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Respiratory assessment

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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.

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Assessment of the Chest and Lungs
Functions of the Respiratory System  Ventilation  Diffusion and Perfusion  Control of Breathing
Functions  Ventilation  Movement of air into and out of the lungs  Inspiratory phase  Expiratory phase
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
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
Anatomical Structures  Reference points for pinpointing findings from the physical examination  Topographical Landmarks  Reference Lines
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
Manubrium Manubriosternal junction (Angle of Louis) Nipple Costal Angle
Reference Lines  Anterior Chest  Midsternal line  Anterior axillary lines  Midclavicular lines  Posterior Chest  Vertebral line  Midscapular lines  Axilla  Anterior axillary lines  Midaxillary lines  Posterior axillary lines
Anterior Chest
Posterior Chest
Axilla
Anatomy
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
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
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
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
Respiratory assessment
Respiratory assessment
Respiratory assessment
Respiratory assessment
Chest Anatomy  Web Anatomy: http://www.gen.umn.edu/faculty_staff/jensen /1135/webanatomy/
History  Chief Complaint and HPI  Cough  Shortness of breath/Dyspnea
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?
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?
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
History  Personal and Social History  Tobacco  Alcohol  Drugs  Home environment  Occupational environment  Travel  Health Promotional Activities
Physical Examination
Equipment and Techniques  Equipment  Stethoscope  Techniques  Inspection  Palpation  Percussion  Auscultation
Inspection  General  Appearance  Posturing  Breathing effort  Trachea position  Midline
Inspection  Chest Wall Configuration  Form  Symmetry  Muscle development  Anterior-Posterior (AP) diameter  Approximately ½ the transverse diameter  Transverse: Anterior-Posterior = 2:1  Costal angle  90 degrees or less
Inspection  Oxygenation: cyanosis  Nails  Skin  Lips  Respiratory Effort  Respiratory rate and depth  Breathing pattern  Chest expansion
Palpation  Trachea – for position  Chest wall – for symmetry
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
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)
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
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
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
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
Auscultation Copy this URL into your Web browser to hear normal and abnormal lung sounds : http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm
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
Developmental Variations  Neonates  Breathing is diaphragmatic and abdominal  Signs of compromise  Stridor (“crowing”)  Grunting  Central cyanosis  Flaring nares
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
Developmental Variations  Pregnancy  Costal angle increases to about 105 degrees in the third trimester  Dyspnea and orthopnea are common  Breathes more deeply
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)
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

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Respiratory assessment

  • 1. Assessment of the Chest and Lungs
  • 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
  • 8. Manubrium Manubriosternal junction (Angle of Louis) Nipple Costal Angle
  • 9. Reference Lines  Anterior Chest  Midsternal line  Anterior axillary lines  Midclavicular lines  Posterior Chest  Vertebral line  Midscapular lines  Axilla  Anterior axillary lines  Midaxillary lines  Posterior axillary lines
  • 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/
  • 23. History  Chief Complaint and HPI  Cough  Shortness of breath/Dyspnea
  • 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
  • 29. Equipment and Techniques  Equipment  Stethoscope  Techniques  Inspection  Palpation  Percussion  Auscultation
  • 30. Inspection  General  Appearance  Posturing  Breathing effort  Trachea position  Midline
  • 31. Inspection  Chest Wall Configuration  Form  Symmetry  Muscle development  Anterior-Posterior (AP) diameter  Approximately ½ the transverse diameter  Transverse: Anterior-Posterior = 2:1  Costal angle  90 degrees or less
  • 32. Inspection  Oxygenation: cyanosis  Nails  Skin  Lips  Respiratory Effort  Respiratory rate and depth  Breathing pattern  Chest expansion
  • 33. Palpation  Trachea – for position  Chest wall – for symmetry
  • 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