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296 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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Chest Wall Symptoms
Chest pain with tenderness. See Chest Wall Signs, pages 300-301.
Lung and Pleura Symptoms:
Shortness of breath—dyspnea. See page 294.
Cough is a sudden, forceful, noisy expulsion of air from the lungs. A
Cough.
cough has three stages: preliminary inspiration, glottis closure with respiratory muscle contraction, and sudden opening of the glottis producing an outward blast of air. The sensory nerve endings for the cough reex are branches
of the vagus (CN X) in the larynx, trachea, and bronchi. Exudates in the pharynx or bronchial tree, foreign body irritation, and tracheobronchial inammation each trigger cough. Cough can also be induced by external acoustic
meatus stimulation via the auricular branch of the vagus, and by esophageal stimulation from acid reux.
involuntary, single or paroxysmal. A productive cough raises sputum. Chronic
unexplained coughs are most commonly caused by chronic post-nasal drip,
gastroesophageal reux, or asthma. DDX: A brassy cough is nonproductive
with a strident quality occurring with narrowing of the trachea or glottal
space, most commonly with laryngitis or epiglottitis, but also with laryngeal
paralysis, vocal cord neoplasm, or aortic aneurysm. In pertussis a long strident inspiratory noise, a whoop, precedes the cough.
CLINICAL OCCURRENCE: Congenital: Tracheoesophageal stula, medi-
astinal teratoma; Endocrine: Substernal thyroid; Degenerative/Idiopathic:
Emphysema, gastroesophageal reux;
gitis, epiglottitis, tracheobronchitis, pneumonia, bronchiectasis, lung abscess,
subphrenic abscess, typhoid; Inammatory/Immune: Inhaled allergens,
asthma, chronic bronchitis, interstitial lung disease, vasculitis, Goodpasture
syndrome, relapsing polychondritis, endobronchial amyloidoma; Metabolic/
Toxic: Tobacco smoking, inhaled irritants, angiotensin-converting enzyme
inhibitors; Mechanical/Traumatic: Cervical osteophytes, inhaled foreign bod-
ies, acute and chronic aspiration, tympanic membrane irritation, mediastinal mass and lymphadenopathy; Neoplastic: Cancer of the larynx and lung,
endobronchial adenoma, thymoma, mediastinal lymphoma, metastases to
the lung;
ure (CHF), vasculitis (Wegener, Churg–Straus), aortic aneurysm, pulmonary
embolism , pulmonary hemorrhage.
Psychosocial: Cough tics and habits; Vascular: Congestive heart fail-
Coughing is characterized as voluntary or
Infectious: Sinusitis, pharyngitis, laryn-
Chest pain intensied by breathing. See Chest Wall Syndromes, page 339.
Respiratory pain—intercostal neuralgia. Irritation of an intercostal nerve
produces sharp, lancinating, stabbing pain along the nerve's course. The pain
is frequently intensied by respiratory motion, trunk movements, or exposure to cold. Tenderness along the nerve is diagnostic. Pain is greatest near
the vertebral foramen, in the axilla, or at the parasternal line, corresponding
to the nerve’s major cutaneous branches.
CLINICAL OCCURRENCE: Herpes zoster, diabetes mellitus, tabes dorsa-
lis, mediastinal neoplasm, neurobroma (an intercostal mass may be felt),
perineural cysts (Tarlov cyst), vertebral tuberculosis, or obesity with nerve
stretching.
Chest, Trachea, and Respiratory Signs 297
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Herpes zoster (shingles). See Chapter 6, page 144.
Cardiovascular Symptoms
Chest pain. See Chest Pain page 292 and Myocardial Ischemia SixDermatome Pain Syndromes page 350.
Palpitation. Palpitation, awareness of heart action, is described as pounding,
uttering, ip-opping, skipping a beat, missing a beat, stopping, jumping,
and/or turning over. The frequency, regularity, rate, and intensity vary with
the cause. Ask whether the sensation is a single extra beat, a pause, or a series
of beats. If the latter, ask whether it starts and ends abruptly or gradually,
whether it is fast or slow, and whether it is regular or irregular. Have them
tap out the rhythm with their nger. Identify precipitating circumstances and
associated symptoms preceding, accompanying or following the palpitations.
Next, perform a physical exam and obtain an ECG. Ambulatory or homebased electrocardiographic monitoring is recommended for patients who tolerate the palpitations poorly, have heart disease, syncope, falls or sustained
palpitations.
Claudication—exertional limb pain.
and energy requirements. Energy is stored, but oxygen must be continuously delivered to meet the increased demand. Inability to increase blood
ow during exertion produces ischemic muscle pain relieved by rest. Anemia
increases symptoms by loss of oxygen-carrying capacity, whereas polycythemia increases blood viscosity slowing capillary ow.
complains of calf pain at a xed walking distance requiring him/her to stop
or sit for relief. It is consistently reproducible. Claudication can occur in any
exercising muscle; be alert for reproducible exertional extremity or gluteal
pain. Pulses are usually diminished or absent in the popliteal, dorsalis pedis,
and/or posterior tibial arteries of the affected leg.
CLINICAL OCCURRENCE: Atherosclerotic, thrombotic or embolic obstruction
of major leg arteries is most common. Exertional buttock and/or thigh
pain may be true claudication or pseudoclaudication from spinal stenosis.
Predisposing factors are tobacco use and diabetes.
Unilateral claudication in the young—popliteal artery entrapment syndrome.
Entrapment of the popliteal artery by the medial head of the gastrocnemius muscle is a congenital anomaly. A young person develops unilateral
claudication with absent or diminished pulses in the ipsilateral popliteal and
dorsalis pedis arteries.
Cold hands and/or feet. This is caused by regional vasoconstriction to conserve heat. Examine carefully for decreased peripheral pulses or skin changes
suggesting ischemia.
Exercising muscle has high oxygen
The patient usually
CHEST, TRACHEA, AND RESPIRATORY SIGNS
Chest Wall Signs
Thoracic spine abnormalities. See Musculoskeletal Signs, Chapter 13,
page 559, for a complete discussion. Thoracic spine and chest wall deformities can decrease chest compliance, limit respiratory excursions and increase
298 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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FIG. 8-28 Curvatures of the Spine Affecting the Thorax. A. Kyphotic thorax. B. Lordotic thorax.
C. Scoliotic thorax. Note the n arrowing of t he rib inters paces on the ri ght and the acce ntuation o f the inters paces, poste rior
humping of the chest, and elevation of the shoulder on the left.
the work of breathing. In either curved or angular kyphosis (Fig. 8-28A), the spinal exion can x the thorax in the inspiratory position with increased anterior posterior diameter and horizontal ribs. Curved kyphosis appears identical to the barrel chest of pulmonary emphysema, but the auscultatory signs of
emphysema are absent. Conversely, accentuating the lumbar lordosis throws
the thoracic spine backward attening the thoracic cage, creating an expiratory position (Fig. 8-28B). Lateral thoracic spine curvature is usually accompanied by some rotation of the vertebral bodies; only the lateral deviations of
the spinous processes are visible (Fig. 8-28C). Minor functional scoliosis has
a single lateral curve, usually with convexity to the right. Structural curves in
the thorax are associated with an opposite compensatory curve inferiorly, the
line of spinous processes forming an S-shape. The spinous processes always
rotate toward the concave side. On the convex side, vertebral rotation attens
the ribs anteriorly and bulges the posterior chest, lifting the shoulder and
lowering the hip. Viewed from the back, the posterior bulge becomes more
prominent with spine anteexion (Chapter 13, Fig. 13-13, page 540).
Rib cage abnormalities. Rib cage deformities are congenital, or acquired
from surgery, poor nutrition, trauma, or adaptation to changes in the heart,
lungs, and/or diaphragm.
Rib mass. Masses on ribs are caused by callus around an old fracture or
brous dysplasia, neoplasm (e.g., chondrosarcoma), myeloma, desmoid tumor, metastasis of carcinoma, angioma, eosinophilic granuloma, and bone
Chest, Trachea, and Respiratory Signs 299
D. Funnel breast
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A. Rachitic rosary
B. Pigeon breast
FIG. 8-29 Deformities of the Thorax. A. Rachitic rosary. B. Pigeon breast. C. Harrison grooves.
D. Funnel breast. E. Barrel chest.
C. Harrison grooves
E. Barrel chest
cysts, including osteitis brosa cystica. An intercostal nerve neurobroma
may cause visible or palpable swelling near the neck of the rib.
Pigeon breast (pectus carinatum). The sternum protrudes from the narrow
thorax like the keel of a ship (Fig. 8-29B). It can be congenital or acquired. In
rickets, a skeletal disorder caused by prolonged vitamin D deciency in childhood, the softened upper ribs bend inward, forcing the sternum forward increasing the AP dimension at the expense of the width. Vertical grooves form
in the line of the costochondral junctions persisting after the rickets heals.
Pigeon breast also occurs in Marfan syndrome. A similar but asymmetric deformity occurs in severe primary kyphoscoliosis.
Harrison groove (Harrison sulcus). During active rickets, the protuberant rachitic abdomen pushes the plastic lower ribs outward on a fulcrum formed
by the diaphragm’s costal attachments. The line of bending forms a groove or
sulcus in the rib cage extending laterally from the xiphoid process, with aring of the cage below the groove (Fig. 8-29C). The deformity remains when
the rickets heals.
Rachitic rosary. The sternal ends of rachitic ribs bulge at their costochondral junctions. In severe cases of rickets, the outward bulging produces knobs
300 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
Slipping 10th rib
for rib fracture
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A. Compression test B.
FIG. 8-30 Examining for Rib Pain. A. Compression test for rib fracture. Whe n the site of sus pected rib f racture
is located by point tenderness, the sternum is pushed toward the spine with one hand whereas the other hand supports the
patient’s back. The maneuver will elicit pain at the untouched fracture site. B. Slipping tenth rib. When the te nth rib lacks
an anterior attachment, it can slip forward upon the ninth rib during respiratory movements and cause pain.
at the costochondral junctions (Fig. 8-29A) that resolve completely with
treatment.
Funnel breast (pectus excavatum). The reverse of the pigeon breast, the lower
costal cartilages, inferior sternum, and xiphoid process are retracted toward
the spine. Its most mild form is an oval pit near the infrasternal notch. A more
severe deformity forms when the entire lower sternum sinks, signicantly
diminishing the thorax’s AP dimension (Fig. 8-29D). Rickets and Marfan syndrome are causes, but many cases are unexplained.
Barrel chest. Emphysema with chronic airow obstruction increases residual
volume leading to increased AP chest diameter, horizontal ribs, and a depressed diaphragm. Since both the AP and the transverse chest dimensions
enlarge, the ribs become nearly perfect circles (Fig. 8-29E).
Chest and respiratory pain with tenderness. The distinction between respiratory pain with tenderness and chest pain with tenderness is articial, many
conditions presenting in either manner, or with both pain at rest and with
respirations. The patient may recognize the pain as supercial, sharp, and
well localized. The skin and subcutaneous tissues, fat, skeleton, or breasts can
be the site of pain. Careful chest exam localizes the pain to specic structures.
Skin and subcutaneous structures. Inammation, trauma, and neoplasm in
these tissues offer no diagnostic problem, provided they are considered and
searched for. The presence of bruises, lacerations, ulcers, hematomas, masses,
trigger points, or tenderness is usually diagnostic.
Chest, Trachea, and Respiratory Signs 301
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Chest wall pain. Have the patient point to the site of pain. Four maneuvers
identify chest wall pain. (1) Palpate the chest wall for tenderness by applying rm, steady pressure to the sternum, costosternal junctions, intercostal
spaces, ribs, and pectoralis major muscles and their insertions. (2) Adduct the
arms horizontally by lifting one arm after the other by the elbow and pulling
it across the chest toward the contralateral side, with the head rotated toward
the ipsilateral side. (3) Extend the neck as the arms are pulled backward and
slightly upward. (4) Put vertical pressure on the head. If any of these tests
reproduces the patient’s pain, the problem is in the chest wall.
Costochondritis and Tietze syndrome. This is a common cause of chest pain.
The onset may be sudden or gradual. The pain is usually dull and may be
intensied by respiratory motion and shoulder movements. The only physical sign is tenderness at the costochondral junction. There is no swelling and
there are no X-ray ndings. In Tietze syndrome, the pain is accompanied by
tender, fusiform swelling of one or more costal cartilages, often that of the
second rib. The overlying skin is reddened. Pain may radiate to the shoulder,
neck, or arm. There is no lymphadenopathy. The pain may subside in a few
weeks or persist for months, whereas the swelling can persist after the pain
and tenderness subside. The cause is unknown, and the condition must be
distinguished from osteitis, periostitis, rheumatic chondritis, and neoplasm
of the ribs.
Rib fracture.
cinating pain. The patient complains of chest pain with breathing. Usually
there is a history of chest trauma. Without a history of trauma, symptoms
can suggest pleurisy. Ask about recent severe coughing. Inspiration is limited, and palpation discloses point tenderness on a rib. The fracture and/
or crepitation may be felt. With one hand supporting the back, compressing
the sternum with the other hand elicits pain at the untouched fracture site
(Fig. 8-30A).
Cough fracture. The fracture is caused by a shearing force on the rib anterior
to the serratus anterior attachment, that pulls the rib upward, and posterior
to the abdominal external oblique attachment, that pulls the rib downward.
Repeated coughing leads to structural fatigue and a
from the second to the eleventh, most commonly the sixth, can break. After coughing for some time, pain develops with respiratory movements and
coughing. The typical signs of fracture of a rib are present. If rib palpation is
not performed, pleurisy may be misdiagnosed.
Xiphisternal arthritis. The pain is reproduced by palpating the xiphoid
cartilage.
Slipping cartilage. The ligament between two ribs, commonly between the
ninth and tenth costal cartilages, is weak or ruptured. When breathing or with
movement, the tenth rib overrides the ninth producing an audible or palpable
click (Fig. 8-30B). The pain may be falsely attributed to intraabdominal disease.
Palpable pleural friction rub. The inamed pleural surfaces, having lost
their lubricating uid, rub together during breathing producing vibrations
Movement of rib fragments causes well-localized, sharp, lan-
stress fracture. Any rib
302 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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like two pieces of dry leather rubbing together (dry pleurisy). The rub is heard
with the stethoscope or unaided ear as a creaking sound.
Inspiratory interspace retraction. Airway obstruction or decreased lung
compliance leads to increased negative inspiratory intrapleural pressure collapsing the intercostal spaces. The inward movement is usually most evident
in the lower chest. Sudden, violent retractions occur in tracheal obstruction
and severe paroxysms of asthma.
Diminished chest excursion. This points to a lesion in the underlying chest
wall, pleura, or lung; causes include pain, brosis, or consolidation. The
restricted movement may be best observed from the foot of the bed.
Localized chest bulging during expiration—ail chest.
tiguous ribs or the separation of several contiguous costal cartilages destroys
chest wall integrity. Negative intrathoracic pressure during inspiration pulls
the segment inward, while rising intrathoracic pressure during expiration
bulges it outward.
tion and can contribute to respiratory failure in trauma victims. Concurrent
lung contusion, hemothorax, pneumothorax and inspiratory splinting secondary to severe pain should be ruled out in patients with ail chest.
Inspiratory convergence of costal margins. When the dome of the dia-
phragm is attened, contraction pulls the costal margins inward rather than
upward. The normal outward are of the lower costal margins decreases.
Inspiration may move the lower ribs inward. A attened diaphragm can be
caused by pulmonary emphysema with air trapping, large pleural effusions
or pneumothorax.
Fluctuant intercostal masses and sinuses. These ndings usually indicate an
abscess. An abscess lacking surrounding inammation (cold abscess) is usually tuberculosis in a nearby rib. Actinomycosis frequently produces lung
abscesses that invade through the chest wall. An abscess may form when an
untreated pleural empyema points through the interspaces.
Subcutaneous and mediastinal emphysema. Air can enter the chest wall
from the neck, from esophageal rupture, or directly from the lung. Rupture
of alveoli permits air to travel beneath the visceral pleura to the hilum of
the lung, then along the trachea into the neck. The thoracic wall is involved
secondarily by migration from the neck. When a fractured rib or penetrating
foreign-body punctures the pleura, air travels across the pleura to the thoracic
wall causing emphysema in the deep muscle layers and later the subcutaneous tissues. Crepitus is the sensation imparted small globules of air mov-
ing in the tissues under the palpating ngers. Soft-tissue crepitus can be the
rst clue to rupture of the alveoli, pleura, or esophagus. The air invading the
mediastinum may produce a distinctive systolic precordial sound described
as a crunch, the Hamman sign. Soft tissue compression in the neck can produce
massive neck and face swelling accompanied by cyanosis.
The paradoxical chest movements decrease minute ventila-
Fracture of several con-
Pulsating sternoclavicular joint. There is an enlarged major vascular structure impinging posteriorly on the manubrium. It is seen with dissection of the
Chest, Trachea, and Respiratory Signs 303
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aortic arch, ruptured saccular aortic aneurysm, persistent right aortic arch, or
fusiform aneurysms of the innominate, carotid, or subclavian artery.
Trachea Signs
Lateral deviation of the trachea. At the level of the suprasternal notch lateral
deviation is caused by a mass higher in the neck, such as cervical goiter or
enlarged lymph nodes (Chapter 7, page 238, Fig. 7-68), or by a mediastinal
shift within the chest. Below the suprasternal notch, an eccentric retrosternal
goiter can push the trachea to one side. The trachea and mediastinum deviate
to the opposite side with pleural effusion and tension pneumothorax. Atelectasis and reduced lung volume from brosis of the lung or pleura displace the
trachea to the ipsilateral side.
Trachea xation. Palpate the cricoid cartilage or tracheal rings with the thumb
and index nger and ask the patient to swallow. Normally, the larynx and trachea rise cephalad. Grasp the trachea gently and move it side to side; usually,
it is easily mobile. Fixation is normal when the neck is extended. Abnormal
xation occurs with pulmonary emphysema, adhesive mediastinitis, aortic
aneurysm, and mediastinal neoplasm.
Lung, Pleura, and Respiratory Signs
Hiccup. Hiccup is a sudden involuntary diaphragm contraction producing
an inspiration interrupted by glottis closure causing a characteristic sharp
sound. It is thought to be mediated centrally through the phrenic nerve, by
direct phrenic nerve stimulation, or by direct irritation of the diaphragm. The
contractions occur two or three times each minute.
CLINICAL OCCURRENCE: Hiccough Without Organic Disease: Excessive
laughter, tickling, aerophagia, tobacco smoking, alcohol ingestion; Central
Nervous System Diseases: Encephalitis, meningitis, vertebrobasilar ischemia,
intracranial hemorrhage, intracranial tumor, uremia, degenerative changes in
brain and medulla, tabes dorsalis; Mediastinal Disorders: Phrenic nerve trauma,
enlarged mediastinal lymph nodes (tuberculosis, malignant neoplasm, brosis), obstructed bronchus, adherent pericardium, enlarged heart, myocardial
infarction (MI), obstructed esophagus; Pleural Irritation: Pneumonia with pleurisy; Diaphragm and Abdominal Disorders: Diaphragmatic hernia, subphrenic
abscess, subphrenic peritonitis, hepatic neoplasm, gumma or abscess, stomach
cancer, infarcted spleen, acutely obstructed intestine, acute hemorrhagic pancreatitis, after upper abdomen operations, diaphragm stimulation by cardiac
pacemaker.
Hemoptysis. Cough productive of blood is hemoptysis. The bleeding lesion
may be anywhere from the nose to the alveoli. Expectorated blood usually comes from the upper respiratory tract while blood in the bronchial
tree induces coughing. Patients may not distinguish which is occurring,
so both upper and lower respiratory tract disorders must be considered.
Coagulopathy and thrombocytopenia may contribute to the severity and volume of hemoptysis, but rarely cause signicant hemoptysis in the absence of
other signicant disease.
CLINICAL OCCURRENCE: Upper Respiratory Tract: Epistaxis, bleed-
ing from the oropharynx, gum bleeding, laryngitis, laryngeal carcinoma,
hereditary hemorrhagic telangiectasia; Tracheobronchial Tree: Acute and
304 CHAPTER 8: The Chest: Chest Wall, Pulmonary, and Cardiovascular Systems; The Breasts
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chronic bronchitis, trauma from coughing, bronchiectasis, bronchial carcinoma, broncholiths, foreign-body aspiration, erosion by aortic aneurysms;
Lungs: Infections (pneumonia, especially caused by Klebsiella, lung abscess,
tuberculosis, fungal infections, amebiasis, hydatid cyst), pulmonary embolism with infarction, trauma, pulmonary hemorrhage (vasculitis, especially
granulomatosis with polyangiitis-Wegener, Goodpasture syndrome), idiopathic pulmonary hemosiderosis, lipoid pneumonia;
stenosis, CHF, arteriovenous stula, anomalous pulmonary artery, hypertension;
lant mediations.
Snoring. Snoring is produced by vibrations of the lax soft palate during sleep,
often in association with obstructive sleep apnea. A similar sound results from
uncleared secretions in the upper respiratory tract. When the latter occurs
during severe illness, it is frequently a grave prognostic sign, the death-rattle.
Stridor. A high-pitched whistling or crowing sound is caused by inspiration
through a narrow glottis. It occurs with vocal cord edema, neoplasm, diphtheritic membrane, pharyngeal abscess, and foreign body in the larynx or trachea. It may signal impending airway closure and asphyxiation.
Vibratory Palpation
Diminished or absent vocal fremitus. Thickened pleura, pleural effusion,
pneumothorax, or loss of lung parenchyma (e.g., emphysema) reduce transmission of vibrations to the chest wall diminishing or eliminating vocal
fremitus.
Hematologic: Thrombocytopenia, leukemia, hemophilia, anticoagu-
Cardiovascular: Mitral
Increased vocal fremitus. Tense lung septae and uid-lled alveoli increase
transmission of vibrations. Consolidating pneumonia and inammation
around a lung abscess in contact with a bronchus or cavity in the lung,
transmits bronchotracheal vibrations more efciently than air-lled alveoli,
increasing vocal fremitus.
Sonorous Percussion
Normal dullness in the lateral decubitus position. If a patient can’t sit, percuss the back with the patient on one side then the other. This is not optimal
since it is difcult to interpret the percussion sounds. The damping effect of
the mattress causes a band of dullness nearest the bed. Directly above this
band is an irregular area of dullness caused by lung compressed by the body’s
weight. If body weight causes a lengthwise sag, the spine exes laterally compressing the chest wall and lung in the upward hemithorax. This produces
another area of dullness (Fig. 8-31).
Abnormal sonorous percussion. Abnormally distributed normal sounds
can be pathologic. The lung is normally resonant. As consolidation occurs its
density increases producing, successively, impaired resonance, dullness, and
atness. Thickened pleura produces dullness. Pleural uid gives dullness to
atness in a dependent distribution.
Dullness replacing resonance in the upper lung. This suggests neoplasm,
atelectasis, or consolidation.
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FIG. 8-31 Areas of Percussion Dullness Created by the Lateral Decubitus Position. The lowest green-
shaded area is dull from compression of the thorax against the mattress. Immediately above, dullness is produced by compression of the lung from the body weight. In the opposite lung, dullness results by lateral deviation of the spine as it follows the
sag in the mattress and compresses the lung.
Dullness replacing resonance in the lower lung. Pleural effusion, pleural
thickening, and elevation of the diaphragm are specic to this area; neoplasm,
atelectasis, and consolidation are other causes.
Flatness replacing resonance or dullness. Almost invariably, atness results
from massive pleural effusion.
Hyperresonance replacing resonance or dullness. When hyperresonance replaces resonance, or the area of hepatic and cardiac dullness is resonant or
hyperresonant, consider emphysema. Asymmetric hyperresonance is suggestive of pneumothorax, or the interposition of gas-lled gut are suggested.
Tympany replacing resonance. This occurs almost exclusively with a large
pneumothorax and tends to be unilateral. Tension pneumothorax is associated with tracheal deviation to the opposite side, elevated jugular venous
pressure, tachycardia, and hypotension.
Auscultating Breath Sounds: Several breath sounds with distinctive qualities
are recognized, all characterized by rising pitch during inspiration and falling
pitch during expiration (Doppler effect). The duration and force of inspiration and expiration affect the breath sounds.
Normal breath sounds—vesicular breathing. While the ratio of inhalation
to exhalation measured by air ow and chest movement in normal breathing is approximately 1:2, this is not consistently reected by auscultation in
normal subjects. Quiet tidal breathing produces vesicular breath sounds characterized by a longer inspiratory than expiratory phase (Fig. 8-32), the later
portion of expiration being silent. Vesicular breath sounds are normal over
the entire lung, except over the manubrium and in the upper interscapular
region, where bronchovesicular sounds are heard. Breath sounds are faintest
over the thinner portions of the lungs.
Cogwheel breathing. This is identical with vesicular breathing except that
inspiration is broken by short pauses, giving the impression of jerkiness
(Fig. 8-32). It has no pathologic signicance.
Bronchovesicular breathing.
Bronchovesicular bronchial breathing arise from
more efcient sound transmission through compressed or consolidated lung.
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