AFMC National Clinical Skills Working Group Evidence-Based Clinical Skills Document

Table 5: Respiratory Exam

Physical Sign / ManoeuvreRationaleTechnique(s)InterpretationEvidencePre-ClerkshipClerkship
Respiratory pattern – rate/rhythm/depthMultiple cardio, respiratory, neurological and metabolic abnormalities alter the respiratory patternDirect observation with patient unaware respiration being monitoredRespiratory rate most affected by abnormal cardiac or pulmonary function, respiratory rhythm by CNS derangement and respiratory depth by metabolic causesFor tachypnea, the inter-rater reliability kappa only 0.25

Spiteri, 1988

Tachypnea >30/min

Predicts hospital mortality +LR = 3.1;
-LR = 0.6

McGee, 2007, p189.
Ribcage/chest position/abdominal movementsHoover’s

Asymmetrical or decreased Chest Movement
Observation of indrawing of lower costal margin on inspiration

This sign reflects hyperinflation, modifying diaphragm action on lower ribcage

Presence of pleural effusion, asymmetrical lung disease, chest wall disease, neuromuscular disease
Asymmetric chest expression favours pleural effusion

+LR = 8.14
-LR = 0.29

Kalantri, 2006.
Chest shapeA barrel-shaped chest may predict air flow limitationObservation of AP diameter to transverse diameter of chest, normal upper limit 0.9Thoracic ratio greater than 0.9 may reflect COPDThis sign not well-supported in adults but finding in children virtually rules in air flow limitation.
Holleman, 1995.
Accessory muscle useAssessment of patients with respiratory distressObservation of nasal flaring, scaleneus, sternocleidomastoid, intercostal, abdominal movementObservation of scalene sternomastoid contraction association with severity of asthma or COPDMaitre, 1995.44
Posture and positionTripod position, bracing, orthpnea/platypneaObservation
Pursed lip breathingAssociated with severe COPD and emphysemaPatient observationInterpreted as a means to increase intraluminal airway pressure preventing collapse at low lung volumesRemains to be assessed44
Finger clubbingAssociation with a number of intra-thoracic as well as extra-thoracic diseasesObservation of hyponychial angle; inter-phalangeal depth ratio, or Shamroth’s signHyponychial angle greater than 190 degrees is abnormal but usually requires instrumental measurement

Low specificity but present in local inflammatory right to left shunt or cardiac right to left shunt situations
Shamroth’s sign not studied.

Reasonably high inter-observer agreement, kappa 0.45
Spiteri, 1988.
CyanosisClinical detection of hypoxemiaObservation inside lips and mouth for central cyanosis and hands for peripheral cyanosisCyanosis will identify patients with a PO2 lower than 50 mmHg provided a Hb of 140 to 160 g/L. Distinction of cardiac from respiratory causes of cyanosis. Central cyanosis uncorrected by oxygen administration suggests met-hemaglobinemia or sulph-hemaglobinemiaMcGee, 2007, Chapter 7.44
StridorStridor is a wheeze confined to inspiration, louder over the neckUsually audible without a stethoscope, best heard as patient breathes rapidly through an open mouthStridor indicates airway diameter less than 5 mm.Geffin, 1971.44
CoughAssociation with both airway and lung parenchymal disease and cardiac diseaseObservationLow specificity, kappa 0.29, suggests low agreement between physicians Holleman, 1995. 44
Differentiate normal aerated lung, consolidation, effusion or pneumo-thoraxIndirect method of plexor finger on one hand striking pleximeter finger of other hand placed against the body wallDistinction of resonance heard in a normal lung from dullness over effusions or consolidation or tympany heard over the abdomenPleural effusion:
+LR = 18.6
-LR = 0.04

Detection of dullness to percussion has kappa value of 0.52 and is one of the more reliable findings in chest examination

Spiteri, 1988.
Breath soundsDifferentiation of vesicular from bronchial breath sounds

Absence of breath sounds due to pnemothorax, pnemonectomy, etc.
Auscultation with stethoscope diaphragm comparing sides of the chest

Bronchial breath sounds are high pitched, wide space between inspiration and expiration., with a long expiratory component.

1. Higher pitched bronchial breath sounds suggest consolidated lung tissue between the proximal airways and chest wall. In patients with cough and fever, bronchial breath sounds argue for pneumonia. LR = 3.3

2. Decreased or absent breath sounds in pleural effusion
McGee, 2007, Chapter 27

+LR 5.24
Kalantri, 2006.
Wheezes and cracklesWheezes caused by airway wall vibration and crackles mostly inspiratory and due to abrupt opening of previously collapsed distal airways are heard in a variety of lung and cardiac conditionsAuscultation comparing sides of the chest

Auscultation for crackles in lateral decubitus position for suspected pneumonia.
Unforced wheezing argues for the diagnosis of COPD (LR=2.8)

Finding crackles argues for:

1) pulmonary fibrosis in asbestosis exposure

2) elevated left atrial pressure in heart disease

3) pneumonia in patients with cough and fever - higher agreement between observers when patient in lateral decubitus position
McGee, 2007, Chapter 7.

Wipf, 1999.
Pleural rubAuscultation to detect inflammation of pleuraAuscultation of chest concentrating on expiratory phase when pleural rub is loudestPleural rub crackling sound suggests inflammation of pleuraForgacs, 196914
Forced expiratory timeTo measure airflow particularly if COPD suspectedPatient is asked to take a full breath in and then to exhale with mouth wide open. Observer listens at mouth or tracheal auscultation can be used.Forced expiratory time greater than 9 seconds predicts an FEV1 to FVC ratio of 70%, suggesting airflow limitationHolleman, 199513
Vocal resonanceBronchophonyIncreased transmission of spoken voice as heard through the stethoscope, when heard in an unusual place (not the trachea and right apex)Implies consolidation of the lungFor detection of pneumonia;
Sensitivity is low
Specificity is 96-99^
Palpable crepitusPalpation on the chest wall on the non-dependent areasSubcutaneous emphysemaAirway injury, pneumothorax or chest wall injury
Palpation for symmetryPalpation of chest wallSee above for inspection for symmetry
Tracheal descent (laryngeal height)Laryngeal measurements are used in diagnosing obstructive airway diseaseLaryngeal height is the distance between the top of the thyroid cartilage and the suprasternal notch. Laryngeal descent is the distance between maximum laryngeal height at the end of expiration and minimum laryngeal height at the end of inspirationSignificant relationship between inspiratory descent of the trachea (Campbell’s sign) and severity of airflow obstruction, age and duration of symptoms but recent data shows low likelihood ratio for COPDStraus, 2000.34
Tactile vocal fremitusDifferentiation of normal lung consolidation or pleural effusion to corroborate percussion and auscultatory findingsPalpation of chest wall bilaterally with ulnar edge of hands while patient utters low frequency sound – for example “one one one”Fremitus reduced if underlying pleural effusion and increased compared to normal if underlying consolidationVariable reliability and inter-observer agreement noted in different studies.

Low-Spiteri, 1988.
Moderate-Kalantri, 2007.