Pulmonary Assessment

Ed Litwin, BS, RRT

Pulmonary Assessment

• ABG’s• CXR• PFT’s

Pulmonary Assessment

InspectionPalpation

PercussionAuscultation

Pulmonary Assessment:Inspection

• Respiratory Pattern

• Chest Abnormalities

• Trachea Position

• Retractions• Symmetry

• Accessory Muscle Use

• Splinting• Level of

Consciousness• Cyanosis

Respiratory Pattern

• Normal Adult Rates• 10 – 16 for quiet effortless

breathing• 20 – 30 for hypoxemia, pain, fear• RR > 30 can’t be maintained for

long• Dramatic Δ in rate may indicate

problems!

Inspection: Respiratory Pattern

• Hyperventilation• Hypoxemia• Pain, fear• Metabolic Acidosis• Hyperthermia• Midbrain lesion/trauma• Restrictive lung disease

Inspection:Respiratory Pattern

• Hypoventilation• Narcotic effects• Sedatives, alcohol• Incomplete reversal from

anesthesia• Hypothermia

Inspection:Respiratory Pattern

• COPD’ers• Lower rate• Prolonged expiration• Pursed lip expiration• Tripod position

Breathing Pattern:Cheyne-Stokes

Breathing Pattern:Biot’s/Ataxic Breathing

Breathing Pattern:Kussmaul’s

Chest Abnormalities:Pectus excavatum/carinatum

Chest Abnormalities:Scars

Chest Abnormalities:Barrel Chest

Inspection:Trachea Position

• Deviates Towards Atelectasis, Fibrosis

• Deviates Away From Pleural Effusion, Tension Pneumothorax

Inspection:Retractions

• Retractions are caused by high work of breathing or airway blockage

• Check the top of the ribcage and intercostal spaces

• Bulging between ribs may indicate a pneumothorax

Inspection:Chest Symmetry

• Are both sides of the chest moving equally?

• movement on one side:• Hemidiaphragm paralysis• Pneumothorax• Old lung resection• Fibrosis

Inspection:Accessory Muscle Use

• High WOB• Hypoxemia• Obstruction• COPD’ers

Inspection:Splinting

• Splinting –protecting or favoring a side• Trauma• Incision• Check during

palpation

Inspection:Level of Consciousness

• Decreased sensorium, somulence, confusion, or coma may be caused by hypoxia and/or PaCO2

• Get an ABG!

Inspection:Cyanosis

• Questionable indicator (late)

• Central vs. peripheral

• Cyanosis when pink before

• Can be cyanotic without being hypoxic

Palpation

• Collecting information through touch

Palpation

• Trachea• Check with fingers, should enter at

middle of the suprasternal notch• Chest Symmetry

• Position hands on both sides of the spine or sternum

• Thumbs should move equal amounts from midpoint with inspiration

• See effects of scoliosis, lordosis

Palpation:Tenderness on Palpation

• Incisional• Cracked ribs, tissue trauma –

overlooked, fall

Palpation:Crepitus

• Open chest wound

• Fresh CT’s, trache

• Pneumothorax/ tension pneumo

Palpation:Secretions

Palpation

• Tactile Fremitus• Fluid increases

sound transmission

• Used to assess consolidation, atelectasis

Percussion• Five Notes

• Flat, dull, resonant, hyperresonant, tympanic

• Uses• Diaphragm

excursion• Pleural effusion• Pneumothorax

Auscultation

• Which lobe are you listening to?

• What lung sounds are you hearing?

Auscultation:Lung Borders

• Apex rises 2 – 4 cm above inner third of clavicle

• Inferior borders at:• 6th rib mid-clavicular

line• 8th rib mid-axillary

line• 10th rib mid-scapular

line

Oblique Fissure

• Separates lower lobes from rest of lungs• Runs from T3, along lower scapular border,

just below 4th rib mid-axillary, and ends at 6th rib mid-clavicular line

• Anything below and behind this is LL’s

Horizontal Fissure

• Separates RUL from RML• Runs from ~4th rib mid-axillary line to

sternum• Usually crosses at the nipple line

Auscultation Landmarks

• Sternal angle is at the 2nd intercostal space – next rib down is 3rd

• With the patient’s neck flexed, biggest bump is C7, next T1, T2, then T3

Auscultation

Listen to anterior, posterior, and lateral surfaces. Cover all the bases!!

Listening Techniques

• Sit Patient Up• Deep Breathe Through Mouth• Stethoscope on Skin• TV, Radio, Visitors OFF!• Systematic Comparison of L and

R, and All Lobes

Normal Breath Sounds

• Vesicular

• Tracheal or Bronchial

• Bronchovesicular

Vesicular Breath Sounds

• Heard over the majority lung periphery

• Medium pitch and loudness

• Inspiration is louder and longer than expiration

Insp.

Exp.

Insp.

Tracheal/Bronchial Breath Sounds

• Heard over and around trachea

• Loud, high pitched, harsh, “tubular”

• E is louder and longer then I

• Short pause between I and E

Insp.

Exp.

Bronchovesicular• Combination of the

other 2• Heard around

sternum, between scapula, anterior RUL

• I and E are equal duration and loudness, no pause

• More muffled than Bronchial

Insp. Exp.

Adventitious (Abnormal) Breath Sounds

One Man’s Rhonchi is Another Man’s Rale

Several groups are advocating for changes in breath sound terminology. Wheezes, rhonchi, and crackles are used with descriptors of tone, pitch, and I or E. I’ll try to blend old and new terminology here.

Adventitious (Abnormal) Breath Sounds

• Bronchial or Bronchovesicular where you should hear vesicular• Indicates fluid filled or

consolidated areas• Fluid transmits vibrations better

than air• Breath sounds are “telegraphed”

from large airways to periphery

Adventitious (Abnormal) Breath Sounds

• Rhonchi/Wheezes• Continuous “musical” notes• Primarily heard on E• Large airways=low pitch=sonorous

rhonchi (“Snoring” type of sound)• Small airways=high

pitch=wheeze=sibilant rhonchi• Caused by narrowed airways from

secretions, edema, bronchospasm

Adventitious (Abnormal) Breath Sounds

• Rales/Crackles• Discontinuous notes, “bubbling”,

“pops”, “fizz”, moist or dry• Mainly heard on I, often clears

with coughing• Lg airways=low pitch=bubbling

coarse rales/crackles• Sm airways=high

pitch=fine/velcro/dry rales/crackles

Adventitious (Abnormal) Breath Sounds

• Rubs• Heard at lung apices• End of I and beginning of E• Like creaking leather or balloon• From pleural/visceral membranes

rubbing• Pleurisy, some neoplasms

Adventitious (Abnormal) Breath Sounds

• Diminished/Absent Breath Sounds• Fluid, blood, or air between lung

and chest wall• Complete airway blockage (mucus,

tumor, foreign body) causes diminished/absent breath sounds

• Pneumo, severe emphysema, resection, obesity, effusion

Extrapulmonary Signs

• Cyanosis – 5 gm of Hgb/100 ml of blood is desaturated

• Sputum - check:• Color• Amount• Thickness• Presence, color and amount of blood• odor

Extrapulmonary Signs

• Clubbing• Seen in

pulmonary, cardiovascular, and hepatobiliarydiseases

• May indicate a chronic purulent resp. disorder