Pulmonary Examination

The pulmonary examination is a portion of the physical examination involving the assessment of the lungs and airways by a healthcare worker to evaluate for signs of disease or illness. The examination includes inspection, auscultation, percussion, and palpation. A careful pulmonary exam provides important clues that, along with the history, can guide the physician to a presumptive diagnosis.

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Introduction

Positioning:

  • Patient sits upright with arms at side.
  • Perform all exams on undressed patient while preserving patient’s modesty.

Environment:

  • Ensure good lighting, privacy, and hygiene. 
  • Drape patients with a clean gown, towel, or sheet.

Initial steps:

  • Explain the steps of the exam to the patient and obtain their consent.
  • Obtain vital signs, including pulse oximetry (oxygen saturation).
  • Ask the patient to indicate areas of tenderness to avoid exacerbating pain.

Inspection

The 1st part of the pulmonary exam begins with an inspection of the patient noting pertinent positive and negative findings.

Inspection overview

General appearance/distress level of patient:

  • Pertinent positives:
    • Well or in no acute distress
    • Comfortable, normal affect
  • Pertinent negatives:
    • In distress (mild, moderate, or severe)
    • Disheveled
    • Evasive, oppositional

Level of consciousness:

  • Alert: normal response
  • Confused: disoriented to surroundings
  • Lethargic: drowsy, needs stimulation to initiate response
  • Obtunded: slowly responding, needs repeated stimulation to maintain attention
  • Stuporous: minimal response to stimulation
  • Comatose/unresponsive: no response to stimulation

Respiratory rate (RR):

  • Normal RR: 12–20/min in adults (pediatric RR varies based on age)
  • Bradypnea: RR < 12/min
  • Tachypnea: RR > 20/min, shallow breathing
  • Hyperpnea: RR > 20/min, deep breathing
Table: Normal respiratory rate ranges in children
Age groupAgeNormal respiratory rate range
Infant0–12 months30–60/min
Toddler1–3 years24–40/min
Preschooler4–5 years22–34/min
School age6–12 years18–30/min
Adolescent and adult13 years and older12–16/min

Work of breathing:

  • Note any observable breathing patterns.
  • Labored breathing (abnormal respirations with ↑ effort to breathe, use of accessory muscles, stridor, grunting, or nasal flaring):
    • Accessory muscles: sternomastoid, scalene, and pectoralis major
    • Pursed lip breathing (seen in emphysematous patients)
    • Intercostal retractions
  • Tripod position:
    • Lean forward while sitting and rest the hands on the knees
    • Seen in patients with asthma, emphysema, and respiratory distress

Inspection of thorax:

  • Symmetry of thorax
  • Symmetric movement of the chest through all phases of breathing
  • Visible chest wall/general abnormalities:
    • Inspect for flail chest, obvious trauma, or other skin lesions/rashes.
    • Congenital abnormalities of the spine: kyphosis, lordosis, scoliosis, etc. 
    • Chronic obstructive pulmonary disease (COPD) barrel chest: ↑ anteroposterior diameter of the chest

Examine extremities for signs of respiratory illness:

  • Cyanosis
  • Nail clubbing (abnormally rounded nailbeds):
    • Subcutaneous reaction due to chronic hypoxemia 
    • Seen in lung cancer, interstitial lung disease, cystic fibrosis, and bronchiectasis
    • Not present in asthma or COPD
Nail clubbing

Nail clubbing:
Clubbed nails are abnormal, rounded nail beds often seen in association with conditions causing chronic hypoxemia, such as cystic fibrosis or interstitial lung disease.

Image: “Nail clubbing” by Department of Internal Medicine, Cleveland Clinic Florida, 2950 Cleveland Clinic Boulevard, Weston, FL 33331, USA. License: CC BY 3.0

Examine neck:

  • Jugular venous distension (JVD):
    • Tension pneumothorax 
    • Possible right heart failure

Breathing patterns

Certain breathing patterns help to narrow the differential diagnosis and direct patient care.

Table: Breathing patterns and associated conditions
Breathing patternSigns on examAssociated diseases
TachypneaBreathing rate > 20/min in adults
  • Nonspecific
  • Fever/sepsis
  • Shock
  • Anxiety
BradypneaBreathing rate < 12/min
  • Nonspecific
  • Narcotic use
  • Stroke
  • Head injury
ApneaNo breathing
  • Cardiac arrest
  • Stroke
  • Head injury
  • Death
Prolonged expiratory phaseExpiration phase > ⅔ of breath length (normal inspiration ⅓ of breath, expiration ⅔ of breath)
  • Airway obstruction
  • Asthma
  • COPD
Cheyne-Stokes breathing
  • Alternating periods of deep breathing followed by apnea
  • Pattern repeats with each cycle (usually 30 sec to 2 minutes).
  • Pulmonary edema
  • Advanced heart failure
  • Brain stem lesions
  • ↑ ICP
Kussmaul breathingRapid sighing respirationMetabolic acidosis (e.g., DKA)
AgonalIrregular breathing patternImminent cardiorespiratory arrest
COPD: chronic obstructive pulmonary disease
ICP: intracranial pressure
DKA: diabetic ketoacidosis

Chest wall abnormalities

Visualization of the chest wall can help determine the etiology of disease pathology.

Table: Chest wall abnormalities and associated conditions
Chest wall findiingClinically important causes
Cachexia (extreme thinness or wasting)
  • Cancer
  • Severe COPD
  • Chronic infection
Obesity
  • Asthma
  • Obstructive sleep apnea
  • Obesity hypoventilation
Surgical scars
  • Thoracotomy
  • Pleural drains
  • Mediastinoscopy
  • Sternotomy
Hyperexpanded barrel chest
  • Severe airway obstruction
  • Horizontal ribs
  • COPD
Spinal abnormalities
  • Scoliosis: lateral curvature of the spine
  • Kyphoscoliosis: anterior and lateral curvature of the spine
Sternal abnormalities
  • Pectus excavatum: sternum sunken into the chest
  • Pectus carinatum: sternum protruding from the chest
Chest wall masses
  • Lipomas
  • Tumors
COPD: chronic obstructive pulmonary disease

Palpation

  • Palpate the chest:
    • Technique:
      • Gently press the chest wall.
      • Work systematically, top to bottom, comparing left with right.
    • Assess for:
      • Areas of tenderness 
      • Masses 
      • Subcutaneous emphysema
  • Palpate tracheal position: 
    • Technique:
      • Use the index, middle, and ring finger to gently feel the area of the thyroid.
      • Use both hands to feel both sides simultaneously and compare.
    • Assess for:
      • Tracheal deviation
      • Crepitus
      • Swelling/masses
  • Observe chest expansion for asymmetry:
    • Technique:
      • Place palms on patient’s back, fingers parallel to ribs, and thumbs at 10th ribs.
      • Instruct patient to inhale.
      • Observe movement of thumbs on patient’s back for symmetry.
    • Assess for:
      • Asymmetry in expansion
      • Paradoxical movement
  • Feel for tactile fremitus:
    • Vibration is transmitted through the lungs and felt on the chest wall.
    • Place bony parts of the hand around the borders of the patient’s scapula. 
    • Instruct patient to say “99” or “1, 1, 1” to test for fremitus.
    • Fremitus asymmetry: pneumonia
    • ↓ Fremitus:
      • Effusion
      • Obstruction
      • Pneumothorax
      • Emphysema
      • Atelectasis
Pulmonary Exam - Palpation

Evaluation of chest movement:
During the pulmonary exam, the physician can utilize their hands as a reference to evaluate different portions of the chest moving symmetrically during the respiratory cycle.

Image by Lecturio.

Percussion

Technique

  • Place middle finger of 1 hand over area of interest on chest or back.
  • Strike distal interphalangeal joint with middle finger of the other hand.
  • Percuss in systematic pattern from upper chest to lower ribs.
  • Compare resonance between left and right sides of the chest.

Findings

  • Normal: resonant, loud, low-pitched
  • Abnormal:
    • Dullness:
      • Medium intensity and pitch
      • Found in pneumonia, hemothorax, and atelectasis 
    • Hyperresonance: 
      • Very loud, very low-pitched, and longer
      • Indicates presence of air inside the thoracic cavity
      • Found in pneumothorax and emphysema
Pulmonary Exam - Percussion

Percussion location:
Percussion is a key component of the lung exam. A systematic and symmetric percussion of a patient’s back can help identify areas of dullness consistent with infection, effusion or atelectasis.

Image by Lecturio.

Auscultation

Auscultation is done with stethoscope diaphragm on unclothed skin.

  • Ask the patient to take a deep breath: Hear full inspiration and expiration.
  • Listen to breath sounds anteriorly and posteriorly, starting superiorly, and comparing bilateral lungs, moving inferiorly.
Table: Normal breath sounds
SoundDescriptionNormal location
Tracheal breathingLoud and high-pitchedHeard over neck
Bronchial breathing
  • Loud and high-pitched
  • Expiratory sounds last longer.
Heard over large airways (over sternum)
Bronchovesicular breathing
  • Intermediate intensity and pitch
  • Inspiratory and expiratory sounds are equal.
Heard over 1st and 2nd intercostal spaces
Vesicular breathing
  • Lower-pitched, rustling sounds
  • Inspiratory sounds last longer.
Heard over both lung fields
Table: Pathological breath sounds
SoundDescriptionAssociated conditions
Crackles (rales or crepitations)
  • Heard during inspiration only
  • Discontinuous, intermittent
  • High (fine) or low (coarse)
  • Pneumonia
  • COPD
  • Pulmonary edema
Wheezes or rhonchi
  • Heard in both inspiration and expiration
  • Continuous sound
  • High (wheeze) or lower (rhonchi)
  • Asthma
  • COPD
  • Foreign body aspiration
Inspiratory stridorHigh-pitched, musical breath sound from turbulent airflow during inspirationObstruction above the glottis:
  • Epiglottitis
  • Retropharyngeal/peritonsillar abscess
Expiratory stridorHigh-pitched, musical breath sound from turbulent airflow during expirationObstruction below the glottis:
  • Asthma
  • COPD
Inspiratory stridorHigh-pitched, musical breath sound from turbulent airflow during inspirationObstruction above the glottis:
  • Epiglottitis
  • Retropharyngeal/peritonsillar abscess
Biphasic stridorHigh-pitched, musical breath sound from turbulent airflow during the entire respiratory cycleObstruction at the glottis:
  • Foreign body aspiration
  • Bilateral vocal cord palsy
Pleural friction rub
  • Discontinuous, low-pitched sound
  • Heard in both inspiration and expiration
Pleuritis
Muffled or absent breath sounds
  • Continuous sounds with musical quality
  • When in the respiratory cycle the wheeze occurs; usually louder in expiration
  • Emphysema
  • Status asthmaticus
  • Pneumothorax
  • Effusion
  • Pleural fibrosis
  • Tumor
COPD: chronic obstructive pulmonary disease

Important Pulmonary Conditions

Table: Overview of important pulmonary conditions and findings in pulmonary exam
DiseaseInspectionPalpationPercussionAuscultation
Status asthmaticus
  • Tachypnea
  • Chest hyperinflation
  • Auxiliary respiratory muscle use
  • Prolonged expiratory phase
Increased fremitus
  • Hyperresonant
  • Depression of the diaphragm
Expiratory wheezes
Pneumothorax
  • Distress
  • Tachypnea
  • ↓ Tactile fremitus
  • Trachea shift to healthy side
HyperresonantFaint/no respiratory sound
Pleural effusion
  • Distress
  • Tachypnea
  • ↓ Tactile fremitus
  • Trachea shift to healthy side
DullFaint respiratory sound
Atelectasis
  • Distress
  • Tachypnea
  • ↓ Tactile fremitus
  • Trachea shift to diseased side
DullFaint respiratory sound
Consolidation (pneumonia)
  • Distress
  • Tachypnea
↑ Tactile fremitusDull
  • Bronchial breath sounds
  • Crackles

Clinical Relevance

The following are common conditions found utilizing the 4-part pulmonary examination.

  • Pneumonia (pulmonary inflammation): acute or chronic inflammation of lung tissue caused by bacterial, viral, or fungal infections. Exam findings include fever, tachypnea, increased tactile fremitus, dullness in percussion, and bronchial breath sound or crackles during auscultation. Patients may go into sepsis and decompensate. Management is with targeted antibiotic therapy.
  • Atelectasis: a condition characterized by progressive collapse of alveoli and small airways due to plugging or other mechanisms. Presentation includes respiratory distress and hypoxemia. Exam findings include dullness to percussion, absence of breath sounds, and tracheal shifting towards the side of atelectasis. Chest X-ray shows lung opacification. Management is with respiratory physiotherapy or positive end-expiratory pressure, or bronchoscopy.
  • Pleural effusion: a pathological accumulation of fluid in the pleural cavity caused by inflammation, infection, malignancy, or other pathology. Exam findings include decreased breath sounds, dullness to percussion, and decreased fremitus. Management depends on treating the underlying condition but often starts with the removal of fluid (thoracentesis).
  • Pneumothorax: an abnormal collection of air in the pleural space, including simple and tension pneumothoraces. Physical exam findings include decreased breath sounds, hyperresonance on percussion, tracheal deviation/mediastinal shift away from tension pneumothorax, decreased tactile vocal fremitus, and jugular venous distension (JVD). Management includes needle decompression and chest tube placement.
  • Pulmonary edema: a condition caused by excess fluid in the interstitial space of the lungs. Pulmonary edema is a consequence of the disease process rather than a primary pathology and is classified as cardiogenic or noncardiogenic based on the cause of edema. Exam findings include bilateral crackles, lower extremity swelling, and often JVD. Management is pulmonary toilet with diuretics.
  • Chronic obstructive pulmonary disease (COPD): a summary of chronic respiratory diseases where airflow limitation occurs. Exam findings include wheezing, prolonged expiratory phase, and sometimes barrel chest; approximately 90% of cases are caused by smoking. Acute management involves an inhaled, short-acting beta-agonist as well as steroids, supplemental oxygen, and, in severe cases, ventilatory support with positive end-expiratory pressure.

References

  1. McCormack, M. (2020). Overview of pulmonary function testing in adults. UpToDate. Retrieved January 27, 2021, from https://www.uptodate.com/contents/overview-of-pulmonary-function-testing-in-adults
  2. Lone, N. (2019). Pulmonary Examination Technique. Emedicine. Retrieved February 26, 2021, from https://emedicine.medscape.com/article/1909159-technique 
  3. Bickley L. Bates’ Guide to Physical Examination and History-Taking. (2012). Lippincott Williams & Wilkins.
  4. Walker HK, Hall WD, Hurst WJ, Silverman ME, Morrison G. Clinical Methods: The History, Physical, and Laboratory Examinations. (1999). Butterworths.
  5. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. (2014). N Engl J Med. 370 (8): p.744-751.

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