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92 • THE RESPIRATORY SYSTEM

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Thorax
It is often easiest to examine the patient reclining on the bed or 4 Check the cricosternal distance. In health, three average fingers
an examination couch at about 45 degrees, with the thorax fit between the sternal notch and the cricoid.
exposed and the head supported by a pillow. 5 Examine the cervical lymph nodes from behind with the patient
sitting forward. Upward movement of the sternum and down-
Inspection ward movement of the trachea on inspiration are normal but
may become more obvious with forceful inspiratory efforts in
Inspection from the end of the bed. respiratory disease. Rarely, systolic downward movement of
1 shape the trachea is felt in patients with aortic aneurysm (sometimes
2 respiratory movements of the chest wall. called ‘tracheal tug’).
3 Pursed-lip’ breathing on expiration. 6 Assess thoracic expansion in both the upper & lower anterior
chest wall. First, place the palms of your hands over the pectoral
4 Indrawing of the intercostal spaces during mid-inspiration
region overlying both upper lobes & oppose the elevated thumbs
5 Recruitment of muscles not normally involved in breathing (‘ over the midline. Ask the patient to take a deep breath using the
accessory muscles’). These include the SCM muscles lifting the thumbs as pointers to judge how much each hand moves outwards.
sternum, and the trapezius and the scalenes lifting the shoulder Then, cup your hands, with fingers spread, around the patient’s
girdle. Patients sometime sit forwards and brace their arms on a lower anterior chest wall overlying the lingula & right middle lobe,
surface, allowing them to use the pectoralis major to pull the pressing the fingertips firmly in the mid-axillary line. Pull your
hands medially towards each other to tighten any loose skin, and
ribs outwards during inspiration. once again use your thumbs (off the skin) as pointers to judge how
6 Diminishes thoracic volume much each hand moves outwards when the patient is instructed to
7 raises resting respiratory rate. take a full breath in (Fig. 5.13). In a healthy thorax, the ribs move
out and up with inspiration. Check for any asymmetry. This is more
8 Chest deformity (Fig. 5.5) may be congenital, as in pectus important than the absolute degree of expansion, which will vary
excavatum, or acquired, as in pectus carinatum. between individuals. In COPD with hyperinflation, the normal out-
9 surgical scars thoracotomy scars may be visible only from the ward movement of the lower ribs on inspiration is replaced by para-
side or behind. doxical inward movement (‘Hoover’s sign’), caused by contraction
of the abnormally low, flat diaphragm (see Fig. 5.4).
10 Asymmetry of the chest may be 8 rarely reveal surgical emphysema, indicating air trapped in the
11 chest drains subcutaneous tissues (Fig. 5.14). This most commonly complicates
12 skin for relevant abnormalities pneumothorax with chest drainage or rib fracture and feels like a
Neck palpable crackling under the skin of the upper thorax,
supraclavicular fossa and neck.
SVC obstruction, the JVP may be raised above the angle of the 9 Finally, examine carefully for any tumour deposits (see Fig. 5.6A).
jaw, making pulsatility invisible. In those who are using the SCM
as accessory muscles, it is frequently impossible to see the JVP
Percussion
as the internal jugular vein lies deep in the active muscle. Examination sequence (Videos 2F and 2G)
Examination sequence (Video 2D)
1 apply the middle finger of your nondominant hand firmly to an
• Support the patient’s head with a pillow to facilitate relaxation intercostal space, parallel to the ribs & drum the middle phalanx
with the flexed tip of your dominant index or middle finger
of the SCM muscles.
(Fig. 5.15A). The movement should come from the wrist & not
• Using a tangential light source, examine the JVP.
the elbow.
Palpation 2 Starting in the supraclavicular fossae, compare percussion at
mirror image sites on right and left before moving to the next
1 Locate the apex beat level (see Fig. 5.15B).
2 Palpate for a right ventricular heave. 3 Posteriorly, the scapular & spinal muscles obstruct percussion,
In patients with significant hyperinflation, the apex beat may so position the patient sitting forwards with their arms folded in
be impalpable because the lingula expands between the heart front to move the scapulae laterally. Percuss a few cm lateral
and the chest wall (see Fig. 5.4B). In this situation, the heart to the spinal muscles, taking care to compare positions the
sounds are often barely audible and may be heard better by same distance from the midline on right & left (see Fig. 5.15C).
auscultating in the epigastrium. 4 Percuss the lateral chest wall in the mid-axillary line, comparing
In pulmonary hypertension, the lower sternum is lifted by both sides.
the cardiac cycle (right ventricular heave) and a finger gently In healthy people, anterior chest percussion is symmetrical
placed over the pulmonary area may detect closure of the except for the area immediately lateral to the lower left sternal
pulmonary valve: a so-called palpable P2. edge, where the right ventricle causes dullness; this ‘cardiac dull-
3 Check for tracheal deviation by gently advancing a single ness’ is lost in hyperinflated patients in whom the lingula overlies
finger resting in the sternal notch in the midline (Fig. 5. 12). The the heart (see Fig. 5.4).
trachea should be equidistant from the two SCM heads.
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98 • THE RESPIRATORY SYSTEM

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Clear resonance ( ‘hyperresonance’) is the usual finding over a 2 Ask the patient to take repeated slow, deep breaths in and
pneumothorax, although the difference between a normal lung out through their open mouth. Auscultate the anterior chest
and the pneumothorax may be quite subtle because normal lung wall from top to bottom, always comparing mirror image
is almost all air. positions on right and left before moving down.
3 Use the same sequence of sites as for percussion.
Auscultation 4 Note whether the breath sounds are soft and muffled, absent,
In the distal airway, the large combined cross-sectional area of or loud and harsh (bronchial, like those heard over the larynx).
the multitude of bronchioles means that 5 L can easily pass at Seek and note any asymmetry and added sounds, deciding
slow flow rates, so flow is normally virtually silent. The harsh ‘ which side is abnormal.
bronchial’ sound generated by the major airways can be appreci- 5 Auscultate the lateral chest wall in the mid-axillary line, again
ated by listening with the diaphragm of the stethoscope applied comparing right with left before changing level.
to the larynx (try this on yourself).
Most of the sound heard when auscultating the chest wall orig- Added sounds
inates in the large central airways but is muffled and deadened by The three common added sounds are wheezes, crackles and rubs.
passage through overlying air-filled alveolar tissue; this, together Wheeze is a musical whistling sound accompanying airflow
with a small contribution from medium-sized airways, results in and usually originates in narrowed small airways. It is most
‘normal’ breath sounds at the chest wall, sometimes termed ‘ve- commonly expiratory, due to dynamic airway narrowing on
sicular’. In the same way, with soft speech (‘say one, one, one’), expiration, but can also occur on inspiration. Usually, multiple
the laryngeal sounds are muffled by healthy lung but heard wheezing sounds are heard together (polyphonic wheeze);
clearly and loudly at the chest wall overlying consolidation and this sign is common in asthma, bronchitis and exacerbation of
fibrotic scarring, due to improved conduction of major airway COPD. A single (monophonic) wheeze that is present consis-
sounds through diseased lung. tently with each breath and does not clear with coughing is
When there is lobar collapse caused by a proximal bronchial consistent with a fixed bronchial obstruction and may indicate an
obstruction, the signs are different from those in simple consol- underlying cancer partially obstructing a bronchus.
idation. The usual findings are diminished expansion, sometimes Crackles are brief non-musical sounds that are most often
with chest asymmetry due to loss of volume, dullness to per- heard on inspiration but may occur in any phase of breathing.
cussion over the collapsed lobe, and reduced breath sounds and They are thought to represent the sudden opening of small
vocal resonance. airways but sometimes indicate secretions in the airways or
Use of the stethoscope underlying interstitial fibrosis. In healthy people, gravitational
Normal breath sounds are relatively quiet, so the greater area of compression of the dependent lung bases may cause a few
contact offered by the diaphragm is usually well-adapted to crackles on the first few deep breaths; these should clear with a
chest auscultation. deliberate cough and are of no pathological significance. Crackles
The two common exceptions are in patients with: that persist after several breaths and a cough are pathological.
1 Cachectic chest wall with sunken intercostal spaces, where They are graded as ‘fine’, meaning soft, multiple crackles, to
it may be impossible to achieve flat skin contact with the ‘coarse,’ indicating loud, scanty crackles that tend to change with
diaphragm. each breath. Showers of fine crackles during inspiration, resem-
2 Hairy chest wall, where movement of chest hairs against the bling the sound made by peeling a Velcro fastener, are charac-
diaphragm is easily mistaken for lung crackles. In these teristic of interstitial pulmonary fibrosis, and are commonly heard
situations, use the stethoscope bell instead to listen to the at the lung bases posteriorly and laterally. Fine crackles also oc-
breath sounds. cur in pulmonary oedema and some viral pneumonias. Coarse
Breath sounds crackles are generally heard in patients with significant purulent
Absolute volume and character of breath sounds in individuals airway secretions such as those with bronchopneumonia or
are greatly affected by the thickness, muscularity & fat content
bronchiectasis. Inspiratory crackles may also be heard over in-
of the chest wall. The symmetry of sounds is therefore the key
feature. completely inflated lung immediately above a pleural effusion.
A pleural rub is a rasping, grating sound occurring with each
Examination sequence (Videos 2H and 2I) breath and sounding superficial, just under the stethoscope, like
1 Auscultate the apices, comparing right with left, and changing two sheets of sandpaper rubbing together. It indicates pleural
to the bell if you cannot achieve flat skin contact with the inflammation, usually due to infection or infarction of the lung,
diaphragm. and is often accompanied by pleuritic chest pain. In pneumonia,
a pleural rub and the associated pain may disappear if a para-
pneumonic effusion or empyema develops.
Very rarely, a clicking or crunching sound may be heard synchron-
ous with the heartbeat; this can indicate a pneumomediastinum.
pneumomediastinum.
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• A hairy chest wall, where movement of chest hairs against the
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Investigations • 99

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Vocal resonance
Breath sounds normally reveal the presence of consolidation or
fibrotic scarring (bronchial breath sounds) or pleural air or fluid
(diminished or absent breath sounds). These signs can be
confirmed by asking the patient to generate laryngeal sounds
deliberately (‘Please say “one, one, one” each time I move my
stethoscope’) and listening on the chest wall in the same
sequence of sites used for breath sounds. Through the stetho-
scope, the spoken sound is muffled and deadened over healthy
lung but is heard loudly and clearly over consolidated or fibrotic
scarred lung. As with breath sounds, vocal resonance is absent
or greatly diminished over pneumothorax and pleural effusion.
‘Whispering pectoriloquy’ may be used to confirm the same
changes in sound conduction. Whispered speech is muffled to
silence by normal lung but may be heard over consolidated or
scarred lung.

Reduced cricosternal
distance (sternum high)
Reduced outward
movement
B Hyperinflated
Lingula overlies heart
– loss of cardiac dullness
Paradoxical inward
Low, flat diaphragm movement of lower ribs
due to flat diaphragm

Fig. 5.4 Respiratory movement of the ribs, sternum and diaphragm. A In normal adults. B In chronic hyperinflation due to obstructive lung disease.
Hyperinflation causes upward displacement of the sternum and clavicles, increased anteroposterior thoracic diameter, loss of cardiac dullness at the lower left
sternal edge, and a low flat diaphragm that pulls the lower ribs in during inspiration.

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A B C
Fig. 5.15 Percussion of the chest. A Technique. B Anterior and lateral sites. C Posterior sites.
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The physical examination • 93

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A B

C D
Fig. 5.5 Abnormalities in the shape of the chest. A Hyperinflated chest with raised sternum and shoulder girdle. B Kyphoscoliosis. C Pectus carinatum with
Harrison’s sulcus (arrow). D Pectus excavatum.

A B

Fig. 5.13 Assessing chest expansion from the front. A Expiration. B

Fig. 5.12 Examining for tracheal deviation.