This document provides an overview of how to examine the respiratory system. It discusses examining the cardinal symptoms, general physical exam including looking for cyanosis and clubbing, and examining the upper and lower respiratory tract through inspection, palpation, percussion, and auscultation. Specific assessment techniques are described for each part of the exam, such as how to check tracheal position and vocal fremitus through palpation. Common lung sounds and their potential causes are also outlined. The goal is to perform a thorough respiratory exam to evaluate for any abnormalities.

1. EXAMINATION OF
RESPIRATORY SYSTEM
MODERATOR : DR.SURYA PRAKASH
DONE BY
M.JAYAPRITHA ,I YEAR POSTGRADUATE

2. CONTENTS
 Cardinal symptoms
 General physical examination
 Systemic examination
• Inspection
• Palpation
• Percussion
• Auscultation

3. CARDINAL SYMPTOMS
 Cough
 Difficulty in breathing
 Chest pain
 Hemoptysis
 Noisy breathing

4. GENERAL PHYSICAL EXAMINATION
 Syndromic facies
 Nutritional status
 Hydration status
 Dyspnoea
 Oral hygiene

5. GENERAL EXAMINATION
CYANOSIS:
• Reduced Hb >5 g/dl
• CENTRAL CYANOSIS:
 Impaired pulmonary function:
 Cardiac shunts :cyanotic congenital heart diseases (TOF, TGA with VSD, TAPVR,
tricuspid atresia) pulmonary AV fistula, multiple small intrapulmonary shunts
 Hemoglobin abnormalities( Methemoglobinemia , carboxyhemoglobinemia ,
sulfhemoglonibemia )

6. GENERAL EXAMINATION
• PERIPHERAL CYANOSIS:
 Cold exposure
 Congestive heart failure
 Arterial obstruction (emboli, Raynaud phenomenon)
 Venous obstruction (thrombophlebitis)

7. CENTRAL VS PERIPHERAL CYANOSIS

8. GENERAL EXAMINATION
CLUBBING
 Mechanism: sustained hypoxia --> endothelial growth factors release
 ETIOLOGY:
• Respiratory : Bronchiectasis, chronic bronchitis, empyema, tuberculosis, cystic
fibrosis
• Cardiac : cyanotic congenital heart diseases, infective endocarditis
• Hepatic : chronic active hepatitis, biliary cirrhosis
• Unilateral: anomalous aortic arch, aortic or subclavian artery aneurysm,
pulmonary hypertension with PDA, pancoast tumor

9. GENERAL EXAMINATION
 GRADES OF CLUBBING:
I. Softening of nail bed- fluctuation of nail bed
II. Obliteration of nail fold angle – approaches 180 – schamroth sign
III. Swelling of subcutaneous tissues over base of nail bed – parrot beak or
drumstick appearance
IV. Hypertrophic pulmonary osteoarthropathy

10. GRADES OF CLUBBING:

11. GENERAL EXAMINATION
 LYMPH NODE EXAMINATION
• cervical nodes
• Supraclavicular nodes
• Infraclavicular nodes
• Axillary nodes

12. GENERAL EXAMINATION
Skeletal deformities
• KYPHOSIS:
spinal deformity with anteroposterior angulation
• SCOLIOSIS:
Lateral displacement or curvature of the spine with rotation of vertebra

13. GENERAL EXAMINATION

14. GENERAL EXAMINATION
 PERIPHERAL STIGMATA:
• Horner syndrome
• Saddle nose
• supraclavicular scar
• BCG scar
• TB Sinuses
• Boils and eczema

15. EXAMINATION OF UPPER AIRWAY
o NOSE
• anatomical defects
• Congestion
• Discharge
• Flaring of alae nasi
• Bleeding
• Foreign body
o Air sinusus
• tenderness

16. EXAMINATION OF UPPER AIRWAY
o PHARYNX:
• Congenital defects
• Uvula
• Palatopharyngeal incoordination
• Congestion
• Tonsils and adenoid
o LARYNX
o EYES

17. EXAMINATION OF LOWER RESPIRATORY
TRACT -INSPECTION
o RESPIRATORY RATE:
• Counted for one full minute
• Ideal – sleeping respiratory rate
• Done by – counting no of chest rises / placing palm of hand over abdomen
• Normal respiratory rates
0 to 2 month --- 60/min
2 month to 1 year---50 /min
1 year to 5 year ---40/min
5 year to 12 year ---30/min

18. INSPECTION
RESPIRATORY RHYTHM:
• Tachypnea / bradypnea
• Periodic breathing:Three or more brief pauses separated by interval shorter than
20 secs
• Cheynes strokes breathing: cycles of increasing and decreasing depth of
respiration separated by brief periods of apnea
• Biot breathing: cycles of variable depth of respiration interrupted by apnea
• Kussmaul breathing: deep and rapid respiration
• Sighing: normal breathing pattern interspersed with single deep breaths
• Apneustic: Gasping deep inspiration with prolonged inspiratory pause

19. RESPIRATORY RHYTHM

20. INSPECTION
 RESPIRATORY EFFORT:
• Retractions
• Use of accessory muscles
• Flaring of alae nasi
• Paradoxical movements

21. INSPECTION
 CHEST SHAPES
Barrel chest, pectus excavatum, pectus carinatum, kyphoscoliosis , gibbus and alar
chest
 Prerequisites
• standing erect, arms by the side, feet together child facing forward
• Supine lying on flat back, arms by side,facing upwards, both scapula in contact with
couch, neck straight
• Child examined from the front, from the side, from the foot end

23. INSPECTION
 To look for
• Deformities – chest wall or vertebral
• Tracheal position
• Movements of chest wall
• Apical impulse
• Fullness or flattening
• Drooping of shoulders
• Winging of scapula
• Inter scapular distance

24. PALPATION
 TRACHEAL POSITION
• Prerequisites: Head fixed straight, patient standing or sitting
• 1st method: 2nd and 4th fingers placed on each side of sternal notch, 3rd finger
placed in midline over trachea
• 2nd method: placing index finger over cricoid cartilage and sliding it downwards
towards suprasternal notch
• 3rd method: Index finger is slid in the angle between the trachea and
sternomastoid angle

26. PALPATION – TRACHEAL SHIFT
OPPOSITE SIDE OF
LESION
SAME SIDE OF LESION NO SHIFT
Pleural effusion collapse Consolidation
Empyema fibrosis Emphysema
hydropneumothorax Bronchiectasis
pneumothorax Bronchial asthma

27. PALPATION
 Chest expansion and symmetry
Each palm should encircle chest wall anteriorly or posteriorly at the level of
nipples, thumbs facing each other in midline
Normal chest expansion 3-5 cm in older children
 Chest tenderness
 Crepitus
 VOCAL FREMITUS: Vibrations detected by palpating the chest with palm of
hand placed flat on chest wall with child counting numbers

28. PALPATION
INCREASED VOCAL
FREMITUS
DIMINISHED ABSENT
Consolidation
Large superficial cavity
Bronchial obstruction Pleural effusion
Pneumothorax
Collapse
Fibrosis

29. PERCUSSION
RULES OF PERCUSSION:
• Place the hand on child chest such that middle finger resting along intercostal space, other
fingers lifted
• Tap the middle phalanx with middle or index finger of other hand
• Movement only at the wrist joint
• Lift plexor immediately off the pleximeter after tapping
• All areas percussed and each compared with contralateral side immediately
• Percuss the lung apices by tapping the middle of clavicle directly

30. PERCUSSION
 DIRECT PERCUSSION: clavicle
 INDIRECT PERCUSSION:
• Kronig’s isthmus/Supraclavicular area
• Infra-clavicular area
• Infra-mammary area
• Axillary area
• Infra axillary area
• Supra-scapular area
• Inter-scapular area
• Infra-scapular area

31. PERCUSSION
PERCUSSION NOTE RESPIRATORY CONDITION
Hyper resonant Pneumothorax
Resonant Normal
Impaired or dull Consolidation
Collapse
Thickened pleura
Fibrosis
Abscess
Lung fibrosis
Infarction of lung
Sequestration of lung
Stony dull Pleural effusion
Massive collapse or consolidation
Solid tumors

32. PERCUSSION
 SHIFTING DULLNESS:
In a sitting child, percussion over chest is done when dullness is noted. Then child
is made to lie in opposite side and percussed . If that area becomes resonant then
shifting dullness is present
 TIDAL PERCUSSION:
Right side anterior chest wall percussed from 2nd ICS along mid clavicular line.
After dullness is noted same spot percussed again with deep inspiration.
In effusion – dullness noted
Liver – resonant sound heard as expanding lung pushes liver away

33. AUSCULATATION
 BREATH SOUNDS
• Present or not
• Intensity and quality
VESICULAR BREATH
SOUNDS
BRONCHIAL BREATH
SOUNDS
Quiet,low pitched,rustling Louder,transmitted through airless
tissues
No gap between phases of
inspiration and expiration
Gap between inspiration and
expiration
Expiratory phase shorter than
inspiration
Expiration phase prolonged

34. AUSCULATATION
CAUSES OF BRONCHIAL BREATH SOUNDS:
• Normally heard over central airway
• High pitched (Tubular) in consolidation, collapsed lung with patent bronchus
• Low pitched (Cavernous) in thick walled cavity with connection with bronchus
• Low pitched metallic (Amphoric ) in tension pneumothorax, broncho pleural
fistula

35. AUSCULTATION
 VOCAL RESONANCE:
• Resonance perceived by examiner during ausculataion of chest while child is
repeating words and intensity and character is noted
VOCAL RESONANCE RESPIRATORY CONDITIONS
Increased Consolidation
Superficial cavity
Decreased Collapse,fibrosis
absent Pleural effusion
Pneumothorax
Empyema
Hydro pneumothorax

36. AUSCULTATION
TYPES OF VOCAL RESONANCE
• BRONCHOPHONY: Sound appears to be originating from near the earpiece in
consolidation
• WHISPERING PECTORILOQUY: child is asked to say words such as one two
three and heard as if directly said into ears seen in consolidation
• AEGOPHONY: Nasal quality or bleating quality of VR heard over area of
consolidation or just above area of pleural effusion .
It is due to dilatation of lung from above and compression of lung from below

37. AUSCULTATION –ADVENTITIOUS SOUNDS
 WHEEZE: Continuous prolonged musical sounds which occur due to airflow from
constricted bronchial smooth muscles
High pitched when large lumen is obstructed in bronchitis and asthma
Low pitched when small lumen obstruction in bronchiolitis
 CREPITATIONS:
Discontinous crackling or bubbling sound of short duration
 Pleural friction rub:
When both layers of pleura rub against each other
 STRIDOR

38. THANK YOU