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Examination of the

respiratory system

Ding Xuhong
Department of Pulmonary Medicine
Renmin Hospital, Wuhan University
Common symptoms

Cough and sputum
Chest pain
Breathlessness inappropriate to
the level of physical exertion, or
even occurring at rest
• Severity
Is the dyspnea related only to
How far can the patient walk at
normal pace on the level?
• Variability
Are there good days or bad days?
(seasonal variation)
Are there any times of day or night
that are usually worse than others?
• Acute or chronic
How long has the cough been
• Time relationship
Is the cough worse at any time of
day or night?
• Precipitating factors
Is the cough aggravated by
anything, for example dust, pollen or
cold air?
• Productive or nonproductive
Is sputum produced?
• Type and quantity of sputum
What does it look like?
How much is produced?
Coughing of blood in the sputum
Is there any blood in the sputum?
Is it fresh or altered blood?
How often has it been seen and for
how long?
Difficulty in justify the origin of
blood: gums, nose, stomach
Chest pain
• caused by lung diseases usually
arises from the pleura: pleuritic pain
• caused by local invasion of the
chest wall by a lung tumor: constant,
unrelated to breathing
Pleuritic pain
sharp, stabbing, made worse by
deep breathing or coughing
• inflammation of the pleura
• spontaneous pneumothorax
• pulmonary infarction
The Examination of The
Respiratory System
• Relevant anatomy
• Examination of the chest
• Putting it together
Relevant anatomy
Sternal angle (Louis angle)
• The junction of the manubrium and
body of the sternum
• The location of other important
structures at the same level: (1) the
second rib; (2) the disc between the
fourth and fifth thoracic vertebrae;
(3) the bifurcation of the trachea; (4)
the upper level of the atria of the
Major interlobar fissure
(Oblique fissure)
from 2nd thoracic spine downward
and laterally, then anteriorly and
medially to the sixth rib in the
midclavicular line
the upper border of the lower lobe
• Minor interlobar fissure
(Horizontal fissure)
a horizontal line from the sternum at
the level of the fourth costal
cartilage to meet the line of the
major interlobar fissure
the boundary between the upper and
middle lobes
Inspection of the chest
Palpation of the chest
Percussion of the chest
Auscultation of the chest
Inspection of the chest
Appearance of the chest
Bilaterally symmetrical and elliptical in
Kyphosis — forward bending
Scoliosis — lateral bending
Flattening — PA diameter < half of the
transverse diameter
Over-inflation (barrel-shaped chest) —
PA diameter (in COPD)
Movement of the chest

Intercostal recession (“Three

depressions sign”)
A drawing in of the intercostal spaces
with inspiration
Severe upper airways obstruction, as in
laryngeal disease, tumor of the trachea
Contradictory movement
the lower ribs move inwards on
inspiration instead of the normal outward
movement (respiratory muscle fatigue)

Venous pressure
right heart failure
obstruction of the superior vena cava
Respiratory rate and rhythm

14-16 breaths/min
Cheyne-Stokes breathing
Cheyne-Stokes respiration

Cyclic deepening and quickening of

respiration, followed by shallowing and
slowing of respiration, with a short period of
apnea, then being repeated
Severe cardiac failure, narcotic drug
poisoning, neurological disorders
occasionally seen in elderly persons
Sleep Apnea
Central apnea
complete cessation of respiratory
effort during sleep

Obstructive apnea
obstruction of the upper airways by
soft tissues in the region of the
pharynx, apnea despite continuation of
respiratory effort
Palpation of the chest
Chest expansion
The examiner’s hands should be
placed over the lower anterolateral
aspect of the chest with the thumbs
along the costal margin, each pointing
toward the xiphoid process, and the
palms and fingers extended over the
anterolateral wall
• Expansion should be tested during both
quiet and deep inspiration

• Expansion may be limited in

Acute pleurisy
Fibrous thickening of the pleura
Fractured ribs
Other trauma to the chest wall
Vocal fremitus
The resonance of sounds in the chest
made by the voice (the vibrations
transmitted from the vocal cords to the
chest as the patient repeats a phrase,
‘ninety-nine’) — detected with the hand on
the chest
Percussion of the chest

1. The middle finger of one hand (usually
the left if the examiner is right-handed)
is pressed firmly against the chest wall
parallel to the ribs but with the palm
and other fingers held off the skin
2. A very short quick blow is struck at the
middle phalanx of the pleximeter finger
with the tip of the middle finger of the
right hand
3. When properly performed, the forearm
is virtually stationary the entire
movement being executed from the wrist
1.the plexor finger should strike the
pleximeter finger only instantaneously
and must be immediately withdrawn one side of the thorax with
the opposite side as you proceeds with
the percussion sensitive to the vibratory sensations
that are being received from the chest wall
by the pleximeter finger
Percussion note
Dullness (reduction of resonance)
short, high pitched, not loud, the
pleximeter finger perceives relatively
little vibratory sensation
1. Consolidation: the underlying lung
more solid than usual
2. Pleural effusion: the pleural cavity
contains fluid
3. Pleural thickening
Hyperresonance (increase in
Pneumothorax: the pleural cavity contains
Auscultation of the chest
The breath sounds
Normal breath sounds: vesicular
Reduced: emphysema, pleural thickening
or pleural effusion
Bronchial breathing: louder, harsh, the
expiratory sound has a more sibilant
character than inspiratory sound
consolidation of the lung (pneumonia)
Added sounds
The noise is often both inspiratory
and expiratory
Associated with laryngeal disease
or localized narrowing of the
trachea or the large airways

musical sounds associated with
airway narrowing
Widespread polyphonic wheezes
dynamic compression of the bronchi
accentuated in expiration when
airway narrowing is present
diffuse airflow obstruction, as in asthma
and COPD
Fixed monophonic wheezes
localized narrowing of a single bronchus
by a tumour or foreign body
may be inspiratory or expiratory or both
Short, explosive sounds, produced by
sudden changes in gas pressure related
to the sudden opening of previously
closed small airways
COPD: crackles at the beginning of
Bronchiectasis: localized loud and
coarse crackles
Diffuse interstitial fibrosis: fine and late
inspiratory crackles
The pleural rub
creaking or rubbing in character
Pleural inflammation
associated with pleuritic pain
Vocal resonance
The resonance of sounds in the
chest made by the voice (the
vibrations transmitted from the
vocal cords to the chest as the
patient repeats a phrase, ‘ninety-
nine’)— detected through
Not distinct syllables but a resonant

Detecting the conductivity of the lungs

Compare the area on one side with the

corresponding on the other side
Consolidation: vocal resonance
louder and clearer
Whispering pectoriloquy: much
louder and clearer, in large area of
Egophony: nasal or bleating, ‘eee
aaa’, over the area of large amount of
pleural effusion
Putting it together

The referred procedure for the

examination of the chest
Observe the patient generally
Ask the patient’s permission for the
examination, and ensure lying back
comfortably at 45 degrees
Examine the hands
Check the face tor anemia or cyanosis
Observe the respiratory rate
Inspect the chest movements and the
anterior chest wall
Feel the position of the trachea, and
check for lymphadenopathy
Feel the position of the apex beat
Check the symmetry of the chest
movements by palpation
Percuss the anterior chest and axillae
Listen to the breath sounds
Check the vocal resonance
Check the tactile vocal fremitus
Sit the patient forward;
Inspect the posterior chest wall
Percuss the back of the chest
Listen to the breath sounds
Check the vocal resonance
Check the tactile vocal fremitus

Thank the patient and ensure the patient

is dressed or appropriately covered
Interpreting the signs
If movements are diminished on one
side, there is likely to be an
abnormality on that side
The percussion note is dull over a
pleural effusion and an area of
The breath sounds, the vocal
resonance and tactile vocal fremitus
are quieter or less obvious over a
pleural effusion, and louder or more
obvious over an area of consolidation
Over a pneumothorax, the percussion
note is more resonant than normal but
the breath sounds, vocal resonance
and tactile vocal fremitus are quieter
or reduced. Pneumothorax is easily