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Inspection  Inspection or observation involves observing the respiratory rate which should be in a ratio of 1:2 inspiration:expiration. where the accessory muscles of respirations of the neck are contracting to aid inspiration. It can be seen in newborn babies which is sometimes physiological (normal). An acidotic patient will have more rapid breathing to compensate known as Kussmaul breathing. Retractions can be supra-sternal.  Tracheal deviation . This is a sign of respiratory distress. It is best to count the respiratory rate under pretext of some other exam. there is visible contraction of the inter costal muscles(between the ribs) to aid in respiration. which can hint pneumothorax. Observe for barrelchest (increased AP diameter) seen in COPD. Another type of breathing is Cheyne-Stokes respiration. Also observe for retractions seen in asthmatics. so that patient does not sub consciously increase his baseline respiratory rate. which is alternating breathing in high frequency and low frequency from brain stem injury. Retractions can also be intercostal. Observe for shifted trachea or one sided chest expansion.

chest wall increased anteriorposterior.anteriorposterior  Scoliosis .sternum protruding from the chest .curvature of the spine . normal in children.curvature of the spine . typical of hyperinflation seen in COPD  Pectus excavatum .sternum sunken into the chest  Pectus carinatum .Chest wall deformities  Kyphosis .lateral  Barrel chest .

Signs of respiratory deformities  Cyanosis .seen in COPD (used to increase      end expiratory pressure) Accessory muscle use (scalene muscles) Diaphragmatic paradox . suspect flail segment in trauma Intercostal indrawing movement of chest-chest movement decreases on the affected side jugular venous pulse-indicates right heart failure .person turns blue  Pursed-lip breathing .the diaphragm moves opposite of the normal direction on inspiration.

check whether trachea is in centre line. This is because sound travels faster through denser material than air. place both palms or medial aspects of hands on the      posterior lung field.the patient says boy-O-boy or ninety-nine. palpation may reveal increased vibration and dullness on percussion. Tracheal deviation . If the patient has a consolidation (maybe caused by pneumonia). If there is pneumonia. If there is pleural effusion.Palpation  For palpation.check if there has been deviation of heart . The point of this part is to feel for vibrations and compare between the right/left lung field. Ask the patient to count 1-10. palpation should reveal decreased vibration and there will be 'stony dullness' on percussion. Tactile fremitus .check whether expansion is equal Location of apex beat . Respiratory expansion . the vibration will be louder at that part of the lung. whilst physician sense with ulnar aspect of hand for changes in sound conduction.

Percussion  On percussion.normal is 3 to 6 cm. the percussion will be dampened and sound muffled. If there is fluid between the pleural membranes. you are testing mainly for pleural effusion     or pneumothorax. dullness indicates consolidation hyper-resonance (as can be simulated by percussing the inflated cheek) suggests a pneumothorax (can be related to COPD or a pleural effusion) diaphragmatic excursion . Middle finger strikes the middle phalanx of the other middle finger. The sides of the chest are compared. The sound will be more tympanic if there is a pneumothorax because air will stretch the pleural membranes like a drum. .

Inspiratory crackles (decompensated congestive heart failure) Expiratory wheezes (asthma. They are heard on expiration and inspiration. Rhonchi are bubbly sounds similar to blowing bubbles through a straw into a sundae.Ausculation  Lung auscultation is listening to the lungs bilaterally at the anterior      chest and posterior chest. Wheezing is described as a musical sound on expiration or inspiration. It is the result of alveoli popping open from increased air pressure. vesicular breath sounds Appropriate ratio of inspiration to expiration time (expiration time increased in COPD) . It is the result of narrowed airways. It is the result of viscous fluid in the airways. Crackles or rales are similar to rhonchi except they are only heard during inspiration. emphysema) Stridor and other upper airway sounds Bronchial vs.

Vocal fremitus  Egophony  Whispered pectoriloquy .

Systematic Approach.Initial investigations  Peak Flow Recording  Spirometry  Chest X-ray . .