Respiratory

assessment
Introduction

A comprehensive respiratory assessment includes physical examination and

diagnostic tests that provide information about respiratory function. Diagnostic
tests can be used to explore potential disease states. Common respiratory
diagnostic tests include pulse oximetry, blood gas analysis, chest x-ray,
pulmonary function tests, and thoracic CT and MRI scans.
However, bedside clinical assessment provides vital information about
respiratory function. It is important for nurses in all practice settings to be able
to perform a basic respiratory assessment. This includes taking a patient
history, and using the techniques of inspection, palpation, percussion, and
auscultation. This course reinforces these techniques, as they are available
for bedside assessment.
Respiratory Structure

The respiratory system is essential for life. Normal lung function requires a
balanced interrelationship between the respiratory, nervous, and
cardiovascular systems. The brain receives and sends out stimuli to maintain
a normal oxygen and carbon dioxide balance. The medulla and the pons are
the major brain centers that affect respiration. The body's respiratory center in
the medulla is normally stimulated by an increased concentration of carbon
dioxide, and to a lesser extent, by decreased levels of oxygen in arterial
blood. Stimulation of the respiratory center causes an increase in the rate and
depth of breathing, thus blowing off excess carbon dioxide and reducing blood
acidity. The heart pumps oxygenated blood from the left side of the heart
through the arterial circulation to all parts of the body. Oxygen is transported
primarily in red blood cells. As oxygen is used by cells, unoxygenated blood
containing carbon dioxide returns to the heart and lungs through the venous
circulation.

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The medulla is one of the major brain centers affecting respiration.
 True

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The thoracic cavity is made up of 12 pairs of ribs that connect in the posterior
thorax to the vertebral bodies of the spinal column. The lungs lie within the
thoracic cavity on either side of the heart, extending from the diaphragm to
just above the clavicles or collarbones. Light, spongy and elastic structures,
the lungs inflate with inspiration and deflate, but do not completely collapse,
with expiration. The right lung is shorter and wider than the left lung. Each
lung is divided into lobes – the right lung has three lobes; the left lung has two
lobes. The lung's lobes are further divided into segments. The pleurae are
membranes that cover each lung and line the thoracic cavity. The visceral
pleura are serous membranes that cover the outer surface of each lung. The
parietal pleura line the inner rib cage and upper surface of the diaphragm. The
smooth opposing surfaces of the pleura, lubricated by pleural fluid, allow the
lungs to move easily within the rib cage during inspiration and expiration. The
pleural space is the potential space between the visceral and parietal pleurae.

Instant Feedback:
Which lobes of the lung are most accessible when examining the patient's back?

Left and right upper lobes

Left and right lower lobes

Respiratory Function

Gasses are able to move in and out of the lungs through muscular energy
exerted on the thorax and changes between intrathoracic and atmospheric
pressures. The pressure within the lungs and thorax must be less than
atmospheric pressure for inspiration to occur. Air then flows from an area of
higher pressure to one of lower pressure. As the diaphragm and intercostal
muscles work to increase the size of the thorax, intrathoracic pressure
decreases below atmospheric pressure and air moves into the lungs. During
exhalation, the inspiratory muscles relax, and the elastic recoil of the lung
tissues, combined with a rise in intrathoracic pressure, causes air to move out
of the lungs
The diaphragm, a dome shaped structure that separates the thoracic and
abdominal cavities, is the major muscle of respiration. The phrenic nerve
innervates the diaphragm. The external and internal intercostal muscles
elevate the ribs, increasing the anterior-posterior diameter of the thoracic
cavity. Breathing may need to be assisted by other muscles, known as
secondary or accessory muscles of respiration. These muscles may include
the parasternal, scalene, sternocleidomastoid, trapezius, and pectoralis
muscles. Accessory respiratory muscles do not function during normal
ventilation, but may be needed in some respiratory disorders.

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The diaphragm is the major muscle of respiration and is innervated by the
phrenic nerve.

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Structures in the respiratory conduction system help conduct air into the lungs
where the exchange of oxygen and carbon dioxide takes place. The
respiratory conduction system is divided into the upper and lower airways.
• The upper airway consists of the nose, pharynx, epiglottis, and larynx.
The upper airway structures protect the lower airway from foreign
materials, and warm, filter, and humidify inspired air.
• Lower airway structures include the trachea, left and right mainstem
bronchi, segmental bronchi, and terminal bronchioles. The lower airway
structures conduct air through the many branches of the respiratory tree
to the alveolar level where gas exchange takes place. Gas exchange
takes place in the alveoli, small air sacs at the end of the respiratory
bronchioles.
Carbon dioxide must be eliminated on a continuous basis to maintain the
body's acid-base balance. Acid-base balance is controlled by chemoreceptors
located near the respiratory center that are sensitive to changes in the pH of
cerobrospinal fluid. When ventilation is inadequate, the pH drops and the
carbon dioxide level rises. The rise in carbon dioxide stimulates the respiratory
center to increase the rate and depth of respirations to remove excess carbon
dioxide.

If hypoventilation becomes chronic, as in patients with chronic obstructive

pulmonary disease (COPD), chemoreceptors lose their sensitivity and
respond to increases in carbon dioxide levels inadequately. When central
chemoreceptors fail, peripheral chemoreceptors attempt to regulate
respiratory function and restore acid-base balance. Peripheral
chemoreceptors are sensitive to the amount of oxygen in peripheral blood.
Therefore, the patient's stimulus to breathe is no longer an increase in carbon
dioxide levels, but from a low oxygen level sensed by peripheral
chemoreceptors. If the blood oxygen level is increased significantly by giving
supplemental oxygen, the peripheral chemoreceptors will not stimulate
breathing, resulting in apnea. This alteration in physiologic function is the
reason that patients with COPD are given supplemental oxygen at very low
levels.

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Gas exchange takes place in the bronchioles.

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Anatomic Landmarks

It is important to review the anatomy of the chest wall and thoracic cavity, as
you will use anatomic landmarks to document the location of respiratory
assessment findings.
The thoracic cavity is made up of 12 pairs of ribs that connect in the posterior
thorax to the vertebral bodies of the spinal column. In the anterior thorax, the
first 7 pairs of ribs are attached to the sternum or breastbone by cartilage. The
lower 5 ribs do not attach to the sternum. The 8th, 9th, and 10th ribs are
attached to each other by costal cartilage. The 11th and 12th ribs, known as
“floating ribs,” are not attached in any way to the sternum; they move up and
down in the anterior chest, allowing for full chest expansion.
 Please review the important landmarks of the bony thoracic anatomy.

The following diagram shows the anterior chest again, with the lobes of the
lungs included. Various reference lines and angles are commonly used to
identify respiratory findings. For example:
• The angle of Louis (also called the sternal angle) is a useful place to
start counting ribs, which helps localize a respiratory
finding horizontally. If you find the sternal notch, walk your fingers
down the manubrium a few centimeters until you feel a distinct bony
ridge. This is the sternal angle. The 2nd rib is continuous with the
sternal angle; slide your finger down to localize the 2nd intercostal
space. The angle of Louis also marks the site of bifurcation of the
trachea into the right and left main bronchi and corresponds with the
upper border of the atria of the heart.
• Reference lines help pinpoint findings vertically. For example, the
major division ("fissure") between lobes in the anterior chest crosses the
5th rib in midaxillary line and terminates at the 6th rib in the
midclavicular line.
Other terms used to document locations for chest physical assessment
include:
• Supraclavicular - above the clavicles
• Infraclavicular - below the clavicles
• Interscapular - between the scapulae
• Infrascapular - below the scapulae
• Bases of the lungs - the lowermost portions
• Upper, middle, and lower lung fields
Taking a Respiratory History

Start your respiratory assessment by interviewing the patient and conducting

a respiratory history. Starting the assessment with an interview helps you
establish rapport with the patient and may lessen the patient's anxiety. During
the history, you will be gathering information about the patient's current and
any previous respiratory problems. You may interview the patient, and in some
cases, family members or significant others. When doing your assessment,
keep in mind these six important respiratory symptoms:
 • cough,
• sputum production,
• dyspnea,
• hemoptysis,
• chest pain, and
• wheezing.
The following questions may be useful in taking a respiratory history:
• Are you having any trouble breathing?
• Do you have any chest pain with breathing? If so, what is the pain like,
when does it occur, and what relieves it?
• Do you have a cough? If yes, what does the cough sound like, when
does it occur, do you bring up any phlegm (sputum) when you cough,
what does the phlegm look like? Normal sputum is thin, clear to white in
color, and tasteless and odorless. Yellow-green colored sputum may
indicate a bacterial infection and rust-colored sputum is characteristic of
pneumonia.
• Are you ever short of breath? If so, does your shortness of breath occur
at rest or with activity? Ask the patient specific questions about
shortness of breath that impacts daily living, such as being able to carry
groceries from a car, or being able to clean floors or do laundry.
• Do you have any problems breathing at night? If so, do you use pillows
to help you get in a position to breathe easier?
• Do you have any allergies? If yes, how does your allergy affect your
breathing?
• Do you smoke now or have you ever smoked? If yes, how many years
did you smoke and how many packs of cigarettes did you smoke daily?
• What kind of work do you do/did you do? In your work are/were you
exposed to substances such as asbestos, chemicals, or cigarette
smoke?
• Do you have a personal or family history of asthma, tuberculosis, lung
cancer, cystic fibrosis, bronchitis, emphysema, or any other lung
disease?
Answers to these questions provide you with important information about the
patient's current problem and background data that could be contributing
factors to respiratory disease. Conduct the assessment in a comfortably warm
room. Ask the patient to sit upright. During all aspects of the assessment,
observe for fatigue or discomfort. Allow the patient time to rest if necessary.
In taking a history for an infant, ask the parents about any episodes of
respiratory distress, cyanosis, apnea, sudden infantdeath syndrome (SIDS) in
a sibling or other family member, exposure to passive smoke, or a history of
prematurity orm echanical ventilation. In taking a history for a child, ask
parents about any asthma history, including factors related to asthma
epidoses, adequacy of asthma treatment, and whether or not the child has a
history of night coughing, swollen lymphnode s, sore throat, or facial pain.
If the patient is an older adult, ask the patient whether or not he or she has
had an annual flu immunization and pneumonia vaccine. Ask about any recent
changes in exertional capacity, fatigue, a change in the number of pillows
needed to sleep at night, any significant weight change, or a history of night
sweats, or hand or leg swelling.
After the interview is completed, proceed in an orderly fashion by following the
steps of respiratory physical assessment:
• inspection,
• palpation,
• percussion, and
• auscultation.

Instant Feedback:
It is helpful to ask the patient specific questions about activity level and breathing based
on daily life activities.

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Inspection

With the patient sitting, examine the patient's anterior and posterior chest.
Chest inspection allows you to see visible external signs of respiratory
function. Assess the front, back, and sides of the chest for any scars, wounds,
or lesions. Look for symmetry of chest wall movement. Observe the duration
of the inspiratory/expiratory cycle. Prolonged expiration occurs when an
individual has difficulty expelling air, as is often seen in patients with
emphysema. Note the patient's respiratory pattern and breathing rhythm. In a
healthy adult, inaudible respirations should occur between 12 and 20 times
each minute. Look to see if the patient uses accessory muscles of respiration.
Observe for intercostal retractions, nasal flaring, or pursed lip breathing, all of
which indicate airflow obstruction and poor ventilation. Intercostal retractions
are visible indentations between the ribs as the intercostal muscles aid in
breathing. Nasal flaring describes intermittent outward movements of the
nostrils with each inspiration. Pursed lip breathing refers to partial closure of
the lips to allow air to be expired slowly.
Inspect the neck for contraction of the sternocleidomastoid or
other accessory muscles of respiration during inspiration. Normally, none
of these signs are present. Look at the patient's posture. A patient with chronic
obstructive pulmonary disease (COPD) will lean forward and prop himself up
with his arms to improve breathing. Postural changes may also be seen with
thoracic deformities such as scoliosis and kyphosis. Observe the patient's
level of consciousness. Confusion or changes in mental status are important
signs of potential respiratory problems.

Instant Feedback:
Intercostal retractions, nasal flaring, and pursed lip breathing indicate airflow obstruction
and poor ventilation.

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Note the patient's age and it's impact on respiratory function. As people age,
their capacity for exercise decreases. The chest wall becomes stiffer and
harder to move, respiratory muscles may weaken, and the lungs lose some of
their elastic recoil. The speed of breathing out with maximal effort gradually
decreases. Skeletal changes associated with aging may accentuate the dorsal
curve of the thoracic spine, producing kyphosis and increasing the anterior-
posterior diameter of the chest.
In any health care setting, you can use some practical ways of assessing
concerns about shortness of breath in a patient who can ambulate. One
simple and useful assessment method is to walk with the patient down a
hallway or from one room to another or ask the patient to perform an activity
such as climbing stairs. By observing the patient doing these activities, you
can observe changes in the rate, effort, and sounds of the patient's respiratory
pattern. Assessing forced expiratory time is another practical means of
observing respiratory function, especially in a patient who may have COPD.
Ask the patient to take a deep breath in and then to breathe out as quickly and
completely as possible, with the mouth open. While the patient is doing a
forced expiration, listen over the trachea and time the audible expiration. A
forced expiratory time of over 6 seconds suggests obstructive pulmonary
disease.
Normal findings for chest inspection include:
• Side to side symmetric chest shape
• Distance from the front to the back of the chest (anterior-posterior
diameter) less than the size of the chest from side to side (transverse
diameter)
• Normal chest shape, with no visible deformities, such as a barrel
chest, kyphosis, or scoliosis
• No muscle retractions when breathing
• Quiet, unlabored respirations with no use of accessory, neck, shoulder,
or abdominal muscles
• A regular respiratory rhythm, with expiration taking about twice as long
as inspiration
• Skin color that matches the rest of the body's complexion
• A respiratory rate of 12-20 in an adult
Infants and children have faster respiratory rates than adults. A normal
respiratory rate for a newborn ranges from 30 to 60 breaths per minute. By
one year of age, the respiratory rate drops to between 20 and 40 per minute.
The respiratory rate continues to drop as a
child ages. By approximately age 16, a teenager has a respiratory rate similar
to that of an adult.
Rapid, shallow breathing is called tachypnea. Tachypnea is seen in patients
with restrictive lung disease such as kyphosis, and in situations where pleuritic
chest pain prohibits full expansion of the chest wall. Restrictive lung disease
refers to changes in the chest structure that prohibit full chest expansion.
Rapid deep breathing, known as hyperpnea or hyperventilation, occurs as a
result of physical exercise, anxiety, and metabolic acidosis. Kussmal breathing,
characterized by slow, deep breaths, occurs in patients with diabetic acidosis
and coma. Bradypnea, or a much slower than normal respiratory rate, is seen
in patients with drug-induced respiratory depression, and increased
intracranial pressure. Cheyne-Stokes breathing occurs when there are periods of
deep breathing alternating with periods of apnea. A Cheyne-Stokes breathing
pattern may be seen in a patient with heart failure, drug-induced respiratory
depression, uremia, or brain damage. Ataxic breathing, also known as Biot's
breathing, is characterized by unpredictable irregularity. Biot's breathing may
be seen in patients with respiratory depression and brain damage at the level
of the medulla.

Instant Feedback:
A rapid respiratory rate or tachypnea may be seen in patients with restrictive lung
disease or in patients with pleuritic chest pain.

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Palpation

Palpation is an assessment technique in which the examiner uses the surface

of the fingers and hands to feel for abnormalities. Assessment data that can
be obtained through palpation includes identifying chest movement symmetry,
chest skeletal abnormalities, tenderness, skin temperature changes, swelling,
and masses.
To assess the symmetry of chest expansion during breathing, stand behind
the person, and place your hands with fingers spread apart beneath his or her
arms, on the sides of the chest, about 2 inches below the axilla. Your fingers
should be pointing toward the anterior chest - this will let you feel the chest
rising and falling on inspiration and expiration. Ask the person to breathe out
completely – observe your hands and thumbs to see that they have moved
equally on both sides.
After checking for symmetrical chest expansion, feel for tactile fremitus.
Fremitus refers to vibratory tremors that can be felt through the chest by
palpation. To assess for tactile fremitus, ask the patient to say “99” or “blue
moon”. While the patient is speaking, palpate the chest from one side to the
other. Tactile fremitus is normally found over the mainstem bronchi near the
clavicles in the front or between the scapulae in the back. As you move your
hands downward and outward, fremitus should decrease. Decreased fremitus
in areas where fremitus is normally expected indicates obstruction,
pnemothorax, or emphysema. Increased fremitus may indicate compression
or consolidation of lung tissue, as occurs in pneumonia.
Normal findings on palpation include:
 • normal chest size and shape,
• warm, dry skin,
• no tender spots,
• symmetrical chest expansion, and
• tactile fremitus over the mainstem bronchi in front and between the
scapulae in the back of the chest.

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Tactile fremitus is always an abnormal assessment finding.

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Percussion

Percussion is an assessment technique which produces sounds by the

examiner tapping on the patient's chest wall. Just as lightly tapping on a
container with your hands produces various sounds, so tapping on the chest
wall produces sounds based on the amount of air in the lungs. Percussion
sets the chest wall and underlying tissues into motion, producing audible
sounds and palpable vibrations. Percussion helps to determine whether the
underlying tissues are filled with air, fluid, or solid material.
Percussing the anterior chest is most easily done with the patient lying supine;
the patient should sit when percussing the posterior chest. Place the first part
of the middle finger of your nondominant hand firmly on the patient's skin.
Then, strike the finger placed on the patient's skin with the end of the middle
finger of your dominant hand. Watch a video segment of percussion technique.
Work from the top part of the chest downward, comparing sounds heard on
both the right and left sides of the chest. Visualize the structures underneath
as you proceed.
Look at the following diagram that shows percussion notes on the posterior
chest:
 Resonant sounds are low pitched, hollow
sounds heard over normal lung tissue.
Flat or extremely dull sounds are normally
heard over solid areas such as bones.

Dull or thudlike sounds are normally heard over dense areas such as the heart or
liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing
lung tissues, such as occurs with pneumonia, pleural effusions, or tumors.
Hyperresonant sounds that are louder and lower pitched than resonant sounds are
normally heard when percussing the chests of children and very thin adults.
Hyperresonant sounds may also be heard when percussing lungs hyperinflated with
air, such as may occur in patients with COPD, or patients having an acute asthmatic
attack. An area of hyperresonance on one side of the chest may indicate a
pneumothorax.
Tympanic sounds are hollow, high, drumlike sounds. Tympany is normally heard
over the stomach, but is not a normal chest sound. Tympanic sounds heard over the
chest indicate excessive air in the chest, such as may occur with pneumothorax.

Instant Feedback:
The normal sound expected on percussion throughout most of the lung fields is resonance.

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Auscultation

Auscultation is the technique of listening to the sounds of the chest with a

stethoscope. The movement of air in and out of the respiratory system
produces breath sounds. Breath sounds are transmitted through the chest
wall and may be heard through the diaphragm (flat piece) of a stethoscope
placed firmly against the chest wall. Auscultation of the lungs is the most
important examining technique for assessing airflow through the
tracheobronchial tree.
Ask the patient to sit with his arms folded across the chest with the hands
resting, if possible, on the opposite shoulders. This position moves the
scapulae partly out of the way and increases access to the lung fields. Instruct
the patient to breathe deeply with his mouth open. Listen carefully for at least
one full breath in each location. Observe the patient for light-headedness or
fatigue and allow the patient to rest as often as necessary.
Start by listening to posterior chest, beginning with the areas above the
scapulae. It is useful to start here because the lung fields are closer to the wall
of the posterior chest and there's less interference from heart sounds than
with the anterior chest. Move downward in a stair-step fashion, comparing
your findings from one side with those from the other side. Chest auscultation
involves:
• Listening for the sounds generated by normal breathing
• Listening for any adventitious or added sounds
• If abnormalities are detected, listening to the sounds of the patient's
spoken or whispered voice as they are transmitted through the chest
wall
Normal Breath Sounds

Normal breath sounds are classified as tracheal, bronchial, bronchovesicular,

and vesicular sounds. The patterns of normal breath sounds are created by
the effect of body structures on air moving through airways. In addition to their
location, breath sounds are described by:
• duration (how long the sound lasts),
• intensity (how loud the sound is),
• pitch (how high or low the sound is), and
• timing (when the sound occurs in the respiratory cycle).
Tracheal breath sounds are heard over the trachea. These sounds are harsh
and sound like air is being blown through a pipe.
Bronchial sounds are present over the large airways in the anterior chest
near the second and third intercostal spaces; these sounds are more tubular
and hollow-sounding than vesicular sounds, but not as harsh as tracheal
breath sounds. Bronchial sounds are loud and high in pitch with a short pause
between inspiration and expiration; expiratory sounds last longer than
inspiratory sounds.
Bronchovesicular sounds are heard in the posterior chest between the
scapulae and in the center part of the anterior chest. Bronchovesicular sounds
are softer than bronchial sounds, but have a tubular quality. Bronchovesicular
sounds are about equal during inspiration and expiration; differences in pitch
and intensity are often more easily detected during expiration.
Vesicular sounds are soft, blowing, or rustling sounds normally heard
throughout most of the lung fields. Vesicular sounds are normally heard
throughout inspiration, continue without pause through expiration, and then
fade away about one third of the way through expiration.
In a normal air-filled lung, vesicular sounds are heard over most of the lung
fields, bronchovesicular sounds are heard between the 1st and 2nd interspaces
on the anterior chest, bronchial sounds are heard over the body of the
sternum, and tracheal sounds are heard over the trachea.
Normal findings on auscultation include:
• Loud, high-pitched bronchial breath sounds over the trachea
• Medium pitched bronchovesicular sounds over the mainstream bronchi,
between the scapulae, and below the clavicles
• Soft, breezy, low-pitched vesicular breath sounds over most of the
peripheral lung fields.
Abnormal Breath Sounds

Abnormal breath sounds include:

• the absence of sound and/or
• the presence of "normal" sounds in areas where they are normally not
heard.
○ For example, bronchial (loud & tubular) breath sounds are abnormal
in peripheral areas where only vesicular (soft & rustling) sounds
should be heard. When bronchial sounds are heard in areas
distant from where they normally occur, the patient may
have consolidation (as occurs with pneumonia) or compression
of the lung. These conditions cause the lung tissue to be dense.
The dense tissue transmits sound from the lung bronchi much
more efficiently than through the air-filled alveoli of the normal
lung.
The term “adventitious” breath sounds refers to extra or additional sounds
that are heard over normal breath sounds. Sources differ as to the
classification and nomenclature of these sounds, but most examiners
commonly use the following terms to describe adventitious breath sounds.
• crackles (or rales)
• wheezes (or rhonchi)
• pleural friction rubs
• stridor
Detection of adventitious sounds is an important part of the respiratory
examination, often leading to diagnosis of cardiac and pulmonary conditions.
Crackles (or rales) are caused by fluid in the small airways or atelectasis.
Crackles are referred to as discontinuous sounds; they are intermittent,
nonmusical and brief. Crackles may be heard on inspiration or expiration. The
popping sounds produced are created when air is forced through respiratory
passages that are narrowed by fluid, mucus, or pus. Crackles are often
associated with inflammation or infection of the small bronchi, bronchioles,
and alveoli. Crackles that don't clear after a cough may indicate pulmonary
edema or fluid in the alveoli due to heart failure or adult respiratory distress
syndrome (ARDS).
• Crackles are often described as fine, medium, and coarse.
• Fine crackles are soft, high-pitched, and very brief. You can simulate
this sound by rolling a strand of hair between your fingers near your ear,
or by moistening your thumb and index finger and separating them near
your ear.
• Coarse crackles are somewhat louder, lower in pitch, and last longer
than fine crackles. They have been described as sounding like opening
a Velcro fastener.
Wheezes are sounds that are heard continuously during inspiration or
expiration, or during both inspiration and expiration. They are caused by air
moving through airways narrowed by constriction or swelling of airway or
partial airway obstruction.
• Wheezes that are relatively high pitched and have a shrill or squeaking
quality may be referred to as sibilant rhonchi. They are often heard
continuously through both inspiration and expiration and have a musical
quality. These wheezes occur when airways are narrowed, such as may
occur during an acute asthmatic attack.
• Wheezes that are lower-pitched sounds with a snoring or moaning
quality may be referred to as sonorous rhonchi. Secretions in large
 airways, such as occurs with bronchitis, may produce these sounds;
they may clear somewhat with coughing.
• Pleural friction rubs are low-pitched, grating, or creaking sounds that
occur when inflamed pleural surfaces rub together during respiration.
More often heard on inspiration than expiration, the pleural friction rub is
easy to confuse with a pericardial friction rub. To determine whether the
sound is a pleural friction rub or a pericardial friction rub, ask the patient
to hold his breath briefly. If the rubbing sound continues, its a pericardial
friction rub because the inflamed pericardial layers continue rubbing
together with each heart beat - a pleural rub stops when breathing
stops.
Stridor refers to a high-pitched harsh sound heard during inspiration.. Stridor
is caused by obstruction of the upper airway, is a sign of respiratory distress
and thus requires immediate attention.
If adventitious sounds are heard, it is important to assess:
• their loudness,
• timing in the respiratory cycle,
• location on the chest wall,
• persistence of the pattern from breath to breath, and
• whether or not the sounds clear after a cough or a few deep breaths.
○ secretions from bronchitis may cause wheezes, (or rhonchi), that
clear with coughing
○ crackles may be heard when atelectatic alveoli pop open after a
few deep breaths
Instant Feedback:
Rhonchi are discontinuous popping sounds heard during inspiration.

True

False
Instant Feedback:
The adventitious sound heard in the upper apices of the lungs in this case are best
described as:
 Rhonchi

Wheezes

Crackles

Stridor

Transmitted Voice Sounds

If you hear adventitious sounds on auscultation, assess how these sounds change as
the patient speaks. Voice assessment can provide important clues about respiratory
abnormalities. Normal lungs are filled with air, and air does not transmit sound
readily. Normally, transmitted voice sounds are difficult to hear – spoken words are
muffled and indistinct and whispered words are usually not heard at all.
However, when substances such as fluid or solid masses replace air in the lungs,
sounds are transmitted more clearly. The sounds that can be assessed are:
• Whispered pectoriloquy: Ask the patient to whisper a
sequence of words such as “one-two-three”, and listen with a
stethoscope. Normally, only faint sounds are heard. However,
over areas of tissue abnormality, the whispered sounds will be
clear and distinct.
• Bronchophony: Ask the patient to say "99" in a normal voice.
Listen to the chest with a stethoscope. The expected finding is
that the words will be indistinct. Bronchophony is present if
sounds can be heard clearly.
• Egophony: While listening to the chest with a stethoscope,
ask the patient to say the vowel “e”. Over normal lung tissues,
the same “e” (as in "beet") will be heard. If the lung tissue is
consolidated, the “e” sound will change to a nasal “a” (as in
"say").
Assessment findings include:
Inspection • relaxed posture
• normal musculature
• rate 10 - 18 breaths per minute, regular
 • no cyanosis or pallor
• anteroposterior diameter less than transverse diameter
• symmetric chest expansion
Palpation
• tactile fremitus present and equal bilaterally
Percussion • resonant
• vesicular over peripheral fields
• bronchovesicular over sternum (anterior) and between scapulae
Auscultation (posterior)
• infant and child - bronchovesicular throughout
• no adventitious sounds
Atelectasis: In this condition, an area of the lung or an entire lung collapses.
Atelectasis may be due to airway obstruction, or compression of the lung. In the
diagram above, an obstruction blocks the airway, causing the associated alveoli to
collapse and that area of the lung to shrink. Any alveolar air beyond the obstruction
becomes absorbed by the pulmonary capillaries, and the alveolar walls cave in.
Assessment findings include:
• cough
• delayed chest expansion on the affected side
Inspection • increased respiratory rate
• increased pulse
• possible cyanosis
• chest expansion decreased on the affected side
• tactile fremitus decreased or absent over the involved area
Palpation
• with a large collapse, the trachea may deviate or shift toward
the affected side.
Percussion • dull over affected area
• breath sounds decreased or absent over involved area
Auscultation • no adventitious sounds if bronchus is obstructed
• occasional fine crackles if bronchus is patent
Bronchitis: Inflammation of the bronchi with partial obstruction of the bronchi by
secretions or constriction. Bronchitis may be acute or chronic with a productive cough.
Chronic bronchitis is associated with cigarette smoking. In the diagram above,
secretions (produced by proliferation of mucous glands) are obstructing the
passageway, resulting in deflation of the alveoli beyond the obstruction.
Assessment findings include:
• hacking cough with thick sputum
Inspection • chronic bronchitis produces dyspnea, fatigue, possible
clubbing of fingers
Palpation • tactile fremitus normal
Percussion • resonant
• normal vesicular breath sounds
• voice sounds normal.
Auscultation
• Prolonged expiration may be present with chronic bronchitis
• May have wheeze, or crackles over deflated areas

Emphysema: Assessment

Chronic obstructive pulmonary disease (COPD) refers to a group of

progressive respiratory diseases, including both chronic bronchitis and
emphysema. Approximately 117,000 Americans die from COPD each
year,making it the 4th leading cause of death in the U.S. Of the country's ten
leading causes of death, COPD is the only decease in which the morality rate
is increasing.
In the early phase of COPD, patients may experience wheezing, chronic
productive cough, and minimal shortness of breath. However, the person's
quality of life decreases as COPD progresses. Later symptoms include
increasing dyspnea, progressive exercise intolerance, periodic respiratory
infections that occur with increasing frequency and severity, increasing cough,
and purulent sputum.
Emphysema: Caused by destruction of pulmonary connective tissue, usually
by an inflammatory process and/or cigarette smoking. Air sacs distal to
terminal bronchioles become permanently enlarged, and interalveolar walls
are destroyed. The result is airway obstruction, particularly upon expiration.
Lungs become hyperinflated, and lung volume increased. The diagram
above shows tissue destruction throughout the lung, and overdistended
alveoli with destruction of septa.
Assessment findings include:
Inspection • increased anterior-posterior diameter, or "barrel chest"
• use of accessory muscles to assist breathing
• tripod position
 • shortness of breath common, especially on exertion
• tachypnea
• tactile fremitus decreased
Palpation
• chest expansion decreased.
Percussion • hyperresonant
• decreased vesicular breath sounds
• may have prolonged expiration
Auscultation
• muffled heart sounds from overdistention of lungs
• usually no adventitious sounds; occasional wheeze

Pleural Effusion: Assessment

Pleural effusion: Collection of fluid in the intrapleural space, with compression of
lung tissues. Fluid collects by gravity in dependent areas of the chest. The diagram
above, shows pleural fluid compressing lung tissue and alveoli.
Assessment findings include:
• increased respiratory rate
Inspection
• dyspnea
• tactile fremitus decreased or absent.
Palpation • chest expansion decreased on the affected side.
• tracheal shift away from affected side

Percussion • dull to flat

• breath sounds and voice sounds decreased or absent.

Auscultation • bronchial breath sounds and bronchophony, egophony, and
whispered pectoriloquy may be heard over the area of the lung that
is compressed near the effusion.

Pneumonia: Assessment
Pneumonia: An infection in lung tissues causes the alveoli to become swollen
and porous (as in the above diagram), so red and white blood cells move
from the bloodstream into the alveoli. The alveoli become filled, or
consolidated, with bacteria, fluid and blood cells that replace air.
Assessment findings include:
 • increased respiratory rate
• increased pulse rate
Inspection • guarding and lag on expansion on affected side
• children with pneumonia may have nasal flaring and/or
intercostal and sternal retractions
• chest expansion decreased on involved side
Palpation
• tactile fremitus is increased
Percussion • dull over affected area
• breath sounds louder than normal.
Auscultation • bronchophony, egophony, whispered pectoriloquy present
• Crackles, fine to medium

Instant Feedback:
A patient with pneumonia may be expected to have louder than normal breath sounds,
and increased tactile fremitus.

True

False

Pneumothorax: Assessment
Pneumothorax: Air in the pleural space causes partial or complete lung
collapse. Normally, the pleural space is under negative pressure; when air
enters, the negative pressure is neutralized, and the lung collapses.
Pneumothorax can be caused by trauma, causing air to enter through an
opening in the chest wall, or may be spontaneous, causing air to enter the
pleural space through a rupture in the lung wall. Tension pneumothorax
occurs when air trapped in the pleural space increases, compressing the lung
and shifting the mediastinum to the unaffected side.
Assessment findings include:
• unequal chest expansion.
Inspection • with a large pneumothorax, the patient will have increased
respiratory rate, increased heart rate, anxiety, bulging
interspaces, and possibly cyanosis
Palpation • tactile fremitus decreased or absent.
 • tracheal shift to the unaffected side of the chest.
• chest expansion decreased on the affected side.
Percussion • hyperresonant
• breath sounds decreased or absent
Auscultation
• voice sounds decreased or absent

Glossary

Accessory muscles of respiration – muscles other than the diaphragm and

intercostal muscles that may be used for labored breathing. The
sternocleidomastoid, spinal, and neck muscles may be used as accessory
muscles of respiration; their use is a sign of an abnormal or labored breathing
pattern.
Adventitious breath sounds – abnormal breath sounds heard when listening
to the chest. Adventitious sounds may include crackles or rales, rhonchi or
wheezes, or pleural friction rubs. Adventitious sounds do not include sounds
produced by muscular activity in the chest wall or noises made by a
stethoscope on the chest wall.
Ataxic breathing – also known as Biot's breathing, is characterized by
unpredictable irregularity.
Barrel chest – a condition characterized by increased anterior-posterior chest
diameter caused by increased functional residual capacity due to air trapping
from small airway collapse. A barrel chest is frequently seen in patients with
chronic obstructive diseases, such as chronic bronchitis and emphysema.
Cheyne-Stokes respirations – a breathing pattern characterized by a period
of apnea, followed by gradually increasing depth and frequency of
respirations.
Consolidation – the replacement of air in the lungs with fluid or a mass.
Crackles – an adventitious breath sound heard on ausculating the chest,
produced by air passing over airway secretions. A crackle is a discontinuous
sound, as opposed to a wheeze, which is continuous. Crackles are known as
fine or coarse and are also known as rales.
Fremitus – a vibration felt while a patient is speaking and the examiner's
hand is held against the chest.
Intercostal retractions – visible use of the muscles between the ribs
(intercostal muscles) to aid in breathing. Intercostal retractions are a sign of
labored breathing.
Kussmal breathing – a very deep gasping type of respiration associated with
severe diabetic acidosis and coma.
Kyphosis – a deformity in the normal posterior shape of the spine, producing
a humpback appearance.
Nasal flaring – intermittent outward movements of the nostrils with each
inspiration; indicates an increase in the work needed to breathe.
Pleura – a serous membrane covering both lungs and the walls of the thorax
and diaphragm.
Pursed lip breathing – partial closing of the lips to allow air to be expired
slowly; used by patients with chronic obstructive pulmonary disease.
Sibilant rhonchi – a high pitched wheeze; musical and squeaky adventitious
breath sound.
Scoliosis – a lateral curvature of the spine.
Sonorous rhonchi - a lower pitched wheeze; snoring or moaning
adventitious breath sound.
Stridor – a high-pitched harsh sound heard during inspiration. Stridor is
caused by obstruction of the upper airway.
Wheeze - an adventitious or abnormal breath sound heard when listening to
the chest as a person breathes. Wheezes are continuous and musical
sounding, and usually caused by airway obstruction from swelling or
secretions. Wheezes can be high or low pitched, and are also known as
rhonchi.