Assessment of Respiratory System

Anatomy of Respiratory System NasopharynxNasopharynx LarynxLarynx TracheaTrachea BronchiBronchi BronchiolesBronchioles AlveoliAlveoli

Initial Respiratory Survey Observe the patient’s breathing pattern Observe the patient’s breathing pattern Rate (normal vs. increased/decreased) Rate (normal vs. increased/decreased) Depth (shallow vs. deep) Depth (shallow vs. deep) Effort (any sign of accessory muscle use, inspect neck) Effort (any sign of accessory muscle use, inspect neck) Assess the patient’s color Assess the patient’s color cyanosis cyanosis

Normal Respiratory Rates Infant Infant Toddler Toddler Preschooler Preschooler School-age child School-age child Adolescent Adolescent Adult Adult 10-20

SUBJECTIVE ASSESSMENT Fever Fever Peripheral Oedema Peripheral Oedema Sleep Sleep Stress Incontinence Stress Incontinence Functional ability Functional ability Disease awareness Disease awareness Previous physiotherapy Previous physiotherapy Collateral from nursing staff/family. Collateral from nursing staff/family.

SUBJECTIVE ASSESSMENT Using the headings below, write some questions that you could use to find out or confirm the subjective information that you need to know: Pain Pain Exercise tolerance Exercise tolerance Wheeze Wheeze Cough & sputum Cough & sputum Sleep Sleep Functional ability Functional ability Disease awareness Disease awareness Previous physiotherapy Previous physiotherapy

Relevant History Any chronic conditions Any chronic conditions Asthma, COPD, CHF, DM Asthma, COPD, CHF, DM Exposure to new medication Exposure to new medication Inhibitor Inhibitor Recent change in diet Recent change in diet Peanuts, Strawberries Peanuts, Strawberries Substance abuse/Overdose Substance abuse/Overdose Opioid abuse, ASA toxicity (aspirin) Opioid abuse, ASA toxicity (aspirin) Prior DVT. Prior DVT. Recent trauma to chest Recent trauma to chest

OBJECTIVE ASSESSMENT Observe Chart Observe Chart Drug Kardex Drug Kardex General observation General observation Oxygen therapy Oxygen therapy Breathing pattern Breathing pattern Palpation Palpation Auscultation Auscultation Percussion Percussion CXR analysis CXR analysis Mobility Mobility Exercise tolerance Exercise tolerance Spirometry Spirometry ABG ABG Other investigations Other investigations Standardised outcome measures Standardised outcome measures

Inspection Note the shape of the chest and the way it moves Note the shape of the chest and the way it moves Deformities or asymmetry Deformities or asymmetry Increased AP diameter in COPD Increased AP diameter in COPD Abnormal retractions of interspaces during respiration Abnormal retractions of interspaces during respiration Lower interspaces, supraclavicular in acute asthma exacerbation Lower interspaces, supraclavicular in acute asthma exacerbation Impaired respiratory movement Impaired respiratory movement Flail Chest and paradoxical movement with rib fractures. Flail Chest and paradoxical movement with rib fractures.

Percussion Helps to identify if underlying tissues are air- filled, fluid-filled, or solid Helps to identify if underlying tissues are air- filled, fluid-filled, or solid Hyperextend middle finger of either hand and press against chest wall Hyperextend middle finger of either hand and press against chest wall Strike with flexed middle finger of opposite hand Strike with flexed middle finger of opposite hand Always percuss symmetrically on chest wall Always percuss symmetrically on chest wall

Percussion Notes Flatness Flatness Thigh Thigh Dullness Dullness Liver Liver Resonance Resonance Lung Lung Hyperresonance Hyperresonance None None Tympany Tympany Stomach, puffed cheek Stomach, puffed cheek

Percussion Dullness replaces resonance when fluid or solid tissue replaces air containing lung Dullness replaces resonance when fluid or solid tissue replaces air containing lung Pleural Effusions Pleural Effusions Hemothorax Hemothorax Tumor Tumor Unilateral Hyperresonance Unilateral Hyperresonance Pneumothorax Pneumothorax Generalized Hyperresonance Generalized Hyperresonance COPD COPD

Breath Sounds Normal Normal Tracheal Tracheal Bronchial Bronchial Bronchovesicular Bronchovesicular Vesicular Vesicular Abnormal Abnormal Absent/Decreased Absent/Decreased Bronchial Bronchial Adventitious Adventitious Crackles (Rales) Crackles (Rales) Wheeze Wheeze Rhonchi Rhonchi Stridor Stridor Pleural Rub Pleural Rub

Causes of Decreased or Absent Breath Sounds Asthma Asthma COPD COPD Pleural Effusion Pleural Effusion Pneumothorax Pneumothorax Atelectasis Atelectasis

Common Respiratory Disorders

Pneumonia Community-acquired pneumonia Community-acquired pneumonia Hospital-acquired pneumonia Hospital-acquired pneumonia Bacteria Bacteria Viruses Viruses Mycoplasma Mycoplasma Fungi Fungi Chemical Chemical

Pneumonia is an inflammatory response to the uncontrolled multiplication of microorganisms invading the lower respiratory tract.

Pneumonia Studies Studies CXR, sputum culture, bronchoalveolar lavage CXR, sputum culture, bronchoalveolar lavage Management Management Antibiotics, oxygen, pulmonary toilet Antibiotics, oxygen, pulmonary toilet Supportive care Supportive care Nutrition, hydration, rest Nutrition, hydration, rest Prevention Prevention Pneumococcal and influenza vaccines Pneumococcal and influenza vaccines

Pleural Effusion Accumulation of pleural fluid secondary to increased fluid formation Accumulation of pleural fluid secondary to increased fluid formation Increased capillary permeability Increased capillary permeability Deceased colloid osmotic pressure of the blood Deceased colloid osmotic pressure of the blood Increased intrapleural negative pressure Increased intrapleural negative pressure Impaired lymphatic drainage Impaired lymphatic drainage Increased pressure in the capillaries or lymphatics Increased pressure in the capillaries or lymphatics

Assessment of Pleural Fluid H/P finding H/P finding Shortness of breath, chest pain Shortness of breath, chest pain Tachypnea, hypoxemia, pleural rub Tachypnea, hypoxemia, pleural rub Diagnostic studies Diagnostic studies CXR – lateral decubitus CXR – lateral decubitus Thoracentesis Thoracentesis

Pneumothorax Sudden onset of pleuritic chest pain Sudden onset of pleuritic chest pain Dyspnea, shortness of breath, increased work of breathing Dyspnea, shortness of breath, increased work of breathing Diagnostic test Diagnostic test CXR CXR Management Management Oxygen Oxygen Possible placement of chest tube Possible placement of chest tube

Pulmonary Embolism Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries Part of a deep vein thrombosis that has traveled and lodged in the pulmonary arteries Severity depends on the extent of occlusion Severity depends on the extent of occlusion Mismatch of ventilation and perfusion Mismatch of ventilation and perfusion Testing Testing A pulmonary angiogram A pulmonary angiogram Management Management Anticoagulation Anticoagulation

COPD History History Exposure to risk factors, co-morbidities, current medical treatment (beta blockers) Exposure to risk factors, co-morbidities, current medical treatment (beta blockers) Tests Tests Spirometry, ABGs Spirometry, ABGs Management Management Oxygen, education, drug therapy, nutrition, exercise, surgical intervention Oxygen, education, drug therapy, nutrition, exercise, surgical intervention

Asthma A chronic inflammatory disease of the airways A chronic inflammatory disease of the airways Airway hyper responsiveness Airway hyper responsiveness Variable airway obstruction Variable airway obstruction Resolves spontaneously or after using a bronchodilator Resolves spontaneously or after using a bronchodilator

Asthma Testing Testing Spirometry Spirometry Pulmonary function testing Pulmonary function testing Management Management Education, prevent exacerbation, optimize pharmacotherapy Education, prevent exacerbation, optimize pharmacotherapy

Acute Respiratory Failure A sudden and life–threatening deterioration in gas exchange A sudden and life–threatening deterioration in gas exchange Type I – Acute hypoxemic respiratory failure Type I – Acute hypoxemic respiratory failure Type II - Acute hypercapnic respiratory failure Type II - Acute hypercapnic respiratory failure Type III – Combined hypoxemic and hypercapnic failure Type III – Combined hypoxemic and hypercapnic failure

Acute Respiratory Failure Tests Tests ABGs, CXR, CT, thoracentesis ABGs, CXR, CT, thoracentesis Management Management Correction of gases, oxygen therapy Correction of gases, oxygen therapy Reversal of any narcotics Reversal of any narcotics Possible mechanical ventilation Possible mechanical ventilation