*17 Physical Examination of the Lungs

Question 1

Physical exam compartmentalization

• Inspection
• Palpation
• Percussion
• Auscultation

Answer 1

• Inspection
  
  • Inspection begins even before laying hands on the patient
  • You might note body posture, tobacco smells, cough, throat clearing, all of which may be diagnostic clues
• Palpation
  
  • One palpates the chest in search of asymmetry of excursion, masses, temperature differences, crepitation, and differences in fremitus
• Percussion
  
  • A percussion note is resonant (over the lung), hyperresonant (over emphysematous lung), tympanitic (over the gastric bubble), or dull (over pleural effusion or consolidated lung)
  • A pneumothorax may give hyperresonance or an amphoric note
    
    • The latter is a low-pitched hollow sound like one might hear percussing a bottle or jar (Latin amphora: bottle; jar)
• Auscultation

Question 2

Inspection:
Surface structures:
Symmetry and shape of the thorax

Answer 2

• Disorders of symmetry and position
  
  • Kyphosis
  • Scoliosis
  • Prior thoracic surgery (resections)
• Disorders of shape
  
  • Pectus excavatum
  • Pectus carinatum
• These musculoskeletal abnormalities can have a profound and deleterious effect on pulmonary function

Question 3

Inspection:
Surface structures:
Tracheal position

Answer 3

• The position of the trachea can give important clues to intrathoracic pathology
• The trachea deviates toward the side of volume loss and away from space occupying disease
  
  • For example, the trachea will deviate toward atelectasis and away from a tension pneumothorax

Question 4

Inspection:
Surface structures:
Intercostal spaces

Answer 4

• Normally, the intercostals spaces bulge inward during inspiration and outward during expiration
• Intercostal retractions are exaggerated in patients who must generate highly negative intrathoracic pressures during the respiratory cycle
  
  • This is observed in patients with obstructive airway disease or pulmonary fibrosis
• Exaggerated bulging of the intercostal muscles occurs in patients whose lungs are not emptying efficiently as is seen in obstructive airway disease

Question 5

Inspection:
Surface structures:
Skin

Answer 5

• One evaluates for…
  
  • Surgical scars
  • Rashes
    
    • Shingles is a common cause of chest pain and would demonstrate a dermatomal rash following the path of the intercostal nerve
  • Wounds
    
    • Infections such as actinomyces and nocardia can cause cutaneous fistulas
• Pay attention to scars
  
  • They are the hieroglyphics of the patient’s history
  • There are few things more embarrassing things than presenting a patient with a pulmonary complaint to an attending and missing the fact that the patient had prior thoracic surgery

Question 6

Inspection:
Respiratory rate

Answer 6

• Normally, you will take the respiratory rate with the vital signs
  
  • One should measure the respiratory rate unobtrusively so that the patient is not aware (such as when taking a pulse or listening to the heart) since many patients breathe faster if they are consciously aware of their breathing
• The normal rate is 14-18
  
  • In general, a rate greater than 20 is abnormal

Question 7

Inspection:
Respiratory pattern:
Cheyne-Stokes respiration

Answer 7

• Pattern of apnea alternating with crescendo increases in rate and amplitude of respirations
• Seen in patients with congestive heart failure and in various neurological disorders (stroke, infection)
• Pathophysiology in congestive heart failure
  
  • Increased circulatory time to the brain that results in a delay in signaling changes in PaCO2 to the respiratory center
  • Increased sensitivity of the chemoreceptors in the respiratory center to PaCO2, resulting in exaggerated response to changes in arterial carbon dioxide

Question 8

Inspection:
Respiratory pattern:
Kussmaul’s respirations

Answer 8

• Deep regular breaths, whether the rate is slow, normal, or fast
• Typically seen in metabolic acidosis (particularly diabetic ketoacidosis and uremia)
• Most effective in compensating for acidosis since dead space is minimized and therefore CO2 elimination (as a compensation for the acidosis) is most efficient

Question 9

Inspection:
Respiratory pattern:
Others

• Biot’s breathing
• Central neurogenic hyperventilation
• Apneustic breathing
• Ataxic breathing

Answer 9

• Biot’s breathing
  
  • Similar to Cheyne-Stokes in that it is characterized by periods of alternating apnea
  • But the respiration pattern is one of deep regular breaths that terminate abruptly
    
    • In contrast to Cheyne-Stokes where there is a crescendo-decrescendo pattern in both rate and depth
  • Seen in patients with meningitis
• Central neurogenic hyperventilation
  
  • Pattern of rapid deep hyperpnea
  • Often seen in patients with brainstem injury from midbrain to pons
  • Relatively rare
• Apneustic breathing
  
  • Characterized by a prolonged inspiratory cramp
  • Rare finding but one of great value in that it localizes the neurological injury to the mid to lower pons
• Ataxic breathing
  
  • Completely irregular both in the depth and pace of respiration
  • Patients with damage at the level of the medulla may manifest this type of breathing

Question 10

Inspection:
​Respiratory effort

Answer 10

• Observe the patient for sternocleidomastoid muscle use in respiration
• The use of sternocleidomastoid muscles correlates with severity of respiratory impairment
• In general, use of sternocleidomastoid muscles suggests that the FEV1 is reduced to 30% of normal

Question 11

Inspection:
Respiratory paradox

Answer 11

• During normal respiration, the abdominal wall moves outward as one takes a breath due to displacement of the abdominal contents caused by the descent of the diaphragm
• Respiratory paradox (or thoracoabdominal paradox) occurs when the diaphragm weakens and is pulled up by the negative intrathoracic pressure generated by the accessory muscles of respiration (sternocleidomastoids)
  
  • The abdominal wall moves inward as the diaphragm moves up
  • This is a sign of impending respiratory failure

Question 12

Palpation:
Chest excursion

Answer 12

• Palpate chest excursion from behind with hands on the sides and have the patient take a deep breath
• One may see asymmetric expansion in patients with paralyzed diaphragm, localized pain, fibrosis, or airspace disease

Question 13

Palpation:
Crepitation

Answer 13

• Latin crepit-: to creak, to crackle
• Caused by subcutaneous air
• Subcutaneous air due to thoracic disease generally implies a bronchopleural fistula
• Subcutaneous air may be found in trauma patients with fractures of the trachea, bronchi, or ribs, patients with pneumothorax, and patients with airflow obstruction

Question 14

Palpation:
Fremitus

• General
• What increases and decreases fremitus
• Right vs. left upper lobe

Answer 14

• General
  
  • Latin fremere: to roar, to murmur
  • Vibration that is felt through the chest wall
  • Vocal fremitus is vibration caused by the vocal cords that is transmitted to the chest wall
    
    • Detected by placing hands on the chest and having the patient say ninety-nine, boys, toys, etc.
• What increases and decreases fremitus
  
  • Solids and liquids transmit sound and vibration better than air
  • Therefore, patients with consolidation of the lung have increased fremitus
  • Patients who have airway obstruction from tumor have decreased fremitus
  • Patients who have pneumothorax or pleural effusion have decreased fremitus
    
    • The presence of effusion moves the airways (and the source of the vibration) farther from the chest wall thereby making the vibration less perceptible to the examiner
• Fremitus in the right upper lobe is more intense than the left upper lobe
  
  • This is because the trachea is in direct contract with the right upper lobe but is separated by the aorta from the left upper lobe
  • The opposite would be true in someone with a right-sided aortic arch

Question 15

Auscultation:
Breath sounds:
Vesicular

Answer 15

• Latin vesicular: small blister or bladder
• Breath sounds made by normal alveoli
• Characterized by a longer inspiratory phase than expiratory phase
• Audible over the anterior and posterior chest
• Normal
  
  • No pathological process causes vesicular breath sounds

Question 16

Auscultation:
Breath sounds:
Bronchial

Answer 16

• Reflect conduction of sound from the large airways and indicate that there is a solid connection between the large airways and your stethoscope
• Have a longer expiration than inspiration
• Always pathological
• Reflect consolidation (e.g. pneumonia) of the lung
• To simulate bronchial breath sounds, one listens over the trachea

Question 17

Auscultation:
Breath sounds:
Bronchovesicular

Answer 17

• Intermediate between vesicular and bronchial
• The inspiratory and expiratory phases are roughly equal
• The presence of bronchovesicular sounds suggests a small degree of consolidation

Question 18

Auscultation:
Adventitious sounds:
American thoracic society (ATS) classification

• Course crackle
  
  • Common synonyms
  • Acoustic characteristics
• Fine crackle
  
  • Common synonyms
  • Acoustic characteristics
• Wheeze
  
  • Common synonyms
  • Acoustic characteristics
• Rhonchus
  
  • Common synonyms
  • Acoustic characteristics

Answer 18

• Course crackle
  
  • Common synonyms
    
    • Course rale
  • Acoustic characteristics
    
    • Discontinuous
    • Interrupted explosive sounds (loud, low in pitch)
    • Early inspiratory or expiratory
• Fine crackle
  
  • Common synonyms
    
    • Fine rale
    • Crepitation
  • Acoustic characteristics
    
    • Discontinuous, interrupted explosive sounds
    • Less loud than above and of shorter duration
    • Higher in pitch than coarse crackles or rales
    • Mid- to late inspiratory
• Wheeze
  
  • Common synonyms
    
    • Sibilant rhonchus
  • Acoustic characteristics
    
    • Continuous sounds
    • Longer than 250 msec, high-pitched
    • Dominant frequency of 400 Hz or more, a hissing sound
• Rhonchus
  
  • Common synonyms
    
    • Sonorous rhonchus
  • Acoustic characteristics
    
    • Continuous sounds
    • Longer than 250 msec, low-pitched
      Dominant frequency about 200 Hz or less, a snoring sound

Question 19

Auscultation:
​Adventitious sounds:
Rales

Answer 19

• French: rattle
• Crackling sounds (aka crepitations)
• Rales and crackles are synonymous
• Some clinicians divide rales into fine or coarse rales
  
  • While there is a qualitative spectrum of rales, these distinctions are in no way absolute
• Rales usually reflect the presence of parenchymal diseases such as heart failure, pneumonia, or fibrosis

Question 20

Auscultation:
​Adventitious sounds:
Rhonchi

Answer 20

• Greek rhonch-: to snore
• Lower pitched continuous sounds
• A continuous, low-pitched sound
• Most often heard in expiration
• Reflects the presence of airway disease such as asthma, COPD, or secretions

Question 21

Auscultation:
​Adventitious sounds:
Wheezing

Answer 21

• Old Norse hvaesa: to hiss
• Occurs when there is turbulent airflow through the airways as in obstructive airway disease or bronchial obstruction from tumor or foreign body

Question 22

Auscultation:
​Adventitious sounds:
Pleural friction rubs

Answer 22

• Caused by inflammatory disease of either or both pleural surfaces and result from those surfaces rubbing against each other
• Usually has both an inspiratory and expiratory component
• Caused by pneumonia, pulmonary embolism, rheumatologic disease, and malignant disease

Question 23

Auscultation:
Voice changes:
Bronchophony

Answer 23

• Means “bronchus sound”
• Consolidated lung transmits sound better than normally aerated lung
• Vocalized words sound muffled and indistinct when auscultated at the periphery of normal lung
  
  • In contrast, when listening over consolidated lung, the words sound as if they are much closer to the ear and the syllables are clearly distinguishable

Question 24

Auscultation:
Voice changes:
Whispered pectoriloquy

Answer 24

• Pectoriloquy literally means “chest-speaking”
  
  • Latin roots: pectoro: chest; and loquy: speak
• Present when the patient’s whispered words (not just syllables as in the case of bronchophony) are audible at the periphery of the lung
• As with bronchophony, it is a sign of consolidated lung

Question 25

Auscultation:
Voice changes:
Egophony

Answer 25

• Greek ego: goat
• Change in timbre of a sound
  
  • Timbre is the quality of a musical note
  • It is what allows you to differentiate a trombone from a trumpet even if they play the same note at the same intensity
• Present when the patient vocalizes the letter “e” but it is heard as an “a” at the periphery of the lung
• Sign of consolidated lung

Question 26

Summary

• If the trachea deviates, it deviates…
• The further away the lung is from your stethoscope (effusion or pneumothorax),…
• Consolidated vs. aerated lung
• Fluid
• Obstruction of the airways (with a mucus plug or tumor)
• Adventitious sounds
• If there is no air entry to a region of the lung (from tumor or mucus plug),…

Answer 26

• If the trachea deviates, it deviates…
  
  • To the side of volume loss (atelectasis)
  • Away from the side of a space occupying lesion (pneumothorax or massive effusion)
• The further away the lung is from your stethoscope (effusion or pneumothorax),…
  
  • The more diminished the breath sounds
• Consolidated vs. aerated lung
  
  • Consolidated lung (pneumonia) transmits sound and vibrations better than aerated lung (tubular breath sounds, bronchophony, egophony, whispered pectoriloquy, and increased fremitus are all variations on this theme)
• Fluid
  
  • Dull to percussion (pleural effusion and consolidated lung)
• Obstruction of the airways (with a mucus plug or tumor)
  
  • Decreases transmission of breath sounds and vibration to the chest wall
• Adventitious sounds
  
  • Abnormal and reflect parenchymal disease (rales/crackles) or airway disease (wheezing and rhonchi)
• If there is no air entry to a region of the lung (from tumor or mucus plug),…
  
  • There are no adventitious sounds

Question 27

Salient physical exam findings for common conditions:
Small pleural effusion

• Tracheal deviation
• Fremitus
• Percussion
• Breath sounds
• Pectoriloquy
• Rales
• Wheezing

Answer 27

• Tracheal deviation: no
• Fremitus: decreased
• Percussion: dull
• Breath sounds: decreased
• Pectoriloquy: no
• Rales: no
• Wheezing: no

Question 28

Salient physical exam findings for common conditions:
Atelactasis and branchial plug

• Tracheal deviation
• Fremitus
• Percussion
• Breath sounds
• Pectoriloquy
• Rales
• Wheezing

Answer 28

• Tracheal deviation: left
• Fremitus: decreased
• Percussion: dull
• Breath sounds: decreased
• Pectoriloquy: no
• Rales: no
• Wheezing: no

Question 29

Salient physical exam findings for common conditions:
Massive consolidation

• Tracheal deviation
• Fremitus
• Percussion
• Breath sounds
• Pectoriloquy
• Rales
• Wheezing

Answer 29

• Tracheal deviation: none
• Fremitus: increased
• Percussion: dull
• Breath sounds: bronchial
• Pectoriloquy: yes
• Rales: yes
• Wheezing: no

Question 30

Salient physical exam findings for common conditions:
Pulmonary fibrosis

• Tracheal deviation
• Fremitus
• Percussion
• Breath sounds
• Pectoriloquy
• Rales
• Wheezing

Answer 30

• Tracheal deviation: none
• Fremitus: normal
• Percussion: normal
• Breath sounds: normal
• Pectoriloquy: no
• Rales: yes
• Wheezing: no

Question 31

Salient physical exam findings for common conditions:
Wheezing

• Tracheal deviation
• Fremitus
• Percussion
• Breath sounds
• Pectoriloquy
• Rales
• Wheezing

Answer 31

• Tracheal deviation: none
• Fremitus: normal
• Percussion: normal
• Breath sounds: normal
• Pectoriloquy: normal
• Rales: no
• Wheezing: yes