511CHAPTER 26 Respiratory System

Continued

TABLE 26-7 COMMON ASSESSMENT ABNORMALITIESRespiratory System

FINDING DESCRIPTION POSSIBLE ETIOLOGY AND SIGNIFICANCE*InspectionPursed-lip breathing Exhalation through mouth with lips pursed together to

slow exhalationCOPD, asthma; suggests breathlessnessStrategy taught to slow expiration, dyspnea

Tripod position; inability to lie flat

Learning forward with arms and elbows supported on overbed table

COPD, asthma in exacerbation, pulmonary edemaIndicates moderate to severe respiratory distress

Accessory muscle use; intercostal retractions

Neck and shoulder muscles used to assist breathing; muscles between ribs pull in during inspiration

COPD, asthma in exacerbation, secretion retentionIndicates severe respiratory distress, hypoxemia

Splinting Voluntary in tidal volume to pain on chest expansion Thoracic or abdominal incision; chest trauma, pleurisy AP diameter AP chest diameter equal to lateral; slope of ribs more

horizontal (90 degrees) to spineCOPD, asthma, cystic fibrosis; lung hyperinflation;

advanced ageTachypnea Rate >20 breaths/min; >25 breaths/min in elderly Fever, anxiety, hypoxemia, restrictive lung disease

Magnitude of above normal rate reflects increased work of breathing

Kussmaul respirations Regular, rapid, and deep respirations Metabolic acidosis; in rate aids body in CO2 excretionCyanosis Bluish color of skin best seen in lips and on the palpebral

conjunctiva (inside the lower eyelid)Reflects 5-6 g of hemoglobin not bound with oxygen; oxygen transfer in lungs, cardiac output; nonspecific, unreliable indicator

Finger clubbing Depth, bulk, sponginess of distal portion of finger (see eFig. 26-2 on the Evolve website for this chapter)

Chronic hypoxemia; cystic fibrosis, lung cancer, bronchiectasis

Abdominal paradox Inward (rather than normal outward) movement of abdomen during inspiration

Inefficient and ineffective breathing pattern; nonspecific indicator of severe respiratory distress

PalpationTracheal deviation Leftward or rightward movement of trachea from normal

midline positionNonspecific indicator of change in position of mediastinal

structures; medical emergency if caused by tension pneumothorax; trachea deviates to the side opposite the collapsed lung

Altered tactile fremitus Increase or decrease in vibrations In pneumonia, pulmonary edema; in pleural effusion, lung hyperinflation; absent in pneumothorax, atelectasis

Altered chest movement Unequal or equal but diminished movement of two sides of chest with inspiration

Unequal movement caused by atelectasis, pneumo-thorax, pleural effusion, splinting; equal but diminished movement caused by barrel chest, restrictive disease, neuromuscular disease

PercussionHyperresonance Loud, lower-pitched sound over areas that normally

produce a resonant soundLung hyperinflation (COPD), lung collapse (pneumothorax),

air trapping (asthma)Dullness Medium-pitched sound over areas that normally produce a

resonant sound Density (pneumonia, large atelectasis), fluid pleural

space (pleural effusion)

AuscultationFine crackles Series of short-duration, discontinuous, high-pitched sounds

heard just before the end of inspiration; result of rapid equalization of gas pressure when collapsed alveoli or termi nal bronchioles suddenly snap open; similar sound to that made by rolling hair between fingers just behind ear

Idiopathic pulmonary fibrosis, interstitial edema (early pulmonary edema), alveolar filling (pneumonia), loss of lung volume (atelectasis), early phase of heart failure

Coarse crackles Series of long-duration, discontinuous, low-pitched sounds caused by air passing through airway intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa; evident on inspiration and, at times, expiration; similar sound to blowing through straw under water; increase in bubbling quality with more fluid

Heart failure, pulmonary edema, pneumonia with severe congestion, COPD

Rhonchi Continuous rumbling, snoring, or rattling sounds from obstruction of large airways with secretions; most prominent on expiration; change often evident after coughing or suctioning

COPD, cystic fibrosis, pneumonia, bronchiectasis

Wheezes Continuous high-pitched squeaking or musical sound caused by rapid vibration of bronchial walls; first evident on expira tion but possibly evident on inspiration as obstruction of airway increases; possibly audible without stethoscope

Bronchospasm (caused by asthma), airway obstruction (caused by foreign body, tumor), COPD

Stridor Continuous musical or crowing sound of constant pitch; result of partial obstruction of larynx or trachea

Croup, epiglottitis, vocal cord edema after extubation, foreign body

AP, Anterior-posterior; COPD, chronic obstructive pulmonary disease.*Limited to common etiologic factors. (Further discussion of conditions listed may be found in Chapters 27 through 29.)