Immersion: Landmarks

• Ribs and intercostal spaces. The first rib passes under the clavicle and isn’t palpable.  The 2nd rib attaches to the sternum at the sternal angle and the second intercostal space is just below it.
• Costal margin.  The lower edge of the rib cage.
• Costovertebral angles.  On the back, where the lower rib cage meets the spine.
• Midclavicular line (MCL) The line that runs through the midpoint of the clavicle towards the feet.
• Midaxillary line.  The line that runs up the lateral chest through the middle of the raised arm.

 

Immersion: Exam steps

Observe respiratory effort.

Normal breathing should be quiet at rest, without apparent effort.  Rapid breathing, use of the muscles of the neck or abdomen to help with breathing and pulling in of the space between the ribs are all signs of respiratory distress.

Observe respiratory excursion.

Place the hands on either side of the spine and watch as your patient breathes in.  The hands should move equally because normal lungs should expand equally with inspiration.  Asymmetric expansion can be caused by weakness of the diaphragm (the muscle responsible for breathing) or by a lung problem that is limiting the intake of air.

Inspect the skin

As you perform the chest exam, move the gown to the sides to inspect the skin of the posterior and lateral chest.  Pull the gown down slightly to examine the skin of the upper anterior chest as you listen to the upper lobes.

Percuss the lungs

Use indirect percussion, with one or more fingers of your non-dominant hand pressed firmly against the chest in the intercostal spaces. Compare the right side to the left side at each level as you percuss down the posterior chest.

Percussion creates vibrations that are transmitted to the underlying tissue and reflected back again, like radar.  The examiner can both hear and feel differences based on the density of the underlying tissue. Tissue that is filled with air, like normal lung, is described as resonant to percussion. The right and left sides of the posterior chest should be symmetric. If you percuss over your own upper right anterior chest, you should find normal resonant lung.

Lung that has been filled with fluid or displaced by fluid or solid tissue will be dull to percussion. Percuss over your liver, in the lower anterior right chest, to find a dull percussion note.

Lung that has been replaced by air will be hyperresonant to percussion. Percuss over your stomach in the left upper quadrant and compare this more resonant percussion note to the others.

Percuss the spine and costovertebral angles

Use direct percussion with the side of the fist, and moderate force.  The normal spine is not tender to percussion, but if you hit someone hard it will hurt. Tenderness of the spine can indicate injury, inflammation or cancer, while costovertebral angle tenderness suggests a kidney infection.

Auscultate the lungs

With the diaphragm of the stethoscope applied firmly to the skin, auscultate the lungs.

• • Posteriorly: from the apex to the interscapular area to the base (lower margin) of the lungs.
  • Laterally: up the midaxillary line from the base of the lungs to the axilla
  • Anteriorly: over the superior lobes and the right middle lobe.

Over the lung fields, normal breath sounds are soft and low pitched.  Inspiration is longer and more audible than expiration, which may not be heard at all.  These normal breath sounds are described as vesicular breath sounds.

Over the large airways in the anterior central chest, breath sounds are louder and higher pitched, like air rushing through a tube. The expiratory phase is also longer.  These bronchial breath sounds are normal over central airways but abnormal over peripheral lung.

Immersion: Exam Video

Immersion: Documentation

Immersion: Knowledge Check

Term 2: Hypothesis driven exam

Assessing tactile fremitus

To assess tactile fremitus, 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. Consolidated lung transmits vibrations from the vocal cords more effectively than air, increasing tactile fremitus. Pleural effusion and pneumothorax dampen transmission of vibrations, decreasing tactile fremitus.

Clinical signficance: When breath sounds are asymmetric, tactile fremitus can differentiate between several possible causes. Tactile fremitus that is stronger over the area of decreased breath sounds indicates consolidation. Tactile fremitus that is weaker over the area of decreased breath sounds suggests pleural effusion, pneumothorax or large pulmonary blebs.

Egophany

Egophany is a change in the quality of sound that passes through consolidated lung. Auscultate over the area of suspected consolidation while asking your patient to say “Eeee.”   If consolidation is present, you may hear “Aaaah” instead.

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 of egophany, this maneuver is not typically performed if a chest x-ray is available.

Term 2: Abnormal findings

Inspection

Asymmetric chest expansion is causes by localized lung disease.  It is seen in most patients with large pleural effusions and in some 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 defined as respiratory contraction of muscles other than the diaphragm.  The sternocleidomastoids and scalenes raise the clavicles to expand the chest and assist the diaphragm with inspiration. Accessory muscle use suggests respiratory muscle fatigue.

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

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

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

• Pneumothorax. Air displaces and compresses normal lung tissue
• Pleural effusion. Fluid around the lung displaces and compresses normal lung tissue and decreases transmission of sound
• COPD/emphysema. Destruction of normal lung tissue decreases lung sounds.
• Pneumonia. Consolidation of lung decreases air movement..

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

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 are high-pitched musical sounds produced by airflow through tightly constricted airways, as in asthma or COPD exacerbations.

Stridor may be confused with wheezing but is caused by a 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

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

Knowledge Check

References & Resources