James Wight

Examination of the Respiratory System

• Wash your hands.

• Introduce yourself to the patient, and ask permission to examine them.
• Expose the patient, and position them at 45°.

Inspection
Look around the bed Oxygen mask/nasal prongs, sputum pot, drips, PEFR,
inhalers, nebuliser, cigarettes
Look at the patient Comfortable at rest, cyanosis, breathless, use of
accessory muscles, scars (eg following a rib for
pneumonectomy), asymmetry, deformity, hyperexpansion
(Barrel chest), pectus carinatum, pectus excavatum,
cachexia, radiotherapy marks, chest drain
Look at the hands Clubbing (purulent lung disease – CF, bronchiectasis,
bronchogenic carcinoma – but not small cell), peripheral
cyanosis, nicotine staining, muscle wasting, CO2 retention
flap, tremor (β2-agonists)
Feel the radial pulse Assess rate and count respirations
Ask for blood pressure Enquire about pulsus paradoxus
Look at the face Ptosis, Miosis and Anhydrosis (Horner’s), SVC
obstruction
Look in the eyes Anaemia
Look in the mouth Central cyanosis, pursed lips, tonsils, hoarse voice,
stridor.
Look at the neck Examine the JVP (raised in cor pulmonale and tension
pneumothorax)

Palpation

Check trachea is central Including the cricosternal distance

Check for lymphadenopathy
Feel for the apex beat May be displaced, eg in pneumothorax or effusion
Assess chest expansion
anteriorly

Percussion
Percuss anteriorly Compare L with R, and don’t forget the axillae and
supraclavicular regions. Can be normal, hyperresonant,
dull and stony dull.
Auscultation
Auscultate anteriorly, Compare L with R, listening for air entry, crackles,
asking pt to breath though wheeze and bronchial breathing. Don’t forget the
their mouth supraclavicular regions and axillae.
Assess vocal resonance, Compare L with R, listening for increased vocal
asking pt to say 99 resonance

Repeat chest expansion, percussion and auscultation posteriorly, with the patient’s
arms crossed in front of them.

Final manoeuvres
Examine for ankle and
sacral oedema
Thank the patient and
cover them up

I would complete my examination by….

“I would like to take a blood pressure, examine the sputum pot, look at the observations
chart (temperature, sats) and perform a peak flow measurement”.

Glossary

Pectus carinatum – a chest deformity in which the sternum bulges forwards (‘pigeon chest
deformity’)
Pectus excavatum – a chest deformity in which the sternum caves inwards
Cachexia – severe wasting usually associated with cancer