Assessment of the Thorax and Lungs

The Respiratory System

Respiratory System

Health History Inspection Palpation Percussion Auscultation

Health History Cough:

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 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

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

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 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 thesitting position. Begin at theapex and listen from side toside.

Normal Breath Sounds Vesicular

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 secretionsin the distal bronchioles

Fine crackles (Rales) – hi pitched,popping sound, like rubbing of hair.Heard during inspiration. Does notclear with coughing. Heard withobstructive diseases.

Coarse crackles – low pitched,crumpling cellophane paper sound.Heard throughoutinspiration, maybeexpiration 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 withcroup, 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.