OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY

SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
OUTLINE
Introduction
A. Review of Respiratory Anatomy A.
B. Review of Respiration Physiology B.
History-Taking
C.
Presenting Symptoms
D.
A. Cough
E.
B. Dyspnea
C. Hemoptysis
D. Abnormal Laboratory

Physical Examination
Initial Survey
Inspection
Palpation
Percussion
Auscultation

I. INTRODUCTION
A. Review of Respiratory Anatomy
Conducting System
Made out of tubes
Nasal cavity and pharynx (upper airways) larynx
trachea main bronchi distal bronchioles (lower
airways)
Bulk of respiratory system
Disturbance would result in a physical complaint

It is important to do PE on both upper and lower

hemithorax due to differences in accessibility
Table 2. Areas to that allow access to the lobes
of the lungs.
Anterior
RUL, RML, LUL (mostly the lingual), LLL
Xiphoid
RML, LLL
Posterior Wing out to examine the upper lobes,
but you will mainly examine the lower
lobes from this position
RUL
posterior
segment,
LUL
apicoposterior segment
Right
All lobes of the right lung, but in limited
Lateral
amounts
Left
LUL, LLL
Lateral

Gas Exchange System

Ensures you get enough O2 and get rid of CO2
Main structures in the periphery
Interruption in this structures with the circulatory syste
can result in dyspnea and cyanosis
Terminal bronchioles alveolar ducts alveoli sacs
o The terminal bronchioles divide into 2-5 alveolar
ducts, each of which consists of 10-16 alveoli
o The adult respiratory system contains ~300M
alveoli
o The surface area of the alveolo-capillary membrane
available for O2-CO2 exchange is approximately 7085m2

Figure 1. Anterior view of the lungs and its

lobes.

Table 1. Cells found in the alveolar level of the

lungs.
Aleveoli
Cell Lining cell which accounts for 95%
Type
I of the alveolar surface area
Pneumocytes
Alveoli
Cell Produces surfactant, a mixture of
Type
II phospholipids, which maintains
Pneumocytes
alveolar stability
Macrophages
Acts as phagocytic defense against
infection
Lung Anatomy
Right Lung (3 lobes)
o Upper Lobe (not accessible from posterior)
o Middle Lobe
o Lower Lobe (direct access from the back)
Left Lung (2 lobes)
o Upper Lobe + Lingular segment
Lingular is observed on the left of the hemithorax
Not accessible from posterior except if you do
maneuver with respect to the scapula
o Lower Lobe
When patients are supine, no access of the posterior
segments
Patients need to hug themselves to wing the scapula
to access the left and right upper lobes posteriorly
Dependent area of the patient when lying supine is the
right lobe
Food tends to lodge at the posterior right upper lobe,
and this is also the common site for aspiration
Lateral view requires that the patient raise his hands
In anterior view, the axis point of the RML is near the
xiphoid

Markikay, James, Allie

Figure 2. Posterior view of the lungs and its

lobes.

Figure 3. Right and left lateral views of the lungs

and its lobes.
B. Review of Respiratory Physiology

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012

Gas Exchange
Primary function of the respiratory system
Exchange of oxygen (O2) and carbon dioxide (CO2)
between the alveoli and pulmonary circulation
Anything that disrupts this function leads to pulmonary
symptoms
Breathing
Largely an automatic act controlled in the brainstem
and mediated by the muscles of respiration
o In a spinal cord injury there may be a problem in
breathing even though anatomy of respiratory
system is normal
Dome-shaped diaphragm is the primary muscle of
respiration
Inspiration is an active process while expiration is a
passive process
o During inspiration, as these muscles contract, the
thorax expands intrathoracic pressure decreases
draws air into the tracheobronchial tree into the
alveoli lungs expand gas exchange takes
place in the alveoli
o
o During inspiration, air enters the upper airway,
travels through the lower airways until it reaches
the alveoli
After inspiratory effort stops, the expiratory phase
begins
o The chest wall and the lungs recoil
o The diaphragm relaxes and rises passively, air
flows outward and the chest and abdomen return
to their resting positions
Any disruption at the level of C3-C4 / (C5) of the spinal
cord leads to disruption of pulmonary function
(remember: C345 keeps the diaphragm alive!)
II. HISTORY TAKING
Systematic investigation surrounding patients chief
complaint (backbone of how you will ask
subsequent questions)
Main task: to land on a valid diagnosis
Basically asking a series of questions in a logical order
so as to pay more attention to the relevant/pertinent
findings
o Relevance of given data is determined based on
experience
o Need to probe deeper with follow-up questions to
clarify the validity of information obtained
Classify uncovered data to pertinent positives and
negatives, and relate all retrieved data to chief
complaint
A good history and PE clinches the diagnosis in 80-90%
of cases (so added labs and maneuvers will only add
10-20%)
Past
medical
history,
family
history,
personal/social history, occupational history
Always ask WHAT, WHEN, HOW in the history of
present illness
Aims of History Taking

Designed to integrate the pertinent positives and

negatives
Establish chronology of events, and link all factors
that may be pertinent
Isolate precipitating and relieving factors most of the
time
Establish severity

Markikay, James, Allie

Treatment/consultation done, lab tests, and possible

response or other findings
The most important goal is to have a directedness in
the lab tests that you will request (if needed): dont
assume the House mentality wherein ordering all
the tests will come first before ruling in or ruling out
certain diagnoses.
Chief Complaint
Common Chief Complaints:
o Cough (most common)
o Dyspnea
o Hemoptysis
o Chest Pain
o Radiographic Abnormality
It is important that the major chief complaint be
isolated especially that Filipinos usually have a lot of
complaints
The chief complaint will direct the next steps in the
history
Past Medical History
Similar symptoms in the past (that could have been
becoming worse or more persistent) and how the
patient responded:
o Dati po ba meron na kayong paubo-ubo?
o You may often times give them cues because
patients may usually forget such instances

Kumusta po ba kayo noong bagong taon? Noong

nagputukan sa inyo?

Any previous operation (e.g. biopsy or surgery)

would give us an inkling of the pulmonary reserve/
capacity of the patient
o Due to the fact that use of gas anethetics will
concern the pulmonary system and any significant
event during the surgery would be valuable
Other diseases and possible treatment
Consultation for other complaints
Previous hospitalization
Family History
Hereditary/ familial diseases (e.g. asthma)
o May na sabihan na ba na may hika katulad niyo?
o Note that allergies shared by family members
could be a contributing factor to asthma
Similar symptoms in the family (significant exposure
history)
o Sa pamilya niyo ba meron ring may ubo katulad
ng sa inyo?
Other diseases like infectious diseases (specially about
close contact), confirmed or suspected (e.g. PTB)
Personal History
Smoking history
o Document whether active or passive
o How many in the family are smoking
Vices (i.e. Drug history)
Drinking history
Sexual history (HIV can have different manifestations
of common pulmonary diseases)
Travel history
o Especially if patient came from an area endemic for
a disease
Occupational History
Work history
o Current and past occupations even among
unemployed

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
o Constant annual check-ups that would be the
reason why the patient is rejected from a job (can
be a clue)
o You may ask his/her specific job description

Recall, the construction worker assumed to be

exposed to certain agents but actually only doing
clerical work (time keeping only)

Exposure to dust, fumes, and other hazards,

protective equipment used, like masks, gloves etc.
Similar symptoms in co-workers
Symptoms when away from job
o Yung bang nararamdaman mo sa trabaho
bumubuti kapag nasa bahay ka?
III. PRESENTING SYMPTOMS
A. Cough
Duration: 2 weeks as cut-of
o Acute (<2 wk) usually infectious; can be asthma
as well (cough can be seen in 30-70% of asthma
cases)
o Chronic (>2wk) PTB, COPD
o TOP THREE differential diagnoses:

Post-nasal drip (most common cause)

Asthma (2nd most common)
PTB (3rd most common cause

o Asthma prevalence in the Philippines: 22%

o In the Philippines, chronic cough w/o any obvious
cause should rule out PTB
Precipitating/relieving factors/timing
o Precipitating factors exposure to a particular
agent

Anong nagpapalala?
e.g. asthma (usually patient is aware of the trigger) in
the Philippines, house dust mite (cleaning the house)
remains the #1 trigger of asthma; change of weather
can also trigger

o Relieving factors

Filipinos love to self-medicate; thus, beta-adrenergics

(e.g. salbutamol) and lagundi are usually used
If relieved by inhaler and nebulizer (pinausukan) = MAY
weigh towards asthma as one of the potential causes

But in general, these information on non-specific

medication will not give pertinent data
o Timing when the symptoms are felt

Postnasal drip: symptoms worsen during morning or

when the patient assumes a recumbent position, due to
pooling of secretions that could trigger cough (but not
yet 100% proven)
It is known that when we sleep (even for normal
people), the caliber of our airways decrease = one of
the reason why people with obstructive sleep apnea
snore

Any accompanying symptoms

o Hemoptysis

Any pathology that has connection to the airway lesion

can lead to hemoptysis
Does not warrant a diagnosis of lower respiratory tract
disease such as PTB
From blood-tinged sputum to dark blood coughed up

o Phlegm

If the phlegm is yellow or purulent, it may signify an

infection, particularly bacterial rather than viral

o Fever

In PTB, fever is intermittent; also with wasting/cachexia

If accompanied by phlegm or fever implies infection.

Any previous medications and response

o Most medications non-specific and focus only on
symptomatic relief

OTC drugs such as mucolytics (e.g., carbocisteine) are

commonly used by Filipinos
Tuseran, Robitussin
Non-specific medication such as lagundi is also used

Markikay, James, Allie

o Some may be taking bronchodilators such as a 2

agonist Salbutamol (if a patient responds to this
drug he/she may not necessarily asthmatic)
o Inhalants

BLUE/GREEN rescue drugs such as salbutamol

RED/BROWN/ORANGE - steroid

o Information on anti-TB drugs may not be voluntarily

given by the patient so you might have to probe

So ask who gave it to them (if from health center then

if anti-TB meds, they are in a banig and not only one
type)
Change in color in urine since taking rifampicin

o Dont forget to ask for the patients response to the

drug
Labs done
o Diagnosis of the previous doctor

Most remarkable if parenchymal disease

In a lot of instances, patients remember doctors advice
and pertinent findings

o Chest X-ray (CXR)

Ask if there was anything found in the CXR

Coughing Sounds
Etiology cannot be determined by the sound of the
cough
o Although, in pediatric cases etiology may be
determined by the sound
Sound does not dictate severity
Character and timing of cough are not helpful in
predicting its cause in adults
ACTIVITY: Are you going to use a mucoactive agent?
o Non-specific
o With eheck eheck eheck
o High pitch eheck
o Waaheeeeck: mahalak yung ubo
o With wheezing: mahuni na ubo
o It would seem that last two are worse, but
actually all came from cancer patients
B. Dyspnea
Subjective complaint so mainly determined by
patients threshold
Duration
o Filipinos tend to underestimate dyspnea, which is
why it is important for patients to quantify their
dyspnea
o Most of the time dyspnea is secondary to chronic
disease
o Acute dyspnea may be more life threatening than
chronic type
o You might have to challenge the patient because
Filipinos tend to deny their symptoms

Talaga kahapon lang? Kamusta kayo last month?

Precipitating/relieving factors/timing
o Principally important in association with other
symptoms, such as chest pain
o The degree of activity that precipitates it
o Compensatory activities should be asked

From Taft to PGH, usually you walk, but patient used a

pedicab
Using of elevators even if climbing the stairs is more
practical (like going up to the LRT station)
Nagtago sa banyo dahil sa putukan during New Year

o Diferentiate pulmonary and cardiac etiology

Dyspnea with cough is usually pulmonary in
origin
Table 3. Pulmonary vs.
Pulmonary
Relief upon
expectoration
Usually associated with

Cardiac Etiology.
Cardiac
Relieved with certain
meds (nitrates) and rest
Other associated

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
sputum
Awakens after only a
few hours of sleep
(pooling of secretions)
Circadian variations
(dramatic during early
mornings)

symptoms
Awakens after several
hours (since pressure
changes first before loss
of breath)
Orthopnea, PND
Worsens at the end of
the day

Any accompanying symptoms

o Cough (may be a sign of chronic bronchitis or
emphysema)

Note that in CHF (cardiac rather than

pulmonary), some may complain of exporation of
frothy saliva
o Chest Pain (occurs both in cardiac and pulmonary
in origin; if pulmonary in origin, it is worsened by
deep breathing)
o Edema (in heart failure; if cardiac in etiology,
called cor pulmonare)
Any previous medications and response
o Nitrates given in previous MI
o If pulmonary in origin, beta-2 agonists make
patients feel better because of bronchodilation =
obstructive
lung
dieases
(COPD,
asthma,
ephysema, chronic bronchitis)
o Note that previous hospitalization due to dyspnea
is common, so pertinent to inquire
Labs done
o CXR
o Spirometry
o ECG (to check if cardiac in etiology)
C. Hemoptysis
Blood-tinged sputum
Signals any pathology connected with the airway might
slough off parenchyma causing blood release, so can
be:
o Sinusitis: Inhaled nasal secretions
o Bronchitis: when you try to produce expectorate on
inflamed airway, friction will occur
Amount tentative cut-off: 600 ml
o >600 ml massive hemoptysis (most critical factor
is hematologically unstable since nobody really
measures, so matter of estimation)
o <600 ml non-massive hemoptysis
o Most of the time, this amount is not significant

Focus on the accompanying symptoms

Patients dont tend to exaggerate since they know that
doctors might result to invasive techniques

Duration majority of bacterial infections have short

duration (<1 wk) of hemoptysis
o Acute allergy, bacterial infection
o Chronic lung malignancy, TB
Accompanying symptoms
o Cough (most common accompanying symptom)
and if persistent, fever and events prior to
hemoptysis

If frothy = congestion
If pinky = secretions in congestive heart failure)

o Weight loss, loss of appetite (TB)

Precipitating/relieving factors/timing
o Usually inhaled foreign body (localized wheeze =
localized obstruction) that precipitated it
o Ate tuna sandwhich then started coughing then on
X-ray there was a fishhook (from the tuna)
Causes may be TB or any malignancy
Labs acid fast bacilli (AFB) smear, CXR

Markikay, James, Allie

D. Abnormal Laboratory
Usually asymptomatic (according to patients) but
there are incidental findings on tests
Why was lab/investigation done in the first
place?
o Was it because the patient sought for consult
because he/she is not feeling well?
o Was it because the physician has already
suspected an abnormality?
o For the purpose of pre-employment or abroad
clearance?
Duration of symptoms
Previous labs or medical advice
o Comparison of CXR (4-6 mo interval)
o Without change in lesion within the said interval
can be a stable lesion that has progressed already
to fibrosis and calcification
IV. PHYSICAL EXAMINATION
Note that these are from Bates (in preparation for
OSCE so we know how to position the patient)
For men, arrange the gown so that you can see the
chest fully
For women, cover the anterior chest when you
examine the back and for the anterior examination,
drape the gown over each half of the chest as you
examine the other half
With the patient sitting, examine the posterior thorax
and lungs
o The patient's arms should be folded across the
chest with hands resting, if possible, on the
opposite shoulders

This position moves the scapulae partly out of the way

and increases your access to the lung fields

With the patient supine, examine the anterior thorax

and lungs
o The supine position makes it easier to examine
women because the breasts can be gently
displaced
o Wheezes, if present, are more likely to be heard
For patients who cannot sit up without aid,
o Get help so you can examine in the sitting position
o If this is impossible, roll the patient to one side
o Percuss upper lung, and auscultate both lungs in
each position

Because ventilation is relatively greater in the

dependent lung, your chances of hearing abnormal
wheezes or crackles are greater on the dependent side

A. Initial Survey Of Respiration And Thorax

Can be done while questioning/interviewing the
patient
Observe respiration:
o Rate (Normal RR=14-20/min. adult)
o Rhythm
o Depth and effort of breathing
o Note whether expiration lasts longer than usual
Any signs of respiratory distress
o Cough
o Alar flaring
o Ask open-ended questions so patient will offer
answers in sentences to assess if patient speaks in
sentences/phrases or words
o Contraction of the accessory muscles in the neck
(sternocleidomastoid, scalene), or supraclavicular
retraction
o Abnormal retraction of the interspaces during
inspiration
Most apparent in the lower interspaces

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
Assess patients color for cyanosis
Listen to patients breathing (e.g. labored? audible
wheeze?)
Observe shape of the chest (i.e. AP diameter)
B. Inspection
Examine skin over the chest for lesions that restrict
respiratory excursion
Chest wall structural deformities. (e.g. barrel chest,
pigeon breast)

Focus on areas of tenderness, abnormalities in

overlying skin, respiratory expansion and
fremitus
Palpate if trachea is midline, any lymph node
enlargement, costochondral enlargement, thyroid
from the back
Identify tender areas
o Rib/costochondral tenderness
o Soft tissue masses/ tenderness
Assess any observed abnormalities
o Soft masses
o Sinus tracts: blind, inflammatory, tube-like
structures opening onto the skin
o Lesions
Test chest expansion
Feel for tactile fremitus
Palpate and compare symmetric areas (equality)
Testing Chest Expansion

Ask the patient to hug himself (right hand over left

shoulder and left hand over right shoulder) to WING
OUT SCAPULA for easy access
Place your thumbs at about the level of the 10th
-11th ribs, with your fingers loosely grasping and
parallel to the lateral rib cage
Table 4. Chest shapes.
As you position your hands, slide them medially just
enough to raise a loose
Wider than it is deep (lateral>AP
Inspect while in front of or
fold of skin on each side
Normal
diameter)
between your thumb and
at the side of the patient.
Pectus
spine
Observe
retraction
of
Depression on lower portion of sternum
Excavatum

Ask the patient to inspire

interspaces and other signs
Compression of heart great vessels may
(Funnel
of
labored
breathing
Watch
the
distance
cause
murmurs
Chest)
especially
during
between your thumbs as
conversation (i.e. use of
Increased AP diameter
they move apart and feel
Barrel
sternocleidomastoids)
for
the
range
and

Normal
during
infancy,
often
Chest
From a midline position
symmetry
of
the
rib
cage
accompanies COPD, chronic bronchitis
as
it
expands
and
behind the patient (expose
Sternum is displaced anteriorly,
contracts
the patient well and ask
increasing the AP diameter
Pectus
permission),
note
the
Any pathology can lead
Carinatum Costal cartilages adjacent to the
shape of the chest and the
to chest lag something
(Pigeon
way it moves, including:
interferes with air going
protruding
Chest)
o Abnormal retraction of
out of the lungs
sternum are depressed
interspaces
during
o
Accumulation of air
Most often secondary to trauma
inspiration
(note
(pneumothrorax), fluid,
supraclavicular retraction)
mucus and inflammation (in pneumonia)
o Impaired respiratory movement on one or both
sides or unilateral lag or delay in movement
Figure 4. From left to right: Pigeon chest; typical
chest of COPD patient; kyphoscoliosis (spinal
deformity)

Ipsilateral displacement towards the affected lung

indicates a volume-loss problem

C. Palpation
Palpate to test respiratory excursion, especially
posteriorly
Palpate for tracheal position
Palpate for any soft tissue masses/tenderness (which
students usually miss)
Palpate for rib/costochondral tenderness
Palpate for tactile fremitus, using base of fingers or
edge of your hand, comparing the two sides of the
chest
Palpate from posterior (Pxs back) to anterior
Tracheal Position
Very important
If trachea is displaced ipsilaterally to the affected
lung volume loss problem
Use the clavicular head of SCM as take-off point
Palpation of the Chest

Markikay, James, Allie

Figure 5. Respiratory excursion

Tactile Fremitus
Palpable vibration of the chest wall from sounds
transmitted from the phonating larynx
Ask the patient to hug himself to wing out scapula
Place hand diagonally on an ICS (ONE level at a
time!) and palpate for tactile fremiti using the base
of the fingers, palm or ulnar surface of your hand (if
anterior, avoid cardiac area)
Ask the patient to say ninety-nine or tres-tres
creates the greatest vibration in the larynx
Compare symmetry and perform at different levels

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
Often more prominent on the right side than on the
left
Disappears below the diaphragm
If normal and no impediment, the vibration will be
transmitted equally
Findings: may be decreased or increased if abnormal
o Increased TF: fibrothorax with collapsed airway,
intervening tissue, after surgical procedures,
consolidation secondary to pnemonia
o Decreased TF: pleural effusion, lobar consolidation,
fluid effusion, solid mass

Figure 7. Areas of Percussion

Figure 6. Points to feel for tactile fremitus. Avoid

the cardiac area when feeling for the fremitus
over the anterior aspect of the chest.
D. Percussion
Defines density of underlying structures by
differences in sound wave conduction
Again if you percuss in the posterior aspect, WING
OUT SCAPULA
Avoid bony structures like the scapula and the
vertebra
Table
5.
Percussion
Notes
and
their
Characteristics (MUST KNOW!)
Sound
Intensi Pitch
Durati
Example
ty
on
Flatness
Soft
High
Short
Thigh
muscle
Dullness
Mediu
Mediu
Mediu
Liver
m
m
m
Resonanc Loud
Low
Long
Normal
e
lung, over
right
pectoralis
HyperVery
Lower
Longer
None,
resonanc
loud
normally;
e
Pneumothor
ax
(accumulati
on of air)
Tympany
Loud
High
Longer
Gastric air
bubble

Markikay, James, Allie

Figure 8. Ladder-like pattern for percussion and

auscultation over the anterior (left) and
posterior (right) thorax.
Technique
Avoid injury by cutting your fingernails
Hyperextend the middle finger of your left hand,
known as the pleximeter finger. Press its distal
interphalangeal joint firmly on the surface to be
percussed
Avoid surface contact by any other part of the hand
as this dampens our vibration (only one finger should
be tapped; 2nd and 4th finger are only used to
stabilize the 3rd finger)
Position your right forearm quite close to the surface
with the hand cocked upward. The middle finger
should be partially flexed, relaxed and poised to
strike
With a quick, sharp but relaxed wrist motion,
strike the pleximeter finger with the right middle
finger or plexor finger
Make sure that you:
o Aim at your distal interphalangeal joint
o Strike using the tip of the plexor/middle finger, not
the finger pad
o Your finger should be almost at right angles to the
pleximeter
o Withdraw your striking finger quickly to avoid
dampening the vibrations you have created
In summary, the movement is at the wrist. It is
directed, brisk yet relaxed and a bit bouncy.

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
o If you hear or suspect abnormal sounds, auscultate
adjacent areas so you can fully describe the extent
of any abnormality
o Listen to at least one full breath in each location
Normal Breath Sounds (MUST KNOW!)

Figure 9. Examination of the chest percussion.

Note though that in the figure, only one finger
should be in contact with the surface since the
more fingers in contact, the more the sound is
dampened.
Dull - over thigh
Flat -over forehead
Resonant - over right pectoralis
Notes:
o Preceptors particularly observe the movement of
the wrist
o Make sure you percuss on the intercostal
spaces and NOT on the ribs
o Anterior percussion: avoid the cardiac shadow
o Lateral percussion not required
o Ask patient to inspire, check the descent of the
lungs
o Percussion not usually done on side of hemithorax

E. Auscultation
(A)

(B)

Tracheal and Bronchial Breath Sounds

o Loud, high-pitched tubular sounds heard over the
trachea and mainstem bronchi (central, large
airways).
o Produced by turbulent airflow patterns.
o Located at the parasternal areas
o IE ratio= 1:2 to 1:3.
o Sound frequency = 200 to 2,000Hz.
o Heard over chest wall on either side of the sternum
from 2nd to 4th ICS anteriorly and along vertebral
column from 3rd to 6th ICS posteriorly.
Vesicular breath sounds (in peripheral airways)
o Airway opens up
o Peripheral
o Produced by changes in airflow patterns, quieter
than bronchial/tracheal BS
o Inspiration is heard clearly, immediately followed
by expiration which quickly fades as airflow rates
rapidly decline and turbulent airflow is directed
towards the central airways
o IE ratio=3:1 to 4:1. Sound frequency = 200-600Hz
Bronchovesicular breath sounds (at posterior)
o Heard anteriorly and posteriorly over large central
airways (proximal airways)
o Pitch & duration between vesicular and bronchial
breath sounds
o IE ratio=1:1
Bronchial Breath Sounds (at large airways,
bifurcations)
o Occurs when lung tissue between central airways
and chest wall becomes airless because of
conditions that increase lung density, thus
enhancing transmission of breath sounds which
become louder, more tubular
o IE ratio=1:1 or 1:2
o Seen in consolidation, atelectasis and fibrosis
(which increase lung tissue density by fluid
accumulation, lung collapse or fibrotic scarring)
How Dr. Benedicto described the normal breath sounds
(Note that the information he supplied were not consistent
with the information from literature, specially on duration of
sounds)

(C)

(D)

Figure 10. Areas of Auscultation and Percussion

(A) Anterior (B) Posterior (C) Right Lateral (D)
Left Lateral
Process
Learn to identify patterns of breath sounds by intensity,
pitch, and the relative duration of inspiratory and
expiratory phases
Listen to the breath sounds with the diaphragm
(from Bates, but sir said bell) of a stethoscope
(10-12 inches)
Instruct the patient to breathe deeply through an
open mouth
Use the pattern suggested for percussion, moving from
one side to the other and comparing symmetric
areas of the lungs

Markikay, James, Allie

o Trachael: tubular and longer expiration and shorter

inspiration since stethoscope is in the neck
o Parasternal (Bronchial): Larger airways also tubular
o Back: tubular first as it goes to terminal bronchioles,
then to the alveoli (like bubbles)
o In peripheral lung fields: faster expiration since
stethoscope nearer to the alveoli
Table 6. Characteristics of breath sounds
Duratio
Intensit
Pitch of
n of
y of
expirato
sounds
expirato
ry
ry
sounds
sounds
Vesicul
Insp >
Softer
Relativel
ar
Exp
y low
Bronch
ovesicul
ar

Insp =
Exp

Intermedi
ate

Intermed
iate

UPCM 2016 B: XVI, Walang

Kapantay!

Normal
location

Both
lung
fields
1st and
2nd ICS
anteriorl
y;
between
scapulae

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OS 213: Circulation and Respiration

LEC 09: PHYSICAL DIAGNOSIS OF THE RESPIRATORY
SYSTEM
Exam 2 | Dr. Jubert P. Benedicto| August 14, 2012
Bronchi
al

Insp <
Exp

Loud

Relativel
y high

Trache
al

Insp =
Exp

Very loud

Relativel
y high

Over
manubri
um
At
sternal
notch

Figure 11. Normal breath sounds with graphic

representation of duration and quality during
inspiration and expiration.
Abnormal Voice Sounds (must-know)
Voice sounds are produced by vibrations of the vocal
cords as air from the lungs passes over them
Normally, vowel tones which contain high frequency
sounds are filtered and diminished. However, over
consolidated or atelectatic lung tissue, less filtering
takes place, thus, enhancing transmission
These sounds are rarely heard
The three types of abnormal voice sounds:
o Bronchophony clear, distinct and intelligible
voice sound heard over airless lung tissue
o Whispered Pectoriloquy clear, distinct,
intelligible whispered voice sound heard over
airless, consolidated/atelectatic lung tissue; in
pleural
effusion

with
nasal
twang;
scratching/rasping sound
o Egophony voice sound with a nasal or bleating
quality heard over the chest wall over
consolidated/atelectatic lung tissue, also seen in
upper border of a large pleural effusion
Adventitious Sounds (ATS, 1977)
Crackles (Rales) discontinuous sounds and heard
more in inspiration
o Coarse crackles loud & low pitched (pus-filled or
phlegm, usually due to infection, e.g. pneumonia,
inflammatory condition)
o Fine crackles less intense, higher pitch & short
duration (hemorrhage, congestion, or fluid-filled)
o Sound produced when you rub hair strands
together
o Not required to be differentiated during OSCE,
identifying the presence or absence of crackles will
suffice
o 2015: accdg. to Sir, parang straw sa softdrinks
pag ubos na
o Any fluid filled alveoli will have a respiratory sound
with crackles , wherein the fluid is thinner so
sound is finer
Wheezes

Markikay, James, Allie

o Continuous sounds that are high-pitched with

hissing sound, due to narrowing of airways
o Problem in airways so heard more in expiration
(but can be also inspiration)
o Indicates small airway obstruction
o E.g. asthma
o Tends to be exaggerated during expiration since
our airways collapse during expiration
o 2015: parang dinosaur
Rhonchi or Low-Pitched Wheezes
o Low-pitched continuous sounds
o Heard primarily during inspiration (but according
to sir, it is again better heard in expiration since a
problem of airway like wheezes)
o Airway problem (COPD, asthma)
o Caused by fluids/secretions partially blocking large
airways
o Harsh, tubular sounds
Pleural Friction Rub
o Due to generalized inflammation of visceral and
parietal pleura
o Leathery quality (like crackles but heard all
throughout since affects the pleura)
o But rarely heard since usually accompanied by
pleural effusion which dampens sound
Stridor
o Loud musical sound (no more tubular quality) that
is heard at a distance without a stethoscope
o Narrowing of airway passage
o Caused by laryngeal spasm (allergic) and
mucosal swelling (prolonged intubation causes
inflammation)
o Typically heard during inspiration, but maybe heard
throughout the respiratory cycle
o Patient is breathing in while closing the glottis
o Indicates upper airway obstruction like the
trachea
o Localized
hacking
sound;
2015:
parang
lagari/saw

END
Marky: Im so boring na I dont have any message in
particular. BUUUT Ray just gave me an idea. I would
like to greet Mich. I love you and I miss you! More
drama soon. Heehee! To Lee Tan, I love you too. To Erik,
Im sad that you hate me
James: Malapit na mag-sembreak! Nag-aaya kami ni
Terence ng surf trip this weekend sa LU since long
weekend naman. Tara!
Allie: It wasnt a dark and stormy night. It should
have been but thats the weather for you. (Gaiman &
Pratchett, 1990)

UPCM 2016 B: XVI, Walang

Kapantay!

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