Pulmonary examination

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.

See also differential diagnoses of dyspnea.

The following should be assessed:

Breathing pattern

• Normal respiratory rates
  • 12–20/min in adults
  • 30–60/min in infants and neonates
  • See also “Normal vital signs at rest” for all age groups.
• Bradypnea
  • Respiratory rate < 12/min in adults
  • < 30/min in infants and neonates
  • < 40/min in newborns
• Tachypnea
  • Respiratory rate > 20/min, shallow breathing in adults
  • > 60/min in pediatric patients
• Hyperpnea: respiratory rate > 20/min, deep breathing
• Inspiratory:expiratory ratio: The ratio of the inspiratory time to expiratory time during spontaneous breathing, which is normally 1:2.
• Common abnormal patterns of breathing include: ^[1]
  • Cheyne-Stokes breathing: alternating periods of deep breathing followed by apnea
    • Results from a delay in detecting changes in ventilation and arterial carbon dioxide pressure.
    • Common causes include: advanced heart failure, damage to respiratory centers (e.g., stroke, traumatic brain injuries, metabolic encephalopathies), and central sleep apnea
  • Ataxic breathing: irregular breathing in rhythm and depth
  • Obstructive breathing: prolonged exhalation

Increased effort of breathing

• Tachypnea
• Use of accessory muscles of respiration during inspiration
  • Sternomastoid muscles
  • Scalene muscles
  • Pectoralis major
• Trachea off midline
• Tripod position: patients with emphysema and respiratory distress will lean forward while sitting, resting with their hands on their knees.

Peripheral signs of respiratory dysfunction

• Cyanosis: bluish discoloration of the skin and mucosa (due to deoxygenated hemoglobin)

Nail clubbing ^[2]

• Definition: Nail clubbing is a physical finding characterized by painless swelling of the distal phalanges typically associated with chronic hypoxemia.
• Pathophysiology
  • Not fully understood
  • Hereditary factors may predispose to clubbing.
  • Fibrovascular proliferation in the region of the nail bed due to accumulation of megakaryocytes and platelets in digital vessels and subsequent local PDGF and VEGF release is suggested.
• Associated conditions
  • Respiratory conditions, such as:
    • Interstitial lung disease
    • Idiopathic pulmonary fibrosis
    • Cystic fibrosis
    • Lung cancer
  • Cardiovascular conditions, such as:
    • Cyanotic congenital heart disease
    • Cardiac shunts
  • Infections, such as:
    • Tuberculosis
    • Infections causing lung abscesses
  • Hypertrophic osteoarthropathy: a syndrome (either hereditary or paraneoplastic) that manifests with painful nail clubbing, synovial effusions, and periostitis
  • IBD
  • Not associated with COPD, asthma
• Clinical features
  • Painless swelling of connective tissue in the distal phalanges
  • Lovibond 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 test
    • Place distal phalanges against each other so that both fingernails touch
    • When there is nail clubbing, the normal diamond-shaped “window” between the nail beds will not be seen.

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
• Hemoptysis: See "Etiology of hemoptysis.”

In newborn and infants

• Jugular, sternal, and intercostal retraction
• Nasal flaring or flaring of the nostrils
• Neck extension

• General: Evaluate areas of tenderness or bruising.
• Symmetry of chest expansion
  • Place both hands on the patient's back at the level of the 10^th 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:^[3]

• Technique
  • 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
  • Hyper-resonant percussion note
    • Louder and hollower than normal
    • Sign of increased air inside the thoracic cavity: emphysema, bronchial asthma, pneumothorax
  • Dull percussion note
    • Muffled and softer note
    • Sign of fluid inside the thoracic cavity: pneumonia, pleural effusion
• 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 3–5.5 cm).

References:^[3]

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 1^st and 2^ndintercostal 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
• Cavernous breathing
  • A harsh, hollow breath sound with high-pitched overtones heard on lung auscultation
  • It is produced by air passing through a large, superficial cavity that communicates with the bronchial system (e.g., a cyst or abscess)
  • Can not be heard if there is fluid or a fungal ball within the cavity

Pathological breath sounds

• Also known as adventitious or added sounds
• Consider secretions (such as in bronchitis) if breath sounds clear after coughing

Types of pathological breath sounds

• Crackles or rales: discontinuous, intermittent
  • Fine: soft, high-pitched (e.g., normal, asbestosis, sarcoidosis)
  • Coarse: loud, low-pitched (e.g., COPD, pulmonary edema) ^[4]
• Wheezes (sibilant wheezing): musical, prolonged
• Rhonchi (sonor wheezing): low-pitched, snoring
• Stridor: high-pitched, over trachea ; which may occur on:
  • Inspiration (inspiratory stridor): narrowing of the extrathoracic airway; characteristic of epiglottitis, pseudocroup, foreign body aspiration, bilateral vocal cord palsy
  • Expiration (expiratory stridor): obstruction of the intrathoracic airways; characteristic of bronchial asthma, COPD
  • Inspiration and expiration (biphasic stridor): obstruction at the level of the glottis
• 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 (e.g., pleural effusion, pneumothorax)

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 pulmonary consolidation

References:^[3][4]

See “Dyspnea” for more information.

References:^[3]