1. The Respiratory System Examination
Dr Mike Henry
Dr Claire Bowker
Dept of Respiratory Medicine
Leeds General Infirmary

2. Major Symptoms of Respiratory Disease
Cough
Sputum production
Dyspnoea
Haemoptysis
Wheeze
Chest pain - pleuritic

3. Cough Larynx / Pharynx – harsh and painful
Trachea – harsh, dry and painful / productive
Bronchitis - paroxysmal / productive Acute Chronic
Carcinoma – short / dry - haemoptysis
Bronchiectasis – productive purulent sputum
Pneumonia – painful and productive
Pulmonary Oedema – dyspnoea/ orthopnoea/ PND
Fibrosing alveolitis – dry / short / persistent

6. Sputum
Amount
Character
Viscosity
Taste or odour

7. Dyspnoea Dyspnoea associated with increased work of breathing
Dyspnoea associated with increased pulmonary ventilation
Dyspnoea associated with weakness of muscles of respiration
Dyspnoea associated with multiple factors

8. Acute Onset Dyspnoea Sudden Rapid (minutes) (hours – days)
Pneumothorax Acute asthma
Severe acute asthma Pulmonary oedema
Pulmonary embolism Pneumonia Laryngeal oedema Acute bronchitis
Foreign body Allergic alveolitis
Pulmonary oedema (orthopnoea / PND)

9. Gradual Onset Dyspnoea
Onset days – weeks – months
Pleural effusion
Chronic asthma
Fibrosing alveolitis
Tuberculosis
Chronic bronchitis
Bronchial carcinoma

10. Slow Onset Dyspnoea Onset months – years Pleural fibrosis Emphysema
Pneumoniconiosis
Sarcoidosis Chronic broncitis Ankylosing spondylosis

11. Haemoptysis Type and degree Frank – whole blood / clots
Carcinoma / PE / Bronchiectasis / TB
Blood Stained – blood/sputum mixed Suppurative pneumonia / Carcinoma
Blood Streaked – streaks or flecks Carcinoma / chronic bronchitis
Rusty – degraded Hb Pneumococcal pneumonia

13. Aetiology of Wheeze

14. Upper reterosternal – tracheitis
Chest Pain Site Character Radiation Severity Duration Frequency and periodicity Aggravating factors Relieving factors Associated phenomena
Upper reterosternal – tracheitis
Reterosternal – oppressive similar to cardiac pain / not related to exertion
Pleuritic – stretching of inflammed parietal pleura

15. The Physical Examination from the end of the bed - Inspection
Patient comfortable ? / Supine 45
Look around the bed
Measures of respiratory compromise RESPIRATORY RATE Use of accessory muscles
Audible sounds
Patient in pain
Cyanosis
Oedema
SVCO

16. Palpation Hands Finger clubbing Cyanosis Signs of CO2 retention Eyes
Anaemia
Horners syndrome
Papilloedema

18. The Laying on of Hands Palpation
The Neck
Scalene lymph nodes
JVP – jugular venous pressure
Trachea
Central
Tracheal tug
Thyroid
Skin
Erythema nodosum
Metastatic carcinoma nodules
Lupus pernio

19. Chest wall
Symmetry of chest wall movements during tidal and deep breathing
Chest expansion (2-4 cms) Two levels ?
Significance of reduced chest wall movements
Anteropostero:lateral diameter = 5:7
Pectus excavatum / Carinatum / kyphoscholiosis
Thoracic operations / thoracoplasty

20. Chest wall

21. Significance of reduced chest wall movements
Pleural Effusion: reduced unilateral
Consolidation : reduced unilateral
Collapse of lobe: reduced unilateral
Pneumothorax: reduced unilateral
COPD:reduced bilateral
Asthma: reduced bilateral
Pulmonary fibrosis: reduced bilateral

22. Percussion Where to percuss How to percuss - technique
Normal: Resonant
Impaired: consolidation / collapse / fibrosis
Dull: consolidation / collapse / pleural thickening
Stony dull: fluid = pleural effusion
Hyperresonant : pneumothorax
Typanic: hollow viscus
Vocal tactile fremitus
Vocal resonance

23. Percussion

24. Auscultation
Normal breath sounds produced by air through larynx / vocal cords  vibrations
Vibrations transmitted through airways to the chest wall rustling sound = Vesicular
Diminished: airflow obstruction / pneumothorax / pleural effusion
Bronchial breath sounds: consolidation, fibrosis or collapse: resemble breath sounds heard over larynx

25. Auscultation Added sounds
Wheezes – passage of air through narrow bronchi Usually expiratory
If inspiratory – mucosal oedema clear with cough
Describe site
Fixed low pitch – STRIDOR – upper airflow obstruction

26. Explosive reopening of small airways occluded during expiration
Added sounds
Crackles
Explosive reopening of small airways occluded during expiration
Fine crackles: pulmonary oedema / consolidation – usually inspiratory
Course crackles: pulmonary fibrosis / bronchiectasis
Plueral rub / pleural click

27. Interstitial Lung Disease – CFA
Bilateral course / velcro bibasal crackles

30. Pleural Effusion Chest expansion - reduced Percussion - stony dull
Breath sounds - absent or decreased
Added sounds - none
Vocal resonance - absent or decreased

31. Consolidation
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32. Consolidation Chest expansion - reduced Percussion - dull
Breath sounds - bronchial
Added sounds - crackles
Vocal resonance - increased (whispering pectorilouy)

33. ATAELECTASIS - Total right lung collapse

35. Collapse left lower lobe – The Sail Sign

36. Collapse / Atelectasis lobe or lung
Chest expansion - reduced
Percussion note - dull
Breath sounds - absent or diminished
Added sounds - none / crackles or wheeze
Vocal resonance - absent / decreased

37. Pneumothorax Chest expansion - reduced Percussion - hyperresonant
Breath sounds - absent or decreased
Added sounds - none, occasionally click
Vocal resonance - decreased