RESPIRATORY EXAMINATION

Background information
• abnormal patterns of breathing
1. sleep apnoea
• = cessation of airflow for more than 10 seconds more than 10 times a night during
sleep
• causes: obstructive (e.g. obesity with upper narrowing, enlarged tonsils, pharyngeal
soft tissue changes in acromegaly or hypothyroidism)
2. Cheyne-Stokes
• = periods of apnoea alternating with periods of hyperpnoae
• pathophysiology: delay in medullary chemoreceptor response to blood gas changes
• causes
• left ventricular failure
• brain damage (e.g. trauma, cerebral, haemorrhage)
• high altitude
3. Kussmaul's (air hunger)
• = deep rapid respiration due to stimulation of respiratory centre
• causes: metabolic acidosis (e.g. diabetes mellitus, chronic renal failure)
4. hyperventilation
• complications: alkalosis and tetany
• causes: anxiety
5. ataxic (Biot)
• = irregular in timing and deep
• causes: brainstem damage
6. apneustic
• = post-inspiratory pause in breathing
• causes: brain (pontine) damage
7. paradoxical
• = the abdomen sucks with respiration (normally, it pouches uotward due to
diaphragmatic descent)
• causes: diaphragmatic paralysis
• cyanosis
1. refers to blue discoloration of skin and mucous membranes
2. is due to presence of deoxygenated haemoglobin in superficial blood vessels
3. cyanosis does NOT occur in anaemic hypoxia because the total haemoglobin content is low
4. central cyanosis = abnromal amout of deoxygenated haemoglobin in arteries and that blue
discoloration is present in parts of body with good circulation such as tongue
5. peripheral cyanosis = occurs when blood supply to a certain part of body is reduced, and
the tissue extracts more oxygen from normal from the circulating blood, e.g. lips in cold
weather are often blue, but lips are spared
6. presence of central cyanosis should lead one to careful examination of cardiovascular and
respiratory systems
7. causes of cyanosis
• central cyanosis
• decreased arterial saturation
• decreased concentration of inspired oxygen: high altitude
• lung disease: chronic obstructive pulmonary disease with cor
pulmoale, massive pulmonary embolism
• right to left cardiac shunt (cyanotic congenital heart disease)
• polycythaemia
• haemoglobin abnromalities (rare): methaemoglobinaemia,
sulphaemoglobinaemia
• peripheral cyanosis
 • all causes of central cyanosis cause peripheral cyanosis
• exposure to cold
• reduced cardiac output: left ventricular failure or shock
• arterial or venous obstruction
Position: patient sitting over edge of bed
General appearance
• look for the following
• dyspnoea
• normal respiratory rate < 14 each minute
• tachypnoea = rapid respiratory rate
• are accessory muscles being used (sternomastoids, platysma, strap muscles of neck)
- characteristically, the accessory muscles cause elevation of shoulders with
inspiration and aid respiration by increasing chest expansion
• cyanosis
• central cyanosis is best detected by inspecting the tongue - examination of tongue
differentiates central from peripheral cyanosis
• note: severe lung disease may result in significant ventilation-perfusion imbalances
(e.g. pneumonia, chronic airflow limitation, pulmonary embolism)
• character of cough
• ask patient to cough several times
• lack of usual explosive beginning may indicate vocal cord paralysis (bovine cough)
• muffled, wheezy ineffective cough suggests airflow limitation
• very loose productive cough suggests excessive bronchial secretions due to:
• chronic bronchitis
• pneumonia
• bronchiectasis
• dry irritating cough may occur with:
• chest infection
• asthma
• carcinoma of bronchus
• left ventricular failure
• interstitial lung disease
• ACE inhibitors
• sputum
• volume
• type (purulent, mucoid, mucopurulent)
• presence or absence of blood?
• stridor
• = croaking noise loudest on inspiration
• causes: (obstruction of larynx, trachea or large broncus)
• acute onset (minutes)
• inhaled foreign body
• acute epiglottitis
• anaphylaxis
• toxic gas inhalation
• gradual onset (days, weeks)
• laryngeal and pharyngeal tumours
• crico-arytenoid rheumatoid arthritis
• bilateral vocal cord palsy
• tracheal carcinoma
• paratracheal compression by lymph nodes
• post-tracheostomy or intubation granulomata
• is a sign that requires urgent attention
• hoarseness
• causes include:
 • laryngitis
• laryngeal nerve palsy associated with carcinoma of lung
• laryngeal carcinoma
The hands
• clubbing
• commonly cause by respiratory disease (but NOT emphysema or chronic bronchitis)
• occasionally, clubbing is associated with hypertrophic pulmonary osteoarthropathy (HPO)
• = arthropathy in association with lung disease
• characterised by periosteal inflammation at distal ends of long bones, wrists, ankles,
metacarpals and metatarsals
• sweelling and tenderness over wrists and other involved areas
• note that rarely HPO occurs without clubbing
• causes include: primary lung carcinoma and pleural mesothelioma
• staining
• staining of fingers - sign of cigarette smoking (caused by tar, not nicotine)
• wasting and weakness
• compression and infiltration of peripheral lung tumour of lower trunk of brachial plexus
results in wasting of small muscles of hand and weakness of finger abduction
• pulse rate
• tachycardia, and pulsus paradoxus are important signs of sever asthma
• flapping tremor (asterixis) - unreliable sign
• ask patient to dorsiflex wrists and spread out fingers, with arms outstretched
• flapping tremor may occur with severe carbon dioxide retention (severe chronic airflow
limitation)
The face
• eyes:
• Horner's syndrome? (constricted pupil, partial ptosis and loss of sweating which can be due
to apical lung tumour compressing sympathetic nerves in neck)
• nose:
• polpys? (associated with asthma)
• engorged turbinates? (various allergic conditions)
• deviated septum? (nasal obstruction)
• mouth and tongue:
• look for central cyanosis
• evidence of upper respiratory tract infection (a reddened pharynx and tonsillar enlargement
with or without a coating of pus)
• broken tooth - may predispose to lung abscess or pneumonia
• sinusitis is indicated by tenderness over the sinuses on palpation
• facial plethora (an excess of any of the body fluids) or cyanosis may occur if superior vena cava os
obstructed (e.g. due to tumour)
• some patients with obstructive sleep apnoea will be obese with a receding chin, a small pharynx
and a short thick neck
The trachea
• causes of tracheal displacement:
• toward the side of the lung lesion
• upper lobe collapse
• upper lobe fibrosis
• pneumonectomy
• away from the side of teh lung lesion (uncommon)
• massive pleural effusion
• tension pneumothorax
• upper mediastinal masses, such as retrosternal goitre
• tracheal tug (finger resting on trachea feels it move inferiorly with each inspiration) is a sign of
gross overexpansion of the chest because of airflow obstruction
The chest: inspection
• shape and symmetry of chest
• barrel shaped
• = anteroposterior (AP) diameter is increased compared with lateral diameter
• causes: hyperinflation due to asthma, emphysema
• pigeon chest (pectus carinatum)
• = localised prominence (outward bowing of sternum and costal cartilages)
• causes:
• manifestation of chronic childhood illness (due to repeated strong
contractions of diaphragm while thorax is still pliable)
• rickets
• funnel chest (pectus excavatum)
• = developmental defect involving a localised depression of lower end of sternum
(figure 4.3); in severe cases, lung capacity may be restricted
• Harrison's sulcus
• = linear depression of lower ribs just above costal margins at site of attachment of
diaphragm
• causes:
• severe asthma in childhood
• rickets
• kyphosis = exaggerated forward curvature of spine
• scoliosis = lateral bowing
• kyphoscoliosis: causes:
• idiopathic (80%)
• secondary to poliomyelitis (inflammation involving grey matter of cord)
• associated with Marfan's syndrome
• (note: severe thoracic kyphoscoliosis may reduce lung capacity and increase work
of breathing)
• lesions of chest wall
• scars - previous thoracic operations or chest drains for a previous pneumothorax or
pleural effusion
• thoracoplasty (was once performed to remove TB, but no longer is because of
effective antituberculosis chemotherapy) invovled removal of large number of ribs
on one side to achieve permanent collapse of affected lung
• erythema and thickening of skin may occur in radiotherapy; there is a sharp
demarcation between abnormal and normal skin
• diffuse swelling of chest wall and neck
• pathophysiology: air tracking from the lungs
• causes:
• pneumothorax
• rupture of oesopahagus
• prominent veins:
• cause: superior vena caval obstruction
• asymmetry of chest wall movements:
• assess this by inspecting from behind patient, looking down the clavicles during
moderate respiration - diminished movement indicates underlying lung disease
• the affected side will showed delayed or decreased movement
• causes of reduced chest wall movements on one side are localised:
• localised pulmonary fibrosis
• consolidation
• collapse
• pleural effusion
• pneumothroax
• causes of bilateral reduced chest wall movements are diffuse:
• chronic airflow limitation
• diffuse pulmonary fibrosis
The chest: palpation
• chest expansion
• place hands firmly on chest wall with fingers extending around sides of chest (fugyre 4.5)
• as patient takes a big breath in, the thumbs should move symmetrically apart about 5 cm
• reduced expansion on one side indicates a lesion on that side
• note: lower lobe expansion is tested here; upper lobe is tested for on inspection (as above)
• apex beat
• (discussed in cardiac section)
• for respiratory diseases:
• displacement toward site of lesion - can be caused by:
• collapse of lower lobe
• localised pulmonary fibrosis
• displacement away from site of lesion - can be caused by:
• pleural effusion
• tension pneumothorax
• apex beat is often impalpable in a chest which is hyperexpanded secondary to
chronic airflow limitation
• vocal fremitus
• palpate chest wall with palm of hand while patient repeats "99"
• front and back of chest are each palpated in 2 comparable positions with palms; in this way
differences in vibration on chest wall can be detected
• causes of change in vocal fremitus are the same as those for vocal resonance (see later)
• ribs
• gently compress chest wall anteroposteriorly and laterally
• localised pain suggests a rib fracture (may be secondary to trauma or spontaneous as a
result of tumour deposition or bone disease)
The chest: percussion
• with left hand on chest wall and fingers slightly separated and aligned with ribs, the middle finger
is pressed firmly against the chest; pad of right middle finger is used to strike firmly the middle
phalanx of middle finger of left hand
• percussion of symmetrical areas of:
• anterior (chest)
• posterior (back) (ask patient to move elbows forward across the front of chest - this rotates
the scapulae anteriorly, i.e. moves it out of the way)
• axillary region (side)
• supraclavicular fossa
• percussion over a solid structure (e.g. liver, consolidated lung) produces a dull note
• percusion over a fluid filled area (e.g. pleural effusion) produces an extremely dull (stony dull)
note
• percussion over the normal lung produces a resonant note
• percussion over a hollow structure (e.g. bowel, pneumothorax) produces a hyperresonsant note
• liver dullness:
• upper level of liver dullness is determined by percussing down the anterior cehst in mid-
clavicular line
• normally, upper level of liver dullness is 6th rib in right mid-clavicular line
• if chest is resonant below this level, it is a sign of hyperinflation usually due to
emphysema, asthma
• cardiac dullness:
• area of cardiac dullness is uaully present on left side of chest
• this may decrease in emphysema or asthma

The chest: auscultation

• breath sounds
• introduction
• see figure 4.7 - one should use the diaphragm of stethoscope to leisten to breath
 sound in each area, comparing each side
• remember to listen high up into the axillae
• remember to use bell of stethoscope to listen to lung ap[ices from above the
clavicles
• quality of breath sounds
• normal breat sounds
• are heard with stethoscope over all parts of chest, produced in airways rather
than alveoli (although once they had been thought to arise from alveoli
(vesicles) and are therefore called vesicular sounds)
• normal (vesciular) breath sounds are louder and longer on inspiration than
on expiration; and there is no gap between the inspiratory and expiratory
sounds
• bronchial breath sounds
• turbulence in large airways is heard without being filtered by the alveoli,
and therefore produce a different quality; they are heard over the trachea
normally, but not over the lungs
• are audible throughout expiration, and often there is a gap between
inspiration and expiration
• are heard over areas of consolidation since solid lung conducts the sound of
turbulence in main airways to peripheral areas without filtering
• causes include:
• lung consolidation (lobar pneumonia) - common
• localised pulmonary fibrosis - uncommon
• pleural effusion (above the fluid) - uncommon
• collapsed lung (e.g. adjacent to a pleural effusion) - uncommon
• (amphoric sound = when breath sounds over a large cavity have an
exaggerated bronchial quality)
• intensity of breath sounds
• causes of reduced breath sounds include:
• chronic airflow limitation (espescially emphysema)
• pleural effusion
• pneumothorax
• pneumonia
• large neoplasm
• pulmonary collapse
• added (adventitious) sounds
• two types of added sounds: continuous (wheezes) and interrupted (crackles)
• wheezes
• wheeze must be timed in relation to respiratory cycle
• may be heard in expiration or inspiration or both
• pathophysiology of wheezes - airway narrowing
• wheezes tend to be louder on expiration because airway is normally dilated
during inspiration, and narrowed during expiration
• an inspiratory wheeze implies severe airway narrowing
• pitch of wheeze varies, and is determined by velocity of air jet, accordingly
• high pitched wheezes are produced in smaller bronchi
• low pitched wheezes arise from large bronchi
• causes of wheezes include:
• asthma (often high pitched) - due to muscle spasm, mucosal oedema,
excessive secretions
• chronic airflow diseases - due to mucosal oedema and excessive
secretions
• carcinoma causing bronchial obstruction - tends to cause a localised
wheeze which is monophonic and does not clear with coughing
• crackles
• some terms not to use include rales (low pitched crackles) and creptitations
 (high pitched crackles)
• crackles are due to collapse of peripheral airways on expiration and sudden
opening on inspiration
• early inspiratory crackles
• suggests disease of small airways
• characteristic of chronic airflow limitation
• are only heard in early inspiration
• late or paninspiratory crackles
• suggests disease confined to alveoli
• may be fine, medium or coarse
• fine crackles - typically caused by pulmonary fibrosis
• medium crackles - typically caused by left ventricular failure (due to
presence of alveolar fluid)
• coarse crackes - tend to change with coughing; occur with any
disease that leads to retention of secretions; commonly occur in
bronchiectasis
• pleural friction rub
• when thickened, roughened pleural surfaces rub together, a continuous or
intermittent grating sound may be heard
• suggests pleurisy, which may be secondary to pulmonary infarction or
pnuemonia
• rarely may be caused by: malignany involvement of pleura, spontaneous
pneumothorax, pleurodynia (1 - pleuritic pain in chest; 2 - painful affection
of tendinous attachments of throacic muscles, usually of one side only)
• vocal resonanance
• gives information about lungs' ability to transmit sounds
• consolidated lung tends to transmit high frequencies so that speech heard through
stethoscope takes a bleeting quality (aegophony); when a patient with aegophony says
"bee" it sounds like "bay"
• listen over each part of chest as patient says "99"; over consolidated lung, the numbers will
become clearly audible; over normal lung, the sound is muffled
• whispering pectoriloquy - vocal resonance is increased to such an extent that whispered
speech is distinctly heard
The heart
• lie patient at 45 degrees
• measure jugular venous plse for right heart failure
• examine preacordium; pay close attention to pulmonary component of P2 (which is best heard at
2nd intercostal space on left) and should not be louder than A2; if it is louder, suspect pulmonary
hypertension
• cor pulmonale (also called pulmonary hypertensive heart disease) may be due to:
• chronic airflow limitation (emphysema)
• pulmonary fibrosis
• pulmonary thromboembolism
• marked obesity
• sleep apnoea
• severe kyphoscoliosis

The abdomen
• palpate liver for enlargement due to secondary deposits of tumour from lung, or right heart failure
Other
• Permberton's sign
• ask patient to lift arms over head
• look for development of facial plethora, inspiratory stridor, non-pulsatile elevation of
jugular venous pressure
• occurs in vena caval obstruction
 • feet
•inspect for oedema or cyanosis (clues of cor pulmonale)
•look for evidence of deep vein thrombosisd
• respiratory rate on exercise and positioning
• patients complaining of dyspnoea should have their respiratory rate measured at rest, at
maximal tolerated exertion and supine
• if dyspnoea is not accompanied by tachypnoea when a patient climbs stairs, one should
consider malingering
• look for paradoxical inward motion of abdomen during inspiration when patient is uspine
(indicating diaphragmatic paralysis)
• temperature: fever may accompany any acute or chronic chest infection
Bedside assessment of lung function
• forced expiratory time
• measure the time taken by a patient to exhale forcefully and completely through an open
mouth after taking a maximum inspiration
• the normal FET is 3 seconds or less; an increased FET indicates airways obstruction
• note any audible wheeze or cough
• peak flow meter
• using the device, ask patient to take a full breath in and to maximally puff suddenly
• normal values for young men - 600 litres/minute
• normal values for young women - 400 litres/minute
• value depends on age, sex and height - consult a table
• airways obstruction results in reduced and variable PEFR
• spirometry
• spirometer graphically records forced expiration and forced vital capacity
• FEV = volume of air expelled from lungs after maximum inspiration using maximum
forced effort
• FEV1 = volume of air expelled in first second of FEV
• FVC = total volume of air expelled from lungs after maximum inspiratory effort follwed
by maximum expiration
• FEV1/FVC is normally at about 80%, but may decline to as little as 60% in old age
• in obstructive airways disease:
• airways narrowing occurs
• hence: FEV1 decreases lots, FVC decreases a bit, FEV/FVC decreases lots
• (also elastic recoil is decreased, therefore expiration time is increased)
• obstructive diseases include: asthma, chronic bronchitis, emphysema
• in restrictive airways disease
• elastic recoil is increased (i.e. airways collapse more easily)
• hence: FEV1 decreases a bit (only because VC has decreased), FVC decreases,
FEV/FVC increases
• restrictive diseases include: pulmonary firosis, sarcoidosis, pneumonia, neonatal
respiratory distress syndrome
• flow volume curve: this measures inspiratory and expiratory flow, and therefore FVC and FEV1
and other figures can be calculated
COMPARISON OF CHEST SIGNS IN COMMON RESPIRATORY DISORDERS
Mediastinal Chest wall Percussion Breath Vocal
Disorder Added sounds
displacement movement note sounds resonance
reduced over
consolidation none dull bronchial crackles increased
affected area
decreased over absent or
collapse ipsilateral shift dull absent absent
affected area reduced
pleural effusion heart displaced to reduced over stony dull absent over absent, but absent over
opposite side; affected area fluid but pleural rub effusion
tracheal only may be may be found
 bronchial at
displaced if
upper above effusion
massive
border
tracheal deviation
decreased over absent or
pneumothorax to opposite side resonant absent absent
affected area reduced
if under tension
bronchial decreased normal or normal or normal or
none wheeze
asthma symmetrically decreased reduced reduced
fine inspiratory
crackles over
interstitial slightly
affected lobes
pulmonary none decreased normal normal normal
unaffected by
fibrosis symmetrically
cough or
posture