Assessment of the Chest and Lungs
Functions of the Respiratory                  System Ventilation Diffusion and Perfusion Control of Breathing
Functions Ventilation     Movement of air into and out of the lungs     Inspiratory phase     Expiratory phase
Functions Hypoventilation     Slow, shallow breathing     Causes CO2 to build up in the blood         Acidosis Hyperv...
Functions Diffusion and Perfusion     Gas exchange across the alveolar-pulmonary      capillary membranes Control of br...
Anatomical Structures Reference points for pinpointing findings from  the physical examination     Topographical Landmar...
Topographical Landmarks Nipples Manubriosternal junction (Angle of Louis)      Point at which the 2nd rib articulates w...
ManubriumManubriosternal junction(Angle of Louis)      Nipple   Costal Angle
Reference Lines Anterior Chest      Midsternal line      Anterior axillary lines      Midclavicular lines Posterior C...
Anterior Chest
Posterior Chest
Axilla
Anatomy
Anatomy Points to Remember Lungs are symmetric Lungs are divided into lobes     Right lung = 3 lobes     Left lung = 2...
Anatomy Points to Remember Upper Airway     Nose, pharynx, larynx, intrathoracic trachea     Functions in respiration  ...
Anatomy Points to Remember Lower Airway     Trachea, bronchi, bronchioles         Functions in respiration           C...
Anatomy Points to Remember Lower Airway     Trachea splits into left and right mainstem      bronchi which are further s...
Chest Anatomy Web Anatomy:  http://www.gen.umn.edu/faculty_staff/jensen  /1135/webanatomy/
History Chief Complaint and HPI     Cough     Shortness of breath/Dyspnea
Cough   Onset – sudden, gradual   Duration   Nature – dry, moist, hacking, barking   Sputum – amount, color, odor   S...
Shortness of Breath (SOB) /                     Dyspnea   Onset – sudden, gradual   Duration   Severity – disrupts acti...
History Past Health History     Lung disease or breathing problems         Frequent severe colds, asthma, emphysema,   ...
History Personal and Social History     Tobacco     Alcohol     Drugs     Home environment     Occupational environm...
Physical Examination
Equipment and Techniques Equipment     Stethoscope Techniques     Inspection     Palpation     Percussion     Auscu...
Inspection General     Appearance     Posturing     Breathing effort     Trachea position         Midline
Inspection Chest Wall Configuration     Form     Symmetry     Muscle development     Anterior-Posterior (AP) diameter...
Inspection Oxygenation: cyanosis     Nails     Skin     Lips Respiratory Effort     Respiratory rate and depth     ...
Palpation Trachea – for position Chest wall – for symmetry
Palpation Thoracic Expansion (Excursion)      Place both thumbs at about 7th rib       posteriorly along the spinal proc...
Palpation Vocal (Tactile) Fremitus     Use palmar or ulnar surfaces of hands     Systematically position hands over bot...
Auscultation Auscultate in a systematic manner Compare one side to the other Listen one full respiration at each spot ...
Auscultation Evaluate posterior, lateral, and anterior chest Instruct person to sit upright and breathe in  and out slow...
Auscultation Evaluate for normal sounds  Sound              Pitch      Intensity Quality             I:E   Location  Bron...
Auscultation Evaluate for adventitious sounds Sound          Intensity/ Pitch     I/E   Quality                     Clear...
AuscultationCopy this URL into your Web browser to hear normal and abnormal lung sounds :http://medocs.ucdavis.edu/IMD/420...
Developmental Variations Neonates     Measure the chest circumference         Usually 2-3 cm smaller than head circumfe...
Developmental Variations Neonates     Breathing is diaphragmatic and abdominal     Signs of compromise         Stridor...
Developmental Variations Infants and Young Children     Roundness of the chest persist for first 2 years     Chest wall...
Developmental Variations Pregnancy     Costal angle increases to about 105 degrees in      the third trimester     Dysp...
Developmental Variations Older Adult     Chest expansion is often decreased     Bony prominences are marked     AP dia...
Videos of Thorax and Lung                  Assessment Copy these URLs into your Web browser     http://www.conntutorials...
Respiratory assessment
Respiratory assessment
Respiratory assessment
Respiratory assessment
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Respiratory assessment

  1. 1. Assessment of the Chest and Lungs
  2. 2. Functions of the Respiratory System Ventilation Diffusion and Perfusion Control of Breathing
  3. 3. Functions Ventilation  Movement of air into and out of the lungs  Inspiratory phase  Expiratory phase
  4. 4. Functions Hypoventilation  Slow, shallow breathing  Causes CO2 to build up in the blood  Acidosis Hyperventilation  Rapid, deep breathing  Causes CO2 to be blown off  Alkalosis
  5. 5. Functions Diffusion and Perfusion  Gas exchange across the alveolar-pulmonary capillary membranes Control of breathing  Influenced by neural and chemical factors  Pons, medulla, chemoreceptors in the carotid body  Stimulus for breathing  Increased carbon dioxide - PRIMARY
  6. 6. Anatomical Structures Reference points for pinpointing findings from the physical examination  Topographical Landmarks  Reference Lines
  7. 7. Topographical Landmarks Nipples Manubriosternal junction (Angle of Louis)  Point at which the 2nd rib articulates with the sternum Suprasternal notch Costal Angle  Usually no more than 90 degrees  Ribs insert at approximately 45 degree angles Clavicles
  8. 8. ManubriumManubriosternal junction(Angle of Louis) Nipple Costal Angle
  9. 9. Reference Lines Anterior Chest  Midsternal line  Anterior axillary lines  Midclavicular lines Posterior Chest  Vertebral line  Midscapular lines Axilla  Anterior axillary lines  Midaxillary lines  Posterior axillary lines
  10. 10. Anterior Chest
  11. 11. Posterior Chest
  12. 12. Axilla
  13. 13. Anatomy
  14. 14. Anatomy Points to Remember Lungs are symmetric Lungs are divided into lobes  Right lung = 3 lobes  Left lung = 2 lobes Primary muscles of respiration  Diaphragm – divides chest from abdomen  External intercostal muscles  Accessory muscles
  15. 15. Anatomy Points to Remember Upper Airway  Nose, pharynx, larynx, intrathoracic trachea  Functions in respiration  Conduct air to lower airway  Filter to protect lower airway  Warm and humidify inspired air
  16. 16. Anatomy Points to Remember Lower Airway  Trachea, bronchi, bronchioles  Functions in respiration  Conduct air to alveoli  Clear mucociliary structures  Alveoli  Functional unit  Gas exchange  Production of surfactant
  17. 17. Anatomy Points to Remember Lower Airway  Trachea splits into left and right mainstem bronchi which are further subdivided into bronchioles  Right bronchus is shorted, wider and more upright than the left  Functions in respiration  Conduct air to alveoli  Clear mucociliary structures
  18. 18. Chest Anatomy Web Anatomy: http://www.gen.umn.edu/faculty_staff/jensen /1135/webanatomy/
  19. 19. History Chief Complaint and HPI  Cough  Shortness of breath/Dyspnea
  20. 20. 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?
  21. 21. 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?
  22. 22. 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
  23. 23. History Personal and Social History  Tobacco  Alcohol  Drugs  Home environment  Occupational environment  Travel Health Promotional Activities
  24. 24. Physical Examination
  25. 25. Equipment and Techniques Equipment  Stethoscope Techniques  Inspection  Palpation  Percussion  Auscultation
  26. 26. Inspection General  Appearance  Posturing  Breathing effort  Trachea position  Midline
  27. 27. 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
  28. 28. Inspection Oxygenation: cyanosis  Nails  Skin  Lips Respiratory Effort  Respiratory rate and depth  Breathing pattern  Chest expansion
  29. 29. Palpation Trachea – for position Chest wall – for symmetry
  30. 30. Palpation Thoracic Expansion (Excursion)  Place both thumbs at about 7th rib posteriorly along the spinal process Click on the pictures to view video  Extend the fingers of both hands outward over the posterior chest wall  Have the person take a deep breath and observe for bilateral outward movement of thumbs  Normal: bilateral, symmetric expansion  Abnormal: unilateral or unequal
  31. 31. 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)
  32. 32. Auscultation Auscultate in a systematic manner Compare one side to the other Listen one full respiration at each spot Displace breast tissue to listen directly over chest wall DO NOT listen through gowns, clothes, etc.  Place your stethoscope over bare skin
  33. 33. 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
  34. 34. Auscultation Evaluate for normal sounds Sound Pitch Intensity Quality I:E Location Bronchial High Loud Blowing/ I<E Trachea hollow Bronchovesicular Moderate Moderate Combination I=E Between scapulae, 1st & 2nd ICS lateral to sternum Vesicular Low Soft Gentle rustling/ I>E Peripheral lung breezy
  35. 35. Auscultation Evaluate for adventitious sounds Sound Intensity/ Pitch I/E Quality Clear with Cough Crackles/ Soft (fine)/ High I Discontinuous, Possibly Rales Loud (coarse)/ Low nonmusical, brief Wheeze High E Continuous musical Possibly sounds Ronchi Low E Continuous snoring Possibly sounds Pleural I&E Continuous or Never Friction Rub discontinuous creaking or brushing sounds Stridor I Continuous, crowing Never
  36. 36. AuscultationCopy this URL into your Web browser to hear normal and abnormal lung sounds :http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm
  37. 37. 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
  38. 38. Developmental Variations Neonates  Breathing is diaphragmatic and abdominal  Signs of compromise  Stridor (“crowing”)  Grunting  Central cyanosis  Flaring nares
  39. 39. 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
  40. 40. Developmental Variations Pregnancy  Costal angle increases to about 105 degrees in the third trimester  Dyspnea and orthopnea are common  Breathes more deeply
  41. 41. 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)
  42. 42. Videos of Thorax and Lung Assessment Copy these URLs into your Web browser  http://www.conntutorials.com/chapter5.html OR  http://medinfo.ufl.edu/other/opeta/chest/CH_main
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