This document provides information on assessing the chest and lungs, including the functions of the respiratory system, anatomical structures and landmarks, examination techniques, normal and abnormal findings, and developmental variations. It describes ventilation, diffusion, gas exchange, and breathing control. Topics covered include inspection, palpation, percussion, auscultation, breath sounds, and examining infants, children, pregnant patients and older adults. Videos are referenced for demonstrations of examination.

1. Assessment of the Chest and Lungs

2. Functions of the Respiratory
System
 Ventilation
 Diffusion and Perfusion
 Control of Breathing

3. Functions
 Ventilation
 Movement of air into and out of the lungs
 Inspiratory phase
 Expiratory phase

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. 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. Anatomical Structures
 Reference points for pinpointing findings from
the physical examination
 Topographical Landmarks
 Reference Lines

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. Manubrium
Manubriosternal junction
(Angle of Louis)
Nipple
Costal Angle

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. Anterior Chest

11. Posterior Chest

12. Axilla

13. Anatomy

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. 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. 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. 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

22. Chest Anatomy
 Web Anatomy:
http://www.gen.umn.edu/faculty_staff/jensen
/1135/webanatomy/

23. History
 Chief Complaint and HPI
 Cough
 Shortness of breath/Dyspnea

24. 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?

25. 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?

26. 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

27. History
 Personal and Social History
 Tobacco
 Alcohol
 Drugs
 Home environment
 Occupational environment
 Travel
 Health Promotional Activities

28. Physical Examination

29. Equipment and Techniques
 Equipment
 Stethoscope
 Techniques
 Inspection
 Palpation
 Percussion
 Auscultation

30. Inspection
 General
 Appearance
 Posturing
 Breathing effort
 Trachea position
 Midline

31. 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

32. Inspection
 Oxygenation: cyanosis
 Nails
 Skin
 Lips
 Respiratory Effort
 Respiratory rate and depth
 Breathing pattern
 Chest expansion

33. Palpation
 Trachea – for position
 Chest wall – for symmetry

34. 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

35. 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)

36. 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

37. 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

38. 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

39. 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

40. Auscultation
Copy this URL into your Web browser to hear normal and abnormal lung sounds :
http://medocs.ucdavis.edu/IMD/420C/sounds/lngsound.htm

41. 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

42. Developmental Variations
 Neonates
 Breathing is diaphragmatic and abdominal
 Signs of compromise
 Stridor (“crowing”)
 Grunting
 Central cyanosis
 Flaring nares

43. 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

44. Developmental Variations
 Pregnancy
 Costal angle increases to about 105 degrees in
the third trimester
 Dyspnea and orthopnea are common
 Breathes more deeply

45. 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)

46. 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