Examination of the Chest
2004
Examination of the Chest
• Anatomic review
• Brief survey of chest
and respiration
• Inspection
• Palpation
• Percussion
• Auscultation
Bony Structures of the Thorax
Ribs
1-7 articulate w sternum
8-10 w costal cartilage
11-12 “floating”
Costal cartilage
Sternum
Clavicles
Scapula
Thoracic vertebrae
Content of the thoracic
cavity:
• Parietal pleura
• Pleural space
• Visceral pleura
• Lungs
• Mediastinum
– Aorta, trachea, R and L
mainstem bronchi, lymph
nodes, vagus nerves,
esophagus, heart
•
•
•
•
Part of the liver
Part of the spleen
Part of the kidneys
Part of the stomach
Structure of Lungs
Figure 16-10. p. 453.
Slide 16-10
Mechanics of Respiration
Figure 16-10. p. 454.
Slide 16-11
Anterior Thoracic Cage
Figure 16-1. p. 448.
Slide 16-1
Posterior Thoracic Cage
Figure 16-2. p. 449.
Slide 16-2
Reference Lines
Figure 16-3. p. 449.
Slide 16-3
Vertebral, Scapular Lines
Figure 16-4. p. 450.
Slide 16-4
Anterior, Posterior, Midaxillary
Figure 16-5. p. 450.
Slide 16-5
Anterior Location of Lungs
Figure 16-6. p. 451.
Slide 16-6
Posterior Location of Lungs
Figure 16-7. p. 451.
Slide 16-7
Right Lateral Location of Lung
Figure 16-8. p. 452.
Slide 16-8
Left Lateral Location of Lung
Figure 16-9. p. 452.
Slide 16-9
Brief Survey of Chest and
Respiration
• Is the patient in
distress?
• Observe the rate,
rhythm,and depth of
respiration.
• Audible sounds?
• Respirations should be
easy, quiet, and
regular.
Respiratory Inspection
• AP diameter of chest
as compared to the
lateral diameter ( 1/3
to 1/2) ? Barrel chest
• Sternal abnormalities pectus excavatum or
pectus carinatum
• Rate, depth, rhythm of
respirations
• Abnormal breathing
patterns - Kussmaul
• Skin color, clubbing
• Spinal curvatures kyphosis, scoliosis,
kyphoscoliosis
Visual Examination of the Chest
Breathing Patterns
Rate, Depth, Regularity
Normal
Ataxic breathing
Adults:12-20/min
Infants: 44/min
Biot’s breathing
Irregularly irregular
Tachypnea
Rapid, shallow breathing
Cheyne-Stokes breathing
Regular rate, irregular depth
MAY be normal
Hyperypnea
Rapid, deep breathing
Hyperventilation
Kussmaul breathing
Sighs
Bradypnea
Hyperventilation syndrome
1 sigh per 200 breaths
Configuration of Thorax
Barrel
Chest
Normal
Adult
Pectus
Excavatum
Table 16-4. p. 483.
Pectus
Pectus
Carinatum
Cariatum
Slide 16-25
Round Thorax in Infant
Figure 16-25. p. 475.
Configuration of Thorax
Scoliosis
Kyphosis
Table 16-4. p. 484.
Slide 16-26
Position of the Trachea
Systemic Signs of Pulmonary Disease
Clubbed Fingers
Systemic Signs of Pulmonary Disease
Cyanosis
Systemic Signs of Pulmonary Disease
Systemic Signs of Pulmonary Disease
Clues to Increased Work of Breathing
•
•
•
•
•
•
Nasal flaring.
Intercostal/Supraclavicular retractions.
Accessory muscle use.
Pursed-lipped breathing.
Disrupted speech.
Thoraco-abdominal dissociation.
Anterior Chest
•
•
•
•
•
•
Inspection
Palpation
Expansion
Tactile fremitus
Percussion
Auscultation
Posterior Thorax
• Inspect for: shape,
symmetry, deformity,
skin lesions
• Palpate for tenderness
or over any findings or
abnormalities
• Thoracic spine
• CVA percussion
• Respiratory expansion
Posterior Chest
•
•
•
•
Tactile fremitus
Percussion
Level of diaphragm
Diaphragmatic
excursion
• Auscultation
– Diaphragm
– Apices downward
– Compare side to side
Symmetric Chest Expansion
Figure 16-13. p. 461.
Slide 16-12
Tactile Examination of the Chest
Tactile fremitus
• Palpable vibration of the
chest wall from sounds
transmitted from the
phonating larynx.
• “Ninety-nine.”
• Compare symmetry.
• Abnormality MAY be
‘ed or ‘ed.
Tactile Fremitus
Figure 16-14. p. 462.
Slide 16-13
Assess Tactile Fremitus
Figure 16-22. p. 472.
Slide 16-21
Abnormal Tactile Fremitus
Increased Tactile
Fremitus
Decreased Tactile
Fremitus
Rhonchal Fremitus
Table 16-6. p. 485.
Pleural Friction
Fremitus
Slide 16-28
Percussion
• Systematic
• Progress from apices
to base
• Side to side
• Intensity, duration, and
pitch
• Normal = resonance
• Note location of
abnormalities
PERCUSSION
• RESONANCE - NL
• HYPERRESONANCE - too much air such
as emphysema or pneumothorax
• DULLNESS - abnormal density due to
possible pneumonia, pleural effusion,
atelectasis or tumor
Emphysema
Consolidation
Sequence for Percussion
Figure 16-15. p. 463.
Slide 16-14
Sequence for Percussion
Figure 16-23. p. 473.
Slide 16-22
Expected Percussion Notes –
Posterior Chest
Figure 16-16. p. 463.
Slide 16-15
Expected Percussion Notes
Figure 16-24. p. 473.
Slide 16-23
Diaphragmatic Excursion
Figure 16-17. p. 464.
Slide 16-16
Auscultation
• Listen for:
– Intensity
– Pitch
– Duration
• Normal breath sounds
– Vesicular
– Bronchial
– Bronchovesicular
• Adventitious sounds
– Crackles
– Wheezes
– Rhonchi
• Voice Sounds
– Bronchophony
– Egophony
– Whispered
pectoriloquy
Breath Sounds
Normal
Adventitious
(Vesicular, bronchovesicular
(Inspiratory and/or
expiratory)
Transmitted
Voice Sounds
Bronchial, tracheal)
Correct
Location
Incorrect
Location
Whispered
pectoriloquy
Discontinuous
Continuous
Wheezes
Fine
Coarse
Crackles Crackles
Rhonchi
Bronchophony
Egophony
Auscultation of the Chest
Surface Projections
Auscultation of the Chest
Examination Points
 = sites for both percussion & auscultation
Breath Sounds
•BS generated by movement of air thru the bronchial tree
•Turbulence, vortex shedding (whirl pools), and oscillation and
vibration of lung tissue
Breath Sounds
Normal
Adventitious
(Vesicular, bronchovesicular
(Inspiratory and/or
expiratory)
Transmitted
Voice Sounds
Bronchial, tracheal)
Correct
Location
Incorrect
Location
Whispered
pectoriloquy
Discontinuous
Continuous
Wheezes
Fine
Coarse
Crackles Crackles
Rhonchi
Bronchophony
Egophony
Breath Sounds: Normal: Tracheal
Tracheal
• Inspiratory and
expiratory sounds are
about equal
• Very loud
• Relatively high pitched
• Heard over trachea in the
neck
Breath Sounds: Normal:
Bronchial
Bronchial
• Expiratory sounds are
longer than inspiratory
• Loud
• Relatively high pitched
• Heard over manubrium, if
heard at all
Breath Sounds: Normal:
Vesicular (Alveolar)
Vesicular
• BS attenuated by air-filled
parenchyma
• Soft
• Relatively low pitched
• Heard over most of the lungs
• Inspiratory sounds are
longer than expiratory
– Note: true expiratory phase is
2-3x longer than inspiratory phase
Breath Sounds: Normal:
Bronchovesicular
BronchoVesicular
• Inspiratory sounds and
expiratory sounds about
equal
• Intermediate
• Intermediate pitch
• Heard often in the 1st and
2nd interspaces anteriorly
and between the scapula
Auscultation of the Chest
Breath Sound Characteristics
Intensity of
Pitch of
Duration
Expiratory Expiratory
of sounds
Sounds
Sounds
Vescicular
Inspiration
> Expiration
Relatively
low
Both lung
fields
Intermediate
1st & 2nd
interspaces
anteriorly;
between
scapulae
Loud
Relatively
high
Over
manubrium
(?)
Very Loud
Relatively
high
At sternal
notch
Softer
Broncho- Inspiration
Intermediate
vescicular = Expiration
Inspiration
Bronchial
< Expiration
Tracheal
Inspiration
= Expiration
“Normal”
Location
Breath Sounds
Normal
Adventitious
(Vesicular, bronchovesicular
(Inspiratory and/or
expiratory)
Transmitted
Voice Sounds
Bronchial, tracheal)
Correct
Location
Incorrect
Location
Whispered
pectoriloquy
Discontinuous
Continuous
Wheezes
Fine
Coarse
Crackles Crackles
Rhonchi
Bronchophony
Egophony
Stridor
Inspiratory
• Continuous
• High pitched
– Stidor
Wheezes
Expiratory
• Continuous
• High pitched, musical
• Narow airways
– Wheeze
Rhonchi
Expiratory
• Continuous rattle;
fluid in large airways
• Low pitched
– Rhonchi
Crackles
Short, popping; Sudden inflation of alveoli
Early Crackles
Fine Crackles
Crackles heard
In consolidation
Pleural Friction Rub
Grating, leathery; inflammed pleura
Breath Sounds
Normal
Adventitious
(Vesicular, bronchovesicular
(Inspiratory and/or
expiratory)
Transmitted
Voice Sounds
Bronchial, tracheal)
Correct
Location
Incorrect
Location
Whispered
pectoriloquy
Discontinuous
Continuous
Wheezes
Fine
Coarse
Crackles Crackles
Rhonchi
Bronchophony
Egophony
Normal Voice Sounds
• Voice-generated sounds radiate through the
airways and lungs out through the chest wall
and are heard well through the stethoscope.
• They are best heard over the trachea and
large airways but less well peripherally.
• It is hard to understand individual words with
the stethoscope, and with whispering, nothing
is usually heard.
Bronchophony:
• Voice sounds are increased and clearer, even
though one can not detect words.
• Heard under similar circumstances as
bronchial breath sounds, such as when there
is consolidation of the lung but the airways
leading into the consolidation are open.
Whispered pectoriloquy
• Pectoriloquy means “chest speaking.”
• When a normal person whispers it is poorly heard
with a stethoscope.
• With whispered pectoriloquy one can hear words
that are whispered with the stethoscope. This is
usually heard under the same circumstances as
bronchial breath sounds and broncophony has
similar significance.
•
Normal
Egophony
• The word egophony means "goat sound"
from the Greek root "ego" (goat).
• This term describes a high-pitched bleating
sound heard through an area of
parenchymal consolidation
Egophony:
• When a normal individual says "E" it is heard
under normal circumstances as an "E" with a
stethoscope.
• With egophony this "E" becomes "A" when
listening through a stethoscope.
• Usually heard under the same conditions as
bronchial breath sounds and bronchophony and
has similar meanings.
Normal
Egophony
• Egophony is thought to be the most
sensitive physical finding for consolidation.
• Egophony may also occur over atelectatic
or fibrotic regions of the lung, as well as
above pleural effusions due to the upward
compression of the lung by the underlying
fluid.
Common Respiratory Conditions
Normal Lung
Atelectasis
Bronchitis
Lobar
Pneumonia
Table 16-8. p. 486.
Slide 16-29
Common Respiratory Conditions
Asthma
Emphysema
Emphysema
Pleural Effusion
Congestive Heart
Failure Slide 16-30
Table 16-8. p. 491-492.
Putting It All Together
Physical Signs in Selected Chest Disorders
Trachea
Percussion
Note
Breath Sounds
Tactile
Fremitus
Adventitial
Sounds
Normal
None
Normal
Decreased
Wheezes
Normal
Midline
Resonant
Bronchial,
Bronchovesicular,
Vescicular
Obstructive
lung disease
Midline
Resonant
Hyperresonant
Normal
Distant
Lobar
Consolidation
To
involved
side
Dull over involved
site
Bronchial over
involved site
Increased
Late
inspiratory
crackles
Pleural
effusion
From
involved
side
Dull to flat over
fluid
Decreased to
absent
Decreased
None
(Pleural rub?)
Pneumothorax
To
involved
side
Hyperresonant,
Tympanitic over
pleural air
Decreased to
absent
Decreased
None
(Pleural rub?)
Video
Chest/Pulmonary Exam
•Inspection, palpation (including tactile
fremitus), percussion, auscultation of the
posterior, lateral, and anterior chest.
•Examination of the anterior chest may be
conducted with the patient supine or sitting
•Examination of the lateral chest may be
incorporated into examination of the
anterior and/or posterior chest
Anterior Chest
Anterior Chest (lying or
sitting or at 30 0)
73. Inspection: For
symmetry, fully exposed (in
female patient may cover
with gown as in photo)
Anterior Chest
7Palpation: For
tactile fremitus
Palpation:
Alternates from
side to side or
may use both
hands
simultaneously
Anterior Chest: Percussion: 76-78
Percussion:
Must be done:
Bilaterally
Symmetrically
Good tone
Must alternate from
side to side
Anterior Chest:
Auscultation
•(Starting above
clavicles, 3-4 places,
listens throughout
inspiration and
expiration)
• Patient instructed slow, deep
breath, mouth open
• Auscultation:
Alternates from side to
side
• Auscultation: At least
3-4 areas auscultated
on each side
Posterior Chest
84. Inspection: For symmetry
Posterior Chest: Palpation
A.
B.
A. Place hands on the patient’s
posterior/lateral chest
B.Ask the patient to take a deep breath
Apply moderate pressure--
Your thumbs will move apart and the
“dimple’ in the skin will go away
Move hands up and towards the
midline creating a “dimple” in
the skin between the thumbs.-
Feel and visualize the chest expanding
Arrows denote direction of hand movement
Posterior chest: Palpation
:Tactile Fremitus
Start above the scapula
•Use the ulnar aspects of the hands
•May use one hand and alternate from side to side or may use both hands
moving inferiorly
•Ask the pt to say “99” and feel the vibrations
Posterior Chest--Percussion
•
Percussion: includes
percussion, diaphragmatic
excursion, and percussion
over the costovertebral angle
Percussion--(At level of the diaphragm)
•This is done during normal (tidal) breathing
•Start above the scapula
•Alternate from side to side
•Continue inferiorly until dullness of percussion occurs
Posterior Chest-Percussion
Percussion
Diaphragmatic movement
•Once the level of the diaphragm has
been detected during tidal respiration
ask the patient to take a deep breath and hold it
•This will move the diaphragm more inferiorly
Begin to percuss moving more inferiorly until dullness is encountered again
•Begin to percuss moving more inferiorly until dullness
is encountered again
Repeat this process for the other side
Percussion over costovertebral angle
•Place the ball of one hand firmly over the patient’s costovertebral angle.
•Use the ulnar side of your other hand to strike the hand you have placed on the
patient.
•Use enough force to cause a perceptible but painless jar or “thud”
•Repeat on the opposite side
Posterior Chest
Auscultation: 92-96
•Patient needs to be in the correct position with arms folded
and hands on opposite shoulders
•Use the diaphragm of the stethoscope
•Start above the scapula
•Ask the patient to take deep breaths with his/her mouth open
•Listen to complete inspiration and expiration
•Move from side to side working your way inferiorly
•Listen to at least 3-4 places