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 INSPECTION

SHAPE of Thorax

1. Stand in front of the pt.

2. Estimate visually the transverse diameter of the thorax.
3. Move to either side of pt.
4. Estimate visually the width of the AP diameter of thorax.
5.Compare the estimates of these 2 visualizations
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NORMAL

1.AP:T = 1:2 for normal adult

2.Wider from side to side than from front to back
3.Slightly elliptical in shape
4. Barrel chest normal in infants & older adults
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Abnormal

1. Barrel chest - ratio is 1:1,

chest is circular or barrel shaped
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2. Pectus Carinatum - or
pigeon chest, is a marked
protrusion of sternum
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3. Pectus excavatum – or funnel

chest, is a depression in the body
of sternum
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4. Kyphosis orhunchback, an
excessive convexity of
thoracic vertebrae
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5. Scoliosis - a lateral
curvature of the thorax or
lumbar vertebrae
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 SYMMETRY of CHEST WALL

1. Stand in front of the pt

2. Inspect R & L thoraxes
3. Note shoulder height
4. Move behind pt
5. Inspect R & L posterior
thoraxes
Note position of scapula
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Normal
1.Shoulders at same height
2.Scapula at same height
3.No masses
 Abnormal

1.Having one
shoulder or
scapula higher
than the other
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1.Stand in front of pt
2.Visually locate the costal margin
3.Estimate the angle formed by the costal
margins during exhalation & at rest
4.Gently move your fingertips medially to the
xiphoid process
5.As your hands approaches the midline,feel
the ribs as they meet at the apex of costal
margin
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1. < 90° during

exhalation & at rest
2. Widens slightly
during inhalation
due to expansion of
thorax
 Abnormal

Costal margins
> 90° - due to
hyperinflation of
lungs
(emphysema)
 Angle of Ribs

1. Stand in front of pt
2. Visually locate the midsternal area
3. Estimate the angle at which the
ribs articulate with the sternum
4.In a heavy/obese pt, place your
fingertips on midsternal area
5.Move fingertips along a rib laterally
to anterior axillary line
 Intercostal Spaces

1.Stand in front of pt
2.Inspect the ICS throughout
the respiratory cycle

Note any bulging of ICS & any

retractions

Normal: absence of retraction

& bulging of ICS

Abnormal: presence of
retraction
 Muscles for Respiration

1.Stand in front of pt.

2.Observe pt’s breathing for a few resp.
cycle, paying close attention to the
anterior thorax & neck

Note all the muscles that are being used by

the pt.
 Respiration

1.Rate
2.Pattern
3.Depth
4.Symmetry
5.Audibility
6.Patient position
7. Mode
 Respiration RATE

1.Stand in front of pt to right side

2.Observe the pt’s breathing
without stating what you are doing
3.Count the # of resp cycles X 1 full
minute

*Eupnea: 12-20
*Tachypnea: >20
*Bradypnea: <12
*Apnea: lack of spontaneous resp
for >10 seconds
 Respiration Pattern

1.Stand in front of pt to right side

2. While counting the RR, note the
rhythm or pattern of breathing for
regularity or irregularity

Normal: regular & even in pattern

 Abnormal

1. Cheyne-Stokes Respirations –
regularly irregular

2. Biot’s Respirations or ataxic

respirations - irregularly irregular

3. Apneustic respirations - prolonged

gasping during inspiration followed
by very short, inefficient
respiration
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4. Agonal
respirations -
irregularly irregular,
they are of varying
depths and pattern
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 Respiration - DEPTHS

1.Stand in front of pt.

2.Observe the relative depth with which
the pt. draws a breath during respiration

*Normal: Non- exaggerated and

effortless

*Abnormal: Shallow (hypoventilation),

hyperpnea, air trapping, kussmaul’s,
sighi
 Respiration - SYMMETRY

1. Stand in front of pt.

2. Observe the symmetry with which the
chest rises & falls in unison in the respiration
cycle.

*Normal: Thorax rises and falls in unison in

the resp cycle. There is no paradoxical
movement

*Abnormal: Unilateral expansion

 Respiration - AUDIBILITY

1. Stand in front of pt.

2. Listen to the audibility of
respirations

*Normal: normally heard by

unaided ear a few centimeters
from pt’s nose or ears

*Abnormal: audible at few feet

from pt, upper airway sounds
may also be heard
 Respiration – POSITION

1.Ask pt to sit upright

2.Note if pt. can breathe normally when in
supine position
3.Note if pillows are used to prop upright
to facilitate breathing

*Normal: breathes comfortably in

supine, prone or upright position

*Abnormal: Orthopnea
 Respiration – MODE OF BREATHING

1.Stand in front of pt.

2.Note whether the pt. is using
the nose, mouth, or both to
breathe

*Normal: may vary among

individuals, but in general, most
pts inhale & exhale through the
nose

*Abnormal: Continuous mouth

breathing, pursed- lip breathing
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 Palpation of the Thorax : ANTERIOR

1.Stand in front of pt.

2.Place finger pads of dominant hand on
apex of right lung (above clavicle)
3.Using light palpation, assess the
integument
4.Move it down to the clavicle & palpate
5.Proceed with palpation, moving down to
each rib & ICS, with tenderness last
6.Repeat on left anterior thorax
 Palpation of the THORAX: POSTERIOR

1.Stand in front of pt
2.Place finger pads of dominant hand
on apex of right lung (level of T1)
3.Using light palpation, assess the
integument
4.Move it down to the 1st thoracic
vertebrae & palpate
5.Proceed with palpation, moving
down to each thoracic vertebrae &
ICS of right posterior thorax
6.Repeat on left posterior thorax
 Palpation of the Thorax : LATERAL

1.Stand to pt’s right side

2.Have pt lift arm over head
3.Place finger pads of dominant
hand beneath right axillary fold
4.Move finger pads down to each
rib & ICS of right lateral thorax
5.Move to the left side
6. Repeat on left lateral thorax
 Thoracic: EXPANSION

1.Stand directly behind the pt

2.Place thumbs of both hands at level of 10th
spinal vertebrae, approx 1-3 inches apart
3.Gather a small fold of skin between thumbs to
assist with the visualization of the result of this
technique
4.Lay your outstretched palms on posterolateral
thorax
5.Instruct pt. to take a deep breath
6.Observe movement of thumb . Both in
direction & in distance
7.Ask patient to exhale
8.Observe movement of thumbs as they return to
midline
 NORMAL

Thumbs separate an equal

amount from spinal column or
xiphoid process (distance) &
remain in the same plane of
the 10th spinous vertebra or
costal margin (direction).
Normal distance: 3-5cm
 TACTILE FREMITUS

1.Place the ulnar/bolar aspect of hand on pt’s

anterior apex (above clavicle)
2.Instruct pt to say “99” or “1,2,3”, with same
intensity every time you place your hand on
thorax
3.Feel any vibration on ulnar aspect of hand as pt
phonates. If no fremitus is palpated, you may
need to have pt speak more loudly
4.Move hand on same location on left
anterior thorax
5.Compare vibrations on R & L apices
6.Move hand down 2-3 inches & repeat process
on right & then on left
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 NORMAL

1. Felt as buzzing on the ulnar aspect of hand

2. More pronounced near major bronchi (2ICS anteriorly,T1
& T2 posteriorly) & the trachea, less palpable in periphery
of lungs

ABNORMAL
1.Increased tactile fremitus
2.Decreased or absent
3.Pleural friction fremitus
4.Tussive fremitus
5.Rhonchal fremitus
 TRACHEAL POSITION

1.Place finger pads of index finger on

patient’s trachea in the suprasternal notch
2.Move the finger pad laterally to right &
gently move the trachea in the space
created by the border of the inner aspect
of the SCM (sternocleidomastoids) & the
clavicle
3.Move the finger pad laterally to the left &
repeat the procedure

*Normal:
Trachea is in the midline
in the suprasternal notch
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ABNORMAL

1.Tracheal deviation to
the side
2.Tracheal deviation to
the unaffected side
 PERCUSSION : ANTERIOR THORAX

1.Place pt in upright sitting position

with shoulders back
2.Percuss 2-3 strikes along right lung apex
3.Repeat to the left lung apex Note sound
produced from each
percussion strike & compare from each other
4.Move down approx 5cm, or every ICS
5.Percuss in same position on contralateral side
Continue to move down until entire
lung has been percussed
 PERCUSSION : POSTERIOR THORAX

1.Place pt in upright sitting position with slight forward tilt.

2.Have pt bend head down & fold arms in front of waist
3.Percuss the right lung apex located along the top of shoulder, approx 3X
4.Repeat to the left lung apex Note sound produced from each percussion
strike & compare from each other
5.Move down approx 5cm, or every ICS Percuss in same position on
contralateral side
6.Continue to move down until entire lung has been percussed
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NORMAL
1.Normal lung tissue produces a RESONANT sound
2.Diaphragm & cardiac silhouette emit dull sounds
3.Ribs sounds are flat
4.Hyperresonance is normal in thin & decreased musculature adults
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 DIAGRHAMATIC EXCURSION

1.Position pt in for posterior thoracic expansion

2.Patient breathing normally, percuss right lung from apex to below the diaphragm
3.Note level at which percussion note changes quality to orient your assessment to the pt’s
percussion sound
4.Instruct to inhale as deeply as possible & hold that breath
5.With pt holding breath, percuss the right lung in the scapular line from below the scapula to
the location where resonance changes to dullness
6.Mark this location & tell pt to exhale & breathe normally
7.When pt has recovered, instruct to inhale as deeply as possible, exhale fully, & hold exhaled
breath
8.Repercuss the right lung below the scapula in the scapular line in a caudal direction. Mark
spot where resonance changes to dullness
9.Measure distance between two marks
10.Repeat for posterior thorax
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NORMAL
1.Normal distance is 3-5cm
Level of diaphragm is T12 on inspiration &
T10 on expiration
Right side is usually higher than left

ABNORMAL
1.Diaphragmatic excursion of less tan 3cm
*High level diaphragm
 AUSCULTATION : ANTERIOR THORAX

1.Place pt in upright sitting position with

shoulders back
2.Instruct to breath only through mouth
3.Instruct & inhale & exhale deeply &
slowly
4.Place stethoscope on apex of right
lung & listen for 1 complete resp cycle
5.Note sound ausculated Repeat on left
apex 6.Compare on each side
7.Continue to move down 5cm or every
ICS comparing contralateral side
 AUSCULTATION : POSTERIOR THIORAX

1.Place pt in upright sitting position with slight

forward tilt. 2.Have pt bend head down & fold
arms in front of waist
3.Place stethoscope firmly on pt’s right lung
apex. Ask to inhale & exhale deeply & slowly
4.Repeat on left lung apex
5.Move stethoscope down approx 5cm or
every ICS
6.Auscultate in the same position on the
contralateral side
Continue to move inferiorly until lung has been
assessed
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