Systemic Examination Of Respiratory System

Respiratory System Examination : Inspection, Palpation, Percussion & Auscultation

Systemic examination of respiratory system is as following:

Upper respiratory tract

  • Nose, nasal cavity
  • Sinus (Frontal, ethmoidal, maxillary)
  • Oropharynx

Lower respiratory tract

All the findings in the clinical examination should be compared on both sides in the following areas:


  • Supraclavicular area
  • Infraclavicular area
  • Mammary region


  • Axillary region
  • Infra-axillary region


  • Suprascapular region
  • Interscapular region
  • Infrascapular region

A. Inspection


  • Shape
  • Symmetry (Look for lie of ribs, shoulder drooping, intercostal space, spine, flattening, hollowing, fullness, suprascapular fossa, spinoscapular distance)
  • Movement: Rate, rhythm, equality and type of breathing

Position of mediastinum

  • Trachea: Trail’s sign (Present or Absent)
  • Apex beat: It is shifted to the side of mediastinal shift

B. Palpation

Confirmation for position of mediastinum

  • Trachea: Confirmation of trail’s sign (Present or Absent). Slight shift of trachea to the right is normal.
  • Confirmation of apex beat

Confirmation for respiratory movements

  • Assessment of anterior thoracic movement
  • Assessment of posterior thoracic movement

Assessing Symmetry of Chest Expansion

  • Assessment of upper thoracic expansion

Measurement of the Chest Expansion

  • Chest circumference (cm)
  • During deep inspiration


  • Intercostal spaces
  • Ribs

Tactile vocal fremitus

Read: Medical History Taking : Chief Complaints & Suggestive Involved System

C. Percussion

The sitting posture is the best position of choice for percussion. Supine posture is not desirable because of the alteration of the percussion note by the underlying structure on which the patient liesa.

Percussion should be done both side (comparing each other) in following posture:

  • Anterior percussion: The patient sits erect with the hands by his side
  • Posterior percussion: The patient bends his head forwards and keeps his hands over the opposite shoulders. This position keeps the two scapulae further away so that more lung is available for percussion.
  • Lateral percussion: The patient sits with his hands held over the head.

Anterior Chest Wall

  • Clavicular
  • Supraclavicular (Kronig’s isthumus)
  • Infraclavicular
  • 2nd to 6th intercostal spaces

Lateral Chest Wall

  • Fourth to seventh intercostal spaces

Posterior Chest Wall

  • Suprascapular (above the spine of the scapula)
  • Interscapular region
  • Infrascapular region up to the 11th rib

Right Side

  • Liver dullness (Upper border)
  • Tidal Percussion

Left Side

  • Traube’s Space
  • Cardiac dullness

D. Auscultation

Auscultatory areas are as following

  • Anteriorly: From an area above the clavicle down to the 6th rib
  • Axilla: Area upto the 8th rib
  • Posteriorly: Above the level of the spine of the scapula down to the 11th rib

What to observe?

Type of breath sounds 

  • Vesicular
  • Bronchial
  • Vesicular with prolonged espiration

Absent Breath Sounds

Added Sounds

  • Crackles
  • Rhonchi

Pleural rub

Pleuro-pericardial rub

Voice Sounds

  • Vocal resonance

Other foreign sounds

  • Stridor

Special Tests (If required)

  • Heimlich’s manoeuvre
  • Post-tussive suction
  • Succussion splash
  • Coin test
  • DeEspine’s sign
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