Lungs and Thorax

Sophie Tatishvili
 Chest wall anatomy
Neurovascular
structures run along
the inferior margin
of each rib, so
needles and tubes
should be placed
just at the superior
rib margins.
2nd intercostal space for needle insertion for
tension pneumothorax.
4th intercostal space for chest tube insertion.
T4 for the lower margin of an endotracheal tube
on a chest x-ray
8th, 9th, and 10th ribs articulate with the costal cartilages just
Place your finger in the hollow curve of the
above them. The 11th and 12th ribs, the “floating ribs,” have no
suprasternal notch, then move it down approximately 5
cm to the horizontal bony ridge where the manubrium anterior attachments
joins the body of the sternum, called the sternal angle or Note the T7–T8 intercostal space as a landmark for
the angle of Louis. thoracentesis with needle insertion immediately superior to the
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING 8th rib.
 Lines and lobes
The midsternal and vertebral
lines are easily demarcated
and reproducible; the others
are visualized. The
midclavicular line drops
vertically from the midpoint of
the clavicle. To find it,
accurately identify both ends
of the clavicle
The anterior and posterior axillary lines drop vertically from the
anterior and posterior axillary folds, the muscle masses that
border the axilla. The midaxillary line drops from the apex of
the axilla.
Posteriorly, the vertebral line overlies the spinous processes of the
vertebrae. The scapular line drops from the inferior angle of the
scapula.
Also observe the shape of the chest, which is normally wider than
it is deep. The ratio of the anteroposterior (AP) diameter to the
lateral chest diameter is usually 0.7 to 0.75 up to 0.9 and
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
increases with aging
 Lines and lobes 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.
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.
On inspiration, it descends in the chest cavity during
contraction and descent of the diaphragm.
Each lung is divided roughly in half by an oblique (major) fissure.
This fissure may be approximated by a string that runs from the T3
spinous process obliquely down and around the chest to the 6th rib
at the midclavicular line.
The right lung is further divided by the horizontal (minor) fissure.
Anteriorly, this fissure runs close to the 4th rib and meets the
oblique fissure in the midaxillary line near the 5th rib. The right
lung is thus divided into upper, middle, and lower lobes (RUL,
RML, and RLL).
The left lung has only two lobes, upper and lower (LUL, LLL).

Each lung receives deoxygenated blood from its pulmonary artery.

Oxygenated blood returns from each lung to the left atrium via the
Journal of Applied Clinical Medical Physics 15(5):4898 pulmonary veins.
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
 Locations on the Chest
Anatomic Descriptors of the Chest
The trachea bifurcates into its mainstem bronchi at the
Supraclavicular—above the clavicles levels of the sternal angle anteriorly and the T4 spinous
Infraclavicular—below the clavicles process posteriorly.
The right main bronchus is wider, shorter, and more
Interscapular—between the scapulae vertical than the left main bronchus and directly enters the
hilum of the lung.
Infrascapular—below the scapulae The left main bronchus extends inferolaterally from below
Bases of the lungs—the lowermost portions the aortic arch and anterior to the esophagus and thoracic
aorta and then enters the lung hilum.
Upper, middle, and lower lung fields Each main bronchus then divides into lobar then into
segmental bronchi and bronchioles, terminating in the sac-
Accumulations of pleural fluid, or pleural effusions, may be
like pulmonary alveoli, where gas exchange occurs.
transudates, seen in heart failure, cirrhosis, and nephrotic
syndrome, or exudates, seen in numerous conditions Aspiration pneumonia is more common in the right middle
including pneumonia, malignancy, pulmonary embolism, and lower lobe because the right main bronchus is more
tuberculosis, and pancreatitis. Irritation of the parietal pleura vertical.
produces pleuritic pain with deep inspiration in viral pleurisy,
pneumonia, pulmonary embolism, pericarditis, and collagen
vascular diseases.
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
 Deformities of the thorax
The ratio of the anteroposterior (AP) diameter to the lateral chest
diameter is usually 0.7 to 0.75 up to 0.9 and increases with aging.
This ratio may exceed 0.9 in COPD, producing a barrel-chest
appearance, although evidence of this correlation is conflicting.

Test chest expansion. Place your thumbs

at about the level of the 10th ribs, with
your fingers loosely grasping and
parallel to the lateral rib cage. As you
position your hands, slide them medially
just enough to raise a loose fold of skin
between your thumbs over the spine. Ask
the patient to inhale deeply. Watch the
distance between your thumbs as they
move apart during inspiration, and feel
for the range and symmetry of the rib
cage as it expands and contracts. This
movement is sometimes called lung.
[Link] BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
Chest Pain That Can Kill
• Acute Coronary Syndromes
• Pulmonary Embolism
• Aortic Dissection
• Esophageal Rupture
• Pneumothorax
• Pneumonia

Various others: Pulmonary HTN, Myocarditis, Tamponade

Benign Causes
• Musculoskeletal
• Esophagitis
• Bronchitis (Chest Pain secondary to cough)
• Recently placed nipple rings
• “Non-Specific Chest Pain” *

*Most common – means we don’t know, but it is not going to hurt you.
Hypothetical model for integration of sensory inputs in the
production of dyspnea.
Afferent information from the receptors throughout the
respiratory system projects directly to the sensory cortex to
contribute to primary qualitative sensory experiences and to
provide feedback on the action of the ventilatory pump.

Afferents also project to the areas of the brain responsible

for control of ventilation. The motor cortex, responding to
input from the control centers, sends neural messages to the
ventilatory muscles and a corollary discharge to the sensory
cortex (feed-forward with respect to the instructions sent to
the muscles).
If the feed-forward and feedback messages do not match,
an error signal is generated and the intensity of dyspnea
increases.
An increasing body of data supports the contribution of
affective inputs to the ultimate perception of unpleasant
respiratory sensations.

(Adapted from MA Gillette, RM Schwartzstein, in SH Ahmedzai, MF Muer [eds].

Supportive Care in Respiratory Disease. Oxford, UK, Oxford University Press,
2005.)
.

Harrison's Principles of Internal Medicine, 18e

 Dyspnea  Modified Borg scale dyspnea score. This
scale consists of both verbal (10) and
numerical (12) descriptions for dyspnea
assessment. Patients are asked to tick the
boxes that reflect their dyspnea perception
best 

Methods indirectly assess dyspnea and may be affected by nonrespiratory

factors, such as leg arthritis or weakness
Baseline Dyspnea Index July 2013 Supportive Care in Cancer 21(11) DOI
10.1007/s00520-013-1895-3
Chronic Respiratory Disease Questionnaire
Harrison's Principles of Internal Medicine, 18e
 Association of Qualitative Descriptors, Clinical Character
istics, Pathophysiologic Mechanisms of Shortness of BREATH

Harrison's Principles of Internal Medicine, 18e

Mechanisms of Dyspnea in Common Disease

Harrison's Principles of Internal Medicine, 18e

 Elastic recoil pressure of the lung - a positive transmural pressure difference
between alveolar gas and its pleural surface to stay lungs inflated;

generate the equivalent

of negative
transrespiratory pressure

act on the chest wall to generate

the equivalent of positive
pressure across the lungs and
passive chest wall,
While the individual airways in each
successive generation, from most
proximal (trachea) to most distal
(respiratory bronchioles), are smaller
than those of the parent generation,
their number increases exponentially
such that the summed cross-sectional
area of the airways becomes very
Harrison's Principles of Internal Medicine, 18e
large toward the lung periphery.
DOI: 10.13140/RG.2.2.21169.02401
Causes of Impaired Cough
Decreased expiratory-muscle strength
Decreased inspiratory-muscle strength
Chest wall deformity Impaired glottic closure or
Tracheostomy
Tracheomalacia
Abnormal airway secretions
Central respiratory depression (e.g., anesthesia,
sedation, or coma)

Harrison's Principles of Internal Medicine, 18e

 Daytime Sleepiness or Snoring and Disordered Sleep
Sleepiness and snoring, are hallmarks of obstructive sleep apnea,
Ask about problems with commonly seen in patients with obesity, posterior malocclusion of the jaw
snoring, witnessed apneas (retrognathia), treatment-resistant hypertension, heart failure, atrial
(defined as breathing cessation fibrillation, stroke, and type 2 diabetes.
for ≥10 seconds), awakening Mechanisms include instability of the brainstem respiratory center,
with a choking sensation, or disordered sleep arousal, disordered contraction of upper airway muscles
morning headache. (genioglossus malfunction), and anatomic changes contributing to airway
collapse such as obesity, among others.

Important Topics for Health Promotion and Counseling

Tobacco cessation Smoking increases the risk:

Lung cancer
Immunizations—influenza and streptococcal pneumonia  For coronary heart disease by 2 to 4 times
vaccines • For stroke by 2 to 4 times
• Of men developing lung cancer by 25 times
A pack year is defined as twenty • Of women developing lung cancer by 25.7
cigarettes smoked everyday for one year. times
[Link]
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
 Types of Hypoxia
Hypoxia Secondary to High Altitude
Hypoxia Secondary to Right-to-Left Extrapulmonary Shunting
Anemic Hypoxia
Carbon Monoxide (CO) Intoxication
Circulatory Hypoxia
Specific Organ Hypoxia
Increased O2 Requirements
Improper Oxygen Utilization - histotoxic hypoxia

Charlie Goldberg, M.D., UCSD School of Medicine and VA Medical Center, San Diego, California 92093-0611 . Harrison's Principles of Internal Medicine, 18e
 Causes of Cyanosis

Central Cyanosis
Decreased arterial oxygen saturation
• Decreased atmospheric pressure—high altitude
• Peripheral Cyanosis
• Impaired pulmonary function
Alveolar hypoventilation • Reduced cardiac output
Inhomogeneity in pulmonary ventilation and perfusion
(perfusion of hypoventilated alveoli) • Cold exposure
Impaired oxygen diffusion
Anatomic shunts • Redistribution of blood flow
•Certain types of congenital heart disease
•Pulmonary arteriovenous fistulas Multiple small intrapulmonary
from extremities
shunts
•Hemoglobin with low affinity for oxygen
• Arterial obstruction
Hemoglobin abnormalities
Methemoglobinemia—hereditary, acquired
• Venous obstruction
Sulfhemoglobinemia—acquired
Carboxyhemoglobinemia (not true cyanosis)

Harrison's Principles of Internal Medicine, 19e

 Patterns of respiration
Eupnea - The respiratory rate is about 14–20
per min in normal adults and up to 44 per min
in infants.

Slow Breathing (Bradypnea) Slow breathing with

or without an increase in tidal volume that
maintains alveolar ventilation. Abnormal alveolar
hypoventilation without increased tidal volume
can arise from uremia, druginduced respiratory
depression, and increased intracranial pressure.

Sighing Respiration Breathing punctuated by

frequent sighs suggests hyperventilation
syndrome—a common cause of dyspnea and
dizziness. Occasional sighs are normal.

Rapid Shallow Breathing (Tachypnea) Rapid

shallow breathing has numerous causes, including
salicylate intoxication, restrictive lung disease,
pleuritic chest pain, and an elevated diaphragm.
 By Pro B.  July 3, 2017
BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING
 Patterns of respiration
Cheyne–Stokes Breathing Periods of deep breathing
alternate with periods of apnea (no breathing). This pattern is
normal in children and older adults during sleep. Causes
include heart failure, uremia, drug-induced respiratory
depression, and brain injury (typically bihemispheric).
Obstructive Breathing In obstructive lung disease,
expiration is prolonged due to narrowed airways increase
the resistance to air flow. Causes include asthma, chronic
bronchitis, and COPD..
Rapid Deep Breathing (Hyperpnea, Hyperventilation) In
hyperpnea, rapid deep breathing occurs in response to
metabolic demand from causes such as exercise, high altitude,
sepsis, and anemia. In hyperventilation, this pattern is
independent of metabolic demand, except in respiratory
acidosis. Light-headedness and tingling may arise from
decreased CO2 concentration. In the comatose patient,
Ataxic Breathing (Biot Breathing) Breathing is irregular— consider hypoxia, or hypoglycemia affecting the midbrain or
periods of apnea alternate with regular deep breaths which pons. Kussmaul breathing is compensatory overbreathing due
stop suddenly for short intervals. Causes include to systemic acidosis. The breathing rate may be fast, normal,
meningitis, respiratory depression, and brain injury, or slow.
typically at the medullary level. BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING  By Pro B.  July 3, 2017
 Tactile fremitus- “ninety-nine”
• Palpate both lungs for symmetric tactile fremitus. Fremitus
refers to the palpable vibrations that are transmitted through
the bronchopulmonary tree to the chest wall as the patient is
speaking and is normally symmetric. Fremitus is typically
more prominent in the interscapular area than in the lower
lung fields and easier to detect over the right lung than the
left. It disappears below the diaphragm.
• Fremitus is decreased or absent when the voice is higher
pitched or soft or when the transmission of vibrations from the
larynx to the surface of the chest is impeded by a thick chest
wall, an obstructed bronchus, COPD, or pleural effusion,
fibrosis, air (pneumothorax), or an infiltrating tumor.
• Asymmetric decreased fremitus raises the likelihood of
unilateral pleural effusion, pneumothorax, or neoplasm, which
decreases transmission of lowfrequency sounds; asymmetric
increased fremitus occurs in unilateral pneumonia which
increases transmission through consolidated tissue.

BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

 Lung percussion

Estimate the extent of diaphragmatic

excursion by determining the distance
between the level of dullness on full
expiration and the level of dullness on
full inspiration, normally about 3 to
5.5 cm.
Percuss for liver dullness and gastric
tympany. With your pleximeter finger
above and parallel to the expected
upper border of liver dullness, percuss
in progressive steps downward in the
right midclavicular line. Identify the
upper border of liver dullness. Later,
during the abdominal examination, you
will use this method to estimate the size
of the liver. As you percuss down the
chest on the left, the resonance of
normal lung usually changes to the
tympany of the gastric air bubble.

[Link]
 Lung sounds Vesicular sounds are soft, blowing or
rustling sounds normally heard
throughout most of the lung fields.
Vesicular sounds are normally heard
throughout inspiration, continue
without pause through expiration, and
then fade away about one third of the
way through expiration
Bronchial sounds are present over the
large airways in the anterior chest near
the 2nd and 3rd intercostal spaces,
Bronchial sounds are high in pitch,
louder and more tubular and hollow-
sounding than vesicular sounds, but not
as harsh as tracheal breath sounds.
Expiratory sounds last longer than
inspiratory sounds or duration  is the
same. Intensity of inspiration and
expiration is the same. There is a
short gap between inspiration and
expiration.
R. Beňačka, MD, PhD
 Lung sounds
Bronchovesicular sounds are heard in
the posterior chest between the
scapulae and in the center part of the
anterior chest. Bronchovesicular
sounds are softer than bronchial
sounds, but have a tubular quality.
Bronchovesicular sounds are about
equal during inspiration and
expiration; differences in pitch and
intensity are often more easily detected
during expiration.
Tracheal breath sounds are heard over the
trachea. These sounds are harsh and sound
like air is being blown through a pipe.
In a normal air-filled lung, vesicular sounds
are heard over most of the lung fields,
bronchovesicular sounds are heard between
the 1st and 2nd interspaces on the anterior
chest, bronchial sounds are heard over the
body of the sternum, and tracheal sounds
R. Beňačka, MD, PhD
are heard over the trachea.
 
 Abnormal lung sounds
Weezing This is the sound of wheezing when auscultating breath
or lung sounds. It can be heard when there is an airway
obstruction such as when you listen to a patient with mild to
moderate asthma during an exacerbation. Wheeze is mainly
expiratory and occurs during both phases..

Fine Crackles (aka Rales) are high pitched sounds mostly heard in

the lower lung bases. This can be abnormal findings on physical
exam suggestive of things like congestive heart failure, pneumonia
or atelectasis.

Coarse Crackles are low pitched lungs sounds heard in pathologies

such as chronic bronchitis, bronchiectasis, pneumonia, and severe
pulmonary edema. Compared to fine crackles, they are often louder,
longer in duration and lower in pitch.
 

Pleural rub is nonmusical, short,. biphasic (inspiro-

expiratory)  explosive sound (grating, rubbing, creaky, or leathery).
It occurs due to inflamed pleural surface rubbing each other during
breathing.
Squawks short inspiratory wheezes (200 ms; 200 - 300 Hz) in late
inspiration often preceded by late inspiratory crackles. Squawks are found
Stridor is loud, high-pitched, mainly inspiratory, musical sound
in: pulmonary fibrosis, pneumonitis, pneumonia, allergic alveolitis and produced by upper respiratory tract obstruction. It is different from
bronchiolitis obliterans. They are produced by the oscillations of peripheral wheezing:  It is louder over the neck than chest wall. In expiration,
airways in deflated lung zones opened in late inspiration it is biphasic. Stridor is caused by the turbulent flow passing
through a narrowed segment of the upper respiratory tract.
R. Beňačka, MD, PhD
 Adventitious Breath Sounds are abnormal sounds that are superimposed upon
Normal Breath Sounds are divided into three categories based on their sound normal breath sounds and indicate underlying pulmonary pathology. They are
character and anatomic location. The terminology for these sounds can be divided into two broad categories, crackles and wheezes, which are then
misleading as it implies an anatomical source of the sounds. Rather, the different characterized as to their loudness/intensity, pitch/frequency, anatomical location,
sounds heard at the different anatomical locations are due to differential and timing within inspiration or expiration. 
attenuation of the sounds that are produced in the larger airways. Crackles (rales) are abnormal discontinuous explosive sounds associated with
the sudden opening of airways that are either collapsed due to surrounding
a.  Bronchial Breath Sounds are heard over the trachea and hilar region of
inflammation or blocked due to collections of fluid or inflammatory exudate.
the lung field. They have a prominent inspiratory and expiratory Crackles heard throughout inspiration are associated with large or widespread
component. airway disease. Crackles heard at the end of inspiration are usually associated
b.  Bronchovesicular Breath Sounds are intermediate between bronchial and with small airway disease since these are the last airways to open.
vesicular breath sounds. They consist of a soft inspiratory sound with a  Low-pitched crackles are associated with airway secretions and are often
short expiratory sound that is more prominent than vesicular sounds. altered by coughing.
High-pitched crackles are associated with the opening of collapsed peripheral
c.  Vesicular Breath Sounds are heard in the periphery of the lung field.
airways.
They consist of a soft inspiratory sound and a short soft expiratory sound.  Pleural friction rubs are abnormal, low-pitched, discontinuous sounds
associated with roughened pleural surfaces and indicate pleuritic
  Wheezes (rhonchi) are abnormal, continuous sounds with a musical character.
They are believed to result from the vibrations of airway walls in close contact.
The pitch of the wheeze is determined by the stiffness of the opposing tissues
and is not necessarily related to airway diameter. Monophonic wheezes suggest
a single site of airway obstruction while polyphonic wheezes are suggestive of
more generalized pulmonary pathology. Wheezes are often heard during
expiration due to dynamic compression of the airways. Wheezes heard at the end
of inspiration suggest the opening of smaller, inflamed airways. 
Stridor is an abnormal continuous monophonic musical sound generally
focused over extrathoracic airways and therefore heard primarily during
inspiration. It is often associated with laryngeal or tracheal disease.
Stertor is a poorly defined and inconsistently used term that refers to a sonorous
snoring sound without the musical quality of stridor. This can also describe a
harsh discontinuous crackling sound in the trachea or larynx suggestive of
accumulation of secretions, swollen, or edematous tissue within the upper
airways.

2002 SAVMA Symposium

 Percussion

•Author: Nazir A Lone, MD, MBBS, MPH, FACP, FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP.
 Egophony

One way to help distinguish between crackles associated

with alveolar fluid and those associated with interstitial
fibrosis is to assess for egophony. Egophony is the
auscultation of the sound “AH” instead of “EEE” when a
patient phonates “EEE.” This change in note is due to
abnormal sound transmission through consolidated lung
and will be present in pneumonia but not in IPF.
Similarly, areas of alveolar filling have increased
whispered pectoriloquy as well as transmission of larger
airway sounds (i.e., bronchial breath sounds in a lung
zone where vesicular breath sounds are expected).
Patients with emphysema often have a quiet chest with
diffusely decreased breath sounds. A pneumothorax or
pleural effusion may present with an area of absent breath
sounds, although this is not always the case.
Tactile fremitus will be increased in areas of lung
consolidation, such as pneumonia, and decreased with
pleural effusion. Decreased diaphragmatic excursion can
suggest neuromuscular weakness manifesting as
respiratory disease or hyperinflation associated with
COPD.

Pranav Modi; Tripti S. Nagdev. Harrison's Pulmonary and critical care Medicine

 Normal lung

Breath Sounds - Predominantly vesicular

Transmitted Voice - Sounds Spoken words muffled and
indistinct. Spoken “ee” heard as “ee”.
Whispered words faint and indistinct, if heard at all.
Tactile - Fremitus Normal

In the hyperinflated lung of COPD, breath sounds are

decreased (muffled to distant) to absent and
transmitted voice sounds and fremitus are decreased.

[Link] BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING

Consolidated Airless Lung (Lobar Pneumonia)
Consolidation is the result of replacement of air in the alveoli by
transudate, pus, blood, cells or other substances.
Pneumonia is by far the most common cause of consolidation.

The key-findings on the X-ray are:

•ill-defined homogeneous opacity obscuring vessels
•Silhouette sign: loss of lung/soft tissue interface
•Air-bronchogram
•Extention to the pleura or fissure, but not crossing it
•No volume loss
Lobar pneumonia
On the chest x-ray there is an ill-defined area of increased density in the
right upper lobe without volume loss.
The right hilus is in a normal position.
Notice the air-bronchogram (arrow).
In the proper clinical setting this is most likely a lobar or segmental
pneumonia.

[Link]