Examination of the Respiratory Examination

 Introduce yourself. Clubbing:

 Explain procedure Thoracic Tumours: Interstitial:
 Obtain consent Bronchial Carcinoma Fibrosing Alveolitis
 Position patient supine and inclined at Mesothelioma Asbestosis
45 degrees Pleural Fibroma AV Shunt:
 Expose the chest to the waist Atrial Myxoma AV malformations
Thymoma Cyanotic CHD
Inspect: Oesophageal Cancer
 General appearance Sepsis: Non-Thoracic:
 Hands: colour, nails, CO2 Flap Bronchiectasis (+CF) Hepatic Cirrhosis
 Face Lung Abcess IBD
 Tongue Infective Endocarditis Coeliac Disease
 Neck - JVP TB
 Front of chest: deformity, scars, Empyema
 Chest movement and accessory muscle
activity
Chest Wall Deformities
 Respiratory rate Barrel Chest: COPD
Kyphoscoliosis
Pectus Carinatum: Severe
Tracheal Deviation: childhood asthma / osteomalacia
Towards Lesion: Pectus Excavatum
Upper lobe/lung collapse Palpate:
Upper lobe Fibrosis  Trachea
Pneumonectomy  Lymph nodes: neck and axilla
Away from Lesion:  Chest tenderness or lumps
Tension Pneumothorax  Depth and symmetry of breathing
Massive PE  Tactile vocal fremitus: four sites from top to bottom
Upper Mediastinal Mass
Retrosternal Goitre
Lymphoma Decreased Chest Expansion:
Lung Cancer Unilateral:
Pleural Effusion
Lung/lobe collapse
Pneumohthorax
Percussion: Unilateral Fibrosis
Resonant: Bilateral
Normal Lung Percuss: Advanced COPD
Hyperresonant:  Clavicles Diffuse Fibrosis
Pneumothorax  Upper zone
Dull:  Mid zone
Consolidation  Lower zone
Lung/lobe collapse
 Laterally - comparing right and left at each stage
Severe Fibrosis
‘Stoney’ Dull:
Pleural Effusion Tactile Vocal Fremitus:
Haemothorax Trasmission of Vibration from
mouth to chest wall
Over areas of Dull Percussion:
↑TVF: Consolidation/Fibrosis
↓TVF: Fluid/Collapse
 Auscultate: Diminished Vesicular Breathing:
 Upper zone Decreased Conduction:
 Mid zone Obesity
 Lower zones Pleural Effusion
 Laterally -comparing right and left at each stage Pheumothorax
 Check vocal resonance at same sites Decreased Airflow
 Sit patient forward and repeat inspection, palpation, Generalised: COPD
percussion and auscultation on the back of the chest. Localised: collapse

 Look for Sacral/Ankle Oedema

Breath Sounds:
Normal = Vesicular – rustling quality Cause: uniformly conducting tissue
Bronchial Breathing: Common:
High Pitched Consolidation (pneumonia)
Blowing Quality Uncommon:
Insp/Exp Similar length and intensity Local Fibrosis
Characteristic Pause Top of Pleural Effusion
Collapsed lung with major
bronchus patent

Crackles Musical
Wheeze: (inspiratory):
Quality
Opening of collapsed
Osscilating small airways
narrowed Airway
Interrupted,
Usually Loudestnon musical sounds
Expiration
Early:
Inspiratory = Severe Airway disease Mediastinal
DDx
Small airway disease (bronchiolitis) Expansion Percussion Tactile Vocal Auscultation
Middle: Shift Fremitus/
Friction rub: grating sound ‘creaking leather’ Vocal
Pulmonary
pleural Oedema
inflammation and thickening.
Late: Resonance
Stridor: on inspiration
Fine: Pulmonary Pleural Effusion no/away
Fibrosis ↓ Stoney Dull ↓ ↓ Breath Sounds
narrowing of the upper airways
Medium: Pulmonary Oedema Occasional Rub
Coarse: BronchialConsolidation No
Secretions (COPD, Normal/↓ Dull ↑ Bronchial Breathing +
Pneumonia) (pneumonia) Crackles (coarse)
Lobar Collapse
Biphasic: Bronchiectasis - Coarse Towards ↓ Dull ↓ ↓ Breath Sounds
Pneumothorax No (simple) Normal/ ↓ Hyper- ↓ ↓ Breath Sounds
Away (Tension) resonant
Pleural No ↓ Dull ↓ ↓ Breath Sounds
Thickening
Asthma/COPD No ↓ Polyphonic wheeze
COPD: Coarse Crackles