1. RET 1024 Introduction to Respiratory Therapy Module 4.3 Bedside Assessment of the Patient — Palpation, Percussion, Auscultation

2. Bedside Assessment of the Patient  Palpation  The art of touching the chest wall to evaluate underlying structure and function  Vocal and tactile fremitus  Thoracic expansion  Assess skin and subcutaneous tissues of the chest

3. Bedside Assessment of the Patient  Palpation  Vocal Fremitus – vibrations created by the vocal cords during speech When the vibrations travel down the tracheobrochial tree, through the lung, and are felt on the chest wall, it is called tactile fremitus

4. Bedside Assessment of the Patient  Tactile Fremitus  Ask patient to say “ninety-nine” or “one, two, three” or “E” while palpating the anterior, lateral, and posterior chest wall with either the dorsal or palmar aspects of the fingers, or the ulnar aspect of the hand

5. Bedside Assessment of the Patient  Tactile Fremitus  May be …  Increased  Atelectasis  Pneumonia  Decreased  Pneumothorax  Pleural effusion  Emphysema  Obesity  Muscular  Or Absent  Pneumothorax  Pleural effusion

6. Bedside Assessment of the Patient  Thoracic Expansion

7. Bedside Assessment of the Patient  Palpation  Thoracic Expansion  Normal chest wall expands symmetrically during inhalation  Bilateral reduction in chest expansion  Both lungs affected  Neuromuscular diseases  COPD  Unilateral reduction in chest expansion  One lung affected  Lobar consolidation  Atelectasis  Pleural effusion  Pneumothorax

8. Bedside Assessment of the Patient  Thoracic Expansion  Posterior evaluation  Place hands over the posterolateral chest – thumbs extended and meeting at the T-8 vertebra  Anterior Evaluation  Place hands over the anterolateral chest – thumbs extended along the costal margin toward the xiphoid process  Instruct patient to exhale slowly and completely  Extend the tips of the thumbs toward the midline until they are touching  Grasp the chest securely and instruct the patient to take a full, deep breath  Note the distance that the thumbs separate  Normal: Each thumb moves an equal distance of 3 – 5 cm

9. Bedside Assessment of the Patient  Palpation  Skin and subcutaneous tissues  General temperature  Condition of the skin  Subcutaneous emphysema  Air under the skin  Produce a crackling sound and sensation when palpated – called crepitus Subcutaneous emphysema

10. Bedside Assessment of the Patient  Palpation  Subcutaneous emphysema  Bue circle: characteristic of subcutaneous emphysema with muscle bundles of pectoralis muscle becoming visible.  Red arrow : points to subcutaneous emphysema in the supraclavicular area.  White arrow: points to streaky air visible in the mediastinum

11. Bedside Assessment of the Patient  Percussion  The art of tapping on the surface of the chest to evaluate the underlying structure  Produces a sound and palpable vibration  Useful for patients with suspected conditions for which percussion could be helpful (e.g., pneumothorax)

12. Bedside Assessment of the Patient  Percussion  Place the middle finger of the left hand (right-handed people) firmly against the chest wall, parallel to the ribs, within the intercostal space (palm and other fingers off the chest)

13. Bedside Assessment of the Patient  Percussion  Using the tip of the middle finger on the right hand, or the lateral aspect of the thumb to strike the finger against the chest near the base of the terminal phalanx and remove briskly

14. Bedside Assessment of the Patient  Percussion  Systematically, consecutively test comparable areas on both sides of the chest, excluding bony structures and breasts of female patients

15. Bedside Assessment of the Patient  Percussion  Percussion notes are evaluated by intensity (loudness) and pitch  Normal Resonance  Normal lung fields – loud, long, moderately low- pitched sound heard over air-filled structures

16. Bedside Assessment of the Patient  Percussion  Clinical Implications of decreased resonance  Pneumonia  Tumor  Atelectasis  Pleural fluid

17. Bedside Assessment of the Patient  Percussion  Clinical Implications of decreased resonance  Pneumonia  Tumor  Atelectasis  Pleural fluid

18. Bedside Assessment of the Patient  Percussion  Clinical Implications of decreased resonance  Dull  Heard over a solid organ (e.g. liver) – medium intensity, medium pitch, and a medium duration  Flat  Heard over bone – soft intensity, high-pitched, and a short duration

19. Bedside Assessment of the Patient  Percussion  Clinical Implications of increased or hyperresonance  Acute bronchial obstruction (asthma, COPD)  Pneumothorax Air Trapping (asthma)

20. Bedside Assessment of the Patient  Percussion  Clinical Implications of increased or hyperresonance  Tension Pneumothorax  Tympani  Hollow, air-filled structures under pressure - Loud, drum- like, high-pitched note, usually heart with tension pneumothorax

21. Bedside Assessment of the Patient  Auscultation of the Thorax  Listening to thorax with a stethoscope for the purposes of identifying both normal and abnormal lung sounds

22. Bedside Assessment of the Patient  Auscultation  Stethoscope  Bell  Low-frequency heart sounds  Diaphragm  High-frequency lung sounds

23. Bedside Assessment of the Patient  Auscultation  Patient should be sitting up when possible

24. Bedside Assessment of the Patient  Auscultation  Patient should be sitting up when possible

25. Bedside Assessment of the Patient  Auscultation  Instruct patient to breath more deeply than normal through the mouth and then exhale normally  Be careful not to let the tubing rub against any objects, which may be mistaken for abnormal lung sounds  Auscultate over bare skin when possible; clothing can mask sounds

26. Bedside Assessment of the Patient  Auscultation  Proper way to hold stethoscope  Between index and middle fingers  Stabilize the stethoscope firmly against the chest

27. Bedside Assessment of the Patient  Auscultation  Must be systematic – all lobes  Posterior and anterior chest  Start at the bases and work upward; opposite to what is indicated in this photo

28. Bedside Assessment of the Patient  Auscultation  Must be systematic – all lobes  Lateral chest

29. Bedside Assessment of the Patient  Auscultation  Listen to a complete breathing cycle; inspiratory and expiratory in each location  Identify  Pitch  Loudness  Duration InhalationExhalation Duration Pitch Thickness of line indicates loudness Diagram of normal breath sound

30. Bedside Assessment of the Patient  Auscultation  Normal Breath Sounds  Tracheal / Bronchial  Bronchovesicular  Vesicular

31. Bedside Assessment of the Patient  Normal Breath Sounds  Tracheal / Bronchial  Over the trachea  Turbulent flow of gas through the upper airways  Loud, harsh, hollow or tubular quality  High-pitched  Expiratory and inspiratory components are almost equal Diagram

32. Bedside Assessment of the Patient  Normal Breath Sounds  Bronchovesicular  Upper half of sternum and between scapulae  Gas moving between the large airways and alveoli  Not as loud as tracheal / bronchial  Slightly lower in pitch  Expiratory and inspiratory components are almost equal Diagram

33. Bedside Assessment of the Patient  Normal Breath Sounds  Vesicular  Lung parenchyma  Gas moving in/out of small bronchiole and possibly the alveoli  Soft and muffled  Low in pitch  Heard primarily during inspiration, with only a minimal exhalation component Diagram

34. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Breath sounds that are different than what is normally heard over a particular area of the thorax  For example  When bronchial breath sounds replace normal vesicular breath sounds when alveolar atelectasis or consolidation are present

35. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Bronchial  Replace normal vesicular breath sounds when alveolar atelectasis or consolidation are present Consolidation Atelectasis

36. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Diminished (reduced)  Vesicular breath sound are softer than expected  Shallow breathing  Slow breathing  Complete absence of a breathing pattern  Obstructive airway disorders (e.g., emphysema)  Alveolar hyperinflation  Pleural effusion  Pneumothorax  Obesity

37. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Wheezes  Continuous, high-pitched, musical sounds heard primarily on expiration; can be heard on both inspiration and expiration in severe cases  Secretions  Bronchospasm  Mucosal edema  Bronchial tumor (unilateral wheezing)  Foreign objects (unilateral wheezing)  Note: The greater the bronchial narrowing, the higher the pitch of the wheeze (mild, moderate, severe)

38. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Stridor  Commonly caused by inflammation and edema of the larynx and trachea  Tracheal damage resulting from intubation  Heard following extubation  Croup  Barking cough  Subglottic inflammation/edema  Foreign body aspiration

39. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Laryngeotracheobronchitis  Croup  Stridor

40. Bedside Assessment of the Patient  Stridor  Electrical wire stuck in the larynx of an infant; minimal stridor pre-operatively

41. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Crackles  Discontinuous, high-pitched, short, crackling, popping, or bubbling sound that usually heard on inspiration  Coarse crackles (rhonchi)  Airflow causing movement of excessive secretions or fluid in the airways, cleared with coughing or suctioning  Fine Crackles (rales)  Collapsed airways / alveoli popping open during inspiration

42. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Crackles  Common causes  Excessive secretions  COPD  CHF  Pneumonia  Atelectasis  Pulmonary fibrosis  Early tuberculosis

43. Bedside Assessment of the Patient  Abnormal (adventitious) Breath Sounds  Pleural Friction Rub  Creaking or grating sound that occurs when the pleural surfaces become inflamed and the roughened edges rub together during breathing, as in pleurisy  Heard on inspiration and expiration  Usually localized to a certain site on the chest wall

44. Bedside Assessment of the Patient  Voice Sounds  Bronchophony  An increase in intensity and clarity of vocal resonance produced by enhanced transmission of vocal vibrations  Heard during auscultation while the patient is repeating the words “one, two, three,” or “ninety-nine”  Indicative of consolidation

45. Bedside Assessment of the Patient  Voice Sounds  Whisper Pectoriloquy  Auscultate while the patient is whispering “one, two, three” or “ninety-nine, ninety-nine”  Sounds are heard more clearly over areas of consolidation  Egophony  Auscultate while the patient is saying “EEEEE”  Sounds like “AAAAA” over consolidation

46. Bedside Assessment of the Patient  Auscultation  Chest Hair  A fine crackling sound may be heard over areas with chest hair  May be eliminated by wetting the hair or pressing down firmly with the stethoscope

47. Bedside Assessment of the Patient  Auscultation  Subcutaneous Emphysema  Crackling sound is heard when stethoscope is pressed down over an affected area Chest exam reveals seatbelt region bruising and significant upper thoracic, neck, and facial subcutaneous emphysema.

48. Bedside Assessment of the Patient  Auscultation  Bone Crepitus  A clicking sound heard when bone ends rub together as in rib or sternal fractures L. SCAPULAR FRACTURE (arrow) obscured by subcutaneous emphysema, rib fractures, and pulmonary contusion.