Assessment of the Chest and Lungs

Anatomy Anatomy of the respiratory system is available on blackboard as an online lecture.

Subjective Data Cough Shortness of breath Past history of respiratory infections Smoking history Environmental exposures Self care habits

Physical Examination Equipment and Techniques Stethoscope Techniques Inspection Palpation Percussion Auscultation

Inspection General Appearance Posturing Breathing effort Exhale Pucker or purse 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 Respiratory Effort Nails Skin Lips Respiratory rate and depth Breathing pattern Chest expansion

Abnormal Breathing Patterns Kussmaul

Abnormal breathing patterns Hypoventilation Slow, shallow breathing Causes CO2 to build up in the blood Acidosis Hyperventilation Rapid, deep breathing Causes CO2 to be blown off Alkalosis

Palpation Tactile Fremitus: Do you know where it is the greatest? Increased: in periphery with consolidation or compression of lung tissue. Ex lobar pneumonia Decreased: When anything obstructs transmission of vibrations: Ex. Pleural effusion, pneumothorax or emphysema

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

Percuss If you suspect over inflation or consolidation Sound depends on the air-tissue ratio Resonance: normal lung fields Hyperresonance: Overinflated lung Dull tone: consolidation

Auscultation Auscultate in a systematic manner Compare one side to the other Listen one full respiration at each spot Compare bilaterally Displace breast tissue to listen directly over chest wall DO NOT listen through gowns, clothes, etc. Place your stethoscope over bare skin

Auscultation Know where the lungs are!! Assess both anterior and posterior every time Ask patient to lean forward slightly, with arms resting in lap Ask them to breath in through mouth, a little deeper than normal Move from the apices to the bases

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Auscultation Use the diaphragm of the stethoscope

Auscultation Evaluate for normal sounds Sound Pitch Intensity Quality I:E Location Bronchial High Loud Blowing/ hollow I < E Trachea Bronchovesicular Moderate Combination I = E Between scapulae, 1st & 2nd ICS lateral to sternum Vesicular Low Soft Gentle rustling/ breezy I > E Peripheral lung

Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

Auscultation Evaluate for adventitious sounds Sound Intensity/ Pitch I/E Quality Clear with Cough Crackles/ Rales Soft (fine)/ High Loud (coarse)/ Low I Discontinuous, nonmusical, brief Possibly Wheeze High E Continuous musical sounds Ronchi Low Continuous snoring sounds Pleural Friction Rub I & E Continuous or discontinuous creaking or brushing sounds Never Stridor Continuous, crowing

Hemothrorax Blood in the pleural space Chest injury or thoracic surgery Short of breath, anxious, chest pain, respiratory distress, dyspnea, tachypnea, cyanosis. Muffled breath sounds and dullness over affected area.

Atelectasis Collapsed alveoli Caused by external pressure from Tumor, fluid, air in the pleural space Lack of air from hypoventilation or obstruction of secretions Diminished or absent breath sounds O2 sat <90

Asthma – What is It? Asthma is a chronic lung disease that obstructs airflow The obstruction is reversible It involves difficulty in breathing due to Inflammation (swelling) Mucus in the airways Tightening of muscles around the airways

Bronchitis Signs and Symptoms Most prevalent in winter Generally part of an acute URI It may develop after a common cold or other viral infection of the nasopharynx, throat, or bronchi Often with secondary bacterial infection Malaise Chilliness Slight fever Back and muscle pain Sore throat Onset of a distressing cough usually signals onset of bronchitis Cough starts off dry and later produces mucous.

Pneumonia Symptoms Fever Tachypnea Dyspnea Crackles Wheezes Pneumonia occurs when bacteria (most commonly Streptococcus pneumoniae), chemical irritants, or viruses get into your lungs. Pneumonia causes the alveoli in the lungs to fill with pus or other liquid. This causes difficulty in breathing

Pneumonia Most deadly infectious disease in the U.S. 6th leading cause of death

Emphysema Emphysema : unable to breathe in enough oxygen. chronic (long-lasting) disease gradually destroys the lungs. This destruction means unable to breathe in enough oxygen. You also have trouble breathing out carbon dioxide.

Tuberculosis Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis. ► The TB bacteria can affect any part of the body, but usually affects the lungs. ► If not treated properly, a person who has TB infection can develop TB disease. ► If a person develops TB disease and does not get appropriate medical treatment he/she can die.

Lung Cancer Lung cancer is the #1 cause of cancer-related deaths by far in the U.S. …more than breast, prostate, and colon cancer combined. Smoking (90% of all cases) Second-hand smoke (25% of non-smoker cases) Occupational/environmental

Lung Cancer Symptoms Fatigue (tiredness) Cough Shortness of breath Chest pain Loss of appetite Coughing up phlegm Hemoptysis (coughing up blood) If cancer has spread, symptoms include bone pain, difficulty breathing, abdominal pain, headache, weakness, and confusion

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 Inspection General appearance Posture Breathing effort Posterior Thorax Inspect: shape, symmetry Palpate: tenderness and Tactile fremitus Thoracic expansion Tell me percussion would be performed if you suspected overinflation or consolidation of the lungs Auscultate lungs bilaterally

Videos of Thorax and Lung Assessment Anterior Chest Inspect: Respirations Palpate for tenderness and tactile fremitus Ausculate breath sounds Bilaterally

Videos of Thorax and Lung Assessment

Conclusion Today you learned How to complete a physical examination of the respiratory system Identify normal and abnormal variations Common Problems with the respiratory system Age related variations. What is expected for your video.

Lab Bring your stethoscope, pen, textbook You will be Practicing listening to breath sounds You will also be practicing your respiratory exam on your partner using the lab guide I will provide you with. It is highly recommended that you record the video the week that you learn the material.