Inspection of the thorax

Techniques of examination
of the thorax and lungs
Dr. Szathmári Miklós
Semmelweis University
First Department of Medicine
27. Sept. 2011.
Inspection of the thorax
• Observe:
– the shape of chest
• Deformities
– the respiratory movement
• Importance:
– The deformities influence
• The percussion sounds
• The breathing and the circulation
• The diagnostic importance of asymetry
– The decrease of the respiratory movement is the most
important sign of the disease of chest/lung
Inspection of the thorax
• Shape of the chest
– Normal adult thorax: is wider than it is deep.
– Barrel chest: increased anteriorposterior
– Funnel chest: depression in the lower portion
of the sternum.
– Pigeon chest: the sternum is displaced
anteriorly, increasing the AP diameter.
– Thoracic kyphoscoliosis: abnormal spinal
curvatures and vertebral rotation deform the
Dorsal kyphosis and barrel chest
Inspection of the thorax
• Abnormal retraction of the interspaces
during inspiration (severe asthma, COPD
or upper airway obstraction).
• Inspection of movement of chest wall
during inspiration (unilateral impairment or
delay of respiratory movement suggests
disease of the underlying lung or pleura.
Palpation of the chest 1.
• Assessment of
respiratory expansion:
– Place your thumbs about at
the level of and parallel to
the 10th ribs, your hand
grasping the lateral rib
– Slide your hands medially a
bit in order to raise loose
skin folds between thumbs
and spine
– Ask the patient to inhale
– Watch the divergence of
your thumbs during
inspiration and feel for the
range and symmetry of
respiratory movement
Palpation of the chest 2.
Tactile fremitus – refers to
Pleural rub
the palpable vibrations
transmitted through the
bronchopulmonary system to
the chest wall when the
patiens speaks
• Palpate and compare
symmetrical areas of the lungs
• Use the ulnar surface of your
hand. Ask the patient to repeat
ninety-nine or „harminchárom”.
• If fremitus is faint, ask the
patient to speak more loudly or
in a deeper voice.
• Normal pleural surfaces move
smoothly and noiselessly
against each other during
• When pleural surfaces become
inflamed, they move jerkily as
they are repetedly delayed by
increased friction.
• The sounds may be discrete,
but sometimes are so
numerous that they merge into
an apparently continuous
sound. It is localized to a
relatively small area of the
chest wall
Palpation of the thorax
• intercostal tenderness:over inflammed
pleura. Bruises over a fractured rib.
• chest expansion: decreased expansion
in case of pleural effusion, lobar
pneumonia, chronic fibrotic disease of the
underlying lung
• tactile fremitus: Decreased pectoral
fremitus is in case of pleural effusion or
pleural thickening or PTX.
Other bony landmarks on the chest
• Posteriorly, with the fingers of one hand,
press inward and up against the lower
border of the rib cage you can identify the
12th rib
• The inferior angle of the scapula lies
approximately at the level of the 7th rib
• When the patient flexes the neck forward,
the most prominent process is usually that
of the 7th cervical
Percussion of the thorax
• While the patient keeps both
arms crossed in front of chest,
percuss the thorax in
symmetrical locations from the
apices to the lung bases
• Dullness: when fluid or solid
tissue replaces air-containing
lung (pneumonia) or occupies
the pleural space (effusion,
fibrous tissue, tumor)
• Generalized hyperresonance:
emphysema, asthma.
• Unilateral hyperresonance (or
tympanic sound):
Identify the level of the
• Percuss in steps
downward until
dullness clearly
replaces resonance.
• Movement of
diaphragma: the
distance between the
levels of dullness on
full expiration and on
full inspiration
(normally 5-6 cm)
Normal position of the diaphragma
– Paravertebraly at the level of X-XI. thoracic
spinous process
– In the scapular line at the level IX. rib
– In the midaxillary line at the level VIII. rib
– In the medioclavicular line (on the right side)
at the level of VI. rib.
Normal movement of the diaphragma
– On full inspiration 5-6 cm in the scapular line
Abnormal positions of
• Bilaterally deeper position:
– Emphysema, asthma,
– Decreased intraabdominal pressure
• Unilaterally deeper position:
– pneumothorax
• Bilaterally higher position:
– Increased intraabdominal pressure
– Pleural effusion on both side
• Unilaterally higher position:
– Diaphragmatic paralysis
– Unilateral pleural effusion
– Intrabadominal abnormality (subphrenic abscess, splenomegaly)
Abnormal breathing sounds
1. Louder vesicular breathing: during childhood,
forced breathing
2. Faint alveolar breathing:
– Emphysema,
– Pleural thickening, pleural effusion,
– Pneumothorax
– Atelectasis (absortion of the air from the alveoli
because of a plug in a mainstream bronchus)
3. Bronchial breathing replaces the normal
vesicular sounds when lung tissue loses its air:
• Pneumonia (the alveoli fill with fluid)