Pulmonary Examination

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.
Inspection
The following should be assessed:

Breathing pattern

Normal respiratory rates = 12–20/min in adults

Bradypnea
Respiratory rate < 12/min in adults

Tachypnea
Respiratory rate > 20/min, shallow breathing in adults

Hyperpnea: respiratory rate > 20/min, deep breathing

Peripheral signs of respiratory dysfunction

Nail clubbing: physical finding characterized by painless swelling of the distal phalanges,
typically associated with chronic hypoxemia

.
Sputum production or secretions:
 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
Palpation
 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 “99” 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
Percussion
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
Auscultation
For auscultation use diaphragm of your stethoscope. Warm it up with your palm. Ask the patient to cough once
or twice to clear airway mucus that can produce unimportant extra sounds. Instruct the patient to breathe
deeply through an open mouth. Auscultate for at least one full breath in each location.
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
Pathological breath 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)
 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