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Pulmonary examination

Last updated: May 5, 2021

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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

Increased effort of breathing

Peripheral signs of respiratory dysfunction

Nail clubbing [2]

Abnormalities in the shape of the thorax

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

In newborn and infants

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

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:[3][4][5]

  • 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:[4]

  • 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
  • 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).

References:[4]

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 2ndintercostal 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
  • Consider secretions (such as in bronchitis) if breath sounds clear after coughing

Types of pathological breath sounds

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
  • Whispered pectoriloquy

References:[4][6]

Main symptom Tactile fremitus Percussion Auscultation (breath sounds) Tracheal deviation
Physiological

Normal Resonant Vesicular None
Pleural effusion Dyspnea may be present Decreased Dull Decreased To the opposite side of the lesion (no deviation in small effusions)
Pulmonary edema

Severe dyspnea

Possibly increased Dull Fine or coarse crackles, depending on severity None
Simple pneumothorax Acute dyspnea Decreased or absent Hyperresonant

Decreased or absent

None
Tension pneumothorax Severe dyspnea Decreased or absent Hyperresonant Decreased or absent To the opposite side of the lesion
Bronchial asthma1 Paroxysmal attacks of dyspnea, wheezing

Decreased

Hyperresonant

Wheeze, a prolonged expiratory phase, possibly decreased breath sounds

None
Chronic bronchitis1 Chronic cough Decreased Hyperresonant

Wheezing, rhonchi

None
Emphysema Chronic dyspnea Decreased Hyperresonant End-expiratory wheezing, decreased breath sounds None
Pneumonia2 Fever, dyspnea Increased Dull

Coarse crackles

None
Lung fibrosis Cachexia and weakness, dyspnea Normal or slightly increased

Dull

Basal inspiratory crackles To the side of the lesion
Atelectasis Pain may be present Decreased Dull Decreased To the side of the lesion
Pulmonary embolism1

Acute dyspnea, pleuritic chest pain, tachypnea

Normal

Normal Normal None
Tumor1,2,3

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

Possibly decreased

Possibly dull Possibly decreased To the opposite side of the lesion

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

See also dyspnea.

References:[4]

  1. Bickley L. Bates' Guide to Physical Examination and History-Taking. Lippincott Williams & Wilkins ; 2012
  2. 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): p.187-92. doi: 10.1164/arrd.1968.97.2.187 . | Open in Read by QxMD
  3. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. Butterworths ; 1990
  4. Braun SR, Walker HK, Hall WD, Hurst JW. Respiratory Rate and Pattern. Clinical Methods: The History, Physical, and Laboratory. 1990 .
  5. Sarkar M, Mahesh D, Madabhavi I. Digital clubbing. Lung India. 2012; 29 (4): p.354. doi: 10.4103/0970-2113.102824 . | Open in Read by QxMD
  6. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014; 370 (8): p.744-751. doi: 10.1056/NEJMra1302901 . | Open in Read by QxMD
  7. Herold G. Internal Medicine. Herold G ; 2014