lungs in percussion
§ Apex of lungs
Ø Kronig’s isthmus: 5cm in width

§ Anterior border
Ø absolute cardiac dullness area

§ Lower border
Ø 6th, 8th, 10th intercostal space in midclavicular
line, midaxillary line, scapular line,
respectively
Abnormal percussion notes
 Abnormal distribution
§ Dullness replacing resonance in the upper
lung
Neoplasm
Atelectasis
Consolidation of the lung
 Abnormal distribution
§ Dullness replacing resonance in the lower
lung
Neoplasm
Atelectasis
Consolidation of the lung
pleural effusion
pleural thickening
elevation of the diaphragm
 Abnormal distribution
§ Flatness replacing resonance or dullness

massive pleural effusion

 Abnormal distribution
§ Hyperresonance replacing resonance or
dullness
pulmonary emphysema
pneumothorax
 Abnormal distribution
§ tympany replacing resonance

large pneumothorax
Auscultation
 Auscultation
§ Requires a stethoscope
Ø Used to assess body sounds produced by the
movement of various fluids or gases in the
patient's organs or tissues
§ Note characteristics of:
Ø Intensity
Ø Pitch
Ø Duration
Ø Quality
 Auscultation
position:
sequence ：
(1) start from apices of lung，then work
downward
(2) anterior lateral posterior
(3) compare symmetrical points sequentially
 Stethoscope

§ Used to evaluate sounds created by the

cardiovascular, respiratory, and
gastrointestinal systems
 Stethoscope
§ Position of
stethoscope
between index and
middle fingers

Figure 13-3
 Auscultation
§ 12 anterior locations
§ 14 posterior locations
§ Auscultate symmetrically
§ Should listen to at least 6 locations
anteriorly and posteriorly
Order of auscultation
 Sound of auscultation

1. Normal breath sound

2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance
5. Pleural friction rub
 Breath Sounds
§ Normal § Adventitious
Ø Tracheal Ø Crackles (Rales)
Ø Bronchial Ø Wheeze
Ø Bronchovesicular Ø Rhonchi
Ø Vesicular Ø Stridor
§ Abnormal Ø Pleural Rub
Ø Absent/Decreased
Ø Bronchial
 Normal Breath Sounds
§ Created by turbulent air flow
§ Inspiration
Ø Air moves to smaller airways hitting walls
Ø More turbulence, Increased sound
§ Expiration
Ø Air moves toward larger airways
Ø Less turbulence, Decreased sound
§ Normal breath sounds
Ø Loudest during inspiration, softest during
expiration
 Normal Breath Sounds
§ Tracheal
Ø Very loud, high pitched sound
Ø Inspiratory = Expiratory sound duration
Ø Heard over trachea
 Normal Breath Sounds
§ Bronchial
Ø Loud, high pitched sound
Ø Expiratory sounds > Inspiratory sounds
Ø Heard over manubrium of sternum
Ø If heard in any other location suggestive of
consolidation
 Normal Breath Sounds
§ Bronchovesicular
Ø Intermediate intensity, intermediate pitch
Ø Inspiratory = Expiratory sound duration
Ø Heard best 1st and 2nd anteriorly, and between
scapula posteriorly
Ø If heard in any other location suggestive of
consolidation
 Normal Breath Sounds
§ Vesicular
Ø Soft, low pitched sound
Ø Inspiratory > Expiratory sounds
Ø Major normal BS, heard over most of lungs
 Normal breath sound
§ Tracheal breath sound Bronchial
§ Bronchial breath sound
Ø Larynx, suprasternal fossa,
around 6th, 7th cervical vertebra, Bronchovesicular
1st, 2nd thoracic vertebra
§ Bronchovesicular breath sound
Ø 1st, 2nd intercostal space beside
of sternum, the level of 3rd, 4th
thoracic vertebra in interscaplar
area, apex of lung Bronchial
§ Vesicular breath sound
Ø Most area of lungs
Bronchovesicular
Abnormal breath sounds
 Abnormal breath sound

§ Abnormal vesicular breath sound

§ Abnormal bronchial breath sound

§ Abnormal bronchovesicular breath sound

Abnormal vesicular breath sound

1) Decreased or disappeared
¡ ?Movement of thoracic wall
¡ Respiratory muscle weakness
¡ Obstruction of airway
¡ Hydrothorax or pneumothorax
¡ Abdominal diseases: ascites（腹水）, large tumor
2) Increased
¡ Movement of respiration
Abnormal vesicular breath sound
3) Prolonged expiration
¡ Bronchitis
¡ Asthma
¡ emphysema
4) Cogwheel breath sound
¡ TB
¡ Pneumonia
5) Coarse breath sound
¡ Early stage of bronchitis or pneumonia
Abnormal bronchial breath sound
(tubular breath sound)

§ Bronchial breath sound appears in supposed

vesicular breath sound area
¡ Consolidation: lobar pneumonia (consolidation
stage)
¡ Large cavity: TB, lung abscess

¡ Compressed atelectasis: hydrothorax,

pneumothorax
 Abnormal bronchovesicular
breath sound
§ Bronchovesicular breath sound appears in
supposed vesicular breath sound area

Ø The lesion is relatively smaller or mixed with

normal lung tissue
Causes of decreased or absent breath
sounds
§ Asthma
§ COPD
§ Pleural Effusion
§ Pneumothorax
§ ARDS
§ Atelectasis
Asthmatic or obstructive breathing

§ In asthma, the expiratory phase is several

times longer than in bronchial breathing,
and the pitch is much higher
 Amphoric breathing
§ Amphoric breathing is produced by a large
empty superficial cavity that communicates
with a bronchus or an open pneumothorax

§ When the pitch is relatively low and the

sound hollow, it is called cavernous
breathing
 Metamorphosing breathing
§ The breath sounds suddenly change in
intensity in different parts of the cycle. this
is usually caused by movement of a loose
bronchial plug.
 Adventitious sound

§ Crackles (moist rales or bubble sound)

§ wheeze

§ Rhonchi (dryrale)

§ Pleural friction rub

§ bruit
 Adventitious Breath Sounds
§ Crackles (Rales)
Ø Discontinuous, intermittent, nonmusical, brief sounds
Ø Heard more commonly with inspiration
Ø Classified as fine, medium, coarse rales or crepitus
Ø Normal at anterior lung bases
¡ Maximal expiration
¡ Prolonged recumbency
Ø Crackles caused by air moving through secretions and
collapsed alveoli
Ø Associated conditions
¡ pulmonary edema, early CHF, Pneumonia
Mech. of Moist Rales

bubble sounds crackles

coars
e

mediu
m

fine

crepi
ti
 Adventitious Breath Sounds
§ Wheeze
Ø Continuous, high pitched, musical sound,
longer than crackles
Ø Hissing quality, heard with expiration,
however, can be heard on inspiration
Ø Produced when air flows through narrowed
airways
Ø Associated conditions
¡ asthma, COPD
 Adventitious Breath Sounds
§ Rhonchi
Ø Similar to wheezes
Ø Low pitched, snoring quality, continuous,
musical sounds
Ø Implies obstruction of larger airways by
secretions
Ø Associated condition
¡ acute bronchitis
Mech. of Rhonchi
sonorou
s

sibilant
 Adventitious Breath Sounds
§ Stridor
Ø Inspiratory musical wheeze
Ø Loudest over trachea
Ø Suggests obstructed trachea or larynx
Ø Medical emergency requiring immediate
attention
Ø Associated condition
¡ inhaled foreign body
 Adventitious Breath Sounds
§ Pleural Rub
Ø Discontinuous or continuous brushing sounds
Ø Heard during both inspiratory and expiratory
phases
Ø Occurs when pleural surfaces are inflamed and
rub against each other
Ø Associated conditions
¡ pleural effusion, pneumothorax
Auscultation of voice sound
 Voice sound (vocal resonance)
§ METHOD: Ask the patient to say “Ninety-
nine”, should normally be muffled, In the
normal lungs, sounds are faint and their
syllables are not distinct, except over the
main bronchi
 Voice sound
§ Clinical significance:
Increases in loudness and distinctness
consolidation
atelectasis
fibrosis
Decreases in loudness or absent
pleural effusion
pulmonary emphysema
Thank you
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