RESPIRATORY SYSTEM

EXAMINATION
DR AXELLE SAVERETTIAR
 Position of subject
The respiratory system examination is ideally done with the
subject comfortably resting on the bed, sitting at an angle
of 45˚ and supported by pillows.
 RESPIRATORY SYSTEM
EXAMINATION

1.Inspection 2. Palpation 3. Percussion 4. Auscultation

1.INSPECTION I. SHAPE OF THE CHEST

II. MOVEMENTS OF THE CHEST

a. Rate of respiration
b. Depth of respiration
c. Rhythm of respiration
d. Expansion of chest
e. Type of respiration
 1. INSPECTION

I. SHAPE OF THE CHEST

Bilaterally symmetrical
and elliptical in cross
section.

Anteroposterior diameter
is less than the transverse
diameter in a ratio of 5:7.
 Abnormal forms of chest
A. PIGEON CHEST

Chest is elliptical with

prominent sternum.
Seen in rickets.
 Abnormal forms of chest

B. SCOLIOSIS
It is the lateral bending
of the vertebral column.
Prominence of front of
the chest on one side
with flattening on the
other side.
 Abnormal forms of chest

C. KYPHOSIS

It is the forward bending

of the vertebral column
Shortening of the chest
with prominent sternum.
 Abnormal forms of chest

D. BARREL SHAPE CHEST

AP diameter of chest
increases.
It is seen in:
Emphysema
Bronchial asthma
Fibrosis
Collapse of lungs
 1. INSPECTION
II. MOVEMENTS OF THE CHEST
a. Rate of respiration
• Normal rate is 12 – 16 breaths per minute
 1. INSPECTION
II. MOVEMENTS OF THE CHEST

Increased Decreased
respiratory rate respiratory rate
(tachypnea) (bradypnea)
• Exercise • Brain damage
• Fever
• Anemia
 1. INSPECTION

II. MOVEMENTS OF THE

CHEST
b. Depth of respiration
• Deep breathing – brain
damage
• Shallow breathing –
bronchial asthma
 1. INSPECTION
II. MOVEMENTS OF THE CHEST
c. Rhythm of respiration
• The normal respiration has regular rhythm with inspiration
longer than expiration.
 1. INSPECTION
II. MOVEMENTS OF THE CHEST
d. Expansion of chest
• Normally both sides of the chest wall move symmetrically
(equal on both sides)

Diminished or asymmetrical movements:

• Consolidation
• Collapse
• Fibrosis
• Pleural effusion
• Hydro pneumothorax
 1. INSPECTION
II. MOVEMENTS OF THE CHEST
e. Type of respiration
• Normal – Abdominal
2. PALPATION I. POSTION OF TRACHEA

II. POSITION OF APEX BEAT

III. EXPANSION OF CHEST

IV. VOCAL FREMITUS

 2. PALPATION
I. POSITION OF TRACHEA
• Normal position of trachea is central
 2. PALPATION
Trachea pulled towards the Trachea pushed away from affected
affected side side
• Collapse • Pleural effusion
• Fibrosis of lung • Pneumothorax
 2. PALPATION
II. POSITION OF APEX BEAT
Normal position - 9 cm from midline in the left 5th intercostal
space.
 2. PALPATION
• II. POSITION OF APEX BEAT

• Cardiac impulse refers to movements occurring due to the

impact of the heart against the chest wall during the
systole.
• The apex beat is the lowest and outermost point of
definite cardiac impulse, where it is seen / felt most
forcibly (point of maximum impulse).
 2. PALPATION
Absent apex Prominent apex Displaced apex
beat beat beat

• Obesity • Anxiety • Enlargement of

• If lying behind a • After exercise left ventricle
rib • Pleural or
• Dextrocardia pulmonary
diseases
• Deformities of
the chest wall
or the thoracic
vertebrae –
scoliosis
 2. PALPATION

III. EXPANSION OF THE CHEST

Two methods:
1. Using a measuring tape
• Normal chest expansion is 5 – 8 cm.

2. Grasping the chest

 2. PALPATION
III. EXPANSION OF THE CHEST
Using a measuring tape
• Chest expansion can be measured using a measuring tape around the
chest at the level of the nipples.

Grasping the chest

• Place finger tips of both hands on either side of the lower rib cage.
• Tips of the thumbs meet in the midline in the front but not touch the
chest.
• Ask subject to take deep breath so that the distance between the
thumbs will increase and it will indicate degree of expansion.
• If one thumb remains closer to midline this means that there is
decreased expansion of that side.
 EXAMINATION OF CHEST

  RIGHT LEFT
ANTERIOR Supra - clavicular Supra - clavicular
  Supra - mammary Supra - mammary
  Mammary Mammary
  Infra - mammary Infra - mammary
  Axillary  
  Infra - axillary  
     
POSTERIOR Supra – scapular Supra – scapular
  Inter – scapular  
  Infra – scapular Infra – scapular
EXAMINATION OF CHEST
 2. PALPATION
IV. VOCAL FREMITUS

• Vocal: pertaining to voice

• Fremitus: vibratory sensation perceived by palpation

• Sound vibrations from the larynx pass down the bronchi

and cause the lungs and the chest wall to vibrate.
 2. PALPATION

IV. VOCAL FREMITUS

• The vibration may be detected by palpation by ulnar

border of hand placed flat on the chest.
• The subject is then asked to repeat 1 1 1 or 9 9 9 or
Ram Ram Ram
• The vibrations are perceived by the examining hand.
• Compare right and left side
 2. PALPATION
IV. VOCAL FREMITUS
 2. PALPATION

IV. VOCAL FREMITUS

Consolidation Bronchial
obstruction
Pleural effusion
Pneumothorax
Fibrosis
Collapse
 3. PERCUSSION
• Normal percussion note of the lungs is resonant
 3. PERCUSSION
Lower limit of left lung:
Note changes from
resonant to tympanic
due to presence of
stomach
Lower limit of right lung:
• 6th rib – Mammary line
• 8th rib – Mid axillary
line
• 10th rib – Scapular line
 3. PERCUSSION

Pneumothorax Thickening of pleura

Pleural effusion
4. AUSCULTATION I. BREATH SOUNDS
a. Vesicular
b. Bronchial

II. VOCAL RESONANCE

III. ADDED SOUNDS

a. Pleural rub
b. Rhonchi or wheeze
c. Crepitations or crackles
d. Stridor
 4. AUSCULTATION

I. BREATH SOUNDS

Two main types of breath sounds can normally be

heard over the chest:
• Vesicular
• Bronchial
 4. AUSCULTATION
I. BREATH SOUNDS
 4. AUSCULTATION
I. BREATH SOUNDS

a. Vesicular breath sound

• It is characterized by active inspiration due to passage of
air into bronchi and alveoli followed without a pause by
passive expiration due to elastic recoil of the alveoli which
occurs maximally in the early phases giving an apparent
impression of short expiration.
 4. AUSCULTATION
I. BREATH SOUNDS
 4. AUSCULTATION
I. BREATH SOUNDS

b. Bronchial breath sound

• It is characterized by active inspiration due to passage of
air into the bronchi. The alveolar phase is absent
(because of consolidation in alveoli) and hence expiration
is also active occupying the same duration time as
inspiration.
   VESICULAR BREATH BRONCHIAL BREATH SOUNDS
SOUNDS
Origin In larger airways In larger airways
When the lung between the
airways and chest wall is airless
as in consolidation, fibrosis and
collapse of lungs

Character Low pitch rustling sound High frequency and harsh

Inspiration  No gap between end of  Gap between end of
and inspiration and beginning of inspiration and beginning of
Expiration expiration expiration
 Inspiration is twice as long as  Inspiration and expiration are
expiration of same duration

Sites Heard all over healthy lungs Heard over trachea

(chest) Heard in patients with
consolidation, fibrosis and
collapse of lungs
 4. AUSCULTATION

II. VOCAL RESONANCE

• It is the sound of the voice heard on auscultation of the

chest.
• When subject repeats 1 1 1 or 9 9 9, the ear perceives
not only the distinct syllables but a resonant sound.
 4. AUSCULTATION

Bronchophony - Pleural effusion

consolidation Pneumothorax
Egophony - above the
level of pleural effusion
Whispering pectoriloquy
- cavity of lungs and
consolidation
 4. AUSCULTATION
III. ADDED SOUNDS

a. Pleural rub
• It occurs due to inflammation of pleura and it gives rise to
a characteristic friction rub.

b. Rhonchi or wheeze
• They are continuous musical sounds associated with
airway narrowing and particularly heard during expiration
• Seen in bronchitis and bronchial asthma
 4. AUSCULTATION
III. ADDED SOUNDS
c. Crepitations or crackles
• They are crackling sounds produced by sudden change in
pressure related to sudden opening of previously closed
airways.
• It is heard both during expiration and inspiration.
• Seen in pneumonia.

d. Stridor
• It is a loud inspiratory sound heard over the airways due
to obstruction to the respiratory tract mainly the larynx and
trachea.