1. Respiratory System Physical Examination
Ishraq Elshamli
Respiratory Unit
Tripoli Medical Center

2. Preparation for Examination
Privacy : warm, well-lighted, quiet room.
Wash your hands
Introduce yourself to the patient.
Seek permission for the examination and be polite to the patient.
“Stop me at any time if it becomes uncomfortable or I cause you any discomfort

3. Introduction
While seated or standing, the patient should be exposed to the waist OR uncovered intermittently.
Teach the patient how to breathe deeply and quietly, slowly inhaling and exhaling through an open mouth

4. Physical Examination

5. Physical Examination Initial impression
Stand back, to the right hand side of the patient :
General appearance :
Thin, Pink puffer, cachexia.
Obese, blue bloater, cushinoid features
Cyanosis
Features of SVCO

6. Physical Examination (Initial Impression)
SOB?
Using accessory muscles of respiration
Pursed lips
Prolonged expiratory phase ?COPD
Count Respiratory rate
Normal adult, breaths/min regular and unlabored.
Tachypnea is an adult RR> 24 breaths/min.
Bradypnea is an adult RR< 10 breaths/min.

7. Physical Examination (Initial Impression)
Audible cough : is it dry/ productive. Is there a sputum pot? If so, look in it.
Wheeze
Stridor
Hoarseness

8. Note the intercostals retractions (especially at the base of the neck,) and the position of the hands (a position known as 'tripodding.')

9. Tri-Pod Position : In patients with emphysema

10. Pink Puffer

11. Blue Bloater

12. Around the bed Inhalers. Oxygen.
CPAP machine (Obstructive sleep apnoea).
Sputum Pots.

13. Oximeter

14. Provides controlled Oxygen therapy
Venturi mask :
Provides controlled Oxygen therapy
24%, 28%, 35%, 60%

15. Ventolin Inhaler (mdi)
Metered dose inhaler
Foradil (Formetrol)
Powder inhaler

16. Pulmicort and Oxis turbohaler
Seretide diskhaler
Metered dose inhalers(mdi) e.g. Becloforte (Beclomethasone), Ventolin (Salbutamol)
Combivent(Salbutamol+ipratropium bromide)

18. Hands and Pulse Perfusion Nicotine staining Peripheral cyanosis
Bruising/ thin skin: steroid therapy
Clubbing - lung cancer, bronchiectasis, CF, lung abscess/empyema), pulmonary fibrosis, mesothelioma, (HPOA).

19. Examination of the hands
Tremor (fine ? Β2 agonist)
Flapping tremor (CO2 retention) .
Other conditions: e.g. Yellow Nails/ RA hands/ Scleroderma/ Wasting of the intrinsic muscles of the hands (cachexia/ pancoast tumour)
Pulse

23. Finger clubbing

25. Flapping tremor

26. Pulse Pulse: palpate rate, rhythm, character.
Tachycardia: e.g. AF associated with pulmonary disease.
Tachycardia associated with beta 2 agonists (nebulised salbutamol)

27. Face and Neck Central cyanosis Neck veins Lymphadenopathy Crepitus
Neck muscles
Indrawing
Pursed lips

28. Face
Horner’s Syndrome (MEAP! Myosis, enophthalmos, anhydrosis, ptosis).
Central Cyanosis (4g of Hb has to be deoxygenated).
Acneform eruptions associated with immunosuppressive therapy.
Cushingoid appearance with long-term steroid use .

30. Acneform eruptions

33. Pursed lip breathing Improves ventilation. Releases trapped air.
Keeps the airways open longer and decreases the work of breathing
Prolongs exhalation to slow the breathing rate
Relieves shortness of
breath

34. The Neck Position of the trachea
Lymph node enlargement (tuberculosis, lymphoma, malignancy, sarcoidosis)
Scars (phrenic nerve crush for old TB)
Tracheostomy scar􀃆previous ventilation in COPD etc. Central line scars
Scar from LN biopsy
JVP - ? right sided heart failure (cor pulmonale as a result of chronic lung disease)

36. Tracheostomy Scar
Thyroidectomy Scar

38. Chest Traditional Sequence
Inspection.
Palpation.
Percussion.
Auscultation.

39. Remember Always describe the chest in terms of anterior and posterior.
Describe the lungs as zones not lobes
i.e. Upper/ middle/ lower zones

40. Anterior View
Posterior View

41. Left Lateral View
Right Lateral View

42. Inspection Inspection is performed to:
Scars : pneumonectomy ,lobectomy
Chest drains , thoracocentesis.
Radiation tattoo’s (previous radiotherapy).
Shape or Chest wall deformity – pectus excavatum / carinatum(pigeon chested), Barrel chest (Hyper-inflated), Kyphosis, Scoliosis.
Resp rate, depth& Mode of breathing.

43. Inspection Movements . Equal symmetry or reduced on one side?
Respiratory effort, intercostal indrawing or use of accessory muscle .

44. Kyphosis:
Causes the patient to bend forward. X-Ray shows curvature of the spine.

45. Pectus excavatum:
Congenital posterior displacement of lower sternum.
The x-ray shows a concave appearance of the lower sternum.

46. Barrel chest :
In chronic lung hyperinflation (e.g.Asthma, COAD)
Due to increased AP diameter of the chest.

47. Scoliosis
Is an increased lateral curvature of the spine .
(i.e. Like the shape of the Letter “S”).

50. Intercostal retraction

51. ANTERIOR EXAM Palpation
Trachea:
palpate for tracheal position midline or
deviated Rt or Lt

52. Position of the Trachea

53. A Apex Beat

54. Chest expansion
Place your palms on the patient’s chest with your thumbs parallel to each other near the midline
OR lightly pinch the skin between your thumbs
Ask the patient to take a deep breath , observe for bilateral expansion

58. Tactile Vocal fremitus
Place the ulnar side of your hand on the patient’s chest .
Instruct the patient to say “44” each time they feel your hand on their back.
Comment on the tvf increased or decreased

61. Percussion

62. Percussion technique
Place left hand on chest wall, palm downwards with fingers separated
2nd phalanx over area of intercostal space
Right middle finger strikes the 2nd phalanx producing hammer effect
Entire movement comes from wrist

64. Percussion
Technique
Compare like with like

68. Percussion Do not forget the apices of the lungs Compare both sides
Impaired(dull)resonance obtained –
Lung tissue is airless e.g. consolidation, collapse,
fibrosis
Hyper resonant = pneumothorax/ COPD
Stony Dull = Pleural effusion

69. Percussion

71. Auscultation

72. Auscultation technique
Diaphragm of stethoscope covers a larger surface than the bell
Breath deeply with Mouth open
Systematic approach over several areas, comparing both sides
listen to one complete respiration
Repeat asking patient to say “9,9,9” for vocal resonance
Whispering pectoriloquy

73. Auscultation The auscultatory assessment includes
breath sounds audible or not .
Character of breath sounds.
Abnormal sounds or added sounds.
Examination of the sounds produced by the spoken voice.
Use a zigzag approach, comparing the finding at
Each point with the corresponding point on the
Opposite hemithorax.

74. Auscultation
Breath sounds
Added sounds
Vocal sounds (vocal resonance)

75. Vesicular – Normal, Or Diminished localised or diffuse
expiration
inspiration
Vesicular – Normal, Or Diminished
localised or diffuse
inspiration
expiration
inspiration
expiration
Vesicular with prolonged expiration
Bronchial Breathing

76. Vesicular breath sounds
Vibrations of the vocal cords caused by turbulent flow through the larynx
Transmitted along trachea, bronchi to chest wall
Rustling quality
Inspiration continuous with expiration
Intensity increases during inspiration & fades during first 1/3rd expiration

77. Diminished breath sounds
Conduction limited by
Airflow limitation
e.g. diffusely – asthma, emphysema
localised – tumour, collapse
Something separating chest wall from lung
e.g. effusion, fibrosis

78. Bronchial breathing “blowing” inspiratory & expiratory sounds
Expiratory phase as long as inspiration
Distinct pause between phases
High-pitched e.g. consolidation
Low-pitched e.g. fibrosis

79. Added sounds
Rhonchi (wheeze)
Crepitations (crackles)
Pleural sounds

80. Rhonchi
Due to passage of air through narrowed bronchus e.g. bronchospasm, mucosal oedema
Musical quality
High or low pitched
Usually expiratory
Expiration prolonged

81. Crepitations Inspiratory noises, usually 2nd half Non-musical
Due to explosive reopening of peripheral small airways during inspiration which have become occluded during expiration

82. Pleural Rub Creaking noise
Movement of visceral pleura over parietal pleura
Surfaces roughened by exudate
2 separate phases at end inspiration and early expiration

83. Vocal sounds Vocal resonance
Increased when voice sounds are louder and more distinct e.g. consolidation
Reduced when transmission impeded e.g. effusion, collapse

84. Information from auscultation
Type and amplitude of breath sounds
Type of added sounds and their location
Quality and amplitude of conducted sounds

85. Whisper pectoriloquy
With your stethoscope the over area of possible pathology, have the patient whisper the phrase ‘one-two-three’. Listen to hear if the sound is distorted.
Confirm that a similar change is absent over the identicallocation on the contralateral chest.

86. Egophony
With your stethoscope over the area of possible pathology, have the patient vocalize the vowel ‘EEEE’.Listen for the sound to be distorted into the sound ‘AHHH’.
Confirm that a similar change is absent over the identical location on the contralateral chest.

87. I would like to complete my examination by
Reviewing the temperature and blood pressure.
Examine for features of cor pulmonale. (Inspect the JVP / look for peripheral oedema / other signs of right heart failure).
Check the patient’s peak flow and forced expiratory time.

88. Forced expiratory time
Instruct the patient to:
take in as deep breath in as deep as you can and then hold it. Then, breathe out as forcefully and as quickly as possible. Or
blow as hard as you can until all the air has emptied from your lungs.

89. If you can’t empty your lungs in 6 seconds, this suggests a degree of obstruction i.e. COPD.

90. Finishing off the examination
At this stage say to the patient
“Thank-you, you may sit back now”
And to cover them up with the blanket

91. Interpretation of findings
Breath sounds locally reduced or absent over pleural effusion, thickened pleura, collapsed area
Breath sounds diffusely reduced in emphysema, asthma
Rhonchi heard in asthma, COPD
Crepitations may be widespread in COPD, LVF
Crepitations localised in area of consolidation
Pleural rub in pleurisy

92. Interpretation of findings
Pleural effusion
reduced tactile vocal fremitus
reduced chest expansion
stony dull
reduced air entry
no added sounds
reduced vocal resonance
Consolidation
increased tactile vocal fremitus
reduced expansion
dull percussion
bronchial breathing
coarse creps
increased vocal resonance
whispering pectoriloquy

93. Interpretation of findings
Pneumothorax
deviated trachea
reduced tactile vocal fremitus
hyper-resonance
reduced air entry
reduced vocal resonance
Collapse
deviated trachea
reduced tactile vocal fremitus
dull percussion
reduced air entry
+/- creps

94. Pleural effusion

95. pneumothorax

97. A candidate was asked to examine the respiratory system
EXAMPLE:
A candidate was asked to examine the respiratory system

98. Examiner observations:
A reasonable method.
She did commence examination of the chest from the posterior aspect.
The findings:
The patient was breathless at rest.
Was using oxygen via nasal prongs.
There were no peripheral signs .
The chest was normal apart from bilateral basal crepitations.

99. What is your Diagnosis:
Fibrosing alveolitis.
What are other causes of bilateral basal crepitations :
Heart failure.
Brocnhiectasis.
Atypical pneumonia
JVP
sputum pots or inhalers

100. Patient re-examined: General Examination:
The patient was propped up in bed suggesting dyspnoea.
The face was flushed
flaring of the alae nasi
O/E No clubbing but the peripheries were warm with high volume pulse not collapsing
neck we noted a raised JVP almost to the ear lobe with no predominant waveform .
Causes of Dyspnea
A pink puffer
The patient had respiratory distress
cor pulmonale or heart failure

101. On examination of the chest:
Barrel shaped .
There was little movement of the chest wall with respiration being predominantly abdominal.
Respiratory rate was 26 per minute.
The apex beat was difficult to palpate
Respiratory movements were equal on the two sided vocal fremitus unremarkable

102. Percussion not showed increased resonance with diminished cardiac and liver dullness
Breath sounds were vesicular
There were a few crepitations at both bases but they were mostly mid-inspiratory and cleared with coughing
Heart sounds were soft

103. COPD Respiratory failure Cor pulmonale
Diagnosis
COPD Respiratory failure Cor pulmonale

104. This case demonstrate:
A methodical examination .
Evaluation of the findings at each step.
Makes diagnosis much easier.

105. THANK YOU