EXAMINATION OF

RESPIRATORY SYSTEM
 Surface markings of the lung

Right upper lobe Left upper lobe

Transverse fissure

Right middle lobe

Right lower lobe Right lower lobe

Oblique fissure

Signs of respiratory distress:

1. Tachypnoea
2. Tachycardia
3. Rescissions (Use of accessory muscles of respiration: subcostal,
intercostal, supraclavicular and suprasternal)
4. Reduced air entry on auscultation
5. Pallor
6. Sweating
7. Pulsus paradoxus
8. Inability to speak
9. Cyanosis
10. Irritability
11. Symptoms and signs of CO2 retention:
1. Confusion, drowsiness and later coma
2. Warm and sweaty hands (peripheral vasodilatation)
3. Bounding pulse
4. Coarse flapping tremor of the outstretched hands
5. Papilledema (cerebral vasodilatation) in chronic CO2
retention.
INTRODUCTION
CLINICAL ANATOMY OF THE LUNGS:
Division of the respiratory tract: (figure)
A) Upper respiratory tract - Includes nose, nasopharynx, larynx and
extrathoracic trachea.
B) Lower respiratory tract - Includes intrathoracic trachea, bronchi
and lungs.
Right Lung - 3 lobes: - upper, middle, lower lobe.
Left Lung - 2 lobes: - lower and upper lobe including lingula
(corresponding to the middle lobe of the right lungs)

HISTORY:
Please refer to the chapter dealing with the history taking. In addition,
giveparticular emphasis to the following points:
 Cough:
- Character: barking.
- Duration: acute or chronic (more than 3 weeks)
- Severity: interfere with sleeping, feeding, and speaking.
- Painful cough: lesion related to the pleura or ribs (pleurisy, rib
fracture)
- Timing: more at night, seasonal (asthma)
- Dry or productive: dry in pleurisy, productive in pneumonia.
Notice character of sputum:
o Nature: purulent, mucoid, frothy.
o Quantity: scanty or copious.
o Color: blood stained (pneumonia, mitral stenosis), greenish
(cystic fibrosis), yellowish (pneumonia).
o Smell: fetid (lung abscess, cystic fibrosis, bronchiectasis)
 Difficulty in breathing
- At rest or on exertion (during feeding in infant)
 Choking during feed or inability to complete feeds.
 Bluish discoloration of the lips (cyanosis)
 Presence of abnormal sounds during breathing
- Wheezing: may be heard without stethoscope.
- Stridor: “Harsh high pitched sound, heard during or at the end of
inspiration”
- Snoring: “Stridor that occurs at sleep”
- Grunting: “Noise produced at the beginning of expiration by a
forceful expiration against a partially closed glottis”
- Rattling: “Rapid succession of short, sharp sounds due to
passage of air in pooled saliva in the throat”
 Other important symptoms:
- Fever: mention character
- Loss of weight: acute or chronic
- Presence of loose fuel smelling stools. Chronic diarrhea
- Known chronic diseases: neuromuscular, cardiopulmonary,
immunodeficiency.
- Gestational age, history of ventilation, family history of atopic
disorders.
Types of respiratory diseases:

Obstructive respiratory diseases:

Neonates or young infants: Older infants and children:

- Choanal atresia - Bronchial asthma

- Vocal cord paralysis - Foreign body
- meconium aspiration - Laryngotracheobronchitis
- Laryngomalacia - Epiglottitis
- Aspiration syndromes - Bacterial tracheitis
- Gastro-esophageal reflux - Adenotonsillar hypertrophy
- Tracheo-esophageal fistula - Endobronchial tuberculosis
- Palatopharyngeal - Vascular ring
incoordination

Restrictive respiratory diseases:

Neonates and young infants Older infants and children

- Pulmonary agenesis/hypoplasia - Pneumonia

- Hyaline membrane diseases - Pneumothorax
- Diaphragmatic hernia - Foreign body inhalation
- Congenital lobar emphysema - Cystic Fibrosis
- Severe eventration of the - Pleural effusion
diaphragm - Neurological-
- Asphyxiating thoracic dystrophy - poliomyelitis
- myasthenia gravis
- botulism
- muscular dystrophy
- Skeletal- severe kyphoscoliosis
- Obesity
- Trauma - flail chest
CLINICAL EXAMINATION OF THE RESPIRATORY SYSTEM
General evaluation: Look for -
- General appearance: well or ill looking.
- State of alertness – Conscious / Unconscious
- Color (pallor, cyanosis)
- Speech ability (reading for 1 min, counting 1-10 in one breath)
- Tachypnea (respiratory rate > expected for age)
- Grunting (to make a short, low sound instead of speaking, usually
because of anger or pain)
- Active ala-nazi – Movement ( + /-)
- Audible wheezes
- Stridor
- Snoring – during sleep 1+ 2+ 3+
- Built and nutrition
- Note the presence of: Oxygen supply and delivery systems
(nebulizer apparatus, spacer devices, and inhaler devices) sputum
pot.
Examination of upper limbs: Check for:
- Clubbing: increased rounded appearance of the nails with
obliteration of the angle between the nail and its soft tissue base, or
a positive Scramroth’s sign (obliteration of the diamond shaped
space when the nail beds of two corresponding fingers of both
hands meet together).
- Peripheral cyanosis.
- Pulse: count and note the character (bounding pulse - CO2 B

retention) “count apex beat in children below the age of 3 years”.

B

- Blood pressure: Pulsus paradoxus (> 10 mm Hg fall of systolic

blood pressure during inspiration) e.g. severe asthma,
constrictivepericarditis.
Examination of the face: Check for:
- Lips: peripheral cyanosis
- Tongue: central cyanosis
- Ala-nazi: active or not
Examination of the Ear, Nose and Throat:
Keep it for the last, but remember to do it. Explain to the patient or use
proper restrain as indicated.
- Throat:
- Use a good source of light and a strong wooden spatula.
- Don’t miss a spontaneous gag to have a clear view of the throat.
- Don’t over-interpret tonsillar enlargement in a gagging child.
- Ears:
- Use proper size speculum.
- Gently pull the auricle upward, backward and laterally to make
the external auditory canal straight to have a better view of the
tympanic membrane. Note: presence of wax or foreign body.
- Examine the tympanic membrane for: light reflex, color
(remember the ear drum may appear reddish in a crying
child), bulging or retracted, perforation, discharge and mobility
(by a pneumatic device in the otoscope)
 Differential diagnosis of wheezing:
- Asthma
- Bronchiolitis
- Aspiration syndromes-
- Gastro-esophageal reflux
- Tracheo-esophageal fistula (specially H-type) Palatopharyngeal
incoordination
- Achalasia of esophagus
- Pharyngeal pouch
- Cystic Fibrosis, emphysema
- Bronchial obstruction - foreign body, tumor causing obstruction to a
bronchus
- Congestive cardiac failure
- Angioedema
-
Causes of acute stridor: Remember ABCDEFG (not in order of
importance)
A. Angioneurotic edema, Anaphylaxis
B. Bacterial tracheitis
C. Croup (acute laryngotracheobronchitis)
D. Diphtheria
E. Epiglottitis (acute)
F. Foreign body inhalation
G. Rare:
- Tetany
- Trauma to larynx (burn, inhaled hot gas, mechanical trauma)
- Peritonsillar abscess
- Spasmodic croup

Causes of chronic stridor:

- Laryngomalacia - Laryngeal cleft

- Tracheomalacia
- Vocal cord paralysis
- Sub-glottic stenosis
- Laryngeal papillomatosis
- Vascular ring
- Laryngeal web
- Foreign body inhalation

- Sub-glottic or laryngeal hemangioma

- Cyst - posterior to tongue or in the aryepiglottic fold

Causes of stridor in the first few days of life:

- Laryngomalacia
- Vocal cord paralysis
- Laryngeal web
- Congenital sub-glottic stenosis
- Vascular ring
- Hypocalcemia
- Macroglossia (Beckwith-Wiedemann syndrome)
- Choanal atresia
 - Nose:
- Use large size speculum and the usual otoscope (if indicated)
- Look for:
 Foreign body
 Foul smell
 Bleed
- Color of the nasal mucosa.
- Presence of discharge and its character
- Turbinate hypertrophy
- Polyps
- Edema of the nasal mucosa (allergy)

EXAMINATION OF THE CHEST:

Examine both front and back of the chest. Proceed to the back after
completion of the examination of the front.
Inspection:
- Respiratory rate (minimum 30 seconds)
- Expose the chest fully and look for:
o Type of breathing:
 Abdominal in infants.
 Thoracic after 4 - 5 years of age
 Flat abdomen with reduced movements
indicates diaphragmatic hernia

o Use of accessory muscles: suprasternal, intercostal

and subcostal retractions.
o Apex pulsation.
o Scars.
o Shape of the chest:
 Pectus Excavatum (funnel shaped chest)
 Pectus Carinatum (pigeon shaped)
 Barrel shaped (increased antero-posterior
diameter)
 Harrison Sulcus (indrowing of the lower chest
with rib flaring)
 Chest wall asymmetry and unequal chest
movement (should be observed from the foot
end of the bed, with keeping your eye in the
same level of chest wall)
 Shield-shaped chest: Turner’s syndrome
 Flattening of the hemi-chest, absence of
pectoralis muscle i.e., Poland anomaly
 Others:
 Rachitic rosary
 Absent clavicle in cleidocranial dysplasia
 Supernumerary nipple in renal anomaly
 PECTUS CARINATUM: PECTUS EXCAVATUM:
(Pigeon chest deformity) (Funnel-shaped deformity)
Causes Causes
- Asthma Isolated congenital anomaly
- Other obstructive airway diseases Chronic upper airway
- Rickets obstruction: (adenoid
- Osteomalacia
hypertrophy, laryngomalacia)

Causes of deviation of mediastinum (trachea, apex)

a. To the opposite side of the lesion:
- Pneumothorax
- Pleural effusion
- Unilateral hyperinflation: foreign body, tumor causing
bronchial obstruction
- Lobar emphysema: congenital or acquired
b. To the same side of the lesion:
- Collapse
- Fibrosis
- Hypoplasia
c. Heartbeat can be felt outside its usual position in case of the
followings:
- Cardiac enlargement
- Dextrocardia - apex beat on the right side
- Scoliosis
- Diaphragmatic hernia

Causes of changes in the resonance on percussion:

Decreased resonance:
1. Dullness on percussion:
a. Normal - Precordium
- Hepatic dullness
b. Abnormal- consolidation
- Fibrosis
- Collapse
- Pleural thickening
2. Stony dullness (absent resonance)
- Pleural effusion
Increased resonance:
- Normal infant (thin chest wall)
- Pneumothorax
- Asthma
- Emphysema
Palpation.
Proceed gently with warm hands.
Note:
- Obvious swelling and tenderness
- Position of trachea: by comparing the gap between the
sternal head of the sternomastoid and tracheal margin by
your index finger. Normally trachea is slightly deviated to the
right. In young children this is not a reliable sign to detect
mediastinal shift
- Position of the apex beat. Remember dextrocardia
- Tactile vocal fremitus: (in older children) place the palm of
the hand on either side of the upper chest and ask the child
to say ninety-nine. Feel the difference between sides rather
than absolute increase or decrease.
- Chest expansion: (in older children) hook little fingers of both
hands in the axillae with thumbs meeting in the mid-line. Ask
the child to take a deep breath and observe which thumb
moves the least.
Percussion.
1. Perform very gently
2. Explain to the older patients and the attendants
3. Use:
A) Pleximeter finger: placed in an intercostal space flush
with the chest wall, other fingers kept away from
touching the chest wall.
B) Percussing finger (plexor): middle finger of the
dominant hand. Finger should pivot at wrist and not at
the elbow, with a gentle blow hitting perpendicularly to
pleximeter finger.
4. Percuss at: (corresponding points) from up to down.
5. Mid-clavicular lines, and
6. mid-axillary lines
Note:
7. apices: percuss on the clavicle directly
8. Area of the liver dullness
9. Area of cardiac dullness
10. Character of resonance: (normal, increased, reduced,
absent, stony dullness)

Auscultation.
1. Use a child size stethoscope
2. Be sure that the chest piece is adequately warm
3. Use either the bell or the diaphragm (practice the use of any
one).
4. Apply the chest piece firmly to the chest wall to avoid rubbing
noises and escape of breath sounds
5. Auscultate the corresponding points in both sides: Front & Back
Auscultatory areas

Front
Back

Back Vesiculer

Bronchial

Vesiculer with prolonged expiration + ronchi

Character of inspiratory and expiratory phase: Note whether,

Mode of breathing in different diseases:

1. Obstructive:
 Mild: reduced rate, increased tidal volume
 Severe: increased rate, retractions, anxiety, cyanosis
2. Restrictive: Reduced rate increased tidal volume
3. Kussmaul respiration: Increases rate, increased tidal volume,
deep respiration, and metabolic acidosis i.e., Diabetes mellitus
4. Cheyne-Stokes respiration: Gradually increasing tidal volume
followed by gradually decreasing tidal volume and apnea. Due to
CNS injury, depressant drugs, uremia, prematurity.
5. Gasping respiration: Slow rate, variable tidal volume. due to
hypoxia, shock, sepsis.
 a. Character of air entry:-Equal on both sides / Reduced / Increased
b. Character of breath sounds: Vesicular / Bronchial /
Vesicular with prolonged expiration + ronchi
c. Character of inspiration and expiration phase,Note whether:
- Inspiration prolonged
- Expiration prolonged
d. Presence of added sounds:
- Wheezes: continuous, uninterrupted, musical sound
- Inspiratory: example: croup
- Expiratory: example: asthma
- Crackle: discontinuous, interrupted sounds like poppingof bubble
which may be:
- Course: i.e., friction rub (rubbing leathery sound)
- Medium
- Fine crepitations may also be:
- Early inspiratory i.e., in obstructive airway disease
- Late inspiratory i.e., in restrictive airway disease
e. Vocal resonance: (in older children)
As in the tactile vocal fremitus but use chest piece instead of hands. It
may be: Increased, Reduced, Absent
f. Transmitted sounds:
May confuse the added sounds, transmitted sounds maydisappear by:
a. Clearing the secretion by:
i. Cough - suction - physiotherapy
b. Prior hearing of throaty sounds by naked ear(rattling)
c. Putting the stethoscope by the side of the neck,added
sounds increase in intensity
Examination of the back of the chest.
If possible make the child seat and place his hands on his head.Then follow
the sequence of:
Inspection: Look for
- Scoliosis and kyphosis
- Scar
- Position of the scapula: one scapula is higher inSprengel’s
deformity
Palpation: Look for
- Chest expansion
- Tactile vocal fremitus
Percussion:
- Percuss medial to scapula, liver dullness normally startsadjacent to
the spine at the 10th. rib.
Auscultation:
- As in the front of the chest
 Study of Spirometer

Aim: To determine the lung volume like Tidal volume, Expiratory Reserve volume
and Inspiratory Reserve volume.

Apparatus: Spirometer.

Principle: The patient breathes air into the tube via the mouthpiece. During each
cycle of inhalation and exhalation, the jar moves up and down.

Procedure:
Take water ⅔ level of water in outer Chamber
1. Close the nose and blow the air into the mouthpiece.
2. First reading is normal single inspiration and second is normal Single Expiration
Here our expiration is the inspiration of the spirometer, and our inspiration is the
Expiration of the spirometer.
It gives a tidal volume of inspiration and Expiration.
3. Leave deep Expiration into the mouthpiece i. e. Inspiratory reserve volume of
Spirometer.
4. Take deep inspiration through the mouthpiece i.e. Expiratory reserve volume of
Spirometer.

Limitations: Only once reading can be taken. but repeated is not possible.

Precaution:
1. Clean the instrument before using mainly dust.
2. Fill the outer chamber up to ⅔ with water.
3.Every time confirm the zero reading before
use. 4.Use Soda lime and oxygen cylinder
for Continuous reading i.e Spirometer.

Result:
* Record the reading according to
1.TV- Inspiration———
2.TV - Expiration———
3. Expiratory Reserve volume———-
4. Inspiratory Reserve volume———
 Study of Stethography
Aim: To record the respiratory movements using a stethograph.

Apparatus required: Stethograph, Kymograph, Mare's tambour, Bottle of water.

Principle:
The Stethograph is tied around the chest of the subject the movements of the chest
cause a change in the air pressure in the stethograph which is recorded on a
moving drum.

Procedure:
1. The subject was asked to comfortably on a stool with his/her back towards
the sit recording apparatus.
2. The stethograph was tied around the chest of the subject at the level of the
fourth intercostals space and the tambour was connected to it.
3. The writing lever/pen was brought in contact with the paper of the kymograph and
the drum was set to move at slow speed (2.5mm/sec)
4. Normal respiration was recorded for about 5cm
5. The subject was asked to drink water and the effect of deglutition on the
respiratory movement was recorded. Then a normal tracing was taken.
was asked to hold his breath as long as 6. After a normal tracing , the possible
subject after quiet inspiration & expiration and following deep inspiration and deep
expiration and the effects was recorded.
7. Normal respiration was recorded and the drum was stopped. The subject was
asked to take deep breaths as rapidly as possible for one and a half minutes.
Immediately after hyperventilation, the drum was started and the effect on
respiratory movements was recorded.
8. Normal respiration was recorded. The stethograph was disconnected from
Mary's tambour and the subject was asked to exercise (spot jogging) for one
minute.
Immediately after exercise, the stethograph was connected to the kymograph and
the effect of exercise on respiratory movements was recorded.
Precautions:
1. The subject should be seated comfortably and in an erect posture.
2. The stethograph should be tied at the level of 4th intercostal space as the
expansion of the chest is maximum at this level.
3. Before & after the recordings for each maneuver, Normal tracings should be
taken. after.
4. The recording should not be made during the act of hyperventilation but immediately
5. The stethograph must be disconnected from the tambour during exercise
and recording should be made immediately after exercise.
6. For recording Breath-holding time (BHT), recording should be made after
quiet inspiration and expiration, and forceful inspiration & expiration.
7. Below observation should be noted:
*Downstroke refers to inspiration Upstroke refers to expiration
*Apnoea occurs during the act of deglutition
*Duration of BHT following normal and deep respiration varies
*Breathing pattern after Hyperventilation & Exercise differs with the following
periodic breathing.
8. Take the reading from the recorded graph.

I. Respiratory rate: ————breaths/min

Il. Breath holding time

After quiet inspiration: ————breaths/min
After quiet expiration: ———-breaths/min
After deep inspiration: ————-breaths/min
After deep expiration: ————-breaths/min

Results:
Measure by using tape in cms
1.End of expiration———-cms
2.End of the normal inspiration (TV) ——-cms
3.End of the deep maximum inspiration——cms.