Respiratory Assessment Flashcards
costochondral junctions
point in which the ribs join their cartilage
–> NOT palpable
suprasternal notch
hollow U-shaped depression just above the sternum, in-between the clavicles
manubriosternal angle
the intersection between the manubrium and the sternum (bony ridge)
- a few centimeters down from
the manubrium
sternal angle (Angle of Louis)
articulation of the manubrium and the body of the sternum, continuous with the second rib
landmarks with the angle of Louis
a. landmark to start counting the
ribs
b. the site of which tracheal
bifurcation occurs (bronchus
splits into right and left bronchi)
c. landmark for the upper border
(base) of the atria
costal angle
the right and left costal margins
form an angle where they meet the xiphoid process (usually <90 degrees)
- angle > 90 decrees when the rib
cage is overinflated
vertebral prominens
C7 - the most bony projection felt at the base of the neck
spinous processes
- align with their numbered ribs
down to T4 - after T4, spinous processes angle
downwards from their vertebral
bodies
lung borders: anterior chest
apex - 3-4cm above inner thrid of clavicles
base - rests on diaphragm at above the sixth rib in the midclavicular line
lung borders: posterior chest
apex - C7 spinous process
base - T10 –> T12 (deep inspiration)
properties of the right lung
- shorter than the left lung (liver)
- wider than the left lung (no heart)
- 3 lobes
- Right Upper Lobe (RUL)
- Right Middle Lobe (RML)
- Right Lower Lobe (RLL)
- responsible for 55% lung function
properties of the left lung
- longer than the right lung (no
liver) - narrower than the right lung
(heart compresses the lung) - 2 lobes:
- Left Upper Lobe (LUL)
- Left Lower Lobe (LLL)
- responsible for 45% of lung
function
pleurae
two layers that form an envelope between the lungs and chest wall
a. visceral pleura - lines outside of
the lungs
b. parietal pleura - lines the inside
of the chest wall and
diaphragm
pleural cavity (space between the two pleura) contains serous fluid
- lubricates the lungs to allows
frictionless breathing
- creates a negative pressure
which holds the lungs in place
the trachea
lies anterior to the esophagus
- begins at the level of the cricoid
cartilage
- bifurcates at the level of the
angle of louis (anterior) or
T4/T5 (posteriorly)
the bronchi
transports air between the environment and the lung parenchyma
- functions to protect the alveoli
from particles inhaled (lined
with cilia and mucus secreting
goblet cells)
which bronchi is more likely to become obstructed?
the right bronchi –> it is shorter and straighter, allowing foreign objects to enter and obstruct it easier
what is considered the “dead space” of the lungs?
the trachea and the bronchi
- air present in these locations are
not directly involved in gas
exchange
acinus
the functional respiratory unit that consists of the:
1. bronchioles
2. alveolar ducts
3. alveolar sacs
4. the alveoli
hypercapnia
increased levels of carbon dioxide in the blood –> the major stimulus for breathing
hypoxemia
decreased levels of oxygen in the blood –> stimulus for breathing, although not as significant as hypercapnia
what mediates involuntary breathing?
the respiratory centre in the brainstem: the medulla and pons
Inspiration Process - Involuntary
ACTIVE - diaphragm flattens to open thoracic cavity while intercostal muscles move the ribcage up
–> creates a negative pressure
that draws air into the lungs
Expiration Process - Involuntary
PASSIVE - diaphragm relaxes (elasticity in thoracic cage and abdomen push it up), decreasing the thoracic cavity’s space, while the intercostal muscles relax, pulling the ribcage down and in to a more neutral position
–> creates a positive pressure
that pushes air out of the lungs
Forced Inspiration
accessory muscles in the neck pull up the sternum and ribcage
- sternomastoid, scalene, and
trapezius muscles
Forced Expiration
the abdominal muscles contract forcefully to push up the abdominal viscera against the diaphragm –> causes the diaphragm to move up and squeeze against the lungs
what is the major muscle responsible for inspiration?
the diaphragm
Health History Points (7)
- cough
- shortness of breath
- chest pain with breathing
- history of respiratory infections
- smoking history
- environmental exposure
- self care behaviour
Sputum Colours
white/ clear - viral infection
green/ yellow - bacterial infection
red/ pink and frothy - blood (hemopytosis)
Physical Exam Points
- Inspection
- Palpation
- Percussion
- Auscultation
Physical Exam: Inspection
- LOC
- Facial Expressions
- Position taken to breathe
- Development of Accessory Muscles
- Shape and Configuration of chest wall
- Respiration Quality
- Skin Colour and Condition
Kyphosis
C-shaped curve of the spine anterior to posterior (typically seen as a hump of the neck)
–> alters chest wall, decreases
thoracic cavity space for lung
inflation
Barrel Chest
increased anterior-posterior chest diameter caused by increased functional residual capacity
- permanent hyperextension of
the chest due to the
hyperinflation of the lungs
Seen in patients with chronic obstructive diseases
- chronic bronchitis
- emphysema
Scoliosis
S-shaped curve of the spine left to right, hips and shoulders not level
–> alters chest wall, decreases
thoracic cavity space for lung
inflation
Normal Chest Wall Configuration
chest wall is symmetric, without deformity
- distance from the front to the
back of the chest is less than
the size of the chest side to side
- oval shaped thoracic cavity
Respiratory Patterns (4)
- Eupnea (normal breathing)
- Hyperventilation
- Cheyene-Stokes
- Biot
Eupnea
rhythmic breathing, predictable, evenly spaced, each inspiration is the same depth
Hyperventilation
rhythmic breathing, increased rate and depth
Causes:
- acute pain
- activation of the SNS (exercise,
stress)
- ketoacidosis
Cheyene-Stokes
rhythmic breathing (regular pattern), alternating periods of hypercapnia and apnea
Causes:
- dying - regions of the brain are
dying, less oxygen needed
- brain injury
- intoxication
- increased intercranial pressure
Biot
IRREGULAR, unpredictable breathing, periods of breathing and apnea
Cause:
- respiratory depression
- brain injury at the level of the
medulla
- meningitis (spinal) - compresses
brainstem
Physical Exam: Palpation
- Chest Expansion
- Tactile Fremitus
Palpation: Chest Expansion
Anterior - place hands on anterolateral wall with thumbs along the costal margins pointing towards the zyphoid process
–> limitations in chest expansion
is easier to detect anteriorly due
to its increased range of motion
Posterior - place hands on posteriolateral wall with thumbs at the level of T9-10, slide thumbs medially to pinch a small fold of skin
Palpation: Tactile Fremitus
Anterior - start palpation over the ling apices in the supraclavicular areas
–> compare vibrations from side to side (working down) as patient says “ninety-nine”
Posterior - start palpation over the lung apices
palpate skin for lumps, masses, temperature, moisture or otherwise at the same time
Where is tactile fremitus most prominent?
between the scapulae and around the sternum (where the bronchi are closest to the chest wall
Physical Exam: Percussion
start at the apices and percuss both sides of the chest, into the intercostal spaces to make a side to side comparison
–> ensure resonance over lung
fields bilaterally
Resonance
low-pitched, clear, hollow sound that predominates in healthy lung tissue
–> dampened by the scapulae
and visceral organs (including
liver below the right lung)
Physical Exam: Auscultation
start at the lung apices and auscultate both sides of the chest, into the intercostal spaces, and laterally to the side of the chest to make comparisons
–> listen for adventitious sounds
–> ensure vesicular breath
sounds are bilateral
Normal Pulmonary Sounds
- Bronchial Sounds
- Bronchovesicular Sounds
- Vesicular Sounds
Abnormal (Adventitious) Pulmonary Sounds
- Crackles (fine and course)
- Stridor
- Wheezing
- Pleural Friction Rub
Bronchial Sounds
heard over the trachea and larynx
- heard better on expiration
Bronchovesicular Sounds
heard at major bronchi, between scapulae
- heard equally on inspiration and
expiration
Vesicular Sounds
heard over lung fields
- heard more on inspiration
Asthma
allergic hypersensitivity to inhaled allergens –> bronchospasm, inflammation, edema, secretion of mucus in airways
Exam:
- tactile fremitus decreased
- resonant to hyper-resonant
- adventitious bilateral wheezing
on expiration
- diminished air movement,
difficult exhaling
- tachycardia, tachypnea
- dyspnea, accessory muscles
Bronchitis
proliferation of mucous glands in the passageways, excessive mucous secretion
Exam:
- productive cough
- thick mucoid sputum
- tactile fremitus normal
- resonance over lungs
- crackles over deflated regions
Emphysema
destruction of pulmonary connective tissue = enlargement of air sacs and rupture of alveolar walls, increased resistance on expiration results in lung hyperinflation
Exam:
- barrel chest
- tripod position
- tachypnea, tachycardia
- decreased tactile fremitus
(hyper-inflation of lungs)
- hyper-resonant
- prolonged expiration (airway
resistance)
- muffled heart sounds (hyper-
inflation)
Lobar Pneumonia
Infection in lung parenchyma leaves alveolar membrane edematous and porous = RBCs and WBCs fill alveoli air space
Exam:
- tachypnea, tachycardia
- chest expansion decreased on
affected size
- tactile fremitus normal if
unobstructed
- no resonance, dull over affected
area (fluid filled, not air)
- decreased or absent breath
sounds over affected area
- adventitious crackles
Atelectasis
collapsed alveoli (or an entire lung) due to:
a. an airway obstruction (foreign
body, mucoid, tumor
b. compression of the lung
c. lack of surfactant
Exam:
- tactile fremitus decreased or
absent
- trachea might shift towards
affected side
- dull over area of collapse
- vesicular sounds decreased or
absent over affected area
- fine crackles of bronchus is
unobstructive
Pulmonary Embolism
undissolved thrombi lodges in heart to occlude pulmonary vessels
Exam:
- ischemia downstream, hypoxia,
cyanosis
- decreased CO (occlusion)
- tachypnea, tachycardia
- sputum with blood
- hypotension (from dec CO)
- crackles, wheeze
Pleural Effusion
collection of excess fluid in the intrapleural space, compression of overlying lung tissue
Exam:
- tachypnea, tachycardia
- dyspnea
- decreased tactile fremitus
- tracheal shift away from affected
side
- no resonance, dull
- breath sounds decreased or
absent
Heart Failure
pump failure with increasing pressure of cardiac overload resulting in pulmonary congestion
Exam:
- tachypnea, tachycardia
- skin moist, clammy
- tactile fremitus normal (lungs
still inflated)
- resonant (lungs still inflated)
- crackles at lung bases
- paroxysmal nocturnal dyspnea
- orthopnea ^^
- SOB on exertion
Indications of Respiratory Difficulty
- intercostal retractions
- nasal flaring
- pursed lip breathing
- accessory muscle use
- tripod sitting
Older Adult Considerations: Health History (pul)
- Any SOBE?
- decreased vital capacity
- decreased gas exchange = dec
energy, fatigue
- Usual amounts of physical activity
- older adults are less able to
perform activates bc of fatigue,
SOBE - people who are sedentary are at
greater risk for respiratory
issues
- older adults are less able to
- Positive history of respiratory conditions
- Chest pain with breathing
- could indicate a broken rib that
has punctured a lung (after
falling)
- could indicate a broken rib that
Older Adult Considerations: Physical Exam
- costal cartilages become calcified - dec mobility of thorax
- decrease in elastic properties of the lungs - less distensible and lessens their ability to contract and recoil
- lung bases become less ventilated - inc SOBE
- Kyphosis - hunched spine, decreased thoracic cavity space
