"INSPECTION"

During the pulmonary examination, inspection is a useful tool for the physician from which
much information can be garnered. Visual inspection can be used to appreciate the level of
distress, use of accessory muscles, respiratory position, chest structure, respiratory pattern,
and other clues outside of the chest. Although inspection begins when the physician first
visualizes the patient, it should ideally be performed with the patient properly draped so the
chest wall can be visualized.

Initial A:

The patient’s level of distress should be immediately assessed, as those in severe distress
may be experiencing impending respiratory failure that requires intubation. The use of
accessory muscles can also indicate increased work of breathing and should be noted on
initial assessment. These muscles include the sternocleidomastoid, upper trapezius, pectoralis
major, and others.

The position a patient assumes during respiration may also lend clues to a diagnosis. A
patient with asthma or chronic obstructive pulmonary disease (COPD) exacerbation may be
seen sitting and leaning forward with shoulders arched forward to assist the accessory
muscles of respiration.

It is also important to note whether the trachea is midline or deviated. Tracheal deviation
may occur ipsilateral to an abnormality (such as in collapse or mucous plugging) or
contralateral to an abnormality (such as in pleural effusion or pneumothorax).

Items of Inspection:
1-Shape of the chest
2. Symmetry
3. Trachea

4. Apex beat.
5. Movements with respiration
a. Rate
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b. Rhythm
c. Type
6. Scars
7. Pulsations
8. Prominent blood vessels
Before Examination:

Wash hands introduce yourself Confirm patient details – name / Explain the examination
Gain consent Expose the patient’s chest Position patient at 45° Ask patient if they have pain
anywhere before you begin!

Local chest examination:

Inspection:

1-Shape of the chest:

Examination of the shape of the chest is used to assess the structure of the ribs and spine.

There are both congenital and acquired variations of chest wall structure. Congenital
variations include pectus excavatum, in which the sternum is depressed relative to the ribs,
or, conversely, pectus carinatum, which is characterized by anterior protrusion of the
sternum. Kyphoscoliosis, which may be congenital or acquired, is a spinal deformity
characterized by lateral curvature and forward flexion of the spine, which can result in
restrictive lung disease.

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Longstanding obstructive disease can lead to what is commonly known as “barrel” chest, in
which the ribs lose their typical 45° downward angle, leading to an increase of the
anteroposterior diameter of the chest.

2. Symmetry: localised bulge or retraction

3. Position of mediastinum

a. Trachea

b. Apex beat.

4. Movements with respiration

a. Respiratory Rate b. Rhythm c. Type

Differential breathing patterns can give clues to diseases of multiple different organ systems
as much as the respiratory system itself. The breathing pattern encompasses the rate, rhythm,
and volume of a patient’s breathing. The normal breathing rate is 12-20 breaths per minute.

Three principal abnormal patterns of breathing have been described. Cheyne-Stokes

respiration is characterized by periods of apnea that are interspersed between cycles of
progressively increasing then decreasing respiratory rates, which often indicates uremia or
congestive heart failure (CHF). Kussmaul breathing is a rapid, large-volume breathing
caused by acidotic stimulation of the respiratory center; it can indicate metabolic acidosis.
Biot breathing is an irregular breathing pattern alternating between tachypnea, bradypnea,
and apnea, a possible indicator of impending respiratory failure.

5. Scars
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