Pulmonary Examination
The examination of the pulmonary system is a fundamental part of the physical
examination that consists of inspection, palpation, percussion, and auscultation
(in that order). Recognition of surface landmarks and their relationship to underlying
structures is essential. The physical examination of the pulmonary system begins
with the patient seated comfortably on the examination table and his/her upper
body completely exposed. The chest and the patient's breathing pattern are then
inspected, followed by palpation of the chest wall, percussion of the thorax, and
auscultation of the lung fields.
Inspection
The following should be assessed:
Breathing pattern
Normal respiratory rates = 12–20/min in adults
Bradypnea
Respiratory rate < 12/min in adults
Tachypnea
Respiratory rate > 20/min, shallow breathing in adults
Hyperpnea: respiratory rate > 20/min, deep breathing
Peripheral signs of respiratory dysfunction
Nail clubbing: physical finding characterized by painless swelling of the distal phalanges,
typically associated with chronic hypoxemia
.
Sputum production or secretions:
White and translucent: viral infection (for example, bronchitis that presents
with a typical early-morning cough)
White and foamy: pulmonary edema
Yellow-green: bacterial infection
Green: an indication of a pseudomonal infection
Grayish: pneumoconiosis, a waning bacterial infection
Blackish-brown: possibly old blood; should be further investigated (can also be
a harmless incidental finding)
Friable: tuberculosis, actinomycosis
Palpation
Evaluate areas of tenderness or bruising
Symmetry of chest expansion
Place both hands on the patient's back at the level of the 10th ribs with thumbs pointing medially and parallel to the
rib cage.
As the patient inhales, evaluate for asymmetric movement of your thumbs.
Tactile fremitus
Ask the patient to say “99” and feel for vibrations transmitted throughout the chest wall.
Can be asymmetrically decreased in effusion, obstruction, or pneumothorax, among others
Can be asymmetrically increased in pneumonia
Percussion
Physiological finding: resonant percussion note → a comparatively hollow and loud note
Pathological findings:
Hyper-resonant percussion note
Louder and hollower than normal
Sign of increased air inside the thoracic cavity: emphysema, bronchial asthma, pneumothorax
Dull percussion note
Muffled and softer note
Sign of fluid inside the thoracic cavity: pneumonia, pleural effusion
Auscultation
For auscultation use diaphragm of your stethoscope. Warm it up with your palm. Ask the patient to cough once
or twice to clear airway mucus that can produce unimportant extra sounds. Instruct the patient to breathe
deeply through an open mouth. Auscultate for at least one full breath in each location.
Physiological breath sounds
Vesicular breathing
Soft and low pitched, through inspiration and part of
expiration
Heard over both lungs
Bronchovesicular breathing
Intermediate intensity and pitch, through both inspiration
and expiration
Heard over 1st and 2ndintercostal spaces
Bronchial breathing
Loud and high pitched, through part of inspiration and all
of expiration
Heard over the sternum
Tracheal breathing
Very loud and high pitched, through both inspiration and
expiration
Heard over the neck
Pathological breath sounds
Consider secretions (such as in bronchitis) if breath sounds clear after
coughing
Types of pathological breath sounds
Crackles or rales: discontinuous, intermittent
Fine: soft, high-pitched (e.g., normal, asbestosis, sarcoidosis)
Coarse: loud, low-pitched (e.g., COPD, pulmonary edema)
Wheezes (sibilant wheezing): musical, prolonged Rhonchi (sonor wheezing): low-pitched, snoring
Stridor: high-pitched, over trachea which may occur on:
Inspiration (inspiratory stridor): narrowing of the extrathoracic airway; characteristic of
epiglottitis, pseudocroup, foreign body aspiration, bilateral vocal cord palsy
Expiration (expiratory stridor): obstruction of the intrathoracic airways; characteristic of
bronchial asthma, COPD
Inspiration and expiration (biphasic stridor): obstruction at the level of the glottis
