RESPIRATORY ASSESSMENT AND TREATMENT

ASESMEN DAN TREATMENT PADA PERNAPASAN

RESPIRATORY ASSESSMENT

ASESMEN PADA PERNAPASAN

The physical therapy assessment of patients with pulmonary disease has two parts.
Part one assesses the patient clinically through the chest examination. Part two
completes the evaluation through objective assessment of the arterial blood gases,
pulmonary function tests, chest radiography, graded exercise tests, and bacteriological
studies.

Asesmen secara terapi fisik pada pasien dengan penyakit paru memiliki dua
bagian. Bagian pertama menilai pasien secara klinis melalui pemeriksaan dada.
Bagian kedua melengkapi evaluasi melalui penilaian obyektif dari gas darah pada
arteri, tes fungsi paru, radiografi dada, menilai tes latihan, dan studi bakteriologi.
CHEST EXAMINAATION

PEMERIKSAAN DADA

The chest examination is administered by almost all health care professionals

providing services to the patient with pulmonary disease. Although the examination may
be conducted in a similar manner by all, the objectives for the examination may differ.

Pemeriksaan dada dikelola oleh hampir semua ahli kesehatan dengan

memberikan pelayanan kepada pasien yang mengalami penyakit paru. Meskipun
pemeriksaan dapat dilakukan dengan cara yang sama oleh semua ahli kesehatan,
namun tujuan untuk pemeriksaan mungkin berbeda.

The physical therapist has four objectives for the chest examination. First, the
therapist identifies the pulmonary problems acknowledged by the patient. Often the
problems uppermost in the patient’s mind are the cardinal symptoms of pulmonary
disease : dyspnea, cough, sputum, and chest pain. Second the therapist assesses the
coexisting signs of pulmonary disease. For example, the therapist identifies the patient’s
symptom of chest pain. Through further evaluation the therapist determines that the
pain is localized to a small area of chest wal, exquisitely tender to palpation, associated
with both a grating sound during breathing and a shallow, door-step breathing pattern,
and aggravated by coughing and respiratory movements. At this point the coexisting
signs suggest the presence of a rib fracture. Third, the therapist determines the need for
further evaluative procedures when the results of the chest examination are unclear. In
the preceding example, further evaluation by chest radiography not only may confirm
the assessment by the therapist but may also localize the problem anatomically. Fourth,
the therapist identifies treatment goals and formulates a plan to track progress toward
realizing the goals identified. Using the previous example, the therapist identifies pain
reduction and improved ventilation as treatment goals. Pain reduction could be
monitored by palpation, and improvement in ventilation could be monitored through
auscultation.

Terapis fisik memiliki empat tujuan untuk pemeriksaan dada. Pertama, terapis
mengidentifikasi masalah paru yang dikeluhkan oleh pasien. Masalah utama yang paling
sering dikeluhkan pasien adalah gejala utama dari penyakit paru: dyspnea, batuk, dahak,
dan nyeri dada. Kedua terapis menilai tanda nyata dari penyakit paru. Sebagai contoh,
terapis mengidentifikasi pasien dengan keluhan nyeri dada. Melalui evaluasi lebih lanjut
terapis menentukan bahwa rasa sakit lokal untuk area kecil dari dinding dada, lakukan
dengan lembut untuk palpasi, terkait dengan kedua suara kisi selama bernafas dan pola
bernapas pintu-langkah yang dangkal, dan diperburuk oleh batuk dan gerakan
pernapasannya. Pada titik ini tanda-tanda nyata menunjukkan adanya fraktur tulang
rusuk. Ketiga, terapis menentukan kebutuhan untuk prosedur evaluatif lebih lanjut
ketika hasil pemeriksaan dada tidak jelas. Dalam contoh sebelumnya, evaluasi lebih
lanjut oleh radiografi dada tidak hanya dapat mengkonfirmasi penilaian oleh terapis,
tetapi juga dapat melokalisasi masalah anatomis. Keempat, terapis mengidentifikasi
tujuan pengobatan dan merumuskan rencana untuk melacak kemajuan untuk
mewujudkan tujuan yang diidentifikasi. Menggunakan contoh sebelumnya, terapis
mengidentifikasi pengurangan rasa sakit dan peningkatan ventilasi sebagai tujuan
pengobatan. Pengurangan nyeri dapat dipantau dengan palpasi, dan peningkatan
ventilasi dapat dipantau melalui auskultasi.

COMPONENTS OF THE CHEST EXAMINATION

KOMPONEN DARI PEMERIKSAAN DADA

The chest examination has four components: inspection, auscultation, palpation,

and percussion.

Pemeriksaan dada memiliki empat komponen: Inspeksi, Auskultasi, Palpasi, dan

Perkusi
INSPECTION

INSPEKSI

The inspection phase of the chest examination documents the clinical

characteristics associated with the presenting symptoms. During inspection the
therapist detects problems previously unidentified. The results of the inspection
determine what other components of the examination are necessary.

Tahap inspeksi pada pemeriksaan dada berisi karakteristik klinis yang terkait dengan
gejala yang muncul. Selama inspeksi terapis mendeteksi masalah sebelumnya yang tak
dikenal. Hasil inspeksi menentukan apa komponen lain dari pemeriksaan yang
diperlukan.

Part 1 of the inspection consists of evaluation of the patient’s general

appearance. In part 2 the therapist closely inspects the head and neck. The therapist
inspects the chest in parts 3 and 4 and evaluates the breath, speech, cough, and
sputum in part 5.

Bagian 1 dari inspeksi terdiri dari evaluasi penampilan umum pasien. Pada bagian 2
terapis dengan cermat memeriksa kepala dan leher. Terapis menginspeksi dada di
bagian 3 dan 4 dan mengevaluasi napas, ucapan, batuk, dan dahak di bagian 5.

1. Evaluation of general appearance

1. Evaluasi penampilan umum

In evaluating the general appearance of the patient, the therapist assesses the state of
consciousness in reference to seven somewhat ill-defined and often overlapping stages.
Following are the seven stages of consciousness from highest to lowest level:

Dalam mengevaluasi penampilan umum pasien, terapis menilai keadaan kesadaran

mengacu pada tujuh agak tidak jelas dan sering tumpang tindih tahap. Berikut ini adalah
tujuh tahap kesadaran dari yang tertinggi ke tingkat terendah:

1) Alert
2) Automatic
3) Confused
4) Delirious
5) Stuporous
6) Semicomatose
7) Comatose
 1) Siaga
2) Otomatis
3) Bingung
4) mengigau
5) stupor
6) Semicomatose
7) koma

The alert patient is oriented, attends to the therapist’s instructions, and cooperates in
carrying them out. The automatic patient is irritable, shows impaired judgment, and
retains instructions poorly. The confused patient is disoriented, illogical, and able to
respond to simple commands only. The delirious patient is totally irrational, often
agitated, sometimes hostile, and generally uncooperative. The stuporous patient is
unresponsive to the environment and often incontinent. The semicomatose patient is
unconscious but rouses to painful stimuli. The comatose patient is both unconscious
and unarousable.

Pasien peringatan adalah berorientasi , menghadiri instruksi terapis , dan bekerja sama
dalam membawa mereka keluar . Pasien otomatis marah , menunjukkan penghakiman
terganggu , dan mempertahankan petunjuk buruk . Pasien bingung adalah bingung ,
tidak logis , dan mampu merespon perintah sederhana saja. Pasien mengigau benar-
benar tidak masuk akal , sering gelisah , kadang-kadang bermusuhan , dan umumnya
tidak kooperatif . Pasien stupor tidak responsif terhadap lingkungan dan sering
mengompol . Pasien semicomatose tidak sadar tetapi membangkitkan rangsangan
yang menyakitkan . Pasien koma adalah baik sadar dan unaroudsable .

The therapist evaluates body type as normal, obese, or cachectic. In assessing

posture, the therapist take particular note of any spinal malalignmentor unusual
postures. In this part of the examination, the therapist documents kyphosis, scoliosis,
and forward bent or professorial posture.

Terapis mengevaluasi tipe tubuh seperti biasa, obesitas, atau kurus. Dalam menilai
postur, terapis mengambil catatan khusus dari setiap misalignment tulang belakang atau
postur yang tidak biasa. Dalam hal ini bagian dari pemeriksaan, dokumen terapis
kyphosis, scoliosis, dan membungkuk atau keprofesoran postur.

During the extremity evaluation the therapist notes nicotine stains on the fingers,
digital clubbing, painful swollen joints, tremor, and edema. Nicotine stains suggest a
history of heavy smoking and are important in the evaluation of the unconscious patient.
Clubbing of the fingers or toes is associated with cardiopulmonary and small bowel
disease. Painful swollen joints may indicate pseudohypertrophic pulmonary
osteoarthropathy rather than the osteoarthritis or rheumatoid arthritis more familiar to
physical therapists. The presence of asterixis (flapping tremor of the wrists when the
arms are extended) may suggest hypercapnia. Bilateral pedal edema suggests right-
sided heart failure.

Selama evaluasi ekstremitas terapis mencatat noda nikotin pada jari, jari tabuh
digital, bengkak sendi yang menyakitkan, tremor, dan edema. Noda Nikotin
menunjukkan adanya riwayat merokok berat dan sangat penting dalam evaluasi
pasienyang tidak sadar. Jari tabuh pada jari tangan atau kaki yang berhubungan dengan
cardiopulmonary dan penyakit usus kecil. Bengkak sendi serta nyeri mungkin
menunjukkan osteoarthropathy semu hypertrophic paru daripada osteoarthritis atau
rheumatoid arthritis yang lebih akrab dengan terapis fisik. Kehadiran asteriksis (tremor
dengan mengepakkan pergelangan tangan ketika lengan diperpanjang) mungkin
menunjukka hiperkapnia. Bilateral edema pedal menunjukkan gagal jantung sisi kanan.

To complete the evaluation of the patient’s appearance, the therapist notes all
equipment used in managing the patient. For example, the use of a cardiac rhythm
disturbances, or hemodynamic or cardiac output problems respectively.

Untuk menyelesaikan evaluasi penampilan pasien, terapis mencatat semua

peralatan yang digunakan dalam mengelola pasien. Misalnya, penggunaan gangguan
irama jantung atau hemodinamik dan masalah cardiac output masing-masing.

2. Specific evaluation of head and neck

2.Evaluasi spesifik pada kepala dan leher

In evaluating the head and neck, the therapist assesses the face to detect signs of
distress, oxygen desaturation, carbon monoxide poisoning, or hypertension. The
therapist completes this part of the evaluation by observing the neck veins to detect
signs of elevated central venous pressure. Table : presents guidelines for the
recognition and interpretation of clinical signs associated with the evaluation of the head
and neck.

Dalam mengevaluasi kepala dan leher, terapis menilai wajah untuk mendeteksi tanda-
tanda tertekan, desaturasi oksigen, keracunan karbon monoksida, atau hipertensi.
Terapis melengkapi bagian dari evaluasi dengan mengamati vena leher untuk
mendeteksi tanda-tanda tekanan vena sentral meningkat. Tabel: menyajikan pedoman
untuk pengenalan dan interpretasi tanda-tanda klinis yang terkait dengan evaluasi
kepala dan leher.

Characteristic evaluated Clinical sign Interpretation

Facial expression Alaenasi flaring Severe distress
Dilatation of pupils
Sweating
Pallor

Color and mucous Blue Severe arterial oxygen

membranes desaturation
Facial color Plethoric Possible hypertension
Cherry red Possible carbon monoxide
poisoning

Size of neck veins Distended above clavicle Central venous pressure

when sitting may exceed 15 cm H2O

Karakteristik evaluasi Tanda klinis Interpretasi

Ekspresi wajah Alaenasi flaring Tekanan berat
Pelebaran pupil
berkeringat
muka pucat
Warna dan selaput lendir Biru Arteri parah oksigen desaturasi
Warna wajah berlimpah-limpah kemungkinan hipertensi
merah ceri Kemungkinan keracunan karbon
monoksida
Ukuran vena leher y _t Tekanan vena sentral dapat
id UTF-8 melebihi 15 cm H2O
Buncit di atas klavikula saat
duduk

3. Evaluation of the unmoving chest

3. Evaluasi dada tak bergerak

When examining the chest, the physical therapist evaluates the condition of the skin
and the shape and symmetry of the chest. Inspecting the skin ensures documentation of
incisions, scars, and trauma. Evaluating the shape of the chest permits documentation
of congenital defects like pectuscarinatu, pectusexcavatum, or Harrison’s sulcus.
Evaluating the chest in both the anteroposterior and transverse planes facilitates
identification of the barrel-chest abnormality, a feature of obstructive lung disease. A
barrel-chest exists when the anteroposterior diameter is greater than or equal to twice
the transverse diameter.

Ketika memeriksa dada, terapis fisik mengevaluasi kondisi kulit dan bentuk dan
simetri dada. Pemeriksaan kulit memastikan dokumentasi insisi, bekas luka, dan trauma.
Mengevaluasi bentuk dada memungkinkan dokumentasi cacat bawaan seperti
pectuscarinatu, pectusexcavatum, atau sulkus Harrison. Mengevaluasi dada baik di
anteroposterior dan bidang melintang memfasilitasi identifikasi kelainan barel-dada,
fitur penyakit paru obstruktif. Sebuah barel-dada terjadi ketika diameter
anteroposterior lebih besar dari atau sama dengan dua kali diameter transversal.

Therapists next evaluate rib angels and intercostal spaces. Normally, rib angels
measure less than 90 degrees and attach to the vertebrae at an angle of about 45
degrees. The spaces between them are broader posteriorly than anteriorly. Widening of
the rib angles and broadening of the anterior intercostal spaces suggests hyperinflation
of the lungs.

Terapis selanjutnya mengevaluasi rusuk angel dan ruang interkostal. Biasanya, rusuk
angel diukur kurang dari 90 derajat dan menempel pada tulang belakang dengan sudut
sekitar 45 derajat. Ruang diantaranya adalah posterior lebih luas dari anterior.
Pelebaran sudut tulang rusuk dan perluasan ruang interkostal anterior menunjukkan
hiperinflasi paru-paru

Evaluating the musculature around the chest may reveal bilateral trapezius muscle
hypertrophy , which may be associated with chronic dyspnea. Finally comparing the
symmetry of the hemithoraces permits detection of abnormalities like apical retraction.

Mengevaluasi otot di sekitar dada dapat menunjukkan hipertrofi otot trapezius

bilateral, yang mungkin berhubungan dengan dyspnea kronis. Terakhir membandingkan
simetri hemithoraces yang memungkinkan deteksi kelainan seperti retraksi apikal.

4. Evaluation of the moving chest

4. Evaluasi dada bergerak

 Evaluation of the moving chest begins with assessment of the ventilatory rate, which
normally ranges from 12 to 20 breaths per minute. This normal, or eupneic, pattern of
breathing supplies one breath for every four heart beats. Tachypnea refers to a
ventilatory rate faster than 20 breaths per minute. Bradypnea refers to a ventilatory rate
slower than 10 breath per minute. Fever affects ventilatory rate by adding four breaths
per minute for every one Fahrenheit degree of fever.

Evaluasi dada bergerak dimulai dengan penilaian tingkat ventilasi, yang

biasanya berkisar 12 sampai 20 napas per menit. normal, atau eupneic, pola
pasokan pernapasan adalah satu napas untuk setiap empat ketukan jantung.
Takipnea mengacu pada tingkat ventilasi yang lebih cepat dari 20 napas per
menit. Bradypnea mengacu pada tingkat ventilasi lebih lambat dari 10 napas per
menit. Demam mempengaruhi tingkat ventilasi dengan menambahkan empat
napas per menit untuk setiap satu derajat Fahrenheit demam.
Next, the therapist evaluates the ratio of inspiratory and expiratory time, the I : E
ratio. Normally, expiration is twice as long as inspiration, giving a ratio of 1:2. In
obstructive lung disease reports of I:E ratios of 1:4 are common.

Berikutnya, terapis mengevaluasi rasio inspirasi dan ekspirasi waktu, dengan rasio
waktu I: E. Biasanya, waktu berakhirnya inspirasi dua kali lebih lama, memberikan rasio
1: 2. Dalam laporan penyakit paru obstruktif I: E rasio 1: 4 yang umum.

When evaluating the moving chest, one also evaluates the noise of breathing.
Detection of stridor, a crowing sound during inspiration, suggests upper airway
obstruction. Stridor may indicate laryngospasm. Another noise detected during
inspiration is stertor. Stertor is a snoring noise created when the tongue falls back into
the lower palate. Stertor may be heard in patients with depressed consciousness.
During expiration one may also hear grunting sounds, particularly in children with
pulmonary disease. Expiratory grunting may be a physiological attempt to prevent
premature airway collapse. Gurgling sounds heard during both ventilatory phases are
often called “death rattles”.

Ketika mengevaluasi dada bergerak, salah satunya mengevaluasi suara pernapasan.

Deteksi stridor, suara berkokok saat inspirasi, menunjukkan obstruksi jalan napas bagian
atas. Stridor dapat menunjukkan spasme laring. Kebisingan lain yang terdeteksi selama
inspirasi adalah stertor. Stertor adalah suara mendengkur yang muncul ketika lidah
jatuh kembali ke langit-langit yang rendah.
 The therapist then evaluates the pattern of breathing. This pattern reflects not only
the rate but also the depth and regularity of the ventilatory cycle. Some commonly
encountered ventilatory patterns appear in table.

Terapis kemudian mengevaluasi pola pernapasan. Pola ini mencerminkan tidak

hanya tingkatannya tetapi juga kedalaman dan keteraturan siklus ventilasi. Beberapa
pola ventilasi biasa ditemui muncul dalam tabel berikut.

Breathing patterns commonly encountered in the assessment of patients with

respiratory problems.

Pola pernapasan yang biasa ditemui dalam penilaian pasien dengan masalah
pernapasan.

Pattern of breathing Description

Apnea Absence of ventilation
Fish- mouth Apnea with concomitant mouth opening
and closing, associated with neck
extension and bradypnea
Eupnea Normal rate, normal depth, regular rhythm
Bradypnea Slow rate, shallow or normal depth, regular
rhythm, associated with drug overdose
Tachypnea Fast rate, shallow depth, regular rhythm,
associated with restrictive lung disease.
Hyperpnea Normal rate, increased depth, regular
rhythm
Cheyne-stokes (periodic) Increasing then decreasing depth, period
of apnea interspersed, somewhat regular
rhythm, associated with critically ill
patients.
Biot’s Slow rate, shallow depth, apneic periods,
irregular rhythm, associated with central
nervous system disorders like meningitis
Apneustic Slow rate, deep inspiration followed by
apnea, irregular rhythm, associated with
brainstem disorders
Prolonged expiration Fast inspiration, slow and prolonged
expiration yet normal rate, depth, and
regular rhythm, associated with obstructive
lung disease
Orthopnea Difficulty breathing in postures other than
erect
Hyperventilation Fast rate, increased depth, regular rhythm,
results in decreased arterial carbon
dioxide, tension, called “Kussmaul
breathing” in metabolic acidosis, also
associated with central nervous system
disorders like encephalitis
Psychogenic dyspnea Normal rate, regular intervals of sighing,
associated with anxiety
Dyspnea Rapid rate, shallow depth, regular rhythm,
associated with accessory muscle activity
Doorstop Normal rate and rhythm, characterized by
abrupt cessation of inspiration when
restriction is encountered, sassociated
with pleurisy.

Pola pernapasan Deskripsi

Apnea Tidak adanya ventilasi
Mulut Ikan Apnea dengan membuka dan menutup mulut
bersamaan, terkait dengan ekstensi leher dan
bradypnea
Eupnea Tingkat normal, kedalaman normal, irama teratur
Bradypnea Tingkat lambat, dangkal atau normal mendalam,
irama teratur, terkait dengan overdosis obat
Tachypnea Tingkat normal, meningkat kedalaman, irama
teratur
Cheyne-Stokes (periodik) Meningkatkan kemudian menurun mendalam,
periode apnea diselingi, ritme agak teratur,
berhubungan dengan pasien sakit kritis.

Biot’s Tingkat lambat, kedalaman dangkal, periode

apnea, ritme teratur, berhubungan dengan
gangguan sistem saraf pusat seperti meningitis
Apneustic Tingkat lambat, inspirasi dalam diikuti oleh apnea,
irama teratur, berhubungan dengan gangguan
 batang otak
Prolonged expiration Inspirasi cepat, lambat dan berakhirnya
berkepanjangan belum tingkat normal, kedalaman,
dan ritme yang teratur, berhubungan dengan
penyakit paru-paru obstruktif
Orthopnea Kesulitan bernapas di postur selain ereksi
hiperventilasi Fast rate, increased depth, regular rhythm,
results in decreased arterial carbon
dioxide, tension, called “Kussmaul
breathing” in metabolic acidosis, also
associated with central nervous system

After evaluating the pattern and noise of breathing, the therapist evaluates the
symmetry and synchrony of ventilation. The timing and relative motion of one
hemithoraxto the other and to the abdomen is compared during both tidal and deep
breathing. One may find asymmetrical, asynchronous chest motion during deep
breathing in hemiplegia. In patients with flail-chest deformity, expansion of one part of
the chest may occur simultaneously with retraction of the other, a condition creating the
basis for a paradoxical breathing pattern also known as Pendelluft (“pendulum air”). In
chronic obstructive lung disease, the chest and abdomen may move as a unit, hence
the term “en bloc “ motion. At least one exploratory study suggests that asynchronous,
or seesaw, motion between the rib cage and the abdomen has prognostic significance.

Setelah mengevaluasi pola dan suara pernapasan, terapis mengevaluasi simetri dan sinkroni
ventilasi. Waktu dan gerak relatif dari satu hemithorax yang lain dan perut dibandingkan selama kedua
bernapas pasang surut dan mendalam. Satu mungkin menemukan asimetris, asynchronous gerakan
dada saat bernapas dalam-dalam di hemiplegia. Pada pasien dengan deformitas memukul dada,
perluasan satu bagian dada dapat terjadi bersamaan dengan pencabutan dari lainnya, kondisi
menciptakan dasar untuk pola pernapasan paradoks juga dikenal sebagai Pendelluft ("udara
pendulum"). Pada penyakit paru obstruktif kronik, dada dan perut bisa bergerak sebagai satu unit, maka
istilah "en bloc" gerak. Setidaknya satu studi eksplorasi menunjukkan bahwa asynchronous, atau
jungkat-jungkit, gerakan antara tulang rusuk dan perut memiliki makna prognostik.

Next to be evaluated are the muscles of breathing. Gross observation permits

detection of deviations from the normal, diaphragmatic breathing pattern used by men
and children and the costal breathing pattern used by women. Close inspection
facilitates detection of accessory inspiratory or expiratory muscle activity. Moreover,
careful observation of the intercostal spaces may reveal inspiratory retraction
associated with decreased pulmonary compliance or expiratory bulging associated with
expiratory obstruction.

Berikutnya yang akan dievaluasi adalah otot-otot pernapasan. Pengamatan kotor memungkinkan
deteksi penyimpangan dari, pola pernapasan normal diafragma yang digunakan oleh laki-laki dan anak-
anak dan pola pernapasan Kosta digunakan oleh perempuan. Tutup pemeriksaan memfasilitasi deteksi
inspirasi aksesori atau aktivitas otot ekspirasi. Selain itu, pengamatan yang cermat dari ruang interkostal
dapat menunjukkan retraksi inspirasi terkait dengan kepatuhan paru menurun atau menggembung
ekspirasi terkait dengan obstruksi ekspirasi.

7. Evaluation of speech, breath, cough, and sputum

Inspection of the chest continues with evaluation of speech, breath, cough, and
sputum. Conversation with the patient facilitates recognition of various speech patterns
or breath problems. Limited word patterns, frequently interrupted for breath, are known
collectively as “dyspnea of phonation”. Poor voice-volume control is associated with
muscular incoordination and can be found in central nervous system disorders like
cerebral palsy. Bad breath detected during the conversation may indicate anaerobic
infection of the mouth or respiratory tract.

After evaluating speech and breath, one identifies the characteristics of the cough.
The therapist determines if cough is persistent, paroxysmal, or occasional, dry or
productive, and finally notes the circumstances associated with the onset or cessation
of the cough as well as the conditions associated with it enables the therapist to
interpret its significance.

Table : Guidelines for evaluating cough

Cough characteristics Associated features Interpretation

Nonspecific Sore throat, runny nose, Acute lung infection,
runny eyes tracheobronchitis
Productive Preceded by an earlier, Lobar pneumonia
painful, nonproductive
cough associated with an
upper respiratory infection
Dry or productive Acute bronchitis Bronchopneumonia
Paroxysmal, mucoid or Flulike syndrome Mycoplasma or viral
blood-stained sputum pneumonia
Purulent sputum Sputum formerly mucoid Acute exacerbation of
chronic bronchitis
Productive for more than 3 chronic bronchitis
months consecutively and
for at least 2 years
Foul-smelling, copious, Long-standing problem Bronchiectasis
layered purulent sputum
Blood- tinged sputum Month long Tuberculosis or fungal
infection
Persistent, nonproductive Pneumonitis, interstitial
fibrosis, pulmonary
infiltrates
Persistent, minimally Smoking history, injected “Smoker’s cough”
productive pharynx
Nonspecific, minimal Long standing Neoplastic disease
hemoptysis
Nonproductive Long standing, dyspnea Mediastinal neoplasm
Brassy Aortic aneurysm
Violent cough Sudden, onset at the same Aspiration of foreign body
time as signs of asphyxia,
localized wheezing
Frothy sputum Worsens in supine position, Heart failure, pulmonary
dyspnea edema
Hemoptysis Sudden, simultaneous Pulmonary infarct.
dyspnea, pleural effusion
Adapted from Fishman AP : Pulmonary diseases and disorders, vol . 1 , New York,
1980, McGraw-Hill Book Co.

Assessing the voluntary cough permits evaluation of its constituent parts and its
sequencing as well. For example, the cough of a surgical patient is often associated
with a poor inspiratory effort followed by negligible abdominal muscle compression,
these findings contribute to a “poor” nonproductive cough. They provide important clues
for the treatment plan.

Sputum evaluation often follows cough assessment. The source of the sputum
sample and the quantity of expectorate raised per day should be noted. Normally,
persons are unaware of the 100 ml of mucus raised daily. Conscious awareness of any
sputum production is significant. In addition to quantity, the color and consistency of any
sputum raised should be evaluated. Table : presents some guidelines for evaluating
sputum samples.

Table : Guidelines for evaluation of sputum samples.

Source Upper airway

Lower airway
Quantity Milliliters or cupsful per day
Color Red : blood
Rust : pneumonia
Purple : neoplasm
Yellow : infected
Green : pus
Pink : pulmonary edema
Flecked : carbon particles
Consistency Thin, watery
Gritty
Thick, mucous
Layered

The inspection phase of the chest examination closes with a brief evaluation of
the abdomen to detect any impedance to diaphragmatic descent such as ascites,
pregnancy, or a paralytic ileus.

Further evaluation of the signs and symptoms discussed during inspection

occurs during the second phase of the chest examination, auscultation.

AUSCULTATION

Auscultation either confirms the findings of inspection or identifies areas of

impaired ventilation or impaired secretion clearance. In addition, auscultation provides
important feedback about the effectiveness of a treatment program in resolving
pulmonary problems.
 The stethoscope. Readiness for auscultation requires preparation of the
equipment, the patient, and the therapist. A stethoscope is the only piece of equipment
necessary for auscultation. The stethoscope should have binaural earpieces connected
to a removable diaphragm by tubing of sufficient length to permit examination of the
patient in either the supine or seated posture. Excess tubing creates extraneous noise.
Improper tubing, for example, Foley catheter tubing, may not conduct sound adequately
to permit valid and reliable evaluation of all sounds produced.

Two styles and several sizes of earpieces are available to ensure comfortable fit.
Earpieces may be made of hard molded plastic or soft, flexible plastic. Directing the
earpieces forward into the external auditory canals ensures proper position. Occasional
wiping with conventional alcohol maintains earpiece cleanliness.

Most authors agree that the diaphragm rather than the bell of the stethoscope
most accurately transmits lung sounds. Prolonged use or frequent cleaning may break
the diaphragm. Although exposed x-ray film can temporarily substitute for a broken
diaphragm, manufacturers suggest that sounds are less accurately assessed with this
substitute and strongly urge their customers to order appropriate replacements.

Stethoscopes equipped with both diaphragm and bell have a valve that may be
turned toward either the bell or diaphragm to listen.

Preparing the patient for auscultation involves teaching the importance of deep
breathing through the mouth and of reporting dizziness or undue fatigue.

Nomenclature.Before auscultating, the therapist must be aware that there is

disagreement concerning the nomenclature pertaining to breath sounds. In 1974 the
Joint Committee on Pulmonary Nomenclature (JCPN) of the American College of
Cardiologists and the American Thoracic Society recommended the adoption of a
standardized nomenclature for describing variations in the quantity and quality of breath
sounds.

The JCPN suggests interpreting the quantity of breath sounds as absent,

decreased, normal, or bronchial. Normal, or vesicular, breath sounds rustle. The
intensity of this rustling sound increases rapidly, reaching a maximum shortly after
inspiration is begun. This sound persists during the transition to expiration and
disappears shortly thereafter. Bronchial or tubular breath sounds are loud and harsh.
Their initial intensity is maintained through both phases of ventilation but is
conspicuously absent during the transition from inspiration to expiration. Decreased
breath sounds are merely less intense than normal breath sounds.

The recommendations of the JCPN further suggest adopting a uniform

nomenclature for interpreting the quality of abnormal breath sounds. The committee
recognizes two categories of abnormal breath sounds : crackles or rales (French rales )
and wheezes or rhonchi. Crackles are defined as nonmusical sounds whose further sub
classification serves no useful purpose. Inspiratory crackles or rales may be heard
throughout inspiration or only at its termination. Inspiratory crackles are common at the
bases of the lungs in an erect subject. Crackles may represent the sudden opening of
airways previously closed by gravity and therefore may be a sign of abnormal lung
deflation. Expiratory crackles or rales are rhythmical and non rhythmical. Rhythmical
crackles may indicate the reopening of previously closed airways. Non rhythmical
sounds are generally low pitched and occur throughout the ventilatorycycle. They may
represent fluid in the large airways.

Rhonchi, or wheezes, are both continuous and musical. Rhonchi are probably
produced by air flowing at high velocities through apposed airways. Their pitch varies
directly with the velocity of airflow. Rhonchi may be monophonic or polyphonic and may
be heard in either inspiration or expiration. Inspiratory rhonchi unaccompanied by
expiratory rhonchi are usually monophonic. These rarely occurring rhonchi suggest that
the airway is rigid. Inspiratory rhonchi may be caused by stenosis produced, for
example, by bronchospasm or foreign-body impaction. End inspiratory rhonchi occur
when the inspiratory traction forces, initially insufficient to allow some airways to open,
are suddenly overcome. This results in high-velocity airflow across the still-apposed
lumens producing a musical sound of short duration. Expiratory rhonchi are
encountered more frequently. They tend to be low pitched and polyphonic and may
reflect unstable airways that have collapsed. Expiratory rhonchi are associated with
diffuse airway obstruction. Monophonic expiratory rhonchus occurs when only one
airway reaches the point of collapse. The bagpipe sign describes a persistent
monophonic wheeze occurring at end expiration.

During auscultation the sounds produced by vocalization are also evaluated. The
JCPN further recommends that all voice-generated sounds, whether whispered or
spoken, be evaluated as decreased, normal, or increased. Bronchophony, egophony,
and pectoriloquy are voice-generated sounds. They each reflect the clarity and intensity
of sound transmission in the lung.

Other adventitious sounds detected during auscultation include rubs and

crunches. Rubs are coarse, grating, leathery sounds occurring with either the ventilatory
or the cardiac cycle. Pleural rubs are heard concurrently with the ventilatory cycle,
whereas pericardial rubs are heard during the cardiac cycle. Rubs generally indicate
inflammation.

Crunches are crackling sounds heard over the pericardium during systole.
Detection of such crunches suggests the presence of air in the mediastinum, called
mediastinal emphysema.
 The examination : With the above descriptions in mind, the therapist compares
the quality, intensity, pitch, and distribution of the breath and voice sounds of
homologous bronchopulmonary segments of the anterior, lateral, and posterior aspects
of the chest. Figure : presents one method of sequential auscultation of the chest.
Following are the steps for this method of auscultation:

1) Instruct the patient to sit forward (where sitting is not possible, place
patient in side-lying position)
2) Expose the anterior chest sufficiently to permit evaluation of the upper and
middle lung zones.
3) Remind patient to breathe in and out through the mouth.
4) Evaluate at least one breath in each pulmonary segment, comparing the
intensity, pitch, and quality of the breath sounds heard between the right
and left lungs.
5) Proceedcraniocaudally in a systematic manner.