Respiratory Examination

Respiratory Examination 

Dr. Andrew Don-Wauchope 

Lecturer in Clinical Medicine 

© University of Dublin, 2005


General Inspection 

appearance 

− dyspnea, cyanosis, cough, sputum, stridor, 

hoarseness 

respiratory rate (normal < 14) 

depth of respiration (shallow, deep) 

accessory muscles (SCM, platysma, strap 

muscles of neck) 


Looking at the Patient with COPD 

Rennard, S. I. N Engl J Med 2004;350:965-966 


Hands 

clubbing (lung CA, bronchiectasis, , lung 

abscess, CF, asbestosis, idiopathic pulmonary 

fibrosis) 

cyanosis 

nicotine staining 

wasting/weakness 

− wasting of small muscles of hand 

− weakness of finger abduction 

− due to lung CA compressing/infiltrating brachial 

plexus 

anemia (palmer creases) 


A 44-year-old man had had marked swelling of the terminal digits since early childhood 

Reynen, K. et al. N Engl J Med 2000;343:1235 


Hands 



fibrosis) 

cyanosis 






plexus 




Hands 



fibrosis)* 

cyanosis* 






plexus 



Hands contd. 

HPOA (swelling/tenderness at wrist) 

pulse 

− pulses paradoxus (severe asthma) 

− bounding (hypercapnia( 

hypercapnia) 

asterixis (hypercapnia) – flapping tremor 

dilated veins (hypercapnia( 

hypercapnia) 


Face 

eyes 

− anemia 

− Horner’s s Syndrome* 

nose* 

meiosis, ptosis, anhydrosis 

due to apical lung CA compressing sympathetic chain 

− polyps (asthma) 

− engorged turbinates (allergy) 

− deviated septum (obstruction) 


A 53-year-old man was evaluated because of a one-month history of anisocoria and left-sided 

ptosis of 1 mm (Panel A) 

Balcer, L. J. et al. N Engl J Med 1997;337:1359 


Face 

eyes 

− anemia 


nose* 







Clinical Photograph of the Nose 

Weller, P. F. et al. N Engl J Med 2005;352:609-615 


Face 

eyes 

− anemia 


nose* 







Face cont. 

mouth* 

− central cyanosis 

− pharynx (erythema( 

erythema, , purulent tonsils) 

− dentition (lung abscess, pneumonia) 

sinuses 

− tenderness (sinusitis) 

plethora 

− SVO 

− Pemberton’s s sign (arms raised over head causes 

plethora, stridor, , non-pulsatile 

elevation of JVP) 


Clinical Findings in Epstein-Barr Virus (EBV) Infection 

Cohen, J. I. N Engl J Med 2000;343:481-492 



Face cont. 

mouth* 





sinuses 


plethora 

− SVO* 



elevation of JVP)* 


A 79-Year-Old Woman with Facial Swelling 

Betjes, M. G.H. N Engl J Med 2000;342:740 


Face cont. 

mouth* 





sinuses 


plethora 

− SVO* 



elevation of JVP)* 


A 58-year-old woman with a 20-year history of goiter presented with a two-month history of 

progressive dyspnea on exertion, occasional stridor, and a choking sensation while supine 

Basaria, S. et al. N Engl J Med 2004;350:1338 


Neck 

lymph nodes* 

− submental, submandibular, , pre-auricular, post- 

auricular, occipital, cervical chain 

thyroid/goitre 

(airway obstruction) 

trachea 

− displacement (suggests disease of upper lobes) 

towards side of lesion 

• upper lobe collapse/fibrosis, pneumonectomy 

away from side of lesion 

• pleural effusion, tension pneumothorax 

upper mediastinal masses (retrosternal( 

goitre) 




Posteroanterior Film of the Chest Showing Left Inferior Hilar Lymphadenopathy (Arrow) and 

Right Paratracheal Lymphadenopathy (Arrowhead) 

Levitz, S. M. et al. N Engl J Med 1998;339:1835-1843 


Frontal Radiograph of the Chest Showing Bilateral Hilar Lymphadenopathy, Which Is More 

Prominent on the Left Side, and Mediastinal Lymphadenopathy 

Querfurth, H. W. et al. N Engl J Med 1998;338:747-754 


Neck 

lymph nodes* 

− submental, submandibular, , pre-auricular, post- 

auricular, occipital, cervical chain 

thyroid/goitre 

(airway obstruction) 

trachea 

− displacement (suggests disease of upper lobes) 

towards side of lesion 

• upper lobe collapse/fibrosis, pneumonectomy 

away from side of lesion 

• pleural effusion, tension pneumothorax 

upper mediastinal masses (retrosternal( 

goitre) 


Neck cont. 

− 

tug inferiorly with inspiration 

gross overexpansion of chest due to airflow 

obstruction 


Chest 

examine both anteriorly and posteriorly, 

comparing R and L* 

inspection 

− shape 

AP and lateral diameter 

• AP > lateral (barrel-shaped chest) 

• increased AP diameter due to hyperinflation (severe asthma, 

emphysema) 

pigeon chest/pectus carinatum 

• outward bowing of sternum 

• chronic childhood respiratory illness, rickets 






Chest 



inspection 

− Shape* 




emphysema) 

pigeon chest/pectus carinatum 




An 18-year-old man with no clinically significant medical history presented with a six-month 

history of an increasing mass on the left side of his back (Panel A) 

Chaiyasate, K. et al. N Engl J Med 2005;352:e8 


A 13-year-old boy presented with increasing kyphotic deformity, back pain, and progressive 

paraparesis seven years after a one-year course of medical therapy for tuberculosis 

Shaw , B. A. N Engl J Med 1996;334:958-959 



Chest 



inspection 

− Shape* 




emphysema) 

pigeon chest/pectus 

carinatum 




funnel chest/pectus 

excavatum 

• depression at lower sternum 

• developmental defect 

• may restrict lung capacity 

Harrison’s sulcus 

• linear depression of lower ribs along costal margin where 

diaphragm attached 

• severe childhood asthma, rickets 

kyphoscoliosis 

• decreases lung capacity, increases work of breathing 

• idiopathic (80%), poliomyelitis, Marfan’s 


− symmetry of chest wall movement 

reduced or delayed (underlying lung disease) 

• pulmonary fibrosis, consolidation, collapse, pleural effusion, 

pneumothorax 

bilateral reduction 

• chronic airflow limitation, diffuse pulmonary fibrosis 

− scars (previous thoracic surgery, chest drain) 

− erythema/thickened skin (previous RTx) 


palpation 

− chest expansion 

thumbs > 5cm apart with inspiration 

decreased on side of lesion 

− apex beat 

displacement toward side of lesion (lower lobe collapse, 

localized pulmonary fibrosis) 

displacement away from side of lesion (pleural effusion, 

tension pneumothorax) 

impalpable (emphysema) 


− vocal fremitus (99) 

increased vibration (consolidation) 

no vibration (fluid) 

unreliable sign 

− ribs (pain, fracture) 

− subcutaneous emphysema* 

crackling on palpation of skin 

air tracking from pneumothorax, , ruptured esophagus 


A 76-year-old man with chronic obstructive pulmonary disease was admitted after a car accident 

van der Kleij, F. G.H. et al. N Engl J Med 2000;342:1333 


− vocal fremitus (99) 

increased vibration (consolidation) 

no vibration (fluid) 

unreliable sign 

− ribs (pain, fracture) 

− subcutaneous emphysema* 

crackling on palpation of skin 

air tracking from pneumothorax, , ruptured esophagus 


percussion 

− anteriorly, posteriorly, supraclavicular fossa 

− resonant (normal) 

− hyper-resonant (bowel, pneumothorax) 

− dull (consolidation) 

− stony dull (fluid) 


auscultation 

− quality of breath sounds 

vesicular (normal) 

• transmission of air turbulence in large airways filtered through 

normal lung to chest wall 

• sound of “wind rustling in leaves” 

• louder and longer on inspiration than expiration 

• no gap 

bronchial 

• turbulence in large airways is heard without being filtered by 

alveoli 

• hollow, blowing quality (cf. stethoscope over trachea) 

• inspiration = expiration, gap 

• consolidation, pulmonary fibrosis, above pleural effusion, 

collapsed lung 


− intensity of breath sounds 

normal 

reduced (COPD, pleural effusion, pneumothorax, tumour, 

collapse, consolidation) 

− added sounds 

wheeze 

• inspiration/expiration (louder due to narrower airway) 

• pitch (high – small bronchi, low – larger bronchi) 

crackles 

• early inspiration (disease of small airways) 

• late or pan-inspiration (disease confined to alveoli) 

 

 

 

fine (pulmonary fibrosis) 

medium (LVF) 

coarse (pools of retained secretion – bronchiectasis) 


pleural friction rub 

• pleurisy (inflammation of pleura) 

• PE, pneumonia 

− vocal resonance (99) 

muffled (normal) 

clearly audible (consolidation) 

no sound (fluid) 


Soon after returning from Hong Kong, a previously healthy 48-year-old man began to have fever, 

malaise, dyspnea, and a nonproductive cough 

Nicolaou, S. et al. N Engl J Med 2003;348:2006 


Heart 

raised JVP, peripheral edema 

− cor pulmonale (RVF due to COPD, pulmonary 

fibrosis, PE, obesity, sleep apnea, kyphoscoliosis) 

loud P2 (pulmonary hypertension) 


Abdomen 

liver ptosis (emphysema) 

hepatomegaly due to metastases from lung CA 


Legs 

DVT as cause of PE 


A 67-year-old man presented to the emergency department with a five-day history of 

nonproductive cough and progressive dyspnea and a one-day history of right-sided pleuritic 

chest pain 

Sokolove, P. E. et al. N Engl J Med 2001;345:1311 


A 47-year-old man was admitted to the intensive care unit with respiratory failure complicating 

pneumonia due to legionella infection 

van Steijn, J. H.M. et al. N Engl J Med 2004;350:e16

Respiratory Examination

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