Introduction
The respiratory examination follows the systematic structure of Inspection → Palpation → Percussion → Auscultation — applied in turn to the anterior chest, then the posterior chest and axillae. In the exam setting, presenting your findings as you go demonstrates active clinical thinking.
Introduction and General Survey
Introduce yourself and explain what you would like to do, then ask for the patient's consent. Ensure the patient is positioned at 45 degrees, adequately exposed from the waist up (with appropriate privacy).
Stand back and make a general observation of the patient, their surroundings, and any medical equipment:
- Is there supplemental oxygen in use? What flow rate and delivery device?
- Are there inhalers, nebuliser masks, peak flow meters, or sputum pots at the bedside?
- Is the patient in obvious distress, breathless at rest, or using accessory muscles?
State: "The patient is lying comfortably at rest at 45 degrees and does not appear to be grossly cyanosed, anaemic, or in pain or respiratory distress."
Hands
Temperature: Assess the temperature of the hands using the back of your own hand. Cool peripheries may suggest poor perfusion.
Clubbing: Clubbing of the fingernails is a significant respiratory finding. It is characterised by loss of the angle between the nail bed and the proximal nail fold (Schamroth's sign — apposing the two index fingers dorsal surface to dorsal surface should normally produce a diamond-shaped window at the nail bases; in clubbing, this window is obliterated). Respiratory causes of clubbing include: bronchial carcinoma, cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis), asbestosis, mesothelioma, and chronic pulmonary sepsis (empyema, lung abscess, bronchiectasis, cystic fibrosis). Importantly, COPD and asthma do not cause clubbing.
Koilonychia: Soft, thin, brittle, spoon-shaped nails — evidence of severe iron deficiency anaemia (which may contribute to dyspnoea and reduced exercise tolerance).
Nicotine staining: Yellow-brown staining of the fingertips indicates that the patient smokes cigarettes down to the base. It reflects only that they smoke, not how much.
Small muscle wasting (T1 distribution): Wasting of the small muscles of the hand with prominent extensor tendons may indicate brachial plexus invasion by a Pancoast tumour (apical bronchial carcinoma invading the brachial plexus via the thoracic outlet).
Asterixis (CO2 retention flap): Ask the patient to extend both arms straight out in front with eyes closed and wrists extended. A coarse, irregular flapping tremor suggests CO2 retention (also seen in liver failure — hepatic encephalopathy). The flap of CO2 retention is indistinguishable from hepatic flap.
Pulse and Blood Pressure
Assess the pulse rate and rhythm. Also count the respiratory rate (RR) simultaneously — a normal adult RR at rest is 12–20 breaths per minute. An RR above 20 is a significant clinical finding and a key early warning sign of deterioration.
Measure blood pressure and note any pulsus paradoxus — an exaggerated fall in systolic BP (more than 10 mmHg) during inspiration, associated with severe asthma, cardiac tamponade, or constrictive pericarditis.
Jugular Venous Pressure (JVP)
Assess the JVP with the patient positioned at 45 degrees. A non-pulsatile, very high JVP should raise the possibility of superior vena cava (SVC) obstruction — causes include bronchial carcinoma. A raised pulsatile JVP suggests cor pulmonale (right-sided heart failure due to chronic lung disease). In cor pulmonale, look also for peripheral oedema at the ankles.
Face
Conjunctivae: Pull down the lower eyelid and inspect for pallor (anaemia).
Central cyanosis: Inspect the buccal mucous membranes and the tongue for a blue discolouration — central cyanosis indicates significant hypoxia (SaO2 typically below 85%). Note that central cyanosis may not be visible in anaemic patients even when significantly hypoxic.
Horner's syndrome: Unilateral miosis (small pupil), partial ptosis, enophthalmos, and anhidrosis on one side of the face. May indicate a Pancoast (apical lung) tumour invading the sympathetic chain.
Trachea: Assess whether the trachea is central. Place one finger on either side of the trachea in the suprasternal notch — the trachea should sit centrally. Tracheal deviation towards the abnormal side occurs with collapse (the collapsed lobe pulls the trachea toward it) and post-pneumonectomy. Tracheal deviation away from the abnormal side occurs with a large pleural effusion or tension pneumothorax (the mediastinum is pushed away).
Chest — Inspection
Inspect both anterior and posterior chest for:
- Scars: Thoracotomy (posterior lateral), VATS port scars, drain scars, sternotomy
- Chest shape:
- Barrel chest: Increased anterior-posterior (AP) diameter — associated with emphysema and severe COPD (air trapping and lung hyperinflation)
- Pectus carinatum (pigeon chest): Increased prominence of the upper sternum — associated with childhood asthma and Marfan syndrome
- Pectus excavatum (funnel chest): Depression of the lower sternum — may reduce vital capacity; associated with Marfan syndrome
- Scoliosis and kyphosis: Spinal deformity can severely restrict lung volumes and cause type 2 respiratory failure
- Use of accessory muscles: Sternocleidomastoid, scalene, and intercostal muscle use at rest indicates significant respiratory distress
- Intercostal recession: Visible in-drawing of the intercostal spaces during inspiration — in children, this is a particularly important sign of respiratory distress
- Respiratory rate and pattern: Count for a full 30 seconds without making it obvious to the patient
Palpation
Chest Expansion
Place your hands firmly on the lower chest with your thumbs pointing towards each other in the midline, a few centimetres apart. Ask the patient to take a deep breath in. Your thumbs should separate symmetrically. Reduced expansion on one side indicates pathology on that side — collapse, consolidation, effusion, or pneumothorax.
For the upper chest, place your hands flat on either side and assess the relative filling of each lung by feeling for symmetry of movement.
Tracheal Position
Already assessed above. Confirm at this stage by placing your finger into the suprasternal notch and palpating on each side of the trachea.
Vocal (Tactile) Fremitus
Place the flat of your hand on both sides of the chest simultaneously and ask the patient to say "ninety-nine". Repeat over multiple lung zones. Fremitus is increased where the underlying lung is consolidated (sound conducts better through dense material) and decreased or absent where there is an effusion or pneumothorax (fluid or air acts as a barrier to sound transmission).
Percussion
Start anteriorly with the clavicles (percuss directly over the clavicle, which acts as its own pleximeter) and work your way systematically down both sides, always comparing side to side. Repeat posteriorly and in the axillae.
Percussion notes and their clinical significance:
| Note | Character | Causes |
|---|---|---|
| Resonant | Hollow, low-pitched | Normal lung |
| Dull | Short, thud-like | Consolidation, lobar collapse, elevated diaphragm, pleural thickening |
| Stony dull | Completely flat, wooden | Pleural effusion (the dullest sound in clinical medicine) |
| Hyper-resonant | Exaggerated hollow resonance | Pneumothorax, emphysema (hyperinflation) |
Auscultation
Use the diaphragm of the stethoscope. Start above the clavicles and work systematically down both sides anteriorly, then repeat posteriorly and in the axillae. Ask the patient to breathe through their mouth. Count the respiratory rate if not already done.
Breath Sounds
- Vesicular breath sounds: Normal breath sounds — soft, rustling quality; inspiration is louder and longer than expiration; heard over all normal lung fields
- Bronchial breathing: Loud, harsh, equal inspiration and expiration with a gap between them — similar to the sound heard over the trachea. Heard over areas of consolidation (e.g. pneumonia), where the airways are patent but the alveoli are filled, conducting bronchial sounds to the surface. Also heard above a pleural effusion.
- Absent or reduced breath sounds: Pleural effusion, pneumothorax, severe emphysema, obesity
Added (Adventitious) Sounds
- Crackles (crepitations):
- Fine, late-inspiratory crackles: Heard at the end of inspiration; typically basal — represent the opening of collapsed alveoli; classic in pulmonary fibrosis and pulmonary oedema
- Coarse, early-inspiratory or pan-inspiratory crackles: Loud, bubbly sounds heard throughout inspiration; represent secretions in large airways; typical of bronchiectasis, COPD, and pneumonia
- Wheeze (rhonchi): High-pitched, musical, expiratory (usually) sound caused by air passing through narrowed airways. Polyphonic wheeze (multiple pitches) = diffuse airway narrowing (e.g. asthma, COPD). Monophonic wheeze = single narrowed airway (e.g. foreign body, endobronchial tumour — fixed wheeze that does not change after coughing).
- Pleural rub: Creaking, leathery sound caused by inflamed pleural surfaces rubbing together. Heard in pleuritis — typically localised, and changes with the position of the patient but not with coughing. Associated with PE, pneumonia (when pleurisy occurs), and pleural TB.
- Stridor: A high-pitched inspiratory (or biphasic) noise caused by partial upper airway obstruction — not auscultated, but heard from across the room. It is a medical emergency. Causes: foreign body, croup, epiglottitis, anaphylaxis, tumour.
Vocal Resonance
Ask the patient to say "ninety-nine" while you auscultate over the chest zones. In consolidation, the sound is louder and clearer — this is called bronchophony. Whispering pectoriloquy (whisper "ninety-nine") is even more sensitive for consolidation — the whispered sound is clearly heard through consolidated lung.
Repeat the systematic sequence — chest expansion, vocal fremitus, percussion, auscultation, vocal resonance — for the back, axillae, and lateral chest.
Completing the Examination
Examine the axillary, supraclavicular, and cervical lymph node chains (lymphadenopathy in the context of respiratory symptoms may indicate malignancy, sarcoidosis, or TB).
Examine the shins for erythema nodosum (tender red nodules — caused by sarcoidosis, TB, streptococcal infection) and for ankle oedema (cor pulmonale).
State: "I would also like to request a chest radiograph and a pulse oximetry reading / arterial blood gas to complete my assessment."
Signs of Common Respiratory Conditions — Summary
| Condition | Trachea | Expansion | Percussion | Breath Sounds | Added Sounds |
|---|---|---|---|---|---|
| Pneumonia (consolidation) | Central | Reduced (affected side) | Dull | Bronchial breathing | Coarse crackles, pleural rub |
| Pleural effusion | Away (if large) | Reduced (affected side) | Stony dull | Absent (below); bronchial (above) | Pleural rub (sometimes) |
| Pneumothorax | Away (tension) | Reduced (affected side) | Hyper-resonant | Absent/reduced | None |
| Lobar collapse | Towards (affected side) | Reduced (affected side) | Dull | Reduced/absent | None |
| COPD/Emphysema | Central | Bilaterally reduced | Hyper-resonant | Reduced; prolonged expiration | Wheeze, coarse crackles |
| Pulmonary fibrosis (ILD) | Central | Bilaterally reduced | Dull (bilaterally) | Vesicular | Fine late-inspiratory bibasal crackles (Velcro crackles) |
| Asthma | Central | Reduced (bilateral) | Resonant/slightly hyper-resonant | Prolonged expiration | Polyphonic wheeze |
Frequently Asked Questions
What is the difference between consolidation and collapse on clinical examination?
Consolidation (e.g. pneumonia) and collapse (atelectasis) can both cause dullness to percussion on the affected side. Key differences: In consolidation, the airways are patent but filled with inflammatory exudate — bronchial breathing is therefore typically present, as sound conducts through solid material to the chest wall. Vocal resonance and tactile fremitus are increased. The trachea remains central. In collapse (lobar atelectasis), the lobe has lost volume — it deflates and pulls the mediastinum towards it. The trachea deviates towards the affected side. Breath sounds are diminished or absent (the collapsed lobe does not generate breath sounds). Vocal resonance and fremitus are reduced. Percussion is dull in both conditions.
What respiratory conditions cause clubbing?
Clubbing is a soft tissue swelling at the nail bed, obliterating the normal 165-degree angle between the nail plate and the proximal nail fold. Respiratory causes include: bronchial carcinoma (particularly squamous cell and adenocarcinoma — not small cell typically); cryptogenic fibrosing alveolitis (idiopathic pulmonary fibrosis); asbestosis and mesothelioma; and chronic suppurative lung disease — bronchiectasis, lung abscess, empyema, cystic fibrosis. Importantly, COPD and asthma do not cause clubbing. Other causes include congenital cyanotic heart disease, infective endocarditis, Crohn's disease, and ulcerative colitis. Idiopathic (familial) clubbing also exists.
What causes a tension pneumothorax and how does it present?
A tension pneumothorax occurs when air enters the pleural space through a one-way valve mechanism — air enters on inspiration but cannot escape on expiration. This causes progressive accumulation of air under pressure within the pleural space, compressing the ipsilateral lung and eventually shifting the mediastinum to the contralateral side. Clinical features: severe respiratory distress; tachycardia and hypotension (obstructive shock); hyper-resonant percussion and absent breath sounds on the affected side; and tracheal deviation away from the affected side (a late sign). This is a life-threatening emergency. Treatment is immediate needle decompression (14G cannula into the 2nd intercostal space, mid-clavicular line on the affected side) followed by a formal chest drain. Do not wait for a chest X-ray if the clinical diagnosis is made.
How do I differentiate pleural effusion from consolidation on examination?
Both cause dullness to percussion, reduced breath sounds, and reduced chest expansion on the affected side. Key distinguishing features: Pleural effusion: percussion note is "stony dull" (the dullest sound in clinical medicine; like percussing on wood); breath sounds are absent below the effusion level; above the effusion, you may hear bronchial breathing (this is because the effusion compresses the overlying lung into consolidation); vocal resonance is absent over the effusion. Consolidation (pneumonia): percussion note is "dull" but not stony dull; bronchial breathing is present over the consolidation; vocal resonance and tactile fremitus are increased; trachea is central. If in doubt, an ultrasound of the chest is the most sensitive imaging modality for detecting a pleural effusion.
What is the significance of fine late-inspiratory crackles at the lung bases?
Fine, late-inspiratory (end-inspiratory) crackles at the lung bases are caused by the explosive opening of collapsed or fluid-filled small airways and alveoli at the end of a deep inspiration. Common causes include: pulmonary fibrosis (idiopathic pulmonary fibrosis — the crackles have a characteristic "Velcro-like" quality and are typically bibasal and persistent); pulmonary oedema (cardiac failure — the crackles are bibasal, may be associated with a third heart sound, elevated JVP, and peripheral oedema); and early pneumonia. Coarse crackles that clear with coughing are typically caused by secretions in large airways (bronchiectasis, COPD) and are less pathologically significant.
What is Horner's syndrome in the context of respiratory disease?
Horner's syndrome in a respiratory patient should raise the immediate suspicion of a Pancoast tumour (superior sulcus tumour) — a bronchial carcinoma arising in the apex of the lung. The tumour invades the sympathetic chain (particularly the stellate ganglion at the T1 level), causing interruption of sympathetic innervation to the eye, resulting in ipsilateral miosis, partial ptosis, enophthalmos, and anhidrosis of the face. The tumour may also invade the brachial plexus (causing pain and weakness in the arm and hand — particularly the C8/T1 distribution), the subclavian vessels, and the chest wall. A Pancoast tumour should be considered in any patient presenting with Horner's syndrome and ipsilateral arm pain, particularly if they are a smoker.
What is erythema nodosum and which respiratory conditions cause it?
Erythema nodosum is an inflammation of the subcutaneous fat (panniculitis), presenting as tender, warm, red or purple nodules on the shins (anterior aspect of both lower legs). It represents a hypersensitivity reaction to various antigens. In the context of respiratory disease, the key causes are sarcoidosis (erythema nodosum is part of Lofgren's syndrome — bilateral hilar lymphadenopathy, erythema nodosum, fever, and often arthralgia — which carries a good prognosis) and tuberculosis (both primary and post-primary TB). Other causes include streptococcal infection, inflammatory bowel disease, drugs (sulphonamides, the oral contraceptive pill), and pregnancy. Examining the shins is therefore an important part of a complete respiratory examination.
References
- Macleod J, Munro J, Edwards C. Macleod's Clinical Examination. 14th ed. Elsevier, 2018.
- Longmore M, Wilkinson IB, Baldwin A, Wallin E. Oxford Handbook of Clinical Medicine. 10th ed. Oxford University Press, 2022.
- British Thoracic Society. BTS guidelines for the management of pleural disease. Thorax. 2010;65(Suppl 2):ii1–ii76.
- British Thoracic Society. BTS Pneumothorax Guideline. Thorax. 2010;65(Suppl 2):ii18–ii31.
- National Institute for Health and Care Excellence. Pneumonia in adults: diagnosis and management. NICE Clinical Guideline CG191. NICE, 2014.
- NICE. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. NICE Guideline NG115. NICE, 2019.