Respiratory Assessment Flashcards
Upper Airways
- Mouth & oropharynx (open space behind the mouth)
- Nose & nasopharynx (open space behind the nose)
- Pharynx
- Larynx
Lower Airways
- Trachea
- Carina
- Bronchi
- Terminal Bronchioles
Larynx
- vocal cords
- cartilage structure that help prevent collapse
Laryngeal pharynx
- open space behdin parynx
- made up of oropharynx, nasopharynx and laryngeal pharynx
Epiglottis
flap that covers larynx during swallowing to prevent aspiration
Trachea
large tube connecting larynx to bronchi, cartilage keeps the airway patent and clear
Carina
bifurcation points of trachea, extremely sensitive
Right Bronchi
more vertical than left, more likely to see aspiration on right bronchi
Terminal Bronchioles
- narrowing airways that slows down the air
Acinus
- respiratory bronchioles
- alveolar ducts
- alveolar sacs
- alveoli
Aveoli
- like a balloon, takes effort to get in but no effort to take them out
Made up of:
- Type 1 alveolar cells (structure)
- Type 2 alveolar cells (secrets surfactant)
- Alveolar macrophages (immune component that ingests foreign particulars)
Surfactant
lipoprotein that coats the inner surface of the alveolus
- lowers surface tension during expiration so that alveolus doesn’t collapse
Pleura
Double-walled sacs that hold alveoli
Made up of:
- Visceral pleura (inner layer closest to lungs)
- Parietal pleura (outer layer closest to thoracic cavity)
- Pleural space (contain small amount of fluid, allows for smooth, friction free movement)
Pleural effusion
Build up of excess fluid between layers of the pleura, caused by infection
- inflammation of the pleural layers lead to pleural friction rub (abnormal lung sound - low pitch grating noise)
Four Major Functions of the Respiratory System
- Supply oxygen to the body
- Remove CO2
- Maintain homeostasis (acid-base balance)
- Maintain heat exchange
Maintain blood pH level
Blood pH needs to be within a narrow range, outside of this range is fatal
Maintaining pH requires alteration of CO2 in blood
CO2 acts like ACID
hypoventilation - higher CO2, more acidic
hyperventilation - lower CO2, less acidic
Control of respirations
typically involuntary and mediated by the respiratory centre in the brain stem
breathing patterns change in response to varying levels of CO2 and O2 in blood
Stimulus to breathe
Normal stimulus to breathe is an increase in CO2 - hypercapnia
decrease in O2 also increases respirations - hypoxemia
Thoracic cavity
increase during inspiration
decrease during expiration
Thoracic Cage
- sternum
- 12 pairs of ribs
- 12 thoracic vertebrae
- diaphragm
Suprasternal notch
hollow u-shaped depression just above the sternum between clavicles
Sternum
- Manubrium of sternum
- body of sternum
- Xiphoid process
Manubriosternal angle (angle of Louis)
- distint bony ridge
- continuous with second rib
- marks the site of tracheal bifurcation into right and left main bronchi
Costal angel
should be 90 degrees or less
12 pairs of ribs
1st 7 ribs attach directly to sternum
ribs 8, 9, 10 attach to the ribs above cartilage (false ribs)
ribs 11 and 12 are floating ribs, can be felt during deep palpation
Vertebra prominens
C7, most bony protrusion
Spinous processes
aligns with their same-numbered ribs until T4
Inferior angle of scapula
lower tip is usually at the level of the seventh or eighth rib
T12
palpate midway between the spine and side to identify the free tip of the 12th rib
Anterior Reference Lines
Anterior axillary line
Midclavicular line
Midsternal line
Posterior Reference Lines
Scapular line (runs along interior angle of scapula) Vertebral line
Axillary Reference Lines
Anterior axillary line
Midaxillary line
Posterior axillary line
Lungs
Made up of:
- Mediastinum (middle column between L and R lungs)
- Right pleural cavity
- Left pleural cavity
Right lung is ____ because of ____
Left lung is ____ because of ____
R is shorter due to liver
L is narrower due to heart
Right oblique fissure
Left oblique fissure
5th rib midaxillary line to 6th rib midclavicular line
R separates RLL and RML
L separates LUL and LLL
Lobes of the Lungs (anterior)
mostly upper lobes
- top of lungs starts above the clavicle
Lobes of the Lungs (posterior)
mostly lower lobes
upper lobe: T1 to T3
lower lobe: T3 to T10 (expiration) or T12 (inspiration)
Lobes of the Lungs (right lateral)
Horizontal fissure
- separates RUL and RML
- 4th rib to 5th rib midaxillary
Right oblique fissue
- separates RML and RLL
- 5th rib midaxi to 6th rib midclavi
Dev Considerations
infants and children
- surfactant not present in sufficient amounts until 32 weeks gestation (injection may be given for infants born before 32 weeks)
- smaller size of airways and structures, easier to block these passages
- shorter distance, easier for upper resp infection to travel down
- immune system immaturity, immune system not fully mature until 5-6 yos
Dev Considerations
pregnancy
- decrease space for lung expansion, diaphragm elevates 4cm and increased awareness due to pressure
- increased circumference of thoracic cage
- increased O2 demand, increase tidal volume but same resp rate
Dev Considerations
aging adult
- costal cartilage calcification, more rigid
- decreased respiratory muscle strength, less easily inflated and deflated
- decreased elasticity within the lungs, collapse of alveoli and less surface area for gas exchange
- increase in small airway closure, increase risk of SOB
Subjective Respiratory Assessment
- cough (sputum, phlegm, hemoptysis)
- SOB (dyspnea, breathlessness)
- chest pain with breathing
- past history of resp infections
- smoking history
- environmental exposure
- self-care behaviours (immunization)
Hemoptysis
blood in sputum
Objective Respiratory Assessment - Inspection
- skin colour and condition
- nail beds
- thoracic cage (shape and configuration)
- respirations: rate, rhythm, depth, pattern
- WOB, position and facial expression
- LOC
- signs of distress
- sputum
Barrel chest
chest appears to be partially inflated all the time
- lateral width is the same as anterior/posterior view
- air getting trapped
Scoliosis
sideway curvature of the spine
Kyposis
excessive outward curve, rounding of the upper back, hunchback
Pectus excavatum
- structural deformity of the anterior thoracic wall
- produces a depression in sternum
Pectus carinatum
- rare chest wall deformity that cause breastbone to push outward
- sternum protrudes
- pigeon chest or keel chest
Signs of distress
Tracheal tugging
- suprasternal indrawing
Nasal flaring
Retractions/indrawing
Objective Respiratory Assessment - Palpation
- General (lumps, masses, temperature, tenderness, bruising, diaphoresis)
- Symmetrical chest expansion (anterior and posterior)
(asymmetry could suggest lung collapse, atelectasis, pneumonia, fractured rib) - tactile fremitus (tactile vibration, “ninety-nine)
- crepitus (bubble wrap under skin, air leaked into subcu tissue)
Decreased fremitus
anything obstructs transmission of vibrations (obstructed bronchus, pleural effusion, pneumothorax)
Increased fremitus
occurs with compression or consolidation of lung tissue (pneumonia)
- bronchus is patent and consolidation extends to the lung surface
Pneumothorax
collapsed lung, air leaks into the space between lung and chest wall
Pneumonia
consolidation of lung tissue
- alveoli become filled with pus, bacteria, blood cells
- tissue becomes denser
- makes vibrations more pronounced
Objective Respiratory Assessment - Percussion
- compare side to side
- percussion between ribs
Percussion notes: Resonance Hyperresonance (air filled) Dullness (liver, heart, over bone) Tympany (stomach)
Objective Respiratory Assessment - Auscultation
- compare side to side
Expected breath sounds:
Bronchial (tracheal) - around tracheal and larynx, inspiration < expiration [anterior]
Bronchovesicular - heard over main bronchi, inspiration = expiration
Vesicular - rest of lungs, inspiration > expiration
Adventitious Breath Sounds
a. Crackles (fluid in lungs)
- fine: hair between fingers
- coarse: velcro ripped apart
b. Wheezes (lower airway narrowing)
- high pitch squeaky sound
c. Rubs (inflamed pleural)
- leather rubbing
d. Stridor (narrowing of upper airway, in larynx or trachea, or foreign objects)
- whale sounds
Diminished or absent sounds
blockage of air transmission
Increased sounds
pus or secretion in alveoli
Special tests
Bronchophony “ninety-nine”
Egophony “eeeee”
Whispered pectoriloquy “one two three” (detect consolidation)
