Why Respiratory Examination Is Always Examined
Respiratory examination is one of the most technically demanding OSCE stations — not because the findings are rare, but because the examination has many components that must be performed in a specific order and interpreted accurately. The commonest failures are: forgetting to examine the back, not performing vocal resonance, and being unable to explain the signs of consolidation vs effusion vs pneumothorax.
💡 Tip
Start every respiratory examination station by saying: "I'd like to perform a respiratory examination. I'll need to expose your chest and examine both the front and back — is that okay?" Explicitly mentioning the back in your opening statement signals to the examiner you know the full examination, before you've even started.
The Sequence
End of bed → Hands → Face → Neck and trachea → Chest (inspection → palpation → percussion → auscultation → vocal resonance) — front AND back
1. End of Bed
- Does the patient look well or unwell, breathless at rest?
- Respiratory rate — count for a full 30 seconds while appearing to check the pulse (patients slow their breathing if they know you're counting)
- Accessory muscle use — sternocleidomastoid, scalenes
- Pursed-lip breathing — COPD (creates auto-PEEP to prevent small airway collapse)
- Cyanosis — central (tongue) vs peripheral (fingers)
- Sputum pot — note colour and consistency
- Oxygen delivery device — nasal cannulae, venturi mask, non-rebreather
- Inhaler devices by the bedside
💎 Clinical Pearl
Always count respiratory rate from the end of the bed before approaching. Once you're next to the patient taking the pulse, they subconsciously regulate their breathing. A truly accurate RR is your most sensitive vital sign — it deserves proper technique.
2. Hands
| Sign | Significance |
|---|---|
| Clubbing | Lung cancer, bronchiectasis, idiopathic pulmonary fibrosis, mesothelioma, empyema |
| Peripheral cyanosis | Poor perfusion or cold |
| Tar staining | Active smoker |
| Fine tremor | Salbutamol toxicity (beta-agonist side effect) |
| Flapping tremor (CO₂ retention flap) | Hypercapnia — ask patient to hold arms out, wrists dorsiflexed for 15 seconds |
Radial pulse: Rate and rhythm (atrial fibrillation is associated with pneumonia and pulmonary embolism).
Bounding pulse — hypercapnia causes peripheral vasodilation.
3. Face and Neck
- Central cyanosis — blue tongue/buccal mucosa (desaturation >85%)
- Conjunctival pallor — anaemia (worsens breathlessness)
- Horner's syndrome (ptosis, miosis, anhidrosis) — Pancoast tumour of the lung apex compressing the sympathetic chain
JVP:
- Raised in cor pulmonale (right heart failure secondary to chronic lung disease)
- Raised + tracheal deviation = tension pneumothorax (don't forget this combination)
4. Trachea
Palpate in the suprasternal notch with the middle finger, flanked by index and ring fingers to detect deviation.
| Tracheal position | Cause |
|---|---|
| Central | Normal |
| Deviated toward the abnormal side | Collapse (volume loss pulls the trachea) |
| Deviated away from the abnormal side | Tension pneumothorax, massive effusion, large mass |
⚠️ Red Flag
Tracheal deviation toward the same side = collapse (volume loss pulls structures toward it). Tracheal deviation away = tension pneumothorax or massive effusion (volume increase pushes structures away). Confusing these in an OSCE loses marks on the interpretation question — know both.
5. Chest — Inspection
Look at both front and back:
- Shape: barrel chest (COPD — increased AP diameter, horizontal ribs), pectus excavatum/carinatum, kyphoscoliosis
- Asymmetry: one side moving less than the other?
- Scars: thoracotomy, video-assisted thoracoscopic surgery (VATS) ports, chest drain sites
- Radiotherapy skin changes: hyperpigmentation, telangiectasia
6. Palpation — Chest Expansion
Place your hands on the patient's chest, thumbs meeting in the midline (not touching the chest), fingers spread. Ask them to take a deep breath in. Your thumbs should move apart symmetrically by at least 5cm.
Reduced expansion on one side suggests pathology on that side.
7. Palpation — Tactile Vocal Fremitus
Place the ulnar edge of your hand on the chest. Ask the patient to say "99" in a low-pitched voice. Feel the vibration transmitted through the lung:
| Finding | Cause |
|---|---|
| Increased fremitus | Consolidation (solid lung transmits vibration better) |
| Decreased/absent fremitus | Effusion (fluid absorbs vibration), pneumothorax (air doesn't transmit), collapse |
8. Percussion
Percuss systematically — compare side to side at each level. Never percuss the same spot twice without moving.
Place your non-dominant middle finger firmly on the chest (parallel to the ribs), strike with the tip of the dominant middle finger using a quick wrist-flick movement.
| Note | Cause |
|---|---|
| Resonant | Normal aerated lung |
| Dull | Consolidation, collapse, pleural thickening |
| Stony dull | Pleural effusion (the dullest possible note) |
| Hyperresonant | Pneumothorax, emphysema |
Percuss the liver (right side, below 6th rib anteriorly should be dull) and the heart (cardiac dullness left of sternum, 3rd–5th ICS).
💎 Clinical Pearl
The distinction between dull and stony dull is important and examiner-tested. Consolidation and collapse produce a dull note. A pleural effusion produces a stony dull note — the flattest, most leaden sound you can hear on percussion. Practise on real patients to recognise the difference.
9. Auscultation
Auscultate with the diaphragm, comparing side to side. Cover at least 3 levels anteriorly and 3 posteriorly. Listen in the axillae too (where lobar pathology is often most pronounced).
Ask the patient to breathe in and out through their mouth (not nose).
Breath Sounds
| Finding | Cause |
|---|---|
| Vesicular | Normal (soft, rustling, longer on inspiration) |
| Bronchial | Consolidation (hollow, tubular, equal inspiration and expiration, with a gap between) |
| Reduced/absent | Effusion, pneumothorax, collapse, obesity |
Added Sounds
| Sound | Description | Cause |
|---|---|---|
| Coarse crackles | Low-pitched, early-inspiratory | Secretions — bronchiectasis, pneumonia (coarse) |
| Fine crackles | High-pitched, late-inspiratory, like Velcro | Pulmonary fibrosis, early pulmonary oedema |
| Early inspiratory crackles | Short burst at start of inspiration | COPD |
| Wheeze | Musical, expiratory (mainly) | Asthma, COPD, cardiac asthma |
| Monophonic wheeze | Single pitch, fixed | Tumour or foreign body causing fixed obstruction |
| Stridor | Harsh, inspiratory | Upper airway obstruction |
| Pleural rub | Leathery, creaking — heard on both inspiration and expiration, sounds close to the ear | Pleuritis (PE, pneumonia, pleurisy) |
🧠 Mnemonic
Fine vs coarse crackles:
- Fine = Fibrosis (or oedema) — late inspiratory, like Velcro (fine crackles = Velcro)
- Coarse = COPD/Chest infection — earlier, bubblier
Fine crackles = fibrosis/oedema. Coarse crackles = secretions/infection.
10. Vocal Resonance
Place the stethoscope on the chest and ask the patient to say "99". This is the auscultatory equivalent of tactile fremitus:
- Increased (louder/clearer "99") — consolidation
- Decreased/absent — effusion, pneumothorax
- Whispering pectoriloquy — whispered "99" sounds unusually clear = consolidation
- Aegophony — "99" sounds like "ee" = at the top of an effusion
The Three Key Patterns — Know These Cold
| Consolidation | Effusion | Pneumothorax | |
|---|---|---|---|
| Expansion | Reduced ipsilateral | Reduced ipsilateral | Reduced ipsilateral |
| Trachea | Central (or toward in collapse) | Deviated away (if large) | Deviated away (if tension) |
| Fremitus | Increased | Decreased/absent | Decreased/absent |
| Percussion | Dull | Stony dull | Hyperresonant |
| Breath sounds | Bronchial | Reduced/absent | Reduced/absent |
| Vocal resonance | Increased | Decreased | Decreased |
💡 Tip
Learn this table. Examiners will give you a set of signs and ask you to name the diagnosis, or give you a diagnosis and ask for the expected signs. This 3×6 table is the most high-yield knowledge for respiratory examination OSCEs.
How to Present Your Findings
"On examination, the patient appeared [well/breathless at rest]. The respiratory rate was [rate] per minute. Peripherally, I found [clubbing/cyanosis/other or none]. The trachea was [central/deviated]. Chest expansion was [equal bilaterally / reduced on the left/right]. On percussion, there was [resonance bilaterally / dullness / stony dullness / hyperresonance] at [location]. On auscultation, breath sounds were [vesicular / bronchial / reduced] with [added sounds or none]. Vocal resonance was [normal / increased / decreased]. In summary, these findings are consistent with [consolidation/effusion/pneumothorax/COPD/fibrosis], and I would like to confirm with [CXR/CT/ABG]."
Common Examiner Follow-Up Questions
"You've found stony dullness at the left base with reduced breath sounds — what is the most likely diagnosis and how would you investigate?"
"These signs are consistent with a left pleural effusion. I would confirm with a CXR and ultrasound. I would then perform a diagnostic pleural tap, sending the fluid for protein and LDH (to classify as transudate or exudate using Light's criteria), cytology, MC&S, pH, and glucose. Transudate causes include cardiac failure, hypoalbuminaemia, and hypothyroidism. Exudate causes include malignancy, infection, and pulmonary embolism."
"What is the difference between bronchial and vesicular breath sounds?"
"Vesicular breath sounds are soft and rustling, heard predominantly on inspiration, with a gentle fade into expiration and no gap between the two phases. They are normal. Bronchial breath sounds are louder, higher-pitched, and tubular in quality — inspiration and expiration are equal in length with a distinct pause between them. They are heard normally over the trachea and are pathological over lung tissue, where they indicate consolidation."