This document provides information on how to examine the respiratory system. It is presented by Prof. Dr. R.R. Deshpande and contains his contact information. The document describes examining the upper respiratory tract, including the nose, oral cavity, throat and larynx. It also describes examining the lower respiratory system by inspecting, palpating, percussing and auscultating the chest. Specific examination techniques are outlined for different parts of the respiratory examination.

1. Respiratory System Examination
• Presented By –
Prof.Dr.R.R.Deshpande
(M.D in Ayurvdic
Medicine & M.D. in
Ayurvedic Physiology)
• www.ayurvedicfriend.c
om
• Mobile – 922 68 10 630
• professordeshpande@g
mail.com
9/18/2016 1Prof.Dr.R.R.Deshpande

2. Respiratory System Examination
• Respiratory system problems are very
common on medical pracrice
• Examples are Rhinitis, Pharyngitis, Tonsillitis,
Laryngitis, Bronchitis, Pneumonia, Bronchial
Asthama ,Bronchieactasis ,Emphysema,
Tuberculosis
• In India Tuberculosis is very common in India
9/18/2016 2Prof.Dr.R.R.Deshpande

3. Respiratory System Exam – By
Prof.Dr.R.R.Deshpande
9/18/2016 3Prof.Dr.R.R.Deshpande

4. Respiratory System Examination
• This examination is better to be done in sitting
position
• Examination of back side of chest is equally
important
• Many respiratory diseases occur on back side
• Examination is divided into 2 parts
• 1) Upper Respiratory system Examination
• 2) Lower Respiratory system Examination
9/18/2016 4Prof.Dr.R.R.Deshpande

5. Examination of
Upper Respiratory Tract
• 1) Nose
• 2) Oral cavity
• 3) Throat
• 4) Larynx
9/18/2016 5Prof.Dr.R.R.Deshpande

6. Examination of chest
• 1) Inspection
• 2) Palpation
• 3) Percussion
• 4) Auscultation
9/18/2016 6Prof.Dr.R.R.Deshpande

7. Examination of upper Respiratory Tract
• 1) Examination of two nostrils by torch light &
lifting tip of nose
• See the Nasal septum ( DNS = Deviated Nasal
Septum)
• Look for mucous membrane ,any discharge (
watery, mucoid, muco purulent )
• Discharge – white, yellow ,green ( yellow or
green discharge suggests infection & may
need Antibiotics) ,any blood
9/18/2016 7Prof.Dr.R.R.Deshpande

8. Examination of Upper respiratory Tract
9/18/2016 8Prof.Dr.R.R.Deshpande

9. Examination of Nose with Torch
9/18/2016 9Prof.Dr.R.R.Deshpande

10. Examination of upper Respiratory Tract
• 2) Oral cavity & Pharynx –
• Ask the patient to open the mouth & say ‘Aaa’
• Examine ,Tongue,Teeth, Gums, Cheek,
Pharyngeal wall ,Tonsillar fossae ,position of
Uvula, Pharyngeal arches
• Look for redness, secretions ,any patch present
on this mucous membrane
• Look for Leucoplakia ( pre malignancy condition)
• Look for whitish patches of Diptheria
9/18/2016 10Prof.Dr.R.R.Deshpande

11. Examination of oral cavity by Torch
9/18/2016 11Prof.Dr.R.R.Deshpande

12. Examination of upper Respiratory Tract
• 3) Examination of Larynx by 2 ways
• Direct Laryngoscopy
• Indirect Laryngoscopy
9/18/2016 12Prof.Dr.R.R.Deshpande

13. Examination of Chest
• Sitting position
• Hands on waist
9/18/2016 13Prof.Dr.R.R.Deshpande

14. Inspection of chest
• 1) Size & Shape – Symmetrical
• 2) Type or act of Respiration –Abdominal
,Thoracic
• 3) Count RR
• 4) Check Chest Expansion with deep breathing
• 5) Position of Trachea
• 6) Look Apex Beat
• 7) Note Accessory Muscles
9/18/2016 14Prof.Dr.R.R.Deshpande

15. Inspection of chest
• 1) Size & shape
• Symmetrical or asymmetrical
• Convexity on both side
• Transverse diameter > AP diameter
• Barrel shaped Chest – TD = AP diameter (
Emphysema)
• Pigeon Chest – TD < AP diameter ( Bronchial
Asthama ,COPD)
9/18/2016 15Prof.Dr.R.R.Deshpande

16. Look for symmetry of chest
9/18/2016 16Prof.Dr.R.R.Deshpande

17. Abnormal Chest
Barrel Chest Pigeon Ches
9/18/2016 17Prof.Dr.R.R.Deshpande

18. Type or Act of Respiration
• 2) Type or Act of Respiration –
• Abdominal or Thoracic
• If abdominal protrudes forward during
inspiration & going back in expiration – This is
abdominal breathing & seen in males
9/18/2016 18Prof.Dr.R.R.Deshpande

19. In males – Look for
Abdominal Respiration
9/18/2016 19Prof.Dr.R.R.Deshpande

20. Inspection of chest
• 3) Count RR by seeing the movement of
abdomen for 1 min
• Normal RR = 14 to 18 per min
9/18/2016 20Prof.Dr.R.R.Deshpande

21. Count Respiratory rate
9/18/2016 21Prof.Dr.R.R.Deshpande

22. Inspection of chest
• 4) To check the chest expansion –
• Ask the patient to do deep inspiration &
expiration
• There should be equal expansion on both
sides.This means equal quantity of air is going
in both the lungs
• Observe the movement from back .Observe
the movement of scapulae on both sides
9/18/2016 22Prof.Dr.R.R.Deshpande

23. Look for symmetrical Expansion of Scapulae
9/18/2016 23Prof.Dr.R.R.Deshpande

24. Inspection of chest
• 5) Position of Trachea
• Observe the head of sternomastoid muscle
• It should be equally prominent on both sides,
which indicates that Trachea is in central
• In different diseases Trachea can be pulled on
one side or push on other side
• 6) Look for Apex beat – 5th left Intercostal
space ,in mid clavicular line
9/18/2016 24Prof.Dr.R.R.Deshpande

25. Position of Trachea – Look heads of
Sternomastoid muscle
9/18/2016 25Prof.Dr.R.R.Deshpande

26. Look for Apex beat
9/18/2016 26Prof.Dr.R.R.Deshpande

27. Inspection of chest
• 7) Note Accessory muscles ,
• if any are dominant or vigorously acting like
• Alai Nasi in Pneumonia in children or
• Sternocleidomastoid in severe attack of
Bronchial Asthama
• Normally accessory muscles are not prominent
9/18/2016 27Prof.Dr.R.R.Deshpande

28. Look for movements of Alai nasi
9/18/2016 28Prof.Dr.R.R.Deshpande

29. Look for movements of
Accessory muscles of Respiration
9/18/2016 29Prof.Dr.R.R.Deshpande

30. Palpation of chest
• 1) Measurement of Chest ( Card board & Tape)
• 2) Expansion by Circumference ( By Tape ,at
nipple level)
• 3) Palpation of Chest Expansion ( Thumb
movement)
• 4) Position of Trachea
• 5) TVF ( Tactile Vocal Fremitus)
9/18/2016 30Prof.Dr.R.R.Deshpande

31. Palpation of chest
• Palpation – feeling with palm
• 1) Measurement of chest with Tape & card
boards – Transverse & Antero posterior diameter
• 2) Expansion is measured in form of
circumference of chest with tape at nipple level –
during expiration & then after deep inspiration
• Chest expansion is expected about 5 cm after
deep inspiration
9/18/2016 31Prof.Dr.R.R.Deshpande

32. Measuring Antero posterior Diameter of Chest
9/18/2016 32Prof.Dr.R.R.Deshpande

33. Measuring Antero posterior Diameter of Chest
9/18/2016 33Prof.Dr.R.R.Deshpande

34. Measuring Transverse Diameter of chest
9/18/2016 34Prof.Dr.R.R.Deshpande

35. Measuring circumference of chest
after deep Inspiration
9/18/2016 35Prof.Dr.R.R.Deshpande

36. Palpation of chest
• 3) Palpation of respiratory movements or
chest expansion
• 1) From front
• 2) Then from Back
• 3) & also Apices of Lungs
9/18/2016 36Prof.Dr.R.R.Deshpande

37. Palpation of respiratory movements
• 3 a ) Keep your palms ,at nipple level & ask subject to
do deep inspiration & expiration .
• Ask the patient ,to turn his face laterally ( To avoid
droplet contamination to doctor)
• Thumbs are moving away on both sides equally ,it
means expansion of chest is equal on both sides ,it
means equal quantity of air is going on both sides
• 3 b ) Now ask the patient to turn on back side .Keep
hands at mid scapular region .Here also thumb should
move equal distance on both sides
• This suggests that Air Entry is bilaterally equal(AEBE)
9/18/2016 37Prof.Dr.R.R.Deshpande

38. Chest Expansion – Equal on both sides
9/18/2016 38Prof.Dr.R.R.Deshpande

39. Chest expansion equal on both sides –
from posterior side
9/18/2016 39Prof.Dr.R.R.Deshpande

40. Palpation of respiratory movements
• 3 c) Examination at apices is also important because -
• TB mainly occurs at Apex of lungs
• For examination of Apex keep 4 fingers on shoulder
& thumb in mid portion of scapulae
• Ask the patient to do deep inspiration & Expiration
• Upward movement of forefingers or shoulder will
be equal on both sides ,which can be felt by fingers
• This is Palpation of chest for respiratory movements
9/18/2016 40Prof.Dr.R.R.Deshpande

41. Chest expansion –equal at Apex
9/18/2016 41Prof.Dr.R.R.Deshpande

42. Confirm Position of Trachea
by Palpation
• 4) Position of Trachea –
• Put Index & middle fingers ,above the
manubrium sternum & in between
sternomastoid muscle
• If depth for finger is equal on both sides then
Trachea is in center or middle
9/18/2016 42Prof.Dr.R.R.Deshpande

43. Trachea is in central –
confirmed by palpation
9/18/2016 43Prof.Dr.R.R.Deshpande

44. TVF ( Tactile Vocal Fremitus) –
Physics Principle
• 5) TVF –Tactile Vocal Fremitus
• Sound waves travel faster & louder in solid medium as
compare to fluid or air medium
• Subject is asked to say 1-1-1 or 9-9-9
• These words are having nasal twang ,so better
appreciated for sound waves
• With ulnar border of palm ,we palpate chest for
vibration
• In solid medium – TVF is increased
• In Air or Liquid medium – TVF is decreased or reduced
9/18/2016 44Prof.Dr.R.R.Deshpande

45. Tactile Vocal Fremitus – Say 9-9-9
9/18/2016 45Prof.Dr.R.R.Deshpande

46. TVF
• TVF is examined at supra mammary ,mammary & Infra
mammary region
• Asking the patient to take hands on head ,TVF is
examined in Infra axillary region
• Ask the patient to turn back & keep the hands on
shoulder & keeping neck down .So that scapulae
spread apart
• Palpate at supra scapular, Inter scapular & Infra
scapular
• In consolidation – TVF increases
• In Pleurisy & Pneumothorax – TVF decreases
9/18/2016 46Prof.Dr.R.R.Deshpande

47. Tactitile Vocal Fremitus in Axillary
area
9/18/2016 47Prof.Dr.R.R.Deshpande

48. Tactile Vocal Fremitus –
Back side of chest
9/18/2016 48Prof.Dr.R.R.Deshpande

49. Percussion of chest
• 1) From front ,back, infra axillary area
• 2) Identical intercostal space is percussed on
left & right side & percussion note is
compared
• 3) Normally all over chest ,resonant note is
obtained ,except the area of cardiac dullness
9/18/2016 49Prof.Dr.R.R.Deshpande

50. Percussion of chest
9/18/2016 50Prof.Dr.R.R.Deshpande

51. Percussion of chest in Axillary area
9/18/2016 51Prof.Dr.R.R.Deshpande

52. Percussion of chest
from back side of chest
9/18/2016 52Prof.Dr.R.R.Deshpande

53. Auscultation of chest
• 1) From front,back & infra axilary area
• 2) Identical intercostal space is Auscultated on
left & right side & findings are compared
• 3) Air Entry ( Quantity check)
• 4) Type of Breathing ( Quality check)
• 5) Adventitious sounds
• 6) Vocal Resonance ( VC)
9/18/2016 53Prof.Dr.R.R.Deshpande

54. Auscultation of Chest
9/18/2016 54Prof.Dr.R.R.Deshpande

55. Auscultation of chest
• Ask the patient to do deep breathing & put the
stethascope on intercostal spaces
• 1) If Intensity of sound is same on both sides ,it
indicates equal air entry on both sides (AEBE = Air
Entry Bilaterally equal ) – Mammary, Axillary
• Supra scapular ,Inter scapular & Infra scapular
• 2) By Type of breathing ,we check quality of sound
9/18/2016 55Prof.Dr.R.R.Deshpande

56. Difference in ---
• In Air Entry we compare –Intensity of sounds
on both the sides
• In Type of Breathing ,we concentrate on
Quality of sound ,that we are hearing
9/18/2016 56Prof.Dr.R.R.Deshpande

57. Auscultation in Axillary area
9/18/2016 57Prof.Dr.R.R.Deshpande

58. Type of breathing
• a) Vesicular breathing – Rustling of leaves (
Distension & collapse of alveoli make vesicular
sound) Vesicular breathing indicates air is entering in
thousands of alveoli. They are expanding & collapsing
during expiration
• b) Bronchial breathing --- heard on Trachea .It is like
blowing of air through pipe
• 3) If vesicular breathing is replaced by bronchial
breathing ,indicates that part of lung is not
functioning normally like in Pneumonia
9/18/2016 58Prof.Dr.R.R.Deshpande

59. Adventitious sounds
• 3) Adventitious sounds
• a) Whistling sounds –Rhonchi – heard in
Bronchial Asthama ,Bronchitis
• b) Bubbling sound or Crepitus – heard in
Pneumonia ,Pulmonary oedema ,CCF
9/18/2016 59Prof.Dr.R.R.Deshpande

60. Auscultation on back side of chest
9/18/2016 60Prof.Dr.R.R.Deshpande

61. Vocal Resonance
• 4) VR = Vocal Resonance
• 1) Principle is similar to as TVF
• Sound waves travel faster & louder in solid
medium as compare to fluid or air medium
• Ask the patient to say 9 – 9 – 9 & Auscultate
chest on intercostal space on both sides
9/18/2016 61Prof.Dr.R.R.Deshpande

62. Investigations
• All these clinical findings are corelated with
Investigations like
• 1) X ray chest PA view
• 2) Sputum Examination for AFB
• 3) Bronchoscopy
• 4) Lung Function Tests by Spirometry
9/18/2016 62Prof.Dr.R.R.Deshpande

63. Please see also Videos
• Copy ,Paste Link as URL
• Examination of Respiratory System – Part 1 --
By Prof.Dr.R.R.deshpande –
• https://youtu.be/iYitUoIxTIA
• Examination of Respiratory System – Part 2 --
By Prof.Dr.R.R.deshpande –
• https://youtu.be/liKgZjqtnY0
9/18/2016 Prof.Dr.R.R.Deshpande 63

64. Prof.Dr.R.R.Deshpande
• Sharing of Knowledge
• FOR
• Propagating Ayurved
9/18/2016 64Prof.Dr.R.R.Deshpande