respiratory assessment

Assessment of the Chest and Lungs

Functions of the Respiratory System

Ventilation Diffusion and Perfusion Control of Breathing

Functions

Ventilation Movement of air into and out of the lungs Inspiratory phase Expiratory phase

Functions

Hypoventilation Slow, shallow breathing Causes CO2 to build up in the blood

Acidosis

Hyperventilation Rapid, deep breathing Causes CO2 to be blown off

Alkalosis

Functions

Diffusion and Perfusion Gas exchange across the alveolar-

pulmonary capillary membranes Control of breathing

Influenced by neural and chemical factors Pons, medulla, chemoreceptors in the

carotid body Stimulus for breathing

Increased carbon dioxide - PRIMARY

Anatomical Structures

Reference points for pinpointing findings from the physical examination Topographical Landmarks Reference Lines

Topographical Landmarks

Nipples Manubriosternal junction (Angle of Louis)

Point at which the 2nd rib articulates with the sternum

Suprasternal notch Costal Angle

Usually no more than 90 degrees Ribs insert at approximately 45 degree angles

Clavicles

Manubrium

Manubriosternal junction

(Angle of Louis)

Nipple

Costal Angle

Reference Lines

Anterior Chest Midsternal line Anterior axillary lines Midclavicular lines

Posterior Chest Vertebral line Midscapular lines

Axilla Anterior axillary lines Midaxillary lines Posterior axillary lines

Anterior Chest

Posterior Chest

Axilla

Anatomy

Anatomy Points to Remember

Lungs are symmetric Lungs are divided into lobes

Right lung = 3 lobes Left lung = 2 lobes

Primary muscles of respiration Diaphragm – divides chest from abdomen External intercostal muscles Accessory muscles

Anatomy Points to Remember

Upper Airway Nose, pharynx, larynx, intrathoracic

trachea Functions in respiration

Conduct air to lower airway Filter to protect lower airway Warm and humidify inspired air

Anatomy Points to Remember

Lower Airway Trachea, bronchi, bronchioles

Functions in respiration Conduct air to alveoli Clear mucociliary structures

Alveoli Functional unit

Gas exchange Production of surfactant

Anatomy Points to Remember

Lower Airway Trachea splits into left and right

mainstem bronchi which are further subdivided into bronchioles Right bronchus is shorted, wider and more

upright than the left Functions in respiration

Conduct air to alveoli Clear mucociliary structures

Chest Anatomy

Web Anatomy: http://www.gen.umn.edu/faculty_staff/jensen/1135/webanatomy/

History

Chief Complaint and HPI Cough Shortness of breath/Dyspnea

Cough

Onset – sudden, gradual Duration Nature – dry, moist, hacking, barking Sputum – amount, color, odor Severity – disrupts activities Associated symptoms – sneezing, dyspnea, fever,

chills, congestion, gagging What brings it on? – anxiety, talking, activity What makes it better? What has been tried? – medications, treatments Anything similar in the past?

Shortness of Breath (SOB) / Dyspnea

Onset – sudden, gradual Duration Severity – disrupts activities Associated symptoms – night sweats, pain, chest

pressure, discomfort, ankle edema, diaphoresis, cyanosis

What brings it on? – position, time of day, exercise, allergens, emotions

What makes it better? What has been tried? – medications, inhalers, oxygen Anything similar in the past?

History

Past Health History Lung disease or breathing problems

Frequent severe colds, asthma, emphysema, bronchitis, pneumonia, tuberculosis

Last PPD and/or chest x-ray Allergies Medication use

Family History

History

Personal and Social History Tobacco Alcohol Drugs Home environment Occupational environment Travel

Health Promotional Activities

Physical Examination

Equipment and Techniques

Equipment Stethoscope

Techniques Inspection Palpation Percussion Auscultation

Inspection

General Appearance Posturing Breathing effort Trachea position

Midline

Inspection

Chest Wall Configuration Form Symmetry Muscle development Anterior-Posterior (AP) diameter

Approximately ½ the transverse diameter Transverse: Anterior-Posterior = 2:1

Costal angle 90 degrees or less

Inspection

Oxygenation: cyanosis Nails Skin Lips

Respiratory Effort Respiratory rate and depth Breathing pattern Chest expansion

Palpation

Trachea – for position Chest wall – for symmetry

Palpation

Thoracic Expansion (Excursion) Place both thumbs at about 7th rib

posteriorly along the spinal process Extend the fingers of both hands

outward over the posterior chest wall

Have the person take a deep breath and observe for bilateral outward movement of thumbs

Normal: bilateral, symmetric expansion

Abnormal: unilateral or unequal

Click on the pictures to view video

Palpation

Vocal (Tactile) Fremitus Use palmar or ulnar surfaces of hands Systematically position hands over both sides

of posterior chest Have person repeat “1 – 2 – 3” or “99” as you

move from the apices to the bases Normal: bilaterally symmetrical vibrations Decreased or absent: obstruction of

transmission 0bronchitis, emphysema) Increased: consolidation (compression) of lung

tissue (pneumonia)

Auscultation

Auscultate in a systematic manner Compare one side to the other Listen one full respiration at each spot Displace breast tissue to listen directly

over chest wall DO NOTDO NOT listen through gowns, clothes,

etc. Place your stethoscope over bare skin

Auscultation

Evaluate posterior, lateral, and anterior chest

Instruct person to sit upright and breathe in and out slowly through the mouth This makes it easier to hear the air

movement Use the diaphragm of the stethoscope Move from the apices to the bases

Auscultation

Evaluate for normal sounds

Sound Pitch Intensity

Quality I:E Location

Bronchial High Loud Blowing/ hollow

I < E Trachea

Bronchovesicular

Moderate

Moderate Combination I = E Between scapulae,1st & 2nd ICS lateral to sternum

Vesicular Low Soft Gentle rustling/ breezy

I > E Peripheral lung

Auscultation

Evaluate for adventitious soundsSound Intensity/

PitchI/E Quality Clear with

Cough Crackles/ Rales

Soft (fine)/ HighLoud (coarse)/ Low

I Discontinuous, nonmusical, brief

Possibly

Wheeze High E Continuous musical sounds

Possibly

Ronchi Low E Continuous snoring sounds

Possibly

Pleural Friction Rub

I & E Continuous or discontinuous creaking or brushing sounds

Never

Stridor I Continuous, crowing Never

Auscultation

Copy this URL into your Web browser to hear normal and abnormal lung sounds : http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm

Developmental Variations

Neonates Measure the chest circumference

Usually 2-3 cm smaller than head circumference Chest is round (i.e. AP diameter = transverse)

Obligate nose breathers Periodic breathing is common

Sequence of vigorous breathing followed by apnea for 10-15 seconds

Only concern if it is prolonged or baby becomes cyanotic

Developmental Variations

Neonates Breathing is diaphragmatic and

abdominal Signs of compromise

Stridor (“crowing”) Grunting Central cyanosis Flaring nares

Developmental Variations

Infants and Young Children Roundness of the chest persist for first 2

years Chest walls are thinner than the adult’s

Breath sounds may sound louder, and more bronchial than the adult Bronchovesicular sounds may be heard

throughout the chest

Developmental Variations

Pregnancy Costal angle increases to about 105

degrees in the third trimester Dyspnea and orthopnea are common Breathes more deeply

Developmental Variations

Older Adult Chest expansion is often decreased Bony prominences are marked AP diameter is increased with respect to

transverse (but not 1:1)

Videos of Thorax and Lung Assessment

Copy these URLs into your Web browser http://www.conntutorials.com/chapter5.h

tmlOR

http://medinfo.ufl.edu/other/opeta/chest/CH_main.html