Respiratory Exam

Anatomy – surface landmarks

Ribs 1-7 articulate with sternum
Ribs 8-10 articulate with cartilage above
Oblique fissure: from 6^th rib at midclavicular line to 5^th rib midaxillary line, to spinous process of T3 (RLL below ROF; LLL below LOF)
Horizontal fissure: from 4^th rib at sternal border to 5^th rib midaxillary line on right
Lung margins
- Superiorly 3-4 cm above medial end of clavicles
- Inferiorly to 6^th rib mid clavicular line, 8^th rib midaxillary line, between T9-12 posteriorly
Bifurcation at T4, sternal angle of Louis
RHD end exp at 5^th rib anteriorly, T9 posteriorly (slightly higher than LHD)

General

Vitals (respiratory rate and pattern)
- Kussmaul’s – fast and deep breathing (metabolic acidosis)
- Cheyne-Stokes – irregular with periods of apnea (Rx induced depression, CHF, brain damage)
- Apnea (cardiac arrest)
Assess for distress
- Facial expression: nasal flaring, pursed lip breathing, audible breath sounds, cyanosis
- Posture: tripoding, clasp sides of bed (latissimus dorsi), orthopnea
- Neck: accessory muscle use, tracheal tug
- Speaking? In sentences?

Inspection

Configuration of chest: AP diameter, barrel chest, flail chest (paradoxical inward movement during inspiration), kyphoscoliosis, pectus excavatum (depression of sternum), pectus carinatum (protrusion of sternum), body habitus (obese – sleep apnea)
Hands: clubbing (intrathoracic tumors, V-A shunts, chronic pulmonary disease, chronic hepatic fibrosis), nicotine stains, splinter hemorrhages (vasculitis), RA associated with pleural effusions and pulmonary fibrosis
Cyanosis: central (under the tongue, frenulum, lips), peripheral (fingers, toes, nose)
Laryngeal height – sternal notch to thyroid cartilage > 4cm is normal, if less than hyperinflation

Palpation

Areas of tenderness
Posterior chest excursion (@ level of 10^th rib, pulling skin toward midline) – note symmetry
Tactile fremitus (ulnar side of hand against chest wall – “ninety-nine”; increased in consolidations, decreased in pneumothorax, effusions, atelectasis)
Trachea (midline)
Accessory muscles

Percussion

Posterior chest
- Air containing tissue: resonant
- Air-filled structure: tympanic
- Consolidation: dull
- Over-inflation of lungs: hyper-resonance
Diaphragmatic Movement
- Hold deep breath, percuss lowest area of resonance
- Exhale, repeat percussion
- Normally 4-5 cm

Auscultation

Normal breath sounds

Tracheal – very loud, high pitch, insp=exp, harsh, extrathoracic trachea
Bronchial – loud, high pitch, insp<exp, tubular, manubrium
Bronchovesicular – moderate, moderate pitch, insp=exp, rustling but tubular, mianstem bronchi
Vesicular – soft, low pitch, insp>exp, gentle rustling, peripheral lung
Stridor – extrathoracic due to blockage in throat or larynx
- High-pitched musical
- Inspiratory
Crackle (aka rale, crepitation) – excess airway secretions, opening and closing of collapsed distal airways and alveoli
- Short, discontinuous, nonmusical
- Mostly during inspiration
- Bronchitis, Infections, Edema, Atelectasis, Fibrosis, CHF
Wheeze (rapid airflow through obstructed airway)
- Continuous, musical, high pitched
- Mostly during expiration
- Asthma, Edema, Bronchitis, CHF
Rhonchus (transient airway plugging)
- Lower-pitched, more sonorous
- Bronchitis
Pleural rub (inflammation of pleura)
- Grating
- End of inspiration, beginning of expiration
- Pneumonia, Pulmonary infarction

Anterior chest

Palpation

Tracheal position (feel in suprasternal notch)
Tracheal mobility (tracheal tug – support neck, fingers in cricothyroid space with palm facing up, move 1-2 cm) – if fixed, TB or neoplasm
Tactile fremitus

Percussion

Auscultate

Special Tests

Egophony (“eeee” will be heard as “aaaa” over areas of consolidation)
Whispered pectoriloquy (whisper “1-2-3”, normally nothing heard, but transmission increased if consolidation)
Bronchophony (say “ninety-nine”, heard louder over consolidation)

Clinical correlates

Consolidation:

Pleural Effusion

COPD