How is a respiratory examination performed?

How to Perform a Respiratory Examination

A respiratory examination follows a systematic four-step approach: inspection, palpation, percussion, and auscultation, performed in this specific order. 1, 2, 3, 4, 5, 6

Preparation and Patient Positioning

• Position the patient sitting upright in a chair with arms (without wheels for safety) 7
• Ensure a light, warm, quiet, private environment 6
• Expose the chest adequately while maintaining patient dignity
• Have the patient remove clothing from the waist up, including undergarments that may obscure examination

1. Inspection

Visual assessment is the critical first step and provides immediate information about respiratory status.

What to Look For:

Upper respiratory tract:

• Increased nasal secretion
• Mucosal swelling
• Nasal polyps 1

Chest and breathing pattern:

• Respiratory rate (normal: 12-20 breaths/minute in adults)
• Use of accessory muscles (sternocleidomastoid, scalene muscles)
• Hunched shoulders suggesting chronic hyperinflation
• Chest deformities (barrel chest, pectus excavatum, scoliosis)
• Hyperexpansion of the thorax 1, 2
• Symmetry of chest wall movement during breathing
• Prolonged expiratory phase (suggests airflow obstruction) 2, 8

General appearance:

• Cyanosis (central vs peripheral)
• Weight loss or muscle wasting 2, 8
• Signs of respiratory distress (nasal flaring, intercostal retractions)
• Oxygen saturation at rest 2

Skin examination:

• Atopic dermatitis or eczema (suggests atopic tendency) 1

2. Palpation

Use touch to gather information about chest wall movement, tenderness, and tactile fremitus.

Technique:

• Chest expansion: Place hands on the lower chest with thumbs meeting at the midline; assess symmetry of movement during deep inspiration
• Tactile fremitus: Place the ulnar aspect of your hand on corresponding areas of both hemithoraces; ask patient to say "ninety-nine" and compare vibrations
  • Increased fremitus: consolidation (pneumonia)
  • Decreased fremitus: pleural effusion, pneumothorax, emphysema
• Tracheal position: Assess for deviation (suggests mediastinal shift)
• Pain location: Identify areas of chest wall tenderness 5, 6

3. Percussion

Strike the chest to determine the state of underlying tissues based on the sound produced. 4, 5, 6

Technique:

• Place middle finger of non-dominant hand firmly on chest wall
• Strike the distal interphalangeal joint with the tip of the middle finger of dominant hand
• Compare symmetrical areas on both sides

Interpretation of Percussion Sounds:

• Resonant: Normal lung tissue
• Hyperresonant: Emphysema, pneumothorax, asthma 5
• Dull: Consolidation (pneumonia), pleural effusion, atelectasis 5
• Flat: Massive pleural effusion

Detection of diminished breath sounds and hyperresonance has a positive likelihood ratio >5.0 for COPD. 2

4. Auscultation

Listen to and interpret sound transmission through the chest wall using a stethoscope. 4, 6

Technique:

• Use the diaphragm of the stethoscope
• Listen systematically: compare side-to-side in at least 6 areas per hemithorax (anterior, lateral, posterior fields) 9
• Have patient breathe deeply through an open mouth
• Listen during both inspiration and expiration

What to Listen For:

Breath sounds:

• Quiet/reduced breath sounds: Emphysema, pleural effusion, pneumothorax 2, 8
• Bronchial breathing: Consolidation
• Prolonged expiratory phase: Airflow obstruction 1, 8

Adventitious sounds:

• Wheezing: Asthma, COPD, airway obstruction 1, 5
  • Note: Absence of wheeze does not exclude severe disease 8
• Crackles (rales): Pneumonia, pulmonary edema, interstitial lung disease
• Pleural rub: Pleuritis

Critical Pitfalls to Avoid

1. Do not rely on physical examination alone - The examination may be completely normal in mild disease 1, 2. Spirometry is essential for objective assessment 1

2. Absence of findings does not rule out disease - Asthma and COPD can have normal examinations between episodes 1, 2

3. Patient perception is unreliable - Patients' perceptions of airflow obstruction are highly variable; objective testing is mandatory 1

4. Testing position matters - Document whether testing was done sitting, standing, or lying, as this affects measurements 7

Essential Follow-up Investigations

After physical examination, spirometry is mandatory for any suspected respiratory disease in patients ≥5 years old 1, 10:

• Pre- and post-bronchodilator spirometry
• FEV₁/FVC ratio to confirm obstruction
• Reversibility testing (>12% and 200 mL increase in FEV₁ confirms asthma) 1

Chest radiography should be performed during initial evaluation to exclude alternative diagnoses 2

Point-of-care ultrasound (POCUS) can improve diagnostic accuracy for pleural effusion, pneumothorax, consolidation, and pulmonary edema when added to standard examination 11, 9