LUNG AND RS

EXAM
 Techniques

• Inspection

• Palpation

• Percussion

• Auscultation
 Inspection
• General comfort and breathing pattern.
– Do they appear distressed, labored?
– Are the breaths regular or irregular, shallow or
deep?

• Use of accessory muscles of breathing

– e.g. Abdominal muscles,
– sternocleidomastoids.
• Cyanosis (bluish colour)
– usually visible on the lips and nail beds
– indicative of oxygen deprivation.

• Abnormal breathing sounds audible to the

naked ear e.g wheezing.
Cyanosis
• Inability to speak in complete sentences due
to fast breathing or increased work of
breathing.

• Direction of abdominal wall movement during

inspiration.
– Normally, the descent of the diaphragm pushes
intra-abdominal contents down and the wall
outward.
• Any obvious chest or spine deformities.
– May be due to chronic lung disease
• E.g. emphysema
– or can be congenital.
Chest or Spine deformities
 Pectus excavatum
• Congenital posterior displacement of lower
aspect of sternum.

• X-ray: Concave appearance of the lower

sternum.
Pectus excavatum
 Barrel chest

• Increased anterior-posterior diameter as well

as diaphragmatic flattening.

• Associated with
– Emphysema
– lung hyperinflation.
Barrel chest
 Spine abnormalities
Kyphosis

• Causes the patient to be bent forward.

• Increased curvature of the spine.

Kyphosis
 Scoliosis

• Spine is curved to either the left or right.

• One shoulder may appear higher than the

other.
Scoliosis
 Palpation
• Plays a minor role as the lung is covered by
the ribs and therefore not palpable.
 Percussion
• Percussion over air-filled structure (e.g.
normal lung) will produce a resonant note

• Fluid or tissue filled cavity generates a dull

sound.
• If the normal, air-filled tissue has been
displaced by fluid (e.g. pleural effusion) or
infiltrated with white cells and bacteria (e.g.
pneumonia), percussion will generate a dull
tone.
• Processes that lead to chronic air trapping in
the lungs(e.g. emphysema) or acute air
trapping in pleural space (e.g. pneumothorax)
will produce hyper-resonant (i.e. more drum-
like) note on percussion.
 Percussion Technique
• If you're percussing with your right hand,
stand a bit to the left side of patient's back.

• Ask patient to cross their hands in front of

their chest, grasping the opposite shoulder
with each hand.
– Helps pull the scapulae laterally, away from the
percussion field.
• Work down the "alley" between the scapula
and vertebral column, to avoid percussing
over bone.

• Keep striking the distal inter-phalangeal joint

(i.e. the last joint) of your left middle finger
with the tip of the right middle finger.
Percussion
technique
• The left middle finger should rest firmly on
the patient's back.

• Keep the remainder of your fingers from

touching the patient in order to minimize
dampening of the percussion notes.
• When percussing any one spot, 2 or 3 sharp
taps should be made, more taps may be done.

• Then move your hand down several inter-

spaces and repeat the maneuver.

• Percussion in about 5 locations should cover

one hemi-thorax.
• Repeat the same on the right side of the
thorax.

• If you detect any abnormality on one side,

slide your hands across to the other for
comparison.

• Generally, percussion is limited to the

posterior lung fields.
• If auscultation reveals an abnormality in the
anterior or lateral fields, percussion over
these areas can help identify its cause.
Percussion Technique
 Auscultation
• Lower lobes occupy the bottom 3/4 of the
posterior fields

• Right middle lobe heard in right axilla

• Upper lobes in the anterior chest and at the top

1/4 of the posterior fields.

• Put on your stethoscope so that the ear pieces

are directed away from you.
• Gently rub the head of the stethoscope on
your shirt to warm it.

• The upper aspect of the posterior fields (i.e.

towards the top of the patient's back) are
examined first.
• Listen over one spot and then move the
stethoscope to the same position on the
opposite side for comparison.

• The entire posterior chest can be covered by

listening in roughly 4 places on each side.

• If you hear something abnormal, listen in

more places.
• The right middle lobe can be examined while
you are still standing behind the patient.

• Then, move around to the front and listen to

the anterior fields in the same fashion.

• This is generally done while the patient is still

sitting upright.
• Asking female patients to lie down allows
their breasts to fall away laterally to allow
easy access to the chest.

• Ask patient to take slow, deep breaths

through their mouths while examining.
– Forces patient to move greater volumes of air
hence increasing detectability of abnormal breath
sounds.
• Have patient cough a few times prior to
beginning auscultation.
– Clears airway secretions and opens small
atelectatic (i.e. collapsed) areas at the lung bases.

• If patient cannot sit up auscultation can be

performed while lying on their side or in
supine position.
• Requesting patient to exhale forcibly will help
to accentuate abnormal breath sounds.
Keys to performing a sensitive yet thorough exam

• Area to be examined must be exposed - yet

patient kept as covered as possible.

• The need to Palpate sensitive areas in order to

perform accurate exam - requires touching
people w/whom you've little acquaintance -
awkward, particularly if opposite gender.
• Explain what you're doing & why before doing
it.

• Only expose the areas you are examining at a

particular time - requires use of gown & drapes.

• Ask permission to remove bra prior (you can't

hear the heart well through fabric).
• Expose the chest only to the extent needed.
For lung exam, listen to the anterior fields by
exposing only the top part of the breasts .

• Enlist patient's assistance, asking them to

raise their breast to a position that enhances
your ability to listen to the heart.

• Don't rush.
Remember - Don't examine through clothing or
"sneak" stethoscope down shirts/gowns
Good exam options
 Normal breath sounds
Vesicular breath sounds
• A healthy individual breathing at normal tidal
volumes produces a soft inspiratory sound as
air rushes into the lungs, with little noise
produced on expiration.
– Vessicular breath sounds.
 Abnormal breath sounds
Wheezes
• Whistling-type noises produced during
expiration (and sometimes inspiration)

• Is due to air being forced through airways

narrowed by bronchoconstriction, secretions,
and/or associated mucosal edema.

• Occurs in processes that affect all lobes (e.g.

asthma ; emphysema) hence audible in all
fields.
• In cases of significant bronchoconstriction, the
expiration is prolonged.

• Normal is approximatley 1:2 (i.e. expiration

twice as long as inspiration) .
 Rales ( crackles)
• Scratchy sounds that occur when fluid
accumulates within the alveolar and
interstitial spaces.

• Sound similar to that produced by rubbing

strands of hair together close to your ear.

• Pulmonary edema and pneumonia are

common causes
 Rhonchi
• Caused by secretions that collect in larger
airways, e.g. Bronchitis.

• A gurgling-type noise, similar to the sound

produced when you suck the last bits of a milk
shake through a straw.
Thank you