Physical Examination in Respiratory Disease
In patients with respiratory disease, the physical examination should systematically assess respiratory rate, oxygen saturation (at rest and with exertion), weight, height, body mass index, breathlessness severity using the modified Medical Research Council dyspnoea score, and functional capacity through timed walking tests—while recognizing that a completely normal examination is common in mild disease. 1
Vital Signs and Anthropometric Measurements
- Measure respiratory rate at rest as an essential baseline parameter in all respiratory patients 1
- Assess oxygen saturation both at rest and with exertion to detect exercise-induced desaturation that may not be apparent during resting evaluation 1
- Document weight, height, and calculate BMI because weight loss is common in advanced respiratory disease and may indicate occult malignancy 1
- Quantify breathlessness using the modified Medical Research Council (mMRC) dyspnoea score as a standardized measure of functional impairment 1
Functional Capacity Assessment
- Perform an exercise test such as timed walking distance or walking speed because these tests predict mortality particularly well in patients with COPD and provide objective functional assessment 1
Chest Inspection and Palpation
- Look for signs of hyperinflation: loss of cardiac dullness, decreased cricosternal distance (< 3 cm), and increased anteroposterior diameter of the chest 1
- Assess for cyanosis (central or peripheral) as a marker of hypoxemia, though its absence does not exclude minor degrees of oxygen desaturation 1
- Check for peripheral edema which may indicate cor pulmonale and carries prognostic significance 1
- Evaluate for muscle wasting which is common in advanced disease 1
- Examine for finger clubbing which, when present with productive cough, should prompt evaluation for bronchiectasis, interstitial lung disease, or malignancy 2
Chest Auscultation
- Listen for quiet (diminished) breath sounds, which combined with hyperresonance on percussion has a positive likelihood ratio greater than 5.0 for COPD 1
- Detect prolonged expiratory duration as a sign of airflow obstruction 1
- Identify wheezes (rhonchi), especially on forced expiration, which indicate airway narrowing 1, 3
- Auscultate for crackles which may indicate interstitial lung disease, bronchiectasis, or heart failure 2
- Assess for hyperresonance on percussion which, when combined with diminished breath sounds, strongly predicts COPD 1
Cardiovascular Signs of Pulmonary Hypertension
- Examine for raised jugular venous pressure as a sign of right heart strain 1
- Palpate for right ventricular heave indicating right ventricular hypertrophy 1
- Auscultate for loud pulmonary second sound suggesting pulmonary hypertension 1
- Listen for tricuspid regurgitation murmur which may accompany cor pulmonale 1
Note that these cardiovascular signs can be modified or masked by chest hyperinflation 1
Signs of Hypercapnia
- Look for flapping tremor (asterixis) which may occur during acute exacerbations 1
- Assess for bounding pulse as a sign of CO₂ retention 1
- Evaluate mental status for drowsiness though a high PaCO₂ can occur in stable severe COPD without these signs 1
Upper Airway Examination (When Chronic Cough Present)
- Inspect nasal mucosa for congestion, polyps, or purulent discharge to identify upper airway cough syndrome 2
- Examine oropharynx for cobblestoning or mucus which supports an upper airway source of cough 2
Critical Interpretation Principles
- A normal physical examination is common in mild COPD, with signs becoming apparent only as disease progresses 1
- The degree of airflow obstruction cannot be predicted from symptoms or signs alone—objective spirometry is mandatory 1
- No physical finding is sufficiently sensitive or specific to remove the need for objective confirmation through pulmonary function testing 1
- Physical examination findings should guide but never replace spirometry and chest radiography in the diagnostic evaluation 1