Assessment of the Respiratory System

Respiratory System

 

Anatomy of Respiratory System

• The lung are two cone- shaped, elastic structure suspended within the thoracic cavity.

• Lung are paired , they are not complete symmetric , the right lung contain up three lobe, whereas the left lung contain only two lobes.

• The apex of each lung extended slightly above the clavicle, where the base is at the level of diaphragm

• The thoracic cavity contain the nasopharynx , larynx , trachea, bronchi, bronchioles , alveoli .

• The thoracic cavity is lined by a thin, double- layered serous membrane collectively called the pleural

 

Chest bone

• Sternum

• Manubrium

• Xiphoid process

• Clavicles

• 12 pairs of ribs

• 12 pairs of thoracic vertebra

• Scapula

• Respiratory tract extends from mouth/nose to alveoli

• Upper airway filters airborne particles, humidifies and warms inspired gases

• Lower airway serves for gas exchange

 

Blood Supply

Lungs have a double blood supply:

1. Pulmonary circulation for gas exchange with the alveoli (pulmonary artery with subdivisions)

2. Bronchial arteries arising from descending aorta supplies lung parenchyma

 

Lungs blood supply

 

 

Contributors of Respiration

• Controlled in the brainstem

• Mediated by muscles of respiration

– Diaphragm primary muscle of inspiration

– Accessory muscles of inspiration

• Expiration is a passive process from elastic recoil of lung and chest wall, with passive diaphragm relaxation

 

Mechanism of respiration

• The muscles of respiration help the chest cavity expand and contract. the air pressure differences between the outside air and the lung help produce air movement . Together , these action allow inspiration and expiration

• Air pressure differences during inspiration and expiration, air pressure differences allow the bellows-like movement air in and out of the lung. All gases move from area of greater pressure to one of lesser pressure .

 

Resting Phase

– occurring at the end of respiration and expiration

– No pressure different between the atmosphere and the alveoli. And , thus, no airflow occurs.

– The negative intrapleural pressure prevents the lung from collapsing

Inspiration Phase

– Diaphragm contracts, descends and enlarges thoracic cavity

– Intra-pulmonary pressure negative (decrease)

– Air flows through tracheobronchial tree into the alveoli expanding lungs

Expiration Phase

– Diaphragm relax, rise and decrease thoracic cavity

– Intra-pulmonary pressure positive (increase)

– Air flows out lung into the atmosphere

 

Chest Landmarks

Anterior Chest Landmarks.

Anterior Chest Landmarks

Posterior Chest Landmarks.

Posterior Chest Landmarks.

Lateral Chest Landmarks.

Lateral Chest Landmarks.

 

History

Chief complaint / Present illness

• Cough

• Short of breathing / difficulty of breathing

• Chest pain

• Congestion

• Apnea

• Snoring

• Sudden onset breathing problem (aspiration)

 

Past medical history

• Hospitalization for breathing condition

• Chronic pulmonary condition “ e.g. COPD, asthma , TB”

• Other chronic condition “ e.g. heart disease”

• Allergy

• Trauma , surgery to thoracic , nose , mouth

• Medication used

 

Family history

• TB, cystic fibrosis , allergy, asthma , bronchitis, pulmonary embolism (clotting factors), smoking.

 

Personal and social history

• Environmental toxic exposure “ air pollution , pesticides, smoke”

• Tobacco use/expose

• Occupation “coal dust, insecticides, paint, asbestoses fibers”

• Travel

• Exercises tolerance

 

Technique and Equipment for Respiratory

Exam

Before beginning, if possible:

1. Quiet environment

2. Proper positioning (patient sitting for posterior thorax exam, supine for anterior thorax exam)

3. Bare skin for auscultation

4. Patient comfort, warm hands and diaphragm of stethoscope, be considerate of women (drape sheet to cover chest)

Equipment

– Examination gowns and drape

– Glove

– Stethoscope

– Light

– Skin marker

– Metric ruler

Technique

• Inspect . Palpate . Percuss. Auscultate

 

Inspection

1. Rate of respiration (normal vs. increased/decreased)

2. Rhythm of respiration and Depth (shallow vs. deep)

3. Symmetry of chest expansion.

4. Thoracic shape and contour.

5. Assess the patient’s chest color ( cyanosis – clubbing)

6. Weight

7. Cough

8. Hospital setting

 

Normal Respiratory Rates

  • Infant 30-60
  • Toddler 24-40
  • Preschooler 22-34
  • School-age child 18-30
  • Adolescent 12-16
  • Adult 10-20

 

Rhythm of respiration

Normally, the rhythm of respiration is smooth and regular. Carefully evaluate any abnormal breathing patterns, such as:

  • Tachypnea – an increased respiratory rate generally accompanied by a shallower breathing pattern.
  • Bradypnea – a reduced respiratory rate.
  • Apnea – a pattern in which there is an absence of breathing.
  • Cheyne-Stokes (periodic of breathing) : a pattern of increased deep respirations followed by a pattern of normal, then slower respirations, alternating with periods of apnea.
  • Kussmaul (gasp-like breathing) : a pattern of rhythmic, rapid, deep respirations, which usually sounds labored. It usually refer to air hunger

 

Symmetry of chest expansion

It is evaluated at the same time as rate and rhythm.

• Normally, the chest moves upward and outward symmetrically upon inspiration.

• Note any impaired movement or “lag” on either side, which could be caused by pain, atelectasis, or other disease.

 

Thoracic shape and contour

• The normal ratio of anteroposterior to lateral diameter varies from 1:1.4 to 1:2 An abnormal finding is:

  • Barrel chest
  • Funnel chest
  • Kyphosis
  • Lordosis
  • Pigeon chest
  • Scoliosis

 

Barrel Chest

Barrel Chest

• AP diameter increases

• AP – transverse (lateral) 2:1

• Somewhat with age; however, a round or “barrel” chest is often a sign of advanced emphysema.

 

Funnel chest

Funnel chest

• Depression of the lower portion of the sternum

• AP diminish

• Complications

  • Heart damage
  • Decrease cardiac output
  • Murmurs

Kyphosis

• Extreme curvature of the spine

Kyphosis

 

Lordosis

• Abnormal curvature of the lumbar spine

 

Pigeon chest

• Sternum protrudes outward

• Anterior-posterior diameter increased

 

Scoliosis

Thorax pine is Curved to either left or right

 

Palpation of Posterior Chest

Palpation of the posterior chest is performed for the following reasons:

1. Identify areas of tenderness.

2. Assess shape and symmetry.

3. Assess respiratory excursion.

4. Detect tactile fremitus.

 

Palpation

• Lightly palpate the intercostal spaces medially to laterally.

• Note any tenderness, bulging, or retraction.

• Note skin temperature and turgor and be alert to any tenderness or crepitus, especially around a wound site.

 

Respiratory excursion

• Place your hands laterally along each costal margin with the thumbs pointing toward the midline at level T9 or T10.

• Ask the patient to inhale deeply and then exhale.

• Normally, your thumbs will separate approximately 3 to 5 cm anteriorly & 5 to 8 cm posteriorly during maximum inspiration and will return to their original position during full expiration

 

Respiratory excursion

Respiratory excursion

 

Tactile Fremitus

• Ask the patient to say “ninety-nine” several times in a normal voice.

• Palpate using the balm of your hand.

• You should feel the vibrations transmitted through the airways to the lung.

• Increased tactile fremitus suggests consolidation of the underlying lung tissues. fluid in the lung.

• Decreased fremitus sound transmission obstructed by COPD, fluid outside the lung (pleural effusion), air outside the lung (pneumothorax), etc.

 

Percussion

• Percuss from side to side and top to bottom.

• Compare one side to the other looking for asymmetry.

• Note the location and quality of the percussion sounds you hear.

• Find the level of the diaphragmatic dullness on both sides.

 

Percussion of anterior chest

• Evaluation of lung tissue and location of the heart, liver, stomach, and diaphragm.

• Begin percussion at the supraclavicular area, again comparing symmetrical points.

• Move approximately 5 centimeters as you percuss downward below the breast. Listen for resonance which is the most common percussion note over the lungs.

• Normal variations occur in percussion of the anterior chest as you encounter dullness over the heart and liver as well as at the level of the diaphragm and tympany over the stomach.

 

Percussion

Percussion

 

Percussion of Posterior Chest

• Have the patient lean forward and cross his or her arms to separate the scapulae

• Listen for the predominant percussion note over the lungs, which is resonance that changes to dullness at the diaphragm. Compare both the left and right sides at each percussion site and note any discrepancies between sides.

 

Diaphragmatic Excursion

Diaphragmatic Excursion

  • Find the level of the diaphragmatic dullness on both sides.
  • Ask the patient to inspire deeply.
  • The level of dullness should go down 3-5 cm symmetrically.

 

Interpretation

• Flat or Dull: Pleural Effusion or Lobar Pneumonia

• Resonance: Healthy Lung or Bronchitis

• Hyperresonance: Emphysema or Pneumothorax

• Decreased or asymmetric diaphragmatic excursion may indicate paralysis or emphysema.

• Remember that normal percussion notes vary between patients. For example, the note is more resonant in thinner patients and flatter in those with more muscle or fat tissue.

 

Auscultation

• Auscultate from side to side and top to bottom.

• Compare one side to the other looking for asymmetry.

• Note the location and quality of the sounds you hear.

 

Auscultation site

Auscultation site

Interpretation

• The general rule is, the larger the airway, the louder and higher pitched the sound.

• Breath sounds are decreased when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion).

 

Breath Sounds

  • Normal

Tracheal

Bronchial

Bronchovesicular

Vesicular

  • Abnormal

Absent/Decreased

Bronchial

  • Adventitious

Crackles (Rales)

Wheeze

Rhonchi

Stridor

Pleural Rub

 

Normal Breath Sounds

  • Tracheal
  • Very loud, high pitched sound
  • Inspiratory = Expiratory sound duration
  • Heard over trachea
  • Bronchial
  • Loud, high pitched sound
  • Expiratory sounds > Inspiratory sounds
  • Heard over manubrium of sternum
  • If heard in any other location suggestive of consolidation
  • Bronchovesicular
  • Intermediate intensity, intermediate pitch
  • Inspiratory = Expiratory sound duration
  • Heard best 1st and 2nd ICS anteriorly, and between scapula posteriorly
  • If heard in any other location suggestive of consolidation
  • Vesicular
  • Soft, low pitched sound
  • Inspiratory > Expiratory sounds
  • Major normal BS, heard over most of lungs

 

Transmitted Voice Sounds

• If abnormally located bronchial or bronchovesicular breath sounds assess transmitted voice sounds with stethoscope

– Ask the patient to say “Ninety-nine”, should normally be muffled, if heard louder and clearer this is bronchophony

– Ask the patient to say “E A”, should normally hear muffled long E sound, if E to A change this is egophony

– Ask the patient to whisper “Ninety-nine”, should normally hear faint muffled sound, if louder and clearer sounds are heard this is whispered pectoriloquy

• Increased transmission of voice sounds suggests that air filled lung has become airless

 

Adventitious Breath Sounds

  • Crackles (Rales)

– Discontinuous, intermittent, nonmusical, brief sounds

Heard more commonly with inspiration

– Classified as fine or coarse

– Normal at anterior lung bases

  • Maximal expiration
  • Prolonged recumbency

– Crackles caused by air moving through secretions and collapsed alveoli

- Associated conditions

pulmonary edema, early CHF, PNA

  • Wheeze

– Continuous, high pitched, musical sound, longer than crackles

– Hissing quality, heard > with expiration, however, can be heard on inspiration

– Produced when air flows through narrowed airways

– Associated conditions

asthma, COPD

  • Rhonchi

– Similar to wheezes

– Low pitched, snoring quality, continuous, musical sounds

– Implies obstruction of larger airways by secretions

– Associated condition

acute bronchitis

  • Stridor

– Inspiratory musical wheeze

– Loudest over trachea

– Suggests obstructed trachea or larynx

– Medical emergency requiring immediate attention

– Associated condition

inhaled foreign body

  • Pleural Rub

– Discontinuous or continuous brushing sounds

– Heard during both inspiratory and expiratory phases

– Occurs when pleural surfaces are inflamed and rub against each other

– Associated conditions

pleural effusion, Pneumonothorax

 

Causes of decreased or absent breath sounds

1. Asthma

2. COPD

3. Pleural Effusion

4. Pneumothorax: caused by accumulation of air or gas in the pleural cavity.

5. ARDS( adult respiratory distress syndrome)

6. Atelectasis : is defined as a state in which the lung, in whole or in part, is collapsed or without air

 

Five Main Symptoms of Respiratory Disease

1. Cough

2. Sputum

3. Breathlessness

4. Wheeze

5. Pain

 

COUGH

SOME COMMON CAUSES OF COUGH

Viral bronchial infection dry + may last for weeks
COPD smokers
Asthma wakes pt at night; occurs post exercise/exposure to allergens
Bronchiectasis large amounts purulent sputum
Bronchial Carcinoma new cough/ change in cough
Pulmonary TB associated with fever/weight loss
Repeated aspiration recurrent after eating
Interstitial lung disease dry, irritant & distressing
Drug induced cough ACE inhibitors/ beta blockers

 

SPUTUM

  • Sputum = excess tracheobronchial secretions; may contain mucus, celleular debris & micro-organisms
  • Physio often asked to obtain specimens which are then gram-stained & examined under microscope ; antibiotic sensitivities performed on +ve cultures
  • Question Are
  • Colour
  • Consistency
  • Quantity – teaspoon/ egg cup
Saliva clear watery
Mucoid white chronic bronchitis
asthma
Mucopurulent bronchiectasis CF
Purulent thick viscous
yellow-rusty
infection
Frothy pink/white pulmonary oedema
Haemoptysis specks/frank TB,PE
Black black specks smoke inhalation

 

BREATHLESSNESS

• Subjective awareness of increased work of breathing

* “short of breath” * Fatigue on effort

* “feeling puffed” * “can’t get enough air in”

* difficulty breathing in/out”

• Predominant symptom of cardiac and respiratory disease

• Pathophysiology ??

• Orthopnoea:

– Breathlessness when lying flat

• Paroxysmal Nocturnal Dyspnoea (PND)

– Breathlessness that wakes the patient at night.

– In cardiac patients, lying flat increases venous return from the legs so that blood pools in the lungs, causing breathlessness

 

PAIN

• Chest pain of respiratory origin may originate in pleura/ mediastinum/ musculoskeletal

Pleuritic pain

  • Sharp, stabbing; Worse on coughing/deep inspiration
  • Not reproduced on palpation
  • Cause : inflammatory disease

• Mediastinal pain

  • Aching poorly localized retrosternal pain

• Musculoskeletal pain

  • Muscles/bones/joints/nerves
  • Worse with movement ; reproduced on palpation

symptoms of hypoxia

 

INVESTIGATIONS

1. Chest x ray

2. ABGs

3. CT scan

4. Bronchoscopy

5. Laboratory tests : haematology

Full blood count (FBC) will include e.g.

  • Haemoglobin (Hb) normal 12-16
  • Platelets normal 150-400
  • White cell count (WCC) normal 4-10

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