LUNG EXAMINATION

SHAMS ATRASH
 The clinical examination of the lungs is part of almost any physical
examination. Due to the close relationship with nearby structures
such as the heart, great vessels, esophagus, and diaphragm, a careful
examination of the lungs can provide clues towards a diagnosis.

The physical examination of the chest is composed of :

1. Inspection
2. Palpation
3. Percussion
4. Auscultation
 Respiration rate
respiratory rate is also known as breathing rate. This is the number of breaths you take
per minute, while you're at rest.

Process :
1. Set a timer for 1 minute.
2. You should be at rest, either sitting or lying down. Avoid strenuous activity beforehand.
3. Start the timer and measure the amount of breaths taken in 1 minute. This can be done by counting how
many times the chest rises.
 What affect the respiratory rate?
High rate Low rate
1. Sleep apnea
1. Fever 2. Narcotics
2. Dehydration 3. Metabolic issue
3. Asthma 4. Stroke/brain injury
4. COPD 5. Alcohol
5. Heart condition
6. Overdose
7. Infection
8. Anxiety
1.Fever can cause an increased respiratory rate as the body attempts to cool itself down.

2.Dehydration ,decreased fluid levels alter the levels of electrolytes. This can affect the exchange of important gases in
the lungs, causing an increase in respiratory rate.

3.Asthma when it becomes difficult to get enough air into the lungs ; excess mucus may block the airways 
decreased access to the oxygen in the air increased respiration as the body attempts to compensate for the lack of
air exchange.

4. COPD makes it difficult to get enough oxygen. As the body attempts to increase oxygen consumption, respiration
increases.

5. heart disease, heart function deteriorates and it can’t pump as much blood. When this happens, your body doesn’t
get the oxygen it needs and respiration increases.

6. Overdosing on certain drugs, especially stimulants, can lead to an increased breathing rate.

7. Lung infections can cause inflammation of the airways and the lungs. This inflammation can make it difficult to
breath.

8. panic attack/ anxiety activate the fight-or-flight response.

1. Alcohol is a depressant that affects the central nervous system

2. Narcotics can have a major influence on the central nervous system. Some drugs may act as a depressant

3. Metabolic issues: such as Hypothyroidism can weaken the muscles of the lungs, making it harder to breath. This
can slow down your normal respiratory rate.

4. Stroke makes Changes in the respiratory rate can be minor to severe, Minor respiratory changes can lead to sleep
disorders, such as sleep apnea. Major respiratory disturbances can lead to more serious complications, such as the
need for a breathing tube

5. Sleep apnea occurs when the area of the central nervous system that controls breathing doesn’t send the proper
signals while you sleep. This can be caused by underlying factors, such as stroke, heart failure, or certain
medications.
 Inspection
Chest inspection allows you to see visible external signs of respiratory function
Normal findings for chest inspection include:
1. Side to side symmetric chest shape
2. Distance from the front to the back of the chest (anterior-posterior diameter) less than the size of the chest from
side to side (transverse diameter)
3. Normal chest shape, with no visible deformities, such as a barrel chest, kyphosis, or scoliosis
4. No muscle retractions when breathing
5. Quiet, unlabored respirations with no use of accessory, neck, shoulder, or abdominal muscles
6. A regular respiratory rhythm, with expiration taking about twice as long as inspiration
7. Skin color that matches the rest of the body's complexion
8. A respiratory rate of 12-20 in an adult
Chest shape
• Pectus excavatum is a structural deformity of the anterior thoracic wall in which the sternum
 and rib cage are shaped abnormally. This produces a caved-in or sunken appearance of the 
chest. It can either be present at birth or develop after puberty.
• Pectus carinatum, also called pigeon chest, is a malformation of the chest characterized by a
protrusion of the sternum and ribs.

• Barrel chest generally refers to a broad, deep chest found on a patient. 

• Poland syndrome is a birth defect characterized by an underdeveloped chest muscle and 

short webbed fingers on one side of the body. Short ribs, less fat, and breast and nipple
abnormalities may also occur on that side
• cleidocranial dysplasia, is a birth defect that mostly affects the bones and teeth. The collarbones
are typically either poorly developed or absent, which allows the shoulders to be brought close
together.
Could you identify what is wrong with the girl?
• Turner syndrome (TS), is a genetic condition in which a female is partly or completely missing an X
chromosome
Breathing patterns:
1.Kussmal breathing: characterized by slow, deep breaths, occurs in patients with
diabetic acidosis and coma.

2.Bradypnea: or a much slower than normal respiratory rate, is seen in patients

with drug-induced respiratory depression, and increased intracranial pressure.

3.Cheyne-Stokes breathing: occurs when there are periods of deep breathing

alternating with periods of apnea, may be seen in a patient with heart failure,
drug-induced respiratory depression, uremia, or brain damage.

4.Ataxic breathing/Biot's breathing: is characterized by unpredictable irregularity,

seen in patients with respiratory depression and brain damage at the level of the
medulla.

https://www.youtube.com/watch?v=ViGjOiPE2mY
 Palpation
Palpation should focus on detecting abnormalities like masses or bony crepitus
1.evaluate tactile fremitus: the examiner will place both of his hands on the patient's back, medial to the shoulder
blades, and ask the patient to say "ninety-nine."
• An increase in the tactile fremitus points towards an increased intraparenchymal density.
• A decreased fremitus hints towards a pleural process that separates the pleura from the parenchyma (pleural
effusion, pneumothorax).

2.Trachea position Using the forefinger of the right hand, identify the suprasternal notch, then gently push
forefinger upwards and back until the trachea is palpated
3.Checking chest expansion
Position the thumbs together just either side of the midline, ensuring to keep them off the chest (‘in the air’), so they can
move freely with respiration, Ask the patient to breath in and out as normal. During inspiration the thumbs should
move apart, during expiration the thumbs should return together
Check both the anterior and posterior chest!!

https://
www.youtube.com/watch?v=
hBr1ZbRlino
 Percussion
Percussion sets the chest wall and underlying tissues into motion, producing audible sounds and palpable
vibrations.
Percussion helps to determine whether the underlying tissues are filled with air, fluid, or solid material.
What to do?
Percussing the anterior chest is most easily done with the patient lying supine; the patient should sit when
percussing the posterior chest. Place the first part of the middle finger of your nondominant hand firmly on the
patient's skin. Then, strike the finger placed on the patient's skin with the end of the middle finger of your dominant
hand.
* Work from the top part of the chest downward, comparing sounds heard on both the right and left sides of the
chest. https://www.youtube.com/watch?v=Lhe06ZTBV_A

https://
www.youtube.com/
watch?v=oc2UyJPf
NjU
 Auscultation
• While the patient breathes normally with mouth open, auscultate the lungs, making sure to auscultate the apices
and middle and lower lung fields posteriorly, laterally and anteriorly.
• Listen to at least one complete respiratory cycle at each site.
• First listen with quiet respiration. If breath sounds are inaudible, then have him take deep breaths.

Physiological breath sounds

1.Vesicular breathing : Soft and low pitched, Heard over both lungs
2.Bronchovesicular breathing: Intermediate intensity and pitch, Heard over 1st and 2ndintercostal spaces
3.Bronchial breathing: Loud and high pitched, Heard over the sternum
4.Tracheal breathing: Very loud and high pitched, Heard over the neck

https://www.youtube.com/watch?v=SCHeWvu1WlY&t=25s

https://www.youtube.com/watch?v=EgdxiCY0c8k
 Pathological breath sounds/ adventitious 
1.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 . Seen in COPD, Pneumonia and Heart Failure.
Fine: soft, high-pitched (e.g., normal, asbestosis, sarcoidosis)
Coarse: loud, low-pitched (e.g., COPD, pulmonary edema)

2.Wheezes: High-pitched continuous sounds ,Suggestive of asthma, COPD, airway obstruction, or mucus plug.

3.Rhonchi (sonor wheezing): low-pitched, snoring

4.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).
5.Pleural Rub: Occurs due to inflamed pleural surface rubbing each other during breathing. It is difficult to
differentiate from fine crackles, but the sound is similar to rubbing your stethoscope against cotton.

https://www.amboss.com/us/knowledge/Pulmonary_examination
Resources

https://www.amboss.com/us/knowledge/Pulmonary_examination

http://www.meddean.luc.edu/lumen/meded/medicine/pulmonar/pd/pstep29.htm

https://www.ncbi.nlm.nih.gov/books/NBK459253/

https://www.nursingtimes.net/clinical-archive/cardiovascular-clinical-archive/chest-e
xamination-part-1-chest-palpation-31-10-2006
/
https://doctorlib.info/pediatric/visual-diagnosis-treatment-pediatrics/32.html