01Purpose and principlesWhat the assessment is for and the core concepts behind it.
A respiratory examination has two jobs. The first is immediate safety: detect airway obstruction, respiratory fatigue, gas-exchange failure and shock. The second is Bayesian: change the probability and anatomical localisation of disease. Signs rarely work alone. Reduced expansion, stony dullness and quiet breath sounds together support pleural effusion more strongly than any component; tachypnoea, bronchial breathing and focal crackles support consolidation; hyperinflation, quiet sounds and prolonged expiration support obstructive physiology but still require spirometric confirmation when stable.
Use a consistent sequence while adapting to disability, pain, infection control and the clinical question. Obtain consent, expose respectfully and examine anterior and posterior chest. Inspection includes scars, deformity, inhalers, drains, oxygen and work of breathing. Palpation covers trachea, expansion and selected tactile findings. Percussion compares matched sites. Auscultation uses quiet deep breaths through the mouth when tolerated and adds vocal resonance only where it will discriminate consolidation from fluid. Examine the cardiovascular system and legs when congestion or embolism is plausible.
Technique and context determine accuracy. Crackles can clear after coughing, obesity can damp percussion and breath sounds, and supine portable examination reduces basal access. Document objective features rather than vague labels such as 'chesty'. A normal respiratory examination does not exclude pulmonary embolism, early interstitial disease, asthma between attacks or a small pneumothorax; it directs but does not replace appropriate imaging and physiology.
Key points
- Observe before touching: respiratory rate, speech, posture, pattern, accessory-muscle use, symmetry, audible sounds, cough, sputum and oxygen device often reveal severity immediately.
- Record oxygen saturation, device and target alongside pulse, blood pressure, temperature and mental state; an examination without physiology cannot grade acute illness.
- Hands can show clubbing, nicotine staining, peripheral cyanosis, fine beta-agonist tremor or coarse carbon-dioxide-retention flap, but each sign needs clinical context.
- Compare both sides systematically: tracheal position, expansion, percussion note, breath-sound intensity and added sounds localise pleural, parenchymal and airway abnormalities.
- Dull percussion with reduced breath sounds and expansion supports pleural fluid; hyperresonance with reduced sounds supports pneumothorax, but body habitus and technique limit accuracy.
- Bronchial breathing and focal crackles support consolidation; fine late inspiratory crackles suggest interstitial or oedematous processes; wheeze indicates narrowed airflow but not its cause.
- Complete the respiratory examination with cervical and supraclavicular nodes, jugular venous pressure, heart, legs and relevant abdomen because cancer, heart failure and thromboembolism cross organ boundaries.
- End with a synthesis stating severity, localisation, likely mechanism, important alternatives and the next investigation that will test the conclusion.
02Indications, selection and cautionsWhen it is useful, when urgency changes and important limitations.
Stridor, drooling, inability to speak, silent chest, paradoxical breathing, exhaustion, falling respiratory rate or reduced consciousness indicates threatened airway or ventilation. Routine examination should stop while help and respiratory support are mobilised.
Focal reduced expansion, dull percussion, bronchial breathing, inspiratory crackles and increased vocal resonance supports air-space consolidation. Fever and cough strengthen pneumonia, but haemorrhage, infarction and malignancy can produce similar signs.
Reduced expansion, stony dull percussion, diminished breath sounds and reduced vocal resonance over a dependent region supports pleural fluid; a large effusion may displace the trachea away. Ultrasound confirms fluid and guides intervention.
Unilateral reduced expansion and air entry with hyperresonance supports pneumothorax. Severe distress, hypotension, distended neck veins or rapidly deteriorating physiology raises tension, which is treated clinically before radiography.
Prolonged expiration, diffuse wheeze, hyperinflation and accessory-muscle use supports airflow obstruction. A silent chest in a distressed patient is more dangerous than loud wheeze; cardiac oedema and central obstruction can also wheeze.
Fine end-inspiratory basal crackles suggest interstitial fibrosis or pulmonary oedema. Clubbing and dry cough favour fibrotic disease; raised JVP, oedema and orthopnoea favour congestion, but imaging and cardiac assessment are needed.
03Method and interpretationA systematic approach to the test and its findings.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Complete observations and NEWS2First step - Why
- Quantify physiological severity and trigger the appropriate acute response.
- Interpretation and limitations
- Respiratory rate and oxygen requirement may deteriorate before dramatic auscultatory change. NEWS2 supports escalation but does not overrule clinician concern or a focal emergency sign such as stridor.
- 02
Pulse oximetry and arterial blood gas - Why
- Assess oxygenation and, when needed, ventilation and acid-base status.
- Interpretation and limitations
- Record the oxygen device and target. Normal saturation does not exclude hypercapnia; obtain blood gas for severe disease, drowsiness, exhaustion or recognised hypercapnic risk.
- 03
Chest radiograph - Why
- Test examination localisation for air, fluid, consolidation, oedema or focal lesion.
- Interpretation and limitations
- Compare projection and prior films. Radiography can confirm a suspected syndrome but may be normal in embolism, mild asthma or early disease; tension pneumothorax treatment must not wait.
- 04
Thoracic ultrasound - Why
- Confirm pleural fluid, assess peripheral consolidation and support pneumothorax assessment at the bedside.
- Interpretation and limitations
- Ultrasound is mandatory before pleural-fluid intervention. Findings are operator-dependent, and absent lung sliding or B-lines are not disease-specific; use CT or radiography when the question remains unresolved.
- 05
Spirometry and full pulmonary function testing - Why
- Confirm and quantify the obstructive or restrictive physiology suggested by examination.
- Interpretation and limitations
- Do not perform forced testing during significant acute distress. In stable disease, quality-assured obstruction requires a reduced ratio; total lung capacity confirms restriction, and gas transfer helps distinguish parenchymal, vascular and emphysematous processes.
- 06
ECG, natriuretic peptide and echocardiography - Why
- Investigate cardiac disease when crackles, oedema, raised JVP, murmur or orthopnoea suggests it.
- Interpretation and limitations
- Natriuretic peptide supports a referral pathway rather than independently diagnosing heart failure. Echocardiography characterises ventricular and valve disease; pulmonary and cardiac causes commonly coexist.
04Clinical next stepsHow the result changes management or prompts escalation.
01OpeningSafety before ritualFirst stepEvery respiratory examination, especially an acutely unwell patient.+
- 1Observe from the end of the bed, assess speech, breathing effort, pattern, colour, posture and equipment, then measure observations and identify the prescribed oxygen target.
- 2If airway, ventilation or circulation is threatened, switch immediately to ABCDE, call help and treat; do not complete an examination sequence for presentation's sake.
- 3When stable, introduce yourself, confirm consent, position the patient, expose the chest respectfully and adapt for pain, mobility, hearing or infection-control needs.
02Core sequenceCompare and localiseA stable patient requiring a full respiratory examination.+
- 1Inspect hands, face, neck and chest for clubbing, cyanosis, anaemia, nodes, tracheal deviation, scars, deformity and respiratory effort; check pulse and relevant venous pressure.
- 2Palpate trachea and bilateral expansion, then percuss matched anterior, lateral and posterior areas, noting whether dullness or hyperresonance follows an anatomical boundary.
- 3Auscultate matched areas for breath-sound intensity and character, timing and quality of crackles, wheeze or rub; ask the patient to cough and reassess sounds that may represent secretions.
- 4Add vocal resonance only when distinguishing consolidation from effusion, and complete nodes, cardiovascular examination, legs and abdomen as the suspected disease requires.
03SynthesisTurn signs into a decisionAfter completing the examination or finding a material focal abnormality.+
- 1State acute severity first, including oxygen and work of breathing, then localise the abnormality and name the supported syndrome rather than declaring an aetiology prematurely.
- 2AlternativeGive the leading diagnosis and at least one dangerous or plausible alternative, explicitly noting signs that do not fit.
- 3Select the next test that will discriminate the alternatives—radiograph or ultrasound for focal pleural signs, blood gas for ventilatory failure, spirometry when stable for obstruction, or CT for unexplained focal or diffuse disease.
- 4Re-examine after treatment or deterioration because physical signs and secretion burden are dynamic.
04Limited examinationWhen positioning or cooperation is restrictedPain, frailty, critical illness, neurodisability or inability to sit forward.+
- 1Prioritise observation and physiology, use supported positioning and examine accessible anterior and lateral zones without causing unsafe exertion.
- 2Document the limitation explicitly and use bedside ultrasound or portable radiography when posterior findings cannot be assessed reliably.
- 3Seek collateral baseline and repeat examination after analgesia, suction or stabilisation rather than recording an apparently normal incomplete assessment.
05Risks, monitoring and follow-upComplications, safety checks and further assessment.
- Record respiratory rate, SpO2, oxygen device and target, work of breathing, pulse, blood pressure, temperature and consciousness with the examination findings.
- Repeat focal examination after coughing, analgesia, bronchodilation, diuresis or pleural intervention to test whether the proposed mechanism and response align.
- Track new or increasing oxygen requirement even when the saturation remains within target, because support can mask physiological deterioration.
- Document drains, tracheostomy, non-invasive ventilation or inhaler technique and check that equipment function fits the clinical findings.
- Ensure abnormal signs lead to a named investigation, result review and escalation plan rather than remaining an isolated examination note.
06Special situationsVariants, exceptions and circumstances that change the usual approach.
Auscultation is comparative
Breath sounds vary with habitus, effort and room noise. Side-to-side comparison at matched levels is more reliable than judging an isolated area against an imagined universal normal.
Crackles have timing and character
Fine late inspiratory crackles suggest opening of small distal airways in fibrosis or oedema; coarse sounds may reflect larger-airway secretions and can change after coughing. Neither is a diagnosis alone.
Tracheal deviation has competing forces
Large pleural air or fluid can push the trachea away, while upper-lobe collapse or fibrosis can pull it towards disease. Neck anatomy and rotation can create false asymmetry.
Wheeze can be focal
A persistent monophonic or localised wheeze raises central airway obstruction from tumour, foreign body or stenosis and merits imaging or bronchoscopy rather than routine escalation of asthma treatment.
Normal signs do not end reasoning
Pulmonary embolism, early interstitial disease and interval asthma can have little to find at rest. The history and physiological trajectory still determine appropriate testing.
07Common pitfallsFrequent interpretation and management errors.
- 01
Completing a ceremonial examination while missing obvious respiratory fatigue or stridor.
- 02
Writing 'chest clear' without recording air entry, added sounds, oxygen and work of breathing.
- 03
Calling all basal crackles infection and overlooking oedema or fibrosis.
- 04
Calling all wheeze asthma and missing pulmonary oedema or focal central obstruction.
- 05
Diagnosing pleural effusion from dullness without ultrasound before intervention.
- 06
Treating a normal examination as exclusion of pulmonary embolism or early disease.