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RESPIRATORY-SYSTEM-NOTES

This document is a guide for conducting a physical examination of the respiratory system, detailing the general principles and systematic approach to inspection, palpation, percussion, and auscultation. It emphasizes the importance of comparing findings between the left and right sides of the chest and provides specific techniques for assessing respiratory function and identifying abnormalities. Key examination techniques include evaluating chest shape, respiratory effort, tactile fremitus, and breath sounds to detect potential respiratory issues.

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1 views

RESPIRATORY-SYSTEM-NOTES

This document is a guide for conducting a physical examination of the respiratory system, detailing the general principles and systematic approach to inspection, palpation, percussion, and auscultation. It emphasizes the importance of comparing findings between the left and right sides of the chest and provides specific techniques for assessing respiratory function and identifying abnormalities. Key examination techniques include evaluating chest shape, respiratory effort, tactile fremitus, and breath sounds to detect potential respiratory issues.

Uploaded by

Lem obad
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CEBU DOCTORS’ UNIVERSITY

COLLEGE OF MEDICINE
Patient – Doctor Relation
Level II
Respiratory System Physical Examination Guide
Sherwin Ygnacio, M.D.

General Principles of Chest /Lungs Examination:

➢ Patients should disrobe up to the waist for better evaluation of the anterior and
posterior chest wall .
➢ Proceed sequentially from inspection, palpation , percussion and followed by
auscultation.
➢ Always compare the findings in the right side of the chest to the left side when
doing the physical examination.
➢ Be systematic in doing the examination, may either start from the lung apex
going to the bases or vice versa.
➢ If possible, examine the posterior chest with the patient sitting , arms folded
across the anterior chest and the hands resting on the opposite shoulders. This
position moves both scapulae partly out of the way and increases the access to
the lung fields.
➢ For the anterior chest wall, you may examine the patient sitting up with arms at
the sides or preferable on supine position especially in women. Supine position
allows the breasts to be moved and are less likely to interfere with the
examination of the chest.
➢ If patient is unable to sit up by himself/herself for the examination, the patient
may be assisted in sitting up. Or patient may be rolled to either the right or left
lateral decubitus position to gain access to the posterior chest wall.

A. INSPECTION-- Note the following :

1. Shape of the chest – any deformities or asymmetry of the chest


2. Abnormal retractions of the intercostals spaces during inspiration. ICS
retractions are most apparent in the lower interspaces.
3. Note for prominence of accessory muscles of respiration – neck muscles
( strenocleidomastoids, scalenus, trapezius)
Note : Presence of 2 & 3 signifies respiratory distress
➢ Other signs of respiratory distress – flaring of ala nasae , pursed lip
breathing

4. Any asymmetry/lag/delay on the unilateral chest wall during respiration.


➢ Unilateral lag/delay in chest movement suggests significant lung
parenchymal disease or pleural diseases

5. Observe the rate, rhythm, depth and effort of breathing.


➢ Normal breathing rate is 8-16/min, quiet breathing and regular in rhythm
with minimal effort. Dyspneic patients breathe rapidly, often laboring to draw
breaths even at rest. Sleep apnea patients have episodes of stalled breathing
(apnea) in between regular cycle.
B. PALPATION – Note the following :

1. Identify tender areas on the chest wall – palpate and evaluate areas on the
chest where
pain has been reported or if lesions are noted.

2. Assessment of respiratory expansion/symmetry :


> Place your thumbs about at the level of and parallel to the 10th ribs ( for
posterior chest wall) OR along the subcostal margins ( for anterior chest wall) .Your
hands should be grasping the lateral rib cage. Slide your hands medially a bit in order to
raise loose skin folds between the thumbs. Ask the patient to take deep slow inspiration
and watch the normal and symmetric divergence of your thumbs during inspiration and
convergence during exhalation.

> Asymmetric convergence/divergence of the thumbs during respiration –


indicates a delay or diminution of chest expansion brought about by pulmonary fibrosis,
pleural effusion, pleural pain associated with splinting and lung consolidation.

3. Assessment for tactile fremitus :


> Fremitus are palpable vibrations transmitted through the lungs when a person
speaks.
> Use either the ulnar surface of your hands or the ball of your hands ( bony part
of the palm at the base of the fingers)
> Place both hands on both sides of the anterior/posterior chest wall ( same
level or ICS)
> Ask patient to verbalize “ninety-nine” or “ one, two , three” and note if tactile
fremitus palpated is equal on both hands
> Start from the apex and move down repeating the procedure until you have
compared
both lungs in the anterior and posterior chest wall.
> Normal lungs should have equal and symmetrical tactile fremitus on both sides
> Any condition that obstructs the transmission of breath sounds from the airways
to the chest wall will result in diminished tactile fremitus ( Pleural effusion,
pneumothorax, obstructed bronchus – COPD, thick chest wall)
> Lobar consolidation will result in increase tactile fremitus.

C. PERCUSSION

➢ Percussion sets the chest wall and underlying tissues into motion, producing
audible sounds and palpable vibrations
➢ Helps determine whether the underlying tissues are air-filled, fluid-filled or solid.

Technique : Right –handed examiner

➢ Hyperextend the middle finger of your left hand ( pleximeter finger). Press the
distal interphalangeal joint firmly on the surface of the chest to be percussed. To
avoid damping the vibrations, it is best to avoid contact of the chest by any other
part of the hand.
➢ Position the right forearm close to the pleximeter finger, with the wrist partially
extended. The right middle finger partially flexed and relaxed.
➢ Strike the distal interphalangeal joint of the pleximeter finger with the right middle
finger using a brisk, sharp but relaxed flexion at the right wrist joint.
➢ Use the tip of the right middle finger and not the finger pads.
➢ Withdraw the striking finger quickly to avoid damping the vibrations created.
➢ Start from the apex , moving down and comparing the percussion sound elicited
with both sides of the anterior and posterior chest.
➢ Normal percussion sound of a healthy lung is resonant.
➢ Once the lungs/pleura is filled with fluid, blood , fibrosis or mass – it becomes
dull on percussion
➢ A hyperinflated lung due to airway obstruction will result in hyper resonance.

D. AUSCULTATION

➢ May use either the bell or the diaphragm of the stethoscope


➢ Air flowing through the bronchi will produce characteristic breath sounds which
can be picked up by auscultating the anterior and posterior chest wall.
➢ With your stethoscope touching the chest wall, ask the patient to take deep
inhalations and exhale preferably through the open mouth.
➢ Using locations similar to those recommended for percussion, always compare
symmetrical areas of the lungs from apex down to the lower chest.
➢ Listen to at least one full breath (inspiration & expiration) in each location and
note for :

1.) Breath sound characteristics – intensity ( decreases in obesity, thick


muscular chest wall or failure to take deep inhalations); pitch ( low pitched in
vesicular breath sounds vs. high pitched in bronchial breath sounds). ; duration
of inspiratory /expiratory sounds ; locations of vesicular and bronchial breath
sounds.

2.) Added/Adventitious breath sounds – crackles, wheezes, rubs, amphoric


breath sounds, etc.
➢ note what kind of adventitious sounds you hear
➢ where in the respiratory cycle you hear the added sounds ( inspiratory phase ,
expiratory phase or in both phases)
➢ where on the chest wall are they are located

If there are abnormalities (diminished) in tactile fremitus, percussion or auscultation,


check for alterations in the spoken and whispered voice sounds.

a) Egophony – Greek word for “Voice of the Goat”


- with your stethoscope on the chest wall, ask the patient to say “eeee”
as you move the stet from one part to another. Listen in symmetrical areas of
the lungs, noting the intensity and clarity of the sounds. Normally it is muffled
and sounds like “eeee”. However, the “eee” sounds like “ aaaayyy” near the
upper border of a large pleural effusion.

b) Bronchophony – ask the patient to speak or say “ninety-nine” while you are
auscultating the chest. Normally, the sounds will appear muffled as it is being
filtered through the lung parenchyma. In the presence of an airless lung tissue
(consolidation in pneumonia), voice sounds appear louder and clearer than usual
because the higher pitched components are better transmitted.

c) Whispered Pectoriloquy—Ask the patient to whisper “ninety-nine” or “ one, two,


three”. Normally, the whispered voice is heard only faintly and indistinctly.
In the presence of an airless lung, the whispered sounds are louder and heard
more clearly than normal.

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