MODULE 6

THE RESPIRATORY SYSTEM

THE LUNG EXAM
 The 4 major components of the lung exam
(inspection, palpation, percussion and auscultation)
are also used to examine the heart and abdomen.
 Learning the appropriate techniques at this juncture
will therefore enhance your ability to perform these
other examinations as well.
 Vital signs, an important source of information, are
discussed elsewhere.
THE LUNG EXAM
 Inspection/Observation: A great deal of information
can be gathered from simply watching a patient
breathe.
 Pay particular attention to:
 General comfort and breathing pattern of the
patient. Do they appear distressed, diaphoretic,
labored? Are the breaths regular and deep?
 Use of accessory muscles of breathing (e.g.
scalenes, sternocleidomastoids). Their use signifies
some element of respiratory difficulty.
 Color of the patient, in particular around the lips
and nail beds. Obviously, blue is bad!
Cyanosis of nail beds
The lung exam…
 The position of the patient.
 Those with extreme pulmonary dysfunction will
often sit up-right.
 In cases of real distress, they will lean forward,
resting their hands on their knees in what is known
as the tri-pod position.
Patient with emphysema bending over in Tri-Pod Position
The lung exam…
 Breathing through pursed lips, often seen in cases of
emphysema.
 Ability to speak.
 At times, respiratory rates can be so high and/or
work of breathing so great that patients are
unable to speak in complete sentences.
 If this occurs, note how many words they can speak
(i.e. the fewer words per breath, the worse the
problem!).
The lung exam…
 Any audible noises associated with breathing as occasionally,
wheezing or the gurgling caused by secretions in large airways are
audible to the "naked" ear.
 The direction of abdominal wall movement during inspiration.
 Normally, the descent of the diaphragm pushes intra-abdominal
contents down and the wall outward.
 In cases of severe diaphragmatic flattening (e.g. emphysema) or
paralysis, the abdominal wall may move inward during
inspiration, referred to as paradoxical breathing.
 If you suspect this to be the case, place your hand on the patient's
abdomen as they breathe, which should accentuate its movement.
The lung exam…
 Any obvious chest or spine deformities.
 These may arise as a result of chronic lung disease (e.g.
emphysema), occur congenitally, or be otherwise acquired.
 In any case, they can impair a patient's ability to breathe
normally.
 A few common variants include:
 Pectus excavatum:
 Congenital posterior displacement of lower aspect of
sternum.
 This gives the chest a somewhat "hollowed-out" appearance.
 The x-ray shows a subtle concave appearance of the lower
sternum.
Pectus excavatum
Pectus excavatum
The lung exam…
 Barrel chest:
 Associated with emphysema and lung
hyperinflation.
 Accompanying xray also demonstrates
increased anterior-posterior diameter as well
as diaphragmatic flattening.
Barrel chest
Barrel chest
The lung exam…
 Spine abnormalities:
 Kyphosis:
Causes the patient to be bent forward.
Accompanying X-Ray of same patient
clearly demonstrates extreme curvature of
the spine.
Kyphosis
Kyphosis
Scoliosis
 Condition where the spine is curved to either the
left or right.
 In the pictures below, scoliosis of the spine causes
right shoulder area to appear somewhat higher
than the left.
 Curvature is more pronounced on x-ray.
SCOLIOSIS
SCOLIOSIS
Review of Lung Anatomy
 Understanding the pulmonary exam is greatly
enhanced by recognizing the relationships between
surface structures, the skeleton, and the main lobes
of the lung.
 Realize that this can be difficult as some surface
landmarks (eg nipples of the breast) do not always
maintain their precise relationship to underlying
structures.
Review of Lung Anatomy
 Nevertheless, surface markers will give you a rough
guide to what lies beneath the skin.
 The pictures below demonstrate these relationships.
 The multi-colored areas of the lung model identify
precise anatomic segments of the various lobes,
which cannot be appreciated on examination.
 Main lobes are outlined in black. The following
abbreviations are used: RUL = Right Upper Lobe;
LUL = Left Upper Lobe; RML = Right Middle Lobe;
RLL = Right Lower Lobe; LLL = Left Lower Lobe.
ANTERIOR VIEW
ANTERIOR VIEW
ANTERIOR VIEW
POSTERIOR VIEW
POSTERIOR VIEW
POSTERIOR VIEW
RIGHT LATERAL VIEW
RIGHT LATERAL VIEW
RIGHT LATERAL VIEW
LEFT LATERAL VIEW
LEFT LATERAL VIEW
LEFT LATERAL VIEW
THE TRACHEA
THE TRACHEA
Palpation
 Palpation plays a relatively minor role in the
examination of the normal chest as the
structure of interest (the lung) is covered by the
ribs and therefore not palpable.
 Specific situations where it may be helpful
include:
 1. Accentuating normal chest excursion:

 Place your hands on the patient's back with

thumbs pointed towards the spine.
Palpation
 Place your hands on the patient's back with
thumbs pointed towards the spine.
 Remember to first rub your hands together so

that they are not too cold prior to touching the

patient.
 Your hands should lift symmetrically outward
when the patient takes a deep breath.
Palpation
 Processes that lead to asymmetric lung expansion,
as might occur when anything fills the pleural space
(e.g. air or fluid), may then be detected as the hand
on the affected side will move outward to a lesser
degree.
 There has to be a lot of pleural disease before this
asymmetry can be identified on exam.
DETECTING CHEST EXCURSION
Palpation…
 2. Tactile Fremitus:
 Normal lung transmits a palpable vibratory
sensation to the chest wall.
 This is referred to as fremitus and can be detected
by placing the ulnar aspects of both hands firmly
against either side of the chest while the patient
says the words "Ninety-Nine." This maneuver is
repeated until the entire posterior thorax is
covered. The bony aspects of the hands are used as
they are particularly sensitive for detecting these
vibrations.
TACTILE FREMITUS
TACTILE FREMITUS…
 Pathologic conditions will alter fremitus.
 In particular:

 Lung consolidation: Consolidation occurs when the

normally air filled lung parenchyma becomes
engorged with fluid or tissue, most commonly in the
setting of pneumonia. If a large enough segment of
parenchyma is involved, it can alter the transmission
of air and sound. In the presence of consolidation,
fremitus becomes more pronounced.
TACTILE FREMITUS…
 Pleural fluid: Fluid, known as a pleural effusion, can
collect in the potential space that exists between
the lung and the chest wall, displacing the lung
upwards. Fremitus over an effusion will be
decreased.
TACTILE FREMITUS…
 In general, fremitus is a pretty subtle finding
and should not be thought of as the primary
means of identifying either consolidation or
pleural fluid.
 It can, however, lend supporting evidence if
other findings (see below) suggest the presence
of either of these processes.
TACTILE FREMITUS…
 Effusions and infiltrates can perhaps be more easily
understood using a sponge to represent the lung.
 In this model, an infiltrate is depicted by the blue
coloration that has invaded the sponge itself
(sponge on left).
 An effusion is depicted by the blue fluid upon which
the lung is floating (sponge on right).
THE SPONGE MODEL
Palpation…
 3. Investigating painful areas:
 If the patient complains of pain at a particular site
it is obviously important to carefully palpate around
that area.
 In addition, special situations (e.g. trauma) mandate
careful palpation to look for evidence of rib
fracture, subcutaneous air (feels like your pushing on
Rice Krispies or bubble paper), etc.
Percussion
 This technique makes use of the fact that striking a
surface which covers an air-filled structure (e.g.
normal lung) will produce a resonant note while
repeating the same maneuver over a fluid or tissue
filled cavity generates a relatively dull sound.
 If the normal, air-filled tissue has been displaced by
fluid (e.g. pleural effusion) or infiltrated with white
cells and bacteria (e.g. pneumonia), percussion will
generate a deadened tone.
Percussion
 Alternatively, processes that lead to chronic (e.g.
emphysema) or acute (e.g. pneumothorax) air
trapping in the lung or pleural space, respectively,
will produce hyper-resonant (i.e. more drum-like)
notes on percussion.
 Initially, you will find that this skill is a bit awkward
to perform.
 Allow your hand to swing freely at the wrist,
hammering your finger onto the target at the
bottom of the down stroke.
Percussion
 A stiff wrist forces you to push your finger into the
target which will not elicit the correct sound.
 In addition, it takes a while to develop an ear for
what is resonant and what is not.
 A few things to remember:
Percussion…
 1. If you're percussing with your right hand, stand a
bit to the left side of the patient's back.
 2. Ask the patient to cross their hands in front of
their chest, grasping the opposite shoulder with
each hand. This will help to pull the scapulae
laterally, away from the percussion field.
 3. Work down the "alley" that exists between the
scapula and vertebral column, which should help
you avoid percussing over bone.
Percussion…
 4. Try to focus on striking the distal inter-phalangeal
joint (i.e. the last joint) of your left middle finger
with the tip of the right middle finger. The impact
should be crisp so you may want to cut your nails to
keep blood-letting to a minimum!
 5. The last 2 phalanges of your left middle finger
should rest firmly on the patient's back. Try to keep
the remainder of your fingers from touching the
patient, or rest only the tips on them if this is
otherwise too awkward, in order to minimize any
dampening of the perucssion notes.
Percussion…
 6. When percussing any one spot, 2 or 3 sharp taps
should suffice, though feel free to do more if you'd
like. Then move your hand down several inter-
spaces and repeat the maneuver.
 In general, percussion in 5 or so different locations
should cover one hemi-thorax.
Percussion…
 After you have percussed the left chest, move yours
hands across and repeat the same procedure on the
right side. If you detect any abnormality on one
side, it's a good idea to slide your hands across to
the other for comparison. In this way, one thorax
serves as a control for the other.
 In general, percussion is limited to the posterior lung
fields. However, if auscultation reveals an
abnormality in the anterior or lateral fields,
percussion over these areas can help identify its
cause.
PERCUSSION…
 7. The goal is to recognize that at some point as
you move down towards the base of the lungs, the
quality of the sound changes.
 This normally occurs when you leave the thorax.
 It is not particularly important to identify the exact
location of the diaphragm, though if you are able
to note a difference in level between maximum
inspiration and expiration, all the better.
PERCUSSION…
 Ultimately, you will develop a sense of where the
normal lung should end by simply looking at the
chest.
 The exact vertebral level at which this occurs is not
really relevant.
 "Speed percussion" may help to accentuate the
difference between dull and resonant areas.
PERCUSSION…
 During this technique, the examiner moves their left
(i.e. the non-percussing) hand at a constant rate
down the patient's back, tapping on it continuously
as it progresses towards the bottom of the thorax.
 This tends to make the point of inflection (i.e.
change from resonant to dull) more pronounced.
PERCUSSION AREA
PERCUSSION TECHNIQUE
Auscultation
 Prior to listening over any one area of the
chest, remind yourself which lobe of the lung is
heard best in that region:
 lower lobes occupy the bottom 3/4 of the
posterior fields; right middle lobe heard in
right axilla; lingula in left axilla;
 upper lobes in the anterior chest and at the
top 1/4 of the posterior fields.
Auscultation…
 This can be quite helpful in trying to pin down the
location of pathologic processes that may be
restricted by anatomic boundaries (e.g. pneumonia).
 Many disease processes (e.g. pulmonary edema,
bronchoconstriction) are diffuse, producing
abnormal findings in multiple fields.
Auscultation…
 Put on your stethoscope so that the ear pieces are
directed away from you.
 Adjust the head of the scope so that the diaphragm
is engaged.
 If you're not sure, scratch lightly on the diaphragm,
which should produce a noise.
 If not, twist the head and try again.
Auscultation…
 Gently rub the head of the stethoscope on your shirt
so that it is not too cold prior to placing it on the
patient's skin.
 The upper aspect of the posterior fields (i.e.
towards the top of the patient's back) are
examined first.
 Listen over one spot and then move the stethoscope
to the same position on the opposite side and
repeat.
Auscultation…
 This again makes use of one lung as a source of
comparison for the other.
 The entire posterior chest can be covered by
listening in roughly 4 places on each side.
 Of course, if you hear something abnormal, you'll
need to listen in more places.
Auscultation
Auscultation…
 The lingula and right middle lobes can be examined
while you are still standing behind the patient.
 Then, move around to the front and listen to the
anterior fields in the same fashion.
 This is generally done while the patient is still sitting
upright.
 Asking female patients to lie down will allow their
breasts to fall away laterally, which may make this
part of the examination easier.
Important thoughts
 Thoughts On "Gown Management" &
Appropriately/Respectfully Touching Your
Patients:
 There are several sources of tension relating to the
physical exam in general, which are really brought
to the fore during the chest examine.
 These include:
Important thoughts…
 Area to be examined must be reasonably exposed
- yet patient kept as covered as possible
 The need to Palpate sensitive areas in order to
perform accurate exam - requires touching people
w/whom you've little acquaintance - awkward,
particularly if opposite gender
 As newcomers to medicine, you're particularly
aware that this aspect of the exam is "unnatural" &
hence very sensitive.. which is a good thing!
Important thoughts…
 Keys to performing a sensitive yet thorough
exam:
 Explain what you're doing (" why) before
doing it → acknowledge "elephant in the
room"!
 Expose the minimum amount of skin
necessary - this requires "artful" use of gown
& drapes (males & females)
Important thoughts…
 Examining heart & lungs of female patients:
 Ask pt to remove bra prior (you can't hear the
heart well thru fabric)
 Expose the chest only to the extent needed. For
lung exam, you can listen to the anterior fields by
exposing only the top part of the breasts (see
picture below).
 Enlist patient's assistance, asking them to raise their
breast to a position that enhances your ability to
listen to the heart
Important thoughts…
 Don't rush, act in a callous fashion, or cause
pain
 PLEASE... don't examine body parts through

gown as:
 Itreflects Poor technique
 You'll miss things

 You'll lose points on scored exams (OSCE, CPX,

USMLE)!
POOR TECHNIQUES
GOOD EXAMINATION OPTIONS
Chest examination tips
 Ask the patient to take slow, deep breaths through
their mouths while you are performing your exam.
This forces the patient to move greater volumes of
air with each breath, increasing the duration,
intensity, and thus detectability of any abnormal
breath sounds that might be present.
 Sometimes it's helpful to have the patient cough a
few times prior to beginning auscultation. This clears
airway secretions and opens small atelectatic (i.e.
collapsed) areas at the lung bases.
Chest examination tips
 If the patient cannot sit up (e.g. in cases of
neurologic disease, post-operative states, etc.),
auscultation can be performed while the patient is
lying on their side. Get help if the patient is unable
to move on their own. In cases where even this
cannot be accomplished, a minimal examination can
be performed by listening laterally/posteriorly as
the patient remains supine.
Chest examination tips
 Requesting that the patient exhale forcibly will
occasionally help to accentuate abnormal breath
sounds (in particular, wheezing) that might not be
heard when they are breathing at normal flow
rates.
Basic Sounds
 Vesicular sounds
 A healthy individual breathing through their mouth
at normal tidal volumes produces a soft inspiratory
sound as air rushes into the lungs, with little noise
produced on expiration.
 These are referred to as vessicular breath sounds.
Basic Sounds
 Wheezes
 Wheezes are whistling-type noises produced during
expiration (and sometimes inspiration) when air is
forced through airways narrowed by
bronchoconstriction, secretions, and/or associated
mucosal edema.
 As this most commonly occurs in association with
diffuse processes that affect all lobes of the lung
(e.g. asthma and emphysema) it is frequently
audible in all fields.
Basic Sounds
 Wheezes…
 In cases of significant bronchoconstriction, the
expiratory phase of respiration (relative to
inspiration) becomes noticeably prolonged.
 Clinicians refer to this as an increased I to E ratio.
 Normal is approximatley 1:2 (i.e. expiration twice
as long as inspiration) though actual timed
measurements are neither practical nor reliable.
Basic sounds…
 Wheezes..
 Focus instead on simple observation, noting whether
E seems >> I.
 The greater the difference, the worse the
obstruction.
 Occasionally, focal wheezing can occur when
airway narrowing if restricted to a single anatomic
area, as might occur with an obstructing tumor or
bronchoconstriction induced by pneumonia.
Basic sounds…
 Wheezes..
 Wheezing heard only on inspiration is referred to
as stridor and is associated with mechanical
obstruction at the level of the trachea/upper
airway.
 This may be best appreciated by placing your
stethescope directly on top of the trachea.
Basic sounds
 Rales
 Rales (a.k.a. crackles) are scratchy sounds that occur
in association with processes that cause fluid to
accumulate within the alveolar and interstitial
spaces.
 The sound is similar to that produced by rubbing
strands of hair together close to your ear.
 Pulmonary edema is probably the most common
cause, at least in the older adult population, and
results in symmetric findings.
Basic sounds
 Rales
 This tends to occur first in the most dependent
portions of the lower lobes and extend from the
bases towards the apices as disease progresses.
 Pneumonia, on the other hand, can result in discrete
areas of alveolar filling, and therefore produce
crackles restricted to a specific region of the lung.
Very distinct, diffuse, dry-sounding crackles, similar
to the noise produced when separating pieces of
velcro, are caused by pulmonary fibrosis, a
relatively uncommon condition.
Basic sounds…
 Dense consolidation of the lung parenchyma, as can
occur with pneumonia, results in the transmission of
large airway noises (i.e. those normally heard on
auscultation over the trachea... known as tubular or
bronchial breath sounds) to the periphery.
 In this setting, the consolidated lung acts as a terrific
conducting medium, transferring central sounds
directly to the edges.
 It's very similar to the noise produced when
breathing through a snorkel.
Basic sounds…
 Furthermore, if you direct the patient to say the
letter 'eee' it is detected during auscultation over
the involved lobe as a nasal-sounding 'aaa'.
 These 'eee' to 'aaa' changes are referred to as
egophony.
 The first time you detect it, you'll think that the
patient is actually saying 'aaa'... have them repeat
it several times to assure yourself that they are
really following your directions!
Basic sounds…
 Rhonchi
 Secretions that form/collect in larger airways, as
might occur with bronchitis or other mucous creating
process, can produce a gurgling-type noise, similar
to the sound produced when you suck the last bits of
a milk shake through a straw.
 These noises are referred to as ronchi.
Basic sounds…
 Pleural effusion
 Auscultation over a pleural effusion will produce a
very muffled sound.
 If, however, you listen carefully to the region on top
of the effusion, you may hear sounds suggestive of
consolidation, originating from lung which is
compressed by the fluid pushing up from below.
 Asymmetric effusions are probably easier to detect
as they will produce different findings on
examination of either side of the chest.
Basic sounds…
 Emphysema
 Auscultation of patients with severe, stable
emphysema will produce very little sound.
 These patients suffer from significant lung
destruction and air trapping, resulting in their
breathing at small tidal volumes that generate
almost no noise.
 Wheezing occurs when there is a superimposed
acute inflammatory process (see above).
Lung examination..
 Most of the above techniques are complimentary.
 Dullness detected on percussion, for example, may
represent either lung consolidation or a pleural
effusion.
 Auscultation over the same region should help to
distinguish between these possibilities, as
consolidation generates bronchial breath sounds
while an effusion is associated with a relative
absence of sound.
Lung examination..
 Similarly, fremitus will be increased over
consolidation and decreased over an effusion.
 As such, it may be necessary to repeat certain
aspects of the exam, using one finding to confirm
the significance of another.
 Few findings are pathognomonic.
 They have their greatest meaning when used
together to paint the most informative picture.
Other tests
 Observed ambulation (with the use of a pulse
oxymeter, a device that continuously measures heart
rate and oxygen saturation, if available) as a
dynamic extension of the cardiac and pulmonary
examinations.
 Quantifying a patient's exercise tolerance in terms
of distance and/or time walked can provide
information critical to the assessment of activity
induced symptoms.