Inspection is a very essential part of the lung examination, which provides a great amount of information in a short period of time.
In the first instance a general inspection is carried out focusing on parameters related to the breathing and the lungs. Only in the second instance is the thorax examined specifically.
General inspection
1 Breathing
- The type of breathing
Under physiological circumstances chest breathing is observed mainly in women, whereas in men abdominal breathing is often seen. In the case of dyspnoea, abdominal and chest breathing are frequently engaged simultaneously. - Respiratory frequency (in an adult at rest 14-20 breaths per minute)
With breathing difficulties the respiratory frequency is often accelerated: this is reffered to as tachypnoea. The frequency can also be decelerated (bradypnoea), for example due to problems in nervous stimulation. - Depth of respiration
At rest, breathing is usually fairly shallow and during exercise the depth increases. With a very rapid breathing frequency and with thoracic pain due to a rib fracture, for example, breathing is usually shallow. - Regularity of respiration
Normally breathing is reasonably regular. With disturbances in the breathing centre, for example, breathing can exhibit large pauses (apnoea). - The relationship between inspiration and expiration
Normally inspiration (breathing in) is a bit shorter than expiration (breathing out), at a ratio of 5:6. During an asthma attack the expiratory phase may be markedly extended (often accompanied by wheezing). With an upper airway obstruction, for example when choking, the inspiratory phase may be markedly extended (inspiratory stridor). - Cough or audible breathing
If the patient coughs, establish whether it concerns a dry or productive (with production of sputum (phlegm)) cough. Normally breathing should be non-audible. However, under pathological circumstances it may be audible in the form of wheezing with asthma, rumblings with bronchitis or rattling with pulmonary oedema (fluid build-up in the interstitium of the lungs, usually as a result of cardiac failure). - The presence of dyspnoea (breathlessness)
It is important to quantify the degree of breathlessness. Shortness of breath upon exertion (for example when cycling, walking uphill, or even during light exertion such as undressing) is called exertional dyspnoea. Breathlessness when resting is called dyspnoea at rest.
2 The presence of a preferred posture and use of accessory breathing muscles
Patients with shortness of breath often adopt a preferred posture. Dyspnoeic patients often lean over slightly (for example over a table or sink), leaning on stretched arms. Often they make use of the accessory breathing muscles, such as pectoralis major, scalene, sternocleidomastoid and nasalis muscles.
3 The presence of blue/grey lips and tongue (central cyanosis)
This can develop when blood is insufficiently oxygenated.
4 The presence of peripheral cyanosis, clubbed fingers and hourglass nails
Peripheral cyanosis (blue discolourisation of distal parts of the body, such as fingers and toes), clubbed fingers (thickening of the distal phalanges of the fingers) and typical (convex) nail disorders, known as hourglass nails, are associated with lung disorders.