1. Assessment of the Chest and Lungs

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

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

4. Physical Examination Equipment and Techniques
Stethoscope
Techniques
Inspection
Palpation
Percussion
Auscultation

5. Inspection General Appearance Posturing Breathing effort
Exhale
Pucker or purse
Inspection
General
Appearance
Posturing
Breathing effort
Trachea position
Midline

6. 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

7. Inspection Oxygenation: cyanosis Respiratory Effort Nails Skin Lips
Respiratory rate and depth
Breathing pattern
Chest expansion

8. Abnormal Breathing Patterns
Kussmaul

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. Auscultation
Use the diaphragm of the stethoscope

17. 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

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

20. 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

21. 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.

22. 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

23. 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

25. 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.

26. 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

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

28. 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.

29. 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.

31. 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

32. 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

33. 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 seconds
Only concern if it is prolonged or baby becomes cyanotic

34. Developmental Variations
Neonates
Breathing is diaphragmatic and abdominal
Signs of compromise
Stridor (“crowing”)
Grunting
Central cyanosis
Flaring nares

35. 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

36. Developmental Variations
Pregnancy
Costal angle increases to about 105 degrees in the third trimester
Dyspnea and orthopnea are common
Breathes more deeply

37. 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)

38. 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

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

40. Videos of Thorax and Lung Assessment

41. 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.

42. 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.