Respiratory examination

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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.

1 Position/Lighting/Draping
2 Inspection
- 2.1 Chest wall deformities
- 2.2 Signs of respiratory distress
3 Palpation
4 Percussion
5 Ausculation
- 5.1 Vocal fremitus (not usually done)
6 External links

[edit] 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

[edit] Inspection

Tracheal deviation (can suggest of tension pneumothorax)

[edit] 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

[edit] 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

[edit] 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

[edit] 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.

[edit] 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)