PHYSICAL EXAMINATION OF

THE CHEST: FOCUS ON

LUNG SOUNDS
RICARDO M. SALONGA, MD, FCCP, FPCP, FPCCP
Pulmonary Consultant, Manila Doctors Hospital,
Medical Center Manila and UPHDMC
Professor, Pulmonary Section, Dept. of
Medicine, UP College of Medicine-PGH

IMPORTANCE OF HISTORY
AND PHYSICAL
EXAMINATION in CLINICAL
DIAGNOSIS
A good history and physical
examination by an astute
clinician can already lead to a
correct diagnosis in
approximately 80% of cases,
and almost 100% with
additional diagnostic tools(i.e.
Chest x-ray, CT Scan, PFT, etc.)

ANATOMY OF THE RESPIRATORY

SYSTEM
1. CONDUCTING SYSTEM:
from nasal cavity and
pharynx(upper airways)
down to the larynx,
trachea, main bronchi,
down to distal
bronchioles(lower airways).

2. GAS-EXCHANGING
SYSTEM: terminal
bronchioles, alveolar ducts
and alveoli.

ANATOMY(Contd)
The terminal bronchioles divide
into 2-5 alveolar ducts, each
of which consists of 10-16
alveoli. Alveoli has 3 cell
types: Type I, the lining cell
accounts for 95% of the
alveolar surface area. Type II
cell produces surfactant, a
mixture of phospholipids,
which maintains alveolar
stability. The macrophage acts
as phagocytic defense vs
infection.
The adult respiratory system
contains approx. 300 million
alveoli. The surface area of
the alveolo-capillary
membrane available for 02-

I. PHYSIOLOGY OF
RESPIRATION
During inspiration, as these
muscles contract, the thorax
expands. Intrathoracic pressure
decreases, drawing air into the
tracheobronchial tree into the
alveoli and expanding the lungs.
Gas exchange takes place in the
alveoli.
After inspiratory effort stops, the
expiratory phase begins. The
chest wall and the lungs recoil,
the diaphragm relaxes and rises
passively, air flows outward and
the chest and abdomen return to
their resting positions.

II. PHYSIOLOGY OF
RESPIRATION
During inspiration, air enters the
upper airway, travels through the
lower airways until it reaches the
alveoli. Each alveolus is
surrounded by multiple
capillaries.
During systole, deoxygenated blood
returning from the bodys cells is
pumped from the right ventricle
through the arterial pulmonary
circulation to the alveolar
capillaries. CO2 diffuses from the
capillary blood across alveolocapillary membrane and enters
the alveolar air. Simultaneously,
O2 from inspired atm. air in the
alveolus crosses the alv.cap.
membrane and enters the
pulmonary capillary blood.

III. PHYSIOLOGY OF
RESPIRATION
During expiration, CO2 is exhaled from the
lungs. Oxygenated blood travels to the left
side of the heart and is pumped from the
ventricle into the arterial circulation to the
cells of the body, where cellular respiration
occurs.

PHYSICAL EXAMINATION OF THE

CHEST & LUNGS
INSPECTION
PALPATION
PERCUSSION
AUSCULTATION

INSPECTION
Examine

skin over the chest for

lesions that restrict respiratory
excursion and structural deformities.
(e.g. barrel chest, pigeon breast)
Note cough and noisy breathing
Observe respiratory movements: rate,
amplitude and rhythm.
Observe retraction of interspaces and
other signs of labored breathing(i.e.
use of sternocleidomastoids)

SOME CHEST DEFORMITIES SEEN ON INSPECTION

PALPATION
Palpate

to test respiratory excursion,

esp. posteriorly.
Palpate for tracheal position.
Palpate for any soft tissue
masses/tenderness.
Palpate for rib/costochondral
tenderness
Palpate for tactile fremitus, using base
of fingers or edge of your hand,
comparing the two sides of the chest.

RESPIRATORY EXCURSION

Tactile Examination of the Chest

Tactile Fremitus

Palpable vibration of
the chest wall from
sounds transmitted
from the phonating
larynx.
Ninety-nine.
Compare symmetry.
Abnormality MAY be
ed or ed.

PERCUSSION
With

a quick, sharp but relaxed wrist

motion, strike the pleximeter finger
with the right middle finger or plexor
finger. Aim at your distal
interphalangeal joint. Strike using the
tip of the plexor finger, not the finger
pad. Your finger should be almost at
right angles to the pleximeter.
Withdraw your striking finger quickly to
avoid dampening the vibrations you
have created.
In summary, the movement is at the
wrist. It is directed, brisk yet relaxed
and a bit bouncy!

Examination of the Chest

Percussion

Defines density of
underlying structures
by differences in sound
wave conduction.
Dull over thigh.
Flat over forehead.
Resonant over right
pectoralis.

PERCUSSION of the Chest

Examination Points

= sites for percussion

AUSCULTATION
Stethoscope:

ideal length = 1012 inches. Earpieces must fit

tightly and placed into the ears
in an anterior direction.
Auscultatory technique: always
compare both sides of the chest.
Include tracheal area using the
bell. There are auscultatory
sites on the posterior chest wall
and on the anterior chest wall.
(See diagrams with
corresponding landmarks)

Auscultation of the Chest

Examination Points

= sites for auscultation

NORMAL BREATH
SOUNDS
Tracheal and Bronchial Breath Sounds:
- are loud, high-pitched sounds heard
over the trachea and mainstem bronchi.
- produced by turbulent airflow
patterns.
- IE ratio= 1:2 to 1:3.
- sound frequency= 200 to 2,000Hz.
- heard over chest wall on either side
of the sternum from 2nd to 4th ICS
anteriorly and along vertebral column
from 3rd to 6th ICS posteriorly.

NORMAL BREATH
SOUNDS(Contd)
Normal Breath Sounds Heard Over
Other Chest Wall Areas:
1. Vesicular breath sounds produced
by changes in airflow patterns, quieter
than bronchial/tracheal BS. Inspiration
is heard clearly, immediately followed
by expiration which quickly fades as
airflow rates rapidly decline and
turbulent airflow is directed towards
the central airways. IE ratio=3:1 to
4:1. Sound frequency = 200-600Hz.

NORMAL BREATH
SOUNDS(Contd)
2. Bronchovesicular breath
sounds:
heard anteriorly and
posteriorly over large central
airways. Pitch & durationbetween vesicular and
bronchial breath sounds, with
IE ratio=1:1.

Auscultation of the Chest

Breath Sound Characteristics
Intensity of Pitch of
Duration
Expiratory Expiratory
of sounds
Sounds
Sounds
Vescicular

Inspiration
> Expiration

Relatively
low

Both lung
fields

Intermediate

1st & 2nd

interspaces
anteriorly;
between
scapulae

Loud

Relatively
high

Over
manubrium
(?)

Very Loud

Relatively
high

At sternal
notch

Softer

Broncho- Inspiration
Intermediate
vescicular = Expiration
Inspiration
Bronchial
< Expiration
Tracheal

Inspiration
= Expiration

Normal
Location

BRONCHIAL BREATH
SOUNDS
Occurs

when lung tissue between

central airways and chest wall
becomes airless because of
conditions that increase lung density,
thus enhancing transmission of
breath sounds which become louder,
more tubular with IE ratio=1:1 or 1:2.
Seen in consolidation, atelectasis and
fibrosis(which increase lung tissue
density by fluid accumulation, lung
collapse or fibrotic scarring).

ABNORMAL VOICE
SOUNDS
Voice sounds are produced by
vibrations of the vocal cords as air
from the lungs passes over them.
Normally, vowel tones which contain
high frequency sounds are filtered
and diminished. However, over
consolidated or atelectatic lung
tissue, less filtering takes place,
thus, enhancing transmission.

ABNORMAL VOICE
SOUNDS(Contd)
The three types of abnormal voice sounds:
Bronchophony- clear, distinct & intelligible
voice sound heard over airless lung tissue.
Whispered Pectoriloquy clear, distinct,
intelligible whispered voice sound heard over
airless, consolidated/atelectatic lung tissue.
Egophony voice sound with a nasal or
bleating quality heard over the chest wall
over consolidated/atelectatic lung tissue,
also seen in upper border of a large pleural
effusion.

ADVENTITIOUS SOUNDS(ATS,
1977)
A. CRACKLES: discontinuous sounds
1. Loud & low pitched = coarse crackles.
2. Less intense, higher pitch & short
duration = fine crackles.
B. WHEEZES: continuous sounds that are
high-pitched with hissing sound.
C. RHONCHI or LOW-PITCHED WHEEZES:
low pitched, continuous sounds heard
primarily during expiration and caused
by fluids/secretions partially blocking
large airways.
D. PLEURAL FRICTION RUB: due to
inflammation of visceral and parietal
pleura.

Categories of Lung Sounds

(ATS 1997)

STRIDOR
Loud

musical sound that is heard

at a distance without a
stethoscope.
It is caused by laryngeal spasm
and mucosal swelling.
Typically heard during inspiration,
but maybe heard throughout the
respiratory cycle.

Changes in Crackle
Characteristics in the Clinical
Course of Pneumonia (Piirila. CHEST,
102:1, 176-183, July, 1992)

Early

Stages: coarse crackles,

mid-inspiratory(due to edema,
inflammation, alveolar infiltrates)

Later

Stages: fine crackles, late

inspiratory(due to improvement in
inflammation, consolidation with
lowered compliance)

THANK YOU!