A respiratory examination, or lung examination, is performed as part of a

physical examination In a physical examination, medical examination, clinical examination, or medical checkup, a medical practitioner examines a patient for any possible medical signs or symptoms of a Disease, medical condition. It generally consists of a series of ...

, in response to respiratory symptoms such as

shortness of breath Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that con ...

cough A cough is a sudden expulsion of air through the large breathing passages which can help clear them of fluids, irritants, foreign particles and Microorganism, microbes. As a protective reflex, coughing can be repetitive with the cough reflex fol ...

, or

chest pain Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with n ...

, and is often carried out with a cardiac examination. The four steps of the respiratory exam are

inspection An inspection is, most generally, an organized examination or formal evaluation exercise. In engineering activities inspection involves the measurements, tests, and gauges applied to certain characteristics in regard to an object or activity. ...

palpation Palpation is the process of using one's hands to check the body, especially while perceiving/diagnosing a disease or illness. Usually performed by a health care practitioner, it is the process of feeling an object in or on the body to determine ...

percussion A percussion instrument is a musical instrument that is sounded by being struck or scraped by a percussion mallet, beater including attached or enclosed beaters or Rattle (percussion beater), rattles struck, scraped or rubbed by hand or ...

, and

auscultation Auscultation (based on the Latin verb ''auscultare'' "to listen") is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory system, circulatory and resp ...

of respiratory sounds, normally first carried out from the back of the

chest The thorax (: thoraces or thoraxes) or chest is a part of the anatomy of mammals and other tetrapod animals located between the neck and the abdomen. In insects, crustaceans, and the extinct trilobites, the thorax is one of the three main di ...

Stages

After positioning in which the patient sits upright with their arms at the side, with the chest clear of clothing, the four stages of the examination can be carried out. In order to listen to the lungs from the back the patient is asked to move their arms forward to prevent the

scapula The scapula (: scapulae or scapulas), also known as the shoulder blade, is the bone that connects the humerus (upper arm bone) with the clavicle (collar bone). Like their connected bones, the scapulae are paired, with each scapula on either side ...

e (shoulder blades) from obstructing the upper lung fields. These fields are intended to correlate with the lung lobes and are thus tested on the anterior (front) and posterior (back) chest walls.

Inspection

The examiner then estimates the patient's respiratory rate by observing how many times the patient breathes in and out within the span of one minute. This is typically conducted under the pretext of some other exam, so that the patient does not subconsciously change their baseline respiratory rate, as they might do if they were aware of the examiner observing their breathing. Adults normally breathe about 14 to 20 times per minute, while infants may breathe up to 44 times per minute. After obtaining the patient's respiratory rate, the examiner looks for any signs of

respiratory distress Shortness of breath (SOB), known as dyspnea (in AmE) or dyspnoea (in BrE), is an uncomfortable feeling of not being able to breathe well enough. The American Thoracic Society defines it as "a subjective experience of breathing discomfort that c ...

, which may include: *

Cyanosis Cyanosis is the change of Tissue (biology), tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Cyanosis is apparent usually in the Tissue (bi ...

, a bluish tinge of the extremities (peripheral cyanosis), or of tongue (central cyanosis) * Pursed-lip breathing * Accessory muscle use, including the scalene and

intercostal muscles The intercostal muscles comprise many different groups of muscles that run between the ribs, and help form and move the chest wall. The intercostal muscles are mainly involved in the mechanical aspect of breathing by helping expand and shrink th ...

* Diaphragmatic breathing, paradoxical movement of the diaphragm outwards during inspiration * Intercostal indrawing * Decreased chest–chest movement on the affected side * An increased

jugular venous pressure The jugular venous pressure (JVP, sometimes referred to as ''jugular venous pulse'') is the indirectly observed pressure over the venous system via visualization of the internal jugular vein. It can be useful in the differentiation of different f ...

, indicating possible right heart failure The anterior and posterior chest wall are also inspected for any abnormalities, which may include: *

Kyphosis Kyphosis () is an abnormally excessive convex curvature of the Spinal column, spine as it occurs in the Thoracic spine, thoracic and sacrum, sacral regions. Abnormal inward concave ''lordotic'' curving of the Cervical spine, cervical and Lumba ...

, abnormal anterior-posterior curvature of the spine *

Scoliosis Scoliosis (: scolioses) is a condition in which a person's Vertebral column, spine has an irregular curve in the coronal plane. The curve is usually S- or C-shaped over three dimensions. In some, the degree of curve is stable, while in others ...

, abnormal lateral curvature of the spine * Barrel chest, bulging out of the chest wall; normal in children; typical of hyperinflation seen in chronic obstructive pulmonary disease (COPD) * Pectus excavatum, sternum sunken into the chest *

Pectus carinatum Pectus carinatum, also called pigeon chest or pidgon breast, is a malformation of the chest characterized by a protrusion of the Human sternum, sternum and ribs. It is distinct from the related malformation pectus excavatum. Pectus carinatum has ...

, sternum protruding from the chest In addition to measuring the patient's respiratory rate, the examiner will observe the patient's breathing pattern: * A patient with metabolic acidosis will often demonstrate a rapid breathing pattern, known as

Kussmaul breathing Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure. It is a form of hyperventilation, which is any breathing pattern that ...

. Rapid breathing helps the patient compensate for the decrease in blood pH by increasing the amount of exhaled carbon dioxide, which helps prevent further acid accumulation in the blood. * Cheyne–Stokes respiration is a breathing pattern consisting of alternating periods of rapid and slow breathing, which may result from a brain stem injury. Cheyne-Stokes respiration may be observed in newborn babies, but this is occasionally physiological (normal). *Chest retractions may be observed in patients with asthma. During a chest retraction, the patient's skin appears to sink into the chest. During supra-sternal retractions, the skin of the neck appears to sink in as the accessory breathing muscles of the neck contract to aid with inspiration. During intercostal retractions, the skin between the ribs appears to sink in as the intercostal muscles (the muscles between the ribs) aid in respiration. These are signs of respiratory distress. The physician then typically inspects the fingers for

cyanosis Cyanosis is the change of Tissue (biology), tissue color to a bluish-purple hue, as a result of decrease in the amount of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Cyanosis is apparent usually in the Tissue (bi ...

and clubbing. Tracheal deviation is also examined.

Palpation

Palpation is the use of physical touch during examination. During palpation, the physician checks for areas of tenderness, abnormalities of the skin, respiratory expansion and fremitus. * To assess areas of tenderness, palpate areas of pain, bruises, or lesions on the front and back of the chest. Bruises may indicate a fractured rib, and tenderness between the ribs may indicate inflamed pleura. * Palpate any abnormal masses or structures on the front and back of the chest. Abnormal masses or sinus tracts may point to infections. * To observe chest wall expansion on the back of the chest, place palms on the patient's back with fingers parallel to the ribs and thumbs at the 10th ribs. Move hands towards each other to raise some skin on either side of the spine. Instruct the patient to inhale and observe the movement of the thumbs on the patient's back. Repeat the process with each hand on the lower margin of the ribcage at the front of the chest to further observe chest expansion. Asymmetry in chest expansion may be due to disease of lung or pleura. * Place the bony parts of the palm around the borders of the patient's scapulae while he or she says "ninety-nine" or "one one one" to test for fremitus. Repeat the sequence on the front of the chest. A decrease in fremitus may be observed if the patient has a soft voice, obstructed bronchus,

COPD Chronic obstructive pulmonary disease (COPD) is a type of progressive lung disease characterized by chronic respiratory symptoms and airflow limitation. GOLD defines COPD as a heterogeneous lung condition characterized by chronic respiratory s ...

pneumothorax A pneumothorax is collection of air in the pleural space between the lung and the chest wall. Symptoms typically include sudden onset of sharp, one-sided chest pain and dyspnea, shortness of breath. In a minority of cases, a one-way valve is ...

, or other disease or injuries that may obstruct the vibrations of the larynx.

Chest percussion

Percussion A percussion instrument is a musical instrument that is sounded by being struck or scraped by a percussion mallet, beater including attached or enclosed beaters or Rattle (percussion beater), rattles struck, scraped or rubbed by hand or ...

is the act of tapping on the surface of the body in order to assess the structures that lie beneath the skin. Percussion and resonance (the quality and feeling of sound) are used to examine lung movement and possible lung conditions. Specifically, percussion is performed by first placing the middle finger of one hand over the area of interest. The middle finger of the other hand is used to strike the last joint of the placed finger. Percussion is performed in a systematic matter, from the upper chest to the lower ribs, and resonance is compared between the left and right sides of the chest. This is done from the front and back of the thorax. Percussion over different body tissues results in five common "notes". # Resonance: Loud and low pitched. Normal lung sound. # Dullness: Medium intensity and pitch. Experienced with fluid. #*A dull, muffled sound may replace resonance in conditions like

pneumonia Pneumonia is an Inflammation, inflammatory condition of the lung primarily affecting the small air sacs known as Pulmonary alveolus, alveoli. Symptoms typically include some combination of Cough#Classification, productive or dry cough, ches ...

hemothorax A hemothorax (derived from hemo- lood+ thorax hest plural ''hemothoraces'') is an accumulation of blood within the pleural cavity. The symptoms of a hemothorax may include chest pain and difficulty breathing, while the clinical signs may inc ...

. # Hyper-resonance: Very loud, very low pitch, and longer in duration. Abnormal. #*Hyper-resonance can result from asthma or

emphysema Emphysema is any air-filled enlargement in the body's tissues. Most commonly emphysema refers to the permanent enlargement of air spaces (alveoli) in the lungs, and is also known as pulmonary emphysema. Emphysema is a lower respiratory tract di ...

# Tympany: Loud and high pitched. Common for percussion over gas-filled spaces. #*Tympany may result in

. # Flatness: Soft and high pitched.

Auscultation

The areas of the lungs that can be listened to using a

stethoscope The stethoscope is a medicine, medical device for auscultation, or listening to internal sounds of an animal or human body. It typically has a small disc-shaped resonator that is placed against the skin, with either one or two tubes connected t ...

are called the lung fields, and these are the posterior, lateral, and anterior lung fields. The posterior fields can be listened to from the back and include: the lower lobes (taking up three quarters of the posterior fields); the anterior fields taking up the other quarter; and the lateral fields under the

axilla The axilla (: axillae or axillas; also known as the armpit, underarm or oxter) is the area on the human body directly under the shoulder joint. It includes the axillary space, an anatomical space within the shoulder girdle between the arm a ...

e, the left axilla for the lingual, the right axilla for the middle right lobe. The anterior fields can also be auscultated from the front. An area of thinner musculature on the back where sounds may be more audible is called the

triangle of auscultation The triangle of auscultation is a relative thinning of the musculature of the back, situated along the medial border of the scapula which allows for improved listening to the lungs. Boundaries It has the following boundaries: * medially, by the ...

. During auscultation, deep breaths are taken through the mouth and abnormal sounds listened for. Abnormal sounds include: * Wheezes, describing a continuous musical sound on expiration or inspiration. A wheeze is the result of narrowed airways. Common causes include

asthma Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wh ...

and

. * Rhonchi (an increasingly obsolete term) characterised by low pitched, musical bubbly sounds heard on inspiration and expiration. Rhonchi are the result of viscous fluid in the airways. *

Crackles Crackles are the clicking, rattling, or crackling noises that may be made by one or both lungs of a human or animal with a respiratory disease during inhalation, and occasionally during exhalation. They are usually heard only with a stethosco ...

or rales. Intermittent, non-musical and brief sounds heard during inspiration only. They may be described as ''fine'' (soft, high-pitched) or ''coarse'' (louder, low-pitched). These are the result of alveoli opening due to increased air pressure during inspiration. Common causes include

congestive heart failure Heart failure (HF), also known as congestive heart failure (CHF), is a syndrome caused by an impairment in the heart's ability to fill with and pump blood. Although symptoms vary based on which side of the heart is affected, HF typically pr ...

. *

Stridor Stridor () is an extra-thoracic high-pitched breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree. It is different from a stertor, which is a noise originating in the pharynx. Stridor is a physical sig ...

a high-pitched musical breath sound resulting from

turbulent In fluid dynamics, turbulence or turbulent flow is fluid motion characterized by chaotic changes in pressure and flow velocity. It is in contrast to laminar flow, which occurs when a fluid flows in parallel layers with no disruption between ...

air flow in the larynx or lower in the bronchial tree. It is not to be confused with stertor. Causes are typically obstructive, including foreign bodies,

croup Croup ( ), also known as croupy cough, is a type of respiratory infection that is usually caused by a virus. The infection leads to swelling inside the trachea, which interferes with normal breathing and produces the classic symptoms of "bar ...

, epiglottitis, tumours, infection and

anaphylaxis Anaphylaxis (Greek: 'up' + 'guarding') is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of the use of emergency medication on site. It typicall ...

. * Appropriate ratio of inspiration to expiration time (expiration time increased in COPD) *

Bronchial A bronchus ( ; : bronchi, ) is a passage or airway in the lower respiratory tract that conducts Atmosphere of Earth, air into the lungs. The first or primary bronchi to branch from the trachea at the Carina of trachea, carina are the right main b ...

or vesicular breath sounds. Lastly an assessment of transmitted voice sounds is performed. * Egophony * Bronchophony * Whispered pectoriloquy

References

External links

Lung sounds
- 3M - Littmann Stethoscopes {{Respiratory system symptoms and signs Respiratory system procedures Physical examination Medical mnemonics