Respiratory Examination

Equipment Needed

• A Stethoscope
• A Peak Flow Meter

General Considerations

• The patient must be properly undressed and gowned for this examination.
• Ideally the patient should be sitting on the end of an exam table.
• The examination room must be quiet to perform adequate percussion and auscultation.
• Try to visualize the underlying lobes of the lungs as you examine the patient.
• Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.).

Inspection

1. Observe the rate, rhythm, depth, and effort of breathing. Note whether the expiratory phase is prolonged. [p237] [1] [2]
2. Listen for obvious abnormal sounds with breathing such as wheezes.
3. Observe for retractions and use of accessory muscles (sternomastoids, abdominals).
4. Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter. [3]
5. Confirm that the trachea is near the midline? [4]

Palpation

1. Indentify any areas of tenderness or deformity by palpating the ribs and sternum. [p238, p248]
2. Assess expansion and symmetry of the chest by placing your hands on the patient's back, thumbs together at the midline, and ask them to breath deeply.
3. Check for tactile fremitus. ++ [5]

Percussion

Use the proper technique to elicit percussion "notes." [p241]

Posterior Chest

1. Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. [p238]
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear.
4. Find the level of the diaphragmatic dullness on both sides.

   Diaphragmatic Excursion

5. Find the level of the diaphragmatic dullness on both sides.
6. Ask the patient to inspire deeply.
7. The level of dullness (diaphragmatic excursion) should go down 3-5cm symmetrically. [6] ++
   

Anterior Chest

1. Percuss from side to side and top to bottom using the pattern shown in the illustration. [p249]
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the percussion sounds you hear.

Interpretation

Auscultation

Use the diaphragm of the stethoscope to auscultate breath sounds.

Posterior Chest

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. [p244]
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

Anterior Chest

1. Auscultate from side to side and top to bottom using the pattern shown in the illustration. [p250]
2. Compare one side to the other looking for asymmetry.
3. Note the location and quality of the sounds you hear.

Interpretation

Breath sounds are produced by turbulent air flow. They are categorized by the size of the airways that transmit them to the chest wall (and your stethoscope). The general rule is, the larger the airway, the louder and higher pitched the sound. Vesicular breath sounds are low pitched and normally heard over most lung fields. Tracheal breath sounds are heard over the trachea. Bronchovesicular and bronchial sounds are heard in between. Inspiration is normally longer than expiration (I > E). [2]

Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion). Breath sounds shift from vesicular to bronchial when there is is fluid in the lung itself (pneumonia).

Special Tests

Peak Flow Monitoring

Peak flow meters are inexpensive, hand-held devices used to monitor pulmonary function in patients with asthma. The peak flow roughly correlates with the FEV1. [7] ++

1. Ask the patient to take a deep breath.
2. Then ask them to exhale as fast as they can through the peak flow meter.
3. Repeat the measurement 3 times and report the average.

Voice Transmission Tests

These tests are only used in special situations. This part of the physical exam has largely been replaced by the chest x-ray. All these tests become abnormal when the lungs become filled with fluid (referred to as consolidation).

Tactile Fremitus

1. Ask the patient to say "ninety-nine" several times in a normal voice. [p239] ++
2. Palpate using the ball of your hand.
3. You should feel the vibrations transmitted through the airways to the lung.
4. Increased tactile fremitus suggests consolidation of the underlying lung tissues. [8]

Bronchophony

1. Ask the patient to say "ninety-nine" several times in a normal voice. [p247] ++
2. Auscultate several symmetrical areas over each lung.
3. The sounds you hear should be muffled and indistinct. Louder, clearer sounds are called bronchophony.

Whispered Pectoriloquy

1. Ask the patient to whisper "ninety-nine" several times. [p247] ++
2. Auscultate several symmetrical areas over each lung.
3. You should hear only faint sounds or nothing at all. If you hear the sounds clearly this is referred to as whispered pectoriloquy. [9]

Egophony

1. Ask the patient to say "ee" continuously. [p247] ++
2. Auscultate several symmetrical areas over each lung.
3. You should hear a muffled "ee" sound. If you hear an "ay" sound this is referred to as "E -> A" or egophony.

Notes

1. Page numbers refer to A Guide to Physical Examination and History Taking, Sixth Edition by Barbara Bates, published by Lippincott in 1995.
2. A prolonged expiratory phase (E > I) indicates airway narrowing, as in asthma.
3. AP diameter increases somewhat with age, however, a round or "barrel" chest is often a sign of advanced emphysema.
4. The trachea will deviate to one side in cases of tension pneumothorax.
5. Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
6. Decreased or asymmetric diaphragmatic excursion may indicate paralysis or emphysema.
7. It has been said that "a peak flow meter is to asthma as a thermometer is to fever." Peak flow measurements are used to guage severity of asthma attacks and track the disease over time. Ideally new readings are compared to the patient's current "personal best." Readings less than 80% of "best" may indicate a need for additional therapy. Readings less than 50% may indicate an emergency situation.
8. Increased fremitus indicates fluid in the lung. Decreased fremitus indicates sound transmission obstructed by chronic obstructive pulmonary disease (COPD), fluid outside the lung (pleural effusion), air outside the lung (pneumothorax), etc.
9. Whispered pectoriloquy is right up there with borborygmi on Dr. Rathe's list of favorite medical terms.

Author: Richard Rathe, MD
Copyright: 1996 by the University of Florida