11/13/24, 7\:09 PM Guide | Respiratory examination

Respiratory examination

Table of contents
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Introduction

Wash your hands and don PPE if appropriate.
Introduce yourself to the patient including your name and role.
Con
Brie
Gain consent to proceed with the examination.
Adjust the head of the bed to a 45° angle.
Adequately expose the patient's chest for the examination (o
appropriate, inform patients they do not need to remove their bra). Exposure of the patient's lower legs is also helpful to assess
for peripheral oedema.
Ask the patient if they have any pain before proceeding with the clinical examination.

General inspection

Clinical signs

Inspect the patient from the end of the bed whilst at rest, looking for clinical signs suggestive of underlying pathology\:
Age\: the patient's approximate age is helpful when considering the most likely underlying pathology, with younger patients
more likely to have diagnoses such as asthma or cystic
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obstructive pulmonary disease (COPD), interstitial lung disease or malignancy.
Cyanosis\: bluish discolouration of the skin due to poor circulation (e.g. peripheral vasoconstriction secondary to
hypovolaemia) or inadequate oxygenation of the blood (e.g. right-to-left cardiac shunting).
Shortness of breath\: signs may include nasal
and the tripod position (sitting or standing leaning forward and supporting the upper body with hands on knees or other
surfaces). Shortness of breath is a common feature of most respiratory pathology, however possible underlying diagnoses in
an OSCE could include asthma, pulmonary oedema, pulmonary
sentences is an indicator of signi
Cough\: a productive cough can be associated with several respiratory pathologies including pneumonia, bronchiectasis,
COPD and CF. A dry cough may suggest a diagnosis of asthma or interstitial lung disease.
Wheeze\: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often
associated with asthma, COPD and bronchiectasis.
Stridor\: a high-pitched extra-thoracic breath sound resulting from turbulent air
has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Pallor\: a pale colour of the skin that can suggest underlying anaemia (e.g. haemorrhage/chronic disease) or poor perfusion
(e.g. congestive cardiac failure). It should be noted that healthy individuals may have a pale complexion that mimics pallor.
Oedema\: typically presents with swelling of the limbs (e.g. pedal oedema) or abdomen (i.e. ascites) and is often associated
with right ventricular failure. Pulmonary oedema often occurs secondary to left ventricular failure.
Cachexia\: ongoing muscle loss that is not entirely reversed with nutritional supplementation. Cachexia is commonly
associated with underlying malignancy (e.g. lung cancer) and other end-stage respiratory diseases (e.g. COPD).

Objects and equipment

Look for objects or equipment on or around the patient that may provide useful insights into their medical history and current
clinical status\:
Oxygen delivery devices\: note the type of oxygen device (e.g. Venturi mask, non-rebreathing mask, nasal cannulae) and the
current
Sputum pot\: note the volume and colour of the contents (e.g. COPD/bronchiectasis).
Other medical equipment\: ECG leads, medications (e.g. inhalers/nebulisers in asthma/COPD), catheters (note
volume/colour of urine) and intravenous access.
Cigarettes or vaping equipment\: smoking is a signi
Mobility aids\: items such as wheelchairs and walking aids give an indication of the patient's current mobility status.
Vital signs\: charts on which vital signs are recorded will give an indication of the patient's current clinical status and how their
physiological parameters have changed over time.
Fluid balance\:
patient appears
Prescriptions\: prescribing charts or personal prescriptions can provide useful information about the patient's recent
medications.
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Perform general inspection

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

Inspection

General observations
Observe the hands and note your
Colour\: cyanosis of the hands may suggest underlying hypoxaemia.
Tar staining\: caused by smoking, a signi
Skin changes\: bruising and thinning of the skin can be associated with long-term steroid use (e.g. asthma, COPD, interstitial
lung disease).
Joint swelling or deformity\: may be associated with rheumatoid arthritis which has several extra-articular manifestations
that a
Finger clubbing
Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal
angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those
most likely to appear in a respiratory OSCE station include lung cancer, interstitial lung disease, cystic
bronchiectasis.
To assess for
Ask the patient to place the nails of their index
In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth's window).
When
Fine tremor
Assess for the presence of a
Ask the patient to hold out their hands in an outstretched position and observe for a
with beta-2-agonist use (e.g. salbutamol).
Asterixis (
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Asterixis (also known as '
a 2
retention in
conditions that result in type 2 respiratory failure (e.g. COPD). Other causes of asterixis include uraemia and hepatic
encephalopathy.
Whilst the patient still has their hands stretched outwards, ask them to cock their hands backwards at the wrist joint and
hold the position for 30 seconds.
Observe for evidence of asterixis during this time period.

Palpation

Temperature
Place the dorsal aspect of your hand onto the patient's to assess temperature\:
In healthy individuals, the hands should be symmetrically warm, suggesting adequate perfusion.
Cool hands may suggest poor peripheral perfusion.
Excessively warm and sweaty hands can be associated with CO 2
retention.
Heart rate
Assessing heart rate\:
Palpate the patient's radial pulse, located at the radial side of the wrist, with the tips of your index and middle
aligned longitudinally over the course of the artery.
Once you have located the radial pulse, assess the rate and rhythm.
Calculating heart rate\:
You can calculate the heart rate in a number of ways, including measuring for 60 seconds, measuring for 30 seconds and
multiplying by 2 or measuring for 15 seconds and multiplying by 4. The shorter the interval used, the higher the risk of
obtaining an inaccurate result, so wherever possible, you should palpate for a full 60 seconds.
For irregular rhythms, you should measure the pulse for a full 60 seconds to improve accuracy.
Pulse abnormalities
Bounding pulse\: can be associated with underlying CO 2
retention (e.g. type 2 respiratory failure).
Pulsus paradoxus\: pulse wave volume decreases signi
cardiac tamponade, severe acute asthma and severe exacerbations of COPD (therefore it is unlikely to be relevant to
most OSCE scenarios).
Respiratory rate
Assessing respiratory rate\:
Whilst still palpating the radial pulse (but no longer counting it), assess the patient's respiratory rate (palpation of the radial
pulse at this stage purely to avoid making the patient aware you are directly observing their breathing, as this can itself alter
the respiratory rate).
Note any asymmetries in the expiratory and inspiratory phases of respiration (e.g. the expiratory phase is often prolonged
in asthma exacerbations and in patients with COPD).
Calculating respiratory rate\:
Assess the patient's respiratory rate for 60 seconds to calculate the number of breaths per minute.
Respiratory rate abnormalities
In healthy adults, the respiratory rate should be between 12-20 breaths per minute.
A respiratory rate of fewer than 12 breaths per minute is referred to as bradypnoea (e.g. opiate overdose).
A respiratory rate of more than 20 breaths per minute is referred to as tachypnoea (e.g. acute asthma).
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Inspect the hands

Jugular venous pressure (JVP)

Jugular venous pressure (JVP) provides an indirect measure of central venous pressure. This is possible because the internal
jugular vein (IJV) connects to the right atrium without any intervening valves, resulting in a continuous column of blood. The
presence of this continuous column of blood means that changes in right atrial pressure are re
atrial pressure results in distension of the IJV).
The IJV runs between the medial end of the clavicle and the ear lobe, under the medial aspect of the sternocleidomastoid,
making it di
sternocleidomastoid muscle).
Because of the inability to easily visualise the IJV, it's tempting to use the external jugular vein (EJV) as a proxy for assessment
of central venous pressure during clinical assessment. However, because the EJV typically branches at a right angle from the
subclavian vein (unlike the IJV which sits in a straight line above the right atrium) it is a less reliable indicator of central venous
pressure.
See our guide to jugular venous pressure (JVP) for more details.

Measure the JVP

1. Position the patient in a semi-recumbent position (at 45°).
2. Ask the patient to turn their head slightly to the left.
3. Inspect for evidence of the IJV, running between the medial end of the clavicle and the ear lobe, under the medial aspect of
the sternocleidomastoid (it may be visible between just above the clavicle between the sternal and clavicular heads of the
sternocleidomastoid. The IJV has a double waveform pulsation, which helps to di
carotid artery.
4. Measure the JVP by assessing the vertical distance between the sternal angle and the top of the pulsation point of the IJV
(in healthy individuals, this should be no greater than 3 cm).
Respiratory causes of a raised JVP
A raised JVP indicates the presence of venous hypertension. Respiratory causes of a raised JVP include\:
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Pulmonary hypertension\: causes right-sided heart failure, often occurring due to COPD or interstitial lung disease.
There are several other causes of a raised JVP that relate to the cardiovascular system (e.g. congestive heart failure,
tricuspid regurgitation and constrictive pericarditis).
Hepatojugular re
The hepatojugular re
See our cardiovascular examination guide for details on how to elicit hepatojugular re
Assess the JVP

Face

General

Inspect the face for any signs relevant to the respiratory system\:
Plethoric complexion\: a congested red-faced appearance associated with polycythaemia (e.g. COPD) and CO 2
(e.g. type 2 respiratory failure).
retention

Eyes

Inspect the eyes for signs relevant to the respiratory system\:
Conjunctival pallor\: suggestive of underlying anaemia. Ask the patient to gently pull down their lower eyelid to allow you to
inspect the conjunctiva.
Ptosis, miosis and enophthalmos\: all features of Horner's syndrome (anhydrosis is another important sign associated with
the syndrome). Horner's syndrome occurs when the sympathetic trunk is damaged by pathology such as lung cancer
a

Mouth

Inspect the mouth for signs relevant to the respiratory system\:
Central cyanosis\: bluish discolouration of the lips and/or the tongue associated with hypoxaemia.
Oral candidiasis\: a fungal infection commonly associated with steroid inhaler use (due to local immunosuppression). It is
characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous
mucosa.
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Inspect the face

Inspection of the chest

Scars

Closely inspect the chest wall for scars and other abnormalities\:
Median sternotomy scar\: located in the midline of the thorax. This surgical approach is used for cardiac valve replacement
and coronary artery bypass grafts (CABG).
Axillary thoracotomy scar\: located between the posterior border of the pectoralis major and anterior border of latissimus
dorsi muscles, through the 4th or 5th intercostal space. This surgical approach is used for the insertion of chest drains.
Posterolateral thoracotomy scar\: located between the scapula and mid-spinal line, extending laterally to the anterior
axillary line. This surgical approach is used for lobectomy, pneumonectomy and oesophageal surgery.
Infraclavicular scar\: located in the infraclavicular region (on either side). This surgical approach is used for pacemaker
insertion.
Radiotherapy-associated skin changes\: may be present in patients who have been treated for lung cancer. Clinical features
can include xerosis (dry skin), scale, hyperkeratosis (thickened skin), depigmentation and telangiectasia.

Chest wall deformities

Inspect for evidence of chest wall deformities\:
Asymmetry\: typically associated with pneumonectomy (e.g. lung cancer) and thoracoplasty (e.g. tuberculosis).
Pectus excavatum\: a caved-in or sunken appearance of the chest.
Pectus carinatum\: protrusion of the sternum and ribs.
Hyperexpansion (a.k.a.
'barrel chest')\: chest wall appears wider and taller than normal. Associated with chronic lung
diseases such as asthma and COPD.
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Inspect the chest wall

Trachea and cricosternal distance

Assess tracheal position

Gently assess the position of the trachea, which should be central in healthy individuals (this can be uncomfortable, so warn
the patient in advance)\:
1. Ensure patient's neck musculature is relaxed by asking them to position their chin slightly downwards.
2. Dip your index
3. Gently apply side pressure to locate the border of the trachea.
4. Compare this space to the other side of the trachea using the same process.
5. A di
Causes of tracheal deviation
The trachea deviates away from tension pneumothorax and large pleural e
The trachea deviates towards lobar collapse and pneumonectomy.
Palpation of the trachea can be uncomfortable, so warn the patient and apply a gentle technique

Assess cricosternal distance

Cricosternal distance is the distance between the inferior border of the cricoid cartilage and the suprasternal notch\:
1. Measure the distance between the suprasternal notch and cricoid cartilage using your
2. In healthy individuals, the distance should be 3-4
Cricosternal distance is actually based on the size of the patient's
your own, it may be worth using their
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Causes of abnormal cricosternal distance
A distance of fewer than 3
Assess tracheal position

Palpation of the chest

Palpate the apex beat

1. Palpate the apex beat with your
2. In healthy individuals, it is typically located in the 5th intercostal space in the midclavicular line.
Respiratory causes of a displaced apex beat
Right ventricular hypertrophy (e.g. pulmonary hypertension, COPD, interstitial lung disease)
Large pleural e
Tension pneumothorax

Assess chest expansion

1. Place your hands on the patient's chest, inferior to the nipples.
2. Wrap your
3. Bring your thumbs together in the midline, so that they touch.
4. Ask the patient to take a deep breath in.
5. Observe the movement of your thumbs (in healthy individuals they should move symmetrically upwards/outwards during
inspiration and symmetrically downwards/inwards during expiration ).
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6. Reduced movement of one of your thumbs indicates reduced chest expansion on that side.
Respiratory causes of reduced chest expansion
Symmetrical\: pulmonary
Asymmetrical\: pneumothorax, pneumonia and pleural e
Palpate the apex beat

Percussion of the chest

Percussion of the chest involves listening to the volume and pitch of percussion notes across the chest to identify underlying
pathology. Correct technique is essential to generating e

Percussion technique

1. Place your non-dominant hand on the patient's chest wall.
2. Position your middle
3. With your dominant hand's middle
swinging movement of the wrist.
4. The striking
Areas to percuss
Percuss the following areas of the chest, comparing side to side as you progress (see image example below)\:
Supraclavicular region\: lung apices
Infraclavicular region
Chest wall\: percuss over 3-4 locations bilaterally
Axilla
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Types of percussion note
Resonant\: a normal
Dullness\: suggests increased tissue density (e.g. cardiac dullness, consolidation, tumour, lobar collapse).
Stony dullness\: typically caused by an underlying pleural e
Hyper-resonance\: the opposite of dullness, suggestive of decreased tissue density (e.g. pneumothorax).

Tactile vocal fremitus

Assessing tactile vocal fremitus involves palpating over di
number consistently (e.g.
"ninety-nine"). The presence of increased tissue density or
patient's speech is transmitted as vibrations through the chest wall to the examiner's hands.
Technique
1. Ask the patient to say
"99" repeatedly at the same volume and in the same tone.
2. Palpate the chest wall on both sides, using the ulnar border of your hand.
3. Cover all major regions of the chest wall, comparing each side at each location.
Abnormal tactile vocal fremitus
Increased vibration over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).
Decreased vibration over an area suggests the presence of
pneumothorax).
An alternative method of assessment
Vocal resonance (see below) is an alternative method of assessing the conduction of sound through lung tissue and involves
auscultating over di
increased tissue density or
stethoscope. Given both tests assess the same thing, there is no reason to perform both vocal resonance and tactile vocal
fremitus in the same examination.
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Percuss the lung

Auscultation of the chest

When auscultating the chest, it is important that you have a systematic approach that allows you to compare each area on both
the left and the right as you progress.

Auscultate the chest

Technique
avoided).
1. Ask the patient to relax and breathe deeply in and out through their mouth (prolonged deep breathing should, however, be
2. Position the diaphragm of the stethoscope over each of the relevant locations on the chest wall to ensure all lung regions
have been assessed and listen to the breathing sounds during inspiration and expiration. Assess the quality and volume of
breath sounds and note any added sounds.
3. Auscultate each side of the chest at each location to allow for direct comparison and increased sensitivity at detecting local
abnormalities.
Quality of breath sounds
Vesicular\: the normal quality of breath sounds in healthy individuals.
Bronchial\: harsh-sounding (similar to auscultating over the trachea), inspiration and expiration are equal and there is a
pause between. This type of breath sound is associated with consolidation.
Volume of breath sounds
Quiet breath sounds\: suggest reduced air entry into that region of the lung (e.g pleural e
When presenting your
, rather than 'reduced air entry'
.
Added sounds
Wheeze\: a continuous, coarse, whistling sound produced in the respiratory airways during breathing. Wheeze is often
associated with asthma, COPD and bronchiectasis.
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Stridor\: a high-pitched extra-thoracic breath sound resulting from turbulent air
Stridor has a wide range of causes, including foreign body inhalation (acute) and subglottic stenosis (chronic).
Coarse crackles\: discontinuous, brief, popping lung sounds typically associated with pneumonia, bronchiectasis and
pulmonary oedema.
Fine end-inspiratory crackles\: often described as sounding similar to the noise generated when separating velcro.
Fine end-inspiratory crackles are associated with pulmonary

Assess vocal resonance

Assessing vocal resonance involves auscultating over di
number consistently. The presence of increased tissue density or
transmitted to the diaphragm of the stethoscope.
Technique
1. Ask the patient to say
"99" repeatedly at the same volume and in the same tone.
2. Auscultate all major regions of the anterior chest wall, comparing each side at each location.
Abnormal vocal resonance
Increased volume over an area suggests increased tissue density (e.g. consolidation, tumour, lobar collapse).
Decreased volume over an area suggests the presence of
pneumothorax).
An alternative method of assessment
Tactile vocal fremitus is an alternative method of assessing the conduction of sound through lung tissue and involves feeling
for sound vibrations on the chest wall with your hands as the patient speaks. Given both tests assess the same thing, there is no
reason to perform both vocal resonance and tactile vocal fremitus in the same examination.
Auscultate the chest

Lymph nodes

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Palpate the patient's lymph nodes

1. Position the patient sitting upright and examine from behind if possible. Ask the patient to tilt their chin slightly downwards to
relax the muscles of the neck and aid palpation of lymph nodes. You should also ask them to relax their hands in their lap.
2. Inspect for any evidence of lymphadenopathy or irregularity of the neck.
3. Stand behind the patient and use both hands to start palpating the neck.
4. Use the pads of the second, third and fourth
the various characteristics of the lymph nodes. By using both hands (one for each side) you can note any asymmetry in size,
consistency and mobility of lymph nodes.
5. Start in the submental area and progress through the various lymph node chains. Any order of examination can be used, but
a systematic approach will ensure no areas are missed\:
Submental
Submandibular
Pre-auricular
Post-auricular
Super
Deep cervical
Posterior cervical
Supraclavicular – left supraclavicular region is where Virchow’s node may be noted (associated with upper gastrointestinal
malignancy)
Take caution when examining the anterior cervical chain that you do not compromise cerebral blood
compression). It may be best to examine one side at a time here.
A common mistake is a “piano-playing” or “spider’s legs” technique with the
the pads of the second, third and fourth
Example of logical systematic examination of the lymph nodes
1. Start under the chin (submental lymph nodes), then move posteriorly palpating beneath the mandible (submandibular), turn
upwards at the angle of the mandible and feel anterior (preauricular lymph nodes) and posterior to the ears (posterior auricular
lymph nodes).
2. Follow the anterior border of the sternocleidomastoid muscle (anterior cervical chain) down to the clavicle, then palpate up
behind the posterior border of the sternocleidomastoid (posterior cervical chain) to the mastoid process.
3. Ask the patient to tilt their head (bring their ear towards their shoulder) each side in turn, and palpate behind the posterior
border of the clavicle in the supraclavicular fossa (supraclavicular and infraclavicular lymph nodes).
Respiratory causes of lymphadenopathy
Lung cancer with metastases
Tuberculosis
Sarcoidosis
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Lymph nodes of the head and neck

Posterior chest assessment

With the patient still sitting forwards, ask them to fold their arms across their chest so that their hands are touching the
opposite shoulder. This results in rotation of the scapulae to better expose the underlying chest wall for assessment.
Assess the posterior chest including inspection, chest expansion, percussion, tactile vocal fremitus (or vocal resonance) and
auscultation.
Allocate adequate time to assessing the posterior aspect of the chest as this is where you are most likely to identify clinical
signs.
Posterolateral thoracotomy scar
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Final steps

Assess for evidence of pitting sacral and pedal oedema (e.g. congestive heart failure).
Assess the calves for signs of deep vein thrombosis (e.g. swelling, increased temperature, erythema, visible super
as the patient may have shortness of breath secondary to pulmonary embolism.
Inspect for evidence of erythema nodosum, which can be associated with sarcoidosis.
Assess sacral oedema

To complete the examination...

Explain to the patient that the examination is now
Thank the patient for their time.
Dispose of PPE appropriately and wash your hands.
Summarise your
Example summary
" T o d a y I e x a m i n e d M r s S m i t h , a 6 4- y e a r-o l d f e m a l e. O n g e n e r a l i n s p e c t i o n , t h e p a t i e n t a p p e a r e d c o m f o r t a b l e a t r e s t ,
w i t h n o e v i d e n c e o f s h o r t n e s s o f b r e a t h . T h e r e w e r e n o o b j e c t s o r m e d i c a l e q u i p m e n t a r o u n d t h e b e d o f r e l e v a n c e .
"
" T h e h a n d s h a d n o p e r i p h e r a l s t i g m a t a o f r e s p i r a t o r y d i s e a s e a n d w e r e s y m m e t r i c a l l y w a r m . T h e r e w a s n o e v i d e n c e o f a

"
Source\: geekymedics.com
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