• Assessment of Respiratory SystemOutline• part I : assessment of respiratory function: – history – physical examination: • inspection • percussion • palpation • auscultation – laboratory tests: • pulmonary function studies • arterial blood gases • sputum studies • pleural fluid analysis• part II: assessment of respiratory structure:• pulse oximetry• chest –x- ray• computed tomography for chest• magnetic resonrnce imaging• bronchoscopy
Respiratory System Functions1. supplies the body with oxygen and disposes of carbon dioxide2. filters inspired air3. produces sound4. contains receptors for smell5. rids the body of some excess water and heat6. helps regulate blood pH7. Gase exchange
Respiration• Respiration – four distinct processes must happen – Pulmonary ventilation – moving air into and out of the lungs – External respiration – gas exchange between the lungs and the blood – Transport – transport of oxygen and carbon dioxide between the lungs and tissues – Internal respiration – gas exchange between systemic blood vessels and tissues
Anatomy and physiology• The respiratory tract extends from the nose to the alveoli and includes not only the air- conducting passages also but the blood supply• The primary purpose of the respiratory system is gas exchange, which involves the transfer of oxygen and carbon dioxide between the atmosphere and the blood.• The respiratory system is divided into two parts: the upper respiratory tract and the lower respiratory tract
Components of the Upper Respiratory Tract Figure 10.2
The upper respiratory tract includes• The nose• pharynx• adenoids• tonsils• epiglottis• larynx,• and trachea.
Upper Respiratory Tract Functions Passageway for respiration Receptors for smell Filters incoming air to filter larger foreign material Moistens and warms incoming air
Components of the Lower Respiratory Tract Figure 10.3
The lower respiratory tract consists of• the bronchi,• Bronchioles• alveolar ducts• and alveoli• all lower airway structures are contained within the lungs.
Lower Respiratory Tract Functions: Larynx: maintains an open airway, routes food and air appropriately, assists in sound production Trachea: transports air to and from lungs Bronchi: branch into lungs Lungs: transport air to alveoli for gas exchange
lung• The right lung is divided into three lobes (upper, middle, and lower)• the left lung into two lobes (upper and lower)• The structures of the chest wall• (ribs, pleura, muscles of respiration) are also essential
Physiology of Respiration• Ventilation. Ventilation involves inspiration (movement ofair into the lungs) and expiration (movement of air out of the lungs). Air moves in and out of the lungs because intrathoracic pressure changes in relation to pressure at the airway opening.• Contraction of the diaphragm and intercostal muscles increases chest dimensions, thereby decreasing intrathoracic pressure. Gas flows from an area of higher pressure (atmospheric) to one of lower pressure (intrathoracic)
Assessment of respiratoryPart I: Assessment of respiratory function history:1) medical history: Is there pts history of lung disease Cardiac or neuromuscular disease.2) Surgical history of any operation:- is there a history for any surgical operation?
3) Past medical history: - Is there past pulmonary diseases? History of heart problem? Childhood illness exposure to TB,? Diabetes? kidney disease, liver disease? Or hypertension cancer or T.B?
4) Family history: is there a History of lung disease, COPD, cardiac disease ,diabetes, kidney disease, liver disease, hypertension, cancer, T.B, or Others ?5) Smoking History: Is there smoking history? If there is smoking history ? is it current or in the past? environmental exposure to dust, chemicals, asbestos, air pollution
Cough• Type – dry, productive• Onset• Duration• Pattern – activities, time of day, weather• Severity – effect on ADLs• Wheezing• Associated symptoms• Treatment and effectiveness
sputum• amount• color• presence of blood (hemoptysis)• odor• consistency
:Physical Examination] 2[ Posterior Chest: Inspect, Palpate, Percuss, and Auscultate• Preparation before procedure:
Position/ Lighting/ Draping• Position –• patient should sit upright on the examination table.• The patients hands should remain at their sides.• When the back is examined the patient is usually asked to move their arms forward (hug themself position)• Lighting - adjusted so that it is ideal.• Draping - the chest should be fully exposed. Exposure time should be minimized.
Surface markings of the lobes of the lung:(a) anterior, (b) posterior, (c) right lateral and (d) left lateral.(UL, upper lobe; ML, middle lobe; LL, lower lobe). ul ll Ul ml a ul ml ll b ll
1) Inspiction:1. Inspect posterior thorax:1. Assess shape and symmetry. Note rate and rhythm of respiration, movement of chest wall with deep inspiration and full expiration, and signs of distress.2. Estimate the anteroposterior diameter.Respirations are quiet, effortless, and regular, 12–20 breaths per minute. Thorax rises and falls with respiratory cycle.Ribs slope across and down, without movement or bulging in the intercostals spaces3.Observe for abnormalities
II. Palpation. place thumbs close to client’s spine and spread hands over thorax. Note divergence of thumbs, feel for range and symmetry of movement during deep inhalation and full exhalation. Place ulnar aspect of your open hand at right apex of lung and place the hand at each location . Instruct client to say “99” and palpate for tactile fremitus (vibrations created by sound waves). Note areas of increased or
PalpationTactile fremitus •is vibration felt by palpation. Place your open palmsagainst the upper portion of the anterior chest, makingsure that the fingers do not touch the chest. Ask thepatient to repeat the phrase “ninety-nine” or anotherresonant phrase while you systematically move yourpalms over the chest from the central airways to eachlung’s periphery.You should feel vibration of equallyintensity on both sides of the chest. Examine theposterior thorax in a similar manner. The fremitus shouldbe felt more strongly in the upper chest with little or nofremitus being felt in the lower chest
• Move hands from side to side, from right to left, with client repeating the words with the same intensity every time you place your hands on the back.• Thumbs should separate an equal distance (3–5 cm) and in the same direction during thoracic expansion and meet in the midline on expiration. Posterior thorax is free from tenderness, lesions, and pulsations.• Fremitus is equal on both sides of thorax, strongest at the level of trachea.• Examine the body part that may be tender or painful
Note the following characteristics: Pulsations, Temperature of the tissue Presence of lumps or tumors,Swelling Texture of the skin Moisture or dryness of the skin Tenderness or pain, Distensions If a lump, nodule, or tumor is located: Feel for the size, shape, and consistency; attempt to move it with the Fingers.
(III) Using Percussion: Start at lung apices. Move hands from side to side across the top of each shoulder. Note sound produced from each percussion strike . Continue downward and posterolateral every other intercostal space.
Note intensity, pitch, duration -Air-filled lungs create a resonant sound. Identify contralateral sound; bones (e.g., ribs or spine, create a flat sound). - Thorax is more resonant in children and thin adults.
Note these sounds:Flat: Soft intensity, high pitch, short durationDull: Medium intensity, medium pitch, medium duration Dull sound is created in solid or fluid-filled structures (e.g., pneumonia, pleural effusion, or tumors). Pleural fluid sinks to lowest part of pleural space (posteriorly in a supine client).
Resonant: Loud intensity, low pitch, long duration Hyperresonant: very loud intensity, lower pitched; longer duration Hyperresonance in adults occurs in pneumothorax, emphysema, or asthma. Tympany: Loud intensity, lower pitched with musical quality, longer duration
(IV) Auscultation: - Auscultate posterior and lateral surfaces. Place diaphragm of stethoscope on right lung apex. Instruct client to inhale and exhale deeply and slowly when the stethoscope is felt on the back. Repeat on left lung apex. Move downward every other intercostal space and auscultate, placing stethoscope in the same position on both sides.
Auscultation• To assess breath sounds, ask the patient to breathe in and out slowly and deeply through the mouth.• Begin at the apex of each lung and downward between intercostal spaces . Listen with the diaphragm portion of the stethoscope.
• Normal breath sounds Observe:• Pitch• Intensity• Quality• Duration
Auscultate the lateral aspect by placing the stethoscope directly below the right axilla, instructing the client to breathe only through the mouth and to inhale and exhale deeply and slowly. Proceed downward, every other intercostal space on the same side. Repeat on left side. Posterior sounds: bronchovesicular and vesicular sounds; lateral: vesicular sounds.
Normal Breath Sounds• Bronchial: Heard over the trachea and mainstem bronchi (2nd-4th intercostal spaces either side of the sternum anteriorly and 3rd-6th intercostal spaces along the vertebrae posteriorly). The sounds are described as tubular and harsh. Also known as tracheal breath sounds.• Bronchovesicular: Heard over the major bronchi below the clavicles in the upper of the chest anteriorly. Bronchovesicular sounds heard over the peripheral lung denote pathology. The sounds are described as medium-pitched and continuous throughout inspiration and expiration.• Vesicular: Heard over the peripheral lung. Described as soft and low- pitched. Best heard on inspiration.• Diminished: Heard with shallow breathing; normal in obese patients with excessive adipose tissue and during pregnancy. Can also
Anterior Chest: Inspect, Palpate, Percuss, and Auscultate(I) inspection Place client in a sitting or supine position. Instruct client to inhale deeply and exhale fully. Inspect anterior thorax for:a. Symmetry and depth of movementb. Rhythm of respirationsc. Slope of ribs and musculoskeletal deformities Scapula at same height. Thorax rises and falls in unison with respiratory cycle
(II). Palpation: Place finger pads on right apex, above the clavicle. Proceed downward to each rib and intercostal space and note tenderness, pulsation, masses, and crepitance. Repeat on left side. Palpate for tactile Note that fremitus is usually decreased or absent over the precordium.
).Assessing chest expansion in expiration (left) and inspiration (right .Percussion over the anterior chest Direct percussion of the clavicles for disease in the lung apices
(III) percussion: Symmetrically percuss anterior surface Percuss 2–3 strikes along right lung apex, repeat on left lung apex. Proceed downward, percussing in every other intercostal space going from right to left in same position on both sides. Displace breast tissue as necessary.
Assess in each thoracic area: Resonant-lung field Cardiac dullness: third to fifth intercostal spaces left of sternum. Liver dullness: place your pleximeter finger parallel to upper border of expected liver dullness in right midclavicular line; percuss downward. - Gastric air bubble: repeat procedure performed for liver dullness on left side. Resonant sound over lung tissue (hyperresonance in children and thin adults).
• -Note about sounds:• Their presence and location.• Type of sounds• Pulses, heart sounds, lung sounds, and bowel sounds)• Duration and intervals between sounds
Pitch of Intensity of Normal expirator Duration of sound Expiratory Location Sound y sound sound 1-vesicular Inspiratory sound sound lasts longer Relatively Over the lung (both soft than expiratory low lung) one 2- In the 1s1 & 2ndbronchvesicul Inspiratory & intercostals ar sound expiratory intermediate intermediate space anterior sounds are & between equal scapula3- Bronchial Expiratory sound sound lasts longer Relatively loud Over manubrium than high Inspiratory one 4- tracheal Inspiratory & sound expiratory Relatively Over the trachea very loud sound are about high in the neck. equal
1-Crackles Soft, high pitched Secondary to fluid in the air ways, discontinuous popping sounds or alveoli or to opening or collapse occur during inspiration of alveoli 2-Crackles in Same as above Associated with obstructive; early pulmonary disease;fine crackles inspiration associated with bronchitis, or Pneumonia 3-Crackles in Same as above Associated with restrictive late Pulmonary disease Inspiration4-Wheezing or Deep, low, pitched rumbling Caused by air moving throughbronchi sound during narrowed trachio bronchial passage expiration may be from secretion or tumor 5-Sibilant Continues, musical, high-pitched Caused by narrow bronchioles & wheezes whistle like sound during associated with broncho spasm , inspiration & expiration asthma, build up of secretion. 6- Pleural Harsh, crackling sound likes two Secondary to inflammation & loss of friction rub pieces of leather rubber together. lubricating pleural fluid Heard during inspiration alone or during both inspiration & expiration may subside when patient Holds breath.
 laboratory tests:pulmonary function studies: Pulmonary function studies provide information about the volume, pattern, and rates of air flow involved in respiratory function. to determine the need for mechanical ventilation.
Uses: Pulmonary function tests are used to diagnose specific types of lung abnormalities and to assess the risk of respiratory complications. They are also used to monitor the course of pulmonary diseases Evaluate the effectiveness of prescribed medications, and
Arterial blood gas analysis: - ABGs analysis is an essential test in diagnosing & monitoring patient with respiratory disorder, because it gives direct information about ventilatory function. Blood gas results are reported in millimeters of mercury(mmHg). Arterial blood gas studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH
Normal ABG ranges are: PaO2 (partial pressure of O2 in arterial blood) is 80-l00 mmHg. PaCO2 (partial pressure of CO2 in arterial blood) is 35-45 mmHg. The arterial oxygen tension (PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (PaCO2) indicates the adequacy of alveolar ventilation. SaO2 saturation of O2 in arterial blood is greater than 94 % or 95 %. pH → Hydrogen ion concentration or degree of acid base balance 7.35-7.45
Part II assessment of respiratory structure• (1) pulse oximetery Pulse oximetrey is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SpO2 or SaO2). A probe or sensor is attached to the fingertip , forehead, earlobe, or bridge of the nose.
(2) Chest X-Ray Chest radiography, is one of the most frequently performed radiologic diagnostic studies. This study yields information about the pulmonary, cardiac, and skeletal systems. X-rays penetrate air easily; areas filled with air appear dark or black on x-ray film. Bones appear near-white on the film because x-rays cannot penetrate them to reach the film. Organs and tissues appear as shades of gray because they absorb more x-ray than air but less than bone. A routine chest x-ray includes a posteroanterior and lateral view. Films may be taken on full inspiration and on full expiration to detect a pneumothorax.
Chest films can indicate the following alterations and diseases: Lesions (tumors, cysts, masses) in the lung tissue, chest wall, bony thorax or heart Inflammation of lung tissue (pneumonia, atelectasis, abscesses, tuberculosis); pleura (pleuritis); and pericardium (pericarditis) Fluid accumulation in the lung tissue (pulmonary edema, hemothorax); (pleural effusion); and (pericardial effusion) Bone deformities and fractures of the rib and sternum Air accumulation in the lungs (chronic obstructive pulmonary disease, emphysema), and pleura (pneumothorax) Diaphragmatic hernia
(3) Computed Tomography for thorax:• - CT of the thorax is an imaging method in which the lungs are scanned in successive layers by a narrow- beam x-ray.• CT may be used to define pulmonary nodules and small tumors adjacent to pleural surfaces that are not visible on routine chest x-ray, and to demonstrate mediastinal abnormalities and hilar adenopathy, which are difficult to visualize with other techniques. Contrast agents are useful when evaluating the mediastinum and its contents.
• (4) Magnetic Resonance Imaging- MRIs are similar to CT scans except that magnetic fields and radiofrequency signals are used instead of a narrow-beam x-ray.• MRI uses a magnet and radio waves to produce an energy field that can be displayed as an image.- Chest MRI scanning is performed to assist in diagnosing abnormalities of cardiovascular and pulmonary structures.
• (5) Bronchoscopy- This procedure provides direct visualization of the larynx, trachea, and bronchial tree by means of either a rigid or a flexible bronchoscope.- The purpose of the procedure is both diagnostic and therapeutic. The rigid bronchoscope allows visualization of the larger airways, including the lobar, segmental, and subsegmental bronchi, while maintaining effective gas exchange.