- Clinical science
The examination of the pulmonary system is a fundamental part of the physical examination that consists of inspection, palpation, percussion, and auscultation (in that order). Recognition of surface landmarks and their relationship to underlying structures is essential. The physical examination of the pulmonary system begins with the patient seated comfortably on the examination table and his/her upper body completely exposed. The chest and the patient's breathing pattern are then inspected, followed by palpation of the chest wall, percussion of the thorax, and auscultation of the lung fields. A carefully recorded medical history and thorough physical examination allow for differential diagnosis and prompt initiation of therapy.
The following should be assessed:
- Normal respiratory rate is 14–20/min in adults, and up to 44/min in infants
- Common abnormal patterns of breathing include:
- Cheyne-Stokes breathing: alternating periods of deep breathing followed by apnea
- Ataxic breathing: irregular breathing in rhythm and depth
- Obstructive breathing: prolonged exhalation
- Increased effort of breathing
Peripheral signs of respiratory dysfunction
- Cyanosis: bluish discoloration of the skin and mucosa
- Commonly chronic hypoxemia; (including congenital heart disease, cardiac shunts, interstitial lung disease, cystic fibrosis and lung cancer)
- COPD does not cause nail clubbing; and a COPD patient with nail clubbing is concerning for underlying malignancy.
- Can also be seen in ; : a syndrome (either hereditary or paraneoplastic) that manifests with painful nail clubbing, synovial effusions, and periostitis
- Painless swelling of connective tissue in the distal phalanges
- Lovibond's angle ≥ 180°: angle between the base of the nail and its surrounding skin
- Nail bed feels spongy when pressed and springs back when released.
- Schamroth's test
Abnormalities in the shape of the thorax
- The anteroposterior diameter of the thorax may increase in COPD, leading to a “barrel chest” appearance.
- Retraction of the intercostal spaces
- Asymmetric movement may be associated with pleural disease, phrenic nerve damage, or pleural effusion.
- Kyphosis or scoliosis may lead to decreased forced vital capacity, forced expiratory volume and overall respiratory function
Sputum production or secretions, if any
- White and translucent: viral infection (for example, bronchitis that presents with a typical early-morning cough)
- White and foamy: pulmonary edema
- Yellow-green: bacterial infection
- Green: an indication of a pseudomonal infection
- Grayish: pneumoconiosis, a waning bacterial infection
- Blackish-brown: possibly old blood; should be further investigated (can also be a harmless incidental finding)
- Friable: tuberculosis, actinomycosis
- : see section below
In newborn and infants
- Jugular, sternal, and intercostal retraction
- Nasal flaring or flaring of the nostrils
- Neck extension
- Definition: shortness of breath
- Onset : acute (minutes to hours) or chronic (weeks to months)
- Severe dyspnea: features of increased respiratory effort, fragmented speech, diaphoresis
- Imminent respiratory failure: fatigue, cyanosis, impaired mental status
- Secure airway (consider intubation)
- Stabilize cardiovascular function (IV fluids), perform arterial blood gas
- Perform screening examination to exclude reversible causes (e.g., tension pneumothorax, remove upper airway foreign body)
- ECG; and portable chest x-ray
- Perform further tests as required: peak flow and pulmonary function tests; , V/q scan if PE suspected, bronchoscopy
- Treat underlying cause
- Expectoration of blood
- Massive hemoptysis: 100–600 mL of coughed up blood in 24 hours
- (symptoms include SOB, cough, blood-tinged sputum)
- Severe lung inflammation: bronchiectasis, , , bronchitis
- Pulmonary vascular disorders: pulmonary embolism; , raised pulmonary capillary pressure (e.g., mitral stenosis)
- Airway trauma: incessant coughing, foreign body, iatrogenic
- Genetic disorders: Ehlers-Danlos syndrome
- Rheumatic and immune disorders: e.g., Goodpasture's syndrome, lupus pneumonitis
Approach for massive hemoptysis
- Dependent positioning if side of bleeding can be identified (e.g., position the patient in right-side down decubitus position if the right lung is bleeding)
- Secure airway (intubation)
- Stabilize cardiovascular function (IV fluids/transfusion)
- Stop bleeding (correct coagulopathy, flexible bronchoscopy with balloon tamponade, arteriography with embolization if other measures fail)
- Evaluate areas of tenderness or bruising
- Symmetry of chest expansion
- Tactile fremitus
- Hyperextend the nondominant middle finger and place the distal interphalangeal joint against the chest wall.
- Strike the joint with the other middle finger and evaluate the elicited sound.
- Always percuss both sides of the chest at the same level. Often the finding of asymmetry is more important than the specific percussion note that is heard.
- Physiological finding: resonant percussion note → a comparatively hollow and loud note
- Pathological findings
Assess diaphragmatic movement
- Move downwards while percussing over both sides of the chest wall.
- The transition point from resonant to dull percussion notes marks the approximate position of the diaphragm.
- Abnormally high transition points on one side may be seen in unilateral pleural effusion and unilateral diaphragmatic paralysis.
- The distance between the transition point on full expiration and the transition point on full inspiration is the extent of diaphragmatic excursion (normally 3.0-cm–5.5-cm).
Physiological breath sounds
- Soft and low pitched, through inspiration and part of expiration
- Heard over both lungs
- Intermediate intensity and pitch, through both inspiration and expiration
- Heard over 1st and 2nd intercostal spaces
- Loud and high pitched, through part of inspiration and all of expiration
- Heard over the sternum
- Very loud and high pitched, through both inspiration and expiration
- Heard over the neck
Pathological breath sounds
- Also known as adventitious or added sounds
- Types of pathological breath sounds
Crackles or rales: discontinuous, intermittent
- Fine : soft, high-pitched
- Coarse : loud, low-pitched
- Wheezes: musical, prolonged
- Rhonchi: low-pitched, snoring
- : high-pitched, over trachea which may occur on inspiration or expiration
- Pleural friction rub: scratchy, high-frequency sound
- Muffled or absent breath sounds: suggest presence of air or fluid between the lung and the chest wall
- Crackles or rales: discontinuous, intermittent
- Consider secretions (such as in bronchitis) if breath sounds clear after coughing
- Transmitted sounds
- Ask patient to whisper “ninety-nine” while auscultating.
- Normally this is barely audible.
- Clearly audible in the presence of consolidation
|Movement of the chest wall||Tactile fremitus||Bronchophony||Breath sounds|
|Pleural effusion||Dyspnea may be present||Asymmetric||Decreased||Dull||Decreased||Decreased|
|Pulmonary edema|| |
|Symmetric||Possibly increased||Dull||May be present||Fine or coarse crackles, depending on severity|
|Pneumothorax||Acute dyspnea||Asymmetric||Decreased or absent||Hyper-resonant||Absent or decreased|| |
Decreased or absent breath sounds
|Bronchial asthma1||Paroxysmal attacks of dyspnea, wheezing||Symmetric||Depends on the severity of the disease||Hyper-resonant||Depends on the severity of the disease|| |
Wheeze, a prolonged expiratory phase, possibly decreased breath sounds
|COPD1||Chronic cough|| |
|Wheeze, a prolonged expiratory phase when the disease is obstructive, decreased breath sounds in emphysema|
|Pneumonia2||Fever, dyspnea||Asymmetric||Increased||Dull||Increased|| |
|Symmetric but decreased||Decreased||Hyper-resonant|| |
|Lung fibrosis||Cachexia and weakness, dyspnea||Symmetric||Normal, partially increased|| |
|Normal, partially increased||Basal inspiratory crackles|
|Atelectasis||Pain may be present||Asymmetric||Decreased||Dull||Decreased||Decreased|
|Pulmonary embolism1|| |
|Possibly decreased||Possibly dull||Possibly decreased||Possibly decreased|
The following conditions frequently complicate the aforementioned pulmonary disease: 1pneumonia, 2pleural effusion, 3atelectasis.