Thorax and Lung Examination Techniques: Comprehensive Guide by Dr. Szathmári Miklós, Study notes of Medicine

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Techniques of examination

of the thorax and lungs

Dr. Szathmári Miklós

Semmelweis University

First Department of Medicine

22. Sept. 2015.

Inspection of the thorax

• Observe:
  • the shape of chest
    • Deformities
  • the respiratory movement
• Importance:
  • The deformities influence
    • The percussion sounds
    • The breathing and the circulation
    • The diagnostic importance of asymetry
  • The decrease of the respiratory movement is the most

important sign of the disease of chest/lung

Dorsal kyphosis and barrel chest

Inspection of the thorax

• Abnormal retraction of the interspaces during inspiration (severe asthma, COPD or upper airway obstraction).
• Inspection of movement of chest wall during inspiration (unilateral impairment or delay of respiratory movement suggests disease of the underlying lung or pleura.

Palpation of the chest 2.

Tactile fremitus – refers to

the palpable vibrations transmitted through the bronchopulmonary system to the chest wall when the patiens speaks

• Palpate and compare symmetrical areas of the lungs
• Use the ulnar surface of your hand. Ask the patient to repeat ninety-nine or „harminchárom”.
• If fremitus is faint, ask the patient to speak more loudly or in a deeper voice.

Pleural rub

• Normal pleural surfaces move smoothly and noiselessly against each other during respiration
• When pleural surfaces become inflamed, they move jerkily as they are repetedly delayed by increased friction.
• The sounds may be discrete, but sometimes are so numerous that they merge into an apparently continuous sound. It is localized to a relatively small area of the chest wall

Palpation of the thorax

• intercostal tenderness :over inflammed pleura. Bruises over a fractured rib.
• chest expansion: decreased expansion in case of pleural effusion, lobar pneumonia, chronic fibrotic disease of the underlying lung
• tactile fremitus : Decreased pectoral fremitus is in case of pleural effusion or pleural thickening or PTX.

Percussion of the thorax

• While the patient keeps both arms crossed in front of chest, percuss the thorax in symmetrical locations from the apices to the lung bases
• Dullness: when fluid or solid tissue replaces air-containing lung (pneumonia) or occupies the pleural space (effusion, fibrous tissue, tumor)
• Generalized hyperresonance: emphysema, asthma.
• Unilateral hyperresonance (or tympanic sound): pneumothorax

Identify the level of the diaphragma

• Percuss in steps downward until dullness clearly replaces resonance.
• Movement of diaphragma: the distance between the levels of dullness on full expiration and on full inspiration (normally 5-6 cm)

Abnormal positions of diaphragma

• Bilaterally deeper position:
  • Emphysema, asthma,
  • Decreased intraabdominal pressure
• Unilaterally deeper position:
  • pneumothorax
• Bilaterally higher position:
  • Increased intraabdominal pressure
  • Pleural effusion on both side
• Unilaterally higher position:
  • Diaphragmatic paralysis
  • Unilateral pleural effusion
  • Intrabadominal abnormality (subphrenic abscess, splenomegaly)

Abnormal breathing sounds

1. Louder vesicular breathing : during childhood,

forced breathing

2. Faint alveolar breathing :

• Emphysema,
• Pleural thickening, pleural effusion,
• Pneumothorax
• Atelectasis (absortion of the air from the alveoli

because of a plug in a mainstream bronchus)

3. Bronchial breathing replaces the normal

vesicular sounds when lung tissue loses its air :

• Pneumonia (the alveoli fill with fluid)