Present by: Dr. Amira Yahia EXAMINATION OF THE RESPIRATORY SYSTEM Present by: Dr. Amira Yahia

Learning outcomes After completion of this session the students will be able to: Revise knowledge of anatomy and physiology Obtain health history about respiratory system Demonstrate physical examination Differentiate between normal and abnormal findings

Introduction: In addition to performing the exchange of gases essential to body homeostasis, the respiratory system helps in maintain the body's fluid and acid-base balance and assist with speech. Also warm, moist, and filter the air as it enters the body. The structure of upper respiratory tract includes the nasal cavity, paranasal sinuses, pharynx, larynx, and the proximal portion of the trachea.

Introduction:

Introduction: The lower respiratory tract involves the distal portion of the trachea, bronchi, and the lungs. The trachea is located anterior to the esophagus within the mediasternum. About 10-12 cm long and 2.5 cm in diameter. The trachea divides mid-thorax, forming right and left primary bronchi. The right bronchus is wider, shorter, and more vertical than the left.

Introduction: Each bronchus continues to subdivide until the bronchi reach a diameter of less than 1mm; these terminal points are called bronchioles. The pleural membranes surround the external surface of the lungs. They produce a lubricating serous secretion that allows the lungs to move easily during respiration.

Lobes of Lung Right Lung Left Lung 3 lobes, upper, middle , lower Shorter due to liver Left Lung LUL = Left Upper and Lower ( 2 lobes) Narrower due to heart

Landmarks: Thoracic references points and anatomical structures are used when performing the physical assessment. Ribs: 12 ribs, each rib is identified by number, and each intercostals space takes the number of the rib superior to it. The first rib and first intercostals space are deep to the clavicle and are not palpable.

Landmarks: Clavicles: Extends from the manubrium of the sternum to the acromion of the scapula

Landmarks: Sternum: Located in the midline of the anterior thoracic cage. Consists of: manubrium, body, and xiphoid process.

Landmarks: Midsternal line: Midclavicle line: Anterior axillary line: A vertical line that divides the sternum into a right and left half. Midclavicle line: Parallel to the midsternal line, from the middle of the clavicle to the level of the 12th rib. It passes through the nipple of the breast. Anterior axillary line: Parallel to the midsternal line, from anterior axillary fold to the 12th rib.

Landmarks: Vertebral line: Divides the vertebral column into right and left halves. Scapular line: From the inferior angle of the scapula to the level of the 12th rib.

Landmarks: Posterior axillary line: From the posterior axillary fold to the level of the 12th level. Midaxillary line: From the axillae

Mechanics of Respiration 4 Major Functions of the Respiratory System Supply O2 for energy production Remove CO2 , waste product of energy reactions Homeostasis, acid-base balance of arterial blood Heat exchange

Respiration = breathing Inspiration Expiration Control of Respiration Involuntary control by respiratory center in the brain stem consisting of the pons & medulla Hypercapnia is an ↑ in CO2 in the Blood. And provides the normal stimulus to breath

Symptoms: cough Sputum Hemoptysis Dyspnea Chest pain (chest tightness) Wheezing

Cont’n Coughing: character (bovine cough…) Sputum: Abnormal sound: stridor (croaking noise, loudest on inspiration 2° to larynx, trachea or large airways obstruction), or wheezing. Abnormal voice: hoarseness

Cough Type Onset Duration Pattern Severity Wheezing dry, moist, wet, productive, hoarse, hacking, barking, whooping Onset Duration Pattern activities, time of day, weather Severity effect on ADLs Wheezing Associated symptoms

sputum amount color presence of blood (hemoptysis) odor consistency pattern of production

Health History Any risk factors for respiratory disease smoking pack years exposure to smoke history of attempts to quit, methods, results sedentary lifestyle, immobilization age environmental exposure Dust, chemicals, asbestos, air pollution obesity family history

Respiratory infections or diseases (URI) Trauma Surgery Past Health History Respiratory infections or diseases (URI) Trauma Surgery Chronic conditions of other systems Family Health History Tuberculosis Emphysema Lung Cancer Allergies Asthma

Gathering the data: Are you nose- or mouth breather? Do you smoke? When did you start smoking? How much do you smoke per day? Have you ever tried to stop smoking? Do you have a cough? ….? ……? …….? Do you experience frequent colds? Do you have breathing problems? Do you use nebulizer? Any other devices that improve breathing?

Equipment Needed A Stethoscope A Peak Flow Meter

General Considerations: The patient must be properly undressed and gowned for this examination. Ideally the patient should be sitting on the end of an exam table. The examination room must be quiet to perform adequate percussion and auscultation. Observe the patient for general signs of respiratory disease (finger clubbing, cyanosis, air hunger, etc.). Try to visualize the underlying anatomy as you examine the patient.

TECHNIQUES USED IN THORAX EXAM Inspection Palpation Percussion Auscultation

Inspection: Observe the rate, rhythm, depth, and effort of breathing. Listen for obvious abnormal sounds with breathing such as wheezes. Observe for retractions and use of accessory muscles (sternomastoids, abdominals).

Inspection: Observe the chest for asymmetry, deformity, or increased anterior-posterior (AP) diameter. Confirm that the trachea is near the midline? The trachea will deviate to one side in cases of tension pneumothorax. Inspect skin color.

Normal & Abnormal Chest Barrel Chest Normal chest

Normal & Abnormal Chest Pectus Excavatum (Funnel) Pectus Carinatum (Pigeon)

Palpate the posterior thorax: Assess muscle mass, area below skin for masses. Muscle mass should be firm, and the skin and subcutaneous area should be free of masses, lesions, and pain.

Palpate the posterior & anterior thorax: Palpate the thorax for respiratory expansion: Chest expansion determine the depth and quality of movement on each side of the chest. Both sides should be assessed for symmetry. Unilateral decreased chest expansion, which is easier to detect, indicates pathology on that side, for example pneumothorax, pleural effusion, pneumonia and collapsed lung.

Palpate the posterior & anterior thorax: Palpate the chest for tactile fremitus: (Fremitus is the vibration felt on the outer chest wall as the client speaks; the vibration is greatest over the large diameters of the respiratory system; it should be greatest over trachea, less over bronchi, and almost nonexistent over alveoli). (diminished vibrations could indicate obstruction of the tracheobronchial tree, lung consolidation increases vibration).

Percuss Posterior Chest Percuss start at the apices, across shoulders, then interspaces side to side (5cm. Intervals) Avoid scapulae & ribs Resonance predominates in healthy lung Hyperresonance – too much air, emphysema, pneumothorax Dull = abnormal density, pneumonia, tumor, atelectasis

Percussion over the anterior chest. Assessing chest expansion in expiration (left) and inspiration (right). Direct percussion of the clavicles for disease in the lung apices Percussion over the anterior chest.

Expected Percussion notes

Auscultate the posterior thorax: Auscultate the primary bronchi: Move the stethoscope to the right and left of the vertebral line at the level of T3 – T5, the sound is bronchovesicular. Auscultate the lungs: The sound is vesicular. Client with emphysema experience diminished lung sounds due to reduced elasticity of lung tissues.

Normal Breath Sounds Bronchial – Anterior Chest only = over trachea & larynx Bronchovesicular both anterior & posterior Over major bronchi, posterior b/t scapulae, anterior upper sternum, 1st & 2nd ICS Vesicular – Anterior & posterior

Auscultate the posterior thorax: Listen for adventitious sounds: Adventitious (Extra) Lung Sounds Crackles خشخشة These are high pitched, discontinuous sounds similar to the sound produced by rubbing your hair between your fingers. (Also known as Rales) Wheezes أزيز These are generally high pitched and "musical" in quality. Stridor is an inspiratory wheeze associated with upper airway obstruction (croup). Rhonchi These often have a "snoring" or "gurgling" quality. Any extra sound that is not a crackle or a wheeze is probably a rhonchi. Friction rub coarse & low pitched, 2 pieces of leather rubbed together close to ear

Percuss the anterior thorax: Avoid percussion over the sternum, clavicle, rib and heart

Auscultate the anterior thorax: Use the diaphragm of the stethoscope to auscultate breath sounds. Auscultate the lungs: Auscultate in the same pattern you used to percuss the lungs. Auscultate from side to side and top to bottom using the pattern shown in the illustration. The sound is vesicular.