Table of Contents
General Observation of the Patient
- Does the patient look systematically unwell? Does he or she have a fever?
- What is the patient’s level of consciousness?
- Does the patient have difficulty in breathing at rest? Look for the following:
- Abnormal breathing patterns
- Use of accessory muscles
- Pursed lip breathing
- Intercostal recession
- Are there any visible chest wall/general abnormalities?
Some abnormal types of breathing patterns
Prolonged expiratory phase: indicates airways obstruction
Cheyne-Stokes breathing: alternating slow/fast respiratory rate occurs in pulmonary edema and brain stem lesions
Kussmaul’s breathing: rapid sighing respiration caused by metabolic acidosis
Irregular breathing pattern: indicative of imminent cardiorespiratory arrest
Audible stridor: an inspiratory wheeze suggesting significant obstruction of the major airways
Excess abdominal movements on inspiration: occurs in chronic obstructive pulmonary disease (COPD)
Paradoxic abdominal movements: indrawing of the abdomen on inspiration, indicates diaphragmatic weakness
Some visible general/chest wall abnormalities
Cachexia: occurs in cancer, severe COPD, and chronic infection
Obesity: increased risk of asthma, obstructive sleep apnea, obesity, and hypoventilation
Shrunken lung: visibly smaller hemithorax and flattening of the upper anterior chest
Surgical scars: thoracotomy, pleural drains, mediastinoscopy, and sternotomy
Hyperexpanded chest — severe airway obstruction: increased anterior/posterior diameter and horizontal ribs
Kyphoscoliosis: anterior and lateral curvature of the spine, affects the mechanics of ventilation
Chest wall masses: lipomas are common; tumors can occasionally erode
The following can be studied simply by looking at a patient:
- Tachypnea (> 20/min), stridor, coughing, hoarseness, and dyspnea
- Breathing pattern: Kussmaul’s breathing, Cheyne-Stokes breathing, and Biot’s breathing
- Accessory respiratory muscles and withdrawal
- Symmetry of the thorax
- Shape of the thorax: barrel chest, kyphoscoliosis, gibbus, pectus excavatum, and pectus carinatum
- Location of the trachea (in the middle)
- Spinal column/ribs: pain upon percussion, fracture, Tietze syndrome, and rachitis
- Skin emphysema
- Symmetric excursion
- Pain upon compression
What was that again…?
Vocal fremitus: Place your hands laterally on the patient’s thorax and ask the patient to say the number “99” (loud and resounding). Palpable vibrations during the infiltration of the lung (pneumonia, bronchiectasis, and pulmonary congestion) are pathologically intensified. A weakened fremitus can be felt in cases where air or liquids are trapped in the pleural cavity (pneumothorax, pleural effusion).
- Poor technique (e.g., raised finger of the chest wall)
- Pleural effusion: classically very dull and described as “stony dull”
- Lobar/total lung collapse
- Previous pneumonectomy or lobectomy
- Extensive consolidation due to pneumonia
- Pleural thickening/mesothelioma
- Obesity (relative, falsely dull)
- Raised hemidiaphragm (due to loss of lung volume or phrenic palsy)
- Normally over the liver and heart
Quality of percussion sound:
|Hyper sonor||emphysema, pneumothorax|
|Sonor||normal, bronchitis, central pneumonia, pulmonary edema|
|Hypo sonor||pleural effusion, infiltrate, tumor, pleural|
- Respiratory sounds: tracheal, bronchial, bronchovesicular, and vesicular (normal findings are known from many clinical reports: vesicular respiratory sounds)
- Weakened/missing respiratory sounds: emphysema, status asthmaticus, pneumothorax, effusion, pleural fibrosis, and tumor
- Bronchial breath sounds: consolidation (in cases of pneumonia, hemorrhages, and edema)
- Pleural rub (pleuritis)
- Adventitious breath sounds:
- Continuous wheezing and humming
- Discontinuous: Fine bubbling rales are usually of high frequency and occur due to an opening of the small airways, indicative of pulmonary fibrosis or beginning lung edema. Coarse bubble rales are usually of low frequency and occur due to trapped liquid in the small airways, indicative of bronchitis or lung edema.
- Bronchophony: Examination of the forwarding of higher tones. Ask the patient to say the number “66” in a high (slightly hissing) voice. The number can be heard better via infiltrated areas (pneumonia) due to better forwarding. In cases of pneumothorax or pleural effusion, little or nothing may be heard.
Inspiratory/expiratory breath sounds
- Calculate the ratio of inspiration to expiration on breathing.
- Normally, inspiration is slightly longer than the expiration.
Breath sounds: added sounds and their common causes
|Speed of onset||Possible causes|
|Crepitations||Consolidation due to pneumonia (asymmetric, coarse)
Pulmonary fibrosis and other interstitial lung diseases (fine)
Pulmonary edema (fine)
Partial obstruction of a major bronchus (monophonic)
Pulmonary edema (‘cardiac asthma’)
Upper airway obstruction (inspiratory—stridor)
|Pleural rub||Pleural infection
Over-consolidated lung in pneumonia
Other inflammatory effusions (e.g., Dressler’s syndrome)
Recently drained pleural effusions
The lung is not the only organ that can give indications of pulmonary diseases.
Hands: The typical signs of chronic hypoxia are Hippocratic fingers and Hippocratic nails. Pay attention to venous filling and the heart rate!
Head: Color reveals a lot: Is there anemia, jaundice, or cyanosis of the lips? How do the veins on the base of the tongue and the buccal mucosa appear?
Extremities: Sarcoidosis or hypertrophic osteoarthropathy are examples of diseases that can present symptoms of frequent pulmonary manifestation in other parts of the body. Are there signs of thrombosis on the lower leg? A lung embolism might be present. Edema would be a sign of right ventricular insufficiency with a backlog of blood and other problems with the lungs.
- Erythema multiforme: Mycoplasma pneumoniae
- Erythema nodosum: tuberculosis, sarcoidosis, and histoplasmosis
- Purpura: vasculitis
- Lupus pernio: sarcoidosis
- Lupus vulgaris: tuberculosis
For the Pocket in Your Doctor’s Coat: Everything Important at One Glance
|Status asthmaticus||Hyperinflation, auxiliary respiratory muscles||Fremitus||Hyper-resonant, depression of the diaphragm||Expiration, wheezes|
|Pneumothorax||Excursion||Fremitus, shift of the trachea to the healthy side||Hyper-resonant||Faint/no respiratory sound|
|Pleural effusion||Excursion||Fremitus, shift of the trachea to the healthy side||Damped||Faint respiratory sound|
|Atelectasis||Excursion||Fremitus, shift of the trachea to the diseased side||Damped||Faint respiratory sound|
|Consolidation||Excursion||Fremitus||Damped||Bronchial breath sounds, bronchophony|
Fixed airway obstruction: COPD
- Increased respiratory rate
- Using accessory muscles: sternocleidomastoids, trapezius, etc.
- Excessive abdominal movement on inspiration
- Pursed lip breathing
Auscultation throughout both lungs
- Quiet breath sounds
- Prolonged expiratory phase
- +/- expiratory wheeze
Hyperexpanded lungs (hyperexpansion)
- Horizontal angle to the ribs
- ‘Barrel chest’: increased anterior–posterior diameter
- Tracheal lung
- Bilateral reduced chest expansion
- Trachea central
Percussion note: resonant over liver and heart, and below T10
Severe disease: central cyanosis, evidence of cor pulmonale