The document outlines a comprehensive procedure for the respiratory system examination, including inspection, palpation, percussion, and auscultation techniques. It details how to assess the shape, movements, and sounds of the chest, as well as specific abnormal conditions that may be observed. Key points include the normal respiratory rates, identification of respiratory patterns, and the significance of different breath sounds.

1. RESPIRATORY SYSTEM
EXAMINATION
DR AXELLE SAVERETTIAR

2. Position of subject
The respiratory system examination is ideally done with the
subject comfortably resting on the bed, sitting at an angle
of 45˚ and supported by pillows.

3. RESPIRATORY SYSTEM
EXAMINATION
1.Inspection 2. Palpation 3. Percussion 4. Auscultation

4. 1.INSPECTION I. SHAPE OF THE CHEST
II. MOVEMENTS OF THE CHEST
a. Rate of respiration
b. Depth of respiration
c. Rhythm of respiration
d. Expansion of chest
e. Type of respiration

5. 1. INSPECTION
I. SHAPE OF THE CHEST
Bilaterally symmetrical
and elliptical in cross
section.
Anteroposterior diameter
is less than the transverse
diameter in a ratio of 5:7.

6. Abnormal forms of chest
A. PIGEON CHEST
Chest is elliptical with
prominent sternum.
Seen in rickets.

8. Abnormal forms of chest
B. SCOLIOSIS
It is the lateral bending
of the vertebral column.
Prominence of front of
the chest on one side
with flattening on the
other side.

9. Abnormal forms of chest
C. KYPHOSIS
It is the forward bending
of the vertebral column
Shortening of the chest
with prominent sternum.

10. Abnormal forms of chest
D. BARREL SHAPE CHEST
AP diameter of chest
increases.
It is seen in:
Emphysema
Bronchial asthma
Fibrosis
Collapse of lungs

11. 1. INSPECTION
II. MOVEMENTS OF THE CHEST
a. Rate of respiration
• Normal rate is 12 – 16 breaths per minute

12. Increased
respiratory rate
(tachypnea)
• Exercise
• Fever
• Anemia
Decreased
respiratory rate
(bradypnea)
• Brain damage
II. MOVEMENTS OF THE CHEST
1. INSPECTION

13. 1. INSPECTION
II. MOVEMENTS OF THE
CHEST
b. Depth of respiration
• Deep breathing – brain
damage
• Shallow breathing –
bronchial asthma

14. 1. INSPECTION
II. MOVEMENTS OF THE CHEST
c. Rhythm of respiration
• The normal respiration has regular rhythm with inspiration
longer than expiration.

15. 1. INSPECTION
II. MOVEMENTS OF THE CHEST
d. Expansion of chest
• Normally both sides of the chest wall move symmetrically
(equal on both sides)
Diminished or asymmetrical movements:
• Consolidation
• Collapse
• Fibrosis
• Pleural effusion
• Hydro pneumothorax

16. 1. INSPECTION
II. MOVEMENTS OF THE CHEST
e. Type of respiration
• Normal – Abdominal

17. 2. PALPATION I. POSTION OF TRACHEA
II. POSITION OF APEX BEAT
III. EXPANSION OF CHEST
IV. VOCAL FREMITUS

18. 2. PALPATION
I. POSITION OF TRACHEA
• Normal position of trachea is central

19. 2. PALPATION
Trachea pulled towards the
affected side
• Collapse
• Fibrosis of lung
Trachea pushed away from
affected side
• Pleural effusion
• Pneumothorax

20. 2. PALPATION
II. POSITION OFAPEX BEAT
Normal position - 9 cm from midline in the left 5th intercostal
space.

21. 2. PALPATION
• II. POSITION OFAPEX BEAT
• Cardiac impulse refers to movements occurring due to the
impact of the heart against the chest wall during the
systole.
• The apex beat is the lowest and outermost point of
definite cardiac impulse, where it is seen / felt most
forcibly (point of maximum impulse).

22. 2. PALPATION
Absent apex
beat
• Obesity
• If lying behind a
rib
• Dextrocardia
Prominent apex
beat
• Anxiety
• After exercise
Displaced apex
beat
• Enlargement of
left ventricle
• Pleural or
pulmonary
diseases
• Deformities of
the chest wall
or the thoracic
vertebrae –
scoliosis

24. 2. PALPATION
III. EXPANSION OF THE CHEST
Two methods:
1. Using a measuring tape
• Normal chest expansion is 5 – 8 cm.
2. Grasping the chest

25. 2. PALPATION
III. EXPANSION OF THE CHEST
Using a measuring tape
• Chest expansion can be measured using a measuring tape around the
chest at the level of the nipples.
Grasping the chest
• Place finger tips of both hands on either side of the lower rib cage.
• Tips of the thumbs meet in the midline in the front but not touch the
chest.
• Ask subject to take deep breath so that the distance between the
thumbs will increase and it will indicate degree of expansion.
• If one thumb remains closer to midline this means that there is
decreased expansion of that side.

26. EXAMINATION OF CHEST
RIGHT LEFT
ANTERIOR Supra - clavicular Supra - clavicular
Supra - mammary Supra - mammary
Mammary Mammary
Infra - mammary Infra - mammary
Axillary
Infra - axillary
POSTERIOR Supra – scapular Supra – scapular
Inter – scapular
Infra – scapular Infra – scapular

27. EXAMINATION OF CHEST

28. 2. PALPATION
IV. VOCAL FREMITUS
• Vocal: pertaining to voice
• Fremitus: vibratory sensation perceived by palpation
• Sound vibrations from the larynx pass down the bronchi
and cause the lungs and the chest wall to vibrate.

29. 2. PALPATION
IV. VOCAL FREMITUS
• The vibration may be detected by palpation by ulnar
border of hand placed flat on the chest.
• The subject is then asked to repeat 1 1 1 or 9 9 9 or Ram
Ram Ram
• The vibrations are perceived by the examining hand.
• Compare right and left side

30. 2. PALPATION
IV. VOCAL FREMITUS

31. 2. PALPATION
Consolidation Bronchial
obstruction
Pleural effusion
Pneumothorax
Fibrosis
Collapse
IV. VOCAL FREMITUS

32. 3. PERCUSSION
• Normal percussion note of the lungs is resonant

33. 3. PERCUSSION
Lower limit of left lung:
Note changes from
resonant to tympanic
due to presence of
stomach
Lower limit of right lung:
• 6th rib – Mammary line
• 8th rib – Mid axillary
line
• 10th rib – Scapular line

34. 3. PERCUSSION
Pneumothorax Thickening of pleura
Pleural effusion

35. 4. AUSCULTATION I. BREATH SOUNDS
a. Vesicular
b. Bronchial
II. VOCAL RESONANCE
III.ADDED SOUNDS
a. Pleural rub
b. Rhonchi or wheeze
c. Crepitations or crackles
d. Stridor

36. 4. AUSCULTATION
I. BREATH SOUNDS
Two main types of breath sounds can normally be
heard over the chest:
• Vesicular
• Bronchial

37. 4. AUSCULTATION
I. BREATH SOUNDS

38. 4. AUSCULTATION
I. BREATH SOUNDS
a. Vesicular breath sound
• It is characterized by active inspiration due to passage of
air into bronchi and alveoli followed without a pause by
passive expiration due to elastic recoil of the alveoli which
occurs maximally in the early phases giving an apparent
impression of short expiration.

39. 4. AUSCULTATION
I. BREATH SOUNDS

40. 4. AUSCULTATION
I. BREATH SOUNDS
b. Bronchial breath sound
• It is characterized by active inspiration due to passage of
air into the bronchi. The alveolar phase is absent
(because of consolidation in alveoli) and hence expiration
is also active occupying the same duration time as
inspiration.

41. VESICULAR BREATH
SOUNDS
BRONCHIAL BREATH
SOUNDS
Origin In larger airways In larger airways
When the lung between the
airways and chest wall is airless
as in consolidation, fibrosis and
collapse of lungs
Character Low pitch rustling sound High frequency and harsh
Inspiration
and
Expiration
 No gap between end of
inspiration and beginning of
expiration
 Inspiration is twice as long
as expiration
 Gap between end of
inspiration and beginning of
expiration
 Inspiration and expiration are
of same duration
Sites Heard all over healthy lungs
(chest)
Heard over trachea
Heard in patients with
consolidation, fibrosis and
collapse of lungs

42. 4. AUSCULTATION
II. VOCAL RESONANCE
• It is the sound of the voice heard on auscultation of the
chest.
• When subject repeats 1 1 1 or 9 9 9, the ear perceives
not only the distinct syllables but a resonant sound.

43. 4. AUSCULTATION
Bronchophony -
consolidation
Egophony - above the
level of pleural effusion
Whispering pectoriloquy
- cavity of lungs and
consolidation
Pleural effusion
Pneumothorax

44. 4. AUSCULTATION
III.ADDED SOUNDS
a. Pleural rub
• It occurs due to inflammation of pleura and it gives rise to
a characteristic friction rub.
b. Rhonchi or wheeze
• They are continuous musical sounds associated with
airway narrowing and particularly heard during expiration
• Seen in bronchitis and bronchial asthma

45. 4. AUSCULTATION
III.ADDED SOUNDS
c. Crepitations or crackles
• They are crackling sounds produced by sudden change in
pressure related to sudden opening of previously closed
airways.
• It is heard both during expiration and inspiration.
• Seen in pneumonia.
d. Stridor
• It is a loud inspiratory sound heard over the airways due
to obstruction to the respiratory tract mainly the larynx and
trachea.