Inspection: Common abnormal findings

Asymmetric chest expansion occurs when localized lung disease causes one side of the chest to move less than the other.  It is seen in most patients with large pleural effusions and in a minority of patients with pneumonia.

Nasal flaring is a common sign of respiratory distress in children.  During inspiration, the nostrils flare out to augment air flow.

Accessory muscle use is a finding of COPD or other causes of respiratory muscle fatigue and is defined as respiratory contraction of muscles other than the diaphragm.  The sternocleidomastoids and scalenes can raise the clavicles to expand the chest and assist the diaphragm with inspiration.

Intercostal retractions are a finding of obstructive lung disease.  Increased airway resistance causes slow filling of the lungs, so the negative pleural pressure generated in inspiration pulls the intercostal muscles inward.

Paradoxical movement of the abdomen is a sign of diaphragmatic weakness or fatigue.  It is defined as inward movement of the abdominal muscles during inspiration.  Normally, the abdomen moves outward during inspiration as the diaphragm contracts and descends.  If the diaphragm is weak, it is pulled into the chest in inspiration and pulls the abdomen in with it.

Percussion: Common abnormal findings

Dullness to percussion indicates that normal lung tissue has been filled with or displaced by fluid or solid tissue. It is most commonly caused by pleural effusion (fluid surrounding the lung) but can also be caused by pneumonia or a mass (fluid or tissue within the lung parenchyma).

Hyperresonance to percussion indicates that normal lung tissue has been replaced by air. Bilateral hyperresonance suggests obstructive lung disease.  Unilateral hyperresonance suggests pneumothorax or a large pulmonary bleb.

Costovertebral angle tenderness is caused by pyelonephritis (infection of the kidney) or kidney stone.

Vertebral body tenderness suggests cancer, infection, or fracture of the spine,

Auscultation: Common abnormal findings

Decreased breath sounds

Decreased breath sounds can be seen with many types of lung disease:

• Pneumothorax – air is displacing and compressing normal lung tissue
• Pleural effusion – fluid is displacing and compressing normal lung tissue and decreasing transmission of sound
• COPD/emphysema
• Pneumonia

Bronchial breath sounds

In healthy people, bronchial breath sounds are heard over the central airways in the mid-anterior chest.  If they are heard peripherally, over the lung fields, they suggest underlying consolidation caused by pneumonia.

Crackles

Crackles are discontinuous sounds usually caused by the sudden reopening of partially collapsed airways.  Crackles that disappear promptly when the patient coughs may be caused by air bubbling through airway secretions.

Fine crackles sound like hairs being rubbed together or fine Velcro being pulled apart.  They are thought to originate in small distal airways and are characteristic of interstitial lung disease.

Coarse crackles are typically louder, lower in pitch than fine crackles, and less frequent.  They are thought to originate in larger airways and are typical of chronic obstructive pulmonary disease.

Crackles from congestive heart failure and pneumonia often fall in between

Wheezes

These are high-pitched musical sounds produced by the flow of air forced through tightly constricted airways, as in asthma or COPD exacerbations.

Pleural rubs

These are creaky, “sandpaper” sounds caused by inflamed visceral and parietal pleura rubbing together.

Stridor

This is a whistling or shrieking noise caused by focal airway obstruction.  Inspiratory stridor suggests significant obstruction of the upper airway, which can be a medical emergency. Expiratory stridor alone suggests obstruction of a lower airway, as with an aspirated foreign body

Tactile fremitus

If your patient has asymmetric breath sounds, assess tactile fremitus to differentiate consolidation of the lung from pleural effusion or pneumothorax.

Tactile fremitus is vibration transmitted to the examiner’s hands through the chest wall with speech.  It varies between individuals but should be symmetric side-to side.

Consolidation increases tactile fremitus because consolidated lung transmits vibrations from the vocal cords more effectively than air.  Pleural effusion decreases tactile fremitus because the fluid surrounding the lung dampens the vibrations.

To assess tactile fremitus in a patient with asymmetric breath sounds, place your fingertips or lateral hands in the same location on each side of the chest. As the patient speaks, the vibration transmitted to your hands should be symmetric side to side.

Clinical signficance:

Increased tactile fremitus (stronger vibration) over the area of decreased breath sounds indicates the cause is consolidated lung, as in pneumonia. Decreased tactile fremitus (weaker vibration) is caused by pleural effusion, pneumothorax, or large pulmonary blebs.

Egophany

Egophany is the change in the quality of sound that occurs as it passes through consolidated lung.

To test the hypothesis that your patient has lung consolidation due to pneumonia, auscultate over the area of suspected consolidation while asking the patient to say “Eeee.”   If consolidation is present, you may hear “Aaaah” instead.  Because different sound frequencies are transmitted differently through lung tissue, vowels sound different when heard through lung.  This change can be more pronounced over an area of consolidation.

Letter “E” spoken over the healthy side.

Letter “E” spoken over the area of consolidation

Microphone is moved from one side to the other, starting with the healthy side.

Clinical significance. In a patient with suspected pneumonia, a finding of egophany supports the diagnosis, but the absence of egophany doesn’t argue against it. Given the low sensitivity, this maneuver is not typically performed if a chest x-ray is available.

References & Resources

Abnormal lung sounds are from Auscultation of the Lung, New England Journal of Medicine,

Egophany example. YouTube, Lung Sounds (Abnormal Breath Sounds and Auscultation)

From Evidence-Based Physical Diagnosis:

• Pneumonia – ClinicalKey
• Pleural Effusion – ClinicalKey
• Chronic Obstructive Lung Disease – ClinicalKey
• Pulmonary Embolism – ClinicalKey