Respiratory System History and Examination

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Respiratory problems may be caused by disorders of other symptoms and so it may be appropriate to refer also to the separate articles Cardiovascular History and Examination and Ear, Nose and Throat Examination.

Save time & improve your PDP on Patient.co.uk

  • Notes Add notes to any clinical page and create a reflective diary
  • Track Automatically track and log every page you have viewed
  • Print Print and export a summary to use in your appraisal
Click to find out more »

History of presenting complaint

The main respiratory symptoms are:

Other systems

Past medical history

Allergies

Ask about all allergies including, for example, food, inhaled allergens and drugs.

Occupational and social history

Family history

Inspection

Palpation

  • Use the index finger to feel the trachea and to determine whether the trachea feels central or is deviated.
    • The trachea is deviated away from pneumothorax and effusion and towards collapse and consolidation.
    • The trachea may also be deviated by a mass, eg enlarged lymph nodes.
  • Chest expansion:
  • Tactile vocal fremitus:
    • To assess tactile vocal fremitus, use the ulnar side of the hand, by the hypothenar eminence with the palms facing upwards. Place it at various levels over the back, each time asking the patient to say "ninety-nine". Note how the sound is transmitted to the hand.
    • Tactile vocal fremitus is increased over areas of consolidation and decreased or absent over areas of effusion or collapse.
  • Feel for the apex beat of the heart; it will be displaced if the mediastinum is displaced or distorted.

Percussion

  • For percussion of the chest, it is usual to use the middle finger of the dominant hand to do this.
  • The clavicle is percussed directly, usually about a third of the way between the sternum and the acromium. The rest of the chest is percussed by placing the non-dominant hand on the chest and using the dominant middle finger to tap the other middle finger over the middle phalanx.
  • Percuss over all the lobes of the lung, front and back except that the middle lobe does not have surface anatomy on the back.
  • Percuss over the heart. In hyperinflation of the chest, there is loss of cardiac dullness.
  • A hyper-resonant sound suggests hyperinflation or a pneumothorax.
  • A dull sound is easier to distinguish from normal. It may suggest collapse or consolidation, or a pleural effusion.

Auscultation

  • Heart auscultation (see link for separate article): mainly to detect heart abnormalities but severe lung disease may cause pulmonary hypertension and a loud P2.
  • Place the stethoscope over each of the 5 lobes of the lungs in turn, on the front and back of the chest. Ask the patient to take deep breaths in and out with their mouth open.
  • Normal breath sounds are called vesicular. They are described as quiet and gentle. There is usually no gap between the inspiratory and expiratory phase sounds.
  • Rhonchi (wheezes):
    • Musical sound heard on expiration. In severe cases they may be both inspiratory and expiratory. Imply narrowing of the airways.
    • The loudness of rhonchi gives no indication of the severity of the condition.
  • Rales (sometimes called crackles):
    • Probably represent opening of small airways and alveoli.
    • They may be normal at the lung bases if they clear on coughing or after taking a few deep breaths.
    • Basal rales are a classical feature of pulmonary congestion with left ventricular failure. They may be more diffuse in pulmonary fibrosis.
  • Bronchial breathing:
    • The sounds of bronchial breathing are generated by turbulent air flow in large airways (similar sounds can be heard in healthy patients by listening over the trachea.
    • Sounds are harsh and poor in nature. Unlike normal vesicular breath sounds, there is a gap between the inspiratory and expiratory phase sounds.
    • Bronchial breathing suggests consolidation or fibrosis, which permits the sound to be conducted more effectively to the chest wall.
  • Pleural rub: a creaking sound caused by stiff pleural membranes such as with pleurisy.
  • Stridor: harsh inspiratory sound caused by partial obstruction of a large airway.
  • Vocal resonance:
    • Place the stethoscope at various levels over the back and ask the patient to whisper "ninety-nine" each time. Note how well the sound is transmitted.
    • The sound is muffled over a normal lung, increased if there is consolidation, and decreased or absent if there is effusion or collapse.
  • Whispering pectoriloquy:
    • Is elicited as for vocal fremitus but ask the patient to whisper "one, two, three".
    • Whispering pectoriloquy is the increased quality and loudness of whispers that are heard with a stethoscope over an area of lung consolidation.

Initial investigations

See separate articles Peak Flow Recording, Spirometry and Chest X-ray - Systematic Approach.

Further reading & references

  • Epstein O, Perkin GD, Cookson J et al. Clinical Examination (4th ed.) Mosby Elsevier (2008)

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
17/11/2011
Document ID:
1700 (v23)
© EMIS