24.

EXAMINATION OF LUNG

Clinical examination of lungs/Respiratory system includes inspection

palpation, percussion and auscultation.

(I) Inspection :-

1. Shape of the chest :-

For determination of shape of the chest, check the chest from the foot

and of the bed, from the head and of the bed and from a tangent. Also look at

the back of the chest. Normal chest is symmetrical and its side to side to antero

posterior diameter is 7:5. In cross section it appears elliptical. There is no

undue bulging or retraction. Subcostal angle is acute.

* Abnormal shape of the chest:-

(I) Flat chest:-

Heree the anteroposterior diameter is reduced.

(II) Barrel Shaped chest:-

The Anteroposterior diameter is increased; the sub costal angle is more

than 90. Chest is as if held in a position of inspiration and there is accentuation

of dorsal kyphosis (forward bending of vertebral column). It is often seen in

patient’s having pulmonary emphysema, collapse of lungs, fibrosis etc.

(III) Pigeon chest:-

The sternum is prominent and the chest in cross section has a triangular

appearance. It is usually congenital or may be due to rickets in childhood.

(IV) Funnel chest:-

There is a hollowing in the region of the sternum. It is congenital or may

be acquired as in cabblers.
2. Equality of chest movement:-

For testing it ask the patient to lie flat and observe the movements from

the foot end of the bed or from the side at the level of the manubrium or from

the head end of the bed. Patient is asked to take deep breaths. If one side or a

part of it is moving less than its counterpart, it indicates a disease of the lung or

the pleura on that side. If both the sides of the chest are moving less, it

indicates disease of both the lungs e.g. emphysema. Normally, during full

inspiration the chest expansion should be at least 5 cm. (measured at the level

of the nipples)

3. Rate of respiration:-

Normally the rate of respiration is 12-18/min (12-16/min or 14-20/min)

for relaxed normal adult. Count the frequency of breathing by observing

abdominal wall movements for a full minute. If the rate of respiration is

increased but the patient is not aware of it and does not complain of

breathlessness it is called tachypnoea. When the patient complains of

breathlessness or shortness breath and increase the rate of respiration it is

called dyspnoea. When the rate of respiration is decrease it is called

bradypnoea.

4. Type of respiration:-

See whether it is abdominal or thoracic. Normally it is abdominal.

Thoracic type of respiration occurs during pregnancy and the tumors of the GIT.

5. Sternomastoid sing (Trail’s sing):-

Let the patient lie down, looking straight ahead without any tilt of the

nack. Normally both the sternomastoid are equal at site of their insertion over

the clavicle. If however the trachea is shifted to the right side, right
sternomastoid at its root will appear more prominent and vice versa. Thus when

we say “sternomastoid sing is positive on right side” we mean to indicate that

the trachea is shifted to the right side.

6. Apex beat:-

It is also called the point of maximum impulse (PMI) and it is the further

most point outwards and downwards form the sternum at which cardiac impulse

can be felt. Normally the apex beat is situated in left 5th interspace slightly

inside the midclavicular line.

7. Skin and prominent vein over the chest will:-

Normally no any redness, nodules, scar or prominent veins are found on

the chest wall.

(III) Palpation:-

Palpation is done in order to confirm the findings of inspection e.g.,

equality of movements, position of the trachea, and location of the apex beat.

In addition, tactile vocal fremitus (TVF) and any point of tenderness over the

chest are tested

1. Equality of movement:-

Equality of respiratory movement should be tested in the front as well as

at the back. In the front- upper zone, middle zone and the lower zone are

tested. The flat of the hand are applied along the thoracic cage roughly parallel

to the interspaces. Thus the fingers and the palms are horizontal while the tips

of thumbs are kept as much ventricle as possible in the midline over the

sternum. Now patient is ask to take deep breath and the movements of the

thumb which move away from each other are compared. Normally their
displacement should be equal on both sides. For testing movements on the back

the patient is made to seat up while the examiner stands behind.

2. Palpation of the apex beat:-

First feel the apex beat with the palm of the hand and then locate it with

the tip of the index finger. Normally it is located in the left 5th intercostal space

just inside the midclavicular line. It may be displaced because of cardiac or

pulmonary cases. The pulmonary causes like pleural effusion and pneumothorax

which push it to the opposite side while collapse and fibrosis pull it to the same

side. The apex beat may not be palpable in cases of obesity, emphysema or

pericardial effusion and also sometimes in normal individual. If it is behind the

rib it will be felt when the patient is turn to the left lateral position.

3. Palpation of the trachea:-

Ask the patient to lie down supine in bed without pillow and ask him to

keep the neck straight without any tilt and slightly extended looking to be

ceiling. Now put the thumb of the right hand outside the right sternomastoid

muscles little above the clavicle and put the index finger between the trachea

and opposite sternomastoid. Estimate this distance. Now, put thumb between

the trachea and the right sternomastoid and put the index finger outside the

opposite sternomastoid. Judge this distance. Normally as the trachea is central,

both these distance should be equal. For example, if trachea is shifted to the

right side the distance measured first will be found to be less than the other

one.

4. TVF (tactile vocal fremitus):-

TVF is the tactile perception of vibration communicated to the chest wall

from the larynx via bronchi and lungs during the act of phonation. This can be
felt if the ulnar border of the hand (it is more sensitive for perception of

vibration sense) is put on the chest wall and then the patient is ask to repeat

speaking “One Two, Three” with uniform intensity while the hand is put over

corresponding part of the chest wall and the intensity of the sound vibrations is

compared. The intensity of these vibrations will reflect the condition of the

conduction medium. TVF should be tested on corresponding interspaces one by

one and patient should go on repeating “One Two, Three” with uniform tone.

Normally TVF is slightly increased on the the side of the chest in front over the

first and second interspaces near the sternum because of the proximity of the

right bronchus which is a more direct continuation of the trachea than the left

bronchus. (TVF is increased in consolidation or cavity. TVF is decreased in

bronchial obstruction. TVF is totally absent when lung is separated from the

chest wall by pleural effusion or pneumothorax.)

5. Tenderness:-

Look for the tenderness over the chest wall and the ribs and the costal

cartilage specially if the patient has a local swelling or has complained of pain in

that region.

(III) Percussion:-

Percussion is a method of tapping body parts with fingers or hands to

determine the size, consistency, borders of body organs and presence or

absence of fluid in body areas. Here, percussion is of two types, indirect and

direct.

1. Indirect Percussion:-

It requires the use of striking finger (plexor) and intervening finger (plexi

meter) over which the plexor finger strikes so as to elicit a note which is called
the percussion note. For percussion, indirect method is used except over the

clavicles, manubrium and the sternum where the direct method is used.

2. Direct method:-

When the clavicle is percussed it itself acts as the pleximeter and there

for intervention of another finger is not necessary and the stroke is made

directly over the clavicle. Direct method is used for clavicles, manubrium and

the sternum.

* Technique:-

The patient should be in sitting position. If he is not able to sit up he may

be allowed a semi-reclining position with the help of the back rest. He is asked

to turn the head to one side e.g. to the left side and the apex of the right lung

is percussed above the medial half of the clavicle and then the patient turns his

head to the right side so that the left apex can be percussed. Percuss each

clavicle directly over the median half on the right side and then on the left side.

Next percuss the interspaces one by one on corresponding side e.g. right first

space and left first space and so on downwards till the costal border is reached.

* Percussion over the back:-

For this ask the patient to sit up putting the right hand on the left

shoulder and the the left hand on the right shoulder so as to move the scapula

away from the midline. Standing behind the patient, first percuss the apex of

the lung on the right side and then on the left side or vice versa. Percuss each

interspace one by one form above downward till the costal borders are reached.

Percussion of the back of the chest is most important for the diagnosis of

pleural effusion.

* Normal Percussion note:-

 Over both the lungs the percussion note is described as resonant. (It is

only by practice that one learns as to what is the normal resonant note over the

lungs.) However over the following region the note is different.

1. Fifth space downwards on the right side the note is found to be dull

because of the presence of the liver (hepatic dullness)

2. Over the region of the heart (near to the sternum in left fourth and

fifth space) there is a small area which is dull to percussion due to the

presence of the heart (cardiac dullness).

3. On the left side in the lower part 6th space down wards and extending

to left costal border, there is an area of percussion note described as

tympanitic (drum like) due to the presence of air bubble in the

stomach . This is called traube’s semilunar space. Any change in the

note over this region reflects either a cardiac or hepatic or a lung

pathology. (An increase in resonance is seen in pneumothorax &

decrease in resonance-dullness is seen in pleural effusion, pneumonia)

4. Hyper resonant sounds are normally heard when percussing the chests

of children & very thin adults.

* Precaution:-

- Percussion should be done in corresponding space form above

downwards.

- The pleximeter finger (index or middle finger of the nondominant

hand) is put over the interspace without any air space between the

finger & the interspace.

- The plexor finger (index or middle finger of the dominant hand)

strikes on the middle phalanx of the pleximeter finger. Movement of

the plexor finger should be at the wrist.

- In each space percuss the outermost region first and then come

towards the midline.

- Light percussion is made but on the back because of the presence of

thick muscles, heavy percussion is required.

- Percussion is done with the fingertip.

- Not more than two or at the most three strokes are made.

- Tympanitic - Maximum resonance

- Hyper resonant - Increased resonance

- Resonant note - Normal

- Impaired or dull - decreased resonance

- Story dull - Least or absent resonance

(Iv) Auscultation:-

The bell chest piece is preferable then the diaphragm chest piece

because the respiratory sounds are low pitched and therefore better

heard with the bell chest piece.

* Method:-

The patient is lying or sitting or is in the semi reclining position. For

auscultation on the back he should be made to sit up or if the

condition does not permit sitting, he is ask to turn to one and then

to the other lateral side. Ask the patient to take deep breath
 without holding the breath in between. He should keep the mouth

open so as to avoid any sound from the nose. Auscultate in

corresponding areas over the front- apex downwards, laterally in

the axilla above downwards and on the back above downward and

note the finding on the front, laterally and on the back. After breath

sound and the foreign sound are analyzed, test for the vocal

resonance at the same time so that the patient has not to seat up

and lie down repeatedly.

* Air Entry:-

Normal amplitude of the breath sound will be learnt only by

experience and there for the student should auscultate chest of

patient who do not have any disease of the lungs only then he will

be able to judge the amplitude and type in diseased lungs.

* Diminished air entry:-

The amplitude of the breath sound is decreased whenever there is

impaired conduction either due to obstruction in the trachea,

bronchi, alveoli, pleural cavity or due to thick chest wall (obesity).

Thus air entry is found to be absent in total bronchial obstruction,

pneumo thorax & pleural effusion.

* Type of breath sounds:-

1. Vesicular breath sound:-

This is the normal breath sound heard over the lungs except

over the trachea and adjoining to the manubrium, upper sternum

and by the side of the C7 & T1 Vertebra posteriorly. Vesicular

breath sounds have a soft, rustling quality. (rustling - movement of

 the leaves when a breeze passes across them leaving to their

vibration) Inspiration is longer, there is no pause and it is followed

by short expiration which is about ½ or 1/3 of inspiration.

Inspiration is louder than the expiration.

2. Bronchial breath sound:-

Inspiration & expiration are equal & there is a pause. The

most important characteristic of bronchial breath sound is its

blowing quality both during the phase of inspiration & expiration.

Compared to vesicular breath sound, the pitch is higher. It is heard

normally over the trachea and adjoining to the manubrium, upper

sternum and by the side of C7 and D1 vertebra on the back.

Bronchial breath sound is heard in consolidation, fibrosis, cavity and

collapse.

3. Bronchovesicular breath sound:-

Inspiration and expiration are equal there is no pause and the

breath sound has a blowing quality. (These are normal sounds in

the mid-chest area or in the posterior chest between scapulae.)

It is found in early cases of consolidation and partial collapse of the

lung. In well-developed consolidation and collapse it is replaced by

bronchial breathing.

* Foreign sounds:-

1. Crepitation :-( crackles or rales):-

These are moist sounds due to sudden opening of the closed

alveoli or due to presence of secretion in the bronchi. Crepitation

heard during whole of inspiration and changing after coughing. It is

 heard in tuberculosis, cavity, lung abscess, consolidation, acute or

chronic bronchitis and bronchopneumonia. Crepitation may be

occasionally heard at the lung bases in healthy person but

disappear after coughing.

2. Rhonchi:-

These are dry musical sounds occurring due to narrowing of

the air passages on account of spasm or mucosal edema. They are

also described by the terms “wheezing” when loud and when they

can be heard by the patient himself and also by others nearby him.

Causes are bronchial asthma, acute or chronic bronchitis.

3. Pleural rub:-

This is a dry, grating sound which occurs to friction between

two layers of inflammed pleura. It may be heard during inspiration

or expiration or during both the phases. It has a coarse character. It

is localized and does not disappear after coughing. There is

associated pain which is aggravated on deep breath, coughing and

sneezing. It is indicative of dry pleurisy which may be due to

tuberculosis, pneumonia, malignancy or pulmonary infarction.

Pleural rub may be palpable & the patient may sometimes himself

report the grating sound.

* Vocal resonance:-

Just as in testing the TVF, the patient is ask to speak “One

Two Three” repeatedly while the examiner with the stethoscope

listens over different corresponding areas on the front, lateral sides

and the back of the chest. If TVF is found to be increased or

decreased the vocal resonance (VR) will also be correspondingly

increased or decreased. Normally VR is somewhat louder on the

right side in the upper part anteriorly due to proximity of the right

main bronchus. Normally, the VR is heard as buzzing, muffled,

slightly unclear, indistinct sounds. (It is increased in consolidation

collapse and cavity. It is decreased in pleural effusion, fibrosis,

thickened pleura, complete collapse, pneumothorax and

emphysema.)