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The Lung Exam

http://medicine.ucsd.edu/clinicalmed/lung.htm

The Lung ExamThe 4 major components of the lung exam (inspection, palpation, percussion andauscultation) are also used to examine the heart and abdomen. Learning the appropriate

techniues at this juncture !ill therefore enhance "our abilit" to perform these other

examinations as !ell. #ital signs, an important source of information, are discussed

else!here.

Inspection/Observation: $ great deal of information can be gathered from simpl"

!atching a patient breathe. %a" particular attention to:

&. 'eneral comfort and breathing pattern of the patient. o the" appear distressed,diaphoretic, labored $re the breaths regular and deep

*. +se of accessor" muscles of breathing (e.g. scalenes, sternocleidomastoids). Their 

use signifies some element of respirator" difficult".

. -olor of the patient, in particular around the lips and nail beds. biousl", blue is bad0

Cyanosis of nail beds 

4. The position of the patient. Those !ith extreme pulmonar" d"sfunction !ill often

sit up1right. 2n cases of real distress, the" !ill lean for!ard, resting their hands ontheir 3nees in !hat is 3no!n as the tri1pod position.

Patient ith emphysema bending over in Tri!Pod Position 

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. 5reathing through pursed lips, often seen in cases of emph"sema.

6. $bilit" to spea3. $t times, respirator" rates can be so high and/or !or3 of

 breathing so great that patients are unable to spea3 in complete sentences. 2f this

occurs, note ho! man" !ords the" can spea3 (i.e. the fe!er !ords per breath, the!orse the problem0).

7. $n" audible noises associated !ith breathing as occasionall", !hee8ing or the

gurgling caused b" secretions in large air!a"s are audible to the 9na3ed9 ear.. The direction of abdominal !all moement during inspiration. ;ormall", the

descent of the diaphragm pushes intra1abdominal contents do!n and the !all

out!ard. 2n cases of seere diaphragmatic flattening (e.g. emph"sema) or paral"sis, the abdominal !all ma" moe in!ard during inspiration, referred to as

 paradoxical breathing. 2f "ou suspect this to be the case, place "our hand on the

 patient

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o 5arrel chest: $ssociated !ith emph"sema and lung h"perinflation.

$ccompan"ing xra" also demonstrates

increased anterior1posterior diameter as !ell as diaphragmatic flattening.

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o >pine abnormalities: ?"phosis: -auses the patient to be bent for!ard. $ccompan"ing

@1Aa" of same patient clearl" demonstrates extreme curature of

the spine.

>coliosis: -ondition !here the spine is cured to either the left orright. 2n the pictures belo!, scoliosis of the spine causes rightshoulder area to appear some!hat higher than the left. -urature is

more pronounced on x1ra".

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"evie of Lung #natomy: +nderstanding the pulmonar" exam is greatl" enhanced b"recogni8ing the relationships bet!een surface structures, the s3eleton, and the main lobes

of the lung. Aeali8e that this can be difficult as some surface landmar3s (eg nipples of the

 breast) do not al!a"s maintain their precise relationship to underl"ing structures.

 ;eertheless, surface mar3ers !ill gie "ou a rough guide to !hat lies beneath the s3in.

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The pictures belo! demonstrate these relationships. The multi1colored areas of the lung

model identif" precise anatomic segments of the arious lobes, !hich cannot be

appreciated on examination. Bain lobes are outlined in blac3. The follo!ingabbreiations are used: A+L C Aight +pper LobeD L+L C Left +pper LobeD ABL C Aight

Biddle LobeD ALL C Aight Lo!er LobeD LLL C Left Lo!er Lobe.

#nterior $ie

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Posterior $ie 

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"ight Lateral$ie 

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Left Lateral$ie 

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Palpation: %alpation pla"s a relatiel" minor role in the examination of the normal chestas the structure of interest (the lung) is coered b" the ribs and therefore not palpable.

>pecific situations !here it ma" be helpful include:

&. $ccentuating normal chest excursion: %lace "our hands on the patient

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*. Tactile Fremitus: ;ormal lung transmits a palpable ibrator" sensation to the

chest !all. This is referred to as fremitus and can be detected b" placing the ulnar

aspects of both hands firml" against either side of the chest !hile the patient sa"s

the !ords 9;inet"1;ine.9 This maneuer is repeated until the entire posteriorthorax is coered. The bon" aspects of the hands are used as the" are particularl"

sensitie for detecting these ibrations.

#ssessing &remitus

%athologic conditions !ill alter fremitus. 2n particular:

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$. Lung consolidation: -onsolidation occurs !hen the normall" air filled

lung parench"ma becomes engorged !ith fluid or tissue, most commonl"

in the setting of pneumonia. 2f a large enough segment of parench"ma isinoled, it can alter the transmission of air and sound. 2n the presence of

consolidation, fremitus becomes more pronounced.

5. %leural fluid: Fluid, 3no!n as a pleural effusion, can collect in the potential space that exists bet!een the lung and the chest !all, displacing

the lung up!ards. Fremitus oer an effusion !ill be decreased.

2n general, fremitus is a prett" subtle finding and should not be thought of as the

 primar" means of identif"ing either consolidation or pleural fluid. 2t can,ho!eer, lend supporting eidence if other findings (see belo!) suggest the

 presence of either of these processes.

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Effusions

and

infiltratescan

 perhaps be

more easil"understood

using a

sponge torepresent

the lung. 2n

this model,an infiltrate

is depicted

 b" the blue

coloration

that hasinaded the

spongeitself

(sponge on

left). $neffusion is

depicted b"

the blue

fluid upon!hich the

lung isfloating(sponge on

right).

. 2nestigating painful areas: 2f the patient complains of pain at a particular site it is

obiousl" important to carefull" palpate around that area. 2n addition, specialsituations (e.g. trauma) mandate careful palpation to loo3 for eidence of rib

fracture, subcutaneous air (feels li3e "our pushing on Aice ?rispies or bubble

 paper), etc.

Percussion: This techniue ma3es use of the fact that stri3ing a surface !hich coers anair1filled structure (e.g. normal lung) !ill produce a resonant note !hile repeating the

same maneuer oer a fluid or tissue filled cait" generates a relatiel" dull sound. 2f the

normal, air1filled tissue has been displaced b" fluid (e.g. pleural effusion) or infiltrated!ith !hite cells and bacteria (e.g. pneumonia), percussion !ill generate a deadened tone.

$lternatiel", processes that lead to chronic (e.g. emph"sema) or acute (e.g.

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 pneumothorax) air trapping in the lung or pleural space, respectiel", !ill produce h"per1

resonant (i.e. more drum1li3e) notes on percussion. 2nitiall", "ou !ill find that this s3ill is

a bit a!3!ard to perform. $llo! "our hand to s!ing freel" at the !rist, hammering "ourfinger onto the target at the bottom of the do!n stro3e. $ stiff !rist forces "ou to push

"our finger into the target !hich !ill not elicit the correct sound. 2n addition, it ta3es a

!hile to deelop an ear for !hat is resonant and !hat is not. $ fe! things to remember:

&. 2f "ou

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across and repeat the same procedure on the right side. 2f "ou detect an"

abnormalit" on one side, it

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#uscultation: %rior to listening oer an" one area of the chest, remind "ourself !hich

lobe of the lung is heard best in that region: lo!er lobes occup" the bottom /4 of the

 posterior fieldsD right middle lobe heard in right axillaD lingula in left axillaD upper lobesin the anterior chest and at the top &/4 of the posterior fields. This can be uite helpful in

tr"ing to pin do!n the location of pathologic processes that ma" be restricted b"

anatomic boundaries (e.g. pneumonia). Ban" disease processes (e.g. pulmonar" edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.

&. %ut on "our stethoscope so that the ear pieces are directed a!a" from "ou. $djust

the head of the scope so that the diaphragm is engaged. 2f "ou

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4. Then, moe around to the front and listen to the anterior fields in the same

fashion. This is generall" done !hile the patient is still sitting upright. $s3ing

female patients to lie do!n !ill allo! their breasts to fall a!a" laterall", !hichma" ma3e this part of the examination easier.

$ fe! additional things !orth noting.

&. onounds.

Ghat can "ou expect to hear $ fe! basic sounds to listen for:

&. $ health" indiidual breathing through their mouth at normal tidal olumes produces a soft inspirator" sound as air rushes into the lungs, !ith little noise

 produced on expiration. These are referred to as essicular breath sounds.

*. Ghee8es are !histling1t"pe noises produced during expiration (and sometimes

inspiration) !hen air is forced through air!a"s narro!ed b" bronchoconstriction,secretions, and/or associated mucosal edema. $s this most commonl" occurs in

association !ith diffuse processes that affect all lobes of the lung (e.g. asthma and

emph"sema) it is freuentl" audible in all fields. 2n cases of significant bronchoconstriction, the expirator" phase of respiration (relatie to inspiration)

 becomes noticeabl" prolonged. -linicians refer to this as an increased 2 to E ratio.

 ;ormal is approximatle" &:* (i.e. expiration t!ice as long as inspiration) thoughactual timed measurements are neither practical nor reliable. Focus instead on

http://www.med.ucla.edu/wilkes/intro.htmlhttp://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htmhttp://www.rale.ca/Repository.htmhttp://www.rale.ca/Repository.htmhttp://www.med.ucla.edu/wilkes/intro.htmlhttp://www.med.ucla.edu/wilkes/intro.htmlhttp://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htmhttp://www.rale.ca/Repository.htm

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simple obseration, noting !hether E seems II 2. The greater the difference, the

!orse the obstruction. ccasionall", focal !hee8ing can occur !hen air!a"

narro!ing if restricted to a single anatomic area, as might occur !ith anobstructing tumor or bronchoconstriction induced b" pneumonia. Ghee8ing heard

onl" on inspiration is referred to as stridor and is associated !ith mechanical

obstruction at the leel of the trachea/upper air!a". This ma" be best appreciated b" placing "our stethescope directl" on top of the trachea.

. Aales (a.3.a. crac3les) are scratch" sounds that occur in association !ith processes

that cause fluid to accumulate !ithin the aleolar and interstitial spaces. Thesound is similar to that produced b" rubbing strands of hair together close to "our

ear. %ulmonar" edema is probabl" the most common cause, at least in the older

adult population, and results in s"mmetric findings. This tends to occur first in the

most dependent portions of the lo!er lobes and extend from the bases to!ards theapices as disease progresses. %neumonia, on the other hand, can result in discrete

areas of aleolar filling, and therefore produce crac3les restricted to a specific

region of the lung. #er" distinct, diffuse, dr"1sounding crac3les, similar to the

noise produced !hen separating pieces of elcro, are caused b" pulmonar"fibrosis, a relatiel" uncommon condition.

4. ense consolidation of the lung parench"ma, as can occur !ith pneumonia,results in the transmission of large air!a" noises (i.e. those normall" heard on

auscultation oer the tracheaJ 3no!n as tubular or bronchial breath sounds) to

the peripher". 2n this setting, the consolidated lung acts as a terrific conductingmedium, transferring central sounds directl" to the edges. 2t

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Bost of the aboe techniues are complimentar". ullness detected on percussion, for

example, ma" represent either lung consolidation or a pleural effusion. $uscultation oer

the same region should help to distinguish bet!een these possibilities, as consolidationgenerates bronchial breath sounds !hile an effusion is associated !ith a relatie absence

of sound. >imilarl", fremitus !ill be increased oer consolidation and decreased oer an

effusion. $s such, it ma" be necessar" to repeat certain aspects of the exam, using onefinding to confirm the significance of another. Fe! findings are pathognomonic. The"

hae their greatest meaning !hen used together to paint the most informatie picture.

The %ynamic Lung Exam: 

Pulse Oxymeter

ftentimes, a patient !ill complain of a s"mptom that is induced b" actiit" ormoement. >hortness of breath on exertion, one such example, can be a mar3er of

significant cardiac or pulmonar" d"sfunction. The initial examination ma" be relatiel"

unreealing. 2n such cases, consider obsered ambulation (!ith the use of a pulseox"meter, a deice that continuousl" measures heart rate and ox"gen saturation, if

aailable) as a d"namic extension of the cardiac and pulmonar" examinations.

Kuantif"ing a patient

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!ill also generate a measurement that "ou can refer bac3 to during subseuent

ealuations in order to determine if there has been an" real change in functional status.