Respiratory System OSCE Examination

Contents

1. Introduction
2. General Inspection
3. Hand Examination
4. Pulse and Respiratory Rate
5. Face, Eyes and Mouth
6. Neck Examination
7. Chest Inspection
8. Chest Palpation
9. Chest Percussion
10. Chest Auscultation
11. Posterior Chest Examination
12. Completing the Examination
13. Quiz

Introduction

Wash your hands (or apply alcohol gel) before approaching the patient, as good hand hygiene reduces the risk of healthcare-associated infection.

Introduce yourself to the patient and ensure to mention your grade e.g. 3rd year medical student/junior doctor/consultant.

Confirm the patient’s details taking 3 points of identification usually; full name, date of birth and NHS/hospital number.

Obtain consent for the examination, ensuring to explain what the examination will entail.

Position the patient appropriately at 45^o on the bed, as this is the standard position for assessing the jugular venous pressure later in the examination and is comfortable for breathless patients.

Expose the patient’s chest appropriately so the chest wall, neck and arms can be inspected, being mindful of patient dignity throughout.

Ask the patient if they are in any pain before you begin, particularly chest or shoulder pain, as several manoeuvres involve touching the chest wall.

General Inspection

Take a step back and observe the patient from the end of the bed. The aim is to form an overall impression of how unwell they are and to pick up clues before laying a hand on them.

Look at the patient’s comfort and work of breathing. A patient who is short of breath at rest, using their accessory muscles (sternocleidomastoid and scalenes) or sitting forward to fix their shoulder girdle is in respiratory distress. Pursed-lip breathing, in which the patient breathes out slowly through narrowed lips, is commonly seen in chronic obstructive pulmonary disease (COPD); it generates a small amount of positive pressure in the airways which splints them open and reduces the air trapping that occurs when floppy small airways collapse on expiration.

Listen for audible noises. A wheeze heard without a stethoscope suggests significant airway narrowing (asthma or COPD), while stridor (a harsh inspiratory sound) suggests upper airway obstruction and is a red flag. A cough may be dry or productive, and its character can point towards the underlying diagnosis.

Note the respiratory pattern. Prolonged expiration is typical of obstructive disease such as COPD, where narrowed airways slow the outflow of air. Paradoxical (abdominal) breathing, in which the abdomen moves inwards on inspiration, is a sign of diaphragmatic fatigue and impending respiratory failure. Cheyne-Stokes breathing (cyclical waxing and waning of breathing depth with apnoeic pauses) may be seen in advanced heart failure or with central nervous system pathology.

Assess the colour of the patient. Central cyanosis gives a bluish tinge to the skin and is caused by an excess of deoxygenated haemoglobin, indicating hypoxaemia. A plethoric (red, congested) complexion may indicate polycythaemia, where chronic hypoxia drives the kidneys to produce more erythropoietin and therefore more red cells, or carbon dioxide retention.

Look around the bedside for clues about the diagnosis and its severity:

• Oxygen delivery devices (nasal cannulae, masks) and the flow rate being delivered.
• Inhalers, spacers or nebulisers, suggesting asthma or COPD.
• A sputum pot – its contents are informative (purulent sputum in infection, copious volumes in bronchiectasis, frothy pink sputum in pulmonary oedema, blood in haemoptysis).
• Mobility aids, a peak flow meter, or a cigarette packet.

Hand Examination

Pick up the patient’s hands and inspect them carefully, as they carry a surprising number of respiratory signs.

Look for tar staining of the fingers, a yellow-brown discolouration caused by the tar in cigarette smoke. It is a marker of smoking, which is the single biggest risk factor for COPD and lung cancer. (Note that nicotine itself is colourless – the staining is from tar.)

Inspect the nails for finger clubbing, in which there is soft-tissue swelling of the terminal phalanx and loss of the normal angle between the nail and nail fold. It can be confirmed with Schamroth’s window test: when the dorsal surfaces of two opposing fingers are placed together, a normal person has a small diamond-shaped window, which is obliterated in clubbing. The exact mechanism is not fully understood but is thought to involve megakaryocytes and platelet clumps bypassing the lungs and releasing growth factors in the fingertips. Respiratory causes include lung cancer, bronchiectasis, cystic fibrosis, interstitial lung disease and chronic suppurative conditions such as lung abscess and empyema.

Image - Finger clubbing showing loss of the normal nail-bed angle. In a respiratory context this raises suspicion of lung cancer, bronchiectasis or interstitial lung disease

Creative commons source by Russellpa [CC BY-SA 3.0 (https://creativecommons.org/licenses/by-sa/3.0)]

Look at the skin of the hands and forearms. Thin, bruised skin may reflect long-term corticosteroid use in asthma, COPD or interstitial lung disease. Peripheral cyanosis – a bluish tinge confined to the fingertips – reflects sluggish peripheral perfusion rather than central hypoxaemia, although in respiratory failure the two often coexist.

Feel the temperature of the hands. Warm, well-perfused peripheries with a bounding pulse can be a sign of carbon dioxide retention, which causes peripheral vasodilatation.

With the arms outstretched, look first for a fine tremor. This is a rapid, low-amplitude shake most often caused by beta-2 agonist inhalers such as salbutamol, and its presence is a useful clue that the patient is being treated for asthma or COPD.

Then assess for asterixis (a ‘CO₂ retention flap’) by asking the patient to hold their arms out straight with the wrists cocked back for around 30 seconds. A coarse, irregular flapping tremor is caused by the effect of hypercapnia (high blood CO₂) on the brainstem, seen in type 2 respiratory failure. The same sign can occur in hepatic encephalopathy and uraemia, so it must be interpreted in context.

Pulse and Respiratory Rate

Palpate the radial pulse, assessing its rate and rhythm. The normal resting rate is 60–100 bpm. A tachycardia may accompany hypoxia, infection, anxiety or salbutamol use, while an irregularly irregular pulse suggests atrial fibrillation, which can be precipitated by respiratory disease such as pneumonia or pulmonary embolism. Feeling both radial pulses together to check for radio-radial delay is sometimes included; a delay between the two sides can be caused by a large mass at the lung apex compressing the subclavian artery.

A bounding pulse with warm hands again raises the possibility of carbon dioxide retention and its associated vasodilatation.

While appearing to take the pulse, discreetly count the respiratory rate over a full period of breathing. Counting it openly tends to make patients alter their breathing pattern. The normal adult rate is 12–20 breaths per minute. Tachypnoea (a raised rate) is a sensitive early marker of respiratory or systemic illness and is a key component of the NEWS2 early-warning score used throughout the NHS, while bradypnoea may indicate exhaustion, sedation or central nervous system depression.

Face, Eyes and Mouth

Inspect the face generally. A plethoric appearance again suggests polycythaemia or CO₂ retention. Look for the features of Cushing’s syndrome (a rounded ‘moon’ face), which may result from long-term oral steroids.

Look at the eyes for the triad of Horner’s syndrome – ptosis (drooping eyelid), miosis (constricted pupil) and anhidrosis (loss of sweating on that side of the face). Horner’s syndrome arises when the sympathetic chain is interrupted, and in a respiratory examination the classic cause is a Pancoast tumour at the lung apex compressing the sympathetic nerves. Pull down the lower eyelids to look for conjunctival pallor, a sign of anaemia, which may contribute to breathlessness.

Inspect the mouth and under the tongue for central cyanosis, seen as a bluish discolouration of the lips, tongue and oral mucosa. Because it affects the well-perfused central mucous membranes, it specifically indicates a low arterial oxygen saturation and is a more reliable marker of hypoxaemia than peripheral cyanosis. Also look for oral candidiasis (white plaques), which is common in patients using inhaled corticosteroids who do not rinse their mouth afterwards.

Image - Bluish discolouration of the lips (central cyanosis) and fingertips. Central cyanosis indicates hypoxaemia (a low arterial oxygen saturation)

Creative commons source by Göttgens et al. [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)]

Neck Examination

Assess the jugular venous pressure (JVP) with the patient at 45^o and their head turned slightly to the left. The internal jugular vein lies between the two heads of the sternocleidomastoid, and the vertical height of its pulsation above the sternal angle estimates right atrial pressure. A raised JVP in a respiratory patient suggests cor pulmonale – right heart failure caused by chronic lung disease. Chronic hypoxia causes pulmonary vasoconstriction and a rise in pulmonary arterial pressure, which the right ventricle must work against; over time it fails, and the back-pressure raises the JVP. A fixed, non-pulsatile, raised JVP that does not change with respiration suggests superior vena cava obstruction, classically caused by a mediastinal tumour.

Image - The jugular venous pulse is measured vertically above the sternal angle with the patient reclined at 45 degrees. A raised JVP in a respiratory patient points towards cor pulmonale

SimpleMed original

Palpate the position of the trachea by gently placing a finger either side of it in the suprasternal notch (warn the patient that this is briefly uncomfortable). The trachea should sit centrally. Deviation away from a lesion occurs when something pushes the mediastinum across, such as a large pleural effusion or a tension pneumothorax. Deviation towards a lesion occurs when volume is lost on that side, such as in lobar collapse or a pneumonectomy. Also assess the cricosternal distance (normally three to four finger-breadths); a reduced distance reflects lung hyperinflation in COPD.

Palpate the lymph nodes of the neck from behind, including the submental, submandibular, pre- and post-auricular, occipital, cervical chains and supraclavicular nodes. Lymphadenopathy may indicate infection or malignancy; the supraclavicular nodes are of particular concern, with the left one (Virchow’s node) classically reflecting intrathoracic or abdominal malignancy.

Chest Inspection

With the chest fully exposed, inspect it from the front (and later from behind). Comment on the shape of the chest and any deformities:

• Barrel chest – an increased anteroposterior diameter caused by chronic lung hyperinflation in COPD.
• Pectus excavatum – a sunken sternum, and pectus carinatum – a protruding ‘pigeon’ chest. Both are congenital and can affect respiratory mechanics.
• Kyphosis and scoliosis – spinal curvatures that can restrict chest wall expansion and lung volumes.

Look for scars, which give away the patient’s surgical history: a thoracotomy scar (running below the scapula) may follow a lobectomy or pneumonectomy, while small chest drain scars indicate previous pneumothorax or effusion drainage. Note any asymmetry of chest movement, visible pulsations, or use of accessory muscles on inspection.

Chest Palpation

Confirm the patient is not in pain, then palpate the chest systematically.

Locate the apex beat, normally in the fifth intercostal space in the mid-clavicular line. Displacement may reflect mediastinal shift from a large effusion or pneumothorax, or right ventricular enlargement in cor pulmonale. It can be difficult to feel in hyperinflated COPD chests.

Assess chest expansion. Place your hands symmetrically on the chest wall with your thumbs lifted just off the skin so they move freely, and ask the patient to take a deep breath in. Your thumbs should move apart equally. Reduced expansion on one side indicates pathology on that side (such as a large pleural effusion, pneumothorax, consolidation or collapse), because the affected lung cannot inflate normally. Symmetrically reduced expansion is seen in conditions that stiffen both lungs, such as interstitial lung disease, or that limit airflow, such as COPD.

Assess tactile vocal fremitus by placing the ulnar border of your hand on the chest and asking the patient to repeat ‘ninety-nine’ while you compare both sides. The vibrations of speech are transmitted to the chest wall, and how well they conduct depends on what lies beneath. Increased fremitus occurs over consolidation, where solid lung tissue conducts sound better than air. Reduced fremitus occurs when something separates the lung from the chest wall, such as a pleural effusion or pneumothorax. (Tactile vocal fremitus and vocal resonance test the same principle, so in practice only one is usually performed.)

Chest Percussion

Percuss the chest by placing your non-dominant middle finger flat against the chest wall and striking its middle phalanx with the tip of your dominant middle finger. Compare like-for-like areas on both sides, working down the chest and including the axillae and the lung apices above the clavicles. The note produced reflects what lies beneath the chest wall:

• Resonant – the normal note over healthy, air-filled lung.
• Dull – over increased tissue density, such as consolidation or collapse, because solid or fluid-filled tissue absorbs the percussion energy.
• Stony dull – an especially flat, dull note that is the hallmark of a pleural effusion, where a layer of fluid lies between lung and chest wall.
• Hyper-resonant – an unusually booming note suggesting excess air, as in a pneumothorax or a hyperinflated COPD chest.

Chest Auscultation

Auscultate with the diaphragm of the stethoscope, comparing both sides at each level and asking the patient to take steady breaths in and out through an open mouth. First characterise the breath sounds:

• Vesicular breath sounds are the normal soft, rustling sounds of air moving through healthy lung, louder on inspiration with no gap before expiration.
• Bronchial breathing is harsh and blowing, with inspiration and expiration of equal length and an audible gap between them, similar to listening over the trachea. It indicates consolidation, where solid lung transmits the central airway sounds directly to the chest wall.
• Reduced or absent breath sounds occur when air, fluid or collapsed lung prevents sound reaching the stethoscope, as in a pleural effusion or pneumothorax.

Then listen for added sounds:

• Wheeze – a continuous, musical, whistling sound, usually loudest on expiration, produced by air passing through narrowed airways. It is typical of asthma and COPD. A widespread polyphonic wheeze suggests diffuse airway narrowing, whereas a fixed monophonic wheeze may indicate localised obstruction by a tumour or foreign body.
• Crackles – discontinuous popping sounds caused by the sudden reopening of small airways. Fine, late-inspiratory crackles suggest pulmonary oedema or interstitial lung disease, while coarse crackles suggest pneumonia or bronchiectasis. Crackles that clear on coughing are usually not significant.
• Pleural rub – a creaking, ‘leather-on-leather’ sound caused by inflamed pleural surfaces rubbing together, heard in pleurisy or pulmonary embolism.

Finally, assess vocal resonance by listening over the chest while the patient repeats ‘ninety-nine’. The findings mirror tactile vocal fremitus: increased resonance over consolidation and reduced resonance over an effusion or pneumothorax. Over consolidation, whispered words can become abnormally clear (whispering pectoriloquy).

It is worth memorising how the palpation, percussion and auscultation findings cluster together, as recognising the pattern lets you reach a diagnosis quickly in an OSCE. Consolidation gives reduced expansion, dull percussion, increased fremitus and resonance, bronchial breathing and crackles. A pleural effusion gives reduced expansion, stony dull percussion, reduced fremitus and resonance and reduced breath sounds. A pneumothorax gives reduced expansion, hyper-resonant percussion, reduced fremitus and reduced breath sounds. Lobar collapse gives reduced expansion, dull percussion and reduced breath sounds, often with the trachea pulled towards the affected side.

Image - Chest X-ray of a large left-sided pleural effusion. On examination this would produce a stony dull percussion note, reduced breath sounds and reduced vocal resonance over the effusion

Creative commons source by Clinical Cases [CC BY-SA 2.5 (https://creativecommons.org/licenses/by-sa/2.5)]

Posterior Chest Examination

Ask the patient to sit forward and fold their arms across the chest, which rotates the scapulae out of the way and gives better access to the lung fields. The back of the chest is where most clinically significant findings are detected, because the lung bases lie posteriorly.

Repeat the full sequence on the back: inspect for scars and deformity, assess chest expansion, percuss all zones comparing side to side, assess tactile vocal fremitus or vocal resonance, and auscultate the breath sounds and any added sounds. Take care to reach the lung bases and the axillae, as basal crackles of pulmonary oedema, fibrosis or infection are easily missed if examination stops too high.

While the patient is sitting forward, press on the sacrum and palpate the ankles for peripheral oedema. Pitting oedema in a respiratory patient is an important sign of cor pulmonale, where right heart failure secondary to chronic lung disease causes fluid to accumulate in the dependent tissues.

Image - Pitting oedema, where firm pressure leaves a lasting indentation. In a breathless patient this suggests fluid overload from cor pulmonale

SimpleMed original

Completing the Examination

Thank the patient, help them to redress, and wash your hands.

Summarise your findings concisely and offer a differential diagnosis.

State that to complete the examination you would:

• Record a full set of observations, including oxygen saturations and a NEWS2 score.
• Measure a bedside peak expiratory flow rate and review the patient’s sputum pot.
• Perform a cardiovascular examination, as the heart and lungs are closely linked (for example in cor pulmonale).
• Request relevant investigations, such as a chest X-ray, an arterial blood gas if respiratory failure is suspected, spirometry, and blood tests including a full blood count and inflammatory markers.

Quiz

Open SimpleMed+