The Respiratory System Examination

Dr Mike HenryDr Claire Bowker

Dept of Respiratory MedicineLeeds General Infirmary

Major Symptoms of Respiratory Disease

• Cough

• Sputum production

• Dyspnoea

• Haemoptysis

• Wheeze

• Chest pain - pleuritic

Cough• Larynx / Pharynx – harsh and painful• Trachea – harsh, dry and painful / productive• Bronchitis - paroxysmal / productive

AcuteChronic

• Carcinoma – short / dry - haemoptysis• Bronchiectasis – productive purulent sputum• Pneumonia – painful and productive• Pulmonary Oedema – dyspnoea/ orthopnoea/ PND• Fibrosing alveolitis – dry / short / persistent

Sputum

• Amount

• Character

• Viscosity

• Taste or odour

Dyspnoea

• Dyspnoea associated with increased work of breathing

• Dyspnoea associated with increased pulmonary ventilation

• Dyspnoea associated with weakness of muscles of respiration

• Dyspnoea associated with multiple factors

Acute Onset Dyspnoea

Sudden Rapid(minutes) (hours – days)

Pneumothorax Acute asthmaSevere acute asthma Pulmonary oedemaPulmonary embolism PneumoniaLaryngeal oedema Acute bronchitisForeign body Allergic alveolitisPulmonary oedema (orthopnoea / PND)

Gradual Onset Dyspnoea

• Onset days – weeks – months

Pleural effusion

Chronic asthma

Fibrosing alveolitis

Tuberculosis

Chronic bronchitis

Bronchial carcinoma

Slow Onset Dyspnoea

• Onset months – years

Pleural fibrosis

Emphysema

Pneumoniconiosis

SarcoidosisChronic broncitis

Ankylosing spondylosis

Haemoptysis

Type and degree

• Frank – whole blood / clots Carcinoma / PE / Bronchiectasis / TB

• Blood Stained – blood/sputum mixedSuppurative pneumonia / Carcinoma

• Blood Streaked – streaks or flecksCarcinoma / chronic bronchitis

• Rusty – degraded HbPneumococcal pneumonia

Aetiology of Wheeze

Chest PainSite CharacterRadiation SeverityDuration Frequency and

periodicityAggravating factors Relieving factors

Associated phenomena

• Upper reterosternal – tracheitis

• Reterosternal – oppressive similar to cardiac pain / not related to exertion

• Pleuritic – stretching of inflammed parietal pleura

The Physical Examinationfrom the end of the bed - Inspection

• Patient comfortable ? / Supine 45• Look around the bed• Measures of respiratory compromise

RESPIRATORY RATE Use of accessory muscles

• Audible sounds• Patient in pain• Cyanosis• Oedema• SVCO

Palpation• Hands

Finger clubbingCyanosis

Signs of CO2 retention• Eyes

Signs of CO2 retentionAnaemiaHorners syndromePapilloedema

The Laying on of HandsPalpation

• The NeckScalene lymph nodesJVP – jugular venous pressureTrachea

CentralTracheal tug

Thyroid• Skin

Erythema nodosumMetastatic carcinoma nodulesLupus pernio

Chest wall• Symmetry of chest wall movements during

tidal and deep breathing• Chest expansion (2-4 cms) Two levels ?• Significance of reduced chest wall

movements• Anteropostero:lateral diameter = 5:7• Pectus excavatum / Carinatum /

kyphoscholiosis• Thoracic operations / thoracoplasty

Chest wall

• Significance of reduced chest wall movements

• Pleural Effusion: reduced unilateral• Consolidation : reduced unilateral• Collapse of lobe: reduced unilateral• Pneumothorax: reduced unilateral• COPD:reduced bilateral• Asthma: reduced bilateral• Pulmonary fibrosis: reduced bilateral

PercussionWhere to percuss

How to percuss - technique

• Normal: Resonant• Impaired: consolidation / collapse / fibrosis• Dull: consolidation / collapse / pleural thickening• Stony dull: fluid = pleural effusion• Hyperresonant : pneumothorax• Typanic: hollow viscus

• Vocal tactile fremitus• Vocal resonance

Percussion

Auscultation

• Normal breath sounds produced by air through larynx / vocal cords vibrations

• Vibrations transmitted through airways to the chest wall rustling sound = Vesicular

• Diminished: airflow obstruction / pneumothorax / pleural effusion

• Bronchial breath sounds: consolidation, fibrosis or collapse: resemble breath sounds heard over larynx

Auscultation

Added sounds

Wheezes – passage of air through narrow bronchi

Usually expiratoryIf inspiratory – mucosal oedema clear with coughDescribe siteFixed low pitch – STRIDOR – upper

airflow obstruction

Added soundsCrackles

Explosive reopening of small airways occluded during expiration

Fine crackles: pulmonary oedema / consolidation – usually inspiratory

Course crackles: pulmonary fibrosis / bronchiectasis

Plueral rub / pleural click

Interstitial Lung Disease – CFA Bilateral course / velcro bibasal crackles

Pleural Effusion

• Chest expansion - reduced

• Percussion - stony dull

• Breath sounds - absent or decreased

• Added sounds - none

• Vocal resonance - absent or decreased

Consolidation 

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Consolidation

• Chest expansion - reduced

• Percussion - dull

• Breath sounds - bronchial

• Added sounds - crackles

• Vocal resonance - increased (whispering pectorilouy)

ATAELECTASIS - Total right lung collapse

Collapse left lower lobe – The Sail Sign

Collapse / Atelectasis lobe or lung

• Chest expansion - reduced

• Percussion note - dull

• Breath sounds - absent or diminished

• Added sounds - none / crackles or wheeze

• Vocal resonance - absent / decreased

Pneumothorax

• Chest expansion - reduced

• Percussion - hyperresonant

• Breath sounds - absent or decreased

• Added sounds - none, occasionally click

• Vocal resonance - decreased