[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Respiratory system](https://durgical.com/en/clinical-exam/#a-respiratory) › Chest inspection: shape, expansion, accessory muscles and retractions [Clinical exam](https://durgical.com/en/clinical-exam/) · [Respiratory system](https://durgical.com/en/clinical-exam/#a-respiratory) # Chest inspection: shape, expansion, accessory muscles and retractions - Exam technique Look at the chest and the breathing before touching: shape, symmetry, rate and effort say a lot about the lungs. Updated 2026-11-01 **See it in 3D:** [Ribs (back part)](https://durgical.com/en/anatomy/ribs/) · [Sternum](https://durgical.com/en/anatomy/sternum/) · [Sternocleidomastoid](https://durgical.com/en/anatomy/sternocleidomastoid-muscle/) · [Scalenes](https://durgical.com/en/anatomy/scalenus-anterior-muscle/) · [Diaphragm](https://durgical.com/en/anatomy/diaphragm/) · [External intercostals](https://durgical.com/en/anatomy/external-intercostal-muscles/) ## Key points - Count breaths for a full minute without telling the patient, because awareness changes the pattern. - Sternocleidomastoid and scalene use at rest, retractions and nasal flaring mean increased work of breathing. - A barrel chest (anteroposterior diameter close to the transverse) suggests hyperinflation but is not specific for emphysema. - Reduced expansion of one hemithorax points to the diseased side (effusion, pneumothorax, atelectasis, large consolidation or pain). - Paradoxical abdominal breathing (the abdomen moves in on inspiration) suggests diaphragm fatigue or paralysis. - Also look for cyanosis, clubbing, the tripod position and pursed-lip breathing. ## What it is Inspection is the first step of the respiratory exam. The examiner looks at chest shape, the rate, rhythm and depth of breathing, symmetry of expansion and signs of increased work of breathing. Inspection alone often points toward obstruction, restriction or respiratory failure. ## Landmark anatomy - The diaphragm is the main inspiratory muscle; as it descends it pushes the viscera down and the abdomen moves out on inspiration. - The sternocleidomastoid and scalenes lift the sternum and the upper ribs; at rest they should not contract. - The external intercostals raise the ribs; retractions appear when very negative intrathoracic pressure pulls the intercostal spaces in. - The sternal angle (angle of Louis) marks the second rib and roughly the tracheal bifurcation: the landmark for counting ribs. ## Technique, step by step - Explain the exam, ensure privacy and expose the whole chest in good light; seat the patient if possible. - Note the general picture: tripod position, orthopnea, ability to speak full sentences, skin and lip colour. - Count the respiratory rate for one minute while appearing to take the pulse; note rhythm and depth. - Assess shape: anteroposterior versus transverse diameter, pectus excavatum or carinatum, kyphoscoliosis, scars. - Compare expansion of both sides from the front, from behind and in profile during a deep breath. - Look for accessory muscle use, intercostal, supraclavicular or subcostal retractions, nasal flaring and pursed lips. - Watch chest-abdomen coordination: both should rise together on inspiration; an abdomen that sinks in is abnormal. - Look at the hands and nails (cyanosis, clubbing) and the neck (jugular distension, tracheal position). ## Abnormal findings - Barrel chest, pursed lips and prolonged expiration: chronic airflow obstruction (COPD). - Retractions, nasal flaring and accessory muscle use: respiratory distress of any cause, very useful in children. - A wall segment moving paradoxically: flail chest from multiple rib fractures. - Kussmaul breathing (deep and regular) in metabolic acidosis; Cheyne-Stokes in severe heart failure or brain injury. - One-sided reduced expansion: side of an effusion, pneumothorax, atelectasis or pleuritic pain. ## Common errors - Counting for 15 seconds and multiplying misreads irregular patterns. - Examining a clothed or supine patient hides asymmetry and deformity. - Calling fast breathing from anxiety or pain 'respiratory distress' without checking the other signs. ## Memory aid Eyes before hands: watch how the patient breathes, then touch. ## Test yourself Think of the answer, then tap the question to see it. ## Why is the respiratory rate counted without telling the patient? Because patients who know they are watched change their rate and depth; it is counted for one minute while appearing to take the pulse. ## What does an abdomen that moves inward on inspiration suggest? Paradoxical breathing from diaphragm fatigue or paralysis; in a patient in distress it may herald imminent failure. ## Which inspiratory accessory muscles are seen in the neck? The sternocleidomastoids and scalenes; their contraction at rest means increased work of breathing. ## What does a chest wall segment that sinks on inspiration after trauma mean? A flail chest, from several ribs broken in more than one place. [Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/chest-inspection-shape-expansion-accessory-muscles-and-retractions/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Ribs (back part)](https://durgical.com/en/anatomy/ribs/) - [Sternum](https://durgical.com/en/anatomy/sternum/) - [Sternocleidomastoid](https://durgical.com/en/anatomy/sternocleidomastoid-muscle/) - [Scalenes](https://durgical.com/en/anatomy/scalenus-anterior-muscle/) - [Diaphragm](https://durgical.com/en/anatomy/diaphragm/) - [External intercostals](https://durgical.com/en/anatomy/external-intercostal-muscles/) ## Related - [Respiratory rate and breathing patterns](https://durgical.com/en/clinical-exam/respiratory-rate-and-breathing-patterns/) - [Chest palpation: expansion and tactile fremitus](https://durgical.com/en/clinical-exam/chest-palpation-expansion-and-tactile-fremitus/) - [Respiratory distress and respiratory failure: the signs](https://durgical.com/en/clinical-exam/respiratory-distress-and-respiratory-failure-the-signs/) - [Pulmonary hyperinflation syndrome (emphysema)](https://durgical.com/en/clinical-exam/pulmonary-hyperinflation-syndrome/) - [Digital clubbing and nail signs](https://durgical.com/en/clinical-exam/digital-clubbing-and-nail-signs/) - [Pallor, cyanosis and jaundice](https://durgical.com/en/clinical-exam/pallor-cyanosis-and-jaundice/) ## Related conditions - [Chronic obstructive pulmonary disease (COPD)](https://durgical.com/en/conditions/chronic-obstructive-pulmonary-disease/) - [Asthma](https://durgical.com/en/conditions/asthma/) - [Flail chest](https://durgical.com/en/conditions/flail-chest/) - [Acute respiratory failure (hypoxaemic and hypercapnic)](https://durgical.com/en/conditions/acute-respiratory-failure/) [← All of the clinical exam](https://durgical.com/en/clinical-exam/) Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis. Sources: [Chronic obstructive pulmonary disease (COPD): MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000091.htm) (MedlinePlus, U.S. National Library of Medicine, 2024); [Asthma: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000141.htm) (MedlinePlus, U.S. National Library of Medicine, 2024). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/chest-inspection-shape-expansion-accessory-muscles-and-retractions/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/chest-inspection-shape-expansion-accessory-muscles-and-retractions/