Respiratory examination

Overview
In medicine, the respiratory examination is performed as part of a physical examination, or when a patient presents with a respiratory problem (dyspnea (shortness of breath), cough, chest pain) or a history that suggests a pathology of the lungs.

Position/Lighting/Draping
Position - patient should sit upright on the examination table. The patient's hands should remain at their sides. When the back is examined the patient is usually asked to move their arms forward (hug themself position) so that the scapulae are not in the way of examining the upper lung fields.

Lighting - adjusted so that it is ideal. Draping - the chest should be fully exposed. Exposure time should be minimized.

The basic steps of the examination can be remembered with the mnemonic IPPA:
 * Inspection
 * Palpation
 * Percussion
 * Auscultation

Video 1: Respiratory Examination


Video 2: Respiratory Examination


Inspection

 * Tracheal deviation (can suggest of tension pneumothorax)

Chest wall deformities

 * Kyphosis - curvature of the spine - anterior-posterior
 * Scoliosis - curvature of the spine - lateral
 * Barrel chest - chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD
 * Pectus excavatum
 * Pectus carinatum

Signs of respiratory distress

 * Cyanosis - person turns blue
 * Pursed-lip breathing - seen in COPD (used to increase end expiratory pressure)
 * Accessory muscle use (scalene muscles)
 * Diaphragmatic paradox - the diaphragm moves opposite of the normal direction on inspiration; suspect flail segment in trauma
 * Intercostal indrawing

Palpation

 * Tracheal deviation - check whether trachea is in centre line.
 * Tactile fremitus - the patient says boy-O-boy or ninety-nine, whilst physician sense with ulnar aspect of hand for changes in sound conduction.
 * Respiratory expansion - check whether expansion is equal
 * Location of apex beat - check if there has been deviation of heart

Percussion
Middle finger strikes the middle phalanx of the other middle finger. The sides of the chest are compared.


 * dullness indicates consolidation
 * hyper-resonance (as can be simulated by percussing the inflated cheek) suggests a pneumothorax
 * diaphragmatic excursion - normal is 3 to 6 cm.

Ausculation

 * Inspiratory crackles (decompensated congestive heart failure)
 * Expiratory wheezes (asthma, emphysema)
 * Stridor and other upper airway sounds
 * Bronchial vs. vesicular breath sounds
 * Appropriate ratio of inspiration to expiration time (expiration time increased in COPD)

Vocal fremitus (not usually done)

 * Egophony
 * Whisper pectoriloquy

Respiratory System at a Glance
Main lobes are outlined in black. The following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper Lobe; RML = Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.

(Images courtesy of Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California)