Respiratory assessment

Respiratory assessment

1. College Of Nursing Madras Medical College Chennai-03 PRESENTED BY EDWIN JOSE.L MSc(nursing) I YEAR College of nursing Madras medical college Chennai-03 1

2. INTRODUCTION Correct diagnosis depends on an accurate health history and a through physical examination. A respiratory assessment can be done as part of a comprehensive physical examination or as an examination in itself. Judgement must be used in determining whether all or part of the historm and physical examination will be completed based on the problems If respiratory distress is severe ,only pertinent information should be obtained and a through assessment should be deferred until the patient ‘s condition stabilizes 2

3. Review of anatomy –respiratory system 3 The thoracic cage is a bony structure with a conical shape which is narrower at the top. It has sternum ,12 pairs of ribs, and 12 thoracic vertebras. Its floor is diaphragam – musclotendaneous septum. First seven ribs joints with sternum through costal cartilage ,8,9,10th ribs attach to the costal cartilage above and 11,12, are floating

4. Anterior thoracic landmarks 4 Supra sternal notch Sternum Sternal angle or angle of louis Costal angle

5. Posterior thoracic landmark 5 Vertebra prominence Spinous processes Inferior boarder of scapula Twelth rib

6. Reference line 6 Mid sternal line Mid clavicular line Anterior axillary line Mid axillary line Posterior axillary line Scapular line Vertebular line

7. Thoracic cavity 7 Mediastinum Lung borders Lobes of lungs Anterior Posterior Lateral Pleura Trachea and bronchial tree Trachea Bronchi acinus

8. Demographic data Name Age/sex Ward/unit MRD no Educational qualification Occupation/income Address Date/time of admission Medical diagnosis Reason for hospitalisation 8

9. Chief complaints Cough Shortness of breath Chest pain with breathing History of respiratory infection Sputum production Hemoptysis Voice change Fatigue Clubbing of fingers 9

10. COUGH 10 Onset-gradual/sudden, how long, how often, aggrevating factors Acute cough – less than 2 or 3 weeks Chronic cough – lasts over 2 months Continuous through out the day- resp.infection Afternoon/eve –exposure to irritants Night – postnasal irritants Early morning – chronic bronchitis Phelgam /sputum, how much, colour,cough up any blood, streaks or frank blood, foul odor White/ clear – colds,bronchitis,viral infection Yellow /green – bacterial infection Rust colour – TB,pnemococcal pneumonia, Pink, forthy – pulmonary edema Description of cough –hacking, dry, barking, hoarse, congested, bubbling Mycoplasma pneumonia-hacking Early heart failure –dry Croup-barking Colds,bronchitis,pneumonia - congested Cough seem to come with activity,position,fever,talking,anxiety ? Treatment, prescription or OTC Assess the effectiveness of coping ststergies Associated with chest pain,earpain , etc Note siverity

11. Shortness of breath 11 Onset, severity, how long it exits, what brings it Is affected by position such as lying down Orthopnea No of pillows needed Occurs at specific time ,day or night Paroxysmal nocturnal dyspnea Episodes associated with night sweats diaphoresis Associated with cough, chest pain, bluish color around lips, wheezing sound Cyanosis signals hypoxia Related to food, pollen, dust, animals, season, emotion, exercise Asthma attacks Hard breathing attack, special position or pursed lips breathing, use of oxygen, inhalers, or medications Tripod position ,Assess the effect of coping strategies

12. Modified borg dyspnea scale 12

13. Chest pain 13 Onset, constant,or does it come and go Chest pain of thoracic origin occurs with muscle soreness from coughing or from inflammation of pleura, Description of pain : burning/ stabing Brought on by respiratory infection, coughing, trauma, feverdeep breathing, unequal chest inflation Treatment if any

14. History of respiratory infection 14 Past history of breathing trouble,lung disease like bronchitis,emphysema,asthma , pneumonia, covid 19 Consider sequalae of these condition Most people have had some colds,it is meaningfull to ask about excess number or severity Any unusually frequent or unusually severe colds Any family history of allergies,tuberculosis,or asthma

15. Sputum production 15

16. hemoptysis Hemoptysis is defined as the spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage. The patient’s history should help determine the amount of blood and differentiate between hemoptysis, pseudo-hemoptysis, and hematemesis. Hemoptysis is classified as non-massive or massive based on the volume of blood loss considered non-massive if blood loss is less than 200 mL per day In adults, bronchitis, bronchogenic carcinoma, and pneumonia are the major causes. 16

17. Clubbing of fingers 17 A characterized bulging of the distal finger and nail beds often describe in stages Softening of the nail bed ,causing a spongy feeling when the nail is pressed Loss of normal >165 degree angle between nail bed and fold Convex nail growth Thickening of the distal part of the finger Shine and striation of the nail and skin Commonly seen in COPD, asthma,cystic fibrosis,asbestosis,pulmonary fibrosis

18. Past health history: Frequency of upper respiratory problems including childhood respiratory disorders Allergies- medications, pollens, smoke, mold , pet exposure Past history of lower respiratory problems – asthma, COPD, pneumonia, covid 19 etc… History of HIV infection 18

19. Medications: Prescription and over the counter drugs- antihistamines, bronchodilators, corticosteroids, cough suppressants, and antibiotics. Reason for taking medicines –it’s name, dose, frequency, length of time taken, it's effects and side effects ,if any Use of angiotensin converting enzyme (ACE) inhibitors Use of oxygen,FiO2 ,liter flow, method of administration, no of hours used per day, effectiveness of therapy 19

20. Surgery or other treatments: Previous hospitalization, if so the dates, therapy, and current status of the problem Use and the response to respiratory treatments such as nebulizer, humidifier ,airway clearance, high frequency chest oscillation, postural drainage and percussion Tobacco usage: Pack years – is the number of years that a patient has smoked multiplied by number of pack of cigarettes smoked a day Second hand smokers Radon gas Asbestos Paddy fields 20

21. Family history Type of family Ordinal position in the family Role in the family Risk factors among the family members History of any heredity/genetic disorder,cardiac disease , etc …. Enquire family history of tuberculosis,bronchiectasis,cystic fibrosis, lung cancer etc ….. 21

22. Soci -economic history Smoking history Enquire about passive smoker Enquire about exposure to birds Exposure of air pollution Type of house, waste disposal, drainage facility, ventilation Family income 22

23. Occupational history Occupation Exposure to asbestos Paddy field worker 23

24. Functional health patterns Health perception – health management pattern: Describe your daily activities? Health status in last several days? How your breathing problem affects self care abilities? Have you ever smoked? Have you had flu vaccination? What equipments you use to relieve breathing difficulties? 24

25. 2.Nutritional –Metabolic pattern: Have you recently lost weight? How much? Voluntarily? Do any particular foods affect your sputum production or breathing 3. Elimination patterm : Does your respiratory problem make it difficulty for get to the toilet? Are you inactive because of dyspnea which causes constipation? 4.Activity – exercise pattern: Are you ever short of breath during exercise What you do when you get shortness of breath ? Can you walk steps without stopping? 25

26. Sleep rest pattern: Do breathing problems causes you to awaken during the night Can you lie flat at night ?how many pillows do you use? Do you need to sleep upright in a chair? Do you have morning headache Do you fall asleep easily during the day? Cognitive – perceptual pattern: Do you have any pain associated with breathing? Pain scale 0-10 Does it hurt more on inspiration? Self perception- self concept pattern: Describe how your respiratory problems have changed your life Do you ever go out without bringing your oxygen ,when and why? 26

27. Role relationship pattern: Has your respiratory problem caused any difficulty in your work, family or social relationship Sexuality –reproductive pattern: Has your respiratory problem caused a change in your sexual activity? Do you want to discuss ways to decrease dyspnea during sexual activity? Coping stress tolerance pattern: How often do you leave your home? Would you want to join a support group ? Does stress have any effect on breathing? What effects does you respiratory problem have on your emotions? value –belief pattern: What do you believe cause your respiratory problems? Do you think the things you have been told to do for your respiratory problems really help?if not why? 27

28. Physical examination Preparation: Ask the person to sit upright and disrobe to the waist Provide warm room ,a warm diaphragm endpiece Perform inspection,palpation,percussion and auscultation on the posterior and lateral thorax Then repeat anterior chest Clean the stethoscope end piece with alcohol wipe 28

29. inspection NOSE: Patency – naris is checked for air patency by occluding other naris Inflammation- inspect with speculum for edema,exudate or bleeding Deformities – observe for deviation, perforation ,bleeding observe for polyps Discharge – assess for color and consistency purulent/malodorous indicates presence of foregin body watery discharge – allergies or from cerebrospinal fluid. blood discharge – from trauma or dryness thick mucosal discharge – presence of infection 29

30. Mouth and pharynx Inspects the interior of the mouth for color,lesions,masses,gum retraction, bleeding, and poor dentation Tongue is inspected for symmetry and presence of lesions Inspect pharynx for exudate, ulceration, swelling or postnasal drip Tonsils are noted for colour , symmetry and any enlargement Assess for gag reflex – indicates the cranial nerves IX and X are intact 30

31. neck Inspects for symmetry and presence of tender or swollen areas The lympnodes are palpated while the patient is sitting erect with the neck slightly flexed Patient may have small, mobile,non -tender nodes (shotty nodes) which are not a sign of a pathological condition Tender , hard,or fixed nodes indicates disease. 31

32. Thorax and lungs-inspection Appearance – evidences of respiratory distress, tachypnea or use of accessory muscles Shape – elliptical shape with downward slopping ribs abour 45 degrees relative to the spine Chest movements – equal ,symmetry, AP diameter < transverse diameter by a ratio 1:2 32

33. Accessory muscles of respiration 33 Active inspiration: Scalenes – elevates the upper ribs. Sternocleidomastoid – elevates the sternum. Pectoralis major and minor – pulls ribs outwards. Serratus anterior – elevates the ribs Latissimus dorsi – elevates the lower ribs. Active Expiration: Anterolateral abdominal wall – increases the intra-abdominal pressure, pushing the diaphragm further upwards into the thoracic cavity. Internal intercostal – depresses the ribs. Innermost intercostal – depresses the ribs.

34. Cont …. Barrel chest 34 AP diameter = tranverse diameter with ratio of 1:1 Ribs are horizontal indtead of normal downward slope Seen in normal aging and hyperinflated lungs such as COPD Due to overactivity of scalene and sternocleidomastoid muscle which lifts the upper ribs and sternum and this overuse causes remodelling of the chest

35. Pectus excavatum –funnel breast 35 A markedly sunken or concave appearance of sternum and adjacent cartilages Depression begins with 2 nd ICS becoming depressed most at junction of xiphoid process Congenital disorder

36. Pectus carinatum-pigeon chest 36 A forward protrusion of the sternum with ribs sloping back at either side and vertical depression along costochondral junctions Congenital disorder

37. scoliosis 37 A lateral S-shaped curvature of the thoracic and lumbar spine with involved vertebrae rotation.

38. Kyphosis-dowager’s hump 38 Exaggerated posterior curvature of the thoracic spine (humpback)

39. Tripod position-dahl’s sign 39 Bilateral, symmetric, slanting regions of hyperpigmentation on anterior thighs,associated with tripod position Seen in COPD Tripod position – reduced work of breathing and activity of scalene and sternocleidomastoid muscle if ones leans forward ,improvement in thoraco abdominal movements. Dahl’s sign – seen in long term ,chronic respiratory illness caused by patients spending long periods of time in the tripod position

40. Harrison’s sulcus (Harrison’s groove) 40 Visible depression of the lower ribs above the costal margin, at the area of attachment of the diaphragm. Seen in rickets, severe asthma in childhood, cystic fibrosis, pulmonary fibrosis Before the bone mineralize and harden ,the downward tension from the diaphragm and other accessory muscles used during increased respiratory effort can bend the ribs inwards over time

41. hoover’s sign 41 Paradoxical inward movement of the lower costal margins on inspiration Seen in emphysema, chest hyperinflation – COPD When the chest becomes hyperinflated, the diaphragm often becomes stretched, which causes contration of diaphragm at inspiration results in an inward movement , bringing the costal margins with it, as opposed to normal downward movement

42. Pursed lip breathing 42 A breathing practice often taught which includes a long ,slow expiration against pursed lips Seen in COPD Inflammation of the airways leads to destruction of lung parenchyma,results in reduction in elastic recoil,fibrosis , and muscle hypertrophy causes increased airways resistanceand premature airway closing on expiration or expiratory airflow limitation. This results in air trapping at end expiration and with time hyperinflation

43. Tracheal tug 43 Downward displacement of thyroid cartilage during inspiration Most common- respiratory distress/COPD(Campbell’s sign) Less common – Arch of aorta aneurysm (Oliver’s sign)

44. Clubbing of fingers 44 A characterized bulging of the distal finger and nail beds often describe in stages Softening of the nail bed ,causing a spongy feeling when the nail is pressed Loss of normal <165 degree angle between nail bed and fold Convex nail growth Thickening of the distal part of the finger Shine and striation of the nail and skin Commonly seen in COPD, asthma,cystic fibrosis,asbestosis,pulmonary fibrosis

45. respiration 45 NORMAL BREATHING The respiratory rate is about 14–20 per min in normal adults and up to 44 per min in infants. Slow breathing with or without an increase in tidal volume that maintains alveolar ventilation. Abnormal alveolar hypoventilation without increased tidal volume can arise from uremia, drug induced respiratory depression, and increased intracranial pressure

46. 46 Breathing punctuated by frequent sighs suggests hyperventilation Syndrome a common cause of dyspnea and dizziness. Occasional sighs are normal. Rapid shallow breathing has numerous causes, including salicylate intoxication, restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

47. 47 Periods of deep breathing alternate with periods of apnea (no breathing). This pattern is normal in children and older adults during sleep. Causes include heart failure, uremia, drug-induced respiratory depression, and brain injury (typically bihemispheric ). In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.

48. 48 Breathing is irregular—periods of apnea alternate with regular deep breaths which stop suddenly for short intervals. Causes include meningitis, respiratory depression, and brain injury, typically at the medullary level causes such as exercise, high altitude, sepsis, and anemia. Light-headedness and tingling may arise from decreased CO2 concentration. In the comatose patient, consider hypoxia, or hypoglycemia affecting the midbrain or pons. Kussmaul breathing is compensatory overbreathing due to systemic acidosis. The breathing rate may be fast, normal, or slow

49. Skin colour Watch for cyanosis – late sign of hypoxemia For dark skin patient – observe in conjunctiva, lips,palms , and under the tongue 49

50. Palpation- posterior chest 50 Confirm symmetry chest expansion by placing warmed hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10 and pinch a fold of skin Ask to inhale deeply ,thumbs should move apart symmetrically Unequal expansion seen in atelectasis, lobar pneumonia, pleural effusion, thoracic trauma,# ribs, pneumothorax Pain in deep breathing seen when the pleura are inflammed

51. Tactile fermitus 51 Fermitus is a palpable vibrations. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall,where we feel them as vibrations Use either the palmar base of the finger or ulnar edge of one hand and touch the person’s chest while the patient repeats the word “ninety nine” or “blue moon” Start over the lung apices and palpate from one side to another side Decreased fremitus – odstructed bronchus,pleural effusion or thickening, pneumothorax, emphysema Increased fremitus – compression or consolidation of lung tissue Rhonchal fremitus – palpable with thick bronchial secretion Pleural friction fremitus – inflammation of pleura

52. crepitus 52 Normal Abnormal findings using the fingers ,gently palpate the entire chest wall. This enables you to note any areas of tenderness,to note skin temperature and moisture,to detect any superficial lumps pr masses ,and explore any skin lesions noted in inspection Crepitus is a coarse, crackiling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue ,as after open thoracic injury or surgery

53. Percussion-posterior chest 53 Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders Percuss the interspaces, mark a side to side comparison all the way down the lung region Percuss at 5cm intervals Avoid the damping effect of scapula and ribs

54. Percussion –posterior chest 54 Resonance Low pitched, clear, hollow, sound that predominates in healthy lung tissue Hyperresonance Lower pitched ,blooming sound seen in emphysema or pneumothorax Dull Soft, muffled, seen in pneumonia, pleural effusion, atelectasis, or tumor

55. Diaphragmatic excursion 55 Percuss to map out the lower lung border in both expiration and inspiration Ask the patient to exhale and hold it ,and percuss down the scapular line until the sound changes from resonance to dull on each side and mark the spot Now ask the patient to take deep breath and hold it. continue to percuss down from the first mark and mark the level where the sound changes from resonance to dull Measure the difference It should be equal bilaterally equal and measure about 3-5cm Note for high level of dullness and absence of excursion and is seen in pleural effusion or atelectasis in lower lobe

56. Ascultation -posterior chest 56 The passage of air through the tracheobronchial tree creates a characteristic set of sounds that are audible through the chest wall. Breath sounds are changed by obstruction in the passage ways or by disease in the lung parenchyma, the pleura,or the chest wall

57. Breath sounds Evaluate the presence and quality of normal breath sounds Ask the patient to breath little bit deeper than usual Clean the diaphragm endpiece of stethoscope Listen to one full respiration in each location Do not confuse with background noise with lung sounds While standing behind the person listen to the following areas posterior from apices at C7 to T10 and laterally from axilla down to 7 th or 8 th rib 57

58. Bronchial (tracheal) sounds 58 High pitched ,loud Inspiration < expiration Heared over trachea and larynx

59. Broncho vesicular sounds 59 Moderate pitched, Inspiration = expiration Heard over major bronchi where fewer alveolar are located posterior, between scapula especially on right,anterior around upper sternum

60. Vesicular sounds 60 Low ,soft Inspiration > expiration Heard over peripheral lung field through smaller bronchioles and alveoli

61. Adventitious sounds crackles (rales) Non continuous ,explosive popping sounds heared more often on inspiration can also present on expiration It may be fine and coarse Coarse crackles are associated with larger airways and fine crackles are associated with smaller branches Seen in asthma,COPD , bronchiectasis, pulmonary edema, pneumonia, lung cancer, pulmonary fibrosis 61

62. Wheezes Continual, high pitched musical sounds heared at the end of inspiration or at the start of expiration Seen in asthma, COPD, respiratory tract infection Airway narrowing allows airflow induced oscillation of airway walls producing acoustic waves Monophonic wheeze – single notes Polyphonic wheeze – different tones 62

63. Stridor Stridor is a continuous, high-frequency, high-pitched musical sound produced during airflow through a narrowing in the upper respiratory tract. Stridor is best heard over the neck during inspiration, but can be biphasic. Causes of the underlying airway obstruction include tracheal stenosis from intubation, airway edema after device removal, epiglottitis, foreign body, and anaphylaxis. Immediate intervention is warranted. 63

64. pleural rub A pleural rub is a discontinuous, low-frequency, grating sound that arises from inflammation and roughening of the visceral pleura as it slides against the parietal pleura. This nonmusical sound is biphasic, heard during inspiration and expiration, and often best heard in the axilla and base of the lungs. 64

65. mediastinal crunch A mediastinal crunch is a series of precordial crackles synchronous with the heartbeat, not with respiration. Best heard in the left lateral position, it arises from air entry into the mediastinum causing mediastinal emphysema (pneumomediastinum). It usually produces severe central chest pain and may be spontaneous. It has been reported in cases of tracheobronchial injury, blunt trauma, pulmonary disease, use of recreational drugs, childbirth, and rapid ascent from scuba diving. 65

66. bronchophony Ask the patient to say “ninety-nine.” Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony Localized bronchophony and egophony are seen in lobar consolidation from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia. 66

67. Egophony Ask the patient to say “ ee .” You will normally hear a muffled long ee sound. If “ ee ” sounds like “A” and has a nasal bleating quality, an E-to-A change, or egophony, is present. Seen in Over consolidation or compression 67

68. Whispered pectoriloquy Ask the patient to whisper “ninety-nine” or “one-two-three.” The whispered voice is normally heard faintly and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy Seen in mild consolidation 68

69. Inspection –anterior chest 69 Shape and configuration Barrel chest has horizontal ribs and costal angle >90 degree Facial expression Assess symmetrical chest expansion Tensed, strained, tired facies and pursed lipped breathing seen in COPD, Asthma Unequal expansion occurs in obstructed or collapsed lungs Assess the level of consciousness Assess the use of accessory muscle Cerebral hypoxia may reflected by exercise ,drowsiness or anxiety ,restlessness and irritability Seen in airway obstruction and massive atelectasis Note skin color, nail beds, for cyanosis or unusual pallor. Explore skin lesion Clubbing of distal phalanges occurs with COPD because of growth of vascular connective tissue Cutaneous angiomas associated with liver disease or PHT Assess the quality of respirations Assess for respiratory rate Assess for chest retraction or bulging Noisy breathing seen in asthma and COPD Tachypnea, bradypnea, Cheyne-stroke respiration…… Retraction suggests obstruction and bulging suggests emphysema or asthma

70. Palpation-anterior chest 70 Palpate symmetric chest expansion Place hand on the anterior lateral wall with thumbs along the costal margin and pointing towards xiphoid process Ask the person to take a deep breath Watch the thumb move apart symmetrically Assess tactile fremitus Palpate anterior chest wall for tenderness, lumps,masses Abnormal costal wide angle occurs in emphysema Lag in expansion occurs in atelectasis, pneumonia, postoperative guarding Grating sensation indicates pleural friction fremitus

71. Percussion-anterior wall 71 As needed, percuss the anterior and lateral chest, again comparing both sides. The heart normally produces an area of dullness to the left of the sternum from the 3rd to the 5th interspaces. Dullness represents airway obstruction from inflammation or secretions. Because pleural fluid usually sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion can be detected anteriorly. The hyperresonance of COPD may obscure dullness over the heart. The dullness of right middle lobe pneumonia typically occurs behind the right breast. Unless you displace the breast, you may miss the abnormal percussion note.

72. Ascultation -anterior chest Listen to the chest anteriorly and laterally as the patient breathes with mouth open, and somewhat more deeply than normal. Compare symmetric areas of the lungs, using the pattern suggested for percussion and extending it to adjacent areas, if indicated. Listen to the breath sounds, noting their intensity and identifying any variations from normal vesicular breathing. Breath sounds are usually louder in the upper anterior lung fields. Bronchovesicular breath sounds may be heard over the large airways, especially on the right 72

73. DIAGNOSTIC EVALUATION 73

74. OXIMETRY Arterial O2 saturation can be monitored noninvasively andcontinuously using a pulse oximetry probe on the finger, toe, ear,forehead , or bridge of the nose. The abbreviation SpO2is used toindicate the O2 saturation of hemoglobin as measured by pulseoximetry . SpO2 and heart rate are displayed on the monitor as digital readings. Normal SpO2 values are 94% to 99% 74

75. BLOOD STUDIES Hemoglobin: Test reflects the amount of hemoglobin available for combination with oxygen Normal – 13.5 to18mg/dl (men) 12 to 16 mg/dl (women) hematocrit Test reflects ratio of red cells to plasma Increased hematocrit found in hypoxemia Normal – 40 to 54% (men) 38 to 47 (women) 75

76. Arterial Blood Gases ABGs are obtained to determine oxygenation status and acid-base balance. ABG analysis includes measurement of the PaO2 , PaCO2 (the partial pressure of CO2 in arterial blood), acidity (pH), bicarbonate (HCO3 ), and SaO2 . Blood for ABG analysis can be obtained by arterial puncture or from an arterial catheter, which is usually inserted into the radial or femoral artery. Both techniques allow only intermittent analysis, but an arterial catheter permits ABG sampling without repeated arterial punctures. The normal PaO2 decreases with advancing age. It varies in relation to the distance above sea level. At higher altitudes, the barometric pressure is lower, resulting in a lower inspired O2 pressure and a lower PaO2 . 76

77. Sputum studies Culture and sensitivity Single sputum specimen is collected ina sterile container Purpose is to to diagnose bacterial infection ,select antibiotics and evaluate treatment Takes 48 -72 hours for results Gram stain: Staining of sputum permits classification of bacteria into gram negative and gram positive types Results guides therapy until culture and sensitivity results are obtained Acid fast smear and culture: Test is to performed to collect sputum for acid fast bacilli A series of three early morning specimen is used 77

78. cytology Cytology: Single sputum specimen is collected in special container with fixative solution Purpose is to determine presence of abnormal cells that may indicate malignant condition Chest X-ray: It is most commonly used test for assessment that exposes a patients respiratory system Used to assess progressive of disease and response to treatment The most common views used are the posterior-anterior view and lateral 78

79. Computed tomography A computed tomography ,which exposes a patients to radiation may be used to examine cross section of the entire body Used to evaluates areas that are difficulty to assess by conventional X rays Common types of CT scan are helical or spiral CT in which contrast dye is usually used In high resolution CT contrast dye is not used Spiral CT is most common non invasive imaging procedure used to diagnose pulmonary embolism Magnetic resonance imaging: In a strong magnetic field ,the alignment of spinning nuclei can be changed with a super imposed radio frequencyand the rate at which they return to alignment with the field can be measured The patient is not exposed to radiation 79

80. Ventilation-perfusion scan: A ventilation perfusion scan is used primarily to check the presence of pulmonary embolism But it cannot determine with 100% certainty of the presence of PE An iv isotope is given and the pulmonary vasculature is outlined and photographed The patient inhales a radioactive gas (xenon, krypton) which outlines the alveoli and another photograph is taken Pulmonary angiography: Pulmonary angiography is the most specific examination used to confirm the diagnosis of pulmonary edema A series of X- ray is taken after radio opaque dye is injected into the pulmonary artery This test also detect congenital and acquired lesions of the pulmonary vessels 80

81. Positron emission tomography: Positron emission tomography scans the use of radio nuclides with short half lives Used to distinguish benign and malignant solitary pulmonary nodules,because malignant lung cells have an increased uptake of glucose Bronchoscopy : bronchoscopy is a procedure in which the bronchi are visualised through a fiberoptic tube Used to obtain biopsy specimen and assess changes resulting from treatment Small amount (30ml) of sterile saline may be injected through the scope and withdrawn and examined for cells ,a technique termed as bronchoalveolar lavage Used to diagnose pneumonia, mucus plug, foregion bodies Mediastinoscopy: A scopy is inserted through a small incision in the supra sternal notch and advanced through mediastinum to inspect and biopsy lymph nodes The test is used to diagnose carcinoma, non- hodgkins lymphoma, granulomatous infections, and sarcoidosis 81

82. Lung biopsy: Lung biopsy may be done Transbronchially Percutaneously or via transthoracic needle aspiration Video assisted thoracic surgery As an open lung biopsy purpose is to obtain tissue ,cells or secretion for evaluation Thoracenthesis : It is the insertion of a large bore needle through the chest wall into pleural space to obtain specimen for diagnosis ,evaluation ,remove pleural fluids ,or instil medications into the pleural space The patient is positioned upright with elbows in an overbed table and feet supported The skin is cleansed and a local anesthetic is instilled subcutaneously A test tube may be inserted to permit further drainage of fluids 82

83. Pulmonary function test: Pulmonary function test measures lung volumes and airflow The results pf PFT are used to diagnose pulmonary disease,monitor disease progression ,evaluate disability and evaluate response to bronchodilators Airflow is measured by a spirometer and administered by trained personal The patients inserts a mouth piece ,takes as deep breath as possible and exhales as hard fast and long as possible Spirometry may be ordered before and after the administration of bronchodilator to determine the degree of response Home spirometry may be used to monitor lung function in person with asthma or cystic fibrodis 83

84. Exercise testing: Exercise testing is used to disgnose in determining exercise capacity and for disability evaluation A complete exercise test involves walking on a threadmill while expired oxygen and carbondioxide ,respiratory rate ,heart rate, and heart rhythm are monitored A modified test (desaturation test ) may be used to monitor SpO2 Skin test: Skin test may be performed to test for allergic reactions or exposure to tuberculosis bacilli or fungai It involves the intradermal injection of an antigen A positive result on a TB skin test indicate tha TB is currently active A negative results indicates patients has exposed to TB 84