This document provides information on examining the respiratory system. It discusses symptoms like cough, sputum, chest pain, dyspnea, and wheezing. It describes examining the chest through inspection, palpation, percussion, and auscultation. Inspection involves observing respiratory rate, chest shape, deformities, and chest movement. Palpation includes feeling the trachea, apex beat, vocal fremitus, and added sounds. Percussion is used to assess the lungs at different chest sites. The document provides details on techniques for palpation, percussion, and auscultating the lungs.

1. Resperatory System
Examination
Dr. Mustafe Hussein Abdilahi
MBBS, MMED ( internist)

2. Introduction
• The yield in the examination of respiratory system
is variable.
• Disease like asthma can be diagnosed with
confidence on the basis of clinical evaluation alone
• On the other hand tuberclusois in tuberculosis
disease may be fairly advanced but clinical
examination might still be normal.

3. Symptoms
Types of cough
• Dry cough( pharyngitis)
• Productive cough ( bronchiectasis, chronic
bronchitis and resolving pneumonia)
• Persistent ( pharyngitis)
• Episodic ( asthma)
It’s a very common symtom of both upper and lower
respiratory tract disease

4. Sputum
• Note the following characteristics of the sputum.
• For proper assessment you should see the sputum
yourself.
• Amount: for exact measurment ask the patient to
collect the sputum in a graduated container for the
24 hours, large amoun of sputum is produced in
bronchiectasis and lung abscess.

5. Sputum Character:
• Serous: its clear and frothy. It occurs in acute
pulmonary edema.
• Mucoid: it is white and is seen in chronic
bronchitis.
• Purulent: it is yellow or green in color. It occurs in
bronchiectasis, pneumonia and lung abscess.
• Mucopurulent: it is a combination of mucoid and
purulent. It is seen in chronic bronchitis with
secondry infection. s

6. • Viscosity: sputum is viscous, tenacious and
difficult to cough up in bronchial asthma.
• Odor: sptum is foul smelling in bronchiectasis
and lung abscess with anaerobic bacterial
infection.
• Hemoptysis: it means coughing up of blood. It is
important to note its duration amount, frequency
and type.

7. Types of hemomptysis
• Frank hemoptysis: pure blood is coughed up. It
occurs in brochiectasis, pulmonary infarction,
tuberculosis and sometimes mitral stenosis.
• Blood stained sputum: blood is mixed with sputum.
Two important causes are tuberculosis and carcnoma
bronchus.
• Rusty sptum the sputum is golden yellow color due
to degradation of bemoglobin. It occurs in
pneumococcal pneumonia.

8. Chest pain
• It is a common symptom. Site and character of the
pain varies with the disease.
• Retrosternal pain: it may be due to
• 1. acute tracheitis ( there is associated dry cough)
• 2. mediastinal emhysema or mediastinitis: these
are uncommon conditions. Pain resembles
cardiac pain but intesity is not severe and it is not
related to exertion.

9. Pleuritic pain
• It is due to pleurisy.
• pain is felt in the sides of the chest and is
typically exacerbated by breathing and coughing.
• In spontaneous pneumothorax, sharp pain
followed by feeling of tightness across the front
of the chest.

10. Muscluloskeletal pain
• It is felt at the site of the diesease. It may be
due to
• Fracture of ribs
• Metastatic depisits in the ribs
• Costochondritis
• Spinal root lesion herpes zoster

11. Dyspnea
• It means difficulty in breathing. It can be either
due to cardiac disease or repiratory disease.
• In bronchial asthma and acute exacerbation of
chronic bronchitis dyspnea occurs in episode
while in emphysema and chronic interstitial lung
disease like fibrosing alveolitis dyspnea occurs
on exertion and is progressive.

12. In addition to above mentioned conditions, acute
dyspnea can also occur due to following
respiratory disease.
• Spntaneous pneumothorax
• Pulmonary embolism
• Massive rapidly accumulating pleural effusion
• Pnrumonia

13. • Wheeze: it is a musical, whistling sound and can
be described as a loud ronchus audible without a
stethoscope. It is due to narrowing of small
airways.
• Stridor: it is similar to wheeze and occurs due ti
obstruction of major airways by tumor or foreing
body. It is audible only during inspiration.
Differntiation between wheeze and stridor is
discussed.

14. Symtom of Upper Respiratory Tract
Disease.
• Nasal obstruction, nasal discharge and post nasal drip are
symtoms of local nasal pathology.
• Headache: in sinusitis, heachache increases on bending
forward and is of maximum intensity a few hours after sun
rise.
• Epistaxis: it means bleeding from the nose. Local nasal
pathology is the usual cause but it may also be due to:
• Bleeding and clotting diorders
• Hypertension

15. Hoarseness
It may be duengitis
• Laryngitis
• Abuse of voice
• Hypothroidism
• Paralysis of 10th nerve or its branch recurrent
laryngeal nerve.

16. History
In addition to details of presenting symptoms it is important
to find out:
• Past history of chest infection, particularly tuberculosis
• History of BCG vaccination
• History of allergic disorders
• Any previous x-ray available
• Family history of similar problem
• Home circumstances particulary any pets like birds (
pigeons) or animals ( cats

17. • Details of occupation 9number of respiratory
disorders e,g pneumoconiosis are related to
occupation)
• Cigarette smoking (chronic bronchitis and
carcinoma are very common in smokers, find
out age at which smoking started, number of
cigarette smoked per day and their brand and
when did he stop smoking in cas of an ex-sm

18. Examination
• Examination of the respiratory system consists of
inspection, palpation, percusion and auscultation.
• Examin both front and back of the chest.
• First complete the examination on the front or
back and then change the patients position to
examine the other side
• Compare both sides of the chest with each other.

19. Position of the patient
• Expose the chest fully baring the chest and the
abdomen upto the umbilicus
• For the examination of the front and sides of
the chest, the patient should lie supine with
arms abducted.
• For examination of the back the patient should
sit up, with arms crossing front of the chest and
each hand on the opposite shoulder.

20. Inspection
• Inspect the front from the foot end and the back from
behind
• This is important because if patient is examined from the
side or obliquely, small asymmetries can be missed note
the following features:
• Respiratory rate
• Types of respiration
• Shape of the chest
• Deformity
• Prominent veins, pulsations, scar
• Chest movements

21. Respiratory Rate
• This is counted by observing movements of the chest.
• In order to divert patients attention, feel his pulse while
counting respiratory rate.
• Normal is 14-16 minute. Tachypnea means fast
respiratory rate

22. Types of Respiration
• Normally females mostly use thoracic muscle for
respiration and males us diaphragm
• Respiration is thoracoabdominal in females and
abdomino-thoracic in male
• In babies it is abdomino-thoracis

23. This pattern can change
• If there is peritoneal irritation or increased intra abdominal
pressure respiratioin becomes exclusively thoracic
• In anylosing spondylitis pleural pain and intercostal
paralauysis it becomes exlusively abdominal.
• Acidotic breathing: in metabolic acidosis ( renal failure,
ketoacidosis) breathing becomes rapid and deep.
• Chynestokes breathing: periods of over ventilation alternate
with complete apnea ( cessation of breathing).
• This is due to decreased sensitivity of the respiratory center
to carbon dioxide.

24. • Over ventilation leads to fall in PaC02 and apnea
occurs.
• carbon dioxide accumulates, stilulated respiratory
center and ther is over ventilation again
Causes
• Left ventricular failure
• Increased intracranial pressure
• Brain stem lesion
• Narcotic overdose

25. Shape of the chest
• Normal shape is elliptical
• Ratio of antero-posterior (AP) diameter to the tranverse
diameter is 5:7
• Barrel Shaped Chest: antero-posterior diameter and
tranverse diameter become equal.
• It occurs in emphysema
• It more likely occur if disease process starts before the
age of 30
• AP diameter is also increased in kyphosis)

26. Deformity
• Pectus carnatum: it is also called pigeon
chest. There is promincnce of the sternum
and costal cartilage
• This is a common complication of chronic
respiratory disease in childhood
• This may also occur as a result of rickets.

28. • Pectus excavatum: it is also called funnel chest
it is a developmental anomaly.
• There is localized depression of the lowwer end
of the sternum.
• Sometimes whole of the sternum may be
depressed
• Severe form interferes with cardiorespiratory
funciton.

30. • Harrisons sulcus: this is a horzontal grove
due to indrawing of ribs where diaphragm is
attached.
• This occurs as a result of strong contractions
of diaphragm due to respiratory disease in
early childhood.

32. • Thoracic Kyphoscoliosis: kyphosis ( increased
backward curvature of spine ) scoliosis ( lateral
curvature of spine)
• Kyphoscoliosis ( combination of both ) in
minor form are common deformities.
• In severe form trachea and apex beat may be
shifted and respiratory and cardiac failure may
occur.

34. Local bulging of the chest wall: this may be
due to
• Pleural effusion
• Pneumothorax
• Fractrure and malunion of ribs

35. Local flattening or retraction of chest wall: this
may be due to
• Fibrosis of lung
• Collapse of lung
• Pnuemonectomy

36. Prominent veins, pulsation and scar:
• Prominent veins are seen in superior vena cava
obstruction. Direcrion of flow of blood is from
above downwards
• On the front apex beat may be visible. On the
back pulsations are seen in the interscapular
region in the coarcrtation of aorta. Patient should
be bent forward look for these pulsations.
• Scar indicates previous trauma or surgery.

37. Movement of the Chest
• Compare movement of both sides of the chest
• Following abnormalities may be present
Reduced movements
• A part of the chest may be moving less or may not be
moving at all it may be du to
• Pleural effusion
• Pnuemothorax
• Consolidation
• Collapse fibrosis

38. Abnormal movements
• Most of the abnormal movements occur in airway
obstruction (emphysema, severe bronchial asthma,
obstruciton of major airways like larynx and
trachia.
• Movements due to extra respiratory mucles: due
to contraction of extra respiratory mucles (
sternomastoids, sclaeni, trapezii) whole thoracic
cage moves up during inspiration.
• Normaly expiration is a pasive act.

39. • In severe airway obstruction it becomes an active
process with contraction of abdominal muslces and
latissimus dorsi.
• Patient sits up and supports himself against his arms.
• In this way the shoulder girdle is fixed so that latissimus
dorsi can be used to increase expiratory efforts.
• The pateint purses his lips to maintain intra bronchial
pressure above that of surruonding alveoli so that
bronchial walls don’t collapse.

40. B inward movements: there is indrawing of
• Supraclavicular fossae
• Suprasternal notch
• Intercostal spaces
• Epigastrium

41. C. paradoxial movements: there is indrwaing
of
• If there is double fractur of the ribs or
fracture of sternum part of the chest wall
moves inwards during inspiration

42. Palpation
Palpate for
1. Tenderness
2. Crepitus
3. Position of the trachea
4. Apex beat
5. Movements of the chest wall
6. Expansion of the chest
7. Vocal fremitus
8. Palpable added sounds

43. Position of the trachea and apex beat
• The pateint should lie straigh, head and neck in
line with the body and the neck slighly extended(
which can be achieved by placing a pillow under
the shoulders).
• Trachea can be palpated by one finger, two finger
or three finger
• Palpation of the apex beat is described on CVS

45. Movements of the chest
• Compare movements of both sides by palpation.
• Method: crasp sides of the chest with fingers in such a way
that the tips of outstretched thumbs approximate in the
midline
• Thumbs should not touch the chesst wall
• Ask the pateint to take a deep breath and compare
movements of the thumb away from the midline on both
sides.
• Side on which movement of the thumb is less is abnormal

47. Expansion of the chest
• Measure circumference of the chest just below
the nipple with a measuring tape at the end of
deep inspiration and full expiration.
• Difference between the two is chest expansion
• Normally it is more than 5cm
• If it is less than 2cm it abnormal .
• There is high degree of inter observer variation
and this is not a reliable test of vital capacity

49. Vocal Fremitus
• Ask the patient to say one, one, one or similar
words in other languages and feel the
vibrations by placing palm on the chest.
• These vibrations are called vocal fremitus.
• Examine whole chest anteriorly, laterally and
posteriorly, comparing corresponding areas
of both sides.

50. • If there is any abnormality further localize it by
palpating with the ulnar border of the hand,
palcing it in the intercostal spaces.
• When examining front of the chest, keep in mind
the change due to presence of heart on the left
side.
• Normal vocal fremitus is learned with practice
• It canbe increased or decreased.

52. Tenderness and Crepitus
• Tenderness may be due to trauma or inflamation
(costochondritis)
• In subcutaneous emphysema or surgical
emphysema ( air in the subcutaneous tissue)
crackling sensations ( crepitus) are felt on
palpation

54. Palpable added sounds
• Ronchus if loud may be palpable
• Pleural rub may also be palpable as a grating
sensation

55. Percusion
• This is a useful technique in the examination
of the respiratory system
• As abnormal percusion note is found in a
number of respiratory conditions like pleural
effusion, pneumothorax, consolidation etc.

56. Technique and Rules of Percussion
• 1. Place the left middle finger (pleximeter) parallel
to the border of the organ being percussed It should
be in firm contact with the body surface
• 2. Flex tge right middle finger at proximal interphe it
as alangeal joint us plexor it should strike the middle
phalanx of pleximeter at right angle.
• 3. Movement should be entirely at the wrist not at
the elbow

57. • 4. Strike the plexor twice and then lift off, if
it remains in contact with the pleximeter,
character of note will change
• 5.In line of percusion shoul be perpendicular
to the border of the organ to be percussed
• 6. Percuss from resonant to dull area.

58. Sites of percusion
•Percuss anteriorly laterally and
posteriorly
•Keep pleximeter in intercostal spaces
wherever possible
•If sites described below are percussed
most of the lung is covered.

59. Anterior
• At first mark upper border of the liver.
• Start percussing from right 2nd intercostal space and
move downward in midclavicular line
• Normally it is in the 4th and 5th intercostal space ni
midclavicular line.
• Then compare percussion note on two sides by
percussing alternately at corresponding sites.
• Take care of normal cardiac dullness.

60. Percus the following
• Supraclavicular fossae ( place the pleximeter above the
clavicles)
• Clavicles (percuss with 3 fingers of the right hand over the
medial third of the clavicle directly without pleximeter).
• Second to 6th interc
• ostal spaces
• Fourth to 7th intercostal spces on lateral side for lateral
percussion arms of the patient should be adequately
abducted.

61. Posterior
• Apices ( place pleximeter on the anterior
border of the trapezius and percuss in
downward direction.
• Above the spine of sculae
• At a distance of 4-5 cm below the spine of
scapulae down to the 11th rib

62. Types of Percussion Note
• Normal percussion note over the lung is resonant.
• It may become hyper resonant, impaired or dull.
• When an abnormal note is found, delineate its
bounderies by percussing from normal to
abnormal area.

63. Definitions and examples of various notes are given
below
• Resonant: this note is produced by percussing over
normal lung tissue
Increased Resonance:
• Tympanitic: the note is produced by percussing over
large air filled cavity organ eg, emtpy stomach.
• Hyper-resonant: this type is of note prezent if lung is
hyperinflated eg, emphysema or if there is
pneumothorax.

64. Dicreased resonance
• Impaired note: this note is normaly present at the
junction of a solid organ with the lung, eg, upper
border of the liver, borders of the heart. Impjaired
note is also present in fibrosis of lung
• Dull note: this is normally present over solid organs
like liver, heart. Dull note is also present in fibrosis
of lung.
• Stony dull note: this is present over fluid eg: pleural
effusion and empyema.

65. Tidal Percussion
• This is done for movements of diaphragm.
• Determine lower limit of resonance posteriorly
both on expiration and inspiration.
• Distance between the two gives crude
impression about diaphragmatic movements.

66. Auscultation
• It the most useful step in the examination of
respiratory system
• Recognision of normal breath sounds requires
practice
• You can auscultate your self to familiarize with
normal breath sounds.

67. • Position of the patient is the same as
described for other techniques of examination
• If patient is too sick to sit up, auscultate the
back by turning the patient first on one side
and then on the other.
• Auscultate at corresponding sites on two
sides and compare findings

68. • Auscultate most of the chest anteriorly (from above the
clavicle downt to the 6th rib) laterally ( from the axilla to
the 8th rib) and posteriorly 9 from the trapezius down to
the 11th rib) as abnormality may be confined to a very
small area.
• Conventionally diaphragm of the stethoscope is used
because most of the respiratory sounds are high pitched
• Note the following
• Breath sounds ( intensity and character
• Added sounds
• Vocal resonance

69. Breath sounds
• Ask the pateint to open the mouth and take deep
breath in and out.
• Concentrate on intensity, duration and
charaacter of both inspiration and expiration and
note any interval between them.
• Patients with pleural pain should not be asked to
cough or take deep breath until pain is controled

70. • In such pateint test vocal resonance first and
if there is an area with abnormality ask him
to take one or two deep breath to assess
breath sounds
• When abnormal sounds are heard, map out
the area by moving from normal to a
abnormal area.

71. Intensity of breath sounds
• Normal intensity is learned with experience
• If intensity of breath sounds is dimished
repeat auscultation after forceful cough
• Intesnity of sounds will increase if it was
diminished due to bronchial obstruction by
secretions which are dislodged by cough.

72. Causes of diminished breath sounds are
• Pleural effusion
• Pneumothorax
• Collapse with obstructed bronchus
• Thickened pleura
• Emphysema ( reduction in intensity of breath
sounds is generalized

73. Character of breath sounds
1. Vesicular breathing
• This is the character of normal breath sounds
• It has the following characteristics
• Inspiration is longer than expiration
• There is no pause between inspiration and
expiration
• Quality of sounds is rustling

74. 2. bronchial breathing
• It has the following characteristics
• Expiration is as long as and as loud as
inspiration because
• Ther is a difinite pause between inspiration
and expiration
• Character of both inspiratory and expiratory
sounds is blowing

75. Bronchial breathing is normaly heard over the
trachea and the upper part of midline

76. Bronchovesicular breathing
• Inspiration is bronchial while expiration is
vesicular.
• It has no significance.
• Vesicular breathing with prolonged expiration
• It is heard in chronic bronchitis, emphysema
and bronchial asthma.

77. Added Sounds
• If added sounds are present, note their type,
number and site where they are heard.
• You should repeat auscultation after forceful
cough.
• It will help to differntiate between varous added
sounds if there is any doubt ronchi or
crepitations will alter while pleural rub will
remain unchanged

78. Rhonchi
• There are continuous, musical, whistling
sounds produced by passage of air through
narrowed airways.
Causes
• Bronchial asthma
• Chronic bronchitis
• Emphysema

79. Crepetitions
These are interrupted crackling sounds
produced by the following mechanisms
• Bubbling of the air through secretion in the
bronchi and pulmonary cavities, these are
through inspiration and change on couhing
• Explosive reipening of thikened alveoli: these
are heard at the end of inspiration and don’t
change on coughin

81. Pleural Rub
• This is a superficial, scratchy, rough sound ( similar to
pericardial rub) and is produced by rubbing of inflamed
pleural surfaces.
• It does not change with coughing.
• It is audible at the end of inspiration and just afer the
beginning of expiration.
• It may be audible only on deep breathing.
• It disappears with the development of effusion but may
persist above the effusion

83. Vocal Resonance
• It is similar to vocal fremitus but is heard on
auscultation.
• Ask the patient to repeat words like one, one, one or
equivalent and ausculatate the chest.
• A resonant sound is heard and is called vocal
resonance.
• Compare it at corresponding sites on both sides

84. Vocal resonance may be normal, decreased or
increased
• Normal vocal resonance conveys the inmpression as
if it is being produced just at the chest piece of the
stethoscope
• It it seems that the sound is being prodeced nearer
the ear than at the chest piece, vocal resonance is
increased.

85. • Bronchophony: some times vocal resonance is
increased to the extent that it conveys the
impression of being produced near the ear piece of
the stethoscope. It is called bronchophony.
• Aegophony: sometimes a nasal or bleating quality
is added to the sound of vocal resonance. And E
become A during ausculation It is called
aegophony. It usually occurs above the level of a
large pleural effusion.

87. Forced Expriatory Time
• Place the chest piece of stethoscope over the
trachea.
• Ask the pateint to take full deep inspiration
then expire fully at maximum speed
• Not the time taken by expiration
• Normally it is less than 4 seconds.
• It is prolonged in chronic bronchitis,
emphysema and bronchial asthma.

88. Coin Test
• This test is sometimes helpful in confirming the
presence of tensioin pneumothorax.
• Take him to place a coin on the posterior chest
wall of the patient and tap it with a second coin
while you ausculatat on fron
• Normally a dull thud is heard
• If a ringing metalic sound is heardm test is
positive.

89. Succussioin splash
• If the chest of a patient with
hydropneumothorax is shaken.
• A splashing sound is heard.
• It should not be confused with gastric
succussion splash