Respiratory System Physical Examination Notes

Physical Examination of the Respiratory System

Introduction

  • Greeting the patient, introducing yourself, and clearly describing your role.
  • Patient positioning: reclining on an examination couch or bed at approximately 45 degrees, thorax exposed, head supported by a pillow.

Inspection

  • Much can be learned about the respiratory system through careful inspection from the end of the bed.
  • Normal shape and respiratory movements of the chest.
  • Chest deformities or asymmetry.
  • Examination sequence:
    • Note the presence of nebulizers or inhalers, indicating obstructive lung disease.
    • Note the presence of oxygen therapy and cyanosis.
    • Check sputum pots.
    • Look for asymmetry of the chest, deformities, operative scars, and chest drains.
    • Thoracotomy scars may be visible only on the lateral and posterior aspects of the chest.
    • Observe and time respiratory rate without drawing the patient’s attention to it (e.g., breaths in 15 seconds × 4).
    • Feeling the radial pulse while timing breathing is a common solution to avoid altering the patient’s breathing pattern.
    • Inspect the remaining skin for relevant abnormalities.

Palpation

  • Examination sequence:
    • Locate the apex beat: the most inferior and lateral place where the finger is lifted by the twisting systolic movement of the cardiac apex.
      • Normally in the fifth intercostal space in the mid-clavicular line.
      • Count down the intercostal spaces from the second, which is just below the sternal angle.
    • Palpate for a right ventricular heave using a straight arm, with the palm over the lower sternum.
    • Assess chest expansion:
      • Cup hands with fingers spread round the patient’s upper anterior chest wall, pressing the fingertips firmly in the mid-axillary line.
      • Pull hands medially towards each other to tighten any loose skin.
      • Use thumbs (off the skin) as pointers to judge how much each hand moves outwards when the patient is instructed to take a full breath in.
      • In a healthy thorax, the ribs move out and up with inspiration.
      • Check for any asymmetry, which is more important than the absolute degree of expansion, as it varies between individuals.
    • Repeat the process in the lower anterior chest wall.

Percussion

  • Examination sequence:
    • Apply the middle finger of the non-dominant hand firmly to an intercostal space, parallel to the ribs, and drum the middle phalanx with the flexed tip of your dominant index or middle finger.
    • Percuss in sequence, comparing areas on the right with corresponding areas on the left before moving to the next level.
    • Posteriorly, the scapular and spinal muscles obstruct percussion. Position the patient sitting forwards with their arms folded in front to move the scapulae laterally.
    • Percuss a few centimeters lateral to the spinal muscles, taking care to compare positions the same distance from the midline on the right and left.

Auscultation

  • Use of the stethoscope:
    • Remember to wear the stethoscope with the earpieces facing forwards to align them with your auditory canal.
    • Normal breath sounds are relatively quiet, so the greater area of contact offered by the diaphragm is usually well adapted to chest auscultation.
    • Exceptions where the bell is preferred:
      • A cachectic chest wall with sunken intercostal spaces, where it may be impossible to achieve flat skin contact with the diaphragm.
      • A hairy chest wall, where movement of chest hairs against the diaphragm are easily mistaken for lung crackles.
  • Breath sounds:
    • The symmetry of sounds is the key feature.
    • The absolute volume and character of breath sounds in individuals are greatly affected by the thickness, muscularity, and fat content of the chest wall.
  • Examination sequence:
    • Auscultate the apices, comparing right with left, and changing to the bell if you cannot achieve flat skin contact with the diaphragm.
    • Ask the patient to take repeated slow, deep breaths in and out through their open mouth.
    • Auscultate the anterior chest wall from top to bottom, always comparing mirror image positions on the right and left before moving down.
    • Use the same sequence of sites as for percussion.
    • Do not waste time by listening to repeated breath cycles at each position unless you suspect an abnormality and wish to check.
    • Note whether the breath sounds are soft and muffled, absent, or loud and harsh (bronchial, like those heard over the larynx).
    • Seek and note any asymmetry and added sounds, deciding which side is abnormal.
    • Auscultate the lateral chest wall in the mid-axillary line, again comparing the right with the left before changing level.
  • Added sounds:
    • Wheeze: Multiple wheezing or solitary wheeze.
    • Crackles.
    • Pleural rub.

Vocal Resonance

  • These signs can be confirmed by asking the patient to generate laryngeal sounds deliberately (‘Please say “one, one, one” each time I move my stethoscope on the skin’) and listening on the chest wall in the same sequence of sites used for breath sounds.