1. The Respiratory System: History and Physical Assessment

2. Physiologic Function of the Lungs
Exchange respiratory gases
Maintenance of acid-base balance

3. Primary Muscles of Respiration
Diaphragm
External Intercostals
Inspiration active, 70% of your tidal volume is provided from
your diaphragm movement, 30% from your external Intercostals
Inspiration 1/3 of your respiratory cycle, expiration 2/3
Diaphragm moves down with inspiration, pushing lowering
abdominal content to increase the intrathoracic space.
External Intercostals increase anteroposterior diameter
Normal respiratory rate 12-20, in elderly
Discuss changes in the elderly: barrel chest from loss of muscle
strength in thorax and diaphragm, less compliance, skeletal changes
an increase in the dorsal curve of the thoracic spine, decrease in
anteroposterior diameter, alveoli less elastic and more fibrous.
Decreased cough/gag reflects and mucous membranes are drier.
More prone to aspiration and not able to expel secretions, higher
risk for pneumonia

4. Accessory Muscles Trapezius Sternocleidomastoid Abdominal Muscles
Internal Intercostals
Which muscles are used with inspiration and with expiration

5. History Tobacco use Coughing Chest pain Dyspnea
marijuana use- amount in pack years
Pack years = # of years smoked x # of packs per day, age
started and the number of efforts to quit
Coughing: Onset (sudden, gradual, duration)
- nature of cough: dry, wet, hacking, hoarse, barking , whooping,
productive, non-productive
- sputum characteristics: amount, color, odor
- pattern of coughing: regular, related to weather, activities, talking,
deep breaths
-associated symptoms: SOB, Chestpain, tightness, fever,
stuffy nose, choking, hoarseness
Chestpain: onset,duration
- associated symptoms: shallow breathing, fever, radiation
- efforts to treat: heat, splinting, pain medication
Dyspnea: onset, duration
- pattern: position most comfortable, amount of pillows
- related to activities, at rest, worse with inhalation or exhalation

6. History Orthopnea Paroxysmal nocturnal dyspnea (PND)
Activity tolerance
Recurrent pneumonia or bronchitis
Pollutants (asbestos, coal dust, chemicals, etc.)
Passive smoking
R/O risk for TB
Employment
Nutritional status: weight loss, weight gain
Travel exposure
Hobbies: noxious exposure from animals, woodworking

7. History Review family history Pneumonia or influenza vaccine
Date of last TB test
Cystic fibrosis, emphysema. allergies

8. Physical Exam General assessment * Inspect facial expression
* Posture configuration of chest (AP -diameter should be 1/3-1/2 transverse diameter)
* Respiratory rate and pattern
* Inspect hands for clubbing
Ratio of respiration's to heartbeats 1:4
Note the rhythm: regular, irregular and the way the chest moves, not too
shallow or too deep
Orthopnea: SOB when lying down
Platypnea: dyspnea increases in the upright position
Tachypnea: >20/min
Bradypnea: < 12/min
hypopnea: abnormal shallow with pleuritis
Hyperpnea: rapid, deeply with increased WOB
Kussmaul: deep and rapid, metabolic acidosis
Cheyne -Stokes: regular with periods of apnea, followed by
crescendo-decrescendo sequence
Biot: somewhat irregular, varies in depth
Cyanosis: lips, nasal flaring

9. Physical Exam Sitting position for posterior and lateral
May sit or supine for anterior
Undressed from waist up
NEVER listen through clothing!!!!!!

10. Normal Adult

11. Scoliosis

12. Kyphosis

13. Barrel Chest

14. Pectus Excavatum

15. Pectus Carinatum

16. Landmarks of Clinical Importance
Sternum
Clavicle
Suprasternal notch
Manubriosternal angle
Midsternal line
Midclavicular lines
Anterior axillary lines
Midaxillary lines
Posterior axillary lines
Scapular lines
Vertebral line

25. Posterior Chest Palpate for any tenderness or abnormalities
Measure posterior chest excursion
*Should be symmetrical
Crepitus: crackly or crinkly sensation, bubbly feeling, indicates air
in the subcutaneous tissue
Pleural friction rub: palpable, coarse, grating vibration,
mostly on inspiration, like leather rubbing over leather

26. Thoracic expansion during respiration: watch and feel for symmetry,
watch the movement of your thumbs.

27. Posterior Chest Palpate for tactile fremitus
*Vibration of the chest wall during speech
At each position ask the patient to say “99”
If difficulty feeling, ask the patient to speak louder and deeper
Decreased or absent fremitus: excess air as in emphysema, pleural
effusion, massive pulmonary edema or bronchial obstruction.
Increased fremitus: with fluids or solid mass within the lungs or with
consolidation, heavy non-obstructing secretions

29. Tactile Fremitus
Decreased fremitus is caused from excess air (emphysema, pneumothorax, atelectasis).
Increased fremitus is caused by the presence of fluid or a mass.

30. Posterior Chest
Percussion- determine whether the lung tissue is air filled, fluid filled, or solid.
Sounds of percussion
* Resonant
* Dull
* Tympanic
* Flat
* Hyperresonant

33. Posterior Chest Measure diaphragmatic excursion
*Normal should be 3-5cm
*The diaphragm is normally higher on the right.
*Diaphragmatic descent may be limited by pulmonary lesions, abdominal lesions or pain.

34. 1. Ask the patient to inhale deep and hold their breath
2. Percuss along the scapular line until you locate the lower border
, mark the point were resonance turns into dullness
3. Ask the patient to take several deep breath, then exhale as much
as possible
4. Percuss down from the marked point and again mark were
resonance turns into dullness
5. Measure the distance between the marks

35. Posterior Chest
Auscultation
*Use diaphragm of stethoscope

36. Explain arm position while auscultating, do not skip the lateral sides

37. Types of Breath Sounds Bronchial: loud, high pitched.
Bronchovesicular: medium pitch.
Vesicular: soft, low pitched.
Bronchial- loud, high pitched. Heard over the trachea. I < E.
Bronchovesicular- mixture of bronchial and vesicular. Medium pitch.
Heard in the 1st and 2nd ICS anteriorly and between the scapula
posteriorly. I = E.
Vesicular- soft, low pitched. Heard over peripheral lung fields. I > E.

39. Additional Tests
Abnormalities assessed in tactile fremitus, percussion, or auscultation
Bronchophony- In same location as breath sounds say “99” or “eee”.
*Normally sounds are muffled.
Whispered pectoriloquy- In same location as breath sounds whisper “99”.
*Whispered voice should be faint.

40. Lateral Chest
Same as posterior chest, may perform along with posterior chest.

41. Anterior Chest
Inspection
Chest excursion
Evaluate tactile fremitus

44. Anterior Chest
Percussion
Auscultation

48. Adventitious Breath Sounds
Crackles:
Fine Crackles
Medium Crackles
Coarse Crackles
Crackles- mostly heard in the dependant lobes. Caused by opening
of collapsed distal airways.
Fine crackles- high pitched, fine. Heard at the end of inspiration.
Not cleared by coughing.
Medium crackles- lower pitched, more moist. Heard during the
middle of inspiration. Not cleared with coughing.
Coarse crackles- loud, bubbly sounds. Heard during inspiration.
Not cleared with coughing.

49. Adventitious Breath Sounds
Rhonchi
Wheezes
Pleural Friction Rub
Rhonchi- Primarily heard over the trachea and bronchi.
Due to fluid or mucus in the larger airways.
Low-pitched, course sounds. Heard during inspiration and expiration
May be cleared with coughing.
Wheezes- Can be heard over all lung fields.
Airflow through narrowed bronchus. High-pitched, musical sounds.
Heard during inspiration and expiration
Pleural friction rub- Heard over anterior lateral lung field.
Due to inflamed pleura. Has dry, grating quality.
Does not clear with coughing.

50. Order of the Physical Exam
Posterior Chest:
Inspection
- Palpation
- Chest Excursion
- Tactile Fremitus
- Percussion
- Diaphragmatic Excursion
- Auscultation

51. Order of the Physical Exam
Lateral Chest:
Inspection
Palpation
Tactile Fremitus
Percussion
Auscultation

52. Order of the Physical Exam
Anterior Chest:
Inspection
Palpation
Chest Excursion
Tactile Fremitus
Percussion
Auscultation

53. Adventitious Breath Sounds
Rhonchi: Primarily heard over the trachea and bronchi.
Rhonchi: Primarily heard over the trachea and bronchi.
Due to fluid or mucus in the larger airways.
Low pitched , course sounds
Heard during inspiration and expiration
May Clear with coughing

54. Adventitious Breath Sound
Wheezes
Wheezes:
Can be heard over all lung fields
Airflow through narrowed bronchus
High-pitched musical sounds.
Heard during inspiration and expiration

55. Adventitious Breath Sounds
Pleural Friction Rub
Pleural Friction Rub
Heard over anterior lateral lung field
Due to inflammation in pleura
Dry, grating quality
Does NOT clear with coughing