ASSESSMENT OF THE CHEST AND LUNGS

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 7th
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 Pitch Intensity Quality I:E Location
Bronchial High Loud Blowing/ hollow I < E Trachea
Bronchovesicula
r
Moderate Moderate Combination I = E Between scapulae,
1st
& 2nd
ICS lateral to
sternum
Vesicular Low Soft Gentle rustling/
breezy
I > E Peripheral lung

26. Auscultation
 Evaluate for adventitious sounds
Sound Intensity/ Pitch I/E Quality 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 & E Continuous 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)