Examination of the Lungs Examination of the lungs is best performed

with the patient sitting down and the upper body undressed.

Inspection can already yield signs for pulmonary conditions, such as a barrel chest caused

by emphysema. Additional diagnostic clues include an altered respiratory rate, an imbalance

between inspiration and expiration, or signs of dyspnea, such as intercostal retractions

or a notable use of the accessory muscles of respiration.

Now begins the percussion of the lungs. The examiner places one middle finger firmly

on the patient’s chest and strikes it with the middle finger of the other hand. Physiologically,

the air-filled pulmonary tissue should produce a resonant sound. Below the level of the lungs,

auscultation produces a dull sound. Percussion of the lungs is always performed

on both sides and should follow a predetermined pattern. The examination usually starts cranially,

about a hand’s width lateral to the spine and then moves caudally, alternating between

both sides.In the lower thoracic area, percussion is also conducted from medial to lateral.

Dullness to percussion can indicate effusion or, for example, a tumor. In contrast, hyperresonance

results from emphysema or pneumothorax. The mobility of the lungs is best assessed

by first determining the transition from resonance to dullness on complete exhalation, which

corresponds to the inferior border of the deflated lungs. Percussion is then repeated

on maximum inspiration to find the border while the lungs are inflated. The distance

between both borders determines pulmonary respiratory mobility.

Unilateral dullness to percussion should always be compared to the other side to confirm the

finding. Pleural effusion typically presents as dullness that rises from medial to lateral.

Respiratory expansion of the thorax can be checked by palpation. During expiration, the

examiner places both hands on the lateral thorax and applies mild pressure to create

skin folds. On inspiration, these folds should vanish bilaterally. In case of impaired ventilation,

for example in atelectasis or pneumothorax, respiratory expansion can be asymmetric.

Palpation is also used to assess tactile fremitus. If the patient is asked to say the words “Ninety-Nine”

in a deep voice, mild vibrations should be felt in the lower lung segments, around the

level of the 8th to 10th rib. Increased tactile fremitus, which indicates increased sound

conduction, can be found in, for example, pneumonia, whereas decreased fremitus - and

therefore decreased conduction - can result from pleural effusion.

Closely related to tactile fremitus, is bronchophony. The patient is asked to whisper “sixty-six”

while the examiner auscultates the lungs. In states of increased sound conduction, the

whisper is louder. If sound conduction is decreased, it is quieter, or may disappear

completely. The most important test when examining the

lungs is auscultation while the patient is breathing regularly and through the mouth.

It follows the same pattern as percussion. Auscultation allows evaluation of the breath

sounds, which can be diminished or increased, for instance. Furthermore, the ratio of inspiration

to expiration time should be noted. Auscultation may also reveal other abnormal findings, such

as dry or wet crackles, or pleural friction rub.

Breath sounds heard over normal pulmonary tissue are vesicular. Auscultation across

the upper airways results in bronchial breath sounds, which have a higher pitch in comparison.

Bronchial breath sounds heard over pulmonary tissue are considered pathological and hint

at the presence of pneumonia. Evaluating the right middle lobe is best achieved

through anterior auscultation. Therefore, if pneumonia is suspected, the lungs should

always be examined from the anterior as well. Auscultation is not limited to the lungs,

but should also include the trachea. Tracheal stenosis produces inspiratory stridor, which

can best be heard posteriorly in the paravertebral area, or anteriorly above the sternum.