Examination of the Respiratory system

2. Clinical examination of the respiratory system is carried out to assess the functional status of the
respiratory tract and lungs
3. General examination Before doing the examination of the respiratory system, a general
examination relevant to the respiratory system should be carried out. Appearance Pallor cyanosis
clubbing (excessive curvature of the nail) venous pulses lymph node enlargement
4. Examination of the respiratory system is carried out by: -Inspection -Palpation -Percussion -
Auscultation
5. Examination of the chest Inspection Shape of the chest The normal chest is bilaterally
symmetrical and elliptical in cross section the transverse diameter > anteroposterior diameter
Comman abnormalities of shape kyphosis -forward bending of vertebral column scoliosis - lateral
bending of vertebral column barrel shaped chest- increase in anteroposterior diameter flattening
6. Inspection Rate & Rhythm of respiration Rate of respiration in health (adult) 12-14 breaths/min
Measurement of chest expansion chest expansion can be measured with a tape measure around
the chest just below the nipples in a healthy adult it is about 3-5 cm Symmetry of chest expansion
chest expansion of a healthy adult should be equal on both sides Movements of the chest wall
presence of intercostal recessions or the use of accessory muscles
7. Palpation Before making a systemic examination palpate any part of the chest where the patient
complains of pain or where there is a swelling Position of the Apex beat and Trachea In normal
subjects the trachea is in the midline and can be palpated in the suprasternal notch the apex beat
(the lowest and outermost point of definite cardiac pulsations) can be usually palpated in the 5 th
intercostal space within the midclavicular line Displacement of the apex beat and trachea indicates
that the position of the mediastinum has been altered This may be due to diseases of the heart,
lungs or pleura
8. Palpation Expansion of the chest Symmetrical or asymmetrical chest expansion can be assessed
by palpation Vocal fremitus Vocal fremitus is the vibration detected by palpation with the palm of the
hand on the chest, when the patient is asked to repeat ninety nine or anunavaya In a normal
healthy adult, the vibrations felt in the corresponding areas on the two sides of the chest are equal in
intensity
9. Percussion The middle finger of the left hand is placed on the chest and middle phalanx is struck
with the tip of the middle finger of the right hand Compare the percussion note (resonant) with that of
the corresponding area on the opposite side of the chest A resonant sound is produced during
percussion The sound and feel of resonance over a healthy lung has to be learned by practice
10. Auscultation Breath sounds There are 2 types of breath sounds - vesicular breath sounds -
bronchial breath sounds Vesicular breath sounds These originate in the larger airways and are
produced by the passage of air in and out of normal lung tissue In good health, they can be heard all
over the chest - the inspiration is longer than expiration -the inspiratory sound is intense and louder
than the expiratory sound -it is a low pitched rustling sound -there is no gap between inspiration and
expiration ins expi
11. Vesicular breathing with prolonged expiration example: airway obstruction (asthma) ins expi
12. Auscultation Bronchial breath sounds These are produced by the passage of air in the trachea
and larger bronchi In good health, they can be heard only over the trachea In disease, bronchial
breathing may be heard over the area of lung that is affected (lung collapse,fibrosis or when there is
a cavity) -the expiration is long as or longer than inspiration -the pitch and sound of the expiration is
loud or louder than the inspiratory sounds -there is a gap between inspiration and expiration ins expi
13. Auscultation Vocal resonance The resonant sound that is heard with the stethoscope when the
patient is asked to repeat ninety nine or anunavaya This depends on the loudness and the
depth of the patients voice and the conductivity of the lungs
14. Auscultation Added sounds These are abnormal sounds that arise in the pleura or lungs Rhonchi
wheezing sounds (asthma) Crepitations bubbling or crackling noises Pleural rub creaking or
rubbing noises associated with pain



















Presenting complaint:
Ask questions:
Cough.
Sputum
Haemoptysis
Dyspnoea
Wheeze
Chest pain
Fever
Hoarseness
Cough: is it dry or productive. If productive, what sort (and quantity) of sputum is being
produced?
Purulent (yellow or green) may indicate bronchiectasis or lobar pneumonia.
Dark, offensive smelling may indicate lung abscess.
Pink frothy secretions (not actually sputum) is associated with pulmonary oedema.
Haemoptysis (coughing up blood): is a red flag for further investigations. May be due to
Ca lung, TB, pneumonia, pulmonary infarction.
Dyspnoea: (Acute, progressive or paroxysmal).
Dyspnoea worse whilst patient is lying down more likely to be of cardiac origin.
Dyspnoea can be graded from I to IV
Class I: Dyspnoea on heavy exertion.
Class II: Dyspnoea on moderate exertion
Class III: dyspnoea on minimal exertion
Class IV: dyspnoea at rest.
Wheeze: Listen for wheeze audible without auscultation. Indicates narrowing of distal
airways.
Can be caused by asthma, chronic obstructive airways disease, airway obstruction by
tumour.
Always consider presence of a foreign body when patient has wheeze. Especially in young
children.
Chest pain: If from a respiratory source, usually pleuritic in nature (ie sharp and worse
on deep inspiration/coughing).
Always consider cardiac origins & perform ECG on any patient presenting with chest pain.
Fever: history of night fevers may indicate TB or pneumonia.
Hoarseness: any patient in respiratory distress with a hoarse voice is waving a red flag.
Seek prompt assessment by senior doctor.
Past History:
Ask questions:
Previous respiratory illness. Or previous abnormal chest X-rays.
Current medications. Many meds can produce respiratory problems including oral
contraceptive (pulmonary embolism), cytotoxic agents (interstitial lung disease), beta-
blockers (bronchospasm), ACE inhibitors (cough).
Is there history of possible exposure to occupational/domestic irritants such as moulds,
wood dust, spray paint, asbestos, coal etc.
Does the patient have high exposure to animals including birds (Q fever, psittacosis).
Smoking:How many cigarettes/packets a day & for how long?
Inspect:
Respiratory Rate | Rhythm | Depth | Effort.
Increased respiratory rate may be due to pain, fear/apprehension or hypoxia.
Remember respiratory rates above 30 (adult) cannot be maintained for long and are
usually an indication of impending respiratory failure.
Decreased resp rate may be due to narcotics, decreased core temp.
Intercostal recession.
Use of accessory muscles (such as the the scalene muscles), or breathing through
pursed lips.
Position. Does the patient prefer to sit forward or tripod?
Anatomical deformities of the thorax.
Evidence of trauma of the thorax.
Cyanosis. Central | Peripheral.
Movement of chest wall. Document any asymmetrical chest wall movement.
Decreased movement on one side may indicate pneumothorax, pleural effusion,
consolidation, pulmonary fibrosis or flail chest.
Document as symmetrical or asymmetrical, chest excursion.
Oxygen saturation. Document any use of oxygen & delivery device.
Level of consciousness.
Auscultate:
Ideally, position patient upright and have them breath through their mouth. Using your
stethoscope listen to breath sounds, comparing each side with the other. You are listening
for quality, intensity, and for the presence ofadventitious (unexpected) sounds.

Quality:
The normal breath sounds heard over the lung fields are referred to as vesicular. They are
usually louder and longer on inspiration and there is no gap between insp and exp sounds.
Bronchial breath sounds are caused by turbulence in the large airways. They are higher in
pitch, hollow, tubular sounds. They are louder and longer on inspiration than expiration,
and there is often a gap between insp and exp (auscultate over your trachea
or manubrium to get an idea of what they sound like).
If you can hear bronchial breath sounds when auscultating your patients chest it is because
the sounds are being conducted to the peripheral lung fields from the large airways by
consolidation (fluid or lung tissue).
Intensity: Some authors recommend documenting intensity rather than air entry. Reduced
intensity on one side of the chest may be due to pleural effusion, pneumothorax pneumonia
etc.
Adventitious sounds (think added sounds):
There is often much confusion about documenting these sounds, but to make it simple,
there are just two (OK maybe three).
Wheeze: [Listen here] Resulting from distal airflow obstruction. They are continuous, high
pitched.er, sort ofhissing sounds caused when air flows through airways narrowed by
secretions, spasm, lesions or foreign bodies((Dont forget: your patient is an asthmatic a
peek flow assessment should be part of your assessment.)).
Beware the silent chest. If present with other signs of respiratory distress, it may signify
total peripheral airway obstruction. Seek assessment by senior doctor.
Crackles:[ Listen here] Described as interrupted, non-musical sounds They are caused by
the distal airways opening during insp and collapsing during exp. I think of them as static in
the lungs.
They may also be further described as:
* Fine: sound of hair being rubbed between the fingers.
* Medium: sound of dreadlocks being rubbed between the fingers.
* Coarse: characteristic unpleasant cackaling, gurgling quality.
Pleural friction rub:a continuous or intermittent grating sound as thickened pleural
surfaces rub together during breathing. Indicative of pleurisy secondary to pneumonia or
pulmonary infarction.
Stridor:[ Listen Here] Stridor is a loud strangulating sound during inspiration indicating
obstruction of the trachea or larynx (unless proved otherwise) requiring immediate review
by a senior doctor.
Stridor is an upper airways obstruction and can be clearly auscultated over the patients
trachea.
Finally, always keep a close eye (and ear) on any patient who presents with respiratory
distress.
Remember patients that have arrived by ambulance may have had treatment that has
temporarily improved their condition. Listen closely to the paramedic handover to get an
idea of their initial condition and have a high index of suspicion that they may deteriorate.
If your assessment and/or your gut feeling is that this patient is deteriorating, seek
assistance promptly.