Method
General inspection should preferably be carried out with the patient standing up, with the physician standing opposite the patient. If this is not feasible it can be done with the patient sitting on the examination table or, if that is not possible, with the patient lying on the examination table. The examiner is best placed at the foot end of the patient.
Assess the breathing, taking note of the following aspects: type, frequency, depth, regularity, ratio between inspiration and expiration, the presence of a cough or audible breathing, and the presence of dyspnoea. Also look out for the possible presence of a preferred posture and use of accessory breathing muscles, presence of central and/or peripheral cyanosis, and presence of clubbed fingers and/or hourglass nails.
Inspection of the thorax
1 The skin of the thorax
Pay attention to abnormal colour, skin abnormalities, vascular markings and particularly scars. After all, these may indicate previous lung pathology such as the presence of a scar after a (partial) lung resection or a scar after a drain insertion due to a pneumothorax (collapsed lung) in the past.
2 The thoracic subcutis
Make a note of the amount of subcutaneous fat. This will influence, amongst others, the obtained tone during percussion and volume of the breath sounds at auscultation.
3 The breasts
The presence of breasts can influence percussion and auscultation.
4 The musculature (muscle layer)
Pay attention to the size of the thoracic muscles. These can also influence percussion and auscultation findings. In addition, information regarding the dietary situation and condition of the patient may be gained from this.
5 The skeleton
The shape and symmetry of the thorax.
- Locate the previously-described skeletal landmarks. These can be used to describe the position of the lungs.
- The shape and symmetry of the thorax. Abnormalities in the thoracic skeleton may influence the position and expansion opportunities of the lungs and airways. Therefore, take note of the anteroposterior diameter, cross-sectional measurement, length, symmetry, curvature of the spine, position of the scapulae, course of the ribs and size of the costal triangle (the triangle in the upper abdomen between the left and right costal margins).
Some examples of common disorders of the skeletal thorax that may influence the lung function and heart function are congenital disorders such as pectus excavatum (sunken or funnel chest) and pectus carinatum (pigeon chest), disorders of the thoracic spinal column such as scoliosis or extensive kyphosis (curved back) and the barrel-shaped thorax that develops with COPD, where a deep inspiration position is present continuously and the costal triangle has widened.
6 The presence and symmetry of the respiratory excursion
The thorax expands during inspiration because air is being sucked into the lungs. Under physiological circumstances, there is only slight thoracic expansion during breathing at rest; following maximum inspiration, the maximum thoracic diameter can increase by up to 5–10 cm compared to the thoracic diameter after maximum expiration. Normally this expansion is symmetric. However, for example in the case of a (almost) complete pneumothorax (collapsed lung), the affected side will expand less during inspiration.
It is also important to pay attention to (intercostal) retractions. Retractions may be observed with heavily laboured breathing at the supraclavicular and suprasternal fossae and in the intercostal spaces. In such a case it may also be possible to observe bulging of the abdominal wall.
Procedure
Inspect the thorax at the front, from the side and from the back. Always assess the skin, subcutis, the musculature and the skeleton. In women, also assess the breasts. In addition, assess from the front, side and back whether the thorax expands during breathing at rest and then assess the expansion of the thorax during maximum inspiration. During this assessment, pay attention to whether the expansion is sufficient and symmetric. Also, at rest as well as during maximum inspiration and expiration, note any retractions and bulging (Figures 7a to 7c).
Figure 7a: Inspection of the thorax: front
Figure 7b: Inspection of the thorax: side
Figure 7c: Inspection of the thorax: back
If there is doubt as to whether the thorax expansion is sufficient, or in the event of follow-up of patients with lung disorders in which the thorax expansion is reduced, such as COPD patients who experience a continuous state of inspiration, thorax excursions can also be measured objectively using a measuring tape. In such cases, the thoracic circumference is measured at rest with a measuring tape, which should be positioned at nipple height for men and just above the breasts for women. Subsequently, the patient is instructed to take a deep breath and then the difference in thoracic circumference between normal breathing and maximum inspiration is noted (Figures 8a to 8c).
Figure 8a: measurement of the respiratory excursion
Figure 8b: measurement of the respiratory excursion during breathing at rest
Figure 8c: measurement of the respiratory excursion during maximum inspiration