Session 2: Lung

Sounds:
http://meded.ucsd.edu/clinicalmed/lung.htm
https://www.mededportal.org/publication/129
Information
Type
Normal PE
Findings

Lungs

Abnormal PE
Findings

Inspection
Little use of accessory muscles
Abdomen should move outward during inspiration
Palpation
Symmetrical accentuated chest excursion
Percussion:
Resonant percussion
Auscultation:
Soft inspiratory sound with little noise on expiration (Vessicular
breath sounds)
1:2 "I to E" ratio; expiration twice as long as inspiration
Inspection at rest
Diaphoresis
Labored breathing
Use of accessory muscles (scalenes, SCM) to breath at rest
Blue lips, nail beds (cyanosis)
Tri-pod position required to breathe: leaning forward with hands
resting on knees
Breathing through pursed lips (emphysema)
Unable to speak in complete sentences (judge by words/ breath)
Noises w/ breathing that are audible to naked ear (wheezing,
gurgling caused by secretions)
Diaphragmatic flattening w/ emphysema: abdominal wall moves
inward during inspiration (aka paradoxical breathing)
Chest & spine deformities that arise due to lung issues or are
congenital
o Pectus excavatum: chest caves in; posterior displacement of
lower aspect of sternum
o Barrell Chest: increased Anterior-Posterior diameter and
diaphragmatic flattening
Associated with emphysema and lung hyperinflation
o Kyphosis: hump backed; extreme posterior displacement of
spine curvature
o Scoliosis: curved spine, more pronounced on x-ray
Palpation
Asymmetric chest excursion (fluid or air in pleural space); side with
fluid/ air in pleural space will move less; usually requires a lot of
pleural disease to manifest in this part of the exam
Tactile fremitus: subtle finding, used as supporting evidence
o More pronounced: due to lung consolidation; lung

Basic
Physiologic
Principles

parenchyma engorged with fluid or tissue, usually in setting

of pneumonia
o Less fremitus in a certain area: due to pleural effusion;
displaces lung upward
Pain: investigate fro trauma, rib fracture, subcutaneous air, etc.
Percussion:
Dull percussion: fluid filled lung due to pneumonia or pleural
effusion
Hyperesonant: due to chronic (emphysema) or acute
(pneumothorax) air trapping in lungs or pleural space, respectively
Auscultation:
Wheezes: whistling type noise during expiration, sometimes
inspiration due to narrowed airway by bronchoconstriction,
secretions, mucosal edema
o Most commonly occurs diffusely, in all lobes
o With significant bronchoconstriction, expiration becomes
prolonged (increased I to E ratio, E>>>I, normal I:E = 1:2)
o Greater difference = greater obstruction
Focal wheezing: pneumonia in specific area
Stridor: wheezing on inspiration, associated with mechanical
obstruction at level of trachea/ upper airway
Rales/ crackles: scratchy sound associated with processes that
cause fluid to accumulate in alveolar and interstitial spaces
o Sounds like rubbing hair together close to ear
o Usually due to pulmonary edema in older adults w/
symmetric rales
o Pneumonia--> focal rales
Crackles that sound like separating pieces of velcro: pulmonary
fibrosis (relatively uncommon)
Dense consolidation of lung parenchyma (pneumonia, etc.) results
in transmission of large airway noises to periphery
o If you direct patient to say "EEE," it will sound like a nasalsounding "AAAA" over the involved lobe (egophony)
Ronchi: Gurgling noises that can be caused by collection of
secretions in larger airways; sound like slurping of last bit of
milkshake
Auscultation over effusion may sound muffled; auscultation on top
of effusion will suggest consolidation due to compression of lung
by fluid pushing up from below
o Asymmetric effusion easier to detect
Auscultation of severe emphysema patients will produce very little
sound due to significant lung destruction and air trapping
o Wheezing will occur with acute inflammatory process
Khan Academy Lungs:
Air through nose/mout to back of throat, down to thyroid
cartilage, down to trachea, down to lungs, to bronchiole tree that

Correct

Technique and
Appropriate
Landmarks

serves each lobe of lungs, alveoli, location of molecular exchange

in capillaries
Right lung: Upper, middle, lower lbe
Left lung: Upper, lower lobe
o Cardiac notch
Diaphragm: floor
Ribs: walls
Khan Academy Breathing Basics:
Trachea: size restricted by cartilage
Bronchi: size restricted by cartilage
Bronchioles: designed to change size
o Have smooth muscle in walls = contractile capacity; can
modulate air intake and release
o Mucus
Lungs:
Pleural sac: surrounds lung; potential space with little fluid;
reduced friction between rib cage, diaphragm and lung
Inhalation at rest:
o Diaphragm contracts, moves down, increase volume of
thoracic cavity, decreases pressure
Inhalation
at exercise: recruit more muscles

o External intercostals; pull ribcage upward and outward,

increase volume of thoracic cavity
o Neck muscles; contract, pull clavicle upward, increase
volume of thoracic cavity
Exhalation at rest:
o No muscles contract
o Diaphragm relaxes, decreases volume of thoracic cavity
o Elastic recoil of lung tissue
Exhalation at exercise: accessory muscles recruited
o Internal intercostal muscles; pull ribcage downward and
inward--> reduce volume of thoracic cavity
o Abdominal muscles: contract, push contents of abdominal
cavity upward, reduce volume of thoracic cavity
Patient should take slow, deep breaths through mouth during
examination
Perhaps have patient cough beforehand to clear airways
If patient cannot sit up, perform auscultation while patient lays
sideways; if not possible, listen laterally/ posteriorly as patient is supine
May request patient to forcibly exhale
Inspection/ Observation
Watch patient breathe
o Judge comfort, depth of breaths, perspiration, use of
accessory muscles (especially in neck) to assess respiratory

difficulty, observe color of patient (especially around lips and

nail beds), patient position, ability to speak, noises
accompanying breathing, direction of abdominal wall
movement, chest or spine deformities
Palpation: minor role
Accentuate normal chest excursion by placing hands on patients
back with thumbs pointed towards spine; hands should lift
symmetrically when patient takes a deep breath
Tactile fremitus: detect palpable vibratory sensation of chest wall
by placing bony, ulnar aspect of each hand on either side of chest
while patient says "Ninety-Nine;" repeat until entire posterior
thorax is covered
Percussion: generally limited to posterior lung fields except in further
exploring anterior auscultation abnormality; swing hands freely at wrist
(not stiff), hammering finger onto target at bottom of down stroke; go
down "percussion alley" (see photo) between scapulae and vertebral
column to avoid bone
Strike air filled structure to produce resonant note
Strike fluid filled structure to produce relatively dull sound
Have patient cross hands in front of their chest asn grasp opposite
shoulder with each hand to pull scapulae laterally
Percussion technique: strike DIP of left middle finger with tip of
right middle finger while last two digits rest firmly on patient's
back; keep rest of fingers from touching to prevent dulling of
resonance
2-3 taps should suffice
o 5 locations should cover a hemithorax
o Any abnormalities in one side of thorax should be compared
to the other side
"Speed Percussion:" constantly percuss down back to accentuate
difference between resonant and dull sounds and identify location
ofl ungs
Auscultation:
Generally, patient is sitting upright; asking females to lie down will
alow breasts to fall laterally and make anterior auscultation easier
Examine posterior field upper lobes first (top 1/4 of posterior
field)--> posterior field --> axillas --> anterior fields
Listen to lower lobes in bottom 3/4 of posterior field
Listen to upper lobes in anterior chest, top 1/4 of posterior field
o Listen in one spot, then compare to same spot on other lung
Listen to right middle lobe in right axilla (while behind patient)
Linsten to lingula in left axilla (while behind patient)
Gown management:
Area to be examined must be exposed, keep other areas relatively
unexposed
Explain what you're doing before doing it
Expose minimum amount of skin as necessary

o
o
o

Ask patient to remove bra prior to examination

Expose only to extent needed
Enlist patient assistance
Do not rush
DO NOT EXAMINE THRU GOWN or BRA
Ambulation w/ use of pulse oxymeter: helpful in providing objective
information when symptoms seem out of proportion to findings;
generate a measurement that you can refer back to during subsequent
evaluations in order to determine if there has been any real change in
functional status; determine disease and symptom severity over time to
assist diagnosis and rational use of other tests
Keep track of:
o Exercise tolerance
o Rate of exercise
o Duration of exercise
o Distance covered
o Development of dyspnea
o Changes in heart rate, O2 saturation

Age-related
Changes and
Features
Differences in
PE Findings in
Children

Infants:
Assess respiration and pattern of breathing
Use more observation
o Respiratory rate
o Color
o Nasal component of breathing
o Audible breath sounds
Nasal flaring
Stridor, Grunting
o Retractions (chest indrawing)
Inward movement of ribs during inspiration
Indicates respiratory pathology
Percussion not helpful; infant chest is hyper-resonant throughout
Auscultation will be louder as stethoscope is closer to origin of
sounds
Difficult to distinguish transmitted upper airway sounds from
sounds originating in the chest
Hold stethoscope in front of infant nose to compare quality of
sound
Note symmetry from right to left
Expiratory sounds usually from intrathoracic; inspiratory either
from chest or upper airway or nose
Characteristic breath sounds same as for adults (wheezes, crackles,
ronchi, etc. more likely from infection than cardiac disease)
Children

Observation is significant
Tactile fremitus indicates pathology
Auscultate like adult; have them breath normally
Sounds transmit better
Wheezes, ronchi, wet crackles are commonly heard and can be
caused by infection or asthma

Photos
Inspection/ Observation
Cyanosis:

Tri-Pod Position in Emphysema Patient

Pectus excavatum

Barrel Chest

Kyphosis:

Scoliosis: (notice shoulders)

Lung anatomy

Percussion Alley

Class Notes

Respiratory/Chest Exam
Muscles used in the respiratory cycle:
Phase of the
Respiratory Cycle
Inspiration (inhalation)

Expiration (exhalation)

Activity State
At rest
Involves contraction of the
diaphragm
Passive movementinvolves no
active muscle use, only elastic
recoil of diaphragm

During exercise/exertion
Involves diaphragm plus the external
intercostal muscles and neck muscles
(sternocleidomastoid)
Involves the internal intercostal
muscles and the abdominal wall
muscles

Important landmarks:

Trachea (anterior and lateral)

Chest wall:
o Mid-clavicular line
o Mid-axillary line
o Supraclavicular area, clavicles
o Sternum, sternal angle, suprasternal notch, substernal area (xiphoid process)
o Costal margins

Normal vs. abnormal sounds in the respiratory tract:

Normal:
o Bronchial: lower pitched; upper lung fields, trachea
o Bronchovesicular: between bronchial and vesicular in pitch; middle fields

Vesicular: higher pitched; lower lung fields

Adventitious breath sounds:

o Upper airway sounds: e.g., stridor
o Lower airway sounds
Discontinuous (cracklesincl. fine and coarse)
Continuous (wheezesmusical; rhonchi)

Transmitted voice sounds (listen for these if you hear bronchial breath sounds where they
should not be); all of these sounds suggest that the air-filled lung has become airless:
o Bronchophony: 99 (auscultate)if breath sounds louder/clearer than normal,
bronchophony is present.
o Egophony: eee (auscultate)if it sounds like aaay, then egophony is present.
o Whispered pectoriloquy: whisper 1, 2, 3 (auscultate)when these sounds are
louder/clearer than normal), whispered pectoriloquy is present.

Differences in the respiratory exam in infants and children compared to adults:

Infants/young children:
o
o
o
o
o
o

Tongue is larger relative to oropharynx in young children

Larynx in young children (<10yo) is funnel-shaped (cylindrical in adults), narrow cricoid
cartilage relative to thyroid cartilage
Chest is very resonant breath sounds transmitted throughout chest
Chest wall is more compliant accessory muscle use is more apparent (retractions)
Short neck in young infants head bobbing
Grunting

Respiratory examination technique:

Inspection:

Assess the shape of the chest wall and spine noting any chest wall deformities.
Observe the patients breathing, including:
o Assess effort of breathing as normal vs. distressed or labored (incl. use of accessory
muscles, nasal flaring, pursed lip breathing).
o Assess depth of breathing as shallow vs. deep.
o Assess the respiratory rate as normal, low, or elevated for age.
o Assess the rhythm of the breathing pattern as regular vs. irregular.
o Note any audible noises associated with breathing (e.g., stridor), incl. their location in the
respiratory cycle (inspiration vs. expiration, or biphasic).
Inspect for evidence of cyanosis (lips, nail beds).

Palpation:

Assess chest excursion (posterior and anterior), noting any asymmetry.

Palpate areas of pain or sites of trauma.
Assess all lung fields for tactile fremitus (posterior and anterior), noting any asymmetry.

Percussion: assess all lung fields (posterior and anterior) by percussion.

Auscultation: AVOID LISTENING THROUGH CLOTHES!

Assess the duration, pitch, and intensity of sounds in all lung fields (posterior and anterior) by
auscultation, including:
o Distinguish normal vs. abnormal lung sounds, and note their distribution (localized vs.
diffuse), symmetry, and location:
Adventitious (added) sounds: wheezes, cracklesa.k.a., rales, rhonchi

Note the relative duration of inspiration vs. expiration (i:e ratio).