The slides will be helpful to both UGs and PGs during clinical rounds.

1. CLINICAL EXAMINATION OF
RESPIRATORY SYSTEM...
Saswat..

2. THE SEQUENCE OF EXAMINATION...
1.
•Inspection
2.
•Palpation
3.
•Percussion
4.
•Ausculation

3. INSPECTION
• Is what you see.
• 2nd most important method of examination
(2nd to ??).
• Sitting up/standing/lying down position.
• Stripped upto the waist.
• Adequate light.

4. What to look for?
• Symmetry.
• Shape of the chest.
• Movement of the chest.
• Position of the trachea.
• Position of apical impulse.

5. • Involvement of accessory muscles.
• Any visible scars, sinuses, engorged veins or
fistulous tracts.

6. • Presence of bony deformity: kyphosis or
scoliosis.
• If the chest is asymmetrical:
- Drooping of shoulder.
- Spino-scapular distance.
- Lower border of scapula.
- Medial border of scapula.
- Arm-chest distance.
- Level of nipple.

7. The normal chest...
• The normal shape of the chest is ??
Ellipsoidal.
• B/l symmetrical.
• AP:T = 5:7.
• Subcostal or epigastric angle of almost 90
degree (more acute in males).

8. Abnormal shapes of the chest...
• Pectus carinatum/ pigeon chest:
- Forward protrusion of the sternum.
- Straightening of the ribs in the front
- Congenital, rickets, chronic nasopharyngeal
obstruction.
• Alar chest:
- Undue prominence of vertebral borders of
scapula.
- Increased obliquity of ribs.

9. • Funnel chest/ pectus excavatum/ cobbler’s
chest:
- Exagerated hollow over lower end of
sternum.
- Congenital, occupational, Marfan’s syndrome.
• Barrel chest:
- Increased A-P diameter, ribs more horizontal.
- Sternum arched with prominent angle of
Louis.
- Circular cross section.
- Emphysema, kyphosis of spine, old age.

10. • Rachitic rosary:
- Pigeon chest.
- Harrison’s sulcus: grooves or depression on
either side of xiphisternum, corresponding to
costal attachments of diaphragm.
- Rickety rosary: bead-like enlargement of
costochondral jn. (esp. 4-6th ribs).
- Vertical grooves on either sides of sternum.
• Scorbutic rosary:
- Sharp angulation of the ribs.
- Backward displacement of sternum.

11. Barrel Chest…
Pectus Carinatum

12. Pectus excavatum

13. Asymmetry of chest?
Spine
deformity
• Kyphosis
• Scoliosis
• Both
U/l uniform
bulging
• PLEF
• Pneumoth
orax
• Compensa
tory
hypertrop
hy
Localised
bulging
• Empyema
necessitan
s
• Mass
lesion
(lung/medi
astinum/
chest wall)
• Pericardial
effusion
• Aortic
aneurysm
Localised
retraction
• Fibrosis
• Collapse
• Pleural
thickening.
• Muscle
wasting
(polio)

14. Quiz time!!
• Normal respiratory rate is?
• Which is active: Inspiration/expiration?
• Respiration to pulse ratio is?_____
• Type of respiration in females?
Thoracic/abdominal?
• What is the effect of opioid on respiration:
pulse ratio?

15. Altered respiration to pulse ratio
• Heart block.
• Pneumonia.
• Opioid poisoning.

16. Palpation…
• Standing/ sitting position.
• For apical and upper zones, put 2 hands
over the apical region with thumbs
approximated in the midline.
• For middle and lower lobes, hands are
placed on either side of the chest wall and
thumbs are stretched to meet in the
midline.

17. • All inspection
findings are
confirmed.
• Position of trachea.
• Apex beat.
• Chest expansion.
• Measurements of
hemithorax.
• Vocal fremitus.
- Same hand applied
on both sides.
- Compare symmetrical
areas.
- Increased in
consolidation or
fibrosis.
- Decreased in c/o fluid
or air in pleural space.
- Maintain pitch and
tone of voice.

18. • Rib crowding.
• Localised swelling/tenderness.

19. Percussion…
Diagnostic
(determines state
of underlying
tissues)
Topographical
(determine
boundaries)

20. Rules of percussion.
• Sitting/ standing/ recumbent.
• Pleximeter (middle finger of left hand) should be
firmly placed on the chest wall along an
interspace, with no interposed airpockets.
• Other fingers must be held away from the chest
wall.
• The plessor (middle finger of the right hand)
should hit the middle phalanx at 90 degree, with
the pad of the finger.
• Movement of the plessor should be at the wrist.

21. • The force of stroke varies on the thickness of the
chest wall, age , sex and area of chest wall
percussed.
• Proceed from resonant to dull areas or more
resonant to less resonant areas.
• While delineating the borders, the long axis of
pleximeter should be parallel to the expected
border.
• The area must be equidistant from both ears.

22. Sequence of events…
• Direct percussion over clavicle (at
medial 1/3rd and lateral 2/3rd ).
• Kronig’s isthmus.
• Resonant note.
• Abnormal percussion notes.
• Cardiac dullness.
• Liver dullness (at mid-clavicular line,
mid-axillary line and scapular line).
• Traube’s space.

23. • Shifting dullness.
• Succusion splash.

24. Types of percussion note.
• Resonant note: - low pitch.
- Lesions >5cm deep or <2-3cm do not alter the
resonant note.
• Tympany: - normally on abdomen, trachea, larynx.
- drum-like.
- Superficial cavity.
• Subtympany/ Skodaic resonance: - hyper-
resonance with a boxy quality.
- Just above the level of pleural effusion/
consolidation.

25. • Hyper-resonant note: - intermediate in pitch
between resonance and tympany.
- u/l or b/l emphysema
Pneumothorax, large bulla, compensatory
emphysema
• Impaired note: - when part of a lung
becomes comparatively airless.
- consolidation, collapse, fibrosis.
• Dull note: - consolidation, collapse, fibrosis.
• Stony dullness: - dullness associated with
pain in the pleximeter finger of the examiner
(like percussing on a rock).
- Pleural effusion, mass lesion.

26. • Cracked-pot resonance: - normally
elicited over the chest of a crying infant.
- Lung cavity in communication with a
bronchus due to sudden expulsion of
air from cavity into the bronchus.

27. • Kronig’s isthmus: - area of resonance
connecting the large areas of resonance over
the anterior and posterior aspects of each side
of the chest.
- 5-7cm in width.
- Bounded medially by neck muscles, laterally
by acromioclavicular joint, anteriorly by
clavicle and posteriorly by trapezius.
- Percussed medially from the acromioclavicular
joints.

28. Tidal Percussion…
Percuss till
the lung
resonance is
lost.
Ask the patient
to take a deep
inspiration and
then percuss
again.
Dull note persists in case of
diaphragmatic palsy/ PLEF.
Dull note becomes resonant in
case diaphragm is pushed up.

29. • Traube’s space: - area of tympanic note
at the lower border of left lung.
- Bounded above by pulmonary
resonance, below by the costal margin,
liver on the right and spleen on the left.
- Content: fundus of the stomach.
• Ewart’s sign: area of dullness and a
tubular breath sound at the angle of
scapula in c/o a large pericardial
effusion.

30. • Shifting dullness:
- In c/o hydro-pnx or pyo-pnx or
moderate PLEF.
- Delineate the upper border of dullness.
- With the pleximeter at that position, ask
patient to lie down/bend forward
- Demonstrate resonance at the area of
dullness.

32. Auscultation.
• Sitting/ standing position.
• Deep breathing with the mouth.
• Scheme of examination:
- Vesicular breath sounds.
- Abnormal breath sounds.
- Vocal resonance.
- Added sounds.
Right Left

33. • Normal breath sounds are produced
at?
• Sound production is due to turbulent
airflow.
• The higher pitched sounds are filtered
as it is transmitted through the lungs.

34. Properties of the various breath sounds.
• Vesicular: - rustling or breezy quality (low pitched).
- Louder and longer inspiration.
- I:E=3-5:1.
- No pause.
- Characteristic in axillary and infrascapular regions.
• Tracheal sounds: - similar to bronchial breath
sounds but louder.
• Bronchovesicular breath sounds: - intermediate
quality between tracheal and vesicular.
- Normally heard at upper part of sternum, at level
of T3-T4 posteriorly.

35. Abnormal breath sounds.
• Loud vesicular breath sounds: thin chest wall,
compensatory emphysema.
• Reduced breath sounds: - Pain: pleurisy,
percarditis, painful spine.
- Weakness of respiratory muscles: poliomyelitis.
- Decreased lung elasticity: emphysema.
- Decreased conduction of breath sounds: PLEF,
pneumothorax, pleural thickening.
• Absent breath sounds: pneumothorax, PLEF,
collapse.

36. • Bagpipe sign: - In case of partial obstruction
of a large bronchus, breath sound may be
heard even after a forced expiration.
- This occurs due to delay in equalisation of
both pressures.
- B/l in case of asthma and u/l implies partial
obstruction of a large bronchus.
- Similar findings may be observed in
inspiration where, if u/l signifies a large
airway obstruction and b/l implies
epiglottic/tracheal obstruction.

37. Bronchial breath sounds..
• High-pitched.
• I:E =1:1.
• Pause between inspiration and
expiration.
Tubular
Cavernous
Amphoric

38. • Tubular: - high pitched.
- Consolidation, massive PLEF (heard over
lower part of back, as the collapsed LL
conducts sounds from a large bronchus).
• Cavernous: - lower pitched.
- Hollow character.
- Normal over occipital region.
- Cavity with irregular borders, open
pneumothorax, pulled trachea.

39. • Amphoric: - high pitched.
- echo-like/ metallic quality.
- Imitated by blowing across a bottle
mouth/ open end of a rifle.
- Large cavity with smooth walls,
pneumothorax communicating with a
bronchus.

40. Representation of
the various breath
sounds.

41. Added sounds.
1. Wheeze: -
continuous
musical sounds
produced by
flow through
narrowed
airways.
- Produced when
air is forced past
a point at which
opposing walls
are just
touching.
Wheeze
Monophon
ic
Fixed
Rando
m
Polyphon
ic
Expirator
y

42. a. Fixed monophonic wheeze: - constant pitch ,
timing and site.
- Produced when air passes at high velocity through
a localised narrowing in a large airway.
- Intrabronchial mass lesion, fb, lymph node
obstructing a bronchus.
Predominantly in inspiration
•Larynx
Predominantly in expiration
•Lower trachea, main bronchus.

43. b. Random monophonic wheeze: random
single notes of varying duration, timing and
pitch. E.g. bronchial asthma, bronchitis.
c. Polyphonic: - expiratory musical
soundcontaining several notes of different
pitch.
- Due to oscillation of several large bronchi
simultaneously brought to a point of closure
by congestion of mucus lining, thickening of
mucus and contraction of smooth muscles.
- COPD, asthma.
[Inspiratory wheezes are called squawks].

44. 2. Crepitations: - interrupted, short, sharp non-
musical sounds.
- Produced by snapping open of the airways
causing sudden equalisation of pressures
when a closed airway separating 2 adjacent
compartments of the lung, that contain gas
under widely different pressures.
- Early inspiratory: COPD (arises from large
airways, coarser and not related to posture).
- Late inspiratory: ILD, pulmonary edema
(arises from small airways, best heard at
lung bases).
- Expiratory: severe airway obstruction.
Clears on cough
No change on bending forward.

45. • [Crepitations in bronchiectasis is
biphasic, coarse, leathery while that in
ILD is fine, mid-to-late inspiratory].

46. 3. Pleural rub: - due to rubbing of the 2 pleural surfaces.
- Commonest site is the lower part of axilla.

47. Other added sounds.
• Succussion splash: - splashing sound heard with
a stethoscope when the chest of a patient is
suddenly shaken.
- hydropneumothorax, herniation of abdominal
contents into chest, large cavity filled with fluid.
• Hamman’s sign: - systolic crunching sounds
heard over the left sternal border (3rd -5th
intercostal space) with the patient in sitting
position.
- Mediastinal emphysema, lt. pneumothorax,
emphysema of lingula, lower esophageal
dilation, dilation of stomach, pneumoperitoneum
with ascent of lt diaphragm.

48. Interesting..
• Post tussive suction: - medium or low pitched
during long inspiration, following a bout of cough.
- Thin walled, collapsible lung cavity in
communication with a bronchus.
• Falling drop sound: - metallic or tickling sound
induced by change in posture, coughing or
laughing.
- hydropneumothorax, large cavity with fluid and
air.
- Due to fluid falling onto fluid level/ bursting of
bubbles on water surface.

49. • Water-whistle sound: - in case of a fistulous
opening below the level of a fluid in case of a
hydropneumothorax.
- Bubbling sound with a metallic quality.

50. Vocal resonance.
• Auscultatory equivalent of tactile VF.
• Heard as weak, muffled, indistinct sounds.
• Louder and clearer over trachea.
• Louder in suprasternal area, interscapular
area, C7.
• Increased VR: consolidation, superficial
cavity, compensatory emphysema.
• Decreased VR: PLEF, Pneumothorax,
thickened pleura.
• Absent VR: pneumothorax, large PLEF.

51. • Bronchophony: - spoken voice sounds are
unduly loud and clear, although still
indistinguishable.
- consolidation, above the level of PLEF.
• Aegophony: - spoken voice sounds have a
peculiar nasal quality.
- Like the bleating of a goat.
- Above the level of PLEF, cavity filled with
secretion.

52. • Whispering pectoriloquy: - whispered voice
sounds are transmitted to the chest wall with
clearly distinguishable syllables.
- Cavity communicating with a bronchus,
consolidation, above the level of PLEF.

53. D’espine sign…
• A whispering sound followed the
spoken voice in some patients over the
upper thoracic vertebra of some
patients, which was not normal.
• He considered it to be the earliest sign of
enlarged trachea-bronchial LN.