Chapter 4:	Examination of the Chest
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Next, it is time for the RCP to perform a chest examination. This involves inspection, palpation, percussion, and auscultation (IPPA):

Inspection

The thoracic cage provides the framework for the mechanics of ventilation. The normal adult thorax has an antero-posterior (A-P) diameter less than the transverse diameter. Abnormalities of the ribs, spine, clavicles or sternum may seriously affect the ability of the respiratory muscles to cause ventilation.

For example, the A-P diameter gradually increases with age, but prematurely increases in patients with COPD. The typical COPD patient’s chest has an increase in anterior-posterior diameter, referred to as a "barrel chest". A barrel chest results in a mechanical disadvantage to breathing. The chronic air trapping characteristic of the COPD process usually causes this configuration. The diaphragm is low and flat and the anterior chest elevated. Ventilation now occurs only with great effort and increases oxygen consumption.

There can also be disfiguration of the chest in other ways, such as kyphoscoliosis, scoliosis, or restricted lung expansion. These restrictive defects such as kyphosis or scoliosis reduce the patient’s ability to take a deep breath and to cough. This puts these patients at high risk for major surgery. Acute injuries to the chest wall that cause multiple rib fractures may cause flail chest and paradoxical breathing. Ventilatory failure may eventually occur without proper support.

Upon inspection the RCP should note chest configuration, scars, trauma, movement, and the presence of chest tubes or incisions. If there are any visible chest scars, the RCP should ask the patient about them. These are usually due to some past trauma or surgery. The RCP should make note of any splinting of the chest caused by pain, and attempt to visualize any trauma to the lungs may lie beneath the chest’s scars or incisions. Often, patients have experienced contusion pneumonia with hemorrhage beneath. Past chest trauma is also frequently accompanied by significant fibrosis of the lung in adjoining areas. Insertion of chest tubes in the lower chest to drain fluid from the pleural space, and those placed high are to evacuate air are frequently the cause of the visible acute trauma.

The RCP should notice the patient’s use of accessory muscles during ventilation, and pay attention to the synchrony or paradoxical motions of ventilation and count the ventilatory rate. By placing his hands on the patient’s lower chest, with thumbs just barely touching in the back, the RCP can evaluate chest movements. The RCP should then ask the patient take a deep breath, and then observe if the thumbs move apart symmetrically. If not, it may be that the presence of unilateral disease is causing one side to move more than the other. Atelectasis, pneumothorax, and pleural effusions are all conditions that can cause unilateral movement.

In COPD patients, air trapping causes there to be very little observable chest movement. There is also little chest movement seen in patients with restrictive disease. Crackling sounds heard around surgical incision sites when the RCP’s hands are placed on the skin can be suggestive of subcutaneous emphysema.

It should be noted that inspection for the presence respiratory disease requires inspection of more than the thorax. The RCP should inspect the extremities for digital clubbing and cyanosis. The neck should also be assessed for evidence of jugular venous distension (JVD). JVD occurs when the right side of the heart fails due to chronic elevation of pulmonary vascular resistance (PVR). Hypoxemia increases PVR, and over a long period of time the right ventricle cannot effectively work against this added resistance and ventricular failure results.