Respiratory Assessment

Where can you hear bronchovesicular sounds?

- between the scapulae and the first and second ics lateral to the sternum; moderate pitch and intensity, combination of bronchial and vesicular sounds, heard equally in inspiration and expiration

How to assess posture?

- Ask the patient to sit upright for the respiratory assessment - View the patient either before or after the assessment and note the assumed position for breathing. Ask if the assumed position is required for respiratory comfort. - Note if the patient can breathe normally when in a supine position - Note if pillows are used to prop the patient upright to facilitate breathing - A healthy adults breathes comfortably in a supine, prone or upright position - Orthopnoea is difficulty breathing in positions other than upright - The tripod position allows for easier use of accessory muscles

Costal angle?

- Costal angle: angle formed by the intersection of the costal margins at the sternum - place right finger pads on the bottom of the patients anterior left rib cage (10th rib); place your left finger pads on the bottom of the anterior right rib cage (10th rib); move both hands horizontally towards the sternum until they meet in the midsternal line; the angle formed by the intersection of the ribs creates the costal angle.

Creptius

- Crepitus should be absent - The presence of crepitus, also referred to as subcutaneous emphysema, is always an abnormal finding. Fine beads of air escape the lung and are trapped in the subcutaneous tissue. As this area is palpated, a crackling sound may be heard. This air is slowly absorbed by the body. They are usually felt earliest in the clavicular region, but it can easily be found in the neck, face or torso.

Masses

- No masses should be present - The presence of a thoracic mass is abnormal - The presence of a thoracic tumour or cyst should be closely evaluated and malignancy ruled out

Pulsations

- No pulsations should be present - The presence of pulsations on the thorax is abnormal - A thoracic aortic aneurysm that is large may be seen pulsating on the anterior chest wall

Thoracic tenderness

- No thoracic tenderness should be present - Fractured ribs may cause thoracic tenderness

How to assess skin colour?

- Pale or blue-tinged skin is abnormal - Pay close attention to nail beds, lips and tongue - Cyanosis; a bluish discoloration of the skin due to poor circulation or inadequate oxygenation of the blood - Erythema; intense redness of the skin due to excess blood in dilated superficial capillaries, as in fever or inflammation - Jaundice; yellow colour to skin, pale, and sclera due to excess bilirubin in the blood - Pallor; excessively pale, whitish-pink colour to lightly pigmented skin

How to assess audibility?

- Stand in front of the patient and listen for the audibility of the respirations - A patients respirations are normally heard by the unaided ear a few centimetres from the patients nose or mouth - It is abnormal to hear audible breathing when standing one metre away from the patient. Upper airway sounds may also be heard; these should not be confused with pulmonary sounds.

How to assess mode of breathing?

- Stand in front of the patient and note whether the patient is using the nose, mouth or both to breathe. - Note for which part of the respiratory cycle each is used - Normal findings vary among individuals but, generally, most patients inhale and exhale through the nose - Continuous mouth breathing is abnormal

How to assess muscles of breathing?

- Stand in front of the patient and observe the patient's breathing for a few respiratory cycles paying close attention to the anterior thorax and the neck - Forced breathing involves contraction of accessory muscles in the neck (inspiration) and internal intercostal and abdominal muscles (expiration) - Note all of the muscles that are being used by the patient - No accessory muscles are used in normal breathing - Accessory muscles attempt to create an extra respiratory effort to inhale needed oxygen

How to assess depth of breathing?

- Stand in front of the patient and observe the relative depth with which the patient draws a breath during inspiration - Shallow/deep? - The normal depth of inspiration is not exaggerated and effortless

How to assess symmetry of breathing?

- Stand in front of the patient and observe the symmetry with which the chest rises and falls during the respiratory cycle - The healthy adults thorax rises and falls in unison in the respiratory cycle; there is no paradoxical movement - Unilateral expansion of either side of the thorax is abnormal.

How to assess patterns of breathing?

- Stand in front of the patient and while counting the respiratory rate, note the rhythm or the pattern of the breathing for regularity or irregularity - Normal respirations are normal and regular in rhythm

How to assess rate of breathing?

- Stand in front of the patient or to the right and observe the patient's breathing without stating what you are doing (the patient may change respiratory rate (increase or decrease) if aware that you are watching; can be conducted simultaneously with the pulse rate assessment.) count the number of respiratory cycles that the patient has for one full minute. A respiratory cycle consists of one inhaled and one exhaled breath. - In a resting adult, the normal respiratory rate is 12 to 20 breaths per minute. This type of breathing is termed eupnoea or normal breathing - A respiratory rate greater than 20 breaths per minute is termed tachypnoea. By increasing the respiratory rate, the body is trying to supply additional oxygen to meet the body's demands. - A respiratory rate lower than 12 breaths per min is termed bradypnoea. - Apnoea is the lack of spontaneous respirations for 10 or more seconds.

What is barrel chest?

- barreled shaped in appearance; ap diameter to transverse diameter is 1:1

Shape of thorax?

- cone shapes structure (narrower at the top and wider at the bottom) that consists of bones, cartilage and muscle - stand in front of patient and estimate transverse diameter and move to the side and estimate ap diameter; normal adult is wider from side to side than front to back

What is pectus excavatum (funnel chest)?

- depression in the body of the sternum; ap diameter of the chest decreases

Scoliosis

- is a lateral curvature of the thorax or lumbar vertebrae

Kyphosis (or humpback)

- is an excessive posterior convexity of the thoracic vertebrae

Where can you hear vesicular sounds?

- over the peripheral lung field; has a low pitch and soft intensity, has a gentle, breezy, rustling quality and heard longer on inspiration than expiration

Where can you hear bronchial sounds?

- over the trachea; high in pitch, loud in intensity and has a hollow or blowing quality. longer in expiration than inspiration

What is pectus carinatum (pigeon chest)?

- protrusion of the sternum, increasing ap diameter of the thorax

Thoracic expansion

- thoracic expansion assesses the extent of chest expansion and the symmetry of chest wall expansion. - anterior and posterior thoracic expansions can be assessed. to perform anterior thoracic expansion: 1) Stand directly in front of the patient. Place the thumbs of both hands on the costal margins and pointing towards the xiphoid process. Gather a small fold of skin between the thumbs to assist with visualisation of the results of this technique. 2) Lay your outstretched palms on the anterolateral thorax 3) Instruct the patient to take a deep breath. 4) Observe the movement of the thumb, both in direction and in distance 5) Ask the patient to exhale 6) Observe the movement of the thumbs as they return to the midline To perform posterior thoracic expansion: 1) Stand directly behind the patient. Place the thumbs of both hands at the level of the 10th spinal vertebra, equidistant from the spinal column and approx. 2.5 and 7.5cm apart. Gather a small amount of skin between the thumbs as directed for exterior expansion 2) Place the outstretched palms on the posterolateral thorax 3) Instruct the patient to take a deep breath 4) Observe the movement of the thumbs, both in direction and in distance 5) Ask the patient to exhale 6) Observe the movement of the thumbs as they return to the midline

Trachial position?

- tracheal position is midline in the suprasternal notch - gently place the pad of the index finger in the midline of the suprasternal notch and palpate for the position of the trachea - tracheal deviation to the affected and unaffected side is abnormal

Abnormal/adventitious breath sounds

Breath sounds that are not normal can be classified as either abnormal or adventitious breath sounds. Abnormal breath sounds are characterised by decreased or absent breath sounds. Adventitious breath sounds are superimposed sounds on the normal bronchial, Bronchovesicular and vesicular breath sounds. There are five adventitious breath sounds; 1) Fine crackle 2) Coarse crackle 3) Wheeze 4) Pleural friction rub 5) Stridor Decreased breath sounds are abnormal

General palpation - anterior, postierior and lateral

General palpation assesses the thorax for pulsations, masses, thoracic tenderness and crepitus To perform anterior palpation 1. Stand in front of the patient 2. Place the finger pads of the dominant hand on the apex of the right lung (above the clavicle) 3. Using light palpation, access the integument of the thorax in that area 4. Move the finger pads down to the clavicle and palpate 5. Proceed with the palpation, moving down to each rib and ICS of the right anterior thorax. Palpate any areas of tenderness last 6. Repeat the procedure on the left anterior thorax To perform posterior palpation 1) Stand behind the patient 2) Place the finger pads of the dominant hand on the apex of the right lung (approx. at the level of T1) 3) Using light palpation, assess the integument of the thorax in that area 4) Move the finger pads down to the first thoracic vertebra and palpate 5) Proceed with the palpation, moving down to each thoracic vertebra and ICS of the right posterior thorax 6) Repeat the procedure on the left posterior thorax To perform lateral palpation 1) Stand to the patient's right side 2) Have the patient lift the arms overhead 3) Place the finger pads of the dominant hand beneath the right auxiliary fold 4) Using light palpation, assess the integument of the thorax in that area 5) Move the finger pads down to the first rib beneath the auxiliary fold 6) Proceed with the palpation, moving down to each rib and ICS of the right lateral thorax 7) Move to the patient's left side 8) Repeat steps 2-6 for the left lateral thorax

Auscultation - anterior, posterior and lateral

To perform anterior thoracic auscultation: 1) Place the patient in an upright sitting position with the shoulders back 2) Instruct the patient to breathe only through the mouth. Mouth breathing, when compared to nasal breathing, decreases air turbulence which can interfere with the interpretation of breath sounds. Have the patient inhale and exhale deeply and slowly every time the stethoscope is felt or instructed to do so. 3) Place the stethoscope on the apex of the right lung and listen for one complete respiratory cycle 4) Note the sound that is auscultated 5) Repeat on the left apex 6) Note the breath sound auscultated in each area and compare one side to the another 7) Continue to move the stethoscope down approx. 5cm or every second ICS, comparing contralateral sides. Visualise the anatomic topography of the chest during auscultation To perform posterior thoracic auscultation: 1) Place the patient in an upright sitting position with a slight forward tilt, head bent down and arms folded in front at the waist. These actions move the scapulae laterally and maximise the lung area the is auscultated 2) Place the stethoscope firmly on the patients right lung apex. Ask the patient to inhale and exhale deeply and slowly. 3) Repeat this process on the left lung apex 4) Move the stethoscope down approx. 5cm or every second ICS and auscultate that area 5) Auscultate in the same position on the contralateral side 6) Continue to move inferiorly with the auscultation until the entire posterior lung has been assessed To perform lateral thoracic auscultation: 1) Place the patient in an upright sitting position with the hands and arms directly overhead 2) Auscultate the entire right thorax first and then the entire left thorax. The stethoscope should initially be placed in the ICS directly below the axilla. 3) Instruct the patient to breathe only through the mouth and have the patient inhale and exhale deeply and slowly. 4) Note the sound that is auscultated and continue to move the stethoscope inferiorly approx. every 5cms or every second ICS until the entire thorax has been auscultated

How to assess diameter?

Transverse diameter - Stand in front of patient and observe, estimate visually the transverse diameter of the thorax Anteroposterior diameter (AP) - Move to one side of the patient and estimate visually the width of the anteroposterior diameter of the thorax The normal adult is wider from side to side than from front to back. The normal thorax is slightly elliptical in shape.