Respiratory Examination

General appearance

Dyspnoea:

- Watch the patient for signs of dyspnoea at rest. Count the respiratory rate; the normal
rate at rest should not exceed 25 breaths per minute (range 16-25).
- Tachypnoea refers to a rapid respiratory rate of greater than 25. Bradypnoea is defined
as a rate below 8, a level associated with sedation and adverse prognosis
- Look to see whether the accessory muscles of respiration are being used. These muscles
include the sternomastoids, the platysma and the strap muscles of the neck.

Cyanosis:

- Central cyanosis is best detected by inspecting the tongue

- Cyanosis is usually obvious when the arterial oxygen saturation falls below 90% in a
person with a normal haemoglobin level (hypoxaemia)

Character of the cough:

- Ask the patient to cough several times.

o Lack of the usual explosive beginning may indicate vocal cord paralysis (the
'bovine' cough).
o A muffled, wheezy ineffective cough suggests obstructive pulmonary disease.
o A very loose productive cough suggests excessive bronchial secretions due to
chronic bronchitis, pneumonia or bronchiectasis.
o A dry, irritating cough may occur with chest infection, asthma or carcinoma of
the bronchus and sometimes with left ventricular failure or interstitial lung
disease

Sputum:

- The colour, volume and type (purulent, mucoid or mucopurulent), and the presence or
absence of blood, should be recorded

Stridor:

- Obstruction of the larynx, trachea or large airways may cause stridor, a rasping or
croaking noise loudest on inspiration. This can be due to a foreign body, a tumour,
infection (e.g. epiglottitis) or inflammation

Hoarseness:

- Listen to the voice for hoarseness, as this may indicate recurrent laryngeal nerve palsy
associated with carcinoma of the lung (usually left sided), or laryngeal carcinoma.
However, the commonest cause is laryngitis. Non-respiratory causes include
hypothyroidism.
The Hands

Clubbing:

- hypertrophic pulmonary osteoarthropathy (HPO). HPO is characterised by the presence

of periosteal inflammation at the distal ends of long bones, the wrists, the ankles, the
metacarpal and the metatarsal bones. There is swelling and tenderness over the wrists
and other involved areas

Staining:

- staining of the fingers (caused by tar), a sign of cigarette smoking

Wasting and weakness:

- Compression and infiltration by a peripheral lung tumour of a lower trunk of the brachial
plexus results in wasting of the small muscles of the hand and weakness of finger
abduction

Pulse rate:

- Tachycardia and pulsus paradoxus are important signs of severe asthma

o common side-effect of the treatment of asthma with β-agonist drugs

Flapping tremor (asterixis):

- Dorsiflex the wrists with the arms outstretched and to spread out the fingers. A flapping
tremor may occur with severe carbon dioxide retention, usually due to severe chronic
obstructive pulmonary disease
- unreliable sign

The Face

Eyes:

- Inspect the eyes for evidence of Horner'sa syndrome (a constricted pupil, partial ptosis
and loss of sweating), which can be due to an apical lung tumour compressing the
sympathetic nerves in the neck

Nose:

- In this position it may readily be inspected inside and out. Get the patient to tilt the head
back. It may be necessary to use a nasal speculum to open the nostrils and a torch. Look
for polyps (associated with asthma), engorged turbinates (various allergic conditions)
and a deviated septum (nasal obstruction)

Tongue:

- Central cyanosis

Mouth:
 - Evidence of an upper respiratory tract infection (a reddened pharynx and tonsillar
enlargement, with or without a coating of pus). A broken tooth or a rotten tooth stump
may predispose to lung abscess or pneumonia.

Sinus

- Sinusitis is suggested by tenderness over the sinuses on palpation

o If acute sinusitis is suspected, a torch can be used to transilluminate the frontal
and maxillary sinuses. A torch is placed in the patient's mouth and the sinuses
examined in a dark room
- The torch should then be used to look for purulent discharge in the pharynx.

Look at the patient's face for the red, leathery, wrinkled skin of the smoker
There may be facial plethora or cyanosis if superior vena caval obstruction is present

Some patients with obstructive sleep apnoea will be obese with a receding chin, a small
pharynx and a short thick neck.

The Trachea

o From in front of the patient the forefinger of the right hand is pushed up and
backwards from the suprasternal notch until the trachea is felt. If the trachea is
displaced to one side, its edge rather than its middle will be felt and a larger space
will be present on one side than the other. Slight displacement to the right is fairly
common in normal people
o Significant displacement of the trachea suggests, but is not specific for, disease of
the upper lobes of the lung
o A tracheal tug is demonstrated when the finger resting on the trachea feels it move
inferiorly with each inspiration. This is a sign of gross overexpansion of the chest
because of airflow obstruction
o If the patient appears dyspnoeic and use of the accessory muscles of respiration is
suspected, the examiner's fingers should be placed in the supraclavicular fossae
o Even more severe dyspnoea will result in use of the sternomastoid muscles

The Chest

o Examined anteriorly and posteriorly by inspection, palpation, percussion and

auscultation. Compare the right and left sides during each part of the examination.

Inspection

Shape and symmetry of the chest

- An increase in the AP diameter compared with the lateral diameter (the thoracic
ratio) beyond 0.9 is abnormal and is seen often in patients with severe asthma or
emphysema
 - A pigeon chest (pectus carinatum) is a localised prominence (an outward bowing
of the sternum and costal cartilages). It may be a manifestation of chronic childhood
respiratory illness

- A funnel chest (pectus excavatum) is a developmental defect involving a localised

depression of the lower end of the sternum. The problem is usually an aesthetic one, but in
severe cases lung capacity may be restricted.

- Harrison's sulcus is a linear depression of the lower ribs just above the costal
margins at the site of attachment of the diaphragm. It can result from severe asthma in
childhood, or rickets.

- Kyphoscoliosis may be idiopathic (80%), secondary to poliomyelitis, or associated

with Marfan's syndrome. Severe thoracic kyphoscoliosis may reduce the lung capacity and
increase the work of breathing

- Lesions of the chest wall may be obvious. Look for scars from previous thoracic
operations, or from chest drains for a previous pneumothorax or pleural effusion

- Subcutaneous emphysema is a crackling sensation felt on palpating the skin of the

chest or neck. On inspection, there is often diffuse swelling of the chest wall and neck. It is
caused by air tracking from the lungs and is usually due to a pneumothorax; less commonly
it can follow rupture of the oesophagus or a pneumomediastinum (air in the mediastinal
space).

- Prominent veins may be seen in patients with superior vena caval obstruction

- Movement of the chest wall should be noted. Look for asymmetry of chest wall
movement anteriorly and posteriorly. Assessment of expansion of the upper lobes is best
achieved by inspection from behind the patient, looking down at the clavicles during
moderate respiration

o Diminished movement indicates underlying lung disease. The

affected side will show delayed or decreased movement
o Reduced chest wall movement on one side may be due to localised
pulmonary fibrosis, consolidation, collapse, pleural effusion or
pneumothorax. Bilateral reduction of chest wall movement indicates
a diffuse abnormality such as chronic obstructive pulmonary disease
or diffuse pulmonary fibrosis.

Palpation

Chest expansion
Apex Beat

o When the patient is lying down, establishing the position of the apex beat may be
helpful as displacement towards the side of the lesion can be caused by collapse of
the lower lobe or by localised pulmonary fibrosis.
o Movement of the apex beat away from the side of the lung lesion can be caused by
pleural effusion or tension pneumothorax.
o The apex beat is often impalpable in a chest which is hyperexpanded secondary to
chronic obstructive pulmonary disease.

Vocal fremitus

o Palpate the chest wall with the palm of the hand while the patient repeats 'ninety-
nine'. The front and back of the chest are each palpated in two comparable
positions, with the palm of one hand on each side of the chest. In this way
differences in vibration on the chest wall can be detected
o Vocal fremitus is more obvious in men because of their lower-pitched
voices. It may be absent in normal people (high-pitched voice or thick chest
wall). It is only abnormal if different on one side from the other

Ribs

o Gently compress the chest wall anteroposteriorly and laterally. Localised pain
suggests a rib fracture, which may be secondary to trauma, or may be spontaneous
 as a result of tumour deposition, bone disease or sometimes the result of severe and
prolonged coughing

Percussion

With the left hand on the chest wall and the fingers slightly separated and aligned with the
ribs, the middle finger is pressed firmly against the chest. Then the pad of the right middle
finger (the plexor) is used to strike firmly the middle phalanx of the middle finger of the left
hand (the pleximeter)

o Percussion of symmetrical areas of the anterior, posterior and axillary regions is

necessary.
o Percussion in the supraclavicular fossa over the apex of the lung should not be
omitted.
o Percuss the clavicle directly with the percussing finger.
o On percussion posteriorly, the scapulae should be moved out of the way by asking
the patient to move the elbows forward across the front of the chest; this rotates
the scapulae anteriorly.

The feel of the percussion note is as important as its sound. The note is affected by the
thickness of the chest wall, as well as by underlying structures. Percussion over a solid
structure, such as the liver or a consolidated area of lung, produces a dull note. Percussion
over a fluid-filled area, such as a pleural effusion, produces an extremely dull (stony dull)
note. Percussion over the normal lung produces a resonant note and percussion over hollow
structures, such as the bowel or a pneumothorax, produces a hyperresonant note

Liver dullness:

The upper level of liver dullness is determined by percussing down the anterior chest in the
midclavicular line. Normally, the upper level of the liver dullness is the fifth rib in the right
midclavicular line. If the chest is resonant below this level, it is a sign of hyperinflation,
usually due to emphysema or asthma

Cardiac dullness:

The area of cardiac dullness usually present on the left side of the chest may be decreased in
emphysema or asthma.

Auscultation

Breath sounds:

Quality of breath sounds. Normal breath sounds are heard with the stethoscope over nearly
all parts of the chest. The patient should be asked to breathe through the mouth so that
added sounds from the nasopharynx do not interfere. These sounds are produced in the
airways rather than the alveoli. They had once been thought to arise in the alveoli (vesicles)
of the lungs and are therefore called vesicular sounds. They have rather fancifully been
compared by Laënnec to the sound of wind rustling in leaves. Their intensity is related to
total airflow at the mouth and to regional airflow. Normal (vesicular) breath sounds are
louder and longer on inspiration than on expiration and there is no gap between the
inspiratory and expiratory sounds. They are due to the transmission of air turbulence in the
large airways filtered through the normal lung to the chest wall.

With bronchial breath sounds turbulence in the large airways is heard without being filtered
by the alveoli, producing a different quality. Bronchial breath sounds have a hollow, blowing
quality. They are audible throughout expiration and there is often a gap between inspiration
and expiration. The expiratory sound has a higher intensity and pitch than the inspiratory
sound. Bronchial breath sounds are more easily remembered than described. They are
audible in normal people, posteriorly over the right upper chest where the trachea is
contiguous with the right upper bronchus. They are heard over areas of consolidation, as
solid lung conducts the sound of turbulence in main airways to peripheral areas without
filtering.
Intensity of the breath sounds. It is better to describe breath sounds as being of normal or
reduced intensity than to speak about air entry. The entry of air into parts of the lung cannot
be directly gauged from the breath sounds

- Causes of reduced breath sounds include COPD (especially emphysema), pleural

effusion, pneumothorax, pneumonia, a large neoplasm and pulmonary collapse

Added (adventitious) sounds. There are two types of added sounds-continuous (wheezes)
and interrupted (crackles).

o Continuous sounds are called wheezes. They are abnormal findings and have a
musical quality. The wheezes must be timed in relation to the respiratory cycle.
They may be heard in expiration or inspiration, or both. Wheezes are due to
continuous oscillation of opposing airway walls and imply significant airway
narrowing. Wheezes tend to be louder on expiration. This is because the airways
normally dilate during inspiration and are narrower during expiration. An
inspiratory wheeze implies severe airway narrowing
o High-pitched wheezes are produced in the smaller bronchi and have a whistling
quality, whereas low-pitched wheezes arise from the larger bronchi.
o usually the result of acute or chronic airflow obstruction due to asthma (often
high pitched) or chronic obstructive pulmonary disease (often low pitched),
secondary to a combination of bronchial muscle spasm, mucosal oedema and
excessive secretions
o A fixed bronchial obstruction, usually due to a carcinoma of the lung, tends to
cause a localised wheeze, which has a single musical note (monophonic) and
does not clear with coughing
o Interrupted non-musical sounds are best called crackles
 Crackles are probably the result of loss of stability of peripheral airways
that collapse on expiration
 Early inspiratory crackles (cease before the middle of inspiration)
suggest disease of the small airways, and are characteristic of chronic
obstructive pulmonary disease

Vocal resonance:

Auscultation over the chest while a patient speaks gives further information about the lungs'
ability to transmit sounds

- Normal lung: low-pitched components of speech are heard with a booming quality and
high-pitched components are attenuated
- Consolidated lung: tends to transmit high frequencies so that speech heard through the
stethoscope takes on a bleating quality
o Ask the patient to say 'ninety-nine' while you listen over each part of the chest.
Over consolidated lung the numbers will become clearly audible, while over
normal lung the sound is muffled
The Heart

- Lay the patient down at 45 degrees and measure the jugular venous pressure for
evidence of right heart failure
- Examine the praecordium
o Listen to pulmonary component of the second heart sound (P2)
 Best heard at the second intercostal space on the left
 It should not be louder than the aortic component, If the P2 is
louder, pulmonary hypertension should be strongly suspected

The Abdomen

- Palpate the liver for ptosis due to emphysema, or for enlargement from
secondary deposits of tumour in cases of lung carcinoma

Other

Pemberton's sign

Ask the patient to lift the arms over the head and wait
for one minute. Note the development of facial
plethora, cyanosis, inspiratory stridor and non-pulsatile
elevation of the jugular venous pressure. This occurs in
superior vena caval obstruction

Feet

Inspect for swelling (oedema) or cyanosis, which may be clues to cor pulmonale, and look for
evidence of deep venous thrombosis.

Respiratory rate on exercise

Patients complaining of dyspnoea should have their respiratory rate measured at rest, at
maximal tolerated exertion (e.g. after climbing one or two flights of stairs), and supine. If
dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should
consider the possibility of anxiety or malingering

Temperature

Fever may occur with any acute or chronic chest infection.