Examination of the respiratory system

General points
Introduce self to patient
Ask for permission to examine
Have patient reclining at 45o
Have patients chest bare

1 - Inspect from end of bed
General appearance - evidence of weight loss
Severe kyphoscoliosis
Ankylosing spondylitis may be missed when patient is lying down
Breathlessness - at rest or while removing clothes. Use of accessory muscles for breathing. Accessory muscle useage suggests chronic small airways disease, pleural effusion or pneumothorax.
Pursing of lips (chronic small airways obstruction)
Central cyanosis - (cor pulmonale, fibrosing alveolitis, bronchiectasis) Central cyanosis may be difficult to recognise. It is always preferable to look at the oral mucous membranes
Indrawing of intercostal muscles or supraclavicular fossae (hyperinflation or indrawing of the lower ribs on inspiration (due to low, flat diaphragms in emphysema). Localised indrawing of intercostal muscles suggests bronchial obstruction
Scars thoracotomy or radiotherapy field markings

2 - Listen while observing
Expiration - prolonged & difficult. Chronic airways disease.
Additional sounds - wheeze or clicks
Noisy breathing - breathlessness
Difficult & noisy inspiration is usually caused by obstruction of the major bronchi - mediastinal masses, retrosternal thyroid, bronchial carcinoma.
More prolonged, noisy, wheezy expiration os due to chronic small airways obstruction- asthma, bronchitis

3 - Observe movement of the chest wall
Upwards - emphysema
Asymmetrical - fibrosis, collapse, pneumonectomy, pleural effusion, pneumothorax

4 - Inspect hands
Clubbing
Tar staining from tobacco
Coal dust tattoos
Signs of rheumatoid arthritis or systemic sclerosis
Cyanosis - if present check for flapping tremor of CO2 retention


5 - Pulse
If bounding check for flapping tremor

6 - Raised venous pressure
Cor pulmonale or fixed distension of the neck veins (SVC obstruction)

7 - Localise the trachea
Place index finger & ring finger on manubrium sternae over the prominent points on each side. Use middle finger to gently feel the tracheal rings to detect either deviation or a tracheal tug

8 - Check for lympthadenopathy
Carcinoma, TB, lymphoma, sarcoidosis
Cervical region & axillae

9 - Localise apex beat
Difficult if chest hyper-inflated
In conjunction with tracheal deviation this will give evidence of mediastinal shift - collapse, fibrosis, pneumonectomy, effusion, scoliosis

10 - Look for asymmetry
Rest one hand lightly on either side of front of chest to see if there is any reduction of movement - effusion, fibrosis, pneumonectomy, collapse, pneumothorax

11 - Expansion
Grip the chest symmetrically with the fingertips in ribspaces on either side and approximate the thumbs to meet in the middle in a straight horizontal line
Note distance between both thumbs & try to express expansion in centimetres
Assess in both supramammary & inframammary regions.
Better practice to use tape measure
Compare both sides at each level

12 - Percuss chest
Start at supraclavicular fossae & over the clavicles
Percuss over axilla
Few clinicians now map out area of cardiac dullness
Healthy people - dullness behind lower left quarter of sternum which is lost together with normal liver dullness

13 - Tactile vocal fremitus
Check both sides at once with ulnar aspects of hand
Ask patient to say 99

14 Auscultation of breath sounds
Start high at apices
Remember to listen in axillae
Cover both lung fields with bell before using diaphragm
Compare corresponding points on opposite side of chest
Ensure patient breathes with mouth open, regularly & deeply but not noisily
Early inspiratory crackles - chronic bronchitis, asthma
Early & mid-inspiratory & recurring in expiration crackles - bronchiectasis (altered by coughing)
Mid/late inspiratory crackles - restrictive lung disease (fibrosing alveolitis) & pulmonary oedema



15 - Vocal resonance

16 -Examine back
Repeat steps 10 - 15
May help to cross arms in front of patient to pull scapulae apart
Palpate cervical lymph nodes from behind

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Check peak flow, temperature, bedside spirometry
Look for evidence of Horner’s syndrome & wasting of muscles in one hand
Palpate liver/percuss liver for emphysema