Collapse all sections REGISTER LOG IN

Pulmonary examination Last updated: February 13, 2023

Summary

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. A carefully
recorded medical history and thorough physical examination allow for differential diagnosis and prompt initiation of therapy.
See also differential diagnoses of dyspnea.

Inspection

The following should be assessed:

Breathing pattern

Normal respiratory rates

12–20/min in adults

30–60/min in infants and neonates

See also “Normal vital signs at rest” for all age groups.

Bradypnea

Respiratory rate < 12/min in adults

< 30/min in infants and neonates

< 40/min in newborns

Tachypnea

Respiratory rate > 20/min, shallow breathing in adults

> 60/min in pediatric patients

Hyperpnea: respiratory rate > 20/min, deep breathing

Inspiratory:expiratory ratio: The ratio of the inspiratory time to expiratory time during spontaneous breathing, which is normally 1:2.

Common abnormal patterns of breathing include: [1]

Cheyne-Stokes breathing: alternating periods of deep breathing followed by apnea

Results from a delay in detecting changes in ventilation and arterial carbon dioxide pressure.

Common causes include: advanced heart failure, damage to respiratory centers (e.g., stroke, traumatic brain injuries, metabolic encephalopathies), and
central sleep apnea

Ataxic breathing: irregular breathing in rhythm and depth

Obstructive breathing: prolonged exhalation

Increased effort of breathing

Tachypnea

Use of accessory muscles of respiration during inspiration

Sternomastoid muscles

Scalene muscles

Pectoralis major

Trachea off midline

Tripod position: patients with emphysema and respiratory distress will lean forward while sitting, resting with their hands on their knees.

Peripheral signs of respiratory dysfunction

Cyanosis: bluish discoloration of the skin and mucosa (due to deoxygenated hemoglobin)

Nail clubbing [2]

Definition: Nail clubbing is a physical finding characterized by painless swelling of the distal phalanges typically associated with chronic hypoxemia.

Pathophysiology

Not fully understood

Hereditary factors may predispose to clubbing.

Fibrovascular proliferation in the region of the nail bed due to accumulation of megakaryocytes and platelets in digital vessels and subsequent local
PDGF and VEGF release is suggested.

Associated conditions

Respiratory conditions, such as:

Interstitial lung disease

Idiopathic pulmonary fibrosis

Cystic fibrosis

Lung cancer

Cardiovascular conditions, such as:

Cyanotic congenital heart disease

Cardiac shunts

Infections, such as:

Tuberculosis

Infections causing lung abscesses

Hypertrophic osteoarthropathy: a syndrome (either hereditary or paraneoplastic) that manifests with painful nail clubbing, synovial effusions, and
periostitis

IBD

Not associated with COPD, asthma

Clinical features

Painless swelling of connective tissue in the distal phalanges

Lovibond angle ≥ 180°: angle between the base of the nail and its surrounding skin

Nail bed feels spongy when pressed and springs back when released.

Schamroth test

Place distal phalanges against each other so that both fingernails touch

When there is nail clubbing, the normal diamond-shaped “window” between the nail beds will not be seen.

Abnormalities in the shape of the thorax

The anteroposterior diameter of the thorax may increase in COPD, leading to a “barrel chest” appearance.

Retraction of the intercostal spaces

Asymmetric movement may be associated with pleural disease, phrenic nerve damage, or pleural effusion.

Kyphosis or scoliosis may lead to decreased forced vital capacity, forced expiratory volume and overall respiratory function

Sputum production or secretions, if any

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

Hemoptysis: See "Etiology of hemoptysis.”

In newborn and infants

Jugular, sternal, and intercostal retraction

Nasal flaring or flaring of the nostrils

Neck extension

Access full content

Extend your medical knowledge beyond Pulmonary examination

Start your trial, and get 5 days unlimited access to over 1,100 medical articles and 5,000 USMLE and NBME exam-style questions.

TRY FREE FOR 5 DAYS

Palpation

General: 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 “toy boat” 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

References:[3]

Percussion

Technique

Hyperextend the nondominant middle finger and place the distal interphalangeal joint against the chest wall.

Strike the joint with the other middle finger and evaluate the elicited sound.

Always percuss both sides of the chest at the same level. Often the finding of asymmetry is more important than the specific percussion note that is
heard.

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

Assess diaphragmatic movement

Move downwards while percussing over both sides of the chest wall.

The transition point from resonant to dull percussion notes marks the approximate position of the diaphragm.

Abnormally high transition points on one side may be seen in unilateral pleural effusion and unilateral diaphragmatic paralysis.

The distance between the transition point on full expiration and the transition point on full inspiration is the extent of diaphragmatic excursion (normally
3–5.5 cm).

References:[3]

Auscultation

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

Cavernous breathing

A harsh, hollow breath sound with high-pitched overtones heard on lung auscultation

It is produced by air passing through a large, superficial cavity that communicates with the bronchial system (e.g., a cyst or abscess)

Can not be heard if there is fluid or a fungal ball within the cavity

Pathological breath sounds

Also known as adventitious or added 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)

[4]
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

Pleural friction rub: scratchy, high-frequency sound

Muffled or absent breath sounds: suggest presence of air or fluid between the lung and the chest wall (e.g., pleural effusion, pneumothorax)

Transmitted sounds

Bronchophony

Increased transmission of voice sounds

Ask patient to say “ninety-nine” in a normal voice while auscultating.

An asymmetric increase in voice transmission suggests a collapsed lung or atelectasis.

Egophony

Ask the patient to say “ee” while auscultating.

If it sounds like “A” rather than “E”, this is called egophony and suggests lobar pneumonia.

Whispered pectoriloquy

Ask patient to whisper “ninety-nine” while auscultating.

Normally this is barely audible.

Clearly audible in the presence of pulmonary consolidation

References:[3][4]

Overview of pulmonary examination findings

Main symptom Tactile Percussion Auscultation (breath sounds) Tracheal deviation

fremitus

Physiological – Normal Resonant Vesicular None

Pleural Dyspnea may be present Decreased Dull Decreased To the opposite side of the lesion
(no deviation in small effusions)
effusion

Pulmonary Severe dyspnea Possibly Dull Fine or coarse crackles, depending on None
increased severity
edema

Simple Acute dyspnea Decreased or Hyperresonant Decreased or absent None

absent
pneumothorax

Tension Severe dyspnea Decreased or Hyperresonant Decreased or absent To the opposite side of the lesion
absent
pneumothorax

Bronchial Paroxysmal attacks of dyspnea, Decreased Hyperresonant Wheeze, a prolonged expiratory None
wheezing phase, possibly decreased breath
asthma
sounds
1

Chronic Chronic cough Decreased Hyperresonant Wheezing, rhonchi None

bronchitis
1

Emphysema Chronic dyspnea Decreased Hyperresonant End-expiratory wheezing, decreased None

breath sounds

Fever, dyspnea Increased Dull Coarse crackles None

Pneumonia 2

Lung fibrosis Cachexia and weakness, dyspnea Normal or Dull Basal inspiratory crackles To the side of the lesion
slightly
increased

Atelectasis Pain may be present Decreased Dull Decreased To the side of the lesion

Pulmonary Acute dyspnea, pleuritic chest pain, Normal Normal Normal None
tachypnea
embolism
1

Hemoptysis, constitutional symptoms Possibly Possibly dull Possibly decreased To the opposite side of the lesion
Tumor 1,2,3
(weight loss, fever, night sweats) decreased

The following conditions frequently complicate the aforementioned pulmonary disease: 1pneumonia, 2pleural effusion, 3atelectasis.

See “Dyspnea” for more information.

References:[3]

References

1. Bickley L. Bates' Guide to Physical Examination and History-Taking . Lippincott Williams & Wilkins ; 2012

2. Braun SR, Walker HK, Hall WD, Hurst JW. Respiratory Rate and Pattern. Clinical Methods: The History, Physical, and Laboratory. 1990.

3. Sarkar M, Mahesh D, Madabhavi I. Digital clubbing. Lung India. 2012; 29 (4): p.354.doi: 10.4103/0970-2113.102824 . | Open in Read by QxMD

4. Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014; 370 (8): p.744-751.doi: 10.1056/NEJMra1302901 .|
Open in Read by QxMD

© 2020 AMBOSS Medical Knowledge Terms and Conditions Privacy Privacy Settings Legal Notice Get Support & Contact Us