1. Assessment of Respiratory System

2. 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

3. A Stethoscope
A Peak Flow Meter
Equipment Needed

4. 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

5. 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.

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

7. 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

8. INSPECTION

9. 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

10. 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

11. 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

12. 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

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

14. 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

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

16. 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

17. 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

18. ‘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 .

19. PALPATION

20. 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

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

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

24. 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

26. 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.

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

28. Where should I listen?

29. 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?

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

32. 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

33. 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

34. 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

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

36. 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

37. 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

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

39. 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

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

42. 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

43. 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

44. Incentive Spirometry

45. 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.

46. PEAK FLOW METER

47. 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