Chest

&
Lungs
 Objectives
• To enumerate and discuss the common
symptoms of patient with problem of the
chest or lungs
• To discuss the importance of past medical
history, family history and personal social
history in the development of some common
lung disease
• To review the anatomy of the chest and lungs
 Objectives

• To enumerate the different steps of

examination of the chest
• To explain the proper procedure in the
examination of the chest
• To explain the significance of the different
finding on examination of the chest
Symptoms:
• Dyspnea
• Cough/expectoration
• Hemoptysis
• Chest pain
• Hoarseness
• Snoring
• Altered mental function
• Past history
• Occupational (Work) history
• Life style
• Travel
 Cough
Forceful projection of air under pressure from the
tracheo-bronchial tree and alveoli
Mechanism of cough:
voluntary/ reflex
Afferent limb – sensory distribution of the Trigeminal,
Glossopharyngeal, Superior laryngeal & Vagus nerve
Efferent limb – Recurrent laryngeal nerve (glottic
closure); Spinal nerves (causes contraction of the
thoracic & abdominal muscle)
 Cough
Stimulus initiates
Deep inspiration
↓
Glottic closure
Relaxation of diaphragm
Muscle contraction against closed Glottis
↓
Increases intrathoracic & airway pressure
Narrowing of the trachea
↓
Sudden opening of the glottis
 Cough

Sudden opening of the glottis

↓
Sudden release of pressure plus tracheal narrowing
↓
Very fast airflow ( close to the speed of sound)
↓
Forces mucus and foreign bodies out of the airway
 Cough

Etiology:
Inflammation
Mechanical irritation
Decreased pulmonary compliance
Chemical
Thermal
 Cough

Complication:
• Cough syncope
• Rupture of emphysematous bleb
• Rib fracture
• costochondritis
 Cough
• Onset
• Character
• Associated symptoms
• Aggravating condition
 Cough
Acute onset
Laryngitis URTI
Tracheatis Pneumonia
Bronchitis Asthma
Bronchiolitis Pleural effusion
Acute pulmonary
edema
 Cough
Chronic cough
PTB Mediastinal Mass
COPD Interstitial lung disease
Lung tumor Chronic rhinitis/sinusitis
Bronchiectasis GI problem
Fungal infection Cardiovascular disease
 Cough
• Onset
• Character
• Associated symptoms
• Aggravating condition
 Cough
• Onset
• Character
• Associated symptoms
• Aggravating condition
 Cough
Cause Characteristic
Foreign body
Immediate while still Cough associated with
in upper airway progressive evidence of
asphyxiation
Cardiovascular
Pulmonary infarction Cough associated with
hemoptysis, usually with
pleural effusion
 Cough
Problem Cough & Sputum Associated Symptoms
& Setting
Acute
Inflammation
Laryngitis Dry cough, maybe Acute, fairly minor ill-
productive of ness with hoarseness.
variable amount Often associated w/
of sputum viral nasopharyngitis
Tracheobron- Dry cough, may Acute, often viral ill-
chitis become product- ness, w/burning retro-
ive (as above) sternal discomfort
 Cough
Problem Cough & Associated
Sputum Symptoms & Setting
Acute
Inflammation
Mycoplasma Dry hacking Acute febrile illness,
& viral cough, often often with malaise,
Pneumonias becoming headache, and
productive of possibly dyspnea
mucoid sputum
 Cough
Problem Cough & Sputum Associated Symtoms
& Setting
Acute
Inflammation
Bacterial Pneumococcal: An acute illness with
Pneumonias Sputum mucoid or chills. High grade
purulent; may be fever, dyspnea, and
blood-streaked; chest pain. Often is
diffusely pinkish or preceded by acute
rusty URTI
Klebsiella: similar; Typically occurs in
or sticky, red & older alcoholic men
jellylike
Chronic Cough
 Cough

Cause Characteristic
Chronic Infections
Bronchiectasis Cough, copious, foul, purulent,
often since childhood; forms
layers upon standing
 Cough
Cause Characteristic
Parenchymal
Inflammatory
Processes
Interstitial Cough, non-productive, persistent,
fibrosis difficulty of breathing
Smoking Cough usually associated with injected
pharynx; persistent, most marked in
morning, usually only slightly
productive unless succeeded by
chronic bronchitis
 Cough
Cause Characteristic
Foreign body
Later when lodged Non-productive cough,
in lower airway persistent, associated with
localized wheezes
Cardiovascular
Left ventricular Cough intensifies while
failure supine, along with
aggravation of dyspnea
 Cough
Problem Cough & Associated
Sputum Symptoms & Setting
Chronic
Inflammation
Postnasal Chronic cough, Repeated attempts
Drip sputum mucoid to clear the throat.
or mucopurulent Postnasal discharge
may be sensed by
patient or seen in
posterior pharynx
Associated with
chronic sinusitis
 Cough
Problem Cough & Associated
Sputum Symptoms & Setting
Chronic
Inflammation
Chronic Chronic cough; Often longstanding
Bronchitis sputum mucoid cigarette smoking.
to purulent, Recurrent super-
maybe blood- imposed infections.
streaked or Wheezing & dyspnea
even bloody may develop.
 Cough
Problem Cough & Associated
Sputum Symptoms & Setting
Chronic
Inflammation
Pulmonary Cough dry or Early, no symptoms.
Tuberculosis sputum that is Later, anorexia,
mucoid or weight loss, fatigue,
purulent; maybe fever, night sweats
blood-streaked
of bloody
 Cough
Problem Cough & Associated
Sputum Symptoms & Setting
Chronic
Inflammation
Lung abscess Sputum Febrile illness. Often
purulent & foul poor dental hygiene
smelling; may & prior episode of
be bloody impaired
consciousness
 Cough
Problem Chronic Inflammation
Asthma
Cough & Cough, with thick mucoid sputum,
Sputum specially near end of an attack
Associated Episodic wheezing & dyspnea, but
Symptoms & cough may occur alone. Often a
Setting history of allergy
 Cough
Problem Chronic Inflammation
Gastroesophageal reflux
Cough & Chronic cough specially at night or
Sputum early in the morning
Associated Wheezing, specially at night (often
Symptoms & mistaken as asthma), early morning
Setting hoarseness, & repeated attempts to
clear the throat. Often a history of
heartburn & regurgitation
 Cough
Problem Cardiovascular Disorders
Left Ventricular Failure or Mitral
Stenosis
Cough & Often dry, specially on exertion or at
Sputum night; may progress to the pink
frothy sputum of pulmonary edema
or to frank hemoptysis
Associated Dyspnea, Orthopnea, Paroxysmal
Symptoms nocturnal dyspnea
& Setting
 Cough
Problem Cardiovascular Disorders
Pulmonary Emboli
Cough & Dry to productive; maybe dark or
Sputum bright red blood
Associated Dyspnea, anxiety, chest pain, fever:
Symptoms & factors that predispose to deep
Setting venous thrombosis
 Cough
Cause Characteristic
Tumors
Benign tumors Cough non-productive;
occasionally have hemoptysis
Mediastinal Cough often w/ breathlessness,
tumors caused by compression of large
airways
Aortic Brassy cough
Aneurysm
 Cough
Problem Cough & Sputum Associated
Symptoms & Setting
Neoplasm Cough dry to Usually a long
Lung productive; history of cigarette
Cancer sputum maybe smoking. Associated
blood streaked or manifestation are
bloody numerous
Irritating Variable. There Exposure to irritants.
Particles, maybe a latent Eyes, nose, & throat
Chemicals, period between maybe affected
or Gases exposure &
symptoms
 Dyspnea
Sensation experienced by the patient when
the act of breathing becomes uncomfortable,
distressing, difficult and labored
Mode of onset Frequency of occurrence
Precipitating factor Associated symptoms
Severity Exacerbating &
Duration ameliorating factor
 Dyspnea
• Trepopnea – difficulty of breathing on lateral
decubitus position
• Platypnea – difficulty of breathing on upright
position
• Orthopnea – difficulty of breathing on supine
position
 Dyspnea
Acute dyspnea
Asthma Chest Injury
Acute Pulmonary edema ARDS
narcotic overdose Pleural Effusion
high altitude Pulmonary Hemorrhage
neurogenic Pneumothorax
Pneumonia Acute Pulmonary
embolism
 Dyspnea
Problem Asthma
Process Bronchial hype-responsiveness involving
release of inflammatory mediators, inc.
airway secretions, & bronchoconstriction
Timing Acute episodes, separated by symptom-free
periods. Nocturnal episodes are common
Factors that Variable, including allergens, irritants,
Aggravate respiratory infections, exercise, & emotion
Reliever Separation from aggravating factors
Asso. Symp. Wheezing, cough, tightness in chest
Setting Environmental & emotional condition
 Dyspnea
Problem Pulmonary Edema (Left Heart Failure)
Process Elevated pressure in pulmonary capillary bed
with transudation of fluid into interstitial spaces
& alveoli, decreased compliance of the lungs, inc.
work of breathing
Timing Dyspnea may progress slowly, or suddenly as in
acute pulmonary edema
Aggravate Exertion, lying down
Relieved by Rest, sitting up, may become persistent
Associated Often cough, orthopnea, paroxysmal nocturnal
Symptoms dyspnea; sometimes wheezing
Setting Hx of heart disease or its predisposing factors
 Dyspnea
Problem Spontaneous Pneumothorax
Process Leakage of air into the pleural space
through blebs on visceral pleura, with
resulting partial or complete collapse of
the lung
Timing Sudden onset
Asso. Pleuritic pain, cough
symptoms
Setting Often a previously healthy young adult for
primary but in secondary any underlying
lung disease
 Dyspnea
Problem Pneumonia
Process Inflammation of lung parenchyma
from the respiratory bronchioles to
alveoli
Timing An acute illness, timing varies with
the causative agent
Associated Pleuritic pain, cough, sputum, fever,
Symptoms though not necessarily present
Setting varies
 Dyspnea
Problem Acute Pulmonary Embolism
Process Sudden occlusion of all or part of pulmonary
arterial tree by blood clot that usually originates
in deep veins of legs or pelvis
Timing Sudden onset of dyspnea
Associat- Often none. Retrosternal oppressive pain if the
ed occlusion is massive. Pleuritic pain, cough &
Symp- hemoptysis may follow an embolism if
toms pulmonary infarction ensues. Anxiety
Setting Postpartum or postoperative periods; prolonged
bed rest; CHF; chronic lung disease, & fractures
of hip or leg; DVT(often not clinically apparent)
 Dyspnea
Problem Anxiety with Hyperventilation
Process Over-breathing, with resultant respiratory
alkalosis & fall in blood PaCO2
Timing Episodic, often recurrent
Aggra- More often occurs at rest then after exercise.
vated by Possible prior upsetting event
Relieved Breathing in & out of a paper or plastic bag
by sometimes helps the associated symptoms
Asso. SX Sighing, light headedness, numbness &/or
tingling of hands & ft, palpitations chest pain
Setting Other manifestations of anxiety
 Dyspnea
Chronic Progressive Dyspnea
COPD Left ventricular failure
Asthma Diffuse interstitial fibrosis
Pleural effusions Pulm. Thromboembolic
Psychogenic Anemia, severe
Tracheal stenosis Pulm. Vascular disease
Hypersensitivity disorder
 Dyspnea
Problem COPD (emphysema)
Process Over distention of air spaces distal to termi-
nal bronchioles, with destruction of alveolar
septa & chronic obstruction of the airway
Timing Slowly progressive dyspnea; relatively mild
cough later
Aggravated Exertion
Relieved Rest, though dyspnea may becomes
persistent
Asso SX Cough, with scanty mucoid sputum
Setting History of smoking, air pollutants, sometimes
a familial deficiency in alpha-1-antitrypsin
 Dyspnea
Problem Chronic Bronchitis
Process Excessive mucus production in bronchi
followed by chronic obstruction of airways
Timing Chronic productive cough followed by slowly
progressive dyspnea
Aggra- Exertion, inhaled irritants, respiratory tract
vated by infection
Relieved Expectoration; rest, though dyspnea may
by become persistent
Assoc. Chronic productive cough, recurrent resp.
SX infections; wheezing may develop
Setting Hx of smoking, air pollutants; recurrent URTI
 Dyspnea
Problem Diffuse Interstitial Lung Disease (Sarcoidosis,
widespread neoplasm, Asbestosis & Idiopathic
Pulmonary Fibrosis)
Process Abnormal & widespread infiltration of cells, fluid,
& collagen into interstitial spaces between alveoli.
Many causes.
Timing Progressive dyspnea, which varies in its rate of
development with the cause
Aggravate Exertion
Reliever Rest, though dyspnea may become persistent
Asso. SX Often weakness, fatigue, cough less common than
in other lung diseases
Setting Varied. Exposure to one of many substances
 American Thoracic Society Dyspnea Scale
Grade Degree
Not troubled by shortness of breath when
0 None
hurrying on the level or walking up a slight hill
Troubled by shortness of breath when hurrying on
1 Mild
the level or walking up a slight hill
Walks more slowly than people of the same age
2 Mode-
on the level bec. of breathlessness or has to stop
rate
for breath when walking at own pace on the level
Stop for breath after walking about 100 yards or
3 Severe
after a few minutes on the level
Too breathless to leave the house, breathless on Very
4 severe
dressing or undressing
 Hemoptysis
• Coughing up blood
• Origin
• Quantity
 Hemoptysis
Inflammatory Others
bronchitis Pulmonary emboli
bronchiectasis Left heart failure
PTB Trauma
Lung abscess Hemorrhagic diathesis
Pneumonia 1˚ Pulmonary HTN
Neoplasm AV malformation
Lung CA Eisenmenger’s Synd.
Bronchial Adenoma Pulm. vasculitis
 Hemoptysis
Airways:
• Bronchitis
• Bronchiectasis
• Cystic fibrosis
• Neoplasm(bronchogenic, carcinoid)
 Hemoptysis
Parenchymal
• Localized
pneumonia
lung abscess
tuberculosis
aspergilosis
 Hemoptysis
Parenchymal
• Localized • Diffuse
pneumonia Goodpsature’s
lung abscess syndrome
tuberculosis Idiopathic pulmonary
aspergilosis hemosiderosis
 Hemoptysis

• Vascular
Pulmonary emboli
AV malformation
Vasculitis
 Chest Pain
• Quality
• Severity
• Frequency
• Associated symptoms
• Ameliorating factors
• Exacerbating circumstances
 Chest Pain
Problem Cardiovascular - Angina Pectoris
Process Temp. myocardial ischemia, usually 2˚ to coronary
atherosclerosis
Location Retro-sternal or across the ant. Chest, sometimes
radiating to the shoulders, arms, neck, lower jaw, or
upper abdomen
Quality Pressing, squeezing, tight, heavy, occ. burning
Severity Mild to mod., sometimes perceived as discomfort rather
than pain
Timing Usually 1-3 min but up to 10 min. Prolong episodes up
to 20 min.
Factors that Aggravate Exertion, specially in the cold; meals, emotional stress
may occur at rest
Factors that Relieve Rest nitroglycerin
Associated symptoms Sometimes dyspnea, nausea, sweating
 Chest Pain
Problem Cardiovascular – Myocardial Infarction

Process Prolong myocardial ischemia, resulting in

irreversible muscle damage or necrosis

Location Same as angina

Quality Same as angina

Severity Often but not always a severe pain

Timing 20 min to several hours

Associated Nausea, vomiting, sweating, weakness

Symptoms
 Chest Pain
Problem Cardiovascular - Pericarditis
Process Irritation of partial pleural adjacent to Mechanical unclear
the pericardium
Location Precordial, may radiate to the tip of the Retrosternal
shoulder & neck
Quality Sharp, knifelike Crushing
Severity Often severe Severe
Timing Persistent Persistent
Factors that Breathing, changing position coughing,
Aggravates lying down, sometimes swallowing

Factors that Sitting forward may relieve it

Relieves
Associated Of the underlying disease Of the underlying
symptoms illness
 Chest Pain
Problem Cardiovascular - Dissecting Aortic Aneurysm
Process A splitting within the layers of the aortic wall,
allowing passage of blood to dissect a channel
Location Ant. chest, radiating to the neck, back, or abdomen
Quality Ripping, tearing
severity Very severe
Timing Abrupt onset, early peak, persistent for hours or
more
Factors that Hypertension
Aggravates
Associated Syncope, hemiplegia, paraplegia
symptoms
 Chest Pain
Problem
Pulmonary Tracheobronchitis Pleural Pain
Process Inflammation of Inflammation of the parietal pleura,
trachea & large as from pleurisy, pneumonia,
bronchi pulmonary infarction or neoplasm
Location Upper sternum Chest wall overlying the process
Quality burning Sharp, knifelike
Severity Mild to moderate Often severe
Timing variable Persistent
Factors the coughing Breathing, coughing, movement of
Aggravates the trunk
Factors the Lying on the involved side may
Relieves relieve it
Associated cough Of the underlying illness
Symptoms
 Chest Pain
Problem
Pulmonary Tracheobronchitis Pleural Pain
Process Inflammation of Inflammation of the parietal pleura,
trachea & large as from pleurisy, pneumonia,
bronchi pulmonary infarction or neoplasm
Location Upper sternum Chest wall overlying the process
Quality burning Sharp, knifelike
Severity Mild to moderate Often severe
Timing variable Persistent
Factors the coughing Breathing, coughing, movement of
Aggravates the trunk
Factors the Lying on the involved side may
Relieves relieve it
Associated cough Of the underlying illness
Symptoms
 Chest Pain
Problem Gastrointestinal Diffuse Esophageal Spasm
Reflux Esophagitis
Process Inflammation of the esophageal Major dysfunction of the
mucosa by gastric acid esophageal muscle
Location Retro-sternal, may radiate to Retrosternal, may radiate
the back to the back, arm & jaw
Quality Burning, squeezing Squeezing
Severity Mild to severe Mild to severe
Timing variable variable
Factors that Large meal, bending over, lying Swallowing of food or cold
Aggravate down liquid, emotion stress
Factors that Antacids, sometimes belching Sometime nitroglycerin
Relieve
Associated Sometimes regurgitation, dysphagia
Symptoms dysphagia
 Chest Pain
Problem Gastrointestinal Diffuse Esophageal Spasm
Reflux Esophagitis
Process Inflammation of the eso- Major dysfunction of the
phageal mucosa by gastric acid esophageal muscle
Location Retrosternal, may radiate to the Retro-sternal, may radiate
back to the back, arm & jaw
Quality Burning, squeezing Squeezing
Severity Mild to severe Mild to severe
Timing variable variable
Factors that Large meal, bending over, lying Swallowing of food or cold
Aggravate down liquid, emotion stress
Factors that Antacids, sometimes belching Sometime nitroglycerin
Relieve
Associated Sometimes regurgitation, dysphagia
Symptoms dysphagia
 Chest Pain
Problem Chest Wall Pain Anxiety
Process Variable, often unclear Unclear
Location Often below the left breast Precordial, below the left
or along the costal cartilages; breast, or across the anterior
also elsewhere chest
Quality Stabbing, sticking or dull, Stabbing, sticking or dull,
aching aching
Severity Variable Variable
Timing Fleeting to hours or days Fleeting to hours or days
Factors that Movement of the chest, May follow effort, emotional
Aggravate trunk, arms stress
Associated Often local tenderness Breathlessness, palpitations,
Symptoms weakness, anxiety
 Chest Pain
Problem Chest Wall Pain Anxiety
Process Variable, often unclear Unclear
Location Often below the left breast Precordial, below the left
or along the costal cartilages; breast, or across the anterior
also elsewhere chest
Quality Stabbing, sticking or dull, Stabbing, sticking or dull,
aching aching
Severity Variable Variable
Timing Fleeting to hours or days Fleeting to hours or days
Factors that Movement of the chest, May follow effort, emotional
Aggravate trunk, arms stress
Associated Often local tenderness Breathlessness, palpitations,
Symptoms weakness, anxiety
• Hoarseness
• Snoring
• Altered mental status
 Drug Toxicity/ Reaction
• Interstitial Infiltrating Disease
Bleomycin, Cyclophosphamide,
Methotrexate, Nitrofurantoin
• Non-Cardiogenic Pulmonary Edema
Aspirin
 Drug Toxicity/ Reaction
• Bronchospasm
beta-blockers, non-steroidal anti-
inflammatory drugs
• Pulmonary Vasculitis
intravenous drug abuse
 Drug Tocixity/ Reaction
• Pulmonary Thromboembolism:
oral contraceptives
• Respiratory muscle weakness
aminoglycoside antibiotics
 Family History
• Cystic disease
• Pulmonary emphysema sec to α-1-antitrypsin
deficiency
• Cystic fibrosis
• Asthma
• Hereditary telangiectasia
• Kartagener’s syndrome
• Alveolar microlithiasis
• Infection: TB, fungi, schistosoma
 Occupational History
• Asbestos • Cotton dust
• Coal • Titanium oxide
• Silica • Silver
• Beryllium • Nitrogen dioxide
• Bagasse • Animals
• Iron oxide • Air conditioners
• Tin oxide • Furnace
humidifier
Personal & Social History
• Tobacco consumption
• Alcohol consumption
• Travel
• Residence
 Personal & Social History

• Histoplasmosis: south and mid western US

• Coccidioidomycosis: southwestern US
• Hydatid cysts: Mediterranean basin
• Paragonimiasis: Central China
• Schistosomiasis causing cor pulmonale: Egypt
 Personal & Social History
• Bronchospasm: allergic to pets
• Acute pneumonitis: psittacosis, tularemia,
Q fever
• Alcoholics: aspiration pneumonia
pneumococcal pneumonia
klebsiella pneumonia
• IV drug abusers: lung abscess
• Pneumocystis jiroveci
Physical Examination
of the Chest
• Inspection
• Palpation
• Percussion
• Auscultation
 Inspection
Face
• Color, Expression, Level of consciousness, Nasal
flaring, Pursed lip breathing
Body Position
• Posture, Weight
Neck
• Tracheal position from midline
• Jugular vein distention
 Inspection
Chest
• Diameter (normal A/P = ½ to 2/3 lateral)
• Symmetry – pneumothorax, flail chest,
splinting
• Rib angles – 45˚
COPD – more horizontal
• Deformities – Pectus excavatum, scars,
lesions, kyphoscoliosis
• Muscular hypertrophy
Normal Adult
Thorax is wider than it is deep, its lateral diameter is larger
than it’s A-P diameter
Barrel Chest
↑ A-P diameter . Normal during infancy & often
accompanies in aging & COPD
Funnel Chest (Pectus Excavatum)
Characterized by a depression in the lower portion of the
sternum. Compression of the heart & great vessels may
cause murmurs
Pigeon Chest (Pectus Carinatum)
Sternum is displaced anteriorly, increasing the A-P
diameter. The costal cartilages adjacent to the protruding
sternum are depresses
Thoracic Kyphoscoliosis
Abnormal spinal curvatures & vertebral rotation deform the
chest. Distortion of underlying lungs may make interpretation
of lung findings very difficult
Traumatic Flail Chest
If multiple ribs are fractured, paradoxical movements of the
thorax may be seen. As descent of the diaphragm decreases
intrathoracic pressure on inspiration, the injured area caves
inward, on expiration, it moves outward
 Inspection
Breathing Pattern
• Excursion Chest vs. abdominal
depth, retractions or bulging
use of accessory muscle
unilateral
• Rate – tachypnea/bradypnea, etc.
• I/E ratio
• Rhythm – Cheyne-Stoke, Kussmaull’s, Biot’s
Respiratory Rate and Rhythm

Eupnea Cheyne-Stoke
Tachypnea Biot’s
Apnea Kussmaul’s
Hyperpnea Apneustic
Hypopnea
Eupnea
normal rate (12 – 20 BPM), normal rhythm,
sighs 7/hr
Causes : normal physiology
Tachpnea
↑ rate (> 25 BPM), regular rhythm
Causes: normal during sleep, Diabetic
coma, metabolic acidosis, brain tumor,
↑ICP, uremia, drugs intake (Alcohol,
narcotics)
Apnea
Absence of breathing
Causes: respiratory of cardiac arrest, ↑ICP

_______________________________
Hyperpnea
↑depth, normal rate, regular rhythm
Causes: exertion, fever, pain, respiratory
disease
Hypopnea
↓depth, normal rate , regular rhythm
Causes: circulatory failure, meningitis,
uncal herniation
Cheyne-Stokes Respiration
Increasing breaths (rate & depth) then
decreasing breaths followed by periods of
apnea(20-60 sec.)
Causes: normal in newborn & aged, CHF, Aortic
valve lesion, dissecting aneurysm, ↑CO2
sensitivity, meningitis, ↑ICP, cerebral anoxia,
drug overdose (morphine), renal failure
Biot’s Breathing
Fast & deep breath with periods of apnea,
no set rhythm
Causes: spinal meningitis, ↑ICP, CNS
lesions or disease
Kussmaul’s respiration
Fast & deep breath (>20/min) like sighs
with no expiratory pause
Causes: Diabetic ketoacidosis, severe
hemorrhage, peritonitis, renal failure,
uremia
Apneustic breathing
Long gasping inspirations with insufficient
expiration
Causes: lesions in the pneumotaxic center
 Inspection
• Skin – mucous membranes, color
• Fingers – clubbing, tremors
• Sputum
• Vital signs
 Clubbing of the Digits
Pulmonary & Thoracic
Primary lung cancer
Metastatic lung cancer
Bronchiectasis
Cystic fibrosis
Lung abscess
 Clubbing of the Digits
Pulmonary & Thoracic
Pulmonary fibrosis
Pulmonary AV malformation
Empyema
Mesothelioma
Neurogenic diaphragmatic tumor
 Clubbing of the Digits
Cardiac
Congenital cyanotic heart disease
Sub-acute bacterial endocarditis
 Clubbing of the Digits
Gastointestinal & Hepatic
Hepatic cirrhosis
Chronic ulcerative colitis
Regional enteritis (Crohn’s disease)
Miscellaneous
Hemiplegia
 Palpation
• Trachea
• Chest excursion
symmetry/lagging
3 cm in women; 4 – 6 cm in men
• Tenderness/ fractures
 Palpation
• Skin – turgor, masses, subcutaneous
emphysema, diaphoresis
• PMI
• Tactile fremitus
 Palpation
Decreased fremitus Increased fremitus
Air, fluid or fibrous Consolidation
barrier atelectasis
• Pneumothorax pneumonia
• Effusion infarction
• Pleural thickening tumor
• Thick chest wall
Decreased airflow –
airway obstruction
 Percussion
• Set the chest wall & underlying tissues in
motion, producing audible sound &
palpable vibrations
• Help establish underlying tissues are air-
filled, or solid
• Penetrates only 5 – 7 cm into the chest
 Percussion
Technique of Percussion (right handed)
• Hyperextend the middle finger of your left
hand, known as the pleximeter finger.
Press its distal interphalangeal joint firmly
on the surface to be percussed. Avoid
surface contact by any other part of the
hand, because this dampens out vibrations.
Note that the thumb and 2nd, 4th, and 5th
fingers are not touching the chest.
 Percussion
Technique of Percussion (right handed)
• Position your right forearm quite close to
the surface, with the hand cocked upward.
The middle finger should be partially flexed,
relaxed, and poised to strike.
 Percussion
Technique of Percussion (right handed)
• With a quick, sharp but relaxed wrist
motion, strike the pleximeter finger with
the right middle finger, or plexor finger.
Aim at your distal interphalangeal joint.
You are trying to transmit vibrations
through the bones of this joint to the
underlying chest wall.
 Percussion
Technique of Percussion (right handed)
• Strike using the tip of the plexor finger, not
the finger pad. Your finger should be almost
at right angles to the pleximeter. A short
fingernail is recommended to avoid self-
injury.
• Withdraw your striking finger quickly to
avoid damping the vibrations you have
created.
Percussion
Percussion
Percussion
Percussion
Percussion
Percussion notes & their Characteristics
Relative Relative Relative Example of Pathologic Example
intensity Pitch Duration Location

Flatness Soft High Short thigh Large pleural

effusion
Dullness Medium Medium Medium Liver Lobar pneumonia
Resonance Loud Low Long Healthy Simple chronic
lung bronchitis
Hyperreso- Very loud lower longer Usually COPD,
nance none pneumothorax
Tympany loud high Gastric air Large pneumo-
bubble or thorax
puff-out
cheek
Percussion
Percussion
 Auscultation
• Normal Breath Sounds
• Adventitious sounds
• Intensity of Breath sounds
• Vocal Fremitus
 Auscultation
• Normal Breath Sounds
Bronchial
Broncho-vesicular
Vesicular
Tracheal
 Auscultation
• Adventitious Sounds
Crackles
Wheezes
Rhonchi
Stridor
Auscultation
Auscultation
 Characteristic of Breath Sounds
Type Duration of Sounds Intensity of Pitch of
expiratory expiratory
sound Sound
Vesicular Inspiratory sounds last Soft Low
longer than expiratory
ones
Broncho- Inspiratory & expiratory Intermediate intermediate
Vesicular sounds are about equal

Bronchial Expiratory sounds last Loud Relatively

longer than inspiratory high
ones
Tracheal Inspiratory & expiratory Very loud Relatively
sounds are about equal high
Characteristic of Breath Sounds
Type I:E Area normally heard
Vesicular 3:1 Breezy Over most of both lungs

Broncho- 1:1 breezy/ Often in the 1st & 2nd

vesicular tubular interspaces anteriorly &
between the scapulae
Bronchial 2:3 Hollow/ Over the manubrium, if
Tubular/Loud heard at all
Tracheal 5:6 Tubular/ Over the trachea in the
Loud/Harsh neck
 Adventitious Lung Sounds
• Discontinuous • Other
Crackles Pleural friction
• Continuous rub
Wheezes Mediastinal
Rhonchi Crunch
Stridor
 Adventitious Lung Sounds
Crackles: (Discontinuous Sounds)
results from tiny explosions when small
airways, deflated during expiration, pop
open during inspiration
result as air bubbles flowing through
secretions or lightly closed airways during
expiration
 Adventitious Lung Sounds
Discontinous Sounds ( Crackles )
intermittent, non-musical and brief – like
dots in time
Fine Crackles
Coarse Crackles
 Adventitious Lung Sounds
Discontinous Sounds ( Crackles )
Fine Crackles (…..) – soft, high pitched
and very brief 5 – 10 msec.
 Adventitious Lung Sounds
Discontinous Sounds ( Crackles )
Coarse Crackles ( ….. ) somewhat louder,
lower in pitch, and not quite so brief 20
– 30 msec.
 Adventitious Lung Sounds
Crackles (Discontinuous Sounds)
Late Inspiratory Crackles – usually fine,
fairly profuse, and persist from breath to
breath. Appear 1st at lung bases, spread
upward as condition worsens, and shift to
dependent regions with changes in
posture.
Causes : Interstitial lung disease & early
CHF
 Adventitious Lung Sounds
Crackles (Discontinuous Sounds)
Early Inspiratory Crackles – appear and end
soon after the start of inspiration. Often
coarse & relatively few, expiratory crackles
are sometime associated.
Causes: Chronic bronchitis & Asthma
Mid-inspiratory & Expiratory Crackles –
Heard in Bronchiectasis but not specific
 Adventitious Lung Sounds
Continuous Sounds
are > 250 msec. notably longer than
crackles – like dashes in time – but do
not necessarily persist throughout the
respiratory cycle. Unlike crackles they are
musical
 Adventitious Lung Sounds
Continuous Sounds
Wheezes – are relatively high pitched @ 400
Hz or higher and have a hissing or shrill
quality
• Occurs when air flow rapidly through bronchi
that are narrowed nearly to the point of closure
 Adventitious Lung Sounds
Continuous Sounds
Wheezes
• Often audible at the mouth as well as through
the chest wall
• Causes of generalized wheezes : COPD, Asthma,
& CHF
• Persistent localized wheezes suggests partial
bronchus obstruction, by tumor or foreign body
 Adventitious Lung Sounds
Continuous Sounds
Rhonchi – are relatively low pitched @ 200
Hz or lower & have a snoring quality
• Suggest secretions in the large airway
 Adventitious Lung Sounds
Continuous Sounds
Stridor
• A wheeze that is entirely or predominantly
inspiratory
• Often louder in the neck than over the
chest wall
 Adventitious Lung Sounds
Continuous Sounds
Stridor
• Indicates partial obstruction of larynx or
trachea
• Demands immediate attention
 Adventitious Lung Sounds
Continuous Sounds
Pleural Rub
• Caused by inflamed & roughened pleural
surfaces that grate against each other
• Resemble crackles acoustically
 Adventitious Lung Sounds
Continuous Sounds
Pleural Rub
• Sounds may be discrete but sometimes are so
numerous that they merge into a seemingly
continuous sounds
• Usually confined to a small area of the chest wall
• Heard in both phase of respiration
 Adventitious lung Sounds
Continuous Sounds
Mediastinal Crunch (Hamman’s Sign)
• A series of precordial crackles synchronous
with the heart beat not with respiration
• Best heard in the left lateral position
• Due to mediastinal emphysema
(pneumomediastinum)
• A medical emergency
 Intensity of Breath Sounds
Decreased Increased
Causes Consolidation:
• ↓ air movement as consolidation ↑,
airway obstruction sounds change from
restrictive lung disease vesicular to broncho-
vesicular to bronchial
• Insulation
Causes
Air – pneumothorax
Tumor Atelectasis
Fat – obesity (chest wall)
Infarct Pneumonia
Fluid – effusion
Fibrosis
Fibrosis – Thicken pleura
 Transmission of Voice Sounds
Normal Abnormal
(consolidation)
Broncho- Spoken syllables Increased
phony are non-distinct distinction

Whispered Whispers faint & Increased

Pectoriloquy non-distinct. distinction
Hardly audible
Egophony E→E E→A
 Physical Examination Finding of Different Lung Diseases
Condition Trachea Percussion Breath Sounds Tactile Adventitious
fremitus & Sounds
Transmitted
Voice Sounds
Normal Midline Resonant Vesicular, normal None, except
except bron- for few
chovesicular transient
& bronchial inspiratory
sounds over crackles at the
large bronchi base of the
& trachea lungs
respectively
Left sided midline resonant normal normal Late inspiratory
heart failure crackles in
(early) dependent
portions,
possibly
wheezes
Physical Examination Finding of Different Lung Disease
Condition Consolidation
Trachea Midline
Percussion Dull over airless area
Breath Sounds Bronchial over involvedarea
Tactile Fremitus & Inc. over involved area, bronchophony
Transmitted Voice & whispered pectroliloquy
Sounds

Adventitious Sounds Late insp. Crackles over involved area

 Physical Examination Finding of Different Lung Disease
Condition Atelectasis (lobar obstruction)
Trachea Maybe toward the involved side
Percussion Dull over airless area
Breath Sounds Usually absent when bonchial plug persists.
Exceptions: RUL atelectasis, where adjacent
tracheal sounds may be transmitted
Tactile Usually absent when bronchial plug persists;
Fremitus & may be increase in RUL atelectasis
Transmitted
Voice Sounds
Adventitious none
Sounds
 Physical Examination Finding of Different
Lung Disease
Condition Pleural effusion
Trachea Toward opposite side in large effusion
Percussion Dull to flat over the fluid
Breath Sounds Decrease to absent; bronchial breath
sounds may be heard near top of a large
effusion
Tactile Fremitus & Decrease to absent, but may be increase
Transmitted Voice toward the top of large effusion
Sounds
Adventitious Sounds None, except a possible pleural rub
 Physical Examination Finding of Different
Lung Disease
Condition Pneumothorax
Trachea Toward opposite side if much air
Percussion Hyper-resonance or tympanitic over
pleural air
Breath Sounds Decreased to absent breath sounds
over pleural air
Tactile Fremitus & Decreased to absent over pleural air
Transmitted Voice Sounds
Adventitious Sounds None
 Physical Examination Finding of Different
Lung Disease
Condition Emphysema
Trachea Midline
Percussion Diffusely hyperresonance
Breath Sounds Decreased to absent
Tactile Fremitus & Transmitted Decreases
Voice Sounds
Adventitious Sounds None, or crackles, wheezes, &
rhonchi of associated chronic
bronchitis
 Physical Examination Finding of Different
Lung Disease
Condition Asthma
Trachea Midline
Percussion Normal to diffusely hyperresonant
Breath Sounds Often obscured by wheezes
Tactile Fremitus & Transmitted Decreased
Voice Sounds
Adventitious Sounds Wheezes possibly crackles
Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Asthma Orthopnea, Normal or Normal or ↓breath
dyspnea, ↓fremitus hyper- sounds (severe
cyanosis resonance cases),
maybe,↑RR, wheezes,
↑expiratory crackers
phase, use of
accessory
muscles, ↑A-P
diameter
Atelectasis ↓chest Decrease dull Increase or
expansion fremitus decrease
(same side), breath sounds,
↑RR, cyanosis crackles,
(maybe), whispered
Tracheal pectrolloquy
deviation
(same side)
Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Chronic Fat or stocky, Normal or Normal to Decrease
Bronchitis dyspnea, cyanosis, decrease dull breath
inc. chest A-P fremitus sounds,
diameter, inc. use crackles,
of accessory wheeze
muscles, dec.
diaphragm
movement,
increase RR, inc.
expiratory phase
 Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Emphysema Thin, increase chest Normal or Hyper- Decrease breath
A-P diameter, decrease resonance sounds, crackles,
hypertrophy of fremitus wheeze
accessory muscles,
orthopnea, dec.
chest movement,
dec. diaphragm
movement, inc. RR,
inc. expiratory phase
Large Mass Usually normal Dec. dull Dec. breath
fremitus if sounds if airway
airway occluded, inc.
occluded; bronchial sounds
inc.fremi- if not occluded,
tus if not crackles, friction
occluded rub may be
 Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Pleural Inc, RR, cyanosis, Decrease Dull/flat Decrease breath
Effusion dec. chest fremitus (same sound (same
movement (same (same side) side) side), friction rub
side), tracheal maybe present,
deviation (opposite egophony (above
side) effusion)
Pleural Dec. expansion Dec. Dull (same Decrease breath
thickening (same side) fremitus side) sound (same side)
(same side)
Pneumonia Dec. chest expansion Increase Dull (same Inc. bronchial
(same side) fremitus side) sounds, crackles,
(same side) friction rub,
egophony,
whispered
pectroliloquy
Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Pneumothorax Inc. RR, Dec. Hyper- Decrease breath
cyanosis, fremitus resonance sounds
lagging(sam (same side) (same side)
e side),
tracheal
deviation
(opposite
side)
Pulmonary Orthopnea, Increase dull Increase
Edema inc. RR, fremitus broncho-
cyanosis, or vesicular sounds.
pale, use of Crackles,
accessory wheezes (may
muscles be)
 Differential Diagnosis of Some Common Pulmonary
Diseases from Respiratory Assessment Findings
Disease Inspection Palpation Percussion Auscultation
Pulmonary Dyspnea, sharp normal normal Dec. breath
Embolism chest pain, sound locally,
apprehension, crackles,
cough, wheezes,
hemoptysis, friction rub
tachypnea locally
Pulmonary Inc. RR, use of Normal or Normal or Inc. broncho-
Interstitial accessory increase dull vesicular
fibrosis muscles, cyanosis fremitus sounds,
(late), clubbing crackles,
(may be) whispered
pectoriloquy