ASSESSMENT OF THE

RESPIRATORY
SYSTEM

Functions:
Gas Exchange
Regulation of blood pH
Voice production
Olfaction
Innate Immunity

Lungs tendency to
recoil:
Elastic fibers
Surface tension
Is prevented from
collapsing:
Surfactant
Pleural Pressure
Atelectasis (collapsed lung)
10

The Thoracic Cavity

Chest X-ray shows organs within thoracic cavity.

Ribs
Air-filled
lung

Position
of
the heart
Position of the diaphragm

Diseased lung

atelectasis

tuberculosis
12

Respiratory Membrane
Thickness
Surface Area
Partial Pressure

Gas Exchange

Respiration process of gas

exchange in the body

Breathing/Ventilation
process by which gases are
exchanged between the
atmosphere & alveoli
Inspiration air moves into
the lungs
Expiration air moves out
of the lungs

External Respiration
exchanges of gases
between the lungs & blood

Internal Respiration
exchange of gases between
blood & cells

Ventilatory Principles

Changes in volume result in changes in

pressure
as a volume of a container increases, pressure
within decreases and as volume decreases,
pressure within increases

Air flows from areas of higher to lower

pressure
air flows from an area of higher pressure toward
the area of lower pressure

INSPIRATION
stimulation of respiratory center
Phrenic nerve

Impulse
intercostal nerve

Diaphragm

intercostal muscle
CONTRACTION

Downward movt
Top to bottom
Thoracic cavity
enlargement

ext. intercostal muscle

elevates ribs

lung stretched
lowering of pressure in the cavity
lung pressure < atmospheric pressure
air enters lungs
lung pressure = atmospheric pressure

Inhibition of Respiratory Center

EXPIRATION
Relaxation of diaphragm & ext. intercostal muscle
Decrease size of thoracic activity
Resting size
Recoil of the distended lung
Decrease intrapulmonary pressure
Lung pressure > atmospheric pressure
Forceful inspiration contraction of accessory muscle is necessary
Forceful Expiration contraction of abdl muscles
Push abdl contents against diaphragm
Rising of the abdomen
contraction of internal
intercostal muscles
Decrease in the diameter of the thorax

BREATHING
Enlarges the
Chest wall &
lungs recoil, the thoracic cavity, and
pushes the
diaphragm rises,
abdominal wall
and air flows
outward, and
outwards
causes a decrease
in thoracic pressure

19

GENERAL APPROACH
Arrange

the patients gown so that you can

see the chest fully
Proceed

in an orderly fashion: inspect,

palpate, percuss & auscultate
Try

to visualize the underlying lobes of the

lungs

GENERAL APPROACH

Posterior thorax & lungs

Patients arm should be folded across the chest
with hands resting on opposite shoulders

Anterior thorax & lungs

Generally supine or sitting may be satisfactory

Skeletal landmarks
Sternal angle

Spinous process

subscapular angle
xiphoid

Intercostal space
Costalspinal angle

22

Anterior imaginary lines and landmarks

Suprasternal fossa

Supraclavicular fossa

Infraclavicular fossa

Sternal line

Sternal angle
Parasternal line

Anterior midline

Midclavicular line
epigastric angle
23

Lateral imaginary lines

Posterior axillary line

Anterior axillary line
Midaxillary line

24

Posterior imaginary lines and

landmarks
Suprascapular region
Scapular region

Interscapular region

Infrascapular region
Scapular line

Posterior midline

25

Anterior view of lobes

26

Posterior view of lobes

27

Right lateral view of lobes

28

Left lateral view of lobes

29

Anterior Chest
Sternum
Angle
Louis

Intercostal
space

xiphoid

clavicle

Posterior Chest
Scapula
Subscapular
Angle/
Infrascapular
region (7th
ICS)

Spine /
vertebra

Costalspinal angle

Remember???

Focused Interview

Questions

Are you having difficulty breathing?

At rest
Upon exertion

How many pillows used when lying down /

sleeping?
Any cough? Color? Consistency ?
Frequency? Amount ?
Any runny nose? Allergies ? Food ? Drugs ?
Seasonal / environmental/ psychological ?
Smoking ? Kind ? # per day?

Questions
Environmental factors?
Taking any meds? Rx ? OTC ? Herbal ?
Any respiratory illnesses in the past?

INSPECTION
Patient Position: sit upright with arms relaxed
at the sides
Observe the rate, rhythm, and effort of
breathing

Normal VS

Neonate, Infant
RR 30-60/min PR 110-160/min

Child 2-4 yrs

RR24-32/ min

Child 6-10 yrs

RR 20-26/min

PR 90-130/min
PR 100/min

Adult
16-20/min

PR 60-100/min

Normal Breathing

Tachypnea

Hyperventilation

Bradypnea

Cheyne-Stokes

Biots
Obstructive
Breathing

38

INSPECTION
Patient Position: sit upright with arms relaxed
at the sides
Observe the rate, rhythm, and effort of
breathing
Check for cyanosis
Check for retractions
Listen to patients breathing
Observe the shape of the chest

39

Check for cyanosis

Central cyanosis

Peripheral cyanosis
40

Clubbing

41

Schamroths Technique
42

Pursed lip breathing

Nasal flaring
43

Check for retractions

Intercostal retractions

Sternal retractions

Check for retractions

Subcostal
45

Use of accessory muscles

46

Thoracic Configuration
Anteroposterior (AP) diameter to
transverse diameter (T)
> AP: T = 1:2
> Increases slightly with age
> Increases prematurely
with COPD

47

Assess any observable

abnormalities (thoracic deformities)

Barrel chest

Kyphosis

Assess any observable

abnormalities

Scoliosis

Pectus Carinatum
(pigeon chest)
49

Assess any observable

abnormalities

Pectus Excavatum
(sunken/funnel chest)
50

Inspection

Jugular Vein Distention

51

Inspect and Palpate

Normally in the middle

of the neck
Directly below the
center of the
suprasternal notch

Position of the Trachea

52

Position of the Trachea

Shifts toward:
Collapsed lung
Atelectasis
Pneumonectomy

Shifts away:
Increased air ( tension
penumothorax)
Increased fluid ( pleural
effusion)
Increased tissue (tumor)

53

PALPATION

Palpate for tenderness & sensations

Use your fingerpads, left right; bilaterally
Identify tender areas may indicate inflamed
fibrous connective tissue.
Palpate ribs & sternum for pain & deformity

Test for chest expansion

Watch divergence of your thumbs.
Unilateral decrease or delay in chest
expansion maybe due to pleural effusion,
lobar pneumonia, chronic fibrotic disease

Fremitus palpable vibrations

Feel for tactile fremitus
transmitted through the

bronchopulmonary tree to the

chest wall when the patient
speaks

May be
Increased
Atelectasis
Pneumonia
Decreased
Soft voice
Pneumothorax
Pleural effusion
Emphysema
Obesity
Muscular
Or Absent
Soft voice
Pneumothorax
Pleural effusion
56

Percussion

Involves tapping body

parts to produce
sound waves

To determine tissue
density

Percuss in between
ribs (ICS)

TECHNIQUE OF
PERCUSSION
Position your right
hand with middle
finger partially
flexed, relaxed &
poised to strike
Hyperextend the
middle finger of
your left hand
(pleximeter)

PERCUSSION NOTES
Intensity

Pitch

Duration Location

FLAT

Soft

High

Short

Dullness

Medium

Medium Medium

Liver

Resonance

Loud

Low

Lung
Simple Chronic

Long

Thigh
Pleural effusion
Lobar pneumonia

Bronchitis

Hyperresonance Very
loud
Tympany
Loud

Lower
High

Longer
-

COPD
None
(emphysema,
normally
Pneumothorax)

Gastric air
Large
bubble/
puffed
pneumothorax
out cheek

Auscultation
Listening for
Most important
breath
sounds
Listen
for
examining
adventitious
technique
for
Listen
to
sounds
assessing
air flow
transmitted
sounds

Auscultation

Diaphragm of
stethoscope placed firmly
& directly on the chest
wall
Ask patient to deep
breath through the mouth
Listen for at least once, a
complete respiratory
cycle
Watch out for patients
comfort

General Approach

63

Order of auscultation

64

BREATH SOUNDS

Bronchial
Vesicular
E>I
I>E
Loud
Soft
Relatively
Low High
Quality:breezy
tubular
Quality:

Tracheal
I<E
Bronchovesicular
Very
I = loud
E
Relatively
high
Intermediate
Quality:
tubular
Intermediate
Quality: tubular
w/ rustling of
leaves

Characteristics of Breath Sounds

Duration of
Sounds

Intensity of
Expiratory
Sound

Pitch of
Expiratory
Sound

Locations
Where
Heard
Normally

Clinical
Significanc
e

Vesicular

Inspiratory
sounds last
longer than
expiratory
ones

Soft

Relatively
Low

Over most of
both lungs

Regional
ventilation

Bronchovesicular

Inspiratory &
expiratory
sounds are
about equal

Intermediate

Intermediate

Often in the
1st & 2nd
interspaces
anteriorly &
between the
scapulae

Large airway
patency

Bronchial

Expiratory
sounds lasts
longer than
inspiratory
ones

Loud

Relatively
High

Over the
manubrium,
if
heard at all

Patency of
large
airways

Tracheal

Expiratory
sounds lasts
longer than

Very loud

Relatively
high

Over the
trachea in
the neck

Patency of
airway

ADVENTITIOUS BREATH SOUNDS

Discontinuous Sounds

DISCONTINUOUS
FINE
CRACKLES
Intermittent
COARSE
CRACKLES
Soft
pitched, brief
Non-musical
Louder, lower pitched
Quality:
Loudness,
pitch,
duration
rolling
strand
Quality: bubbling or
of hairNumber
b/w fingers
velcro
Clinical
Timing
Significance:
Clinical Significance:
Location
opening
of collapsed
secretions
in airways
Changes
alveoliafter coughing or
changing position

ADVENTITIOUS BREATH SOUNDS

Continuous Sounds
Continuous
Sounds
Wheezes (sibilant)

>
Longer
than crackles
High
pitched
Wheezes
(sonorous)/Ronchi

Stridor
Do
not
persist
throughout
low-pitched
Heard primarily
during
snoring
Friction
Rubor
A
wheeze
that
is
entirely
the respiratory
cycleor
moaning
sounds
expiration
low-pitched,
dry, grating
predominantly
inspiratory

Clinical
Significance:
heard
duringairway
Musical
occursprimarily
during
inspiration
&

obstruction
louder in the neck than chest
expiration ( bronchospasm)
wall
may clear
with coughing
Significance:
pleurisy
Clinical
Clinical
Significance:
Clinical Significance: Upper
airway
airway obstruction
obstruction ( airway
secretions)

68

TRANSMITTED SOUNDS
Sounds are normally muffled &
indistinct
When the patient
says ee, youll
Louder
&muffled
clearer long
voiceee
sounds
are
hear
a
sound.
Ask called
the patient
to whisper ninetyBRONCHOPHONY
When
ee
is
heard
as ayisits
called
nine. Whispered voice
usually
EGOPHONY
faint
and indistinct.
Louder clearer sounds are called
WHISPERED PECTORILOQUY

Case Scenarios

70

Case Scenarios
Inspection: dyspnea, RR,
use of accesory muscles,
audible wheezes, anxiety
Palpation:

tactile fremitus

Percussion: Resonance to
hyperresonance
Ausculation: wheezes
ASTHMA
71

Case Scenarios
Inspection: tachypnea,
productive cough, chills
Palpation: tactile fremitus,
chest expansion
Percussion: dull
Auscultation: bronchophony,
egophony, whispered
pectoriloquy, bronchial breath
sounds and crackles

PNEUMONIA
72

Case Scenarios
Inspection: dyspnea,
productive cough, tachypnea,
use of accessory muscles
Palpation: normal tactile
fremitus
Percussion: resonance
Auscultation: wheezes and
ronchi

CHRONIC BRONCHITIS
73

Case Scenarios
Inspection: dyspnea, tracheal
shift to unaffected side
(severe)
Palpation: tactile fremitus &
chest expansion on affected
side
Percussion: dullness over fluid
Auscultation: or absent breath
& voice sounds, possible
pleural rub

PLEURAL EFFUSION
74

Case Scenarios
Inspection: tachypnea,
tracheal shift
Palpation:

tactile fremitus

Percussion: hyperresonance
Auscultation: or absent
breath & voice sounds

PNEUMOTHORAX
75

Case Scenrios

ATELECTASIS

CONGESTIVE HEART
FAILURE
76

DOCUMENTATION
RR 18/min, relaxed &
(normal findings)
even. AP less than

No dyspnea, cough, or
chest pain with
breathing, at rest or
with activity. No past
history or family history
of respiratory diseases.
Has never smoked &
works in well-ventilated
factory. Reports one
or two colds per year.
No known allergies

Subjective Data

transverse diameter.
Chest expansion
symmetric. No retractions
or bulging of intercostal
spaces. Tactile fremitus
symmetric. Percussion
tones resonant over all
lung fields. Vesicular
breath sounds
auscultated over lung
fields. No adventitious
sound present

Objective Data
77

DOCUMENTATION

Shortness of breath
with chest pain and
cough that gets worse
at night as verbalized
Subjective Data

Lying in right lateral position

with 2 pillows. RR 34/min,
irregular & shallow.
Increased used of accessory
muscles, intercostal
retractions observed.
Asymmetric chest expansion
with lagging, tactile fremitus
decreased on left chest.
Decreased breath sounds.
Crackles at lung bases.

Objective Data
78

79