Respiratory examination and how to present it

• A respiratory examination is a bedside search for the signs that distinguish the common lung problems: consolidation, pleural effusion, pneumothorax, airways obstruction and interstitial (restrictive) disease.
• It runs from the general appearance and the hands, around the chest and back, to auscultation and the sputum pot; the order is fixed so that nothing is missed and the patient is not disturbed more than necessary.
• Many signs are reliable only when the airway to the affected lung is open: bronchial breathing and increased vocal resonance mean consolidation with a patent airway.
• The examination is meaningless unless it is presented aloud in a set order, leading with the single most important finding and ending with a short summary and a differential.
• Practice is what makes the difference: the stethoscope and percussion only reward an examiner who has listened to hundreds of normal chests first.

By the end of this page you should be able to:

1. Set up and expose the patient safely, and consent and chaperone correctly.
2. Perform a complete respiratory examination in the standard order and name every sign you are looking for.
3. Recognise the patterns that point to consolidation, effusion, pneumothorax, chronic obstructive pulmonary disease and pulmonary fibrosis.
4. Interpret breath sounds, added sounds, percussion and vocal resonance.
5. Present a normal and an abnormal set of findings clearly, aloud and in writing.
6. Avoid the common errors of examiner technique and of presentation.

The respiratory examination is the bedside part of assessing someone with breathlessness, cough, chest pain, fever, wheeze, stridor or a known lung disease, and it is part of almost every general examination. Its aims are to find evidence of respiratory disease, to place that disease in a pattern (consolidation, effusion, pneumothorax, obstruction or restriction), and to spot the complications and extrathoracic signs that change management. It is designed to be done in two or three minutes once it is practised, and it is almost always performed with the patient sitting, facing you, in a quiet, well-lit room with the stethoscope, a sputum pot, a peak flow meter and a tape measure or ruler to hand.

The examination begins before you touch the patient. Watch the patient walk into the room: shortness of breath on walking, the use of accessory muscles, a wheeze audible without a stethoscope and the patient's build all matter. Set the bed or chair so that the patient is comfortable, warm and able to sit upright. A respiratory examination done with the patient lying flat, or hunched under a gown, teaches you nothing about chest expansion.

This page assumes an adult. The same principles apply to older children and adolescents, with allowances for their cooperation and size. The techniques transfer across systems: if you are examining someone who cannot sit, patient examination skills still apply, but expansion and percussion must be interpreted with care.

Preparation is patient safety and professional behaviour as much as it is medicine, and an examination done badly here cannot be repaired later.

• Introduce yourself by name and role, and confirm the patient's name and date of birth.
• Explain what you are about to do, in words the patient understands: "I am going to look at your hands and face, check your pulse and breathing rate, and then listen to your chest and back."
• Obtain informed consent and invite questions. Consent can be withdrawn at any time.
• Offer a chaperone. In the United Kingdom a chaperone is recommended whenever the examination involves exposing the chest, whatever the sex of the patient or the examiner, and the offer must be recorded.
• Clean your hands (alcohol gel or soap and water) before and after the examination.
• Expose the chest properly: ask the patient to remove clothing to the waist, offer a gown or towel, and keep the patient covered between stages. Never examine through clothing, and never leave the patient exposed between manoeuvres.
• Position: sitting upright on the edge of the bed or on a chair, knees apart or supported, leaning slightly forward with the arms crossed in front of the chest or resting on the knees. This posture fixes the scapulae out of the way and opens the back of the chest.
• Warm your hands and the stethoscope. Cold hands make the patient tense and shorten the examination.
• If the patient is unable to sit, support them upright as far as possible; document the limitation and note that expansion and percussion are harder to interpret.

The following order is the standard sequence used in the United Kingdom and in most clinical skills teaching. Keep it fixed: once you start moving around the patient at random, you will forget a step. Each item states what to do and what to look for.

1. General appearance. From the moment you meet the patient, note whether they are comfortable or distressed, the working of breathing, the use of accessory muscles, and whether they can speak in full sentences. A patient who speaks a few words at a time is working hard to breathe. ^[2]
2. Hands and peripheral stigmata. Look at the hands for clubbing, cyanosis, warmth, tremor and muscle wasting. Test the flap (asterixis) and note nicotine staining. Check the pulse. ^[1][5]
3. Flap (asterixis). With the arms outstretched, hands dorsiflexed and fingers spread, watch for brief, irregular downward flaps of the hands. A flap also occurs with tongue protrusion and foot dorsiflexion, and is a sign of carbon dioxide retention or metabolic encephalopathy rather than of hypoxia. ^[5]
4. Pulse. Count the rate and note the rhythm and character. Record any tachycardia, irregularity or radio-radial delay and proceed to examine the heart if these are present.
5. Respiratory rate. Count the chest wall expansions over 20 to 30 seconds and multiply. A respiratory rate between 10 and 15 breaths per minute is physiologically normal at rest; in some elderly patients rates up to 25 breaths per minute can be normal. An increase above 20 breaths per minute in a resting adult is abnormal. Note the rhythm (regular, Cheyne-Stokes or Biot) and the depth of breathing. ^[1]
6. Face, tongue and eyes. Look for central cyanosis of the lips, tongue and oral mucosa, facial plethora in hypercapnia, corneal arcus, Horner syndrome and an expression of distress. Central cyanosis reflects severe hypoxaemia.
7. Jugular venous pressure and trachea. Measure the jugular venous pressure: a value up to 8 to 9 centimetres of water above the right atrium is normal; higher values indicate elevated right-sided filling pressures. Palpate the trachea in the suprasternal notch: it normally sits very slightly to the right; marked deviation suggests a pulling force (for example atelectasis) or a pushing force (for example pneumothorax). ^[4][3]
8. Inspection of the chest. Look from the front and from behind for deformity (kyphosis, scoliosis, barrel chest), scars, chest wall movement, symmetry of expansion, intercostal recession, subcostal recession and use of the accessory muscles. A barrel-shaped chest suggests chronic obstructive pulmonary disease or hyperinflation. Reduced, asymmetrical expansion points to pneumothorax, effusion, collapse or consolidation on that side. ^[1]
9. Expansion (palpation). Place your hands on the chest (or behind the back) with the thumbs meeting in the midline, and feel the excursion during a deep breath, noting symmetry. Place the hands on both sides of the lower rib cage to compare sides. ^[3]
10. Tactile vocal fremitus. Ask the patient to say "one, two, three" while you move both palms or the sides of your hands from top to bottom of the front and back of the chest. Fremitus is increased over consolidation and decreased over effusion, pneumothorax and collapse. ^[2]
11. Percussion. Percuss from the apex to the base on both sides, anteriorly and posteriorly, including the axillae. Normal lung is resonant; dullness suggests consolidation or fluid; hyperresonance suggests air trapping or pneumothorax. Compare sides at every level. ^[2]
12. Auscultation. Listen anteriorly and posteriorly, comparing sides at each level, through a full inspiration and expiration. Note the breath sounds (normal, bronchial, diminished or absent), any added sounds (crackles, wheezes, rhonchi, pleural rub) and any extrapulmonary sounds. Keep the patient breathing a little deeper than normal and use the diaphragm for higher-pitched sounds. ^[2]
13. Vocal resonance. Listen while the patient says "ninety-nine" and then whispers "one, two, one, two"; record bronchophony, egophony and pectoriloquy. Enhanced, distinct syllables over consolidation mean the airway to that lobe is patent. ^[2]
14. Back examination. Inspect and palpate the back for tenderness, asymmetry, scoliosis, muscle wasting, surgical scars, sacral oedema and lymph nodes. Percuss the kidneys if renal disease is a possibility. ^[3]
15. Lymph nodes. Palpate the cervical, supraclavicular and axillary nodes, and the nodes of the neck and behind the ears. Supraclavicular nodes, especially on the left, are important in thoracic disease. ^[3]
16. Peripheral oedema and legs. Check the ankles and sacrum for pitting oedema; look at the legs for wasting and deep venous thrombosis. Oedema with an elevated jugular venous pressure points to right heart strain. ^[4]
17. Peak flow. Measure the peak expiratory flow rate with a peak flow meter, using the best of three attempts, and record it against the predicted for age, sex and height. Peak flow is effort-dependent, so coach the manoeuvre. ^[6]
18. Sputum pot. Inspect any sputum: amount, colour, consistency, odour and blood. This costs no extra time and changes the differential.

The following table collects the signs you have just elicited, with the way to elicit each and a short interpretation. It is not exhaustive: a full respiratory examination also looks for clubbing causes, infection clues and heart disease signs. The patterns in the notes below are the ones a medical student must know.

A few numerical points follow directly from the sources, and every one of them is recorded in the accompanying claims ledger:

• Respiratory rate. Count expansions over 20 to 30 seconds and multiply. A resting rate of 10 to 15 breaths per minute is physiologically normal; in some elderly patients rates up to 25 breaths per minute can be normal; an increase above 20 breaths per minute in a resting adult is abnormal. ^[1]
• Schamroth sign and clubbing. Putting the dorsal surfaces of the distal segments of the fingers together should leave a diamond-shaped aperture at the nail bed; its absence indicates clubbing. The Lovibond nail-fold angle is normally under about 160 degrees, and clubbing develops as this is lost with soft-tissue swelling of the digit. ^[1]
• Late crackles in pulmonary fibrosis. In one study the crackles of pulmonary fibrosis began at 45 percent of inspiration, compared with 25 percent in chronic obstructive pulmonary disease, 33 percent in bronchiectasis and 37 percent in heart failure. ^[2]
• Wheeze and rhonchus frequencies. Wheezes are continuous sounds longer than 250 milliseconds with a dominant frequency above 400 hertz; rhonchi (low-pitched wheezes) have a dominant frequency around 200 hertz or less. ^[2]
• Jugular venous pressure. A value up to 8 to 9 centimetres of water is normal. ^[4]

Bedside signs rarely exist alone; the diagnosis is in the constellation. The table below collects the patterns every medical student must recognise on the spot, and the notes that follow explain why each sign appears.

• Consolidation (for example pneumonia or pulmonary infarction): the alveoli fill with inflammatory exudate or blood, but the conducting airway stays open, so sound travels from the large airways to the chest wall and produces bronchial breathing, increased fremitus and the vocal resonance signs. Late-inspiratory crackles reflect the opening of small, fluid-afflicted airways. Hypoxaemia is common; sepsis may be present.
• Pleural effusion: fluid in the pleural space insulates the lung from the chest wall. The classical combination is reduced or absent expansion, stony-dull percussion and absent breath sounds and fremitus. A very large effusion also splints the diaphragm and pushes the mediastinum. The physical signs disappear at the upper level of the fluid, where a horizontal "stony" edge may be felt.
• Pneumothorax: air in the pleural space collapses the lung and produces the mirror-image of consolidation: reduced expansion, hyperresonance, and absent breath sounds and fremitus. Tension is diagnosed by severe distress, tracheal deviation, haemodynamic compromise and the need for immediate decompression, not by the size of the pneumothorax alone.
• Chronic obstructive pulmonary disease: the problem is air trapping. The chest becomes barrel-shaped, the diaphragm is low, percussion is hyperresonant and expiration is prolonged, with wheeze. Peak flow and forced measures are reduced. The examination also looks for the systemic effects: weight loss, pursed-lip breathing and right heart strain.
• Pulmonary fibrosis: stiff, shrunken lungs produce fine, late-inspiratory crackles at the bases, finger clubbing and a restrictive pattern with reduced expansion but a relatively preserved peak flow. The oxygen desaturation may be out of proportion to the auscultatory findings. Connective tissue disease, occupational exposure and drugs are common backgrounds.

Presentation is a separate skill from examination, and it is tested in every clinical examination and long case. The aim is to give the listener the findings in an order they can follow, leading with what matters most, and to end with a summary and a differential that makes sense.

Speak in this order, without apologising for missing steps you did not perform:

1. State the patient and the chest's overall appearance at rest: "He is comfortable at rest, with no respiratory distress."
2. The most important positive finding first: "The important findings are on the left side: reduced expansion, stony-dull percussion and absent breath sounds, with tracheal deviation to the right."
3. The other positive findings, in the order of the examination: hands and clubbing, flap, pulse and rate, face, neck and trachea, then chest front and back, and auscultation.
4. The negatives that matter for the differential: "There is no clubbing, no cervical lymphadenopathy and no peripheral oedema." Do not list every negative you looked for; chosen negatives are the ones that would change the differential.
5. Investigations you have to hand or are about to do: "Peak flow is 280 litres per minute, which is roughly 60 percent of his predicted."
6. End with a one-sentence summary and a differential: "In summary, this is a large left pleural effusion, most likely a parapneumonic effusion; the alternatives are malignant effusion and tuberculosis."

• Speak in the past tense for findings you have completed: "The pulse was regular, 88 per minute."
• Use numbers, not impressions: "resonant", "stony dull" and a rate in beats per minute are better than "fairly normal".
• Use the standard terms (vesicular, bronchial, crackles, wheeze, rub) rather than private descriptions.
• State both sides when you have compared them: "breath sounds were reduced over the lower left chest, with bronchial breathing just above the stony dullness."
• Do not present a finding as if it is a diagnosis: say "stony dullness and absent breath sounds over the lower left chest", not "a large pleural effusion". The diagnosis is stated only in the final summary.
• Lead with what is abnormal and important, not with the normal first step; the examiner already knows you started at the hands.
• Finish with the patient, not with yourself: return the curtains or gown to the patient before you present.

A written entry mirrors the spoken one, in short numbered or bulleted lines rather than prose:

• Patient sitting comfortably, no respiratory distress.
• Hands: no clubbing, no cyanosis, no flap. Pulse 88, regular, no radio-radial delay.
• Respiratory rate 18, regular.
• Face: no central cyanosis. JVP not raised. Trachea central.
• Chest: barrel shaped; hyperresonant percussion; reduced expansion both sides; decreased tactile fremitus; vesicular breath sounds with prolonged expiration and diffuse wheeze.
• Back and lymph nodes: no abnormalities.
• No ankle or sacral oedema. Peak flow 280 L/min (about 60 percent of predicted). Sputum pot: scant, mucoid, no blood.
• Summary: chronic obstructive pulmonary disease with expiratory obstruction, severity to be assessed clinically; consider a chest radiograph and spirometry.

All patient details below are invented and illustrative; they are not real patient records.

Normal examination, spoken. "This 24-year-old woman was comfortable at rest. Her hands were warm, with no clubbing or cyanosis, and the flap was negative. The pulse was regular at 72 per minute, with no radio-radial delay. The respiratory rate was 14, regular. Her face was pink, with no central cyanosis; the jugular venous pressure was not raised and the trachea was central. The chest was symmetrical, with normal expansion. Tactile fremitus was equal on both sides, percussion resonant, and vesicular breath sounds were heard throughout, with no crackles, wheezes or rubs. Vocal resonance was normal over both lungs. There was no cervical lymphadenopathy, no back tenderness and no peripheral oedema. Peak flow was 480 litres per minute, appropriate for her build, and the sputum pot was empty. In summary, this is a normal respiratory examination."

Consolidation. "This 58-year-old man was comfortable at rest, with no respiratory distress. The findings were on the right side: reduced expansion, increased tactile fremitus, stony dullness to percussion over the lower right chest, with bronchial breathing and coarse late-inspiratory crackles above and at the dullness. Vocal resonance was increased on the right, with egophony and whispered pectoriloquy. There was no clubbing and no central cyanosis. The trachea was central and the jugular venous pressure was not raised. The left side was normal. In summary: right lower lobe consolidation with a patent airway, most likely bacterial pneumonia; the alternatives are pulmonary infarction and lung cancer."

Pleural effusion. "On the left there was reduced expansion, stony dull percussion, absent breath sounds and absent tactile fremitus over the lower two-thirds of the hemithorax, with the trachea deviated slightly to the right. Vocal resonance was absent in the dull area. The right side was normal. There was no clubbing, but there was pitting ankle oedema and a raised jugular venous pressure. In summary: a large left pleural effusion, with signs of raised right heart pressures; causes to consider include parapneumonic effusion, malignancy and heart failure."

Pneumothorax. "The right hemithorax was hyperresonant, with reduced expansion, absent breath sounds and absent tactile fremitus, and the trachea was deviated to the left. The patient was breathless at rest with a respiratory rate of 26. There was no mediastinal crunch. In summary: a right pneumothorax with tracheal deviation; this must be assessed for tension and treated urgently while arranging imaging."

Chronic obstructive pulmonary disease and pulmonary fibrosis. "In the first patient, inspection showed a barrel chest with prolonged expiration; there was hyperresonance, globally reduced expansion and diffuse wheeze, with a peak flow of 180 litres per minute. In the second, there was no barrel chest but finger clubbing and a fine, late-inspiratory crackle best heard at the bases, with a restrictive pattern of reduced expansion; peak flow was relatively preserved. In summary, the first is obstructive disease, the second interstitial, fibrotic disease."

• Examining through clothing or with the patient slouched; this destroys the yield of inspection and percussion.
• Forgetting to expose and warm the stethoscope; a cold chest piece makes every patient tense.
• Percussing only on one side, or not comparing at the same level; every percussion note must be compared side to side.
• Listening only at the front; the back is where many basal signs are loudest, and it is where fluid and fibrosis first show.
• Using too much pressure with the bell, which then behaves as a diaphragm and misses low-pitched sounds.
• Describing the sound you heard in private words ("like rice crispies") instead of "fine late-inspiratory crackles".
• Calling bronchial breathing a murmur, or confusing a pleural rub with crackles; rubs are heard in both phases of respiration.
• Presenting a finding as a diagnosis ("large effusion") rather than describing the signs.
• Forgetting to take the negatives that change the differential (clubbing, lymphadenopathy, tracheal position).
• Performing the examination in a different order each time, so steps are skipped when the patient tires.
• Omitting the sputum pot and peak flow: these take seconds and add classification.
• Not presenting aloud at all, or apologising and starting again; once started, finish.
• Treating the respiratory examination as separate from the cardiovascular one; tachycardia, oedema and an elevated jugular venous pressure are part of the same patient.

• The respiratory examination is ordered: general look, hands, pulse, rate, face and neck, chest inspection and expansion, fremitus, percussion, auscultation, vocal resonance, back, lymph nodes, oedema, peak flow and sputum.
• Normal resting respiratory rate is 10 to 15 breaths per minute; an increase above 20 in a resting adult is abnormal.
• Schamroth sign and clubbing reflect chronic hypoxaemia or other chronic disease; always state whether clubbing is present.
• Bronchial breathing, increased fremitus and bronchophony or egophony mean consolidation with a patent airway.
• Dull, stony percussion with reduced expansion and absent breath sounds suggests pleural effusion.
• Hyperresonance with reduced expansion and absent breath sounds suggests pneumothorax; absent fremitus supports this.
• Obstruction gives a barrel chest, hyperresonance, prolonged expiration, wheeze and a reduced peak flow; fibrosis gives clubbing and late fine crackles at the bases with relatively preserved peak flow.
• A pleural friction rub is heard in both inspiration and expiration.
• Wheezes are continuous sounds above 400 hertz and longer than 250 milliseconds; rhonchi are at about 200 hertz or less.
• Present findings in a fixed order, lead with the most important positive, state the negatives that matter, and end with a one-sentence summary and a differential.
• Consent, chaperone, exposure and dignity are part of the examination.
• Counts and thresholds must be measured, not estimated.

Respiratory examination is best learned alongside the approach to breathlessness, chronic obstructive pulmonary disease, asthma, pneumonia, pleural effusion, pneumothorax and pulmonary fibrosis, and alongside cardiovascular examination and general inspection and vital signs. These are written up as separate topics in the library.