Respiratory Examination
DPR II
Learning Objectives
• Describe and demonstrate inspection of the chest
• Describe and demonstrate palpation of the chest
• Describe and demonstrate auscultation of the breath sounds and
adventitious sounds
• Describe and demonstrate percussion of the chest
Inspection
• Observe the rate, rhythm, depth, and effort of breathing.
• Always inspect the patient for any signs of respiratory
difficulty.
• Assess the patient’s colour for cyanosis.
• Look at the shape of the fingernails.
• Listen to the patient’s breathing. Is there any audible
wheezing/stridor?
Inspect the neck.
• During inspiration, is there contraction of the sternomastoid or
other accessory muscles, or supraclavicular retraction?
• Is the trachea midline?
Also observe the shape of the chest.
• The AP diameter may increase with aging.
PALPATION
• Tenderness
• Abnormalities in the overlying skin
• Respiratory expansion
• Fremitus.
Test chest expansion
• Place your thumbs at about
the level of the 10th ribs
– With your fingers parallel to
the lateral rib cage.
• Slide your hands medially
– just enough to raise a loose
fold of skin on each side
between your thumb and the
spine.
• Ask the patient to inhale
deeply.
Feel for tactile fremitus
• Palpable vibrations transmitted
through the bronchopulmonary
tree to the chest wall when the
patient speaks.
• To detect fremitus, use either the
ball or the ulnar surface of your
hand
Palpate and compare symmetric areas
• Ask the patient to repeat the words of the lungs in the pattern shown in the
photograph.
“ninety-nine”
Identify and locate any areas of
increased, decreased, or absent
fremitus.
PERCUSSION
• Percussion helps you establish whether the underlying tissues
are air-filled, fluid-filled, or solid.
Technique
• Hyperextend the middle finger of your left hand (pleximeter
finger).
– Press its DIPJ firmly on the surface to be percussed.
• Avoid surface contact by any other part of the hand
– because this dampens out vibrations.
• With a quick sharp but relaxed wrist motion, strike the
pleximeter finger with the plexor finger.
• Aim at your DIPJ.
– Strike using the tip of the plexor finger, not the finger pad.
– The movement is at the wrist.
• While the patient keeps both arms crossed in front of the chest,
percuss the thorax in symmetric locations from the apices to
the lung bases.
• Identify the descent of the diaphragms, or diaphragmatic
excursion.
AUSCULTATION
Auscultation involves
(1) listening to the sounds generated by breathing,
(2) listening for any adventitious (added) sounds,
(3) if abnormalities are suspected, listening to the sounds of the patient’s
spoken or whispered voice
Breath Sounds (Lung Sounds)
Normal breath sounds are:
• Vesicular (soft and low pitched)
– They are heard through inspiration, continue without pause through
expiration, and then fade away about 1/3 of the way through expiration.
• Bronchovesicular
– with inspiratory and expiratory sounds about equal in length
• Bronchial (louder and higher in pitch)
– with a short silence between inspiratory and expiratory sounds.
– Expiratory sounds last longer than inspiratory sounds.
Adventitious (Added) Sounds.
Detection of adventitious sounds—
• crackles (sometimes called rales), wheezes, and rhonchi
• Crackles may be due to abnormalities of the lung
– (pneumonia, fibrosis, early congestive heart failure) or of the airways
(bronchitis, bronchiectasis).
• Wheezes suggest narrowed airways
– as in asthma, COPD, or bronchitis.
• Rhonchi suggest secretions in large airways.
If you hear crackles, especially those that do not clear after cough,
listen carefully for the following characteristics.
• Loudness, pitch, and duration • Fine late inspiratory
– (summarized as fine or coarse crackles) crackles that persist
from breath to breath
• Number (few to many) suggest abnormal lung
tissue.
• Timing in the respiratory cycle
•
Clearing of crackles,
• Location on the chest wall
wheezes, or rhonchi
after cough suggests
• Persistence of their pattern from breath to breath
that secretions caused
• Any change after a cough or a change in thethem, as inposition
patient’s bronchitis
or atelectasis.
Transmitted Voice Sounds.
If you hear abnormally located
bronchovesicular or bronchial breath sounds,
continue on to assess transmitted voice sounds.
With a stethoscope, listen in symmetric areas
over the chest wall:
• Ask the patient to say “99”
– Normally the sounds transmitted through the chest
wall are muffled and indistinct.
• Increased transmission of voice sounds suggests that air-filled
lung has become airless.
– Louder, clearer voice sounds are called bronchophony.
• When “ee” is heard as “ay,”
– an E-to-A change (egophony) is present, as in lobar consolidation from
pneumonia.
– The quality sounds nasal.
Examination of the Anterior Chest
• INSPECTION
• Observe the shape of the patient’s chest and the movement of
the chest wall.
• Note:
– Deformities or asymmetry
– Abnormal retraction of the lower interspaces during inspiration
PALPATION
• Identification of tender areas
• Assessment of observed
abnormalities
• Further assessment of chest
expansion.
Assessment of tactile fremitus
PERCUSSION
• Percuss the anterior and
lateral chest, again comparing
both sides.
• The heart normally produces
an area of dullness to the left
of the sternum from the 3rd to
the 5th interspaces.
• Percuss the left lung lateral to
it.
Questions
• Dullness to percussion on the chest wall can indicate which one of the
following pathologies?
A. Pneumothorax
B. Consolidation
C. Chronic obstructive pulmonary disease
D. Asthma
E. Normal lung
Questions
• In patients with an area of consolidated lung you can expect to find which
change to breath sounds?
A. A total absence of breath sounds
B. Vesicular sounds
C. Reduced breath sounds
D. Louder tubular breath sounds (Bronchial Sounds)
E. An added clicking sound that occurs in tune with the pulse
Text Book Required
• Bates' Guide to Physical Examination and History Taking
