This document provides information on assessing the chest and lungs, including the functions of the respiratory system, anatomical structures and landmarks, examination techniques, normal and abnormal findings, and developmental variations. It describes ventilation, diffusion, gas exchange, and breathing control. Topics covered include inspection, palpation, percussion, auscultation, breath sounds, and examining infants, children, pregnant patients and older adults. Videos are referenced for demonstrations of examination.
2. Functions of the Respiratory
System
Ventilation
Diffusion and Perfusion
Control of Breathing
3. Functions
Ventilation
Movement of air into and out of the lungs
Inspiratory phase
Expiratory phase
4. Functions
Hypoventilation
Slow, shallow breathing
Causes CO2 to build up in the blood
Acidosis
Hyperventilation
Rapid, deep breathing
Causes CO2 to be blown off
Alkalosis
5. Functions
Diffusion and Perfusion
Gas exchange across the alveolar-pulmonary
capillary membranes
Control of breathing
Influenced by neural and chemical factors
Pons, medulla, chemoreceptors in the carotid
body
Stimulus for breathing
Increased carbon dioxide - PRIMARY
6. Anatomical Structures
Reference points for pinpointing findings from
the physical examination
Topographical Landmarks
Reference Lines
7. Topographical Landmarks
Nipples
Manubriosternal junction (Angle of Louis)
Point at which the 2nd rib articulates with the sternum
Suprasternal notch
Costal Angle
Usually no more than 90 degrees
Ribs insert at approximately 45 degree angles
Clavicles
14. Anatomy Points to Remember
Lungs are symmetric
Lungs are divided into lobes
Right lung = 3 lobes
Left lung = 2 lobes
Primary muscles of respiration
Diaphragm – divides chest from abdomen
External intercostal muscles
Accessory muscles
15. Anatomy Points to Remember
Upper Airway
Nose, pharynx, larynx, intrathoracic trachea
Functions in respiration
Conduct air to lower airway
Filter to protect lower airway
Warm and humidify inspired air
16. Anatomy Points to Remember
Lower Airway
Trachea, bronchi, bronchioles
Functions in respiration
Conduct air to alveoli
Clear mucociliary structures
Alveoli
Functional unit
Gas exchange
Production of surfactant
17. Anatomy Points to Remember
Lower Airway
Trachea splits into left and right mainstem
bronchi which are further subdivided into
bronchioles
Right bronchus is shorted, wider and more
upright than the left
Functions in respiration
Conduct air to alveoli
Clear mucociliary structures
22. Chest Anatomy
Web Anatomy:
http://www.gen.umn.edu/faculty_staff/jensen
/1135/webanatomy/
24. Cough
Onset – sudden, gradual
Duration
Nature – dry, moist, hacking, barking
Sputum – amount, color, odor
Severity – disrupts activities
Associated symptoms – sneezing, dyspnea, fever, chills,
congestion, gagging
What brings it on? – anxiety, talking, activity
What makes it better?
What has been tried? – medications, treatments
Anything similar in the past?
25. Shortness of Breath (SOB) /
Dyspnea
Onset – sudden, gradual
Duration
Severity – disrupts activities
Associated symptoms – night sweats, pain, chest
pressure, discomfort, ankle edema, diaphoresis, cyanosis
What brings it on? – position, time of day, exercise,
allergens, emotions
What makes it better?
What has been tried? – medications, inhalers, oxygen
Anything similar in the past?
26. History
Past Health History
Lung disease or breathing problems
Frequent severe colds, asthma, emphysema,
bronchitis, pneumonia, tuberculosis
Last PPD and/or chest x-ray
Allergies
Medication use
Family History
27. History
Personal and Social History
Tobacco
Alcohol
Drugs
Home environment
Occupational environment
Travel
Health Promotional Activities
34. Palpation
Thoracic Expansion (Excursion)
Place both thumbs at about 7th rib
posteriorly along the spinal process
Click on the pictures to view video
Extend the fingers of both hands
outward over the posterior chest wall
Have the person take a deep breath
and observe for bilateral outward
movement of thumbs
Normal: bilateral, symmetric
expansion
Abnormal: unilateral or unequal
35. Palpation
Vocal (Tactile) Fremitus
Use palmar or ulnar surfaces of hands
Systematically position hands over both sides of
posterior chest
Have person repeat “1 – 2 – 3” or “99” as you
move from the apices to the bases
Normal: bilaterally symmetrical vibrations
Decreased or absent: obstruction of transmission
0bronchitis, emphysema)
Increased: consolidation (compression) of lung
tissue (pneumonia)
36. Auscultation
Auscultate in a systematic manner
Compare one side to the other
Listen one full respiration at each spot
Displace breast tissue to listen directly over
chest wall
DO NOT listen through gowns, clothes, etc.
Place your stethoscope over bare skin
37. Auscultation
Evaluate posterior, lateral, and anterior chest
Instruct person to sit upright and breathe in
and out slowly through the mouth
This makes it easier to hear the air movement
Use the diaphragm of the stethoscope
Move from the apices to the bases
38. Auscultation
Evaluate for normal sounds
Sound Pitch Intensity Quality I:E Location
Bronchial High Loud Blowing/ I<E Trachea
hollow
Bronchovesicular Moderate Moderate Combination I=E Between scapulae,
1st & 2nd ICS lateral to
sternum
Vesicular Low Soft Gentle rustling/ I>E Peripheral lung
breezy
39. Auscultation
Evaluate for adventitious sounds
Sound Intensity/ Pitch I/E Quality Clear with Cough
Crackles/ Soft (fine)/ High I Discontinuous, Possibly
Rales Loud (coarse)/ Low nonmusical, brief
Wheeze High E Continuous musical Possibly
sounds
Ronchi Low E Continuous snoring Possibly
sounds
Pleural I&E Continuous or Never
Friction Rub discontinuous creaking or
brushing sounds
Stridor I Continuous, crowing Never
40. Auscultation
Copy this URL into your Web browser to hear normal and abnormal lung sounds :
http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm
41. Developmental Variations
Neonates
Measure the chest circumference
Usually 2-3 cm smaller than head circumference
Chest is round (i.e. AP diameter = transverse)
Obligate nose breathers
Periodic breathing is common
Sequence of vigorous breathing followed by apnea
for 10-15 seconds
Only concern if it is prolonged or baby becomes
cyanotic
42. Developmental Variations
Neonates
Breathing is diaphragmatic and abdominal
Signs of compromise
Stridor (“crowing”)
Grunting
Central cyanosis
Flaring nares
43. Developmental Variations
Infants and Young Children
Roundness of the chest persist for first 2 years
Chest walls are thinner than the adult’s
Breath sounds may sound louder, and more
bronchial than the adult
Bronchovesicular sounds may be heard
throughout the chest
44. Developmental Variations
Pregnancy
Costal angle increases to about 105 degrees in
the third trimester
Dyspnea and orthopnea are common
Breathes more deeply
45. Developmental Variations
Older Adult
Chest expansion is often decreased
Bony prominences are marked
AP diameter is increased with respect to
transverse (but not 1:1)
46. Videos of Thorax and Lung
Assessment
Copy these URLs into your Web browser
http://www.conntutorials.com/chapter5.html
OR
http://medinfo.ufl.edu/other/opeta/chest/CH_main