Table 5: Respiratory Exam
| Physical Sign / Manoeuvre | Rationale | Technique(s) | Interpretation | Evidence | Pre-Clerkship | Clerkship |
|---|---|---|---|---|---|---|
| Inspection | ||||||
| Respiratory pattern – rate/rhythm/depth | Multiple cardio, respiratory, neurological and metabolic abnormalities alter the respiratory pattern | Direct observation with patient unaware respiration being monitored | Respiratory rate most affected by abnormal cardiac or pulmonary function, respiratory rhythm by CNS derangement and respiratory depth by metabolic causes | For 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. | 3 | 4 |
| Ribcage/chest position/abdominal movements | Hoover’s Asymmetrical or decreased Chest Movement | Observation of indrawing of lower costal margin on inspiration Observation | 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. | 3 | 4 |
| Chest shape | A barrel-shaped chest may predict air flow limitation | Observation of AP diameter to transverse diameter of chest, normal upper limit 0.9 | Thoracic ratio greater than 0.9 may reflect COPD | This sign not well-supported in adults but finding in children virtually rules in air flow limitation. Holleman, 1995. | 4 | 4 |
| Accessory muscle use | Assessment of patients with respiratory distress | Observation of nasal flaring, scaleneus, sternocleidomastoid, intercostal, abdominal movement | Observation of scalene sternomastoid contraction association with severity of asthma or COPD | Maitre, 1995. | 4 | 4 |
| Posture and position | Tripod position, bracing, orthpnea/platypnea | Observation | ||||
| Pursed lip breathing | Associated with severe COPD and emphysema | Patient observation | Interpreted as a means to increase intraluminal airway pressure preventing collapse at low lung volumes | Remains to be assessed | 4 | 4 |
| Finger clubbing | Association with a number of intra-thoracic as well as extra-thoracic diseases | Observation of hyponychial angle; inter-phalangeal depth ratio, or Shamroth’s sign | Hyponychial 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. | 4 | 4 |
| Cyanosis | Clinical detection of hypoxemia | Observation inside lips and mouth for central cyanosis and hands for peripheral cyanosis | Cyanosis 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-hemaglobinemia | McGee, 2007, Chapter 7. | 4 | 4 |
| Stridor | Stridor is a wheeze confined to inspiration, louder over the neck | Usually audible without a stethoscope, best heard as patient breathes rapidly through an open mouth | Stridor indicates airway diameter less than 5 mm. | Geffin, 1971. | 4 | 4 |
| Cough | Association with both airway and lung parenchymal disease and cardiac disease | Observation | Low specificity, kappa 0.29, suggests low agreement between physicians | Holleman, 1995. | 4 | 4 |
| Percussion | ||||||
| Differentiate normal aerated lung, consolidation, effusion or pneumo-thorax | Indirect method of plexor finger on one hand striking pleximeter finger of other hand placed against the body wall | Distinction of resonance heard in a normal lung from dullness over effusions or consolidation or tympany heard over the abdomen | Pleural 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. | 3 | 4 | |
| Auscultation | ||||||
| Breath sounds | Differentiation 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. Auscultation | 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. | 3 | 4 |
| Wheezes and crackles | Wheezes 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 conditions | Auscultation 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. | 3 | 4 |
| Pleural rub | Auscultation to detect inflammation of pleura | Auscultation of chest concentrating on expiratory phase when pleural rub is loudest | Pleural rub crackling sound suggests inflammation of pleura | Forgacs, 1969 | 1 | 4 |
| Forced expiratory time | To measure airflow particularly if COPD suspected | Patient 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 limitation | Holleman, 1995 | 1 | 3 |
| Vocal resonance | Bronchophony | Increased 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 lung | For detection of pneumonia; Sensitivity is low Specificity is 96-99^ | ||
| Palpation | ||||||
| Palpable crepitus | Palpation on the chest wall on the non-dependent areas | Subcutaneous emphysema | Airway injury, pneumothorax or chest wall injury | |||
| Palpation for symmetry | Palpation of chest wall | See above for inspection for symmetry | ||||
| Tracheal descent (laryngeal height) | Laryngeal measurements are used in diagnosing obstructive airway disease | Laryngeal 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 inspiration | Significant 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 COPD | Straus, 2000. | 3 | 4 |
| Tactile vocal fremitus | Differentiation of normal lung consolidation or pleural effusion to corroborate percussion and auscultatory findings | Palpation 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 consolidation | Variable reliability and inter-observer agreement noted in different studies. Low-Spiteri, 1988. Moderate-Kalantri, 2007. | 3 | 4 |
References
- Forgacs P. Lung sounds. Br.J.Dis.Chest 1969 Jan;63(1):1-12.
- Geffin B, et al. Stenosis following tracheostomy for respiratory care. JAMA 1971 Jun 21;216(12):1984-1988.
- Holleman DR, et al. Does the clinical examination predict airflow limitation? JAMA 1995 Jan 25;273(4):313-319.
- Kalantri S, et al. Accuracy and reliability of physical signs in the diagnosis of pleural effusion. Respir.Med. 2007 Mar;101(3):431-438.
- Maitre B, et al. Physical examination of the adult patient with respiratory diseases: inspection and palpation. Eur.Respir.J. 1995 Sep;8(9):1584-1593.
- McGee SR. Evidence-based physical diagnosis. 2nd ed. St. Louis, Mo.: Saunders Elsevier; 2007.
- Sapira JD. About egophony. Chest 1995 Sep;108(3):865-867.
- Spiteri MA, et al. Reliability of eliciting physical signs in examination of the chest. Lancet 1988 Apr 16;1(8590):873-875.
- Straus SE, et al. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. CARE-COAD1 Group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease. JAMA 2000 Apr 12;283(14):1853-1857.
- Wipf JE, et al. Diagnosing pneumonia by physical examination: relevant or relic? Arch.Intern.Med. 1999 May 24;159(10):1082-1087.