1. Physical Examination in Respiratory System
In the name of GOD
Physical Examination in Respiratory System
Hassan Ghobadi MD
Assistant professor of Internal Medicine
Ardabil University of Medical Science

2. Respiratory History Important to cover Occupational History,
Allergies,
Snoring,
Daytime somnolence,
Sexual history,
Hobbies
And Pets.

3. Respiratory Examination
OBSERVATION (Closer inspection)
-Fingernails
Clubbing (cyanotic heart & lung diseases)
Peripheral cyanosis
Smoking stains
-Wrists
Hypertrophic Pulmonary Osteoarthropathy (HPOA)
Count Respiratory Rate over one minute.
Observe the rate, rhythm, depth, and effort of breathing.
Note whether the expiratory phase is prolonged.
Observe for use of accessory muscles (sternomastoids, abdominals).

4. Respiratory Examination
OBSERVATION CONTINUED
Face
-Reddish (CO2 retention)
-Bluish (cyanosis)
Eyes
-Horner’s Syndrome (ptosis, pupillary miosis and facial anhydrosis)
Eyelids
-erythema/scaling/pigmentation (allergies)
Conjuctiva
-pale (anaemia)

5. Respiratory Examination
OBSERVATION CONTINUED
Nose
-Allergic crease
-Nasal flaring (respiratory distress)
Teeth
-nicotine staining
Lips/mucous membranes
-cyanosis (central)
-tonsils (enlarged, obstructing, pus)

6. Respiratory Examination
OBSERVATION CONTINUED
Trachea
-midline, heaving, “tracheal tug”
-vessel congestion
Chest
-barrel, pigeon, tunnel chest, paroxysmal breathing
Abdomen
-central obesity (OSA)

7. Respiratory Examination:
PALPITATION
Lymph nodes:
- Cervical chain, post auricular, sub-mental, axillae
Chest:
- Anterior, Posterior and Axillae
- Chest Expansion
- Vocal resonance “99” – stethoscope
- Vocal Fremitus “99” – hands

8. Respiratory Examination:
PALPITATION CONTINUED
Chest:
- Whispering pectoriloquy - Ask the patient to whisper "ninety-nine" several times, auscultate several symmetrical areas over each lung, you should hear only faint sounds or nothing at all.
If you can hear this clearly is suggests pneumonia
- Increased fremitus, indicates fluid in the lung (consolidation).
- Decreased fremitus, indicates sound transmission obstructed by chronic obstructive pulmonary disease (COPD), fluid outside the lung (pleural effusion), air outside the lung (pneumothorax), etc.

9. Respiratory Examination
PERCUSSION
- Side to side, top to bottom, comparing like with like
- Dull to resonant
Diaphragmatic excursion
percuss to the level of dullness bilaterally, ask the patient to inspire deeply and percuss both sides again
(should be 3-5 cm difference)

10. Respiratory Examination
ASCULTATION
- Comparing like with like, side to side, top to bottom
- Breath sounds – vesicular (normal) to bronchial (fluid in airways eg pneumonia), increased or decreased, crackles (coarse, fine), wheeze
Associated systems exam.
- CVS (Corpulmonale)

11. Respiratory Examination
6MWD
- 6 Minute Walk Distance ( Test )
MMRC
- For evaluation of dyspnea severity

12. Chest wall Lines & Hallmarks

13. Anterior lines and landmarks
epigastric angle
Infraclavicular fossa
Anterior midline
Suprasternal fossa
Supraclavicular fossa
Sternal line
Parasternal line
Midclavicular line

14. Lateral imaginary lines
Anterior axillary line
Midaxillary line
Posterior axillary line

15. Posterior lines and landmarks
Scapular line
Posterior midline
Infrascapular region
Interscapular region
Suprascapular region

16. Anterior view of lobes

17. Posterior view of lobes

18. Right lateral view of lobes

19. Left lateral view of lobes

20. Respiratory Examination
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

21. Inspection
1 - Respiratory movement
Abdominal breathing: male adult and child
Thoracic breathing: female adult
2 - Respiratory rate: f/min
Tachypnea: > 18 f/min
Bradypnea: < 12 f/min
Shallow and fast
respiratory muscular paralysis, pneumonia, pleurisy, elevated intra abdominal pressure,
Deep and fast
Agitation, intension
Deep and slow
Severe metabolic acidosis (Kussmaul’s breathing)

22. Inspection Continued 3 - Respiratory rhythm
Cheyne-Stokes’ breathing
Biot’s breathing
Decreased excitability of respiratory center
Inhibited breathing
Sudden cessation of breathing due to chest pain
Pleurisy, thoracic trauma
Sighing breathing
Depression, intension

23. Thoracic deformity
Kyphosis

24. Thoracic deformity
Pectus excavatum

25. Thoracic deformity
Barrel chest

26. Respiratory Examination
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

27. Palpation Thoracic expansion Vocal fremitus (tactil fremitus)
Massive hydrothorax, pneumonia, pleural thickening, atelectasis
Vocal fremitus (tactil fremitus)
Pleural friction fremitus
Cellulose exudation in pleura due to pleurisy
Holding breathing - disappeared
Tuberculous pleurisy, uremia,
pulmonary embolism

28. Respiratory Examination
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

29. Percussion 1- Method Order:
Pleximeter: distal inter-phalangeal joint of left middle finger
Plexor: right middle finger tip
Order:
Up to down, anterior to posterior

30. Percussion 2. Affected factors Thickness of thoracic wall
Calcification of costal cartilage
Hydrothorax
Containing gas in alveoli
Alveolar tension
Alveolar elasticity

31. Percussion 3. Classification Resonance Hyperresonance Tympany Dullness
Normal
Hyperresonance
Emphysema
Tympany
Cavity or pneumothorax
Dullness
Hydrothorax, atelectasis
Flatness
Massive Hydrothorax

32. Percussion 4. Normal sound Lung’s sound in percussion Resonance
Slight dullness in some areas (upper, back) due to thickness of muscles and skeletons

33. Respiratory Examination
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

34. Order of auscultation

35. Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance

36. Normal sound Border of lungs in percussion Apex of lungs
Anterior border
absolute cardiac dullness area
Lower border
6th, 8th, 10th intercostal space in midclavicular line, midaxillary line, scapular line, respectively
Down: emphysema
Up: atelectasis, intraabdominal pressure goes up

37. 1. Normal breath sound Tracheal breath sound Bronchial breath sound
Bronchovesicular
Tracheal breath sound
Bronchial breath sound
Larynx, suprasternal fossa, around 6th, 7th cervical vertebra, 1st, 2nd thoracic vertebra
Bronchovesicular breath sound
1st, 2nd intercostal space beside of sternum, the level of 3rd, 4th thoracic vertebra in interscaplar area, apex of lung
Vesicular breath sound
Most area of lungs
Bronchovesicular
Bronchial

38. Shifting range of bottom of lung
Normal sound
Decreased:
Emphysema,
Atelactasis,
Fibrosis,
Pulmonary edema,
Pneumonia
Detected impossibly:
Pleura adhesion,
Massive hydrothorax,
Pneumothorax,
Diaphragmatic paralysis
Shifting range of bottom of lung
6-8 cm

39. Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance

40. Abnormal sound The depth of the lesion > 5 cm
Dullness, flatness, hyper resonance or tympany appear in the area of supposed resonance.
Unchanged sound (resonance)
The depth of the lesion > 5 cm
The diameter of the lesion  3 cm
Mild hydrothorax

41. Abnormal sound Dullness or flatness
Decreased containing gas in alveoli
Pneumonia
Atelectasis? TB
Pulmo. embolism
Pulmo. edema
Pulmo. Fibrosis
No gas in alveoli
Tumor
Pulmonary Hydatid
Pneumocystis
Non-liquefied lung abscess
Others
Hydrothorax
Pleural thickness

42. Abnormal sound Hyperresonance Tympany Dullness Emphysem Pneumothorax
Large cavity (TB, lung abscess, lung cyst)
Dullness
Decreased tension and gas in alveoli
Atelectasis
Congestive or resolution stage of pneumonia
Pulmonary edema

43. Abnormal vesicular breath sound(1)
Decreased or disappeared
Movement of thoracic wall
Respiratory muscle weakness
Obstruction of airway
Hydrothorax or pneumothorax
Abdominal diseases: ascites, large tumor
Increased
Movement of respiration

44. Abnormal vesicular breath sound (2)
Prolonged expiration
Bronchitis
Asthma
emphysema
Cog-wheel breath sound TB
Pneumonia
Coarse breath sound
Early stage of bronchitis or pneumonia

45. 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

46. Abnormal bronchovesicular breath sound
Bronchovesicular breath sound appears in supposed vesicular breath sound area
The lesion is relatively smaller or mixed with normal lung tissue

47. Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance

48. Adventitious sound Crackles ( fine, coarse ) wheezes Rhonchi
Pleural friction rub

49. Moist crackles Mechanism
During inspiration, air flow passes thin secretion in the airway to rupture the bubbles, or to open the collapse of bronchioli due to adhesion by secretion.

50. Classification of crackles
According to intensity of the sound
Loud moist crackles
Slight moist crackles
According to diameter of the airway crackles appeared
Coarse: trachea, main bronchi, or cavity
Bronchiectasis, pulmo. edema, TB, lung abscess, coma
Medium: bronchi
bronchitis, pneumonia
Fine: bronchioli
pneumonia
Crepitus:
Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion), elder subject, pat. bed rest for long time

51. Site of crackles Local: local lesion Both bases Full fields
Pneumonia, TB, bronchiectasis
Both bases
Pulmo. edema, bronchopneumonia,
chronic bronchitis
Full fields
Acute pulmo. edema, severe bronchopneumonia, chronic bronchitis with severe infection

52. Rhonchi (wheezes) Mechanism
The turbulent flow is formed in trachea, bronchi or bronchioli due to airway narrow or incomplete obstruction.
Causes
Congestion
Secretion
Spasma
Tumor
Foreign subject
Compression

53. Characteristics of rhonchi
Adventitious sound
High pitch
Dominance in phase of expiration
Variable intensity of character or site
Wheezing

54. Site of rhonchi 1- Both fields Asthma Chronic bronchitis
Acute left heart failure
2- Local site
Tumor
Endobronchial TB

55. Pleural friction rub Cellulose exudation in pleurisy (rough pleura)
Area of auscultation
Anterolateral thoracic wall (maximal shifting area of lung)
Friction rub disappeared if holding breath
Friction rub appeared both breath and heart beat:
mediastinal pleurisy
Causes
Tuberculous pleurisy
Pulmo. embolism
Uremia
Pleural mesothelioma

56. Sound of Auscultation 1. Normal breath sound 2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance

57. Vocal resonance Bronchophony Pectoriloqny Egophony Whispered
Consolidation
Pectoriloqny
Massive consolidation
Egophony
Upper area of hydrothorax
Whispered

58. الهی عاقبت محمود گردان به حق صا لحان و نیک مردان