Assessment of the Thorax and Lungs The Respiratory System

Respiratory System Health History Inspection Palpation Percussion Auscultation

Health History Cough: SOB Chest pain - with or without inspiration Productive, nonproductive Sputum SOB Chest pain - with or without inspiration Smoker Environmental exposures Past medical hx. Resp. illnesses, allergies, thoracic surgery Family hx. TB, CF, Emphysema, Allergies, Asthma, Malignancy

Age Considerations Children Elderly Hx. of colds, frequent respiratory infections, allergies, smokers in the home Elderly Hx. of SOB, fatigue, activity level, recent weight changes, current medications

General Assessment Respiratory Rate Rhythm (Regular or Irregular) Use of accessory muscles Anteroposterior (AP:L) diameter [2:1] Purse lip breathing Depth of respirations (shallow or deep) Type of respirations (diaphragm or chest)

Pursed Lip Breathing is the act of exhaling through tightly pressed, pursed lips. Doctors and respiratory therapists teach the technique to their patients to ease shortness of breath and to promote deep breathing, also referred to as abdominal or diaphragmatic breathing. The purpose of PLB is to create back-pressure inside airways to splint them open; moving air thus then takes less work.

Inspection Lips and Nails Thoracic configuration

Lips and Nails Clubbing of nails Color Normal, (-) clubbing Nail angle 160° or less Abnormal, (+) clubbing Nail angle straightens to 180° or >, spongy Color Mucous membranes Capillary refill (< 3 sec)

Thoracic configuration Deformities, shape and symmetry AP to Lateral diameter, 2:2, Barrel chest Pectus Carinatum – pigeon chest, protrusion Excavatum – funnel chest, inward Spinal deformities Intercostal spaces Retractions (flail chest – sucking in) Bulging Tracheal deviation – never normal

Normal Chest

Pectus carinatum

Pectus excavatum

Deviated trachea

Spinal deformities

Pattern of Respirations: Men & Children Diaphragmatic Women Thoracic or costal Resting respiratory rate – should be smooth and rhythmical 12 – 20 (12-25) Tachypnea Bradypnea

Additional Respiratory Patterns Hyperventilation Increased rate and shallow Hypoventilation Decreased rate and shallow, irregular Cheyne-Stokes Alternating tachypnea and apnea Biot’s respiration Irregular pattern of normal resp. and apnea Paroxysmal nocturnal dyspnea (PND) Awakening from sleep with SOB Kussmaul Deep rapid and laborious

Palpation

Palpation Angle of Louis/Manubriosternal angle Articulation of the manubrium and body of sternum It is continuous with the 2nd rib Good place to start counting ribs Marks the site of tracheal bifurcation, and the upper border of the atria of the heart Tenderness

Crepitus Air that has escaped into the SQ tissues Cellophane paper crackling

Palpation Masses Thoracic expansion Tactile fremitus Place hands over lung fields, thumbs touching With deep breath – smooth, symmetrical, flattens Tactile fremitus Vibration, have pt. say 99 or blue moon; should be equal Increased – consolidation, tumors, pneumonia Decreased – pneumothorax, pleural effusion, emphysema, atelectasis, obstruction

Percussion Percuss lung borders side to side: Anteriorly Posteriorly Left – resonance to 3rd ICS, then dullness d/t heart Right – resonance to 5th ICS, then dullness d/t liver Posteriorly Left –resonance to 9th ICS, then dullness d/t diaphragm Right – resonance to 8thICS, then dullness d/t diaphragm

Auscultation Auscultate with pt. in the sitting position. Begin at the apex and listen from side to side.

Normal Breath Sounds Vesicular Bronchovesicular Bronchial Found over lung periphery. Low pitched, soft breezy sound. Inspiration > Expiration by 2 ½ times. Bronchovesicular Found on either side of sternum and between scapula on back. Moderate intensity. Inspiration = Expiration Bronchial Found over the trachea and above manubrium. Loud, harsh, high pitched, blowing sound. Inspiration < Expiration by ½. Absent breath sounds

Adventitous Breath Sounds - Discontinuous Crackles – indicate serous secretions in the distal bronchioles Fine crackles (Rales) – hi pitched, popping sound, like rubbing of hair. Heard during inspiration. Does not clear with coughing. Heard with obstructive diseases.

Coarse crackles – low pitched, crumpling cellophane paper sound. Heard throughout inspiration, maybe expiration Heard with pneumonia, CF, pulmonary edema

Pleural Friction Rub – heard in lower part of chest, anterolateral surface. Coarse rubbing or grating sound. Does not clear with coughing. Pleuritis

Adventitious Breath Sounds - Continuous Wheezes Sibilant (rhonchi) – hi pitched, musical. Heard during inspiration, but most often during expiration d/t bronchospasm. Heard with asthma, emphysema, and other obstructive lung dx. Sonorous (rhonchi) – low pitched, snoring sound. Clears with coughing. Commonly heard during expiration. D/t partial obstruction from secretions, tumor, bronchitis. Stridor Hi pitched, crowing sound. Heard with croup, obstructed airway

Documentation Document adventitious breath sounds for: Frequency Timing Location Effect of position change

Vocal Fremitus/Resonance Bronchophony Auscultate posterior chest. 99 should be soft and muffled, if loud and clear, consider lung consolidation. Egophony Evaluates intensity of spoken voice. Have pt. say eee, should hear soft, muffled eee, if aaa heard, consider lung consolidation. Whispered Pectoriloquy Performed when a (+) bronchophony is auscultated. Have pt. whisper 1,2,3. Sound should be faint and muffled. Clear with lung consolidation.