1. Assessment of the Thorax and Lungs
The Respiratory System

2. Respiratory System Health History Inspection Palpation Percussion
Auscultation

3. 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

4. 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

5. 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)

6. 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.

8. Inspection
Lips and Nails
Thoracic configuration

9. 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)

10. 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

11. Normal Chest

12. Pectus carinatum

13. Pectus excavatum

14. Deviated trachea

16. Spinal deformities

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

18. 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

19. Palpation

20. 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

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

22. 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

23. 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

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

25. 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

27. 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.

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

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

30. 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

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

32. 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.