Respiratory assessment Flashcards
Pharynx
- The membrane-lined cavity behind the nose and mouth, connecting them to the esophagus
- Open space
Larynx
- Commonly called the voice box
- Organ in the top of the neck involved in breathing, producing sound, and protecting the trachea against food aspiration - Houses the vocal folds, and manipulates pitch and volume
Mouth & Oropharynx
- The mouth is an oval-shaped cavity inside the skull.
- The two main functions of the mouth are eating and speaking
- Parts of the mouth include the lips, vestibule, mouth cavity, gums, teeth, hard and soft palate, tongue and salivary glands
- Also known as the oral cavity or the buccal cavity
- The oropharynx is the part of the throat just behind the mouth
- Includes the: back 1/3 of the tongue. soft area at the back of the roof of the mouth (soft palate)
Nose & Nasopharynx
- The nasopharynx is the space above the soft palate at the back of the nose and connects the nose to the mouth
- Allows a person to breathe through the nose
- The soft palate separates the nasopharynx from the oropharynx, which sits just below the soft palate
Glottis
- Opening between the vocal cords
- Flap that covers the larynx that assists with swallowing
Trachea
- Large tube supported by moon shaped cartilage
- Connects the larynx to the bronchi
- Keeps the airway open
Carina
- Where the trachea branches into the two bronchi
- Very sensitive area
Bronchi
- The main passageways into the lungs
- Right and left
- Right more vertical
Terminal Bronchioles
- Lower airways end at the terminal bronchioles
- Slows down the air before it enters the gastric airways
- Creates a greater time for gas exchange
Acinus
- Gas exchange airways
Terminal bronchioles > Respiratory bronchioles > alveolar ducts > alveolar sacs > alveoli
Alveoli
- Gas exchange sites within the lungs
Respiratory bronchioles
- The narrowest airways of the lungs, 0.5 mm across
- The bronchi divide many times before evolving into the bronchioles
- The respiratory bronchioles deliver air to the exchange surfaces of the lungs
- They are interrupted by alveoli which are thin walled evaginations
Alveolar ducts
- Are numerous ducts in the respiratory system that connect the alveolar sacs to the bronchioles
- The alveolar sacs are sacs of many alveoli, which are the cells that exchange oxygen and carbon dioxide in the lungs
Alveolar sacs
- Are sacs of many alveoli, which are the cells that exchange oxygen and carbon dioxide in the lungs
- The alveolar ducts assist the alveoli in their function by collecting the air that has been inhaled and transported through the tract, and dispersing it to the alveoli in the alveolar sac
Alveoli
- Any of the many tiny air sacs of the lungs which allow for rapid gaseous exchange
- Type I and Type II
Upper airway components
- Mouth & oropharynx
- Nose & nasopharynx
- Pharynx
- Larynx
Lower airway components
- Trachea
- Carina
- Bronchi
- Terminal Bronchioles
Acinus components
- Respiratory Bronchioles
- Alveolar ducts
- Alveolar sacs
- Alveoli
Type I Alveoli Cells
- Provide structure
Type II Alveoli Cells
- Secrete surfactant; a lipoprotein that coats the inner surface of the alveoli and the purpose is to lower the surface tension during respiration so the alveoli does not collapse
Alveolar Macrophages
- Alveoli have small immune factor to them
- Alveolar macrophages which attack foreign bodies and move them to the lymphatic system
Pleura
- The layers of the lungs
3 layers
- Visceral pleura
- Pleural space
- Parietal pleura
Visceral Pleura
- Inner layer
- Covers the lungs themselves
Parietal pleura
- Outer layer
- Closer to the thoracic cage
Pleural space
- In between the visceral and parietal pleura
- Fluid exists there; allows for smooth friction free movement across the two layers
- Can be too much exudate or inflammation of the pleural space which can cause issues
The four major functions of the respiratory system
- Supply oxygen to the body
- Remove carbon dioxide
- Maintain homeostasis (acid-base balance)
- CO2 levels can be altered to maintain levels through slowing or quickening our breath
- Hypoventilation and hyperventilation - Maintain heat exchange
Hypoventilation and homeostasis
- Increases CO2 in the blood
- Correlates with a lower pH level in the blood
- The body becomes more acidic
Hyperventilation and homeostasis
- Decreases CO2 in the blood
- Correlates with a higher pH level in the blood
- Body becomes less acidic
Control of respirations
- Normally, breathing patterns change without our awareness- involuntary
- Mediated by the respiratory centre in the brain stem
- Breathing patterns change in response to varying levels of CO2 AND O2 in the blood
Hypercapnia
- Stimulus to breathe
- CO2 builds up to a certain level which triggers taking a breath
- This is the stimulus to breathe in healthy people
Hypoxemia
- Stimulus to breathe
- Decrease in O2 triggers respiration
- Less effective than hypercapnia
- Not commonly found
Inspiration & Expiration
Inspiration
- Diaphragm contracts
- Chest expands
- Vertical diameter increases
- Sternum and ribs expand in places
- Anterior-posterior boarder also increases
Expiration
- Opposite happens;
- Chest contracts
- Diaphragm relaxes
- Vertical and AP boarder decrease
The thoracic cage
- Protects the lungs
- Sternum
- 12 pairs of ribs
- 12 thoracic vertebrae
- Diaphragm
Ribs
- First 7 attache directly to the sternum by costal cartilage; called true ribs
- 8-10 attached to the ribs by cartilage; called false ribs
- 11-12 are floating ribs because they don’t attach to anything
Landmarks: Anterior Chest
- Ribs: 2, 4, 5, and 6
- Suprasternal notch
- Manubrium of sternum
- Manubriosternal angle (angle of Louis)
- Body of sternum
- Xiphoid process
- Costal angle
Suprasternal notch
- A large, visible dip in between the neck and the two collarbones of the human anatomy
- Hollow U-shaped depression
Manubrium of sternum
- “Top of tie” of the sternum
- The broad upper part of the sternum
- Joins with the body of the sternum, the clavicles and the cartilages of the first pair of ribs
Angle of Louis
- Also called manubriosternal angle
- Ridge where the manubrium of sternum meets body of sternum,
- In line with the 2nd rib and is where the trachea divides into right and left bronchi
Coastal angle
- Should be 90 degrees of less
- The meeting point of the lower border of the false ribs with the axis of the sternum.
Ribs for landmarking on anterior chest
- Ribs 2,4,5, and 6 are significant marking of the edges of the lungs; we count them down
Landmarks: Posterior Chest
- 12th rib
- Vertebra prominens C7
- T1
- Spinous process T3
- Inferior angle of scapula
- Spinous process of T10 & T12
Inferior boarder of the scapula
- The inside boarder
- Closest to the vertebrae
12th rib importance for landmarking
- Bottom boarder of the lung when we breath in
Anterior reference lines for respiratory assessment
- Midsternal line
- Midclavicular line
- Anterior axillary line
Posterior reference lines for respiratory assessment
- Vertebral line
- Scapular line; inferior angle of the scapula
Axillary reference lines for respiratory assessment
- Anterior axillary line
- Midaxillary line
- Posterior axillary line
Mediastinum
- Middle part between the right and left lungs
- Contains the esophagus, heart, the trachea and the vessels
Right pleural cavity
- Contains the right lung
- Shorter than the left cavity due to the liver
- Contains 3 lobes; right upper, right middle, right lower
Left pleural cavity
- Contains the left lung
- Narrower than the right due to the heart pushing into that side
- Has 2 lobes; left upper and left lower
Lobes of the lungs: anterior view
- Mostly upper lobes
- RUL until the horizontal fissure/4th rib/5th rib midaxillary line
- RML until right oblique fissure/ 6th rib midclavicular line then RLL
- LUL until left oblique fissure/6th midclavicular line then RLL
Lobes of the lungs: posterior view
- Almost all lower lobes
- LUL and RLL until T3
- LLL and RLL from T3-T10/T12
- As your thoracic cage gets bigger (when you breathe in) you lungs expand from T10-T12
- Right middle lobes does not project onto posterior side at all
Lobes of the lungs: right lateral view
- RUL until 4th rub/right oblique fissure/5th rib at midaxillary line
- RML until 6th rib at midclavicular line
- RLL underneath
- Good for assessing RML
Lobes of the lungs: left lateral view
- LUL until left oblique fissure/T3/6th rib at midclavicular line
- The LLL
- No left middle lobe (!)
Respiratory developmental considerations: infants and children
1) Surfactant
- Until 32 weeks gestation; before not an adequate amount of surfactant to life outside utero to maintain alveoli structure
2) Smaller size of the respiratory system
- Nasal passages; more easily blocked by secretions, swelling, foreign bodies
- Diameter of airway; children’s trachea is more funnel shaped, prone to issues with things lodging
- Distance between structures; everything is closer together, easier for bacteria and viruses to move around and become more severe
3) Immune system immaturity
- Not fully mature until 5-6 years old
- More prone to infections
Respiratory developmental considerations: pregnancy
1) Decreased space for lung expansion
- With growing fetus the diaphragm is pushed up 3-4cm
- The vertical thoracic cage get smaller but compensates by getting wider
2) Increased circumference of thoracic cage
3) Increased O2 demand
- Needs met because tidal volume increases during pregnancy
- Little change in the resp. rate in a pregnant person
- Due to pressure in upper diaphragm there is often increased awareness of need to breathe and can be uncomfortable for some people
Respiratory developmental considerations: aging adults
1) Costal cartilage calcification
- Becomes more rigid
2) Decreased respiratory muscle strength
- Lungs become weaker
3) Decreased elasticity within the lungs
- As a whole, the aging lung is less easily inflated and deflated, more rigid
- These changes tend to result in small airway closed or collapse of alveoli
4) Increase in small airway closure
- Less opportunity for gas exchange
- Increase risk of shortness of breath
Respiratory assessment: subjective data
Cough
- Type pf cough; dry, wet, barking, etc.
- Productive; anything coming up, colour
- Hemoptysis; blood in the sputum
- PQRSTU-AAA
SOB (Dyspnea)
- What causes it
- Affected by position; may be cardiac related
- Time of day is occurs
- Associated with any colour changes, with wheezing, or with any sort of exposure to anything
- Emotional response ; panic attacks
Chest pain with breathing
- Can strain intercostal muscles
- Or with pneumonia
Past history of respiratory infections
- Unusually severe cold
- TB, asthma, bronchitis, etc.
Smoking history
- What are you smoking
- How much
- Point of access for health promotion teaching
- Second hand smoking exposure
Environmental exposure
- Precautions to protect themselves
Self care behaviours
- Flu shot
- Tb test
- Pneumonia vaccines
- Last chest x-ray
Inspection of respiratory system
Skin colour and condition
- Colour inconsistencies
- Lesions
- Wide spread colour changes
Nail beds
- Nails and capillary refill
- Clubbing with chronic illness (chronic hypoxia)
Thoracic cage: shape and configuration
- Expected finding; spinal process is straight, thoracic cage is symmetrical, the anterior posterior diameter is less than the transverse and horizontal diameter
Respirations: rate, rhythm, depth, pattern
- Rate 12-20
- Tachypnea >20
- Bradypnea <12
WOB, persons position and facial expression
- Work of breathing
- Accessory muscle use, a lot of effort going into each breath; bracing to open and facilitate breathing
- Appears that they are labouring to breathe
LOC
- Level of consciousness
- Want alert
Signs of distress
- Increased WOB
- Sudden onset of SOB
- Gasping
- Colour changes around lips and nail beds
- Increasing RR
- Decreasing oxygen saturation
- Changes in LOC
- Tracheal tugging (children)
- Retractions/indrawing (children)
- Nasal flaring (children)
Sputum
- Amount/viscosity/colour/etc.
Unexpected thoracic cage configuration: barrel chest
- AP diameter is equal to the TH diameter
Unexpected thoracic cage configuration: scoliosis
- Sideways curvature of the spine
Unexpected thoracic cage configuration: kyphosis
- Older persons
- Curvature of the thoracic spine
- “hunch back”
Unexpected thoracic cage configuration: pectus excavatum
- A structural deformity of the anterior thoracic wall in which the sternum and rib cage are shaped abnormally
Unexpected thoracic cage configuration: pectus carinatum
- A rare chest wall deformity that causes the breastbone to push outward instead of being flush against the chest
Palpation of respiratory system
General
- Lumps, masses, bruising, skin temperature, moisture
Symmetrical chest expansion
- Have client take deep breath and want to expand symmetrical when big breath in
- Non-symmetrical could in indicate of pneumonia, lung collapse, fractured rib,
Tactile fremitus
Tactile fremitus
- Tactile vibration we can feel
- As we ask the client to say something the sound is transmitted and felt as a vibration
- “99” or “blue moon” to produce a strong vibration sound
- The amount of fremitus is different between people
- Looking for symmetry between different spots
- Position 2 might feel strong vibrations of the right because it is closer to the bronchial vibrations than the left
- Want to stay within the inferior boarders of the scapula, it will dull the vibrations
- A decreased vibrations tells us there’s something in the lung that blocking the transmission
- Consolidation of lung tissue; means it’s now denser
Pleural effusion
- Too much fluid between the pleural space
Pneumothorax
- Too much air in the plural cavity
Consolidation of the lung tissue: pneumonia
- Lung tissue become denser when we have pneumonia
- Alveoli becomes filled with pus, bacteria, blood cells, etc.
- Alveolar cells become dense and filled with tissue
- Amplifies the sound or increases the vibration during assessment
Crepitus
- Feels like bubble wrap under the skin
- Air has leaked into the subcutaneous tissue
- Post thoracic injury or surgery
- Or recent tube insertion
- Air has leaked in
Percussion of the respiratory system
- Method of tapping on a surface to determine the underlying structure
- Begin at apices and move downwards, always comparing side to side
Percussion notes:
- Resonance; air filled
- Hyperresonance; very air filled
- Dullness; over an organ, over bone, lung consolidation
- Tympany; very hollow sound, over an empty stomach
Sequence for respiratory percussion
- Compare side to side
- Missing bone
- Snaking your way down
Expected percussion notes for respiratory assessment
Posterior
- Resonance over lungs
- Flat over scapula/spine, and ribs
- Visceral dullness over organs
- Liver dullness
Anterior
- Flat over muscle and bone
- Resonance over lungs
- Cardiac dullness
- Liver dullness
- Stomach tympany
Auscultation of the respiratory system
- Begin at apices and continue downward, comparing side to side
Expected Breath Sounds
- Bronchial (tracheal)
- Bronchovesicular
- Vesicular
Bronchial (tracheal) breath sound
- Up around trachea and larynx
- Inspiration phase seems less than the expiration phase
Bronchovesicular breath sound
- Over where we have the bronchi
- Inspiration sound equal to expirations phase
Vesicular breath sound
- All over the rest of the lung field
- Inspiration phase seems greater than expirations phase
Sequence for auscultation of respiratory system
- Start at top
- Compare sides
- Snake your way down
- 5 anteriorly
- 9 posteriorly
Expected breath sounds
Anterior
- Bronchial (tracheal) over throat
- Bronchovesicular in midline
- Vesicular over lungs
Posterior
- Bronchovesicular in midline upper
- Vesicular in lungs
Adventitious breath sounds: crackles
- Tells us there is fluid in the lungs
- Fine crackles; sounds like rubbing air between fingers
- Coarse crackles; sounds like 2 pieces of velcro being torn apart
Adventitious breath sounds: wheezes
- Tells us there’s airway narrowing (due to swelling, secretions, etc.) in the lower airway
- High pitched squeekier sound
- Document whether is inspiratory or expiratory; or it can be both
Adventitious breath sounds: rubs
- When the 2 layers of the pleural come inflamed and they rub together
- Sounds like 2 pieces of leather rubbing against each other
Adventitious breath sounds: stridor
- Narrowing of the upper airway (larynx or tracheal area)
- In children often due to lodged foreign body
- “whale sound”; high pitched sound
- Don’t often need stethoscope to listen for; can hear when you walk into the room
Auscultation abnormal/unexpected breath sounds
Diminished, decreased or absent sounds
- Can’t hear air all the way down; something may be blocking the transmission of air all the way down
- Can be decreased or totally absent
Increased sounds
- Increased transmission found with pneumonia
Consolidation testing: voice sounds
Bronchophony
- “Ninety-nine”
- Expected; you can hear sound but cannot distinguish exactly what is being said
- Unexpected; you auscultate a clear “99”
Egophony
- “eeeeeee”
- Expected; you hear “eeeee”
- Unexpected; you auscultate “aaaaaa”
Whispered pectoriloquy
- Whispered phrase such as “one, two, three”
- Expected; what you hear is faint, muffled, almost inaudible
- Unexpected; whispered voice is transmitted clearly and distinctly
Pulse oximetry
- Non-invasive assessment of arterial oxygen saturation (SpO2)
- Healthy range from 95-100% (or >98%)
- <90% requires action
- Look at patient; how are the looking when their SpO2 has dropped, are they okay?
