Unit III:

Assessment of Thorax and

Lungs
Acknowledge By : Farzana Barkat Ali
Presenter By : Ali Hasnnain

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 Objectives
▪ Describe the components of health history that should be elicited during assessment of
respiratory system.
▪ Describe the following:
– Chest contour and symmetry
– Respiratory rate and pattern
– Tactile fremitus
– Chest expansion
– Density of lung fields
– Diaphragmatic excursion
– Auscultated lung sounds
 Assess the respiratory system including inspection, palpation, percussion and auscultation.
 Document findings.
 List the changes in respiratory system that are characteristics of aging process.

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 Anatomy and Physiology of Thorax and
Thoracic Cage
Lungs
The thoracic cage is a bony structure with a conical shape, defined by:
▪ Sternum – 3 parts: manubrium, body, and xiphoid process
▪ Ribs – 12 pairs
1st seven attach to the sternum
Ribs 8,9,&10 attach to the costal cartilage above
Ribs 11 & 12 are floating ribs
▪ 12 Thoracic vertebrae
▪ Diaphragm – the floor, separates the thoracic cavity from the abdomen

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 Anterior Thoracic Landmarks
1. Suprasternal notch: Hollow U shaped depression just
above sternum.

2. Sternum: The long flat bone in the upper middle of the

front of the chest. The sternum articulates (comes
together) with the cartilages of the first seven ribs and
with the clavicle (collarbone) on either side. The
sternum consists of three parts: the manubrium (the
upper segment of the sternum, a flattened, roughly
triangular bone), the corpus (body) of the sternum, and
the xiphoid process.

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3. Manubriosternal angle / Angle of Louis:
Where manubrium articulates with the body of the
sternum. It is the location of the second pair of ribs
and becomes a reference point for counting ribs
and intercostal spaces
Each intercostal space is numbered by the rib
above it.

4. Costal angle: The right and left costal margins

form an angle where they meet at the xiphoid
process,90 degree or less

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 Reference Lines
Used to pinpoint a finding vertically on the chest
Anteriorly:
Midsternal line and Midclavicular line .
Posterior chest :
Vertebral line and Scapular line .
Lateral side of thorax (Lift arm up):
Anterior axillary line, Midaxillary line and Posterior axillary line.

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 The Thoracic Cavity
The thoracic cavity consists of the
mediastinum and the lungs.
Mediastinum: is the middle section of
thoracic cavity containing :
Esophagus,
Trachea,
Heart and great vessels.

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 Lung Borders
▪ Lungs are two cone-shaped
▪ Anteriorly the apex is 3 or 4 cm above the
clavicle; and thee base rests on the
diaphragm at about 6th rib in MCL.
▪ Laterally lung tissue extend from apex of
axilla down to 7th or 8th rib.
▪ Posteriorly C7 marks apex & T10 to the
base. Deep inspiration expands the lungs
and lower border drops to level of T12.

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 Lobes
Lungs are divided into lobes by fissures.
The right lung is made up of three lobes, whereas the left lung contains only
two lobes.
Fissures separating the lobes run obliquely through the chest
Right lung is shorter because of liver
Left lung is narrower because of the heart.

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Anterior: the oblique fissure crosses the fifth rib in MAL and terminates at
the sixth rib in MCL. Horizontal fissure divides the Right upper and middle
lobes.

Posterior: almost all lower lobes, upper lobes occupies apices at T1 down to
T3 or T4.
 Note that Right middle lobe doesn’t project onto posterior chest at all.

Lateral: extend from apex of axilla down to 7th or 8th rib.

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 Pleurae
The thoracic cavity is lined by a thin, double-layered serous membrane. It
form an envelop between the lungs and wall referred as pleura.
Visceral pleura covers outside of the lungs, continuous with Parietal
pleura lining inside of chest wall and diaphragm.

The Pleural space lies between the two pleural layers. The lubricating
serous fluid between the layers allows movement of the visceral layer over
the parietal layer during ventilation without friction.

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 Tracheal & Bronchial Tree
Trachea lies anterior to esophagus, begins at
cricoid cartilage level, bifurcate below sternal
angle, posteriorly at level T4 or T5

Right bronchus is shorter wider and more vertical

than left.

An Acinus is a functional respiratory unit consist

of bronchioles, alveolar ducts, alveolar sacs
&alveoli.

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 Mechanics Of Respiration
▪ Four major functions of the Respiratory System:
1.Supply O2 for energy production
2.Remove CO2 , waste product of energy reactions
3.Homeostasis, acid-base balance of arterial blood
4.Heat exchange
▪ Lungs help maintaining balance by adjusting level of CO2 through respiration,
hypoventilation (slow breathing) causes increase of Co2, hyperventilation
(rapid breathing) causes CO2 to be blown off.

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 Control Of Respirations
▪ Breathing changes in response to cellular demand.

▪ Involuntary control of resp. is mediated in the brainstem.

▪ Under normal circumstances, the strongest stimulus to breathe is an increase of

carbon dioxide in the blood (hypercapnia). A decrease in oxygen (hypoxemia)
also increases respiration; but is less effective than a rise in carbon dioxide
levels.

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 Changing Chest Size
Air pushes into lungs, chest increases (inspiration) and expelled from lungs as
chest size recoils (expiration).

This alter the vertical diameter by upward or downward movement of

diaphragm and the anteroposterior (A-P) diameter increases or decreases
accomplished by elevation or depression of ribs.

Expiration is primarily passive, as diaphragm relaxes, elastic forces within

lung, chest cage and abdomen cause it to dome up, creates positive pressure
within alveoli and air flows out.

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▪ Forced inspiration commands use of accessory neck muscles, in
forced expiration the abdominal muscles contract powerfully to push
viscera in and up against diaphragm making it dome upward.

▪ During inspiration thoracic size increases creating a negative pressure

more in relation to atmospheric pressure, so air rushes in to fill partial
vacuum influenced by the diaphragm. This process causes the chest to
descend & flatten.

▪ Lengthening vertical diameter, elevate ribs so increase anterior

posterior diameter.
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History and
Examination

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 History of presenting complaint
The main respiratory symptoms are:
1. Dyspnea
2. Cough and Sputum
3. Hemoptysis
4. Pain – pulmonary pain, pleural pain, muscular pain,
cardiac pain.
5. Wheezes (Asthma, Bronchitis)
6. Hoarseness

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 Other Systems
 Loss of appetite
 Significant loss of weight may well be indicative of serious illness - eg, malignancy
or tuberculosis.
 Upper gastrointestinal symptoms: gastro-oesophageal reflux is a common cause of
chronic cough.
 Heart disease may cause respiratory symptoms. Establish whether there are any
indications of heart failure or coronary heart disease.
 Severe anemia may cause breathlessness.
 Rheumatoid arthritis and other connective tissue diseases may cause respiratory
symptoms.
 Neuromuscular diseases may cause respiratory symptoms, particularly dyspnea.

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 Past Medical History
Use of inhalers (assess compliance and technique).
Use of steroids (some measure of severity in asthma).
Other drugs which may have relevance in respiratory disease - eg, angiotensin-converting
enzyme (ACE) inhibitors (cough).

Allergies
Ask about all allergies including, for example, food, inhaled allergens and drugs.

Family History
 Respiratory diseases with a genetic component - eg, cystic fibrosis, emphysema (alpha-1-
antitrypsin deficiency).
 Infectious diseases such as tuberculosis (remember high-risk groups).
 Atopic diseases such as asthma, hay fever and eczema.

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Occupational And Social History
 An occupational history may be very important in respiratory disease.
 Hobbies and pets may also be responsible for respiratory disease (refer to the
article on extrinsic allergic alveolitis).
 Lifestyle and alcohol consumption are also very relevant to respiratory
diseases. Ask about illicit drugs.
 Smoking history should detail, for example, the type and number of
cigarettes smoked currently and in the past. Ask also about passive smoking.
 Sexual history may be relevant to risk of HIV and AIDS.

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Equipment for Exam Preparation….
 Stethoscope  Sitting position
 Small ruler (marked in centimeters)  Ensure comfort to the patient
 Marking pen  Warm, quiet, well ventilated
 Alcohol wipe room
 Examination gown and drape

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 Inspection
o Pattern of respiration (regular, effortless, rate)
o Facial expression
o Assess the patient’s color for cyanosis (Nails and lips)
o Level of consciousness (orientation)
o Use of accessory muscle (Neck and trapezius muscle)
o Listen to the breathing
o Inspect neck
o Any visible bulges, mass

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 Inspect the anterior chest
Note shape and configuration of chest wall, ribs are sloping down ward
symmetrically
Note the skin color & condition
Assess respiratory rate rhythm, (regular & even, no noise), symmetry (chest
expand symmetrically)
Note the shape of chest. Note any retraction or bulging of interspaces on
inspiration
Note any use of accessory muscles

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 Inspect posterior chest
Thoracic cage : Note the shape &configuration of chest wall.
o Spinous processes appear in straight line,
o Thorax is symmetrical, elliptical in shape with downward
sloping ribs, about 45 degree relative to the spine, scapulae
symmetrical
o Anterior-posterior diameter should be less than transverse or
lateral diameter, ratio from 1:2

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 Antero-Posterior Transverse position

Shape & Diameter of the chest (Anteroposterior : Transverse=1:2)

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Shape of the chest
Shape of the chest The picture show
normal shape of the chest is
Elliptical chest which has diameter
(AP:L=1:2)

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The picture show Barrel
Chest shape which has
diameter (AP:L=2:2) Mostly
found in patient with
emphysema

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The picture show Pectus
Carinatum (Pigeon
shape which has diameter
(AP:L=2:2)
In this Sternum displaced
anteriorly, AP diameter
increases, costal
cartilages depressed

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The picture show Pectus
Excavatum (Funnel). This shows
depression in the lower portion of
the sternum

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 Palpation
Using the fingers gently
palpate the entire chest wall,
note any areas of tenderness,
skin temperature and
moisture, superficial lumps
or masses, skin lesions.

Sequence of Palpation

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Palpate the anterior chest through chest expansion
o Palpate symmetric chest
expansion
o Place your hands on anterolateral
wall with thumbs along costal
margins and pointing toward
xiphoid process, ask client to
take a deep breath, watch your
thumbs moves apart
symmetrically.

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Palpate Posterior Chest Through Chest Expansion
o Symmetric expansion: confirm chest
expansion by placing your warmed
hands on posterior lateral chest wall
with thumbs at the level of T9 or T10.
o Slide your hands medially to pinch up
a small fold of skin between your
thumbs.
o Ask him to take a deep breath as he
inhales deeply your thumbs should
move apart symmetrically, note any
lag in expansion.

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Palpate anterior chest through Tactile Fremitus

o Assess tactile fremitus over lung

apices, compare vibrations from
one side to the other as person
repeat ninety nine.
o Palpate anterior chest wall to
note any tenderness to detect any
superficial lumps or masses.
o Note skin mobility & turgor ,
temperature & moisture.

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Palpate posterior chest through Tactile Fremitus
o It is a palpable vibration, use either
palmar base of fingers or ulnar edge
of one hand and touch the person's
chest while he repeats the words"99”
o Start over the lungs apices and
palpate one side to another.
o Between scapulae fremitus feel
stronger on right side because right
side is closer to bronchial bifurcation

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Factors that affect normal intensity of tactile fremitus
o Relative location of bronchi to chest wall: most prominent
between scapula and around sternum
o Thickness of chest wall: feels greater over a thin chest wall
than obese or heavily muscular one.
o Pitch and intensity: a loud, low –pitched voice generates more
fremitus than a soft high pitched one.

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Percuss the Anterior Chest
o Percuss apices in supraclavicular
areas, then interspaces and comparing
one side to other, don’t percuss
directly over female breast it will
produce dullness.
 Dullness heard at left 5th ICS or
MCL, similarly dullness over 5th
ICS on right side due to liver
 Tympany noted at fundus

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Percussion of posterior chest
o Percuss all lung fields: start at the
apices , make a side to side
comparison all the way down the lung
region.
 Avoid damping effect of scapulae
and ribs.
o Normal sound heard is Resonance
o Hyper resonance indicates emphysema
or pneumothorax and dull note in
atelectasis.

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 Percuss Diaphragmatic Expansion
o Map out the lower lung border, both in expiration & in inspiration.

o Instruct a client to exhale and hold it, while you percuss down the
scapular line until the sound changes from resonance to dull on each
side, make a spot with a pen.

o Then, instruct a client to take a deep breath and hold it. again percuss
down from your first mark and mark the level sound change to dull.
Mark the point with pen. Its measures about 3-5 cm. it should be
bilaterally equal.

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Exhale Inhale

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 Auscultate Chest
Passage of air creates a characteristic set of noises that are
audible through the chest wall.

It may be modified by obstruction within the respiratory airway

passage or by changes in the lung parenchyma, the pleura or
the chest wall.

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 Auscultate the Anterior Chest

Breath Sounds: Auscultate lung fields over anterior chest

from apices down to the 6th rib. Progress from side to side
as you move downward and listen to one full respiration in
each location.

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Auscultate posterior chest
o Instruct person to take deep breath, use
the flat diaphragm of stethoscope
compare side by side od lung field
o Listen to the sounds from apices at C7 to
the bases (T10) & laterally from axilla
down to the 7th or 8th ribs.
Characteristics of normal breath sounds
1) Bronchial 2) Broncho vesicular
3) Vesicular

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Location of Normal breath sound heard posterior /Anterior
chest wall

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 Characteristics of Normal Breath Sound
Breath Sound Bronchial Broncho-vesicular Vesicular
Pitch High Moderate Low
Intensity Loud Moderate Soft
Quality Blowing/Hollow Combination of Gentle rustling/
Bronchial and breezy
Vesicular
Relative Duration Of I<E I=E I>E
Inspiratory And
Expiratory Phase
Location Trachea Between scapulae first Peripheral Lungs
and second ICS lateral
to the sternum

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Adventitious Breath Sound

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 Auscultate Voice Sounds
o Determine the quality of voice or vocal resonance

o Spoken voice can be auscultated over the chest or felt in tactile fremitus

o Ask the person to repeat a phrase while you listen over the chest wall,
normally voice transmission is soft, muffled & indistinct , hear it by
stethoscope but can't distinguish exactly what is said, pathology that
increases lung density enhances transmission of voice sounds.

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 Voice Sounds
o Bronchophony: Ask pt. to repeat 99 while you listen with
stethoscope over chest wall, normally voice transmission is soft
and indistinct but can't distinguish exactly what is said.

o Egophony: Auscultate chest while person says "eeeeeee" sound,

normally you should hear "eeeeee" through stethoscope.

o Whispered pectoriloquy: Ask person to whisper a phrase like

one-two-three as you auscultate, normally faint muffled and
inaudible.

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 Documentation
A 45 years old patient having respiratory rate 18/ mins
looks relaxed. AP/ T diameter 1:2 with chest
expansion symmetric. No pain or tenderness noted on
palpation. Tactile fremitus symmetric. On percussion
resonance sound heard all over the lung fields.
Diaphragmatic excursion 4 cm and equal bilaterally.
Bronchial sound auscultate on trachea, bronchial
vesicular sounds on bronchi and vesicular sound
heard on both lungs fields

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 References
1. Bates, B., Bickley, L.S. & Hoekelman, R.A. (1995). A guide to physical
examination and history taking Philadelphia: Lippincott
2. Fuller, J. & Schaller - Ayers, J. (2000). Health assessment: A nursing approach.
(3rd ed.). Philadelphia: J.B. Lippincott.
3. Weber, J., & Kelley, J. (2007). Health Assessment in Nursing (3nd
ed.).Philadelphia: Lippincott

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