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1. Local Examination in Respiratory System
“Always listen to
the patient they
might be telling
you the diagnosis”
Sir William Osler (1849-1919)
PREPARED BY DR. RUQAYA AL-KATHIRY
HEAD OF THE MEDICAL DEPARTMENT OF UST

2. LOCAL EXAMINATION OF THE CHEST:
In health the :
•inspection=symmetrical & elliptical in cross-section.
•palpation=equal chest movement on both sides, trachea=central, apex
beat=NL position
•percussion=resonant
•auscultation=vesicular breath sounds
INSPECTION:
1-Abnormalities of the shape of the chest:
i) Barrel Chest:↑ in the AP diameter > Lateral diameter. It is seen in
hyperinflated lung e.g. COPD.
N.B: the degree of deformity doesn’t correlate with the severity of airways
obstruction.

3. ii)Thoracic Kyphoscoliosis:
*kyphosis=hump i.e. over-curvature of the thoracic vertebrae
(upper back).
*scoliosis=crooked i.e. spine is curved from side to side.
*Causes:-idiopathic
-2ary to childhood poliomyelitis or spinal T.B.
*The chest deformity ↓ventillatory capacity of the lungs→ ↓O2,
↑Co2 & R.S.H.F (Cor Pulmonale) at an early age..

4. iv)Pectus Excavatum:(Funnel Chest)
*This is a developmental defect in which there
is a localised depression of the lower end of the
sternum or of its whole length (less common).
* Pts are usu. asymptomatic but concerned
about their appearance.
*The heart may displaced to the left, and the
ventillatory capacity of the lungs restricted.
iii)Pectus Carinatum:(Pigeon Chest)
* This is a localized prominence of the sternum
and adjacent costal cartilages.
*This is a common sequel to childhood chr.
respiratory diseases e.g. severe & poorly
controlled childhood B.A
*It can occur in osteomalacia & rickets.
v)Thoracic Surgeries: may cause chest
deformities.

5. 2-Lesions of the Chest Wall:
LESIONS OF THE CHEST WALL
Skin eruptions, sarcoid nodules, neurofibromas, purpura, bruises,
scars, discharging sinuses.
Cutaneous Lesions
Inflammatory swelling, metastatic tumour nodule, sebaceous cyst,
sarcoid nodule, neurofibroma, lipoma.
Subcutaneous Lesions
Crackling sensation by palpation of air-containing tissue.
Subcutaneous Emphysema
Spider naevi, enlarged vascular channels
(arterial= C.O.A; venous=S.V.C obstruction)
Vascular Anomalies
Clavicles, scapulae, sternum, ribs, costochondral junctions, spinous
processes.
Localised prominences & deformities
Fractured rib, chest wall tumour, spinal N. root dis.
Localised tenderness
Lump, skin changes.
Lesions of the breast
Medial, lateral, anterior, posterior & apical.
Enlargement of axillary L.Ns
3-Observation of Respiratory Movement:
Respiratory Frequency: NL R.R=14/min at rest (upto 20)
-↑ in: *fever *ac. B.A. *ac. exacerbation of COPD *ac. pulmonary
infections *pulmonary oedema *ILD
-↓ in: *hypercapnia *opiod toxicity *hypothyroidism *hypothalamic lesions
*raised intracranial pressure(↑ICP)

6. Respiratory Depth: overventillation & underventillation.
-Kussmaul Breathing (Air hunger):
*Massive embolism
*Metabolic acidosis e.g. DKA, Uraemia, lactic acidosis, poisoning (salicylate, methanol)
-Cheyne-Stokes Breathing:
*Medullary disease *HF *elderly
-Unconcious pts. with severe brain damage due to trauma, haemorrhage or infarction.
Mode of Breathing:
*In♀respiratory movements are predominantly thoracic.
*In♂respiratory movements are predominantly abdominal (and babies).
*If respiratory movements are exclusively thoracic:
-peritonitis
-↑intra-abd.press.(e.g. ascites, gaseous distension of the bowel, large ovarian cyst or
pregnancy)
*If respiratory movements are exclusively abdominal:
-ankylosing spondylitis -intercostal paralysis -pleural pain

7. AbNL Expiratory Movements:
-Pts. with a severe degree of exp. obst. prefer to sit upright,
grasping a bed table or the back of a chair.
-Many pts. exhale through the mouths with pursed lips.
2-Maximum Chest Expansion:
-Measure with a tape the max. insp./exp. difference in the lower chest.
-A value >5cm (5-8cm) = NL
-A value <2cm = ABNL i.e.
Diminished symmetrically in almost every type of diffuse dis. e.g.:
*COPD(B.A&Emphysema)*Diffuse Pulmonary Fibrosis*AnkylosingSpondylitis
Diminished asymmetrically on the same side of the abnormality e.g.:
*Consolidation *Collapse *Unilateral Fibrosis *Pleural Effusion *PnTx
AbNL Inspiratory Movements:
-Contraction of the cervical m.(SCM, scaleni & trapezii)
-Indrawing of suprasternal notch, supraclavicular fossae, ICS & epigastrium.
-Paradoxical movement of the chest (flail chest) due to # of multiple ribs in multiple places.
PALPATION:
1-Pain and Tenderness:
-Palpate gently if there is a swelling or pain at any site.
-Localized tenderness: over *ribs=# or areas of PI *costal cart. in Tietz’s Syndrome.

8. 3-Tracheal Position:
-It is uncomfortable for the pt. if the examiner is rough.
-Feel for the trachea in the suprasternal notch.
-Is it central or deviated to one side.
N.B: A slight deviation of the trachea to the right is NL.
5-Tactile Vocal Fremitus (TVF):
-Vibrations detected by the palm of the hand placed flat on the chest when the pt.
repeats‘99’.
-Compare bilaterally, upwards to downwards.
Increased in: *consolidation *large cavity near the surface
Diminished in: *bronchial obstruction
Absent in: *pleural effusion *PnTx
4-Cardiac Impulse:
-NL: in the 5th I.C.S, 9cm from the midline or 1cm medial to the MCL.
-If there is only deviation of the cardiac impulse alone may be:
*scoliosis *funnel chest *L.V Enlargement
-In the absence of the above, displacement of either or both indicates pleural or lung dis.
-Mediastinum pushed away from the affected lung = *pleural effusion *PnTx
-Mediastinum pushed to the affected lung = *collapse *fibrosis

9. -The upper level of liver dullness is in the 5th rib in the MCL. Resonance below this is a sign
of hyperinflation (COPD or severe B.A).The cardiac dullness may also be ↓.
-Basal dullness of the lung may be due to: *pleural effusion *pleural thickening
*consolidation *collapsed lung *elevation of the hemidiaphragm.
-Tidal percussion: the range of diaphragmatic movement. Measure the distance b/w the
lower borders of pulm. resonance post. in full insp. & forced exp.
PERCUSSION NOTE
Hollow viscus
Tympanitic
PnTx
Hyperresonant
Normal Lung
Resonant
Lung: Consolidation, Collapse, Fibrosis; Solid structures: liver & heart
Dull/Impaired
Pleural effusion, Haemothorax
Stony dull
PERCUSSION:
-It may be used to differentiate reliably b/w PnTx & pleural effusion.
-It is uncomfortable to the pt. when performed repeatedly and inexpertly.

10. Causes of bronchial breathing:
*Consolidation (commonest) *At the top of a pl.effusion *Localized pulm. fibrosis
*Collapse (with a patent major bronchus)
AUSCULTATION:
-Help the pt. to breathe correctly through the mouth by demonstrating than to keep on
saying ‘breathe in & out’.
-Points to note on auscultation:
1-INTENSITY (LOUDNESS) OF BREATH SOUNDS:
-↓in:*localized airway narrowing *emphysema *pleural thickening *pleural effusion
-↑in:*thin people *bronchial breathing
2-QUALITY OF BREATH SOUNDS:
-VESICULAR BREATH SOUNDS:
Quiet low-pitched rustling sounds. There is no pause b/w end of insp. & beginning of exp.
-BRONCHIAL BREATH SOUNDS:
Harsh high-pitched sounds resembling the sounds when listening over the trachea. There is
a gap b/w end of insp. & beginning of exp.
Causes of diminished breath sounds:
*Obesity/Thick chest wall *PnTx *Pl. effusion /thickening *COPD (GENERALIZED)
*Collapse (LOCALIZED)

11. 3-VOCAL RESONANCE (VR):
-NL lung: low-pitched sounds are heard & high-pitched are attenuated.
-Clearly audible (↑): *Consolidation
-Muffled (↓): *Pl. effusion *Collapse *PnTx *Thickened pleura *Emphysema
4-ADDED SOUNDS:
I)Wheezes:
-They are musical sounds due to diffuse bronchoconstrict. e.g. B.A. & bronchitis (COPD).
-It may be monophonic: localized narrowing of a single bronchus e.g. by a tumour or F.B.
-It may be polyphonic
II)Crepitations (Crackles):
-These are short, explosive sounds (bubbling/clicking).
-They are caused by the sudden opening of closed small airways.
-It changes in character after coughing.
-They may be at the:
*beginning of insp.(Early-inspiratory)=airflow obstruction e.g. bronchiolitis.
*middle of insp.(Middle-inspiratory)=pulmonary oedema.
*end of insp.(Late-inspiratory) heard at the lung bases. They may be:
+Fine: (as rubbing hair b/w your fingers) are ch.ch. of pulm. fibrosis.
+Medium: pulmonary oedema
+Coarse: bronchial secretions (COPD, pneumonia, lung abscess, T.B, lungcavities)
*Biphasic: crackles that occur throughout insp. & exp. e.g. bronchiectasis.

12. VII)Mid-expiratory 'squeak‘:
-This is ch.ch in obliterative bronchiolitis (a rare complication of RA) where small airways
are narrowed or obliterated by chr. inflammation & fibrosis.
III)Pleural Rub:
-Ch.ch. of pleural inflammation.
-It has a creaking/rubbing character (best heard with the stethoscope diaphragm).
-May be heard only on deep breathing (end of insp.& beginning of exp.)sometimes palpable.
-It doesn’t change in character after coughing.
IV)Whispering Pectoriloquy:
-Ask the pt. to whisper 1,2,3; become clear & seem to be spoken right into the listener’s ear.
-It occurs when a moderately large bronchus is surrounded by solid lung.
Causes:*Consolidation (commonest) *Cavity communicating with a bronchus *above
the level of a pl. effusion.
V)Aegophonia:
-The sound may sound nasal. Causes:*Above the level of a pl. effusion *Consolidation
VI) Pneumothorax click :
-This rhythmical sound, synchronous with cardiac systole, is produced when there is air b/w
the 2 layers of pleura overlying the heart.

13. 1. INTRODUCTION
Examination of any system should start with inspection.
The pt. should be sitting comfortably at 45° with adequate exposure of chest.
The room should be quiet and warm.
Stand on the pt’s right hand side and, when palpating, use your right hand.
2. INSPECTION
A. Look for signs of breathlessness, discomfort or pain. Use of accessory muscles.
B. Examine face, eyes and mouth for colour and central cyanosis.
C. Look at chest shape, movement, scars and deformities.
D. Examine hands to assess circulation for warmth and venodilation. Look for tar
(nicotine) stain, peripheral cyanosis and finger clubbing. Look for flapping tremor.
3. PALPATION
A. Palpate radial pulse and assess rate and rhythm.
B. Count respiratory rate.
4. NECK
A. Check position of trachea.
B. Assess for subcutaneous emphysema if appropriate.
C. Examine for cervical lymphadenopathy (LAP).
D. Assess right internal jugular vein (IJV) for raised JVP.

14. 5. PALPATION OF CHEST
A. Locate the apex beat.
B. Assess chest expansion anteriorly and posteriorly.
6. PERCUSSION OF CHEST
A. Percuss anteriorly, laterally and posteriorly.
7. AUSCULTATION OF CHEST
A. Auscultate front of chest.
B. If areas of dullness on percussion test for vocal resonance(VR) or vocal fremitus(TVF).
C. Sit pt. forward. Percuss (if not already done) and auscultate posterior chest.
8. OTHER AREAS
A. Feel for ankle oedema.
B. Look in sputum pot if available.
C. Examine any observation charts available. Pulse, BP, Temperature.
D. Measure peak flow.
9. CONCLUSION
A. Thank pt. and wash hands with alcohol gel or water.
B. Summarise and present findings in pt’s notes and orally.

15. “Medicine is learned at
the bedside
and not in the
classroom”
Sir William Osler (1849-1919)
THANK YOU FOR YOUR ATTENDANCE