You are on page 1of 25

Respiratory assessment

Introduction
A comprehensive respiratory assessment includes physical examination and diagnostic tests that provide information about respiratory function. Diagnostic tests can be used to explore potential disease states. Common respiratory diagnostic tests include pulse oximetry, blood gas analysis, chest x-ray, pulmonary function tests, and thoracic CT and MRI scans. However, bedside clinical assessment provides vital information about respiratory function. It is important for nurses in all practice settings to be able to perform a basic respiratory assessment. This includes taking a patient history, and using the techniques of inspection, palpation, percussion, and auscultation. This course reinforces these techniques, as they are available for bedside assessment.

Respiratory Structure
The respiratory system is essential for life. Normal lung function requires a balanced interrelationship between the respiratory, nervous, and cardiovascular systems. The brain receives and sends out stimuli to maintain a normal oxygen and carbon dioxide balance. The medulla and the pons are the major brain centers that affect respiration. The body's respiratory center in the medulla is normally stimulated by an increased concentration of carbon dioxide, and to a lesser extent, by decreased levels of oxygen in arterial blood. Stimulation of the respiratory center causes an increase in the rate and depth of breathing, thus blowing off excess carbon dioxide and reducing blood acidity. The heart pumps oxygenated blood from the left side of the heart through the arterial circulation to all parts of the body. Oxygen is transported primarily in red blood cells. As oxygen is used by cells, unoxygenated blood containing carbon dioxide returns to the heart and lungs through the venous circulation.

Instant Feedback:
The medulla is one of the major brain centers affecting respiration.

True False

The thoracic cavity is made up of 12 pairs of ribs that connect in the posterior thorax to the vertebral bodies of the spinal column. The lungs lie within the thoracic cavity on either side of the heart, extending from the diaphragm to just above the clavicles or collarbones. Light, spongy and elastic structures, the lungs inflate with inspiration and deflate, but do not completely collapse, with expiration. The right lung is shorter and wider than the left lung. Each lung is divided into lobes the right lung has three lobes; the left lung has two lobes. The lung's lobes are further divided into segments. The pleurae are membranes that cover each lung and line the thoracic cavity. The visceral pleura are serous membranes that cover the outer surface of each lung. The parietal pleura line the inner rib cage and upper surface of the diaphragm. The smooth opposing surfaces of the pleura, lubricated by pleural fluid, allow the lungs to move easily within the rib cage during inspiration and expiration. The pleural space is the potential space between the visceral and parietal pleurae.

Instant Feedback:
Which lobes of the lung are most accessible when examining the patient's back? Left and right upper lobes Left and right lower lobes

Respiratory Function
Gasses are able to move in and out of the lungs through muscular energy exerted on the thorax and changes between intrathoracic and atmospheric pressures. The pressure within the lungs and thorax must be less than atmospheric pressure for inspiration to occur. Air then flows from an area of higher pressure to one of lower pressure. As the diaphragm and intercostal muscles work to increase the size of the thorax, intrathoracic pressure decreases below atmospheric pressure and air moves into the lungs. During exhalation, the inspiratory muscles relax, and the elastic recoil of the lung tissues, combined with a rise in intrathoracic pressure, causes air to move out of the lungs

The diaphragm, a dome shaped structure that separates the thoracic and abdominal cavities, is the major muscle of respiration. The phrenic nerve innervates the diaphragm. The external and internal intercostal muscles elevate the ribs, increasing the anterior-posterior diameter of the thoracic cavity. Breathing may need to be assisted by other muscles, known as secondary or accessory muscles of respiration. These muscles may include the parasternal, scalene, sternocleidomastoid, trapezius, and pectoralis muscles. Accessory respiratory muscles do not function during normal ventilation, but may be needed in some respiratory disorders.

Instant Feedback:

The diaphragm is the major muscle of respiration and is innervated by the phrenic nerve.
True False

Structures in the respiratory conduction system help conduct air into the lungs where the exchange of oxygen and carbon dioxide takes place. The respiratory conduction system is divided into the upper and lower airways. The upper airway consists of the nose, pharynx, epiglottis, and larynx. The upper airway structures protect the lower airway from foreign materials, and warm, filter, and humidify inspired air. Lower airway structures include the trachea, left and right mainstem bronchi, segmental bronchi, and terminal bronchioles. The lower airway structures conduct air through the many branches of the respiratory tree to the alveolar level where gas exchange takes place. Gas exchange takes place in the alveoli, small air sacs at the end of the respiratory bronchioles. Carbon dioxide must be eliminated on a continuous basis to maintain the body's acid-base balance. Acid-base balance is controlled by chemoreceptors located near the respiratory center that are sensitive to changes in the pH of cerobrospinal fluid. When ventilation is inadequate, the pH drops and the carbon dioxide level rises. The rise in carbon dioxide stimulates the respiratory center to increase the rate and depth of respirations to remove excess carbon dioxide. If hypoventilation becomes chronic, as in patients with chronic obstructive

pulmonary disease (COPD), chemoreceptors lose their sensitivity and respond to increases in carbon dioxide levels inadequately. When central chemoreceptors fail, peripheral chemoreceptors attempt to regulate respiratory function and restore acid-base balance. Peripheral chemoreceptors are sensitive to the amount of oxygen in peripheral blood. Therefore, the patient's stimulus to breathe is no longer an increase in carbon dioxide levels, but from a low oxygen level sensed by peripheral chemoreceptors. If the blood oxygen level is increased significantly by giving supplemental oxygen, the peripheral chemoreceptors will not stimulate breathing, resulting in apnea. This alteration in physiologic function is the reason that patients with COPD are given supplemental oxygen at very low levels.

Instant Feedback:
Gas exchange takes place in the bronchioles.

True False

Anatomic Landmarks
It is important to review the anatomy of the chest wall and thoracic cavity, as you will use anatomic landmarks to document the location of respiratory assessment findings. The thoracic cavity is made up of 12 pairs of ribs that connect in the posterior thorax to the vertebral bodies of the spinal column. In the anterior thorax, the first 7 pairs of ribs are attached to the sternum or breastbone by cartilage. The lower 5 ribs do not attach to the sternum. The 8th, 9th, and 10th ribs are attached to each other by costal cartilage. The 11th and 12th ribs, known as floating ribs, are not attached in any way to the sternum; they move up and down in the anterior chest, allowing for full chest expansion.

Please review the important landmarks of the bony thoracic anatomy.

The following diagram shows the anterior chest again, with the lobes of the lungs included. Various reference lines and angles are commonly used to identify respiratory findings. For example: The angle of Louis (also called the sternal angle) is a useful place to start counting ribs, which helps localize a respiratory finding horizontally. If you find the sternal notch, walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge. This is the sternal angle. The 2nd rib is continuous with the sternal angle; slide your finger down to localize the 2nd intercostal space. The angle of Louis also marks the site of bifurcation of the trachea into the right and left main bronchi and corresponds with the upper border of the atria of the heart. Reference lines help pinpoint findings vertically. For example, the major division ("fissure") between lobes in the anterior chest crosses the 5th rib in midaxillary line and terminates at the 6th rib in the midclavicular line.

Other terms used to document locations for chest physical assessment include: Supraclavicular - above the clavicles

Infraclavicular - below the clavicles Interscapular - between the scapulae Infrascapular - below the scapulae

Bases of the lungs - the lowermost portions Upper, middle, and lower lung fields

Taking a Respiratory History


Start your respiratory assessment by interviewing the patient and conducting a respiratory history. Starting the assessment with an interview helps you establish rapport with the patient and may lessen the patient's anxiety. During the history, you will be gathering information about the patient's current and any previous respiratory problems. You may interview the patient, and in some cases, family members or significant others. When doing your assessment, keep in mind these six important respiratory symptoms:

cough, sputum production,


dyspnea, hemoptysis, wheezing.

chest pain, and

The following questions may be useful in taking a respiratory history: Are you having any trouble breathing? Do you have any chest pain with breathing? If so, what is the pain like, when does it occur, and what relieves it? Do you have a cough? If yes, what does the cough sound like, when does it occur, do you bring up any phlegm (sputum) when you cough, what does the phlegm look like? Normal sputum is thin, clear to white in color, and tasteless and odorless. Yellow-green colored sputum may indicate a bacterial infection and rust-colored sputum is characteristic of pneumonia. Are you ever short of breath? If so, does your shortness of breath occur at rest or with activity? Ask the patient specific questions about shortness of breath that impacts daily living, such as being able to carry groceries from a car, or being able to clean floors or do laundry. Do you have any problems breathing at night? If so, do you use pillows to help you get in a position to breathe easier? Do you have any allergies? If yes, how does your allergy affect your breathing? Do you smoke now or have you ever smoked? If yes, how many years did you smoke and how many packs of cigarettes did you smoke daily? What kind of work do you do/did you do? In your work are/were you exposed to substances such as asbestos, chemicals, or cigarette smoke? Do you have a personal or family history of asthma, tuberculosis, lung cancer, cystic fibrosis, bronchitis, emphysema, or any other lung disease? Answers to these questions provide you with important information about the patient's current problem and background data that could be contributing factors to respiratory disease. Conduct the assessment in a comfortably warm

room. Ask the patient to sit upright. During all aspects of the assessment, observe for fatigue or discomfort. Allow the patient time to rest if necessary. In taking a history for an infant, ask the parents about any episodes of respiratory distress, cyanosis, apnea, sudden infantdeath syndrome (SIDS) in a sibling or other family member, exposure to passive smoke, or a history of prematurity orm echanical ventilation. In taking a history for a child, ask parents about any asthma history, including factors related to asthma epidoses, adequacy of asthma treatment, and whether or not the child has a history of night coughing, swollen lymphnode s, sore throat, or facial pain. If the patient is an older adult, ask the patient whether or not he or she has had an annual flu immunization and pneumonia vaccine. Ask about any recent changes in exertional capacity, fatigue, a change in the number of pillows needed to sleep at night, any significant weight change, or a history of night sweats, or hand or leg swelling. After the interview is completed, proceed in an orderly fashion by following the steps of respiratory physical assessment: inspection, palpation, percussion, and

auscultation.

Instant Feedback:
It is helpful to ask the patient specific questions about activity level and breathing based on daily life activities.

True False

Inspection
With the patient sitting, examine the patient's anterior and posterior chest. Chest inspection allows you to see visible external signs of respiratory function. Assess the front, back, and sides of the chest for any scars, wounds, or lesions. Look for symmetry of chest wall movement. Observe the duration of the inspiratory/expiratory cycle. Prolonged expiration occurs when an individual has difficulty expelling air, as is often seen in patients with emphysema. Note the patient's respiratory pattern and breathing rhythm. In a

healthy adult, inaudible respirations should occur between 12 and 20 times each minute. Look to see if the patient uses accessory muscles of respiration. Observe for intercostal retractions, nasal flaring, or pursed lip breathing, all of which indicate airflow obstruction and poor ventilation. Intercostal retractions are visible indentations between the ribs as the intercostal muscles aid in breathing. Nasal flaring describes intermittent outward movements of the nostrils with each inspiration. Pursed lip breathing refers to partial closure of the lips to allow air to be expired slowly. Inspect the neck for contraction of the sternocleidomastoid or other accessory muscles of respiration during inspiration. Normally, none of these signs are present. Look at the patient's posture. A patient with chronic obstructive pulmonary disease (COPD) will lean forward and prop himself up with his arms to improve breathing. Postural changes may also be seen with thoracic deformities such as scoliosis and kyphosis. Observe the patient's level of consciousness. Confusion or changes in mental status are important signs of potential respiratory problems.

Instant Feedback:
Intercostal retractions, nasal flaring, and pursed lip breathing indicate airflow obstruction and poor ventilation.

True False

Note the patient's age and it's impact on respiratory function. As people age, their capacity for exercise decreases. The chest wall becomes stiffer and harder to move, respiratory muscles may weaken, and the lungs lose some of their elastic recoil. The speed of breathing out with maximal effort gradually decreases. Skeletal changes associated with aging may accentuate the dorsal curve of the thoracic spine, producing kyphosis and increasing the anteriorposterior diameter of the chest. In any health care setting, you can use some practical ways of assessing concerns about shortness of breath in a patient who can ambulate. One simple and useful assessment method is to walk with the patient down a hallway or from one room to another or ask the patient to perform an activity such as climbing stairs. By observing the patient doing these activities, you can observe changes in the rate, effort, and sounds of the patient's respiratory pattern. Assessing forced expiratory time is another practical means of

observing respiratory function, especially in a patient who may have COPD. Ask the patient to take a deep breath in and then to breathe out as quickly and completely as possible, with the mouth open. While the patient is doing a forced expiration, listen over the trachea and time the audible expiration. A forced expiratory time of over 6 seconds suggests obstructive pulmonary disease. Normal findings for chest inspection include: Side to side symmetric chest shape Distance from the front to the back of the chest (anterior-posterior diameter) less than the size of the chest from side to side (transverse diameter) Normal chest shape, with no visible deformities, such as a barrel chest, kyphosis, or scoliosis No muscle retractions when breathing Quiet, unlabored respirations with no use of accessory, neck, shoulder, or abdominal muscles A regular respiratory rhythm, with expiration taking about twice as long as inspiration Skin color that matches the rest of the body's complexion A respiratory rate of 12-20 in an adult Infants and children have faster respiratory rates than adults. A normal respiratory rate for a newborn ranges from 30 to 60 breaths per minute. By one year of age, the respiratory rate drops to between 20 and 40 per minute. The respiratory rate continues to drop as a child ages. By approximately age 16, a teenager has a respiratory rate similar to that of an adult. Rapid, shallow breathing is called tachypnea. Tachypnea is seen in patients with restrictive lung disease such as kyphosis, and in situations where pleuritic chest pain prohibits full expansion of the chest wall. Restrictive lung disease refers to changes in the chest structure that prohibit full chest expansion. Rapid deep breathing, known as hyperpnea or hyperventilation, occurs as a result of physical exercise, anxiety, and metabolic acidosis. Kussmal breathing, characterized by slow, deep breaths, occurs in patients with diabetic acidosis and coma. Bradypnea, or a much slower than normal respiratory rate, is seen in patients with drug-induced respiratory depression, and increased intracranial pressure. Cheyne-Stokes breathing occurs when there are periods of deep breathing alternating with periods of apnea. A Cheyne-Stokes breathing pattern may be seen in a patient with heart failure, drug-induced respiratory

depression, uremia, or brain damage. Ataxic breathing, also known as Biot's breathing, is characterized by unpredictable irregularity. Biot's breathing may be seen in patients with respiratory depression and brain damage at the level of the medulla.

Instant Feedback:
A rapid respiratory rate or tachypnea may be seen in patients with restrictive lung disease or in patients with pleuritic chest pain.

True False

Palpation
Palpation is an assessment technique in which the examiner uses the surface of the fingers and hands to feel for abnormalities. Assessment data that can be obtained through palpation includes identifying chest movement symmetry, chest skeletal abnormalities, tenderness, skin temperature changes, swelling, and masses. To assess the symmetry of chest expansion during breathing, stand behind the person, and place your hands with fingers spread apart beneath his or her arms, on the sides of the chest, about 2 inches below the axilla. Your fingers should be pointing toward the anterior chest - this will let you feel the chest rising and falling on inspiration and expiration. Ask the person to breathe out completely observe your hands and thumbs to see that they have moved equally on both sides. After checking for symmetrical chest expansion, feel for tactile fremitus. Fremitus refers to vibratory tremors that can be felt through the chest by palpation. To assess for tactile fremitus, ask the patient to say 99 or blue moon. While the patient is speaking, palpate the chest from one side to the other. Tactile fremitus is normally found over the mainstem bronchi near the clavicles in the front or between the scapulae in the back. As you move your hands downward and outward, fremitus should decrease. Decreased fremitus in areas where fremitus is normally expected indicates obstruction, pnemothorax, or emphysema. Increased fremitus may indicate compression or consolidation of lung tissue, as occurs in pneumonia. Normal findings on palpation include:

normal chest size and shape, warm, dry skin, no tender spots, symmetrical chest expansion, and

tactile fremitus over the mainstem bronchi in front and between the scapulae in the back of the chest.

Instant Feedback:
Tactile fremitus is always an abnormal assessment finding.

True False

Percussion
Percussion is an assessment technique which produces sounds by the examiner tapping on the patient's chest wall. Just as lightly tapping on a container with your hands produces various sounds, so tapping on the chest wall produces sounds based on the amount of air in the lungs. Percussion sets the chest wall and underlying tissues into motion, producing audible sounds and palpable vibrations. Percussion helps to determine whether the underlying tissues are filled with air, fluid, or solid material. Percussing the anterior chest is most easily done with the patient lying supine; the patient should sit when percussing the posterior chest. Place the first part of the middle finger of your nondominant hand firmly on the patient's skin. Then, strike the finger placed on the patient's skin with the end of the middle finger of your dominant hand. Watch a video segment of percussion technique. Work from the top part of the chest downward, comparing sounds heard on both the right and left sides of the chest. Visualize the structures underneath as you proceed. Look at the following diagram that shows percussion notes on the posterior chest:

Resonant sounds are low pitched, hollow sounds heard over normal lung tissue. Flat or extremely dull sounds are normally heard over solid areas such as bones.

Dull or thudlike sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. Hyperresonant sounds that are louder and lower pitched than resonant sounds are normally heard when percussing the chests of children and very thin adults. Hyperresonant sounds may also be heard when percussing lungs hyperinflated with air, such as may occur in patients with COPD, or patients having an acute asthmatic attack. An area of hyperresonance on one side of the chest may indicate a pneumothorax. Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax.

Instant Feedback:
The normal sound expected on percussion throughout most of the lung fields is resonance.

True False

Auscultation
Auscultation is the technique of listening to the sounds of the chest with a stethoscope. The movement of air in and out of the respiratory system produces breath sounds. Breath sounds are transmitted through the chest

wall and may be heard through the diaphragm (flat piece) of a stethoscope placed firmly against the chest wall. Auscultation of the lungs is the most important examining technique for assessing airflow through the tracheobronchial tree. Ask the patient to sit with his arms folded across the chest with the hands resting, if possible, on the opposite shoulders. This position moves the scapulae partly out of the way and increases access to the lung fields. Instruct the patient to breathe deeply with his mouth open. Listen carefully for at least one full breath in each location. Observe the patient for light-headedness or fatigue and allow the patient to rest as often as necessary. Start by listening to posterior chest, beginning with the areas above the scapulae. It is useful to start here because the lung fields are closer to the wall of the posterior chest and there's less interference from heart sounds than with the anterior chest. Move downward in a stair-step fashion, comparing your findings from one side with those from the other side. Chest auscultation involves: Listening for the sounds generated by normal breathing

Listening for any adventitious or added sounds

If abnormalities are detected, listening to the sounds of the patient's spoken or whispered voice as they are transmitted through the chest wall

Normal Breath Sounds


Normal breath sounds are classified as tracheal, bronchial, bronchovesicular, and vesicular sounds. The patterns of normal breath sounds are created by the effect of body structures on air moving through airways. In addition to their location, breath sounds are described by: duration (how long the sound lasts), intensity (how loud the sound is), pitch (how high or low the sound is), and

timing (when the sound occurs in the respiratory cycle).

Tracheal breath sounds are heard over the trachea. These sounds are harsh and sound like air is being blown through a pipe. Bronchial sounds are present over the large airways in the anterior chest near the second and third intercostal spaces; these sounds are more tubular and hollow-sounding than vesicular sounds, but not as harsh as tracheal breath sounds. Bronchial sounds are loud and high in pitch with a short pause

between inspiration and expiration; expiratory sounds last longer than inspiratory sounds. Bronchovesicular sounds are heard in the posterior chest between the scapulae and in the center part of the anterior chest. Bronchovesicular sounds are softer than bronchial sounds, but have a tubular quality. Bronchovesicular sounds are about equal during inspiration and expiration; differences in pitch and intensity are often more easily detected during expiration. Vesicular sounds are soft, blowing, or rustling sounds normally heard throughout most of the lung fields. Vesicular sounds are normally heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration. In a normal air-filled lung, vesicular sounds are heard over most of the lung fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces on the anterior chest, bronchial sounds are heard over the body of the sternum, and tracheal sounds are heard over the trachea. Normal findings on auscultation include: Loud, high-pitched bronchial breath sounds over the trachea

Medium pitched bronchovesicular sounds over the mainstream bronchi, between the scapulae, and below the clavicles

Soft, breezy, low-pitched vesicular breath sounds over most of the peripheral lung fields.
Abnormal Breath Sounds

Abnormal breath sounds include: the absence of sound and/or

the presence of "normal" sounds in areas where they are normally not heard. For example, bronchial (loud & tubular) breath sounds are abnormal in peripheral areas where only vesicular (soft & rustling) sounds should be heard. When bronchial sounds are heard in areas distant from where they normally occur, the patient may have consolidation (as occurs with pneumonia) or compression of the lung. These conditions cause the lung tissue to be dense. The dense tissue transmits sound from the lung bronchi much more efficiently than through the air-filled alveoli of the normal lung.

The term adventitious breath sounds refers to extra or additional sounds that are heard over normal breath sounds. Sources differ as to the classification and nomenclature of these sounds, but most examiners commonly use the following terms to describe adventitious breath sounds. crackles (or rales)

wheezes (or rhonchi) stridor

pleural friction rubs

Detection of adventitious sounds is an important part of the respiratory examination, often leading to diagnosis of cardiac and pulmonary conditions. Crackles (or rales) are caused by fluid in the small airways or atelectasis. Crackles are referred to as discontinuous sounds; they are intermittent, nonmusical and brief. Crackles may be heard on inspiration or expiration. The popping sounds produced are created when air is forced through respiratory passages that are narrowed by fluid, mucus, or pus. Crackles are often associated with inflammation or infection of the small bronchi, bronchioles, and alveoli. Crackles that don't clear after a cough may indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome (ARDS). Crackles are often described as fine, medium, and coarse. Fine crackles are soft, high-pitched, and very brief. You can simulate this sound by rolling a strand of hair between your fingers near your ear, or by moistening your thumb and index finger and separating them near your ear. Coarse crackles are somewhat louder, lower in pitch, and last longer than fine crackles. They have been described as sounding like opening a Velcro fastener. Wheezes are sounds that are heard continuously during inspiration or expiration, or during both inspiration and expiration. They are caused by air moving through airways narrowed by constriction or swelling of airway or partial airway obstruction. Wheezes that are relatively high pitched and have a shrill or squeaking quality may be referred to as sibilant rhonchi. They are often heard continuously through both inspiration and expiration and have a musical quality. These wheezes occur when airways are narrowed, such as may occur during an acute asthmatic attack. Wheezes that are lower-pitched sounds with a snoring or moaning quality may be referred to as sonorous rhonchi. Secretions in large

airways, such as occurs with bronchitis, may produce these sounds; they may clear somewhat with coughing. Pleural friction rubs are low-pitched, grating, or creaking sounds that occur when inflamed pleural surfaces rub together during respiration. More often heard on inspiration than expiration, the pleural friction rub is easy to confuse with a pericardial friction rub. To determine whether the sound is a pleural friction rub or a pericardial friction rub, ask the patient to hold his breath briefly. If the rubbing sound continues, its a pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat - a pleural rub stops when breathing stops. Stridor refers to a high-pitched harsh sound heard during inspiration.. Stridor is caused by obstruction of the upper airway, is a sign of respiratory distress and thus requires immediate attention. If adventitious sounds are heard, it is important to assess: their loudness, timing in the respiratory cycle, location on the chest wall, persistence of the pattern from breath to breath, and

whether or not the sounds clear after a cough or a few deep breaths. secretions from bronchitis may cause wheezes, (or rhonchi), that clear with coughing crackles may be heard when atelectatic alveoli pop open after a few deep breaths

Instant Feedback:
Rhonchi are discontinuous popping sounds heard during inspiration.

True False

Instant Feedback:
The adventitious sound heard in the upper apices of the lungs in this case are best described as:

Rhonchi Wheezes Crackles Stridor

Transmitted Voice Sounds

If you hear adventitious sounds on auscultation, assess how these sounds change as the patient speaks. Voice assessment can provide important clues about respiratory abnormalities. Normal lungs are filled with air, and air does not transmit sound readily. Normally, transmitted voice sounds are difficult to hear spoken words are muffled and indistinct and whispered words are usually not heard at all. However, when substances such as fluid or solid masses replace air in the lungs, sounds are transmitted more clearly. The sounds that can be assessed are:

Whispered pectoriloquy: Ask the patient to whisper a sequence of words such as one-two-three, and listen with a stethoscope. Normally, only faint sounds are heard. However, over areas of tissue abnormality, the whispered sounds will be clear and distinct. Bronchophony: Ask the patient to say "99" in a normal voice. Listen to the chest with a stethoscope. The expected finding is that the words will be indistinct. Bronchophony is present if sounds can be heard clearly. Egophony: While listening to the chest with a stethoscope, ask the patient to say the vowel e. Over normal lung tissues, the same e (as in "beet") will be heard. If the lung tissue is consolidated, the e sound will change to a nasal a (as in "say").
Inspection relaxed posture normal musculature rate 10 - 18 breaths per minute, regular

Assessment findings include:

no cyanosis or pallor anteroposterior diameter less than transverse diameter symmetric chest expansion tactile fremitus present and equal bilaterally resonant vesicular over peripheral fields bronchovesicular over sternum (anterior) and between scapulae (posterior) infant and child - bronchovesicular throughout no adventitious sounds

Palpation Percussion

Auscultation

Atelectasis: In this condition, an area of the lung or an entire lung collapses. Atelectasis may be due to airway obstruction, or compression of the lung. In the diagram above, an obstruction blocks the airway, causing the associated alveoli to collapse and that area of the lung to shrink. Any alveolar air beyond the obstruction becomes absorbed by the pulmonary capillaries, and the alveolar walls cave in. Assessment findings include: Inspection Palpation

cough delayed chest expansion on the affected side increased respiratory rate increased pulse possible cyanosis chest expansion decreased on the affected side tactile fremitus decreased or absent over the involved area with a large collapse, the trachea may deviate or shift toward the affected side. dull over affected area breath sounds decreased or absent over involved area no adventitious sounds if bronchus is obstructed occasional fine crackles if bronchus is patent

Percussion Auscultation

Bronchitis: Inflammation of the bronchi with partial obstruction of the bronchi by secretions or constriction. Bronchitis may be acute or chronic with a productive cough. Chronic bronchitis is associated with cigarette smoking. In the diagram above, secretions (produced by proliferation of mucous glands) are obstructing the passageway, resulting in deflation of the alveoli beyond the obstruction.

Assessment findings include: Inspection Palpation Percussion


hacking cough with thick sputum chronic bronchitis produces dyspnea, fatigue, possible clubbing of fingers tactile fremitus normal resonant normal vesicular breath sounds voice sounds normal. Prolonged expiration may be present with chronic bronchitis May have wheeze, or crackles over deflated areas

Auscultation

Emphysema: Assessment
Chronic obstructive pulmonary disease (COPD) refers to a group of progressive respiratory diseases, including both chronic bronchitis and emphysema. Approximately 117,000 Americans die from COPD each year,making it the 4th leading cause of death in the U.S. Of the country's ten leading causes of death, COPD is the only decease in which the morality rate is increasing. In the early phase of COPD, patients may experience wheezing, chronic productive cough, and minimal shortness of breath. However, the person's quality of life decreases as COPD progresses. Later symptoms include increasing dyspnea, progressive exercise intolerance, periodic respiratory infections that occur with increasing frequency and severity, increasing cough, and purulent sputum. Emphysema: Caused by destruction of pulmonary connective tissue, usually by an inflammatory process and/or cigarette smoking. Air sacs distal to terminal bronchioles become permanently enlarged, and interalveolar walls are destroyed. The result is airway obstruction, particularly upon expiration. Lungs become hyperinflated, and lung volume increased. The diagram above shows tissue destruction throughout the lung, and overdistended alveoli with destruction of septa.
Assessment findings include: Inspection increased anterior-posterior diameter, or "barrel chest" use of accessory muscles to assist breathing tripod position

Palpation Percussion

shortness of breath common, especially on exertion tachypnea tactile fremitus decreased chest expansion decreased. hyperresonant decreased vesicular breath sounds may have prolonged expiration muffled heart sounds from overdistention of lungs usually no adventitious sounds; occasional wheeze

Auscultation

Pleural Effusion: Assessment


Pleural effusion: Collection of fluid in the intrapleural space, with compression of lung tissues. Fluid collects by gravity in dependent areas of the chest. The diagram above, shows pleural fluid compressing lung tissue and alveoli.
Assessment findings include: Inspection

increased respiratory rate dyspnea tactile fremitus decreased or absent. chest expansion decreased on the affected side. tracheal shift away from affected side dull to flat breath sounds and voice sounds decreased or absent. bronchial breath sounds and bronchophony, egophony, and whispered pectoriloquy may be heard over the area of the lung that is compressed near the effusion.

Palpation

Percussion

Auscultation

Pneumonia: Assessment
Pneumonia: An infection in lung tissues causes the alveoli to become swollen and porous (as in the above diagram), so red and white blood cells move from the bloodstream into the alveoli. The alveoli become filled, or consolidated, with bacteria, fluid and blood cells that replace air.
Assessment findings include:

Inspection

increased respiratory rate increased pulse rate guarding and lag on expansion on affected side children with pneumonia may have nasal flaring and/or intercostal and sternal retractions chest expansion decreased on involved side tactile fremitus is increased dull over affected area breath sounds louder than normal. bronchophony, egophony, whispered pectoriloquy present Crackles, fine to medium

Palpation Percussion Auscultation

Instant Feedback:
A patient with pneumonia may be expected to have louder than normal breath sounds, and increased tactile fremitus. True False

Pneumothorax: Assessment
Pneumothorax: Air in the pleural space causes partial or complete lung collapse. Normally, the pleural space is under negative pressure; when air enters, the negative pressure is neutralized, and the lung collapses. Pneumothorax can be caused by trauma, causing air to enter through an opening in the chest wall, or may be spontaneous, causing air to enter the pleural space through a rupture in the lung wall. Tension pneumothorax occurs when air trapped in the pleural space increases, compressing the lung and shifting the mediastinum to the unaffected side.
Assessment findings include:

unequal chest expansion. with a large pneumothorax, the patient will have increased respiratory rate, increased heart rate, anxiety, bulging interspaces, and possibly cyanosis tactile fremitus decreased or absent.

Inspection

Palpation

tracheal shift to the unaffected side of the chest. chest expansion decreased on the affected side. hyperresonant breath sounds decreased or absent voice sounds decreased or absent

Percussion Auscultation

Glossary
Accessory muscles of respiration muscles other than the diaphragm and intercostal muscles that may be used for labored breathing. The sternocleidomastoid, spinal, and neck muscles may be used as accessory muscles of respiration; their use is a sign of an abnormal or labored breathing pattern. Adventitious breath sounds abnormal breath sounds heard when listening to the chest. Adventitious sounds may include crackles or rales, rhonchi or wheezes, or pleural friction rubs. Adventitious sounds do not include sounds produced by muscular activity in the chest wall or noises made by a stethoscope on the chest wall. Ataxic breathing also known as Biot's breathing, is characterized by unpredictable irregularity. Barrel chest a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping

from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema. Cheyne-Stokes respirations a breathing pattern characterized by a period of apnea, followed by gradually increasing depth and frequency of respirations. Consolidation the replacement of air in the lungs with fluid or a mass. Crackles an adventitious breath sound heard on ausculating the chest, produced by air passing over airway secretions. A crackle is a discontinuous sound, as opposed to a wheeze, which is continuous. Crackles are known as fine or coarse and are also known as rales. Fremitus a vibration felt while a patient is speaking and the examiner's hand is held against the chest. Intercostal retractions visible use of the muscles between the ribs (intercostal muscles) to aid in breathing. Intercostal retractions are a sign of labored breathing. Kussmal breathing a very deep gasping type of respiration associated with severe diabetic acidosis and coma. Kyphosis a deformity in the normal posterior shape of the spine, producing a humpback appearance. Nasal flaring intermittent outward movements of the nostrils with each inspiration; indicates an increase in the work needed to breathe. Pleura a serous membrane covering both lungs and the walls of the thorax and diaphragm. Pursed lip breathing partial closing of the lips to allow air to be expired slowly; used by patients with chronic obstructive pulmonary disease. Sibilant rhonchi a high pitched wheeze; musical and squeaky adventitious breath sound. Scoliosis a lateral curvature of the spine. Sonorous rhonchi - a lower pitched wheeze; snoring or moaning adventitious breath sound. Stridor a high-pitched harsh sound heard during inspiration. Stridor is caused by obstruction of the upper airway. Wheeze - an adventitious or abnormal breath sound heard when listening to the chest as a person breathes. Wheezes are continuous and musical sounding, and usually caused by airway obstruction from swelling or secretions. Wheezes can be high or low pitched, and are also known as rhonchi.

You might also like