• Clinical science

Pulmonary examination

Abstract

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.

Inspection

The following should be assessed:

  1. Breathing pattern
  2. Increased effort of breathing
    • Tachypnea
    • Use of accessory muscles of respirations during inspiration
    • Trachea off midline
    • Tripod position: patients with emphysema and respiratory distress will lean forward while sitting, resting with their hands on their knees.
  3. Peripheral signs of respiratory dysfunction
  4. 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
  5. 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
    • Hemoptysis: see section below
  6. In newborn and infants
    • Jugular, sternal, and intercostal retraction
    • Nasal flaring or flaring of the nostrils
    • Neck extension

References:[1][2][3]

Dyspnea

References:[1][2]

Hemoptysis

A chest x-ray, to determine the underlying pathology, is mandatory in all patients with hemoptysis. Patients with massive hemoptysis require stabilization before imaging!
References:[1][2][4]

Palpation

  • Evaluate areas of tenderness or bruising
  • Symmetry of chest expansion
    • Place both hands on the patient's back at the level of the 10th ribs with thumbs pointing medially and parallel to the rib cage.
    • As the patient inhales, evaluate for asymmetric movement of your thumbs.
  • Tactile fremitus
    • Ask the patient to say “toy boat” and feel for vibrations transmitted throughout the chest wall.
    • Can be asymmetrically decreased in effusion, obstruction, or pneumothorax, among others
    • Can be asymmetrically increased in pneumonia

References:[2]

Percussion

References:[2]

Auscultation

Physiological breath sounds

  • Vesicular breathing
    • Soft and low pitched, through inspiration and part of expiration
    • Heard over both lungs
  • Bronchovesicular breathing
    • Intermediate intensity and pitch, through both inspiration and expiration
    • Heard over 1st and 2nd intercostal spaces
  • Bronchial breathing
    • Loud and high pitched, through part of inspiration and all of expiration
    • Heard over the sternum
  • Tracheal breathing
    • 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
    • Stridor: 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
  • Consider secretions (such as in bronchitis) if breath sounds clear after coughing
  • Transmitted sounds
    • Bronchophony
      • Increased transmission of voice sounds
      • Ask patient to say “ninety-nine” in a normal voice while auscultating.
      • An asymmetric increase in voice transmission suggests a collapsed lung or atelectasis.
    • Egophony
      • Ask the patient to say “ee” while auscultating.
      • If it sounds like “A” rather than “E”, this is called egophony and suggests lobar pneumonia.
    • Whispered pectoriloquy
      • Ask patient to whisper “ninety-nine” while auscultating.
      • Normally this is barely audible.
      • Clearly audible in the presence of consolidation

References:[5][2]

Differential diagnoses of pulmonary conditions

Main symptom Palpation Percussion Auscultation
Movement of the chest wall Tactile fremitus Bronchophony Breath sounds
Physiological

-

Symmetric

Normal

Resonant Normal Vesicular
Pleural effusion Dyspnea may be present Asymmetric Decreased Dull Decreased Decreased
Pulmonary edema

Severe dyspnea

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

Symmetric

Possibly hyper-resonant

Wheeze, a prolonged expiratory phase when the disease is obstructive, decreased breath sounds in emphysema
Pneumonia2 Fever, dyspnea Asymmetric Increased Dull Increased

Coarse crackles

Emphysema

Chronic dyspnea

Symmetric but decreased Decreased Hyper-resonant

Decreased

Decreased

Lung fibrosis Cachexia and weakness, dyspnea Symmetric Normal, partially increased

Dull

Normal, partially increased Basal inspiratory crackles
Atelectasis Pain may be present Asymmetric Decreased Dull Decreased Decreased
Pulmonary embolism1

Acute dyspnea, pleuritic chest pain, tachypnea

Symmetric

Normal Normal Normal Normal
Tumor1,2,3

Hemoptysis, constitutional symptoms (weight loss, fever, night sweats)

Possibly asymmetric

Possibly decreased Possibly dull Possibly decreased Possibly decreased

The following conditions frequently complicate the aforementioned pulmonary disease: 1pneumonia, 2pleural effusion, 3atelectasis.

References:[2]

  • 1. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Boston, MA: Butterworths; 1990.
  • 2. Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins; 2012.
  • 3. Sarkar M, Mahesh D, Madabhavi I. Digital clubbing. Lung India. 2012; 29(4): p. 354. doi: 10.4103/0970-2113.102824.
  • 4. Amirana M, Frater R, Tirschwell P, Janis M, Bloomberg A, State D. An aggressive surgical approach to significant hemoptysis in patients with pulmonary tuberculosis. Am Rev Respir Dis. 1968; 97(2): pp. 187–92. doi: 10.1164/arrd.1968.97.2.187.
  • 5. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014; 370(8): pp. 744–751. doi: 10.1056/NEJMra1302901.
  • Herold G. Internal Medicine. Cologne, Germany: Herold G; 2014.
last updated 11/27/2018
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