respiratoryassessment and it's examination

It is best for assessment of the chest problem patient

1. ASSESSMENT OF THE
CHEST AND LUNGS
DR.QURATULAIN MUGHAL
ISRA UNIVERSITY
1

2. 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

3. Anterior Chest

4. Posterior Chest

5. Axilla

6. 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

7. 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

8. 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

9. 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

10. History
Chief Complaint and HPI
Cough
Shortness of breath/Dyspnea

11. 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?

12. 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?

13. 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

14. History
Personal and Social History
Tobacco
Alcohol
Drugs
Home environment
Occupational environment
Travel
Health Promotional Activities

15. PHYSICAL
EXAMINATION
15

16. Equipment and Techniques
Equipment
Stethoscope
Techniques
Inspection
Palpation
Percussion
Auscultation

17. Inspection
General
Appearance
Posturing
Breathing effort
Trachea position

Midline

18. 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

19. Inspection
Oxygenation: cyanosis
Nails
Skin
Lips
Respiratory Effort
Respiratory rate and depth
Breathing pattern
Chest expansion

20. Palpation
Trachea – for position
Chest wall – for symmetry

21. Palpation
Thoracic Expansion (Excursion)
Place both thumbs at about 7
th
rib
posteriorly along the spinal process
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
Click on the pictures to view video

22. 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)

23. 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 NOTDO NOT listen through gowns, clothes, etc.
Place your stethoscope over bare skin

24. 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

25. Auscultation
Evaluate for normal sounds
Sound PitchIntensityQuality I:ELocation
Bronchial High Loud Blowing/ hollowI < ETrachea
Bronchovesicula
r
ModerateModerateCombination I = EBetween scapulae,
1
st
& 2
nd
ICS lateral to
sternum
Vesicular Low Soft Gentle rustling/
breezy
I > EPeripheral lung

26. Auscultation
Evaluate for adventitious sounds
Sound Intensity/ PitchI/EQuality Clear with Cough
Crackles/
Rales
Soft (fine)/ High
Loud (coarse)/ Low
I Discontinuous,
nonmusical, brief
Possibly
Wheeze High E Continuous musical
sounds
Possibly
Ronchi Low E Continuous snoring
sounds
Possibly
Pleural
Friction Rub
I & EContinuous or
discontinuous creaking or
brushing sounds
Never
Stridor I Continuous, crowing Never

27. Auscultation
Copy this URL into your Web browser to hear normal and abnormal lung sounds :
http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm

28. 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

29. Developmental Variations
Neonates
Breathing is diaphragmatic and abdominal
Signs of compromise

Stridor (“crowing”)

Grunting

Central cyanosis

Flaring nares

30. 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

31. Developmental Variations
Pregnancy
Costal angle increases to about 105 degrees in
the third trimester
Dyspnea and orthopnea are common
Breathes more deeply

32. 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)