Significant findings in the upper respiratory tract:

Nasal turbinate hypertrophy or polyps causing airway obstruction

Sinus tenderness suggestive of sinusitis

Kartageners syndrome:

Recurrent sinusitis with ciliary dyskinesia

Bronchiectasis

Situs inversus

Male infertility

Wegeners granulomatosis

Necrotizing granuloma

Samter’s triad

Aspirin sensitivity

Bronchial asthma

Ethmoidal polyps

Young’s syndrome

Sinopulmonary disease

Azoospermia

Churg-Strauss syndrome

Asthma/allergic rhinitis

Eosinophilia

Vasculitis

Granuloma

Inspection (Lower Respiratory Tract)

Surface marking of lung

Right side 3 lobes Left side 2 lobes

Right upper lobe (RUL)

Right middle lobe (RML)

Right lower lobe (RLL)

Left upper lobe (LUL)

Left lower lobe (LLL)

Demarcating lower lobe of either side (Figs. 3D.2 to 3D.5):

Lower lobe of either lungs can be demarcated from other lobes by drawing a curvilinear line (major

interlobar fissure/oblique fissure) joining 3 bony points:

Starting from T2/T3 spinous process, curvilinear line along the medial border of scapula

Crossing the 5th rib in the Mid axillary line

Reaching the 6th rib in mid clavicular line

Part of lung below this line is lower lobe.

Marking right middle lobe:

Draw a straight line (minor interlobar fissure/horizontal fissure) from the 4th rib at right sternal border

towards the midaxillary line cutting the major interlobar fissure at 5th rib. The triangular area represents

RML.

Fig. 3D.2: Anterior view of chest showing surface marking of lung fissures and lobes.

Fig. 3D.3: Posterior view of chest showing surface marking of lung fissures and lobes.

Fig. 3D.4: Right lateral view of chest showing right major interlobar (IL) fissure and right minor IL

fissure.

Fig. 3D.5: Left lateral view of chest showing left major interlobar fissure.

Level of lower border Midclavicular line Midaxillary line Scapular

Lung (Figs. 3D.6 and 3D.7) 6th rib 8th rib 10th rib

Pleura 8th rib 10th rib 12th rib

Fig. 3D.6: Lower margin of lung in midclavicular line and midaxillary line.

Fig. 3D.7: Lower margin of lung in scapular line.

Examination of chest:

Front examination Back examination Axillary examination

Predominantly to look for

upper and middle lobe

Predominantly to look for lower lobe

pathology

All three lobes can be assessed

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Examined with patient in

upright sitting position with

hand by the side

Examined with patient in sitting upright with

hands placed on the opposite shoulder and

neck flexed

Examined with patient in the sitting position with

hands raised above the shoulder and placed on

the occiput

Position of patient during examination can be:

Sitting—most of the examination is done in this position

Standing—spine and shoulder droop

Supine—shifting dullness.

Normal chest (Fig. 3D.8)

Spine—central

Shape

Circular—infants and early childhood

Elliptical—adults

Circular—old age

Vertical length > transverse diameter > AP diameter

Transverse: AP = 7:5 (called as Hutchinson’s index)

Subcostal angle ≤ 90 (more acute in males).

Deformities of chest

Flat chest (alar chest) Anterioposterior ratio is 2:1

Pectus carinatum (Fig. 3D.9)

(Pigeon chest/keel chest)

Forward protrusion of sternum seen in rickets and childhood respiratory disease like

asthma. Can also be seen in Marfan syndrome

Pectus excavatum (Fig. 3D.9)

(Funnel chest, cobbler’s chest)

Funnel like depression at the lower end of the chest, seen in Marfan syndrome.

Displaces the heart to the left. Ventilation capacity of the lung is restricted

Rachitic chest Funnel shaped

Keel breast

Harrison sulci (horizontal groove where the diaphragm attaches to the ribs—seen in

rickets, chronic asthma and COPD)

Vertical grooves on either side of sternum

Rachitic rosary (bead like enlargement of costochondral junction especially 4/5/6 ribs) —painless and seen in vitamin D deficiency

Scorbutic rosary Sharp angulation of the ribs arising due to backward displacement of sternum

Painful and seen in vitamin C deficiency

Barrel-shaped chest (Fig. 3D.8) COPD—emphysema

Anteroposterior: Transverse diameter is 1:1

Exaggerated thoracic kyphosis Wide subcostal angle

Phthinoid chest Combination of alar and flat chest

Flail chest Paradoxical movement of the chest in fracture of 3 or more consecutive ribs

Shield-like chest Turner’s and Noonan syndrome

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Fig. 3D.8: Normal- and barrel-shaped chest.

Asymmetry of chest

Deformity of spine Scoliosis

Kyphoscoliosis

Gibbus

Unilateral bulge Pleural effusion

Pneumothorax

Compensatory hypertrophy

Malignancy of lung or pleura

Unilateral flattening Fibrosis

Collapse

Fibrothorax

Pneumonectomy

Agenesis of one lung (McLeod’s syndrome/Swyer-James syndrome)

Mastectomy

Absent pectoralis (Poland’s syndrome)

Local bulging

(fullness)

Supraclavicular fullness (Pancoast tumor/lymphadenopathy/massive pleural effusion/tension

pneumothorax)

Empyema necessitans (cough impulse present)

Aortic aneurysm

Malignant infiltration

Pericardial effusion

Surgical emphysema

Local retraction Apical tuberculosis (Morenheim’s fossa/infraclavicular fossa)

Lung fibrosis

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Fig. 3D.9: Pectus excavatum and pectus carinatum.

Trachea:

Normally central or slightly deviated to right.

Trail sign (Fig. 3D.10):

In the presence of tracheal deviation, there is prominence of the clavicular head of sternocleidomastoid

of same side. The investing layer of cervical fascia splits to enclose the sternocleidomastoid and then

falls back and continues as the pretracheal fascia. When there is tracheal shift to one side, the fascia

covering the ipsilateral sternocleidomastoid relaxes. The sternocleidomastoid goes into a state of

contraction making the clavicular head prominent.

Clinical implication of tracheal shift: It suggests upper mediastinal shift.

Indicates upper lobe fibrosis or collapse.

Fig. 3D.10: Trail sign showing undue prominence of sternocleidomastoid on the right side due to

tracheal shift to right.

Apical impulse:

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Normally 10 cm from sternal margin.

Clinical implication: Suggests lower mediastinal shift.

Examination of drooping of shoulder (Fig. 3D.11):

Examine the standing patient from behind to look for position of shoulder. Drooping of shoulder indicates

volume loss on that side (collapse/fibrosis/fibrothorax/pneumonectomy). Rarely, it can be seen with

paralysis of trapezius.

Associated features include:

Prominent medial border of scapula on the affected side

Space between medial border of scapula and spine is decreased

Inferior angle of scapula is at the lower level (normally it is at level of T7 vertebra).

Fig. 3D.11: Shoulder drooping on right side.

Examination of spine:

Look for position of spine

Look for scoliosis/kyphosis/lordosis/Gibbus (Fig. 3D.12)

In emphysema there is exaggerated thoracic kyphosis.

Fig. 3D.12: Spine deformities.

Causes of scoliosis

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Neuromuscular causes Spina bifida

Marfan syndrome

Cerebral palsy

Friedreich’s ataxia

Spinocerebellar degeneration

Charcot-Marie-Tooth disease

Syringomyelia

Poliomyelitis

Muscular dystrophy (Duchenne’s, facioscapulohumeral, myotonic dystrophy)

Degenerative Osteoporosis

Post-spine surgery

Osteopathic Klippel Feil syndrome

Congenital scoliosis Down’s syndrome

Prader-Willi syndrome

Respiratory diseases Fibrosis

Fibrothorax

Idiopathic –

Differentiation of congenital versus acquired scoliosis:

On bending forwards acquired scoliosis disappears but congenital scoliosis persists.

Respiratory movements:

(describe as equal/diminished in a particular area).

Area Right Left

Supraclavicular

Clavicular

Infraclavicular (arbitrarily up to 3rd rib)

Mammary (arbitrarily 3rd to 6th rib)

Axillary (up to 6th rib)

Infra-axillary (beyond 6th rib)

Suprascapular

Infrascapular

Interscapular

Scapular (mentioned in some books)

Note: There is no inframammary area.

Abnormal signs in respiratory system

Sitting up

and

catching

the edge

Described in COPD where the patient sits up and fixes shoulders to use latissimus dorsi for expiration

Tripod

position

(Fig.

3D.13A)

Patient is sitting in leading forward posture with their outstretched hands on their knees. This position fixes and

lifts the shoulder girdle and improves the function of pectoralis major and minor

Hoover

sign

Paradoxical inspiratory indrawing of lateral rib cage (costal margin). It is a sign of chronic airflow obstruction.

Pulmonary hyperinflation leads to loss of apposition of the diaphragmatic fibers resulting in horizontal

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orientation of fibers. When these horizontally oriented fibers contract, the costal margins get pulled inwards

Pursed lip

breathing

(Fig.

3D.13B)

Seen in COPD to increase the intra-alveolar pressure to maintain a positive intraluminal pressure which

reduces the airway collapse, airway resistance and residual volume and hence improves ventilation

Dahl’s sign Patches of hyperpigmentation/bruising above the knees due to constant tenting position of the hands and

elbows

Litten’s

sign

To look for the diaphragmatic movement

Sit to one side of the patient lying in supine position and look at the diaphragmatic movements

Excessive

usage of

SCM and

scalene

COPD or asthma

Paradoxical

respiration

Indrawing of abdominal wall when the rib cage moves outwards. Best felt by bimanual palpation with one hand

over the patient’s chest and other on the abdomen. Indicates respiratory muscle weakness

Figs. 3D.13A and B: Tripod position with pursed lip breathing.

Inspiratory intercostal retraction (Fig. 3D.13C):

Mild degree of intercostal retraction in the lower chest is normal. Bilateral lower intercostal retractions is

seen in COPD.

Unilateral intercostal retraction Bilateral intercostal retraction

Collapse

Fibrosis

Adherent pericarditis (Broadbent’s sign—indrawing of lower anterior chest wall

with each ventricular systole)

Indicates upper airway obstruction

(adenoids/foreign body)

Hyperinflation of chest (COPD)

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Fig. 3D.13C: Intercostal retractions.

Visible pulsations/scars/sinuses:

Visible pulsation or vessels

Collaterals around scapula Coarctation of aorta (Suzman’s sign)

Engorged veins over the anterior part of chest SVC obstruction seen in

Bronchogenic carcinoma

Mediastinal growth

Mediastinal lymph nodes

Aortic aneurysm

Chronic mediastinal fibrosis

Pulsatile swelling in anterior chest wall Aortic aneurysm

Visible scars

Previous surgery (lobectomy)

Pleural fluid aspiration site

Lymph node biopsy site

Sinuses

Abscess draining points

Empyema thoracis (usually in tuberculosis/actinomycosis)

Palpation (Lower Respiratory Tract)

Trachea:

Normal length: 4–5 cm above suprasternal notch

Normal cricoid to suprasternal notch distance is 3–4 finger breadth (decreased in COPD due to

hyperinflation).

Method of palpation:

Keep the index and ring finger of the right hand on medial ends of the clavicle

↓

With middle finger trace the trachea from above downwards (Fig. 3D.14)

↓

Then, insinuate the middle finger between the trachea and sternal head of sternocleidomastoid, and feel for resistance (Fig.

3D.15)

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Note: Implication of tracheal shift—upper mediastinal shift

Fig. 3D.14: Tracing the trachea down with the middle finger.

Fig. 3D.15: Insinuate the middle finger between the trachea and sternal head of sternocleidomastoid,

and feel for resistance.

Oliver’s sign (tracheal tug sign) (Fig. 3D.16):

Stand behind patient and hold cricoid cartilage give a slight upward thrust.

Positive test Downward pull with each heart beat suggestive of aortic aneurysm

Negative test Normal

False positive Mediastinal tumor attached to abdominal aorta

False negative Thrombosed aortic aneurysm

Tracheal descent on inspiration (Campbell sign): Due to downward pull of the depressed

diaphragm in long standing hyperinflation of lung.

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Laryngeal fixation: Increased pressure on cricoid cartilage due to inflammatory or neoplastic lesion

in mediastinum.

Fig. 3D.16: Demonstration of Oliver’s sign.

Apical impulse:

Confirm the position of apex

Comment on character

Watch for thrills and other palpable heart sounds

Implication of apical impulse shift: It suggests lower mediastinal shift.

Apex not felt/seen in respiratory diseases

Emphysema

Left sided pleural effusion

Left sided pneumothorax.

Mediastinal shift with respect to respiratory diseases

Shift to same side Fibrosis

Collapse

Shift to opposite side Pleural effusion

Pneumothorax

Tumor or mass

No shift of mediastinum Unilateral disease

Pneumonia

Bilateral disease

COPD

Asthma

Bronchiectasis

Interstitial lung disease

Examination of respiratory movements

Upper anterior chest (Figs.

3D.17A and B)

Examined by placing the palms in the infraclavicular areas

Look for superoanterior movement of the palms

This examines the pump handle movement of the upper lobes

Lower anterior chest (Figs.

3D.18A and B)

Grasp the sides of the chest and approximate the tips of the thumbs in the mammary area

with loose fold of skin in between

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Watch for separation of the thumbs and compare the movements with each respiration

It demonstrates the bucket handle movements of the lower chest

Upper posterior chest (Fig.

3D.19)

Examine from the back by placing hand in the supraclavicular fossa and watch for movements superiorly

This demonstrates the movement of the apical segment

Lower posterior chest (Fig.

3D.20)

Grasp the sides of the chest and approximate the tips of the thumbs in the infrascapular

area with loose fold of skin in between

Watch for separation of the thumbs and compare the movements with each respiration

This demonstrate the lower lobe movements

Fig. 3D.17A: Examination of respiratory movements of upper anterior chest.

Fig. 3D.17B: Pump handle movement.

Fig. 3D.18A: Examination of respiratory movements of lower anterior chest.

Fig. 3D.18B: Bucket handle movement.

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Fig. 3D.19: Examination of respiratory movements of upper posterior chest.

Fig. 3D.20: Examination of respiratory movements of lower posterior chest.

Diaphragmatic movements:

Place one hand on chest and other hand on the abdomen (Fig. 3D.21)

Normally—both hands are lifted during inspiration

If chest rises but abdomen remains static—suggests an abdominal pathology which is fixing the

abdomen

If chest rises but abdomen retracts—suggests diaphragmatic palsy.

Causes of decreased chest movements

Unilateral Bilateral

Pleural effusion

Empyema

Pneumothorax

Fibrosis

Collapse

COPD

Asthma

Interstitial lung disease

Ankylosing spondylitis

Systemic sclerosis

Measurements of chest diameters

AP diameter (Fig. 3D.22) Use two cardboards and place as shown in Figure 3D.22.

Normal ratio of AP:T = 5:7

Transverse diameter (Fig. 3D.23)

Chest expansion (Fig. 3D.24) Normal = 5–8 cm (adult), decreases with age (e.g. 60 years ≥3 cm is considered normal)

COPD/ILD expansion is <1.5 cm

Hemithorax expansion (Fig. 3D.25) Stand on side and place the tape from spine to midsternal as shown in Figure 3D.25.

Note: Chest expansion should be assessed as the difference of measurement between deep inspiration

to deep expiration.

Fig. 3D.21: Examination of diaphragmatic movements.

Fig. 3D.22: Examination of anteroposterior diameter.

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Fig. 3D.23: Examination of transverse diameter.

Fig. 3D.24: Examination of chest expansion (crossed tape).

Figs. 3D.25A and B: Examination of hemithorax

circumference.

“THE MOST IMPORTANT EXAMINATION FINDING IS TO CHECK FOR HEMITHORAX EXPANSION

AND HEMITHORAX MEASUREMENT.”

Remember: “The side that moves less is the site of disease.”

Increased hemithorax size with

decreased hemithorax movement

Decreased hemithorax size with

decreased hemithorax movement

Normal hemithorax size with

decreased hemithorax movement

Pleural effusion

Pneumothorax

Fibrosis

Collapse

Consolidation

Examination of spinoscapular distance (Fig. 3D.26): It is the distance between the spine and the

scapular line (scapular line is the vertical line passing through the inferior angle of scapula).

Examination of spino-acromion distance (Fig. 3D.27): It is the distance measured between the spine

and the tip of acromion process.

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Fig. 3D.26: Examination of spinoscapular distance.

Fig. 3D.27: Examination of spino-acromion distance.

Fig. 3D.28: Demonstration of vocal fremitus.

Vocal fremitus

The sounds produced by vocal cords are transmitted along the tracheobronchial tree and heard/felt

over the chest wall.

Place the ulnar border of the hands on identical areas on both sides of the chest (Fig. 3D.28).

Ask the patient to repeat “one-one-one-”

Vocal fremitus

Increased Decreased

Consolidation

Large cavity

Bronchopleural fistula

Pleural effusion

Pneumothorax

Fibrosis

Collapse

Asthma

Emphysema

Thick pleura

Tactile fremitus

These are palpable adventitious sounds

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