Pulmonary Exam

Required Prep: Bates’ Text: Ch. 8. I hope this handout can replace the Techniques of Examination section of the text,
however the text is full of useful clinical information throughout the chapter.

Bates’ PE videos: Vol. 9 or JoVE videos – Respiratory Exam I-II (https://www-jove-

com.proxy.cc.uic.edu/education/19/physical-examinations-i)

Recommended: Examples of abnormal lung sounds discussed in this handout can be found at:
https://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide. (Heart sounds, too.)

I. Agenda
1) Practice appropriate draping techniques
2) Students will perform the Lung exam on each other
3) Preceptors will clarify and demonstrate exam techniques, as needed
4) Discuss appropriate ROS and Documentation of the lung exam
5) Discuss clinical applications (Part V)

II. Items

A. Using a gown, review and practice appropriate draping technique

B. Identify surface anatomy of the thorax (Fig 8-1, Bates’ text, 12e.)

(Bates’ text, 12e.) Picture the lungs and their

fissures and lobes on the chest wall. Anteriorly,
the apex of each lung rises approximately 2 to 4
cm above the inner third of the clavicle (Fig. 8-
7). The lower border of the lung crosses the 6th
rib at the midclavicular line and the 8th rib at
the midaxillary line. Posteriorly, the lower
border of the lung lies at about the level of the
T10 spinous process (Fig. 8-8). On inspiration,
it descends in the chest cavity during
contraction and descent of the diaphragm. The
trachea bifurcates into the mainstem bronchi at
the sternal angle.  

C. Inspection
1. Respiratory effort and pattern - Effort (normal, increased, decreased), Breathing rate & rhythm (Table 8-4),
Depth (shallow, deep), as well as posturing and accessory muscle use, when present.
2. Non-thoracic structures related to respiration – lips, nails, extremities for cyanosis or pallor
3. Skin of the thorax for abnormalities
4. Overall symmetry and shape of thorax (Table 8-5)
5. Rib cage and spinal deformities

D. Palpation
-Given the possible sensitive nature of the exam, remember to inform the Pt of what you will be doing prior to
each maneuver to ensure their comfort
.
1. Ribs/bony structures for tenderness
2. Respiratory excursion (chest expansion) Note: Keep thumbs off chest so you can see them move
Inform Pt, “I’d like to check how your chest and ribs move when you breath”.

a. Anterior – place thumbs over costal angle, where the 7 th rib attaches to the bottom of
the sternum by the xiphoid process, with your fingers pointing laterally along the ribs

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 b. Posterior – place your thumbs along the posterior rib angles, just below the level of
the Pt’s scapulae, and your fingers pointing laterally along the lower ribs (The picture in
Bates’ is a little too low)
c. In Pt’s presenting with cough and fever in the office, decreased chest expansion on a side is
consistent with pneumonia.
d. In the hospital, decreased chest expansion is most commonly seen from pleural effusions

3. Tactile fremitus – use the palms of your hands and simultaneously compare sides while the patient says,
“toy boat” or “ninety-nine”. It’s normally present, but harder to feel in higher pitched voices.
a. Decreased with COPD, pneumothorax, pleural effusion or fibrosis
b. Increased with a mass or lung consolidation (pneumonia) – hard to detect

E. Percussion
Inform Pt, “I’m going to tap on your chest wall to see how it sounds”.
1. Percuss thorax anteriorly in areas 1-4, and posteriorly in areas 1-6, pictured below
 Firmly press the DIP joint of your middle finger (pleximeter) against the thorax
 Using your wrist as a hinge, strike the above with the tip of your other middle finger (plexor) at
almost a right angle to the pleximeter. The strike should be brisk and then quickly withdrawn.
Note: You may need to use your reflex hammer as the plexor in obese patients

 The normal, air-filled lung percussion sound is slightly hollow sounding and lower in frequency
and described as resonant. Compare this to dullness by percussing on the low back.
 Hyper-resonance, a louder, lower, and longer-lasting sound compared to resonance, can be
present in Pt’s with significant COPD or a pneumothorax
 Dullness can be the result of a pleural effusion, consolidation or mass
 In Pt’s with suspected but undiagnosed COPD:
 Hyperresonance in chronic smokers increases the probability of chronic airflow
obstruction (LR 7.3)
 Absence of cardiac dullness at the left lower sternal border increases the probability of
COPD with a LR of 11.8!

2. Diaphragmatic excursion, or descent of the diaphragm, is used for bedside assessment for air trapping,
effusion, or an elevated hemidiaphragm from atelectasis or phrenic nerve paralysis. Clinicians tend to
overestimate the movement, but it serves as a good practice technique to improve your percussion
skills.
 It is easier for the ear to perceive the transition from dull to resonant
 Remember, posteriorly the lung usually rests at the level of T10 and descends to around T12 with
inhalation, so it may help to identify these landmarks and the 12 th rib before starting
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  Ask your Pt to take a full breath in and hold. Starting in the low back, percuss upward until you
find the line of resonance that will represent the line of the diaphragm with full inspiration
 Ask your Pt to fully exhale and hold. Continue percussing upward until you find the new level of
resonance that will represent the line of the diaphragm with full expiration
 Measure the distance between the two lines. Normal is about 3-6 cm’s

F. Auscultation
1. Define and understand
a. Bronchial breath sounds
b.Bronchovesicular sounds
c. Vesicular sounds
d.Crackles (previously called rales)
e. Rhonchi
f. Wheeze
g.Rub

2. Technique
 It’s often a good idea to ask your Pt to take a deep breath and cough to help open the airways before
auscultation
 The patient should be instructed to breathe in and out of their mouth, deeply but not noisily, if
possible. (You don’t want a bunch of noise coming from their upper airway and throat being
resonated through their lungs, which will mask their real lung sounds.) Instruct the patient to let you
know if he/she is feeling dizzy
 Having the Pt cross their arms in the front and give themselves a hug will help move the scapula out
of the way to listen better on the back
 Always listen directly on the skin!
 Inform Pt, “I’d like to listen to you breath”.
 Be systematic (picture below) while listening – start at the posterior apices and compare each side,
then move down some and repeat until you get to the bottom of the lungs. Compare the loudness and
quality of sound from one place to the next. Diminished sound may be the first change noted before
the development of other abnormal sounds. Repeat anteriorly.

S ys te matic Lung Aus c ultatio n

1 2
1 2

3 4 3
4

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Attendance Password: SGZ884

3. Vocal resonance - A normal lung filters out many sounds, however a more solid lung (consolidation, or
mass) transmits sound better than an air-filled lung, thus increasing the transmission of sound. All of
the findings below act on this principle, which are abnormal when heard and may indicate
consolidation of lung tissue or a mass. Pleural effusions significantly decrease vocal resonance,
making it a nice technique to determine the level of the effusion. Since the signs below are based on
the same principle, when examining patients, you will not need to perform all of these on a routine
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 basis. You should always take note if you hear bronchial breathing on exam, and perform vocal
resonance whenever you hear diminished breath sounds or have any concern for a consolidation or
mass.
 Bronchophony – greater clarity and increased loudness of spoken sounds
 Bronchial breathing, similar to bronchophony, is noting high-pitched breath sounds in the
periphery as if the Pt is breathing through a tube (A sound very similar to bronchial sounds
over the sternum, but higher pitched)
 Whispered Pectoriloquy – When bronchophony is extreme, and even a whispered voice is
heard clearly through the stethoscope. Asks the patient to whisper "99" or "1-2-3" while
listening in each area. Normally can faintly hear, or not hear the whisper; abnormal when
whispered sounds are loud and clear.
 Egophony (abnormal and may indicate consolidation of lung tissue) – When the intensity of
the spoken voice is increased and there is a nasal quality (change of "ee" sound to a nasal
"ay"). Asks the patient to say "eee.." out loud while listening at each location.

III. Review of Systems

Cough, shortness of breath, wheezing, increase/change in sputum (color, quantity), hemoptysis, pleurisy, Hx of
asthma, emphysema, bronchitis, pneumonia, or tuberculosis. Last chest x-ray and findings.

IV. Documentation

Write your exam in the same order as you performed the exam.

No cyanosis, pallor, or clubbing was noted. Respiratory effort and pattern were non-labored and regular
(evidence of distress, retractions, Cheyne-Stokes, ataxic, tachypnea, hyperpnea, bradypnea). The thorax was
symmetrical and AP diameter was not increased (increased AP diameter, barrel chest, pigeon chest, flail chest,
thoracic kyphoscoliosis). Bony structures of the thorax were non-tender. Respiratory excursion was ___ cm,
and symmetric. Tactile fremitus was normal (increased or decreased). Lungs were resonant (hyper-resonant,
dull, tympanitic, flat) to percussion in all lung fields. Diaphragmatic excursion was estimated at ____ cm,
bilaterally. Breath sounds were clear to auscultation, bilaterally (When present, note locations of diminished
sounds, wheeze, rhonchi, and crackles). No bronchophony, egophony, or whispered pectoriloquy was
appreciated (When present, document the presence and location of these findings).

V. Clinical Applications

 Subtle differences in chest/rib expansion noted on inspection and/or palpation may be the first clues to an
underlying problem--before abnormal lung sounds are noted.
 If you are hearing the exact same wheeze or rhonchi sound in multiple lung fields, then it may be coming from the
upper airways. (Listen over the neck, face, or nose to find out--Very common in babies and kids!)
 Stridor is a loud, inspiratory, musical sound heard best over the neck
 Wheezes are loudest over the chest, not to be confused with breathing against a partially-closed glottis (grunting
respirations) that can mimic wheezes and are loudest over the neck
 Many respiratory processes can be diagnosed clinically (pneumonia) without the need for radiography, thus saving
money and radiation exposure.
 Pursed-lip breathing and grunting respirations create auto-PEEP that improves gas exchange often seen in Pt’s with
COPD
 Grunting respirations may also been seen in Pt’s with acute pulmonary edema, pneumonia, or other causes of resp
distress
 Hyper-resonance suggests Chronic Obstructive Lung Disease. Dullness with percussion may indicate pleural
effusion or consolidation.
 Wheezing or a prolonged expiratory phase may indicate airflow obstruction—as in asthma or chronic obstructive
lung disease
 Crackles may indicate pulmonary edema, infection, or fibrosis
 Decreased breath sounds may indicate pneumonia, emphysema, pleural effusion, elevated diaphragm, or an
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 obstructing airway mass
VI. Additional Aids
A. Practical Clinical Skills https://www.practicalclinicalskills.com/heart-lung-sounds-reference-guide
B. SAM II model in the Clinic has lung and heart sounds
C. DoCS Resources folder on Blackboard has links to other online resources
VII. Checklist for Skills verification and OSCE’s
Performed Satisfactorily Performed Not
Pulmonary incorrectly or Done
with assistance
1. General
a. Inspects and describes:
1) Respiratory Effort and Pattern – for rate, rhythm, depth
2) Non-thoracic areas related to respiration and oxygenation
– lips, nail beds, tracheal deviation
3) Thoracic structures including chest diameter
2. Chest – Informs Pt before starting, “I like to examine your Anterior Posterior
chest and lungs”.
Palpates: (Informs Pt before starting)
1) Bony structures for tenderness
2) Respiratory excursion: Informs Pt before starting, “I like
to check how your chest and ribs move when you
breath”. With hands over lower chest and thumbs off of
the thorax (thumbs medial and fingers lateral), watches
for symmetry of chest wall motion during inspiration
and expiration; measures expansion with maximal
inspiration.
3) Palpates tactile fremitus: Asks patient to say, “toy boat”
or "99" and palpates over posterior and lateral chest
using palms of hands. Describes a cause of decreased
fremitus.
Percusses: (Informs Pt before starting)
1) Begins at the top of chest wall and works downward,
comparing symmetric points on right and left sides,
alternately. Describes a cause for dullness and hyper-
resonance.
2) Diaphragmatic excursion: Notes distance between levels
of dullness at maximal inspiration and expiration on
posterior thorax; Verbalizes normal findings is 3cm-
6cm.
Auscultates: (Informs Pt before starting)
1) Breath Sounds: Attempts to warm stethoscope. Warns
patient that the stethoscope may be cold. Instructs
patient to breathe in and out through his/her mouth and
to tell examiner if patient becomes dizzy. Applies
diaphragm firmly to chest wall. Systematically
auscultates from apices downward, alternating right
and left sides to compare symmetric points. Asks Pt to
give themselves a hug to move scapulae laterally before
auscultating the posterior fields. Describes what he/she
was listening for.
2) Vocal resonance –
a. Describes bronchial breathing
b. Egophony: Asks the patient to say "eee.." out loud at
each location; auscultates all areas. Describes what are
abnormal findings.
c. Describes bronchophony
d. Whispered pectoriloquy: Asks the patient to whisper
"99" or "1-2-3" in each area; auscultates all areas.
Describes what are abnormal findings.
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