Semiology of

Respiratory System

Lecture - 4

• By Assist. Prof. Dr. Najeebullah Rahimy

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• MD, DEM, DTM&H, MCTM, PhD Scholar
Outlines
• Percussion
• Auscultation
• References

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Percussion
• Percussion of chest is done by placing the left hand on the
chest wall with palm downwards and fingers slightly
separated.
• Always compare the respective points on both sides.
• The chest is percussed anteriorly, laterally, and then
posteriorly.

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 Cont. …
• Following are the rules of percussion:
• Percuss from resonant to dull area.
• Pleximeter (the middle finger of left hand) should be placed
parallel to the border of organ to be percussed.
• Pleximeter should be firmly pressed with the body surface.
• Plexor (middle finger of right hand) should strike the middle
phalanx of pleximeter at right angle.
• Movements should be at the wrist and finger joints.
• Strike the plexor twice and then lift it off the pleximeter, i.e., it
should not remain in contact with pleximeter after it strikes it
(because it stops the overtones and hence changes the character of
the sound produced).
• Line of percussion should be perpendicular to the border of the 4
organ to be percussed.
Cont. …
• Types of Percussion Notes
• Resonant
• Normal percussion notes of lungs are resonant.
• Degree of resonance varies in different parts of chest.
• It is more resonant at areas or below the clavicles and scapulae (due to
thin muscle layers).
• Tympanitic
• This type of percussion note is present in case of cavity of lung
containing air.
• This type of note is normally present over an empty stomach.

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Cont. …
• Impaired notes
• This type is present at the junction of solid organs with lung, e.g., at
upper border of liver and at the borders of heart.
• Dull notes
• Percussion over a solid organ like liver, spleen, and heart gives dull
notes.
• Stony dull notes
• These are present over the fluid, e.g., pleural effusion, ascites.

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 Cont. …
• Hyper-resonant percussion note is present in:
• Emphysema
• Pneumothorax
• Above the level of pleural effusion (Skodiac resonance). This is due to
the large amount of air present in the lung which is floating over the
fluid.
• Dull percussion note is present in:
• Thickened pleura
• Collapse of lung
• Consolidation of lung
• Fluid in pleural cavity (stony dull note)

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Percussion Notes and Their Characteristics
Relative Relative Relative Example of
Intensity Pitch Duration Location

Flat Soft High Short Thigh

Dull Medium Medium Medium Liver

Resonant Loud Low Long Healthy lung

Hyper- Very loud Lower Longer Usually none

resonant
Tympanitic Loud High* Longer Gastric air bubble or
puffed-out cheek
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* Distinguished mainly by its musical timbre.

Auscultation
• Before auscultating the chest of patient, his upper garments
are removed and he is made to lie down on the bed in supine
position.

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Cont. …
• Technique
• For auscultation, the diaphragm of stethoscope is preferred
than bell because chest sounds are relatively high pitched,
so these are better picked up by diaphragm than bell.
• In case of hairy chest and in thin persons due to lack of full
skin contact, extra sounds, indistinguishable from crackles
or pleural rub, may be heard.

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Cont. …
• Technique (cont.)
• So we should be careful interpreting the sounds.
• In such case, one can use bell instead of diaphragm.
• Chest piece of the stethoscope is put on the chest wall in a way
that it is in full contact with the skin, but at the same time no
extra pressure is applied over it.
• Care should be taken that the chest piece should not move on the
skin.
• First auscultate the chest anteriorly and then posteriorly.
• During auscultation ask the patient to breathe through mouth.

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 Cont. …
Method
• Avoid auscultation within 2–3 cm from midline.
• Auscultate the 2 sides alternately on equivalent points.
• Auscultate anteriorly from above the clavicles down to the 6 th rib.
• Laterally from axilla to the 8th rib.
• Posteriorly down to the level of 11th rib.
• To auscultate the back, patient should sit and put hands on opposite
shoulder.
• In this way, scapulae will move apart exposing more lung field.
• Breathing should not be noisy.

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Cont. …
• Points to note on auscultation of the chest
• Vesicular breath sounds
• Bronchial breath sounds
• Vocal fremitus and resonance
• Whispering pectoriloquy
• Aegophony
• Added sounds
• Pleural rub
• Wheezes
• Crackles

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Cont. …

• Vesicular breath sounds

• These are normal breath sounds.
• These are produced by passage of air through smaller airways.
• Characteristics of these sounds are:
• Expiration is shorter (nearly ½) than inspiration.
• Inspiration is harsher than expiration.
• There is no pause between inspiration and expiration.
• This is rustling in character.

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Cont. …
• Bronchial breath sounds
• These are pathological breath sounds.
• Following are the characteristics:
• This is blowing/hollow in character
• Expiration may be prolonged
• Expiration is more harsh and intense than inspiration
• There is a pause between inspiration and expiration
• Causes
• Consolidation
• Cavitation
• Collapse (with patent bronchus)

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Cont. …
• Bronchial breath sounds may be normally heard on these
areas (produced by the passage of air through trachea and
main bronchus):
• Manubrium sterni
• Spine of 4th thoracic vertebra
• Nape of the neck under the hair

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17
Cont. …
• Vocal Fremitus and Resonance
• Ask the patient to say “one, one, one” or “ninety-nine” and then
auscultate.
• Bronchophony
• This is increased vocal resonance.
• Vocal resonance is increased in:
• Consolidation
• Cavitation
• Collapse of patent bronchus

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Cont. …
• Vocal Fremitus and Resonance (Cont.)
• whispering pectoriloquy
• Ask the patient to whisper “one, two, three”.
• On auscultation, the words are heard clearly as if the patient is
speaking directly into the ear.
• This is present in case of consolidation of lung.
• Aegophony (Egobronchophony)
• This sound resembles as if patient is speaking from his nose.
• This type of vocal resonance is present at the upper level of pleural
fluid or consolidated area.

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 Cont. …
• Added sounds
• Extrapulmonary added sounds
• Pleural rub
• Pulmonary added sounds
• Wheezes
• Stridor
• Crackles
• Note
• Older terms such as rales to describe coarse crackles, crepitations to
describe fine crackles and rhonchi to describe wheezes are poorly
defined, have led to confusion and are best avoided.

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Cont. …
• Pleural Rub
• It is a friction rub caused by friction between the visceral and
parietal pleurae.
• It sounds like walking on the snow.
• Following are the points for differential diagnosis from crackles:
• Pleural rub is not changed with coughing.
• Intensity of sound increases on pressing the stethoscope or on deep
breathing.
• Pleural rub is more localized.
• It is present at the start of inspiration and expiration.

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Cont. …
• Pleural Rub (Cont.)
• Pleural rub is characteristic of pleurisy at a stage when
exudate is not enough to separate the inflamed and roughened
surfaces.
• Pleural rub may be palpable in some cases.
• False added sounds resembling pleural rub may arise by
movement of stethoscope over skin or cloths of patients.

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 Cont. …
• Wheezes
• Wheezes are continuous (musical) sounds produced by the
passage of air through narrow bronchi.
• It is heard mostly during expiration.
• Bronchus becomes narrow due to:
• Edema of mucus membrane of bronchus.
• Spasm of muscles of bronchial wall.
• Sticky mucus plugs which vibrate during respiration.

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 Cont. …
• Types of wheezes
• Polyphonic wheezes
• These are heard particularly during expiration.
• These are heard in cases of diffuse air flow obstruction, i.e.,
• Asthma (wheezes are present during expiration)
• COPD (wheezes are present in both inspiration and expiration)
• Bronchitis

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Cont. …
• Types of wheezes (Cont.)
• Monophonic wheezes
• These are localized.
• These are present in narrowing of single bronchus due to
foreign body or tumor.
• This may be inspiratory or expiratory or both.

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Cont. …
• Stridor
• It is high-pitched, noisy respiration, like blowing of the
wind, which can be listened without stethoscope.
• It is heard during inspiration.
• It is produced due to narrowing of the larynx, trachea or
main bronchi in:
• Laryngotracheobronchitis (croup)
• Epiglottitis
• Bacterial tracheitis
• Foreign body

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Cont. …
• Crackles
• These are discontinuous bubbling explosive sounds produced
due to the presence of mucus or fluid in bronchi or alveoli.
• When large airways are full of sputum, a coarse rattling sound
may be heard even without stethoscope.
• In case of bronchiectasis, crackles are localized.
• With coughing crackles may change their character.

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Cont. …
• Crackles are heard in:
• COPD
• Bronchiectasis
• Pulmonary edema
• Diffuse interstitial alveolitis
• Resolving pneumonia

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References
• Longo DL, Fauci AS, Kasper DL, Hauser SL and
Jameson. Harrison's Principles of Internal Medicine, 19

23 Feb 2024
ed. New York, NY: McGraw-Hill; 2015.
• Colledge, Nicki R., Brian R. Walker and Stuart Ralston
Davidson. Davidson's Principles and Practice of Medicine.
23rd ed. Edinburgh: Churchill Livingstone/Elsevier, 2018.
• Kumar, Parveen J., and Michael L Clark. Kumar & Clark's
Clinical Medicine. 9th ed. Edinburgh: Saunders/Elsevier, 2017.

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 23 Feb 2024
THANK YOU!

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