Symmetry of chest movement. Analysis of the symmetry of the moving chest during breathing gives the therapist information about the mobility of the thorax and indicates indirectly what areas of the lungs may or may not be responding.

Procedure: Place your hands on the patient’s chest and assess the excursion of each side of the thorax during inspiration and expiration. Each of the three lobar areas can be checked.

• To check upper lobe expansion, face the patient; place the tips of your thumbs at the midsternal line at the sternal notch. Extend your fingers above the clavicles. Have the patient fully exhale and then inhale deeply.

• To check middle lobe expansion, continue to face the patient; place the tips of your thumbs at the xiphoid process and extend your fingers laterally around the ribs. Again, ask the patient to breathe in deeply.

• To check lower lobe expansion, place the tips of your thumbs along the patient’s back at the spinous processes (lower thoracic level) and extend your fingers around the ribs. Ask the patient to breathe in deeply.

Abnormal Breathing Patterns

• Dyspnea. Distressed, labored breathing as the result of shortness of breath.
• Tachypnea. Rapid, shallow breathing; decreased tidal volume but increased rate; associated with restrictive or obstructive lung disease and use of accessory muscles of inspiration.
• Bradypnea. Slow rate with shallow or normal depth and regular rhythm; may be associated with drug overdose.
• Hyperventilation. Deep, rapid respiration; increased tidal volume and increased rate of respiration; regular rhythm.
• Orthopnea. Difficulty breathing in the supine position.
• Apnea. Cessation of breathing in the expiratory phase.
• Apneusis. Cessation of breathing in the inspiratory phase.
• Cheyne-Stokes. Cycles of gradually increasing tidal volumes followed by a series of gradually decreasing tidal volumes and then a period of apnea. This is sometimes seen in the patient with a severe head injury.

Extent of excursion. The extent of chest mobility can be measured by two methods.

• Measure the girth of the chest with a tape measure at three levels (axilla, xiphoid, lower costal). Document change in girth after a maximum inspiration and a maximum expiration.

• Place both hands on the patient’s chest or back as previously described. Note the distance between your thumbs after a maximum inspiration.

Palpation
Palpation of the thorax provides evidence of dysfunction of the underlying tissues including the lungs, chest wall, and mediastinum.

Tactile (vocal) fremitus. Tactile fremitus is the vibration felt while palpating over the chest wall as a patient speaks.

 Procedure: Place the palms of your hands lightly on the chest wall and ask the patient to speak a few words or repeat “99″ several times. Normally, fremitus is felt uniformly on the chest wall. Fremitus is increased in the presence of secretions in the airways and decreased or absent when air is trapped as the result of obstructed airways.

 Chest wall pain. Specific areas or points of pain over anterior, posterior, or lateral aspects of the chest wall can be identified with palpation.

Procedure: Firmly press against the chest wall with your hands to identify any specific areas of pain potentially of musculoskeletal origin. Ask the patient to take a deep breath and identify any painful areas of the chest wall. Chest wall pain of musculoskeletal origin often increases with direct point pressure during palpation and during a deep inspiration.

Pain in the anterior, posterior, or lateral region of the chest can be of musculoskeletal, pulmonary, or cardiac origin. Pain of pulmonary origin is usually localized to a region of the chest but also may be felt in the neck or shoulder region. Several pulmonary or cardiac conditions can mimic musculoskeletal pain, such as pulmonary embolism, pleurisy, pneumonia, pneumothorax, and pulmonary artery hypertension.

Mediastinal shift. The position of the trachea normally is oriented centrally in relation to the suprasternal notch indicating symmetry of the mediastinum. The position of the trachea shifts as the result of asymmetrical intrathoracic pressures or lung volumes. For example, if the patient has had a pneumonectomy (removal of a lung), the lung volume on the operated side decreases, and the trachea shifts toward that side. Conversely, if the patient has a hemothorax (blood in the thorax), intrathoracic pressure on the side of the hemothorax increases, and the mediastinum shifts away from the affected side of the chest.

Pocedure: To identify a mediastinal shift, have the patient sit facing you with the head in midline and the neck slightly flexed to relax the sternocleidomastoid muscles. With your index finger, gently palpate the soft tissue space on either side of the trachea at the suprasternal notch. Determine whether the trachea is palpable at the midline or has shifted to the left or right.

Mediate Percussion
Mediate percussion is an examination technique designed to assess lung density, specifically, the air-to-solid ratio in the lungs.

Procedure: Place the middle finger of the nondominant hand flat against the chest wall along an intercostal space. With the tip of the middle finger of the opposite hand, firmly tap on the finger positioned on the chest wall. Repeat the procedure at several points on the right and left and anterior and posterior aspects of the chest wall. This maneuver produces a resonance; the pitch varies with the density of the underlying tissue. The subjective determination of pitch indicates the following.
• The sound is dull and flat if there is a greater than normal amount of solid matter (tumor, consolidation) in the lungs in comparison with the amount of air.

• The sound is hyperresonant (tympanic) if there is a greater than normal amount of air in the area (as in patients with emphysema).

• If asymmetrical or abnormal findings are noted, the patient should be referred to the physician for additional objective tests such as a chest radiograph.

Auscultation of Breath Sounds
Auscultation is a general term that refers to the process of listening to sounds within the body, specifically to breath sounds during an examination of the lungs. Breath sounds occur because of movement of air in the airways during inspiration and expiration. A stethoscope is used to magnify these sounds. Breath sounds should be assessed to:

• Identify the areas of the lungs in which congestion exists and in which airway clearance techniques should be performed.

• Determine the effectiveness of any airway clearance intervention.

• Determine whether the lungs are clear and whether interventions should be discontinued.

Procedure: When assessing breath sounds, be sure the setting is quiet. Have the patient assume a comfortable, relaxed, sitting position to allow access to the chest wall. Place the diaphragm of the stethoscope directly against the patient’s skin along the anterior or posterior chest wall. Be sure that the tubing does not rub together or come in contact with clothing during auscultation, as this contact produces extraneous sounds.

Follow a systematic pattern and place the stethoscope against specific thoracic landmarks (T2, T6, T10) along the right and left sides of the chest wall. Ask the patient to breathe in deeply and out quickly through the mouth as you move the stethoscope from point to point. Note the quality, intensity, and pitch of the breath sounds.

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