How do you examine the thorax and lungs?

Thorax and Lung Examination Technique

A comprehensive examination of the thorax and lungs should follow a systematic approach including inspection, palpation, percussion, and auscultation to accurately assess respiratory status and identify pathology.

Inspection

• General observation: Assess patient's breathing position, respiratory rate, use of accessory muscles, and signs of respiratory distress
• Thoracic shape: Note abnormalities such as barrel chest (COPD), pectus excavatum, or kyphoscoliosis
• Breathing pattern: Observe symmetry of chest expansion, mechanics and synchrony of rib cage and abdominal movements 1
• Neck examination: Check for jugular venous distension, tracheal deviation, or supraclavicular retractions
• Extrathoracic signs: Look for cyanosis, digital clubbing, pursed lip breathing 1

Palpation

• Chest expansion: Place hands on posterolateral chest wall with thumbs meeting at midline, assess symmetry during deep inspiration
• Tactile fremitus: Use palmar surface of hands to feel vibration during vocalization (increased with consolidation, decreased with pleural effusion or pneumothorax)
• Chest wall tenderness: Identify areas of pain that may indicate rib fracture, costochondritis, or pleurisy
• Tracheal position: Assess for deviation that may indicate tension pneumothorax, large pleural effusion, or atelectasis
• Subcutaneous emphysema: Feel for crepitus under the skin indicating air in subcutaneous tissues

Percussion

• Technique: Place middle finger of non-dominant hand firmly against chest wall, strike with middle finger of dominant hand
• Normal resonance: Hollow sound over normal lung tissue
• Dullness: Flat sound indicating fluid (pleural effusion) or solid tissue (consolidation)
• Hyperresonance: Booming sound suggesting air trapping (emphysema) or pneumothorax
• Diaphragmatic excursion: Percuss to identify diaphragm position during inspiration and expiration

Auscultation

• Systematic approach: Listen to anterior, lateral, and posterior chest in a methodical pattern
• Normal breath sounds: Vesicular (peripheral lung fields), bronchovesicular (central chest), bronchial (over trachea)
• Abnormal breath sounds:
  • Diminished: Pleural effusion, pneumothorax, COPD
  • Bronchial breathing: Consolidation
  • Crackles: Fine (interstitial disease) or coarse (secretions)
  • Wheezes: Airway obstruction or narrowing
  • Pleural rub: Inflammation of pleural surfaces
  • Stridor: Upper airway obstruction

Advanced Assessment Techniques

Lung Ultrasound

• A-lines: Horizontal reverberation artifacts indicating normal lung aeration 2
• B-lines: Vertical laser-like artifacts suggesting interstitial syndrome (≥3 per intercostal space) 2
• Pleural line assessment: Using M-mode to identify normal lung sliding (Seashore Sign) or pneumothorax (Stratosphere Sign) 2
• Systematic scanning: Examine 8 zones (4 per hemithorax) with probe marker oriented cranially 2

Diagnostic Procedures for Abnormal Findings

1. Pleural Effusion:

   • Thoracentesis: Ultrasound-guided for improved success and decreased pneumothorax risk 3
   • If cytology negative: Consider pleural biopsy via image-guided technique or thoracoscopy 3

2. Suspected Lung Cancer:

   • Diagnosis by least invasive method based on lesion location 3
   • Central lesions: Bronchoscopy recommended 3
   • Peripheral lesions: Consider transthoracic needle aspiration or navigational bronchoscopy 3
   • With pleural effusion: Thoracentesis first, then pleural biopsy if negative 3

3. Undiagnosed Pleural Disease:

   • Image-guided cutting needle biopsies have higher yield (84% sensitivity) than blind Abrams needle biopsy (47% sensitivity) for malignant disease 3
   • Thoracoscopy has 80-99% sensitivity for pleural disease diagnosis 3
   • Bronchoscopy not routinely recommended for undiagnosed pleural effusion unless hemoptysis or bronchial obstruction suspected 3

Common Pitfalls to Avoid

• Inadequate exposure of chest during examination
• Failure to compare symmetrical areas of both lungs
• Not having patient breathe deeply during auscultation
• Overlooking posterior lung fields in bedridden patients
• Misinterpreting transmitted sounds from upper airways
• Relying solely on physical examination without appropriate imaging when indicated

Special Considerations

• Pediatric patients: Adjust technique based on age and cooperation level
• Elderly patients: Consider age-related changes in chest wall and lung compliance
• Critically ill patients: Prioritize essential components of examination
• Infection control: Use appropriate precautions with airborne or droplet precautions

Physical examination of the thorax and lungs requires practice to master but remains an essential skill for identifying respiratory pathology and guiding further diagnostic testing 4, 5.