CHEST AND LUNGS

ANATOMIC LANDMARKS: - nipples

- manubriosternal junction (sternum and point at which 2nd rib
articulates with sternum)
- suprasternal notch
- costal angle
- vertebra prominence (seen and felt best with patient’s head bent
forward – C7)
- clavicles

INFANTS AND CHILDREN

- at about 4 wks gestation, lung is groove on ventral wall of gut
- evolves ultimately from simple sac to involuted structured of tubules
and spaces
- lungs contain no air, alveoli are collapsed
- passive respiratory movements do not open alveoli or move the lung
fields
- at birth, after cord is cut, lungs fill with air for 1st time
- decrease in pulmonary pressure leads to closure of foramen ovale
- increased oxygen tension in arterial blood stimulates contraction and
closure of ductus arteriosus
- chest of newborn is generally round (AP Transverse 1:1)
- relatively thin chest wall of infant and young child makes bony structure more
prominent

PREGNANT WOMEN
- as lower ribs flare, an increase in transverse diameter
- at rest, diaphragm rises above usual resting position - major work of breathing
is done by diaphragm
- ventilation (minute and alveolar) increases
- respiratory rate is unchanged

OLDER ADULTS
- barrel chest is characteristic of most, due to loss of muscle strength in thorax
and diaphragm
- skeletal changes emphasize dorsal curve of thoracic spine, may have
stiffening and decreased expansion of
chest wall
- alveoli become less elastic and relatively more fibrous
- underventilation in lower lung fields and decreased tolerance for
exertion
- mucous membranes become drier and less able to rid mucus

I. REVIEW OF RELATED HISTORY

A. HISTORY OF PRESENT ILLNESS
1. Cough – onset, nature (wet, hacking, productive, nonproductive, etc.),
sputum, pattern, severity,
efforts to treat
 2. Shortness of Breath – onset, pattern (most comfortable, number of
pillows used), severity
3. Chest Pain – onset, duration, efforts to treat, other meds

B. PAST MEDICAL HISTORY

- thoracic, nasal, and/or pharyngotracheal trauma or surgery, use of
oxygen, chronic pulmonary
diseases, other chronic disorders, testing, immunizations

C. FAMILY HISTORY
- when, what kind: tuberculosis (qualify – date of occurrence or
exposure), cystic fibrosis,
emphysema, allergy, asthma, atopic dermatitis, malignancy,
bronchiectasis, bronchitis, lung
cancer
D. PERSONAL AND SOCIAL HISTORY
- nature of employment, home environment, tobacco use, exposure to
respiratory infections, nutritional
status, use of herbal or other remedies, regional or travel
exposures (when and where),
hobbies, use of alcohol and/or illegal drugs, exercise tolerance

II. EXAMINATION AND FINDINGS

A. INSPECTION
- have patient sit upright, if possible
- position patient so that light source comes at different angles
- if patient is in bed and mobility is limited, ensure access to both
sides of bed
- raise and lower bed as needed
- note shape and symmetry of chest from both back and front
- chest will not be absolutely symmetric
- anteroposterior (AP) diameter of chest is ordinarily less than
transverse diameter, often by
as much as half (2:1)

barrel chest – results from compromised respiration as in chronic

asthmas, emphysema, or cystic
fibrous
- ribs are horizontal, spine at least somewhat kyphotic (hunchback),
sternal angle more
prominent, trachea may be posteriorly displaced

- spine may be deviated either posteriorly (kyphosis) or laterally

(scoliosis)
- common structural problems include pigeon chest (pectus carinatum –
prominent sternal protrusion)
and funnel chest (pectus excavatum – indentation of lower
sternum above xiphoid process)
- inspect skin, nails, lips, and nipples, noting whether cyanosis or pallor is
present
 - smell breath
- note supernumerary nipples
- look for superficial venous patterns over chest, which may be a sign of
heart disorders or vascular
obstruction or disease
- underlying fat and relative prominence of ribs give some clue to general
nutrition

1. Respiration – determine rate (12 – 20/min) – ratio of respiration to

heartbeats is approximately 1:4
- rates vary in different waking and sleep states
- note pattern (rhythm) and the way the chest moves
- expansion of chest should be bilaterally symmetric
- find bottom of ribcage, use hands to cinch in waist and feel
expansion
- pattern of breathing should be even, neither too shallow nor too
deep

a. Descriptors
dyspnea – difficult and labored breathing with SOB
- sedentary lifestyle and obesity are common causes
- increases with severity of underlying condition

apnea – absence of spontaneous respiration

orthopnea – SOB that begins or increases when patient lies down

- ask if more than one pillow helps

paroxysmal nocturnal dyspnea – sudden onset of SOB after

period of sleep
- sitting upright is helpful

platypnea – dyspnea increases in upright posture

tachypnea – persistent respiratory rate approaching 25/min

bradypnea – rate slower than 12/min

- may indicate neurologic or electrolyte disturbance, infection
or sensible response to
protect against pain of pleurisy or other irritative
phenomena

hyperpnea – breathing laboriously, as if forced and deeply

Kussmaul breathing – always deep and most often rapid

- eopnymic description applied to respiratory effort
associated with metabolic acidosis

hypopnea – abnormally shallow respirations (pleuritic pain limits

excursion)
 Cheyne-Stokes respiration (periodic breathing) – regular
periodic pattern of breathing with
intervals of apnea followed by crescendo/decrescendo
sequence of respiration
- children and older adults may breathe in this pattern during
sleep, otherwise it
occurs in patients who are seriously ill, particularly with
brain damage at cerebral level or drug-caused
respiratory compromise

- occasional deep, audible sigh that punctuates otherwise regular

respiratory pattern is
associated with emotional distress
air trapping – result of prolonged by inefficient expiratory
effort
- rate increases
- effort becomes more shallow, amt of trapped air
increases, and lungs inflate

biot respiration – irregular respirations varying in depth and

interrupted by intervals
of apnea, but lacking repetitive pattern of periodic
respirations
- usually associated with severe and persistent
increased intracranial
pressure, respiratory compromise resulting from
drug poisoning, or
brain damage at level of medulla
- when breathing is labored or respirations are deeper
than usual, accessory
muscles of respiration (sternocleidomastoid,
trapezius muscles) may
be used

- expansion should be symmetric without apparent use of

accessory muscles
- not unusual to see abdominal respiration, particularly in
very young infants
- thoracic respiration is the rule at most ages unless
intercostal and other thoracic
muscles are compromised
- men are more likely to use diaphragmatic respiration and
women, particularly when
pregnant, thoracic
- chest asymmetry can be associated with unequal expansion and
respiratory compromise
caused by collapsed lung or limitation of expansion by extra
pleural air, fluid or a
mass
 - unilateral or bilateral bulging can be reaction of ribs and
interspaces to respiratory
obstruction
- prolonged expiration and bulging on expiration probably
caused by outflow
obstruction or valvelike action of compression by
tumor, aneurysm, or
enlarged heart

- retractions suggest obstruction to inspiration at any point

- when obstruction is high in respiratory tree, breathing is
stridor (harsh) and chest
wall seems to cave in
- paradoxic breathing occurs when negative intrathoracic
pressure is transmitted to
abdomen by weakened, poorly functioning diaphragm;
obstructive airway
disease; or during sleep, in the event of upper airway
obstruction
- lower thorax is drawn in and abdomen protrudes,
opposite occurs on
expiration
- foreign body in one or the other bronchi causes unilateral
retraction, but suprasternal
notch is not involved
- occurs with asthma and bronchiolitis

- observe lips and nails for cyanosis, lips for pursing, fingers for
clubbing and alae nasi for
flaring - - suggests pulmonary or cardiac difficulty

B. PALPATION
- feeling for pulsations, areas of tenderness, bulges, depressions, unusual
movement, and unusual
positions
- during respiration, stand behind patient, place thumbs along
spinal processes at level of 10th
rib, with palmar or ulnar side of hand lightly in contact, watch
thumbs diverge during
quiet and deep breathing (symmetry)
- note quality of tactile fremitus (palpable vibration of chest wall
resulting from speech or
other verbalizations)
- use a firm, light touch, establishing even contact as patient
speaks (counts)
- vibration should decrease as you palpate down the back
- decreased or absent fremitus may be caused by
excess air in lungs or may
indicate emphysema, pleural thickening, or
effusion, massive
 pulmonary edema, or bronchial obstruction
- increased fremitus, often coarser or rougher in feel,
occurs in presence of
fluids or a solid mass
- should be bilateral symmetry and some elasticity of ribcage, but
sternum and xiphoid should be
relatively inflexible and thoracic spine rigid

crepitus – crackly or crinkly sensation

- can be both palpated and heard (gentle bubbly feeling)
- air in subcutaneous tissue from rupture in respiratory system or
infection with gas-producing
organism
- may be localized or cover a wide area
- requires attention

pleural friction rub – palpable, coarse, grating vibration, usually on

inspiration
- caused by inflammation of pleural surfaces

- note position of trachea

- place index finger in suprasternal notch and move it gently, side
to side
- space above to the inner borders of sternocleidomastoid muscles
should be equal on both
sides
- slight, barely noticeable deviation to right is not unusual

C. PERCUSSION
- compare all areas bilaterally
- suggested sequence: examine back with patient sitting with head bent
forward, arms folded in front
have patient raise arms overhead
for all positions percuss at 4- to 5-cm intervals

resonant – loud intensity, low pitch, hollow qlty flat – soft intensity,
hi pitch, very dull qlty
- heard over the lungs - heard over bone

dull – med. intensity, med./hi pitch, dull thud qlty tympanic –

loud intensity, hi pitch, drumlike
- heard over bone - heard over stomach

D. AUSCULTATION
- characterized by intensity, pitch, quality and duration
- with patient sitting upright, if possible, have him/her breathe slowly and
deeply through the mouth,
exaggerating normal respiration
- be careful of hyperventilation
 - diaphragm is usually preferred to bell for listening to high-pitched
sounds and it provides broader
area of sound
- should be no movement of patient or stethoscope except for respiratory
excursion
- listen systematically at each position throughout inspiration and
expiration

1. Breath Sounds – made by flow of air through respiratory tree

- characterized by pitch, intensity, and quality and relative duration
of inspiratory and
expiratory phases
- relatively more difficult to hear or are absent if fluid or pus has
accumulated in pleural space,
if secretions or a foreign body obstructs bronchi, if lungs are
hyperinflated, or if
breathing is shallow from splinting for pain
- easier to hear when lungs are consolidated

a. Vesicular – low-pitched, low-intensity sound heard over healthy lung

tissue
- heard over lung fields (sides and back)
b. Bronchovesicular – heard over major bronchi and are typically
moderate in pitch and intensity
- abnormal if heard over peripheral lung tissue
- heard right over sternum in the middle
c. Bronchial - ordinarily heard only over trachea
- abnormal if heard over peripheral lung tissue
- heard right under collarbone at neck

amphoric – breathing that resembles the noise made by blowing across

the mouth of a bottle
- heard with a large, relatively stiff-walled pulmonary cavity or
tension pneumothorax with
bronchopleural fistula

cavernous breathing – sounding as if it were coming from a cavern

- commonly heard over pulmonary cavity in which wall is rigid

2. Adventitious Sounds
a. Crackles – abnormal respiratory sound heard more often during
inspiration
- characterized by discrete discontinuous sounds
- individual noise tends to be brief and interval is similarly
brief
- fine, high pitched and relatively short in duration
(sibilant)
- coarse, low pitched, and relatively longer in duration
(sonorous)
 - caused by disruptive passage of air through small airways in
respiratory tree
- dry quality, more crisp than gurgling, apt to occur high in
respiratory tree

b. Rhonci – sonorous wheezes – deeper, more rumbling, more

pronounced during expiration
- prolonged and continuous, less discrete than crackles
- caused by passage of air through airway obstructed by thick
secretions, muscular
spasm, new growth, or external pressure
- may be palpable at times
- tends to disappear after coughing

c. Wheezes – sibilant wheeze – thought of as a form of rhonchus

- continuous, high-pitched, musical sound (almost a whistle)
heard during inspiration
or expiration
- caused by relatively high-velocity air flow through narrowed
airway
- composed of complex combination of variety of pitches or of
a single pitch
- may vary from area to area and minute to minute
- if heard bilaterally, may be caused by bronchospasm of
asthma or acute or chronic
bronchitis
- unilateral or more sharply localized wheezing or stridor may
occur with foreign body

d. Friction Rub – occurs outside respiratory tree

- dry, crackly, grating, low-pitched sound (machine-like
quality)
- heard both in expiration and inspiration, over the heart or
lungs
- caused by inflamed, roughened surfaces rubbing together

e. Mediatinal Crunch (Hamman Sign) – loud crackles and clicking and

gurgling sounds
- more pronounced toward end of expiration
- easiest to hear when patient leans to left or lies down on left
side

3. Coughs – common symptom of respiratory problems

- preceded by deep inspiration, followed by closure of glottis and
contraction of chest,
abdominal and even pelvic muscles, then a sudden
spasmodic expiration, forcing
sudden opening of glottis
- may be voluntary, but are usually reflexive response
 - described according to moisture, frequency, regularity, pitch and
loudness, and quality

III. DEVELOPMENTAL VARIATIONS

A. INFANTS - percussion may be unreliable
- inspect thoracic cage, noting size and shape
- observe nipples for symmetry in size and presence of swelling and
discharge
- patterns of respirations vary with room temperature, feeding and sleep
- cyanosis of hands and feet is common
- expected rates vary from 40 – 60/min, although 80/min is not
uncommon
- note regularity, nasal flaring is common
- coughing is rare and should be considered a problem
- sneezing is frequent and expected
- hiccups are frequent, though silent
- frequent hiccupping, may suggest seizures, drug withdrawal, or
encephalopathy
- palpate ribcage and sternum, noting loss of symmetry, unusual masses
or crepitus
- listen to chest, if baby is crying and restless, wait for quieter time
- not uncommon to hear crackles and rhonchi immediately after birth
- stridor (high-pitched, piercing sound most often heard during
inspiration) is result of obstruction high
in respiratory tree
- respiratory grunting is a mechanism infant uses to expel trapped air or
fetal lung fluid while trying to
retain air and increase oxygen levels

B. CHILDREN – use thoracic muscles for respiration by age 6 or 7

- respiratory rates decrease with age and without significant gender
difference
newborn = 30 – 80 rpm 1 year = 20 – 40 rpm
3 years = 20 – 30 rpm
6 years = 16 – 22 rpm 10 years = 16 – 20 rpm
17 years = 12 – 20 rpm

- if roundness of chest persists past 2nd year of life, be concerned about

possibility of chronic
obstructive pulmonary problem such as cystic fibrosis
- children younger than 5 or 6 may not be able to give enough of
expiration to satisfy, particularly when
subtle wheezing is suspected
- ask child to “blow out” flashlight or blow away tissue

C. PREGNANT WOMEN – dyspnea is common

- decrease in functional residual capacity (resting position of lungs after
normal expiration)
 - increase in vital capacity (amt of air that can be expelled at normal rate
of exhalation after max.
inspiration)
- increased tidal volume (amt of air inhaled and exhaled during normal
breathing)
- increased ventilation by breathing more deeply, not more frequently

D. OLDER ADULTS – chest expansion is often decreased

- may be less able to use respiratory muscles because of muscle
weakness, general physical
disability, or sedentary lifestyle
- bony prominences are marked and loss of subcutaneous tissue
- dorsal curve of thoracic spine is pronounced (kyphosis – hunchback)
with flattening of lumbar curve
- AP diameter increases in relation to lateral diameter
- more difficulty breathing deeply and holding breath
- tire more quickly even when well

IV. COMMON ABNORMALITIES

A. ASTHMA (REACTIVE AIRWAY DISEASE) – chronic obstructive pulmonary disease
(COPD)
- characterized by airway inflammation and generally resulting from
airway hyperreactivity triggered by
allergens, anxiety, upper respiratory infections, cigarette smoke or
other environmental
poisons, or exercise
- paroxysmal dyspnea, tachypnea, cough, wheezing on expiration and
inspiration, chest pain
- may last for minutes, hours or prolonged over days
- varies in intensity

B. ATELECTASIS – incomplete expansion of lung at birth or collapse of lung at any

age
- affected area of lung is airless
- overall effect is to dampen or mute the sounds in the involved area

C. BRONCHITIS – inflammation of mucous membranes of bronchial tubes

- may be accompanied by fever and chest pain
- initial stimulus is irritation by an internal or external noxious influence

D. PLEURISY – inflammatory process involving visceral and parietal pleura, often the
result of pulmonary
infections, bacterial or viral, and sometimes associated with neoplasm or
asbestosis
- onset is usually sudden and typical pleuritic pain is acute
- becomes “dry making breathing difficult
- rubbing can be felt and heard
- respirations are rapid and shallow, with diminished breath sounds
 - accompanied by fever, tachypnea, and malaise

E. PLEURAL EFFUSION – excessive nonpurulent fluid in pleural space resulting in

permanent fibrotic thickening
- findings vary with severity and position of patient
- fluid is mobile and will gravitate to most dependent position
- breath sounds are muted

F. EMPYEMA – occurs when fluid collected in pleural spaces is purulent exudate,

arising most commonly from
adjacent infected, sometimes traumatized, tissues
- may be complicated by pneumonia, penetrating injury, or
bronchopleural fistulae
- breath sounds are distant or absent in affected area, percussion is dull,
vocal fremitus is absent
- patient is febrile, tachypneic and appears ill

G. LUNG ABSCESS – well-defined, circumscribed mass defined by inflammation,

suppuration, and subsequent
central necrosis
- may at first appear to be localized pneumonia
- percussion is dull, breath sounds distant or absent over affected area
- may have pleural friction rub
- cough may produce purulent, foul-smelling sputum
- patient is obviously ill and febrile, sometimes tachypneic
- breath has foul odor

H. PNEUMONIA – inflammatory response of bronchioles and alveolar spaces to

infective agent (bacterial, fungal,
or viral)
- dyspnea, tachypnea, crackles
- diminished breath sounds, percussion is dull

I. INFLUENZA – host of viruses cause this acute, generalized, febrile illness

- characterized by cough, fever, malaise, headache, coryza and mild sore
throat typical of common
cold
- elderly, very young and chronically ill are particularly susceptible (may
prove fatal)
- yearly immunization is often preventive
- crackles, rhonchi, tachypnea, generally nonproductive cough and
substernal pain

J. TUBERCULOSIS – chronic infectious disease that most often begins in the lung but
may then have widespread
manifestations in many organs and systems
- inhaled from airborne moisture of coughs and sneezes of infected
person and given the opportunity
to settle in furthest reaches of lung
K. PNEUMOTHORAX – presence of air or gas in pleural cavity may be result of trauma
or may occur spontaneously
- air becomes trapped on expiration and results in increased pressure in
pleural space
- breath sounds are distant, percussion may boom
- “coin click” = place coin over suspicious area in chest (posteriorly),
while listening on opposite side
(anteriorly), have someone strike coin with edge of another
- clear click will be heard only in event of pronounced
pneumothorax
L. HEMOTHORAX – presence of blood in pleural cavity may be result of trauma or
invasive medical procedures
- air may be present with blood
- breath sounds are distant or absent, percussion is dull and “coin click” is
absent

M. LUNG CANCER – generally refers to bronchogenic carcinoma, malignant tumor that

evolves from bronchial
epithelial structures
- etiologic agents include tobacco smoke, asbestos, ionizing radiation,
and other inhaled chemicals
and noxious agents
- may cause cough, wheezing, variety of patterns of emphysema and
atelectasis, pneumonitis, and
hemoptysis

CHILDREN / ADOLESCENTS
A. CYSTIC FIBROSIS – autosomal recessive disorder of exocrine glands involving
lungs, pancreas, and sweat
glands
- cough with sputum is hallmark in children younger than 5 yrs
- salt loss in sweat is distinctive
- tolerance for exercise diminishes and pulmonary hypertension and cor
pulmonale often occur

B. EPIGLOTTITIS – acute, life-threatening disease almost always caused by type B

influenzae
- begins suddenly and progresses rapidly, often to full obstruction of
airway and resulting in death
- may occur at any age but occurs most often in children between 3 and
7
- child sits straight up with neck extended and head held forward,
appears very anxious and ill, is
unable to swallow, and is drooling from an open mouth
- cough is not common
- fever may be high
- epiglottis appears beefy red, immediate attention is required with help
of anesthesiologist and/or
otolaryngologist and radiologist
 - direct examination of throat with or without tongue blade is to be
avoided
- immunization has greatly reduced incidence, gravity mandates
attention

C. CROUP – syndrome that generally results from infection with a variety of viral
agents particularly parainfluenza
viruses
- occurs most often in very young, generally around 1½ - 3
- boys are more commonly affected, and some children are prone to
recurrent episodes
- harsh, bark-like cough, labored breathing, retraction, hoarseness, and
inspiratory stridor
- fever does not always accompany

OLDER ADULTS
A. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – nonspecific designation that
includes a group of
respiratory problems in which coughs, chronic and often excessive
sputum production, and dyspnea
are prominent features
- irreversible expiratory airflow obstruction occurs
- most patients have been smokers
- chest may be barrel shaped, scattered crackles or wheezes may be
heard
- obstruction can be evaluated during forced maximal expiration
- listen over trachea with diaphragm of stethoscope as patient
inhales to the limit and then
breathes out as quickly as possible through an open mouth
- if forced expiration time is longer than 4 to 5 seconds, suspect
airway obstruction

B. Emphysema – perhaps the most severe COPD, a condition in which air may
take over and dominate a space
in a way that disrupts function
- air spaces beyond terminal bronchioles dilate, rupturing alveolar walls,
permanently destroying them,
reducing their number, and permanently hyperinflating lung
- alveolar gas is trapped, essentially in expiration, and gas exchange is
seriously compromised
- chronic bronchitis is common precursor
- loss of elasticity because of aging, smoking, or impairment of defenses
are also contributors
- percussion tends to be hyperresonant, occasionally prolonged
expiratory effort to expel air
- dyspnea even at rest
- cough is infrequent without much production of sputum
- patient is thin, barrel chested, and even cachectic