NCCP Textbook of Respiratory Medicine D Behera, SN Gaur, SK Katiyar, Bharat Gopal
INDEX
×
Chapter Notes

Save Clear


Physical Examination of Respiratory SystemChapter 1

Jyotsna M Joshi
Clinical approach to a patient with pulmonary disease consists of history taking and clinical examination; general and systemic.
 
GENERAL EXAMINATION
General examination is important and contributes to diagnostic decision-making in several ways. Overall assessment of the nutritional status can be made by measurement of body fat, which is the Body Mass Index (BMI). BMI is estimated by dividing the patient's weight (in kilograms) by the square of height (in meters). The World Health Organization1 (WHO) defines underweight as less than 20, normal 20-25, overweight as a BMI of 25 or more, and obesity as a BMI of more than 30 kg/m2 and extreme obesity with BMI more than 40 kg/m2. Overweight or obesity is common within Obstructive Sleep Apnea Syndrome (OSAS). Low BMI is seen in chronic respiratory diseases including tuberculosis (TB). Low BMI in Chronic obstructive pulmonary disease (COPD) is called pulmonary cachexia or pulmonary sarcopenia and is a systemic manifestation of COPD.
Temperature, pulse, respiratory rate and blood pressure are the important vital signs. Pulse oximetry is now viewed as “the fifth vital sign”.2 Baseline or exercise desaturation can aid in diagnostic and therapeutic decision-making in respiratory diseases. Exercise test3 for this purpose is performed while the patient is encouraged to walk at their own pace on a flat surface for six minutes — six-minute walk test (6MWT), alternatively till the target heart (200-age) rate is reached or until limited by shortness of breath or fatigue. Clinically significant desaturation is considered to be any saturation decrease of 4% or more or to a nadir of 88%.
Pallor, cyanosis and clubbing are important general examination findings. Also look for nicotine staining (COPD), tremors or flaps (CO2 narcosis). Clubbing and pallor point toward chronic inflammatory diseases and malignancies. Elevated jugular venous pressure (JVP) and pedal edema in chronic pulmonary cases help to diagnose cor pulmonale with right heart failure. Clubbing4 is an important general examination finding and is seen commonly in chronic suppurative pulmonary diseases — bronchiectasis, lung abscess, empyema, malignancy — lung cancer, malignant mesothelioma and Idiopathic Interstitial Pneumonias (IIPs) (especially idiopathic pulmonary fibrosis — IPF) apart from several nonpulmonary causes. Eye is examined for icterus and may be seen in anti-TB drug hepatotoxicity; ptosis and pupillary constriction are hallmarks of Horner's syndrome seen in Pancoast's syndrome. Neck examination for enlarged cervical lymph nodes in cases of lung/mediastinal lesions, neck crepitus in pneumomediastinum, and engorged neck veins to superior vena cava (SVC) obstruction is important. The cervical nodes provide accessible site for Fine Needle Aspiration Cytology or Biopsy (FNAC/B).5
 
RESPIRATORY SYSTEM EXAMINATION
Respiratory system examination includes: (i) respiration, (ii) upper respiratory tract examination, and (iii) examination of the chest.5
 
Respiration
Rate of breathing should be observed without the patient's knowledge. This is best done by counting the rate by one hand kept over the abdominal wall while the examiner looks at his watch. Respiratory rate varies in normal individuals between 14 and 18 per minute. Rate may be reduced (hypoventilation) or increased (hyperventilation). Common abnormal breathing patterns6 are pursed lip breathing seen in COPD; Cheyne-Stokes breathing seen in heart failure and consists of periods of hyperventilation followed by hypoventilation ending with an apnea; and Kussmaul's breathing (rapid deep breathing) seen in conditions that cause metabolic acidosis. An accessory muscle of respiration use is indicated by contraction of sternomastoids and scaleni and indicates labored breathing.
 
Upper Respiratory Tract
Nasal discharge presence and type, sinus tenderness and oral examination for teeth/gums, tonsils and pharynx help in assessing Upper Respiratory Tract (URT). Allergic rhinosinusitis is common in asthma and URT infections are associated with chronic pulmonary infections like bronchiectasis. Anatomy of the upper airway (Mallampati classification7); 2based on the visibility of the base of uvula, faucial pillars (the arches in front and behind the tonsils) and soft palate is important in the assessment of OSAS. Scoring may be done with or without phonation as class 1: Full visibility of tonsils, uvula and soft palate, class 2: Visibility of hard and soft palate, upper portion of tonsils and uvula, class 3: Soft and hard palate and base of the uvula are visible, and class 4: only hard palate visible.
 
Chest Examination
Chest examination requires the patient's chest, neck and abdomen to be exposed.8 It is best performed in the sitting or standing position. In patients who have difficulty in sitting, support can be given by someone standing in front and holding his/her hands. In those who are too sick to stand or sit, rolling on one side and then the other for examination of the back is required to examine the back.9 Chest examination is performed under the headings of Inspection, Palpation, Percussion and Auscultation (IPPA). The clinical findings are described in terms of areas over the chest (anteriorly — supraclavicular, clavicular, infraclavicular and inframammary, axilla — axillary and infra-axillary; and posteriorly — suprascapular, interscapular, scapular and infrascapular). The corresponding areas of various lung lobes are as shown in surface marking in Figures 1.1A and B and help in localizing the diseased lobe.
 
INSPECTION AND PALPATION
William Osler's aphorism states “Do not touch the patient, state first what you see!”10 Hence, a thorough inspection is performed first to assess the shape, movements and symmetry of the chest. Normal chest in an adult is elliptical, i.e. side-to-side diameter is greater than anteroposterior diameter. In COPD, anteroposterior diameter is equal to or greater than side-to-side diameter (barrel chest). The other abnormal shapes are kyphosis (anteroposterior bending) or scoliosis (side-to-side bending) of the spine, pectus excavatum or funnel chest (congenital abnormality) and pectus carinatum or pigeon breast (bulging sternum due to childhood obstructive airway diseases associated with rickets). Movement of the chest is looked for before assessing symmetry. This is because clinical examination of the chest is comparative in nature,8 hence the dictum: “The side that moves less is the abnormal side”.
Next step is to look for unilateral prominence of sternomastoid that indicates tracheal shift — Trail's sign,11 cardiac impulse12 (usually present in the fifth intercostal space in the midclavicular line) and subcostal angle (normally acute but becomes obtuse in emphysema, followed by level of the shoulders (equal or drooped on one side), spinoscapular distance on either side (equal, increased or reduced on one side) and shape of the spine (normal, kyphosis, scoliosis or kyphoscoliosis). Finally any dilated vessels, scars or procedure marks are noted. Palpation confirms the findings of inspection, i.e. hemithoracic movements are checked; tracheal position and apex beat are confirmed. In addition, Tactile Vocal Fremitus (TVF) and rib crowding are looked for. Palpation of the thorax during speech elicits vibrations on the chest that are called tactile fremitus or TVF.6 The patient is asked to say one-one-one or nine-nine-nine in English and teen-teen-teen or nau-nau-nau in Hindi and TVF is estimated by moving the ulnar side of the hand from side-to-side and from top to bottom. Increased TVF reflects increased density of the lung, e.g. consolidation by pneumonia or collapse with a patent bronchus. Conversely, the presence of air or fluid in the pleura and collapse with obstructed bronchus decrease TVF.
Findings of inspection and palpation are analyzed together to assess whether the disease is bilateral — indicated by equal chest movements (asthma, COPD, ILD) or unilateral — indicated by reduced movements on one side of the chest.
zoom view
Figs 1.1A and B: Surface marking of lung lobes over the anterior and posterior chest
3
If unilateral; whether associated with increase in hemithoracic volume (bulging of the chest, elevated shoulder, increased spinoscapular distance, and shift of trachea and cardiac impulse/apex beat to opposite side) found in pleural effusion, pneumothorax, hydropneumothorax; reduction in hemithoracic volume (flattening of the chest, depressed shoulder, reduced spinoscapular distance, and shift of trachea and cardiac impulse/apex beat to same side) found in collapse, cavity, pleural thickening or no change in volume (no bulging or flattening, both shoulders at same level, equal spinoscapular distance, central trachea and cardiac impulse/apex beat in the fifth intercostal space in the midclavicular line) noted in consolidation.5
 
PERCUSSION AND AUSCULTATION
Percussion and auscultation add to the findings of inspection and palpation and depend on the principles of sound transmission plays. The technique of digital percussion, as we perform it today, was described by Barth and Roger.13 The middle finger (plessor) of the left hand is applied firmly on the region to be percussed; the other fingers lifted up to prevent dampening of sounds. The striking fingers (from one to three) of the right hand (plessimeter) vary according to the force of the impulse which is needed. Movements of the plessimeter must originate from the wrist and not from the elbow. Percussion must be performed from resonance to dullness and usually parallel to the border to be percussed (except when percussing the heart borders, when percussion is performed along intercostal spaces to avoid gap between the chest and plessor). The percussion notes vary from tympanic (over the stomach gas bubble — “Traube's space”) to dull (over the heart and liver). Traube's space is an area of tympanitic resonance overlying the fundus of the stomach and is bounded on the left by the spleen, right by the left lobe of the liver, inferiorly by the costal margin and superiorly by the lung. In pathological cases hyperresonant notes are heard in cases of pneumothorax and emphysema; whereas, dull notes are produced over consolidation, collapse or pleural effusion. In cases of pleural effusion, a hyperresonant note called “Skoda's resonance” due to compressed underlying lung14 is found.
The physics of chest percussion is determined by the transmission properties of the respiratory system.15 Whilst percussing over the lungs the vibrations produced as a result of percussion are not damped, as a consequence of the large acoustic mismatch between the chest wall (solid medium) and the underlying lung parenchyma (mixture of gas and tissue) resulting in the normal resonant note. In situations where the lung parenchyma is replaced by air, as in pneumothorax, the acoustic mismatch is maximal and there is more underdamping of the percussion notes resulting in a hyperresonant note. If the underlying organ is solid, such as liver or the heart or where the alveolar air is replaced by exudate and/or solid tissue (consolidation or collapse), the acoustic mismatch is minimal, percussing vibrations are overdamped; hence they propagate away from the chest wall resulting in a dull note.
Auscultation via a stethoscope is an integral part of chest examination. Auscultation terms simplified by Forgacs16 are established by the International Lung Sounds Association (ILSA).17 The sounds heard at auscultation are breath sounds (normal or bronchial) and voice sounds (increase vocal resonance/ bronchophony or egophony); whispered sounds — Whispering Pectoriloquy (WP) and adventitious sounds; continuous sounds (wheezing and rhonchi) and intermittent sounds (coarse and fine crackles).18 Other adventitious sounds are those that originate in the upper airways (stridor) or in the pleura (friction rub) and interstitium (squawk) inspiratory squeaking sound.19
The normal breath sounds are the result of turbulent airflow through the larger airways. They are carried downward through the trachea and bronchi into the pulmonary tissues, being modified by the density of the tissues. At the chest wall, the higher frequencies are attenuated by the normal lung parenchyma resulting in vesicular breath sounds. In the presence of consolidation or collapse with a patent bronchus, these higher frequencies are transmitted, leading to “bronchial breathing”. Bronchial breathing is usually high pitched (tubular) and heard over consolidation; collapse with a patent bronchus and just above the level of pleural effusion due to the collapsed (relaxation or passive collapse) lung. Bronchial breathing may be low pitched (cavernous) heard over an irregular-walled cavity or high pitched with metallic intonation (amphoric) heard over a smooth-walled cavity or bronchopleural fistula. The voice sounds and whispered sounds are produced in the larynx. The same mechanism that produces bronchial breathing allows spoken sounds to be transmitted well as Increase Vocal Resonance (VR)/bronchophony (loud and clear)/egophony (with a nasal twang) and also whispered sounds as “positive WP”. The breath sounds (and spoken sounds-VR) are reduced or absent when the lung and chest wall are separated by fluid or air, as in pleural effusion or pneumothorax and due to inability of breath sounds to reach the lungs in collapse with obstructed bronchus.
The findings of clinical examination may be used systematically (Flow Chart 1.1) to make a clinical diagnosis. Further radiological imaging and laboratory tests, performed judiciously on the basis of a clinical diagnosis, help in making a final diagnosis. It is important to remember that no test can substitute physical examination performed by a skilled physician.20
zoom view
Flow Chart 1.1: Respiratory examination
REFERENCES
  1. World Health Organization (WHO). Available: www.who.int/mediacentre/factsheets/fs311/en/index.html.
  1. Tierney LM, Whooley MA, Saint S. Oxygen saturation: A fifth vital sign? West J Med 1997; 4:166285–6.
  1. American Thoracic Society (ATS) Statement. Guidelines for the Six-Minute Walk Test. American Journal of Respiratory and Critical Care Medicine 2002;166:111–7.
  1. Myers KA, Farquhar DR. Does this patient have clubbing? JAMA 2001;286:341–7.
  1. Joshi JM. Clinical assessment: Clinical decision-making in respiratory cases. Evaluation of the respiratory system. Textbook of Pulmonary Medicine, 1st edition. Jaypee Brothers Medical Publishers (P) Ltd;  India: 2009. p. 12.
  1. Swarz MH. History and examination. The science of physical examination: The chest. Textbook of Physical Diagnosis. Saunders;  Philadelphia:  1994;195–222.

  1. 4 Nuckton TJ, Glidden DV, Browner WS, et al. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep 2006;7:29903–8.
  1. Maitre B, Similowski T, Derenne JP. Physical examination of the adult patient with respiratory diseases: Inspection and palpation. Eur Respir J 1995; 8:1584–93.
  1. Fraser RG, Pare JAP, Pare PD, et al. Diagnosis of Diseases of the Chest, 3rd edition. Saunders;  Philadelphia:  1988. pp. 388–457.
  1. Osler W. The Principles and Practice of Medicine. Appleton;  New York:  1892.
  1. Houston AB. Trail's sign in chest examination. Manit Med Rev. 1948; 28(2):84.
  1. Roberts WC. Examining the precordium and the heart. Chest 1970; 57:567–71.
  1. Barth M, Roger H. Traité pratique d'auscultation, suivi d'un précis de percussion, 6ème édition. Asselin;  Paris:  1865.
  1. Skoda J. Abhandlung über Perkussion und Auskultation. Ritter von Mösle's Witwe & Braunmüller;  Wien,  1839.
  1. Yernault JC, Bohadana AB. Chest percussion. Eur Respir J 1995; 8:1756–60.
  1. Forgacs P. Crackles and wheezes. Lancet 1967; 2:203–5.
  1. Mikami R, Murao M, Cugell DW, et al. International symposium on lung sounds. Synopsis of proceedings. Chest 1987; 92:342–5.
  1. Pasterkamp H, Kraman SS, Wodicka GR. Respiratory sounds: Advances beyond the stethoscope. Am J Respir Crit Care Med. 1997; 156:974–87.
  1. Earis JE, K Marsh, MG Pearson, et al. The inspiratory “squawk” in extrinsic allergic alveolitis and other pulmonary fibroses. Thorax 1982; 37:923–6.
  1. Craig DA. Physical examination of the chest. Can Med Assoc J. 1920;10(8):737–42.