Chest Movement During Respiration

The next part of the chest inspection is to observe the patient's chest movement during respiration.
Use of Accessory Muscles

Using accessory muscles implies that the forced expiratory volume in 1 second (FEV1) is decreased to 30% of normal, which is usually between 1.0 and 1.5 liters per second. In such cases, a sitting patient may lean forward with hands propped on the knees. Sternocleidomastoid tension is often present, which is indicated by tense neck muscles, with the muscle being thicker than the patient's thumb.
Diaphragm Movement

Diaphragm movement can sometimes be seen with inspiration as a flickering along the lateral chest. A loss of this movement on one side indicates a paralyzed hemidiaphragm (Litten's sign). Diaphragmatic movement is usually not visible in overweight people.
Chest Symmetry

To check chest symmetry, observe the sides of the chest from the patient's back. Symmetric but decreased expansion suggests extreme old age or emphysema. Decreased chest expansion resulting from substernal goiter is Bryson's sign. Symmetric but increased expansion suggests paralysis of the diaphragm with compensatory intercostal contractions. Asymmetric expansion suggests pneumonia, a large pleural effusion, rib fracture, or pneumothorax. With hemiplegia, the affected side moves more than the unaffected side during quiet respiration but becomes more sluggish with forced respiration (Jackson's breathing sign).
Paradoxic Chest Movements

Paradoxic sternal movement suggests trauma or multiple rib fractures. Paradoxical abdominal movement, in which the abdomen moves out with expiration, can be a sign of a paralyzed diaphragm, respiratory failure, or fatigue during an exacerbation of COPD. Intermittent paradoxic abdominal movement may be caused by muscle fatigue from respiratory pump failure (respiratory alternans). Epigastric depression with inspiration suggests large pericardial effusion or a paralyzed diaphragm (Duchenne's sign).
Intercostal Retractions

Intercostal retractions suggest an imbalance between the negative pressure generated and the ability of the lung to expand. Generalized retractions are a sign of significant inspiratory obstruction. Focal retractions suggests bronchial obstruction, flail chest, or constrictive pericarditis (Broadbent's sign) if over the heart. With flail chest, the ribs themselves show paradoxic movement. Unilateral loss of normal retractions suggests pleural effusion, pneumothorax, or consolidation.
Bulging Interspaces and Apices

Bulging interspaces on inspiration suggests a tension pneumothorax, a large pleural effusion, emphysema, or reactive airways disease. Elevation of the supraclavicular space in an asynchronous manner suggests pleural effusion as the lung floats like a cork on the pleural fluid. The side with the fluid will elevate first.
The Costal Angle (Hoover's sign)

An especially useful observation is to watch the costal angle during respiration (Hoover's sign). Normally this angle should increase as the intercostal muscles open the chest as the diaphragm contracts. Hoover's sign is paradoxic closing of the costal angle with inspiration because of the loss of intercostal contribution secondary to air trapping. This sign indicates chronic obstruction and an FEV1 less than 1 liter per second. Restrictive lung disease by itself does not produce Hoover's sign.
Unilateral Movements

If there are unilateral movements, consider the source of the inequality. One side moving more laterally implies significant atelectasis if it is pulling up from above or subphrenic abscess if pushing up from below. If one side moves more medially than the other, consider intercostal paralysis, pleural effusion, or tension pneumothorax. Unilateral narrowing of the intercostal spaces suggests pneumothorax or inflammation (Przewalski's sign). If you see decreased medial movement with normal lateral movement, consider cardiac enlargement, severe right heart failure, and pericardial effusion.