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

physical examination In a physical examination, medical examination, or clinical examination, a medical practitioner examines a patient for any possible medical signs or symptoms of a medical condition. It generally consists of a series of questions about the patien ...

, in response to respiratory symptoms such as

shortness of breath Shortness of breath (SOB), also medically 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 disc ...

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

, 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 In medicine, the cardiac examination, also precordial exam, is performed as part of a physical examination, or when a patient presents with chest pain suggestive of a cardiovascular pathology. It would typically be modified depending on the ind ...

. 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 beater including attached or enclosed beaters or rattles struck, scraped or rubbed by hand or struck against another similar instrument. Exc ...

, 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 and respiratory systems (hea ...

respiratory sounds Respiratory sounds, also known as lung sounds or breath sounds, refer to the specific sounds generated by the movement of air through the respiratory system. These may be easily audible or identified through auscultation of the respiratory system ...

, normally first carried out from the back of the

chest The thorax or chest is a part of the anatomy of humans, 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 divisions of the crea ...

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 (plural 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 eithe ...

e (shoulder blades) from obstructing the upper lung fields. These fields are intended to correlate with the

lung lobes The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...

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), also medically 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 disc ...

, which may include: *

Cyanosis Cyanosis is the change of body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Body tissues that show cyanosis are usually in locations ...

, a bluish tinge of the extremities (peripheral cyanosis), or of tongue (central cyanosis) *

Pursed-lip breathing Pursed-lip breathing (PLB) is a breathing technique that consists of exhaling through tightly pressed (pursed) lips and inhaling through the nose with the mouth closed. Uses Pursed-lip breathing can help to ease shortness of breath in people w ...

* Accessory muscle use, including the scalene and

intercostal muscles Intercostal muscles are 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 the size ...

* 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 for ...

, 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 spine as it occurs in the thoracic and sacral regions. Abnormal inward concave ''lordotic'' curving of the cervical and lumbar regions of the spine is called lordosis. It can result fr ...

, abnormal anterior-posterior curvature of the spine *

Scoliosis Scoliosis is a condition in which a person's spine has a sideways curve. The curve is usually "S"- or "C"-shaped over three dimensions. In some, the degree of curve is stable, while in others, it increases over time. Mild scoliosis does not t ...

, abnormal lateral curvature of the spine *

Barrel chest Barrel chest generally refers to a broad, deep chest found on a patient. A barrel chested person will usually have a naturally large ribcage, very round (i.e., vertically cylindrical) torso, large lung capacity, and can potentially have great u ...

, bulging out of the chest wall; normal in children; typical of hyperinflation seen in chronic obstructive pulmonary disease (COPD) *

Pectus excavatum Pectus excavatum is a structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally. This produces a caved-in or sunken appearance of the chest. It can either be present at birth or develop after pubert ...

, sternum sunken into the chest *

Pectus carinatum Pectus carinatum, also called pigeon chest, is a malformation of the chest characterized by a protrusion of the sternum and ribs. It is distinct from the related malformation pectus excavatum. Signs and symptoms People with pectus carinatum usua ...

, 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 red ...

. 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 Cheyne–Stokes respiration is an abnormal pattern of breathing characterized by progressively deeper, and sometimes faster, breathing followed by a gradual decrease that results in a temporary stop in breathing called an apnea. The pattern repe ...

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 body tissue color to a bluish-purple hue as a result of having decreased amounts of oxygen bound to the hemoglobin in the red blood cells of the capillary bed. Body tissues that show cyanosis are usually in locations ...

and clubbing.

Tracheal The trachea, also known as the windpipe, is a cartilaginous tube that connects the larynx to the bronchi of the lungs, allowing the passage of air, and so is present in almost all air-breathing animals with lungs. The trachea extends from the la ...

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 Fremitus is a vibration transmitted through the body. In common medical usage, it usually refers to assessment of the lungs by either the vibration intensity felt on the chest wall (''tactile fremitus'') and/or heard by a stethoscope on the chest ...

. * 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 long-term respiratory symptoms and airflow limitation. The main symptoms include shortness of breath and a cough, which may or may not produce mu ...

pneumothorax A pneumothorax is an abnormal 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 shortness of breath. In a minority of cases, a one-way valve ...

, 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 beater including attached or enclosed beaters or rattles struck, scraped or rubbed by hand or struck against another similar instrument. Exc ...

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 inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...

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 incl ...

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

emphysema Emphysema, or pulmonary emphysema, is a lower respiratory tract disease, characterised by air-filled spaces ( pneumatoses) in the lungs, that can vary in size and may be very large. The spaces are caused by the breakdown of the walls of the alve ...

# 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 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, and one or two tubes connected to two earpieces. ...

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 (also, 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 and the thoracic cage, bounded superior ...

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 Muscle, musculature of the Human back, back, situated along the medial border of the scapula which allows for improved auscultation, listening to the lungs. Boundaries It has the followi ...

. 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 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 wheezing, cou ...

and

. *

Rhonchi Respiratory sounds, also known as lung sounds or breath sounds, refer to the specific sounds generated by the movement of air through the respiratory system. These may be easily audible or identified through auscultation of the respiratory system ...

(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 with a respiratory disease during inhalation. They are usually heard only with a stethoscope ("on auscultation"). Pulmonary crackles a ...

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 Alveolus (; pl. alveoli, adj. alveolar) is a general anatomical term for a concave cavity or pit. Uses in anatomy and zoology * Pulmonary alveolus, an air sac in the lungs ** Alveolar cell or pneumocyte ** Alveolar duct ** Alveolar macrophage * ...

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, a group of signs and symptoms caused by an impairment of the heart's blood pumping function. Symptoms typically include shortness of breath, excessive fatigue, a ...

. *

Stridor Stridor (Latin for "creaking or grating noise") is a high-pitched extra-thoracic 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 pha ...

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 a laminar flow, which occurs when a fluid flows in parallel layers, with no disruption between t ...

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 laryngotracheobronchitis, 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 o ...

epiglottitis Epiglottitis is the inflammation of the epiglottis—the flap at the base of the tongue that prevents food entering the trachea (windpipe). Symptoms are usually rapid in onset and include trouble swallowing which can result in drooling, changes t ...

, tumours, infection and

anaphylaxis Anaphylaxis is a serious, potentially fatal allergic reaction and medical emergency that is rapid in onset and requires immediate medical attention regardless of use of emergency medication on site. It typically causes more than one of the follow ...

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

Bronchial A bronchus is a passage or airway in the lower respiratory tract that conducts air into the lungs. The first or primary bronchi pronounced (BRAN-KAI) to branch from the trachea at the carina are the right main bronchus and the left main bronchus. ...

or vesicular breath sounds. Lastly an assessment of transmitted voice sounds is performed. *

Egophony Egophony (British English, aegophony) is an increased resonance of voice sounds heard when auscultating the lungs, often caused by lung consolidation and fibrosis. It is due to enhanced transmission of high-frequency sound across fluid, such as in ...

Bronchophony Bronchophony is the abnormal transmission of sounds from the lungs or bronchi. Bronchophony is a type of pectoriloquy. It is a general medical sign detected by auscultation. Technique The patient is requested to repeat a word several times while ...

Whispered pectoriloquy Whispered pectoriloquy refers to an increased loudness of whispering noted during auscultation with a stethoscope on the lung fields on a patient's torso. Usually spoken sounds of a whispered volume by the patient would not be heard by the clini ...

References

External links

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