Lung

Physical Examination
 The 4 major components of the lung exam:
 Inspection
 Palpation
 Percussion
 Auscultation
 Learning the appropriate techniques at this
juncture will therefore enhance your ability
to perform these other examinations as
well.
 The aim lung exam :
To know there is structural abnormality
or not in lung , doesn’t to diagnose

 Basic principal lung exam :

 There was ‘air’ in the lung
 There was airflow
 There was airway patentcy
 There was block
Inspection
 General appearance
 Body mass (normal, obese, thin or
cachetic/ emaciated/undernourished)
 Skin color (nail beds, lips, mucus
membranes)
 pink ; ashen, gray, dusky ; blue
 Extremity  Clubbing of the digits

 Oedema
 Osteoartropathy hipertrophy
 Neck vein distension
Cyanosis of nail beds
Clubbing of the digits
Inspection
A great deal of information can be gathered from simply
watching a patient breathe. Pay particular attention to:
1. General comfort and breathing pattern of the patient. Do
they appear distressed, diaphoretic, labored? Are the
breaths regular and deep?
2. Use of accessory muscles of breathing (e.g. scalenes,
sternocleidomastoids). Their use signifies some element
of respiratory difficulty.
3. Color of the patient, in particular around the lips and nail
beds. Obviously, blue is bad!
4. The position of the patient. Those with extreme
pulmonary dysfunction will often sit up-right. In cases of
real distress, they will lean forward, resting their hands
on their knees in what is known as the tri-pod position.
5. Breathing through pursed lips, often seen in cases of
emphysema.
6. Ability to speak. At times, respiratory rates can be so
high and/or work of breathing so great that patients are
unable to speak in complete sentences. If this occurs,
note how many words they can speak (i.e. the fewer
words per breath, the worse the problem!).
7. Any audible noises associated with breathing as
occasionally, wheezing or the gurgling caused by
secretions in large airways are audible to the "naked"
ear.
Chest inspection
 Inspection on static and dynamic
 Static
 Symetrically
 Abnormality on chest surface
 Inter Costae Space (ICS)
 Thoracic landmarks & lung structures
 Chest configuration
Thoracic landmarks

 Thoracic landmarks used to locate and

visualize the underlying structures,
particularly the lobes of the lungs and
the heart
 To description abnormality that found in
physical examination
Thoracic lung structure

 Review of Lung Anatomy

Understanding the pulmonary exam is greatly
enhanced by recognizing the relationships
between surface structures, the skeleton, and the
main lobes of the lung. Realize that this can be
difficult as some surface landmarks (eg nipples of
the breast) do not always maintain their precise
relationship to underlying structures.
Nevertheless, surface markers will give you a
rough guide to what lies beneath the skin
Anterior
View
Posterior
View
Right
Lateral
View
Left
Lateral
View
 Chest configuration
 Normal
 Barrel chest
 Pectus excavatum (funnel chest)
 Pectus carinatum (pidgeon chest)
 Scoliosis
 Kyphosis
 Kyphoscoliosis
 Lordosis
 Pectus excavatum
Congenital posterior displacement of lower
aspect of sternum. This gives the chest a
somewhat "hollowed-out" appearance. The x-
ray shows a subtle concave appearance of the
lower sternum.
 Barrel chest
Associated with emphysema and lung
hyperinflation. Accompanying xray also
demonstrates increased anterior-posterior
diameter as well as diaphragmatic flattening.
Barrel chest
Chest
 Dynamic (chest movement)
 Respiratory rate ( N: 12-18/min)
 Respiratory type ( abdominal/thoracal)
 Rytme (breathing pattern)
 Deep of breathing
 Symetrically
Respiratory rate
 Measure
 rate, rhythm, depth @ rest
 visual, palpation, auscultation
 Premature infant 40-90/min
 Newborn (term) 30-50
 Child (2-12yrs) 20-30
 Adult 12-20
Respiratory rate
 Terminology
 Eupnea: normal rate
 Bradypnea: <12 breaths/min
 Tachypnea: >20 breaths/min
 Hypopnea: shallow, small tidal volumes (TV)
 Hyperpnea: deep, large TV’s
 Dyspnea: subjective feeling of shortness of
breath (SOB)
 Chest movement
 normal
 active diaphragm, no accessory muscle use at
rest
 I:E ratio or 1:2 or 1:3

 equal, bilateral chest expansion

 abnormal
 accessory muscle use
 I:E ratio > 1:2, e.g., 1:6 or longer “E” to “I”

 long expiratory phase

 distended jugular veins

 increased A-P diameter, barrel chest

 The direction of abdominal wall movement
during inspiration.
 Normally, the descent of the diaphragm
pushes intra-abdominal contents down and the
wall outward. In cases of severe diaphragmatic
flattening (e.g. emphysema) or paralysis, the
abdominal wall may move inward during
inspiration, referred to as paradoxical
breathing. If you suspect this to be the case,
place your hand on the patient's abdomen as
they breathe, which should accentuate its
movement.
 Breathing patterns
 abnormal
 apnea
 Cheyne-Stokes

 ↑ ICP, CHF, renal failure, meningitis, drug overdose

 Biot’s
 spinal meningitis, CNS conditions
 Kussmaul
 metabolic acidosis, esp. diabetic ketoacidosis
 Apneustic
 lesion in respiratory center
Inspection
 Cough
 evaluate quality, character, and frequency
 quality and character of the cough
 effective or strong
 capable of clearing airways
 ineffective or weak
 pain, poor motivation
 other descriptors
 hoarse, brassy, barking, hacking
Inspection
 frequency of cough
 acute: sudden onset, usually short course
 chronic: daily, ongoing, long course

 paroxysmal: sudden, periodic, prolonged episodes

 Sputum
 normal health adult
 abnormal sputum characteristic/color
 mucopurulent (light to medium yellow)
 purulent (dark yellow to green)

 hemoptysis (red)

 frothy (clear, white, pink)

 tenacious (thick)

 sputum consistency
 sputum production
Palpation
 Trachea position
Is there on normal position or there is deviation?
 Lymph node enlargment
 neck, supraclavicula and axilar
 Chest movement
Placement of palms on the lateral aspect of the
chest wall to evaluate movement and uniform
expansion
 Lymph node enlargment

Trachea position
 Feel for presence of :
 Tactile or vocal fremitus (palpable rhonchi)
 Subcutaneous emphysema (crepitation)
 Investigating painful areas
 Tenderness
 Pedal edema
 Skin temperature of extremities
 warm (normal)
 hot (fever)
 cold or clammy (hypothermia or
hypoperfusion)
 Tactile Fremitus
Normal lung transmits a palpable vibratory
sensation to the chest wall. This is referred to
as fremitus and can be detected by placing the
ulnar aspects of both hands firmly against
either side of the chest while the patient says
the words "Ninety-Nine.“ ( Indonesia : 77)
 This maneuver is repeated until the entire
posterior thorax is covered. The bony aspects
of the hands are used as they are particularly
sensitive for detecting these vibrations.
Pathologic conditions will alter fremitus. In particular:

 Lung consolidation: Consolidation occurs when the

normally air filled lung parenchyma becomes engorged
with fluid or tissue, most commonly in the setting of
pneumonia. If a large enough segment of parenchyma
is involved, it can alter the transmission of air and
sound. In the presence of consolidation, fremitus
becomes more pronounced.
 Pleural fluid: Fluid, known as a pleural effusion, can
collect in the potential space that exists between the
lung and the chest wall, displacing the lung upwards.
Fremitus over an effusion will be decreased.
 Increased fremitus
1. Big cavities
2. Diffuse infiltrat

 Decreased fremitus
1. Emphysema
2. Pneumothorax
3. Hydrothorax
4. Atelectatic
5. Obstruction
Percussion
 Purpose: to assess sound intensity and
pitch or resonance
 Tapping the surface of the chest
 mediate: tapping one finger upon another that
is located on the chest
 immediate: tapping directly on the chest with
one finger
Percussion
 resonance (dull or flat sound)
consolidation (lobar pneumonia or tumors)

fluid filled (pulmonary edema)

pleural effusion (fluid between parietal and

visceral layers)
atelectasis (deflated lung units)

obese (too much tissue, ↓ lung volumes)

hemothorax (blood in chest cavity)

Percussion
  resonance or hyperresonant
 hyperinflated lungs (emphysema)
 pneumothorax
 Diaphragmatic excursion
 diaphragm normally moves about 3-4 cm
and less in COPD and neuromuscular
diseases
Auscultation
Auscultation
Normal lung sounds:
 Tracheobronchial or bronchial
 Loud, coarse, tubular
 High pitch, there is “ gap”
 Tubulent gas flow
 Normal at over upper trachea or over manubrium
 Abnormal in perifer if there is consolidation (infiltrat in alveoli)
 Inspiration < or = expiration)
 Bronchovesicular
 softer, less coarse
 intermediate airways

 Medium pitch

 Normal sound over carina area and between

upper scapulae
 Abnormal in perifer if there is consolidation

 Inspiration = expiration (1:1)

 Vesicular
 softest, smooth
 Low pitch

 Inspiration > expiration ( 3:1)

 laminar gas flow

 largest surface area

 Normal sound over most of lung

Adventitious lung sounds
 Crackles or rales
 short, intermittent sounds
 air passing through fluid in the small airways air
suddenly opening up ateletatic lung units
decreased
 reduced transmission and intensity of sounds
when compared to normal sounds in the same
area
 e.g., hyperinflated lungs, pleural effusion, obese
Crackles

Fine crackles

Coarse crackles
Absent
 no lung sounds noticeable
 e.g., pneumothorax, pneumonia

Wheezing
 high pitched, continous sound
 heard normally on exhalation
 associated with narrowed airways
 bronchospasm, bronchoconstriction,
mucosal edema, foreign body obstr
Rhonchus

 low pitched, continuous sound

 associated with excessive secretions in
the airways which narrows the lumen of
large airways
 tends to clear with coughing
Stridor

 hoarse sound heard on inspiration

 common post extubation because of
tracheal swelling and edema causing
narrowing of the upper airway
 treated with racemic epinephrine, its
alpha effects reduce mucosal swelling
Bronchial

 tubular or tracheal sounds which are transmitted

from the trachea through consolidation at the
bases
 sounds transmit better through solid than air
 egophony: “E” to “A”
 whispered pectoriloquy: “99”
 bronchophony: patient’s words are heard clear
through consolidation, but muffled in normal lungs
Pleural friction rub

 creaky or grating sounds as the patient

breathes in and out similar to old leather
when it is bent to and fro
 related to inflamed or irritated pleural
surface
 pleurisy from pneumonia is common
References
1. Mangunnegoro H. Pemeriksaan Jasmani Paru
2. Luckman, Sorensen’s. Assesment of respiratory disorders.
In:Medical-Surgical Nursing. A Psychophysiologic
approach. Manila; C&E Publishing CO; 2000.p.913-40
3. UCSD School of Medicine and VA Medical Center, San
Diego, California. A Practical Guide to Clinical Medicine.
The Lung Exam. Available at :
http://medicine.ucsd.edu/clinicalmed/lung.htm . Accessed
January 10th , 2006.
4. Murray JF. History and physical examination. In: Murray-
Nadel. Textbook of respiratory medicine.3 rd ed.
Philadelphia; WB. Saunders Company:2000.p.585-605
Thanks you