Chapter 18New ConceptsAnterior Thoracic LandmarksPosterior LandmarksReference Lines: Midsternal and MidclavicularReference Lines: Vertebral and Scapular LinesReference Lines: Anterior, Posterior and Midaxillary LinesAnterior Location of the LungsPosterior Location of LungsRight Lateral Location of LungStructure of the LungsLungsMechanics of RespirationSubjective Data: What You Learn from the PatientOther Subjective DataP Q R S TObjective Data: The Physical ExamThe ExaminationInspectionInspection: Shape AbnormalitiesInspection: Costal AngleInspection: Skin and NailsSlide 23PalpationPalpation: Symmetric ExpansionPalpation: Tactile (or Vocal) FremitusAbnormalities: Tactile FremitusPalpation FindingsPercussion: Anterior and PosteriorSequence for Percussion and AuscultationDiaphragmatic Excursion: TechniqueDiaphragmatic ExcursionNormal Percussion SoundsPercussion Sounds: HyperresonancePercussionAuscultationAuscultation SequenceLocation of Breath SoundsNormal Breath SoundsLung Sounds by LocationAuscultation “Pointers”Sounds heard in AuscultationEgophony SoundAdventitious (abnormal) SoundsSix Major TypesAdventitious Breath SoundsAdventitious Sounds cont’d.Adventitious Sound cont’d.Slide 49Auscultation cont’d.Other Respiratory Assessment TechniquesOther Techniques: BronchoscopyOther Techniques: Chest X-raysOther Techniques: Pulmonary Function TestsOther Techniques: Arterial Blood GasesAge Considerations: PediatricsAge Considerations: PregnancyAge Considerations: Aging AdultCommon Lung AbnormalitiesCommon Respiratory Conditions: COPDCommon Respiratory CondtionsCommon Respiratory ConditionsOther Respiratory ConditionsCOPD: Typical PresentationSlide 65Terminology of Abnormal RespirationsDocumentation: NormalDocumentation: Lung CongestionSlide 69Slide 70Slide 71Breath SoundsSlide 73Chapter 18Thorax and Lungs:Assessing the Respiratory SystemNew Concepts•Inspection of Chest–AP diameter•Palpation findings–Tactile fremitus•Percussion findings–Diaphragmatic excursion•Ausculation–Normal vs. abnormal breath sounds–Sequence•Pathology (diseases) associated with the respiratory systemAnterior Thoracic LandmarksPosterior LandmarksReference Lines: Midsternal and MidclavicularReference Lines:Vertebral and Scapular LinesReference Lines: Anterior, Posterior and Midaxillary LinesAnterior Location of the LungsPosterior Location of LungsRight Lateral Location of LungStructure of the LungsLungsMechanics of RespirationSubjective Data: What You Learn from the Patient•Cough•Presence of sputum•Shortness of breath (SOB)•Chest pain with breathing•Prior respiratory infections•Smoking Hx•Environmental exposure•Self-care behaviorsOther Subjective Data•History of respiratory disease•Other medical problems (cardiac?)•Weight changes•Fevers, night sweats?•Skin color changes•Allergies?–Describe reaction•Occupation•Location of residenceP Q R S T. . . . for any identified symptomObjective Data: The Physical Exam•Organization•Clothing:–Males disrobe to the waist–Females leave on gown and open at back (lift up and drape on shoulders for anterior exam)•Equipment –Stethoscope–Small ruler–Marking pen–Pulse oximeterThe Examination•Positioning•Ensure quiet environment•Order of Physical Exam: –Inspection–Palpation–Percussion–Auscultation of posterior, then anteriorInspection•Respirations –Rate and rhythm•Use of accessory muscles?•Any breathing difficulties?•Skin color/condition•Chest configuration/shape/symmetry –Anterior-posterior (AP) to transverse diameter–CAMP Chest Wall, Accessory Muscles, Masses, Paradoxical MovementInspection: Shape AbnormalitiesInspection: Costal AngleInspection: Skin and Nails•Skin color•Nail beds•Clubbing of nailsInspection•Normal: –Pink–Equal and unlabored–< 90º costal angle–Even, 14-20 bpm, unlabored–AP ratio: 1:2–Trachea midline–Chest expansion: 3” with deep inspiration•Abnormal:–Pallor, cyanosis–Intercostal spaces bulging, retractions–Costal angle: ≥ 90º–R uneven and labored–< 12 bpm–AP ratio: >1:2–Deviation to one side–Chest expansion: < e” with deep inspirationPalpation•Trachea •Palpate the entire chest wall:–Muscle mass? –Tenderness? –Bulging? –“Crepitations”?•Symmetric chest expansion:Palpation: Symmetric ExpansionPalpation: Tactile (or Vocal) Fremitus•Assess for tactile (or vocal) fremitus: “one, two, three” or “99”Abnormalities: Tactile FremitusPalpation Findings•Sensation–Normal: no pain or tenderness•Vocal fremitus–Normal: vibration ↑over periphery and↓over major airways•Thoracic expansion–Normal: symmetric•Sensation–Abnormal: pain, tenderness•Vocal fremitus:–Abnormal: vibration ↑over lung consolidation; ↓ airways•Thoracic expansion–Abnormal: asymmetricalPercussion: Anterior and PosteriorSequence for Percussion and AuscultationDiaphragmatic Excursion: Technique•Have patient exhale–Percuss the back on one side to locate the upper edge of the diaphragm (where the resonance changes to dullness)–Mark the spot•Have the patient inhale–Percuss from the point marked to where you locate the dullness again–Mark the spot•Measure the distance between the two spots•Normal: 3-6 cm bilaterally equalDiaphragmatic ExcursionNormal Percussion Sounds•Resonance over normal lung•Dullness over organs•Flatness over bonePercussion Sounds: Hyperresonance•Pediatric: hyperresonance throughout•Adults: hyperresonance is abnormal– pnuemothorax– COPDPercussion•Normal:–Resonance–Diaphragmatic excursion: descends 3-6 cm •Abnormal:–Hyperresonance over emphysema; dullness over solid masses or fluid–Diaphragmatic excursion: < 3 cmAuscultation•Equipment: diaphragm of stethoscope•Location: all 5 lobes•Specific sounds of lung auscultation:–Trachea: bronchial–Primary bronchi: bronchovesicular–Lungs: vesicularAuscultation SequenceLocation of Breath SoundsNormal Breath SoundsBroncheal (tracheal)loud, high pitched. E > I (louder & longer)Bronchovesicular (2nd space L or R)moderate pitch. I = EVesicular (over rest of lung)low pitch. I louder than ELung Sounds by Location•Breath Sounds•Tracheal•Bronchial•VesicularBronchovesicularAuscultation “Pointers”1. Have patient open mouth to breathe2. Always listen directly on skin 3. Differentiate background sounds from lung sounds4. Auscultate side-to-side