Physical Examination of Chest

The physical examination of the chest is composed of inspection, palpation, percussion, and auscultation. Although it is not unheard of for clinicians to skip the first three steps of the chest auscultation important information can be derived from a complete lung examination.

A respiratory examination, or lung examination, is performed as part of a physical examination, in response to respiratory symptoms such as shortness of breath, cough, or chest pain, and is often carried out with a cardiac examination. The four steps of the respiratory exam are inspection, palpation, percussion, and auscultation of respiratory sounds, normally first carried out from the back of the chest.

Inspection

The examiner then estimates the patient’s respiratory rate by observing how many times the patient breathes in and out within the span of one minute. This is typically conducted under the pretext of some other exam, so that the patient does not subconsciously change their baseline respiratory rate, as they might do if they were aware of the examiner observing their breathing. Adults normally breathe about 14 to 20 times per minute, while infants may breathe up to 44 times per minute.[rx]

  • Skin
    • Color: erythema, ecchymosis, white, black
    • Trophic changes (altered hair growth, sweat production)
    • Scars
    • Abrasions, deformities
  • Muscle tone: atrophy, hypertrophy
  • Deformity: asymmetry, rotation, amputation
  • Respiratory status
    • Rate: tachypneic, bradypneic or eupneic?
    • Ventilation: hyperpnea, hypopnea?
    • Accessory muscle use?
    • Position of the patient: upright, tripod position
    • Speaks in complete sentences
    • Symmetric chest rise
    • Trachea is midline
    • Color: cyanotic or acyanotic
  • Chest
    • Pectus excavatum or carinatum

After obtaining the patient’s respiratory rate, the examiner looks for any signs of respiratory distress, which may include:

  • Cyanosis, a bluish tinge of the extremities (peripheral cyanosis), or of the tongue (central cyanosis)
  • Pursed-lip breathing
  • Accessory muscle use, including the scalene and intercostal muscles
  • Diaphragmatic breathing, paradoxical movement of the diaphragm outwards during inspiration
  • Intercostal indrawing
  • Decreased chest–chest movement on the affected side
  • An increased jugular venous pressure, indicating possible right heart failure

The anterior and posterior chest walls are also inspected for any abnormalities, which may include:

  • Kyphosis, abnormal anterior-posterior curvature of the spine
  • Scoliosis, abnormal lateral curvature of the spine
  • Barrel chest, bulging out of the chest wall; normal in children; typical of hyperinflation seen in chronic obstructive pulmonary disease (COPD)[10]
  • Pectus excavatum, sternum sunken into the chest
  • Pectus carinatum, sternum protruding from the chest

In addition to measuring the patient’s respiratory rate, the examiner will observe the patient’s breathing pattern:

  • A patient with metabolic acidosis will often demonstrate a rapid breathing pattern, known as Kussmaul breathing. Rapid breathing helps the patient compensate for the decrease in blood pH by increasing the amount of exhaled carbon dioxide, which helps prevent further acid accumulation in the blood.
  • Cheyne–Stokes respiration is a breathing pattern consisting of alternating periods of rapid and slow breathing, which may result from a brain stem injury.[14] Cheyne-Stokes respiration may be observed in newborn babies, but this is occasionally physiological (normal).
  • Chest retractions may be observed in patients with asthma. During a chest retraction, the patient’s skin appears to sink into the chest. During supra-sternal retractions, the skin of the neck appears to sink in as the accessory breathing muscles of the neck contract to aid with inspiration. During intercostal retractions, the skin between the ribs appears to sink in as the intercostal muscles (the muscles between the ribs) aid in respiration. These are signs of respiratory distress.

The physician then typically inspects the fingers for cyanosis and clubbing.

The tracheal deviation is also examined.

Palpation

  • Palpate for
    • Effusion
    • Clicking
    • Snapping
    • Crepitus
    • Tenderness
    • Temperature
    • Masses
  • Areas of Emphasis
    • Tactile fremitus
    • Peripheral pulses (regular, irregular, weak, bounding)

Percussion

  • Sounds
    • Resonant: normal
    • Flat or dull: abnormal suggesting soft tissue or fluid
    • Hyperresonant: abnormal suggesting air such as pneumothorax
    • Tympanic

Auscultation

Auscultation of the lungs should be systematic and follow a stepwise approach in which the examiner surveys all the lung zones. For practical purposes, the lung can be divided into apical, middle and basilar regions during auscultation. The description of abnormal breathing sounds should be tagged with the location in which it was heard.

The movement of air generates normal breath sounds through the large and small airways. Normal breath sounds have a frequency of approximately 100 Hz. The absence of breath sounds should prompt the health care provider to consider shallow breath, abnormal anatomy or pathologic entities such as airway obstruction, bulla, hyperinflation, pneumothorax, pleural effusion or thickening, and obesity.

  • Lung sounds
    • Normal (vesicular)
    • Wheezing
    • Rales (crackles)
    • Ronchi
    • Pleural Rub
    • Stridor
    • Absent
  • Cardiac
    • S1 and S2
    • Rate (slow, fast, normal)
    • Rhythm (regular or irregular)
    • Murmur
    • Rub
    • Gallop

Tubular breath sounds are high-pitched, bronchial breath sounds, seen in the following conditions: consolidation, pleural effusion, pulmonary fibrosis, distal collapse, and mediastinal tumor over a large patent bronchus.

  • Vesicular breath sounds/normal breath sounds: While Laënnec considered normal lung sounds to originate from the flow of air in and out of alveoli, later investigations of the origin of respiratory sounds have not shown lung “vesicles” to participate in sound generation. Therefore, vesicular breath sounds is a misnomer for normal breath sounds.
  • Wheezes: High-pitched continuous sounds with a dominant frequency of 400 Hz or more. (ATS) Suggestive of asthma, COPD, airway obstruction, or mucus plug.
  • Ronchi: Low-pitched continuous musical sounds with a dominant frequency of about 200 Hz or less (ATS).
  • Crackles: A “popping” sound generated by the passage of air through the accumulated secretions within the large and medium-size airways, creating the bubbling sounds (brief, non-musical, “discontinuous” sounds). Seen in COPD, Pneumonia, and Heart Failure.
  • Pleural Rub: Occurs due to inflamed pleural surfaces rubbing each other during breathing. It is difficult to differentiate from fine crackles, but the sound is similar to rubbing your stethoscope against cotton.
  • Stridor: A loud, high-pitched, musical sound produced by upper respiratory tract obstruction. It indicates an extrathoracic upper airway obstruction (supraglottic lesions like laryngomalacia, vocal cord lesion) when heard on inspiration. It occurs in expiration if associated with intrathoracic tracheobronchial lesions (tracheomalacia, bronchomalacia, and extrinsic compression). It occurs in both phases if a lesion is fixed, for example, stenosis.

Special Maneuvers

  • Pectoriloquy – Ask the patient to whisper a word such as “one-two-three” or “ninety-nine” and listen with a stethoscope. Typically, words are heard faintly. In cases of consolidation, the whispered sounds will be heard clearly and distinctly.
  • Egophony is elicited by asking the patient to say  “Ee,” and it will sound like an “A.” Suggestive of consolidation or pleural effusion.

Chest percussion

Percussion is the act of tapping on the surface of the body in order to assess the structures that lie beneath the skin. Percussion and resonance (the quality and feeling of sound) are used to examine lung movement and possible lung conditions. Specifically, percussion is performed by first placing the middle finger of one hand over the area of interest. The middle finger of the other hand is used to strike the last joint of the placed finger. Percussion is performed in a systematic matter, from the upper chest to the lower ribs, and resonance is compared between the left and right sides of the chest. This is done from the front and back of the thorax.[rx]

Percussion over different body tissues results in five common “notes”.[rx]

  • Resonance: Loud and low-pitched
  • . Normal lung sound.[rx]
  • Dullness: Medium intensity and pitch. Experienced with fluid.[rx]
    • A dull, muffled sound may replace resonance in conditions like pneumonia or hemothorax.
  • Hyper-resonance: Very loud, very low pitch, and longer in duration. Abnormal.
    • Hyper-resonance can result from asthma or emphysema
  • Tympany: Loud and high-pitched. Common for percussion over gas-filled spaces.
    • Tympany may result in pneumothorax.
  • Flatness: Soft and high-pitched.

Special Tests

  • Egophony: ask the patient to say “Eeeee,” and it will sound like an “A.”
    • Suggestive of consolidation, pleural effusion.
  • Pectoriloquy: