Assessment of Respiratory System

2. Inspection/Observations Subjective Objective 3. Palpation 1. 1. History 2. Inspection/Observations Subjective Objective 3. Palpation Tactile fremitus Symmetric Chest Expansion 4. Percussion 5. Auscultations 6. Lung Sounds

A Stethoscope A Peak Flow Meter Equipment Needed

Surface markings of the lobes of :the lung Anterior Posterior Right lateral. UL:upper lobe ML:middle lobe LL: lower lobe Left lateral UL: upper Lobe LL : lower

Draping - the chest should be fully exposed. Position – patient should sit upright on the examination table. The patient's hands should remain at their sides. For posterior exam the patient is usually asked to move their arms forward (hug them self position This is so the scapulae are not in the way of examining the upper lung fields. Draping - the chest should be fully exposed. Exposure time should be minimized.

Basic Steps Mnemonic Device IPPA: Inspection Palpation Percussion Auscultation Basic Steps

Health History Risk factors for respiratory disease smoking pack years ppd X # years exposure to smoke sedentary lifestyle, immobilization age environmental exposure Dust, chemicals, asbestos, air pollution obesity family history Health History

INSPECTION

Characteristics of Normal Breathing Normal rate and depth Regular inhalation and exhalation pattern Audible on each side of chest Equal rise and fall of each side Movement of the abdomen

Normal Respirations Rates Adult – Over 8 Years Old 12 to 20 rpm Child – 1 to 8 Years Old 15 to 30 rpm Infant – Birth to 1 Year Old 25 to 50 rpm Normal Respirations Rates

Sign of Abnormal Breathing OBJECTIVE SIGNS Rate slower than 8 per minute or faster than 20 per minute Pale or cyanotic skin Shallow or irregular Pursed lips Nasal flaring Sign of Abnormal Breathing

Cough Type dry, moist, wet, productive, hoarse, hacking, barking Onset Duration Pattern activities, time of day, weather Severity effect on Activities of Daily Living Wheezing Associated symptoms i.e allergies Treatment and effectiveness Cough

Sputum color amount presence of blood (hemoptysis) odor consistency Is it productive? Sputum

Inspection Chest wall deformities Tracheal deviation (can suggest of tension pneumothorax) Chest wall deformities Kyphosis - curvature of the spine - anterior-posterior Scoliosis - curvature of the spine - lateral Barrel chest - chest wall increased anterior-posterior; normal in children; typical of hyperinflation seen in COPD Pectus excavatum : Hollow chest grows inward Pectus carinatum Pointed one side flat on other Inspection

Pectus Carnatium with secondary changes in the spine. Kyphosis Pectus exacavatum

Signs of respiratory distress shortness of breath Cyanosis: Person has bluish coloring Pursed lip breathing: eases shortness of breath by prolonging exhalation Accessory Muscle Use: e.g. shoulders lifted on inhalation. Not enough air getting into lungs by diaphragmatic movement Diaphragmatic paradox: moves opposite way. i.e. upwards during inspiration and downwards during expiration due to weak muscles Signs of respiratory distress

Blue Bloater/ Pink Puffer Blue bloater" pathology : chronic bronchitis. They have decreased ventilation and increased carbon dioxide retention (hypercapnia).  Increasing obstruction their residual lung volume gradually increases (the "bloating" part).  Pink Puffer: Pathology: emphysema Results from destruction of the airways distal to the terminal bronchiole destruction of the pulmonary capillary bed decreases ability to oxygenate the blood Blue Bloater/ Pink Puffer

‘blue bloater’ showing ascites from marked cor pulmonale. enlargement of the right side of the heart as a result of disease of the lungs or the pulmonary blood vessels. ‘pink puffer’. Note the pursed-lip breathing .

PALPATION

Tactile fremitus Palpate chest wall Posterior Chest Vibrations felt by hand during palpation Place open palm edge on skin client repeats 99 Should feel equal vibration bilaterally Decreases if sound transmission is obstructed by consolidation Palpate chest wall

Symmetric chest expansion Posterior Chest Symmetric chest expansion Place hands at T9-T10 Equal movement of thumbs with inhaling

Percussion Begin at apices Posterior Chest Find predominant note over lung fields Begin at apices Use same pathway side to side

Percussion Sounds Resonance: Low pitched hollow sound made by air Hyper-resonance : slightly musical due to excessive air in chest cavity Dull: Muffled. Excessive tissue e.g liver or possible tumors Flat: soft thud: Typically heard over bone

Auscultation To assess breath sounds, ask the patient to breathe in and out slowly and deeply through the mouth. Begin at the apex of each lung and zigzag downward between intercostal spaces . Listen with the diaphragm portion of the stethoscope.

What are you listening for? Normal breath sounds Note Pitch Intensity Quality Duration What are you listening for?

Where should I listen?

Basic/Quick Auscultation Points Where should I listen? Anterior and Posterior of Patient Apices– under the clavicular line midpoint Mid-axillary lines (armpit at nipple line) Bases – lower border of rib cage Use Diaphragm of stethoscope One full breath in each position Same pathway Side to side comparison Basic/Quick Auscultation Points Where should I listen?

Posterior Chest Auscultation Use diaphragm of stethoscope; place firmly One full breath at each position Use same pathway side to side comparison

Breath Sounds Bronchial Bronchovesicular Vesicular Loud, harsh sounds over trachea Bronchovesicular Moderate, mixed sounds over bronchi Vesicular Soft, rustling sounds almost silent on expiration Breath Sounds

Decreased or Absent Obstruction Emphysema Silent chest Secretions, mucus plug, foreign body Emphysema Loss of elasticity; air already in lungs Silent chest No air is moving in or out of lungs; ominous sign Decreased or Absent

Bronchial Sounds : Not heard in the normal lung but occurring in pulmonary disease, indicating infiltration Solid tissue conducts sounds to surface better Found in pneumonia with consolidation or fluid in inter-pleural space INCREASED SOUNDS

Crackles (Rales): Fine Fine, discontinuous high- pitched, short crackling sound on inspiration Found in bases of lungs Adventitious Sounds

Adventitious Sounds Crackles: Coarse Loud, low-pitched bubbling or gurgling sounds Start in inspiration, may be in expiration Decrease with coughing, but comes back Found in pulmonary edema and terminally ill with suppressed cough reflex Adventitious Sounds

Adventitious Sounds Wheeze: High pitch High-pitched, musical squeaking sound that predominates with expiration Indicates narrowed passageway Obstruction from acute asthma or chronic emphysema Adventitious Sounds

Wheeze Low-pitch ( Rhonchi) Single note which is more prominent on expiration Air flow obstruction bronchitis or tumor Adventitious Sounds

High-pitched, crowing sound with inspiration Louder in neck Stridor High-pitched, crowing sound with inspiration Louder in neck Upper airway obstruction Croup, acute epiglottis, or foreign body inhalation Adventitious Sounds

PULMONARY FUNCTION TESTS SPIROMETRY INCENTIVE SPIROMETRY PEAK FLOW METERS PULMONARY FUNCTION TESTS

Spirometry Required when lung function is in question Patients must refrain from smoking or using nebulizers or bronchodilators for 6 hours Patients must be given full explanation to ensure correct technique Spirometry

Procedure Assist patient in loosening any constrictive clothing Ensure Privacy Seat patient Gather supplies including spirometer Inform patient if they feel dizzy during procedure they should let staff know immediately Ask patient in inhale deeply and then blow as hard as possible Blast out for 5 seconds Repeat 3 times Procedure

Incentive Spirometry

Place mouthpiece and seal lips tightly around it. Inhale slowly and deeply . See piston rise look on left for good or better indicator Hold breath for 5 seconds. Then exhale slowly and allow the piston to fall to the bottom of the column. Rest for a few seconds and repeat at least 10 times every couple of hours Position the yellow indicator on the left side of the spirometer to show your best effort. Use the indicator as a goal to work toward during each slow deep breath.

PEAK FLOW METER

Move the marker to the bottom of the numbered scale. Stand up straight Move the marker to the bottom of the numbered scale. Stand up straight. Take a deep breath. ... Blow out as hard and fast as you can in a single blow. ... Write down the number you get