CHEST EXAMINATION – (2) Exams + Lung Workup Supplement
CHEST EXAM (1) TOP
Inspection: The examiner determines the respiratory rate by unobtrusively watching the patient’s chest rise and fall and counting the number of breaths per minute. In adults a normal respiratory rate at rest is about 12 breaths per minute. While counting the respiratory rate, the examiner can observe other breathing characteristics. Dyspneic patients breathe rapidly, often laboring to draw breath even when at rest. Retractions of the intercostal and supraclavicular spaces are visible during inspiration. Sleep apnea is characterized by episodes of stalled breathing followed by periods of respiratory compensation. Regular slow breathing is normal.
Palpation: In health, the chest and lung transmit a vibration, called fremitus, during speech. Fremitus abnormalities may be felt in chronic obstructive lung diseases or obesity, in which the vibration is diminished, and in pneumonia, in which it is increased over the infected lobe.
Percussion: Tapping on the chest wall over healthy lung results in a hollow resonant sound. The hollow character of the resonance sometimes is exaggerated in emphysematous lungs or in pneumothorax, and muffled by pleural effusions or pulmonary consolidation.
Normal breath sounds: In the healthy person, breath sounds are low-pitched and have a frequency of 200 to 400 cycles per second (cps); frequency rarely exceeds 500 cps. These sounds are called vesicular breath sounds when heard over the lungs. They are produced by air passing in and out of the airways.
Bronchial and tracheal breath sounds: These are higher-pitched and louder than vesicular sounds, and are produced by air passing over the walls of the bronchi and trachea. These sounds are normally heard only over the bronchi and trachea.
Amphoric and cavernous breathing: These two nearly identical sounds are loud, with a prolonged, hollow expiration. The pitch of amphoric breathing is slightly higher than that of the cavernous type, and may be imitated by blowing over the mouth of an empty jar. It is heard in bronchiectatic cavities or pneumothorax when the opening to the lung is patulous; in the consolidation area near a large bronchus; and sometimes over a lung compressed by a moderate effusion.
Harsh inspiratory sounds are typical of stridor, a medical emergency. Expirations that are prolonged and musical are characteristic of wheezing.
Friction: This sound is produced by the rubbing together of roughened pleural surfaces. It may be heard in both inspiration and expiration. Friction often resembles crackles, but is more superficial and localized than the latter and is not modified by cough or deep inspiration.
Metallic tinkling: A silvery bell-like sound heard at intervals over a hydropneumothorax or large cavity. Speaking, coughing, and deep breathing usually induce this sound. It must not be confused with a similar sound produced by liquids in the stomach.
Crackles: Abnormal bubbling sounds heard in air cells or bronchi. Succussion-splash or hippocratic succussion: A splashing sound produced by the presence of air and liquid in the chest. It may be elicited by gently shaking the patient during auscultation. This sound nearly always indicates either a hydropneumothorax or a pyopneumothorax, although it has also been detected over very large cavities. The presence of air and liquid in the stomach produces similar sounds.
CHEST EXAM (2) TOP
Chest auscultation is a universally available diagnostic tool that may be underappreciated in these days of “high-tech” medicine. Abnormal breath sounds are marked by an unusual location, loudness, or pitch. Adventitious (adventitial) [add-ven-tish-us or ?ul] lung sounds are discontinuous (crackles) or continuous (wheezes and rhonchi) [ron-keye]. Fine crackles occur as many small bronchioles [bron-key-olls]– collapsed from fibrosis, pneumonia, or congestion–snap open at once. They are higher pitched and less intense than coarse (note the spelling, not course) crackles, which may be audible throughout inspiration. Often occurring in smaller bronchi, wheezes tend to be polyphonic, higher-pitched, and more intense than rhonchi, which have a monophonic snoring or moaning quality.
Adventitial sounds are superimposed on a patient’s underlying breath sounds and usually indicate disease. The exact site of breath sound generation is not known. It appears that vesicular [veh-sick-ule-uhr] breath sounds are produced in the lung periphery. Bronchial and tracheal breath sounds appear to be produced centrally, while the origin of bronchovesicular sounds may be somewhere between the two.
The character and quality of normal breath sounds depend on several factors, including low velocity, distance from the point of sound generation, airway patency, and the condition of the pleurae and chest wall.
Airflow velocity. Forceful exhalation and inhalation increase airflow velocity and cause greater air turbulence, greater amplitude of vibration in the bronchial wall, and a louder breath sound. Conversely, if the patient’s rate or volume of respiration is so low that the air moves very slowly, less turbulence and, therefore, much less amplitude of normal breath sounds is produced. This is true for tracheal and bronchial breath sounds but may be less of a factor with vesicular breath sounds.
One of two cone-shaped spongy organs of respiration contained within the pleural cavity of the thorax.
The lungs are connected with the pharynx through the trachea and larynx. The base of each lung rests on the diaphragm, and each lung apex rises from 2.5 to 5 cm above the sternal end of the first rib, the collarbone, supported by its attachment to the hilum or root structures. The lungs include the lobes, lobules, bronchi, bronchioles, alveoli or air sacs, and pleural covering.
The right lung has three lobes and the left two. In men, the right lung weighs approx. 625 g, the left 570 g. The lungs contain 300,000,000 alveoli and their respiratory surface is about 70 sq m. Respirations per minute are 12 to 20 in an adult. The total capacity of the lung varies from 3.6 to 9.4 L in men and 2.5 to 6.9 L in women.
The left lung has an indentation, called the cardiac depression, for the normal placement of the heart. Behind this is the hilum, through which the blood vessels, lymphatics, and bronchi enter and leave the lung.
Air travels from the nasal passages to the pharynx, larynx, and trachea. Two primary bronchi, one on each side, extend from the trachea. The primary bronchi divide into secondary bronchi, one for each of five lobes. These further divide into a great number of smaller bronchioles. The pattern of distribution of these into the segments of each lobe is important in pulmonary and thoracic surgery. There are about 10 bronchopulmonary segments in the right lung and eight in the left, the actual number varying. There are 50 to 80 terminal bronchioles in each lobe. Each of these divides into two respiratory bronchioles, which in turn divide to form two to 11 alveolar ducts. The alveolar sacs and alveoli arise from these ducts. The spaces between the alveolar sacs and alveoli are called atria. In the alveolus, blood and inspired air are separated only by the cell of the alveolus and that of the pulmonary capillary. This respiratory membrane is thin (0.07 to 2.0 Î¼m) and permits oxygen to diffuse into the blood and carbon dioxide to diffuse from the blood to the air.
NERVE SUPPLY: The lungs are innervated by parasympathetic fibers via the vagus nerve and sympathetic fibers from the anterior and posterior pulmonary plexuses to the smooth muscle in the walls of the bronchial tree.
BLOOD VESSELS: The bronchial arteries and veins circulate blood to the bronchial tree. The pulmonary arteries and veins circulate the blood involved in gas exchange.
FUNCTION: The primary purpose of the lung is to bring air and blood into intimate contact so that oxygen can be added to the blood and carbon dioxide removed from it. This is achieved by two pumping systems, one moving a gas and the other a liquid. The volume of the pulmonary capillary circulation is 150 ml, but this is spread out over a surface area of approx. 750 sq ft (69.68 sq m). This capillary surface area surrounds 300 million air sacs called alveoli.
- atelectasis [aa-til-eck-tuh-sis], atelectatic
- auscultation and percussion
- bronchophony, bronchospasm, bronchovesicular
- chest wall
- consolidation (pulmonary)
- crackles (fine or coarse)
- differential diagnosis
- E:A changes – patient says “e,” sounds as “a” in egophony
- edema, edematous
- egophony (e-gof-un-nee)
- hyperinflation, hyperaeration (or hypo-)
- increased density
- intercostal spaces
- interstitium, interstitial
- lung compression
- mainstem bronchi
- pleura (pleural)
- visceral and parietal pleurae
- inspiratory and expiratory phase (prolonged often heard with these)
- mediastinal crunch
- parenchyma, parenchymal (pair-en-kuh-muh)
- patent or patency
- pectoriloquy (patient says, 1, 3, 4 and sound is muffled)
- pitch (low-pitched, high-pitched)
- pleura, pleural, pleurae, pleural fluid, thickening, effusion
- pneumo-words, pneumonia, pneumonitis, pneumothorax, etc.
- pulmonary fibrosis, consolidation
- rales (sounds like “riles”) (rattles), coarse or fine
- rhonchi (ron-ki)
- tubular quality
- Also see Chest Related: Lung Workup
- Abdominal examination
- Heart examination
- Physical examination
- Pulse (Pulses) Exam/Testing
FOR MORE DEFINITIVE INDIVIDUAL REGIONAL EXAMINATIONS (by specialty or problem)