Chest Exam: Benchmarks

Observe respiratory efforts and note the presence or absence of respiratory distress.

Observe the symmetry of chest movements with respiratory efforts.

Observe the shape of the chest.

In respiratory distress, some of the following may occur: accessory muscle use, nasal flaring, intercostal retractions, and abdominal paradox.

A barrel-shaped chest may be seen in chronic obstructive pulmonary disease (COPD).

Confirm midline tracheal position with gentle palpation anteriorly.

Place hands on posterior chest & confirm symmetrical chest expansion with inhalation.

Assess tactile fremitus:

• Place your palms and fingers lightly on patient’s posterior chest
• Ask patient to say “toy boat” or “coin”
• Move your hands sequentially from the apices, to the interscapular region, and then to the pulmonary bases, comparing the vibrations on one side to the other.

Tracheal deviation may occur with tumor, tension pneumothorax, or large pleural effusion.

Tactile fremitus is the vibration felt by the clinician’s hand on the chest wall when a patient speaks. Asymmetric tactile fremitus is abnormal.

• Asymmetric increased vibration occurs with consolidation of the lung, as in acute pneumonia
• Asymmetric decreased vibration occurs with pleural effusion, pneumothorax, large pulmonary blebs.

Percuss the chest on both right and left sides as follows:

• Posteriorly: apices, interscapular region, pulmonary bases
• Laterally: midaxillary line

Percuss the spine and the costovertebral angles, assessing for abnormal tenderness.

How to interpret findings on percussion:

• Resonant (normal lung)
• Flat or dull (consolidation, pleural effusion, or elevated hemidiaphragm)
• Hyperresonant or tympanitic (pneumothorax, large bleb, or emphysema)

Auscultate the chest using the diaphragm of the stethoscope placed firmly on the skin (not the clothing), comparing the right and left sides in each of these locations:

• Posteriorly: apices, interscapular region, & pulmonary bases
• Laterally: midaxillary line
• Anteriorly: assessing bilateral superior lobes, right middle lobe, and left lingular division of superior lobe of left lung

If consolidation is suspected clinically, then assess for E-to-A change (egophony): auscultate over the area of suspected consolidation while asking the patient to say “E.” It will sound like “A” in areas of pulmonary consolidation.

Vesicular breath sounds are normal “lung” sounds.

Bronchial or tubular breath sounds are abnormal, fairly loud, high-pitched sounds heard over areas of consolidated lung. The consolidated lung tissue increases transmission of major airway sounds as compared to the softer normal vesicular breath sounds.

Adventitial sounds: these are all abnormal

• Discontinuous Sounds
  • Coarse crackles. Coarse, low-pitched “rattles” heard during early and mid-inspiration. They are produced in large central airways, and may occur in acute or chronic bronchitis.
  • Fine crackles. Sound like “hairs being rubbed together” or like fine Velcro being pulled apart. They are produced by the sudden reopening of partially collapsed small airways, and usually occur in late inspiration. The small airways may be partially collapsed by scarring [pulmonary fibrosis], pus [pneumonia], blood [alveolar hemorrhage], or fluid [pulmonary edema].
• Continuous Sounds
  • These are produced by the “fluttering” of the airway wall, similar to a reed in a wind musical instrument. The word “continuous” does not imply that they last throughout the respiratory cycle, only that these sounds last longer than the “discontinuous” sounds noted above.
  • Wheeze = high-pitched, hissing or musical type sounds produced by fast jets of air forced through tightly compressed airways (as in asthma or COPD exacerbations).
  • Rhonchus = low-pitched, snoring like sounds produced by partial airway obstruction from mucus or bronchoconstriction (as in chronic bronchitis and occasionally asthma) or aspirated foreign bodies or endobronchial tumors.
• Pleural rubs: loud, creaky, “sandpaper” type sounds (caused by two inflamed pleural surfaces rubbing together)