Assessment of Respiratory

System
BY Merkin Bekele(MSc)
 Session objectives

Review the anatomy and physiology of RS

List some of the general guide line to examine lung

and thorax

Explain the common respiratory symptoms and their

significance.

Identify basic technique to examine lung and thorax

Assess lung and interprets findings

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 Overview of Anatomy
The respiratory system is divided into an upper and lower
respiratory system

The upper respiratory system is composed of the nose, nasal

cavity, nasal sinuses, and pharynx, which filter, warm, and
humidify air

Lower respiratory tract which is composed of the trachea, bronchi,

bronchioles, and alveoli.

In the alveoli, the gaseous exchange of oxygen and carbon dioxide

occurs.

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Directly below the trachea and primary bronchi air is conveyed to
and from the lungs.

The lungs are enclosed in a pleural membrane called the visceral

membrane.

There is a pleural membrane which also lines the thoracic cavity.

This is called the parietal membrane.

Enclosed within the visceral membrane, the lungs are seen as

paired organs with two lobes on the left and three lobes on the
right.

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 Muscle of respiratory
system
• Diaphragm(Primary)

• Intercostal muscles

• Accessory muscles

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Land marks used to locate findings

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 Anterior Landmarks
Land marks that are used to locate findings vertically on the thorax

1. Suprasternal Notch: “U” shaped depression above sternum-

between clavicles.

2. “Angle of Louis” Marks site of tracheal bifurcation into Right and

Left main bronchi.
• It joins the manubrium to the body of the sternum, is the best
guide anteriorly
• Approximately 2-5 cm below sternal notch.

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 Anterior Landmarks …

3. Costal Angle: Right and Left costal margins form an angle

where they meet at the Xiphoid Process.
• Usually 90 degrees or less.

• If greater than 90 degree: emphysema.

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 Posterior landmarks
The posterior landmarks includes:
 Prominence and Processes ( C7 & T1)

 Scapula

 12th rib

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 Reference Lines
 The mid sternal and vertebral lines: are precise but other are
estimated, this line drop vertically in the middle of the sternum
and the vertebral column respectively.
 The mid clavicular line: drop vertically from the mid point of
the clavicle.

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 Locating finding …

 The anterior & posterior axillary line- drops vertically from

the anterior and posterior axillary folds.
 The mid axillary line- drops from the apex of the axilla.

 The scapular line-drop from the inferior angle of the scapulas.

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 Lung boarder
• Anteriorly, the apex of each lung rises about 2-4cm above the
clavicle.
• The lower border/base of the lung crosses the 6th rib at the
midclavicular line and the 8th rib at the midaxillary line.
• Posteriorly, the lower border of the lung lies at about the level of
the T10 spinous process.
• On inspiration, it descends farther.

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 Lungs, Fissures, and Lobes

LUL
RUL RUL
LUL

RML LLL RLL

RLL LLL
T1

T 12

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 Trachea and major bronchi
• Breath sounds over the trachea and bronchi have a different
quality than breath sounds over the lung parenchyma.
• Be sure that you know the location of these structures.

• The trachea bifurcates in to its main bronchi at the level of the

sternal angle anteriorly and
• The spinous process of the 4th thoracic vertebrae posteriorly

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 Pleura of The Lungs
• Parietal Pleura: The outer lining of each lung. It is attached to
the chest wall.
• Visceral Pleura: The inner lining of each lung. It is attached to
the lung itself.
• Pleural Space: Is the space created between these two linings and
it is filled with a small amount of lubricating fluid called pleural
Fluid.

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Frequent complains includes:
– Chest pain or discomfort

– Cough

– Shortness of breath, dyspnea, orthopnea, paroximal

nocturnal dyspnea
– Hemoptysis

– Wheezing

– Diseases of the respiratory system are one of the

commonest causes of mortality and morbidity
throughout the world.

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 Chest pain
• Complaints of chest pain or chest discomfort raise
the possibility of heart disease, but often arise from
structures in the thorax and lung as well.
 Pain or discomfort in the chest, can arise from any
one of the following thoracic structures:
 The heart
 The trachea and large bronchi
 The esophagus
 The chest wall
 The parietal pleura
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 Chest pain
 To assess this symptom, you must pursue a dual investigation of
both thoracic and cardiac causes
 Chest pains associated with pulmonary diseases usually arise from
the pleura.
 Pleuritic chest pain is sharp and stabbing, and is aggravated by
deep breathing or coughing.
 It occurs when the underlying pleura is inflamed, most commonly
by infection in the underlying lung.
 Pain caused by spontaneous pneumothorax may have more of an
aching character than the stabbing pain of pleurisy.
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 Cough
 It is the commonest symptom of diseases of the
lungs and air passages.
 A person may cough voluntarily, but more typically
cough is a reflex response to stimuli that irritate
receptors in the larynx, trachea, or large bronchi.
 The stimuli include both external agents such as
irritating dusts, foreign bodies, and even extremely
hot or cold air, and internal substances such as
mucus, pus, and blood.

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Hemoptysis:
It is the expectoration of blood from the respiratory tract.

This has to be differentiated from epitasis and hematemesis.

The most common site of bleeding is the airways, i.e., the trachea-
bronchial tree.
Dyspnea:
This is a non-painful but uncomfortable awareness of breathing that
is inappropriate to the circumstances.
Only the patient can report the dyspnea.

Dyspnea commonly results from cardiac or bronco-pulmonary

problems.
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Guide lines in chest and thorax examination
Expose the part that you need to examine.

Position the patient.

Use an orderly fashion, IPPA

Compare one side to another side/symmetrically.

Move from the apices to the base

Do not auscultate the chest through gown, cloth

etc……………………bare skin

Instruct person to sit upright and breathe in and out slowly

through the mouth.
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 Techniques of Examination
• It is helpful to examine the posterior thorax and lungs while the
patient is sitting, and the anterior thorax and lungs with the patient
supine.
• Proceed in an orderly fashion: inspect, palpate, percuss, and
auscultate.
• And compare one side with the other symmetrically.

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 Techniques of Examination …
• With the patient sitting, examine the posterior thorax and lungs.

• The patient’s arms should be folded across the chest with hands
resting, if possible, on the opposite shoulders.
• This position moves the scapulae partly out of the way and
increases your access to the lung fields.

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 Inspection
– General Appearance

– Inspect for symmetry of the thorax

– Looking for signs of respiratory distress

– Skin color & condition:

– no cyanosis or pallor,clubbing free nail should occur

– Scapula placed symmetrically

– Respiratory rate and rhythm

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 Inspection …
Tracheal Position
• Any deviation of the mediastinum is abnormal

• Lateral shift: The mediastinum can be either pulled or pushed away

from the lesion
• Pull: Loss of lung volume (Atelectasis, fibrosis, surgical resection,
pleural fibrosis)
• Push: Space occupying lesions (pleural effusion, pneumothorax,
large mass lesions)

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 Inspection …
• Cyanosis: bluish discoloration of the skin.

• Cough: productive or non-productive

• Inspect appearance of sputum: Mucoid vs Purulent

• Symmetry: Check symmetrical expansion of chest wall.

– Bilateral diminished expansion may be due to acute pleurisy,

pleural fibrosis, atelectasis.

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 Inspection …
• Unilateral diminished expansion may be due to pneumothorax

• Causes of unilateral decrease or delay in chest expansion include:

• Pleural effusion

• Lobar pneumonia

• Pleural pain and

• Unilateral bronchial obstruction

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 Inspection …
Abnormal anterior chest
• Barrel chest-enlarged and rounded cross section to chest
associated with COPD and some times asthma. Increased AP
diameter
• Funnel chest-compression the lower part of the sternum/pectus
excavatum/sunken
• Pigeon chest-characterized by a protruding sternum /pectus
carinatum

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Barrel chest

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Pigeon chest Funnel chest

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 Inspection …
Abnormal posterior chest
• Kyphosis: accentuated thoracic curve /hunchback/ may impended
respiratory muscles
• Scoliosis: lateral ‘S’ deviation/curvature of the spine.

• Lordosis: accentuated lumbar curve or a forward curvature of the

lumbar spine associated with kyphosis.

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 2. Palpation
• Using hands to feel the chest and identify abnormalities in chest
wall motion, tenderness or vibrations
• Palpation has four potential uses:

1. Assessment of chest expansion

2. Identification of tender areas

3. Assessment of tactile fremitus

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 Chest expansion (Excursion)
• Place both thumbs at about 10th rib posteriorly along the spinal
process.
• As you position your hands, slide them medially just enough to
raise a loose fold of skin on each side between your thumb and the
spine.
• Extend the fingers of both hands outward over the posterior chest
wall

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 Chest expansion …
• Ask the patient to inhale deeply.

• Watch the distance between your thumbs as they move apart

during inspiration, and feel for the range and symmetry of the rib
cage as it expands and contracts.
• Normal: bilateral, symmetric expansion

• Abnormal: unilateral or unequal or asymmetric

• occurs w/ chest trauma, lobar pneumonia, atelectasis,

pneumothorax or lung collapse

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Chest expansion

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 Tactile / Vocal / fremitus
• Fremitus refers to the palpable vibrations transmitted through the
bronchopulmonary tree to the chest wall when the patient speaks.
• To detect fremitus, use either the ball (the bony part of the palm at
the base of the fingers) or the ulnar surface of your hand to
optimize the vibratory sensitivity of the bones in your hand.

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 Tactile / Vocal / fremitus …
• Ask the patient to repeat the words “ninety-nine” or “Arba Arat.”

• Normal finding is a mild purr like sensation equally on both sides

• Increased tactile fremitius occurs in conditions where solid

conducts vibrations better than air. Ex. Pneumonia, tumor,
pulmonary fibrosis
• Decreased tactile fremitus occurs when there is increased
distance that sound has to travel before it reaches chest wall. Ex.
Pleural Effusion, pneumothorax, COPD, obstructed bronchus,
pleural thickening, and also a very thick chest wall.

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 Chest wall tenderness
• Palpate along ribs and ICS

• Tenderness here indicates pleuritis,ormusculoskeletal injury

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3. Percussion

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 Percussion …
• Tapping on the chest wall to assess underlying structures through
sound production
• Techniques

• Use middle finger of one hand to strike the middle finger of other
hand placed on the chest wall
• Percuss over different areas of the lungs comparing both sides

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 Percussion sound
• Resonant: Normal lung tissue(air filled)

• Dull: Dullness replaces resonance when fluid or solid tissue

replaces air-containing lung.
• Examples include: lobar pneumonia, in which the alveoli are
filled with fluid and blood cells; and pleural accumulations of
serous fluid (pleural effusion), blood (hemothorax), pus
(empyema), fibrous tissue, or tumor
• Hyper-resonant:over areas with excess air(pneumothorax,emphysema)

• The hyperinflated lungs of emphysema or asthma, but it is not a reliable sign

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Locations for percussion & auscultation

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 Auscultation …
• Listening to breath sounds with a stethoscope over various lung
fields.
• Auscultation of the lungs is the most important examining
technique for assessing air flow through the tracheobronchial tree.
• Procedure:
• Use the diaphragm of the stethoscope.

• Ask the patient to breathe deeply through an open mouth.

• Listen in a systematic pattern:

• Start at the top of the lungs and move down, comparing both sides.
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Auscultation

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 Auscultation …
• Auscultation involves:

– listening to the sounds generated by breathing,

– listening for any adventitious (added) sounds, and

– If abnormalities are suspected, listening to the sounds of the

patient’s spoken or whispered voice as they are transmitted
through the chest wall.

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 Normal Breath Sounds …
1. Vesicular
• Soft and low pitched.
• They are heard through inspiration, continue without pause
through expiration, and then fade away about one third of the
way through expiration.
• Heard over most of both lungs

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 Normal Breath Sounds …
2. Bronchovesicular
• With inspiratory and expiratory sounds about equal in length, at
times separated by a silent interval.
• Differences in pitch and intensity are often more easily detected
during expiration.
• Heard often in the 1st and 2nd interspaces anteriorly and between
the scapulae posteriorly.
• Intermediate pitch heard over the mid-chest area

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 Normal Breath Sounds …
3. Bronchial
• louder and higher in pitch, with a short silence between inspiratory
and expiratory sounds.
• Expiratory sounds last longer than inspiratory sounds.

• Location: Over the manubrium, if heard

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 Normal Breath Sounds …
• If bronchovesicular or bronchial breath sounds are heard in
locations distant from those listed, suspect that air-filled lung has
been replaced by fluid-filled or solid lung tissue

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Normal Breath Sounds

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 Abnormal Breath Sounds
• Abnormal breath sounds are called adventitious/ added/ sounds

• Detection of adventitious sounds—crackles (sometimes called

rales), wheezes, and rhonchi is an important part of your
examination, often leading to diagnosis of cardiac and pulmonary
conditions.

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 Abnormal Breath Sounds …
1. Rales (Crackles): are discontinuous intermittent, nonmusical.
• Sounds like hair being rubbed together
• Sound produced by air passing through fluid in air spaces
(CHF, pneumonia).
• Usually on inspiration / not expiration
• Fine crackles: Soft, high-pitched sounds; may indicate
interstitial lung disease or pulmonary edema.
• Coarse crackles: Louder, low-pitched sounds; suggest
conditions like bronchiectasis or pneumonia.
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 Abnormal Breath Sounds …
2. Rhonchi: continuous snoring sound.
• Low pitched (around 200 Hz or lower), snoring quality

• Greater pronounced during expiration.

• Etiology: larger airways are obstructed with mucus or tumor.

• It suggest secretions in large airways.

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 Abnormal Breath Sounds …

3. Wheezing: high pitched (around 400 Hz or higher), continuous

musical, whistling sounds.
• Produced by narrowed airway.

• Can occur during inspiration or expiration.

• Wheezes suggest narrowed airways, as in asthma, COPD, or

bronchitis.

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 Abnormal Breath Sounds …
4. Friction (Pleural) Rub: Course, dry, grating sound heard only
with stethoscope.
 Etiology: Inflamed pleural surfaces rub.

 Sounds similar to cupping hand over ear, scratching back of hand

with other hand.
 Usually heard anteriolateral chest wall

 Continuous during inspiration and expiration.

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 Abnormal Breath Sounds …
5. Stridor: increased musical wheeze heard over trachea on
inspiration.
• Suggests upper airway obstruction (e.g.foreign body).

• Cause: laryngeal obstruction = MEDICAL EMERGENCY

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 Transmitted Voice Sounds
• If you hear abnormally located broncho-vesicular or bronchial
breath sounds, continue on to assess transmitted voice sounds.
• Increased transmission of voice sounds suggests that air-filled lung
has become airless.
• With a stethoscope, listen in symmetric areas over the chest wall as
you do the following:

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 Transmitted Voice Sounds …
• Ask the patient to say “ninety-nine.”

• Normally the sounds transmitted through the chest wall are

muffled and indistinct.
• Louder, clearer voice sounds are called bronchophony.

• Ask the patient to say “ee.” You will normally hear a muffled long
E sound.

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 Transmitted Voice Sounds …
• When “ee” is heard as “a” an E-to-A change (egophony) is present,
as in lobar consolidation from pneumonia.
• Ask the patient to whisper “ninety-nine” or “one-two-three.”

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 Transmitted Voice Sounds …
• The whispered voice is normally heard faintly and indistinctly, if at
all.
• Louder, clearer whispered sounds are called whispered
pectoriloquy

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 Common Abnormal Findings
• Pneumonia:
– Increased tactile fremitus.
– Dullness on percussion.
– Crackles and bronchial breath sounds over consolidation.
• Asthma:
– Wheezing, prolonged expiration.
– Hyper-resonance on percussion (if air trapping is present).
• Pleural Effusion:
– Decreased breath sounds.
– Dullness on percussion.
– Decreased tactile fremitus.
• Pneumothorax:
– Decreased or absent breath sounds.
– Hyper-resonance on percussion.
– Decreased or absent tactile fremitus

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 Summary
• The respiratory examination is a critical aspect of physical
assessments in clinical practice.
• Follow the systematic approach of Inspection, Palpation,
Percussion, and Auscultation.
• Each step helps identify potential respiratory conditions by
revealing abnormal physical signs.

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Thank u