St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue, 2727 Bantay, Ilocos Sur

NCM 101: Health Assessment

Module 13.1

Assessing Thorax
and Lungs

Melanio P. Rojas Jr, MAN

Clinical Instructor

2022

THORAX AND LUNGS 1

 Module No. 13.1
Assessing Thorax and Lungs

Learning Objectives:

After completing this module, the students will be able to:

1. Describe the function and structure of the thorax and lungs.

2. Perform a physical assessment of the thorax and lung using the correct techniques of

inspection, auscultation, palpation and percussion.

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 OVERVIEW OF ANATOMY AND PHYSIOLOGY OF RESPIRATORY SYSTEM

• Respiration. The process of gaseous exchange between the individual and the
environment.
• The process of respiration
1. Ventilation. Refers to the movement of gases in and out of the lungs.
- Inhalation (inspiration) is voluntary phase
- Exhalation (expiration) is involuntary phase
2. Diffusion. The exchange of gases from an area of higher pressure to an area of lower
pressure.
3. Perfusion. The availability and movement of blood for transport of gases, nutrients and
metabolic waste product.
• The respiratory system is composed of the following structures:
1. The Airways
a. Upper Airways
✓ Nasal cavity or nares
✓ Pharynx
✓ Larynx or voice box
b. Lower airways (Tracheobrochial tree)
✓ Trachea
✓ Right and left mainstem bronchi
✓ Segmental bronchi
✓ Subsegmental bronchi
✓ Terminal bronchi
c. Functions of the Upper Airways:
✓ Transport of gases to the lower airways
✓ Protection of the lower airways from foreign matter
✓ Warming, filtration and humidification of inspired air.
d. Function of the Lower Airways
✓ Clearance Mechanism
Cough
Mucociliary system
Macrophages
Lymphatics
✓ Immunologic responses
Cell-mediated immunity in the alveoli
✓ Pulmonary protection in injury
Respiratory epithelium
Mucociliary system
• The opening of the nose on the face area are called nostril or nares.
• Each nostril leads to a cavity called vestibule.
• The hair that lines the vestibule are called vibrissae. The vibrissae filter foreign objects.
• The paranasal sinuses are open areas within the skull, lined with mucous membrane. They help
in phonation. The different sinuses are as follows: frontal, maxillary, ethmoid and sphenoid.
• The pharynx is a funnel shaped tube that extends from the nose to the pharynx. It is a common
opening between the digestive and respiratory system.
• The three sections of the pharynx are as follows: nasopharynx, oropharynx, and larnygopharynx.
• From the middle ear, the euschatian tubes open into the nasopharynx
• The larynx is the voice box
• The epiglottis covers closes when speaking it opens.

THORAX AND LUNGS 3

• The trachea (windpipe) is 12 cm (4 to 5 inches) long. The point at which divides is called carina.
• The trachea and bronchi are lined with cilia and goblet cells.
• The cilia are microscopic hair-like projection which have rapid, coordinated, unidirectional
upward motion.
• The cilia sweep out debris and excessive mucous from the lungs.
• The goblet cells secrete 120 ml of mucous per day. The mucous secretions entrap debris in the
respiratory tract.
• The right mainstem bronchus is shorter, broader, and more vertical than the left.
2. The pleura
• The pleura are serous membranes that enclose the lungs.
• The visceral pleura directly covers the lungs.
• The parietal pleura lines the cavity of each hemothorax.
• The pleural space is a potential space between the two pleurae. Only few ml of
serous fluid is found in the pleural space, to serve as lubricant.
3. The lungs
• The right lung has three lobes while the left lung has two lobes.
• The two lungs are separated by a space called mediastinum
• There are approximately three hundred million alveoli in the lungs.
• The right lung is broader, but shorter due to the presence of the liver on the right
side of the abdomen.
• A. Divisions (structure)
a. Root: consist of the primary bronchus and pulmonary artery and veins bound
together by connective tissue.
b. Hilum. Vertical slit on medial surface of the lung, through which root structure
enter the lung.
c. Lobes; three in the right and two in the left.
d. Apex: pointed upper part of the lung.
e. Base: broad, inferior surface of the lung.
4. Bronchial tree consists of the following:
A. Bronchial: right and left formed by branching of the trachea; right bronchus slightly larger
and more vertical than left each primary bronchus branches into segmental bronchi in
each lung: primary and segmental bronchi all contain C-shaped cartilage
B. Bronchioles: small branches off the secondary bronchi, distinguished by lack of C-
shaped cartilage and a duct diameter about 1 mm, which further branch into terminal
bronchioles, respiratory bronchioles and then alveolar ducts.
C. Alveoli: microscopic sacs composed of a single layer extremely thin squamous epithelial
cells enveloped by a network of capillaries.
4. Covering of the lung: visceral and layer pleura.
B. Function:
A. Bronchi, bronchioles, alveoli ducts: passage to move air into and out of
alveoli.
B. Alveoli: provide a surface area large enough and thin enough to allow rapid
gas exchange:
✓ Type I cells from walls
✓ Type II cells produce surfactant to prevent alveolar collapse

THORAX AND LUNGS 4

 PHYSIOLOGY OF RESPIRATION

A. Mechanism of breathing
1. Following phrenic nerve stimulation, the diaphragm and other respiratory muscles
contract.
2. Thorax increases in size
3. Intrathoracic and intrapulmonic pressures decrease
4. Air rushes from positive pressure in the atmosphere to negative pressure in the alveoli
5. Expiration reverse procedure and inspiration
B. Control of respiration
1. Alveolar stretch receptors respond to inspiration by sending inhibitory impulses to
inspiratory neurons in brainstem to prevent lung distention (Hering- Breuer reflex)
2. Central and peripheral chemoreceptors stimulate respirations in respond to lowered ph,
increased PCO2 or decreased PO2
C. Amount of air exchanged in breathing:
1. Directly related to gas pressure gradient between atmosphere and alveoli and inversely
related to resistance that opposes air flow; pulmonary function can be evaluated with a
spirometer
2. Expiratory reserve volume: largest additional volume of air that can be forcibly expired
after a normal respiration and expiration. Normal ERV is 1000 to 2000 ml.
3. Inspiratory reserve volume: is the amount of extra air that can be inhaled, beyond the
tidal volume. Normal IRS is 3000 ml
4. Residual volume is the amount of air that remains in the lungs after forceful expiration. It
prevents collapse of the lungs during expiration. Normal RV is 1200 ml.
5. Tidal volume is the amount of air that moves in and out of the lungs with each normal
breath. Normal TV is 500 ml
6. Total lung capacity is the total of all four volumes (residual, tidal, inspiratory reserve and
expiratory reserve volume).
7. Forced expiratory volume: volume of air that can be forcibly exhaled within a specific
time usually 1 to 3 seconds.
8. Functional residual capacity is the amount of air that remains in the lung after normal
exhalation.
9. Positions such as orthopnea and fowler’s position can lower abdominal organs and
reduce pressure against diaphragm.
D. Diffusion of gases between air and blood
1. Occurs across alveolar-capillary membranes (in lungs between air in alveoli and venous
lung capillaries: adequate diffusion depends on a balanced ventilation-perfusion (V/Q)
ratio.
2. Direct of diffusion
a) Oxygen: net diffusion toward lower oxygen pressure gradient (from alveolar air to
blood).
b) Carbon dioxide: net diffusion toward lower carbon dioxide pressure gradient (from
blood to alveolar air)
E. The thorax and the diaphragm
• The thorax provides protection for the lungs, heart and great vessels.
• The thorax is made up of 12 pairs of ribs, bounded anteriorly by the sternum and
posteriorly by the thoracic vertebrae.
• The diaphragm is the main respiratory muscle for inspiration. It is supplied by the phrenic
nerve.

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 • The following are the accessory muscles for inspiration: sternocleidomastoid, scalene,
parasternal, trapezius, and pectoralis muscles. They are used during increased work of
breathing.
F. Respiratory Centers
• Medulla oblongata is the primary center
• Pons contains the following:
Pneumotaxic center. Responsible to the rhythmic quality of breathing
Apneustic center. Responsible for deep, prolonged inspiration
• Carotid and aortic bodies
Peripheral chemoreceptors. Take up the work of breathing when the central
chemoreceptors in the medulla oblongata are damaged. It responds to low
oxygen concentration in the blood. Respond to pressures. If the BP is elevated
the respiratory rate becomes slow. (HPN leads to respiratory acidosis). If the BP
is decreased, the respiratory rate becomes rapid (hypotension leads to respiratory
alkalosis). The primary chemical stimulation for breathing is high carbon dioxide
level in the blood.
• Muscles and Joints
Prioreceptors. Exercise increases respiratory rate.

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 ASSESSMENT NORMAL FINDINGS ABNORMAL FINDINGS
PROCEDURE
General
INSPECTON
Inspect for nasal Nasal flaring is not observed. Nasal flaring is seen with labored
flaring and pursed lip Normally the diaphragm and the respirations ( especially in small
breathing. internal costal muscles do most of children) and is indicative of
the work of breathing. This is hypoxia.
evidenced by outward expansion of
the abdomen and lower ribs on Pursed lip breathing may been in
inspiration as well as return to asthma, emphysema, or CHF as a
resting position one expiration. physiologic response to help slow
down expiration and keep alveoli
open longer.
Observe color or face, The client has evenly colored skin Ruddy to purple complexion may
lips and chest. tone, without unsual or prominent be seen in clients with COPD or
discoloration. CHF as a result of polycythemia.
Cyanosis may be seen if client is
cold or hypoxic.
Inspect color and Pink tones should be seen in the Pale or cyanotic may indicate
shape of nails. nailbeds. There is normally a 160- hypoxia. Early clubbing ( 180
degree angle between the nail base degree angle) and late clubbing (
and the skin. greater than a 180 degree) can
occur from hypoxia.
Posterior thorax
INSPECTION
Inspect for Scapulae are symmetric and Spinous processes that deviate
configuration. While nonprotruding. Shoulders and laterally in the thorax are may
the client sits with arms scapulae are at equal horizontal indicate scoliosis.
at the sides, stand positions.
behind the client and Spinous configuration may have
observe position of The ratio of anteroposterior to respiratory implications. Ribs
scapulae and the shape transverse diameter is 1:2. appearing horizontal at an angle
configuration of the greater than 45- degree with the
chest wall. Spinous process appera straight, spinal column are frequently the
and thorax appears symmetric, with result of an increased ( 1 to 1) ratio
ribs slopping downward at between the anterioposterior and
approximately a 45- degree angle in transverse diameter ( barrel chest.
relation to the spine. This condition is commly the result
of emphysema due to
Older Adult Considerations hyperinflation of the lungs.
Kyphosis ( an increased curve of
the thoracic spine) is common in
older clients. It results from a
loss of lung resiliency and a loss
of skeletal muscles.

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 Spinous configuration may have
respiratory implications. Ribs
appearing horizontal at an angle
greater than 45 degree with the
spinal column are frequently the
result of an increased ( 1 to 1)
ratio between the
anterioposterior and transverse
diameter ( barrel chest. This
condition is commly the result of
emphysema due to
hyperinflation of the lungs.
Abnormal findings:
1. Barrel chest
2. Pectus excavatum- funnel
chest
3. Pectum carinatum- pigeon
chest.
4. Scoliosis- curvature of the
spine
5. Kyphosis- is an
exaggerated increased
rounding of the thorcic spine,
often seen with osteoporosis
in older women.

Trapezius or shoulder, muscles

are used to facilitate inspiration
in cases of acute and chronic
airway obstruction or atelectasis.

Observe use of The client does not use Client leans forward and uses
accessory muscles. accessory ( trapezius/shoulder) arms to support weight and lift
Watch as the client muscle to assist breathing. The chest to increase breathing
breathes and note use of diaphragm is the major muscle capacity, referred as the tripod
muscles. at work. This is evidenced by position. This is often seen in
expansion of the lower chest COPD.
during inspiration.
Inspect the client’s Client should be sitting up and Tender or painful areas may
positioning. Note the relaxed breathing easily with indicate inflamed fibrous
client’s posture and arms at sides or in lap. connective tissue. Pain over the
ability to support weight intercostal spaces may be from
while breathing infammed pleurae. Pain over the
comfortably. ribs, especially at the costal
chondral junctions, is a symptom
of fractured ribs.

THORAX AND LUNGS 8

 ASSESSMENT PROCEDURE
PALPATION
Palpate for tenderness and
sensation. Palpation may be
performed with one or both hands,
but the sequence of palpation is
established. Use your fingers to
palpate for tenderness, warmth, pain,
or sensations. Start toward the
midline at the level of the left scapula
( over the apex of the left lung) and
move your hand left to the right,
comparing findings bilaterally. Move
systematically downward and out to
cover the lateral portions of the lungs
at the bases.
Palapte for crepitus. Crepitus, also
called subcutenous emphysema is a
crackling sensation ( like bones or
hairs rubbing against each other) that
occurs when air passes through fluid
or exudate. Use of fingers when
palpating.
Palpate surface characteristics.
Put on gloves and use your fingers to
palpate any lesions that you noticed
during inspection. Feel for any
unusual masses.
Palpate for fremitus. Following the
sequence described previously, use
the ball or ulnar endge of the hand to
assess for fremitus ( vibrations of air
in the bronchial tubes transmitted to
the chest wall). As you move your
hand to each area, ask the client to
say “ninety-nine.” Assess all areas for
symmetry and intensity of vibration.
NORMAL FINDINGS ABNORMAL FINDINGS
Client reports no Muscle soreness from
tenderness, pain or unusual exercise or the excessive
sensations. Temperature work of breathing ( as in
should be equal bilateral. COPD) may be palpated
as tenderness.
Increased warmth may
be related to local
infection.
The examiner finds no Crepitus can be palpated
palpable crepitus. if air escapes from the
lung or other airways into
the subcutenous tissue,
as occurs after an open
thoracic injury, around a
chest tube, or
tracheostomy. It also may
be palpated in areas of
extreme congestion or
consolidation. In such
situations, mark margins
and monitor to note any
decrease or increase in
the crepitant area.
Skin and subcutenous tissue A physician or other
are free of lesions and appropriate professional
masses. should evaluate any
unusual palpable mass.
Fremitus is symmetric and Unequal fremitus is
easily identified in the upper usually the result of
regions of the lungs. If consolidation (which
fremitus is not palpable on increases fremitus) or
either side, the client may bronchial obstruction, air
need to speak louder. A tapping in emphysema,
decrease in the intensity of pleural effusion, or
fremitus is normal as the pneumothorax ( which all
examiner moves toward the decrease fremitus).
base of the lungs. However, Diminished fremitus even
fremitus should remain with a loud spoken voice
symmetric for bilateral indicate an obstruction of
positions. the tracheobronchial tree.

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Assess chest expansion.
Place your hands on the
posterior chest wall with your
thumbs at the level of T9 or T10
and pressing together a small
skin fold. As the clients takes a
deep breath, observe the
movement of your thumbs.
When the client takes a deep
breath, the examiner’s
thumbs should move 5 to 10
cm apart symmetrically and
pressing together a small skin
fold. As the client takes a
deep breath, observe the
movement of your thumbs.
Unequal chest expansion can
occur with severe atelectasis (
collapse or incomplete
expansion), pneumonia, chest
trauma, pneumothorax ( air in the
pleural space).

Older Adult Considerations Decreased chest excursion at

PERCUSSION
Percuss for tone. Start at the
apices of the scapulae and
percuss across the tops of both
shoulder. Then percuss the
interscostal spacess across
and down comparing sides.
Percuss to the lateral aspects
at the bases of the lungs,
comparing sides.
Percuss for diapgramatic
excursion. Ask the client to
exhale forcefully and hold the
breath. Beginning at the
scapular line ( T7), percuss the
intercostal spaces of the right
posterior chest wall.
Percusses downward until the
tone changes from resonance
to dullness. Mark the level and
allow the client to breathe. Next
ask the client to inhale deeply
and hold it. Percuss the
intercostal spaces from the
mark downward until
resonance changes to
dullness. Measure the distance
between 2 marks. Perform this
assessment technique on both
sides of the posterior thorax
Because of calcification of the the base of the lungs is
costal cartilages and loss of characteristic of COPD. This is
the accessory musculature, due to decreased diaphragmatic
the older client’s thoracic
function.
expansion may be decreased,
although it should still be
symmetric
NORMAL FINDINGS ABNORMAL FINDINGS
Resonance is the percussion Hyperresonce is elicted in cases
tone elicited over normal lung of trapped air such as in
tissue. Percussion elicits flat emphysema or pneumothorax.
tones over the scapula.
Exursion should be equal be Dullness is present when fluid or
bilaterally and measure 3-5 solid tissue replaces air in the lung
cm in adults. or occupies the pleural space, such
as in lobular pneumonia, pleural
effusion, or tumor.
Diaphragmatic descent may be
The level of the diaphragm limited by atelectasis of the lower
may be higher on the right lobes or by emphysema, in which
because of the position of the diaphragmatic movement and air
liver. trapping are mininal. The diaphragm
remains in a low position on
In well-conditioned clients, inspiration and expiration.
excursion can up to 7 to 8 cm.
Other possible causes for limited
descent can be pain or abdominal
changes such as extreme ascites,
tumors or pregnancy.
Uneven excursion may be seen with
inflammation from unilateral
pneumonia, damage to the phrenic
nerve or splenomegaly.

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 AUSCULTATION
Auscultate for breath sounds.
To best assess lung sounds, you
will needed to hear the sounds as
directly as possible. Do not
attempt to listen through clothing
or a drape, which may produce
additional sound or muffle lung
sounds that exist. To begin, place
the diagphragm of the
stethoscope firmy and directly on
the posterior chest wall at the apex
of the lung at C7. Ask the client to
breathe deeply through the mouth
for each of auscultation ( each
placement of the stethoscope) in
the auscultation sequence so that
you can best hear inspiratory and
expiratory sounds. Be alert to the
client’s comfort and offer times for
rest and normal breathing if
fatigue is becoming a problem.
Auscultate from the apices of the
lungs at C7 to the bases of the
lungs at T10 and laterally from the
axilla down to the 7 or 8 rib. Listen
at each site for at least one
complete respiratory cycle.
Auscultate for adventitious
sounds. Adventitious sounds are
sounds added or superimposed
over normal breath sounds and
heard during auscultation. Be
careful to note the location on the
chest wall where adventitious
sounds are heard as well as the
location of such sounds within the
respiratory cycle.
NORMAL FINDINGS ABNORMAL FINDINGS
Three types nof normal Diminshed or absent sounds
breath, sounds may be often indicate that little or no
auscultated- bronchial, air is moving in or out of the
bronchovesicular and lung area being auscultated.
vesicular. See table 1. This may indicate obstruction
within the lungs as a result of
secretions, mucus plug, or a
foreign object. It may also
indicate abormalities of the
pleural space such as pleural
thickening, pleural effusion or
Sometimes breath pneumothorax. In cases of
sounds may be hard to emphysema the hyperinflated
hear with obese or nature of the lungs, together
heavily muscled clients with a loss of elasticity of lung
due to increased tissue, may result in
distance to undelying diminished inspiratory breath
lung tissue. sounds. Increased ( louder)
breath sounds often occurs
when consolidation or
compression results in a
denser lung area that
ehnhaces the trasmission of
sounds.
No adventitious sounds, Adventitious lung sounds,
such as crackles such as crackles or rales and
(discrete and discontious wheezes or rhonchi are
sounds) or wheezes evident. See table 2
(musical and continous
sounds) are auscultated. Clinical Tip: If you hear an
abnormal sounds during
auscultation, always have
the client cough, then listen
again and note any change.
Coughing may clear the
lungs.
THORAX AND LUNGS 11
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS
AUSCULTATE VOICE SOUNDS
Bronchopony: Ask the client to Voice transmission is The words are easily understood
repeat the phase “ ninety-nine” soft, muffled, and and louder over of increased
while you auscultate the chest indistict. The sound of the density. This may indicate
wall. voice may be heard but consolidation from pneumonia,
the actual phrase cannot atelectasis or tumor.
be distinguished.
Egophony: Ask the client to Voice transmission will be Over areas of consolidation or
repeat the letter “ E” while you soft and muffled but the compression the sound is louder
listen over the chestwall. letter “E” should be and sound like “ A.”
distinguishable.
Whisphered pectoriloquy: Ask Transmission of sound is Over areas of consolidation or
the client to whisper the phrase very faint and muffled. It compression, the sound is
“one-two-three” while you may be inaudible. transmitted clearly and distinctly.
auscultate the chest wall. In such areas, it sounds as if the
client is whispering directly into the
stethoscope.
ANTERIOR THORAX NORMAL FINDINGS ABNORMAL FINDINGS
INSPECTION
Inspect for shape and The anteroposterior Anteroposterior equals transverse
configuration. Have the client sit
diameter is less than the diameter, resulting barrel chest.
with arms at the sides. Stand in transverse diameter. The This is often seen in emphysema
front of the client and assess ratio of anteroposterior because of hyperinflation of the
shape and configuration. diameter to the lungs.
transverse diameter is
1:2
Inspect position of the sternum. Sternum is positioned at Pectus excavatum is a markedly
Observe the sternum from an midline and straight. sunken sternum and adjacent
anterior and lateral viewpoint. cartilages ( often referred to as
funnel chest). It is a congenital
malformation the seldom causes
symptoms other than self-
conciousness. Pectus carinatum
is a forward protrusion of the
sternum causing the adjacent ribs
to slope backward. Both
conditions may restrict expansion
of the lungs and decrease lung
capacity.
Watch for sternal retractions. Retractions not observed. Sternal retractions are noted, with
severely labored breathing.
Inpsect slope of the ribs. Rib slope downward with Barrel-chest configuration results
Assess the ribs from an anterior symmetric intercostal in a more horizontal position of the
and lateral viewpoint. spaces. Costal angle is ribs and costal angle of more than
within 90 degrees. 90 degrees. This often results from
long-standing emphysema.

THORAX AND LUNGS 12

Observe quality and pattern of Respiration are relaxed,
respiration. Note breathing effortless, and quiet.
characteristics as well as rate, They are of a regular
rhythm, and depth. See table 3. rhythm and normal depth
at a rate of 10-20 per
minute in adults.
Tachypnea and
bradypnea may be
normal in some clients.
ASSESSMENT PROCEDURE NORMAL FINDINGS
Inspect intercostal spaces. Ask No retractions or bulging
the client to breathe normally and of intercostal spaces are
observe the intercostal spaces. noted.
Observe for use of accessory Use of accessory
muscles. Ask the client to breathe muscles ( sternomastoid
normally and observe for use of and rectus abdominis) is
accessory muscles. not seen with normally
respiratory effort. After
strenous exercise or
activity, clients with
normal respiratory status
may use neck muscles
for a short time to
enhance breathing.
Labored and noisy breathing is
often seen with severe asthma or
chronic bronchitis. Abnormal
breathing patterns include
tachypnea, bradypnea,
hyperventilation and
hypoventilation, Cheyne-Stokes
respiration, and Biot respiration.
ABNORMAL FINDINGS
Retraction of the intercostal
spaces indicates an increased
inspiratory effort. This may be the
result of an obstruction of the
respiratory tract or atelectasis.
Bulging of the intercostal spaces
indicates trapped air such as in
emphysema or asthma.
Neck muscles ( sternomastoid,
scalene, and trapezius ) are used
to facilitate inspiration in cases of
acute or chronic airway
obstruction or atelectasis. The
abdominal muscles and the
internal intercostal muscles are
used to facilitate expiration in
COPD.

PALPATION NORMAL FINDINGS ABNORMAL FINDINGS

Palpate for tenderness, No tenderness or pain is Tenderness over thoracic muscles
sensation, and surface masses. palpated over the lung can result from exerising ( e.g,
Use your fingers to palpate for area with respirations. pushups) especially in a
tenderness and sensation. Start previously sedentary client.
with your hand positioned over the
left clavicle ( over the apex of the
left lung) and move your hand to
left to right, comparing findings
bilaterally. Move your hand
systematically downward toward
the midline at the level of the
breasts and outward at the base to
include the lateral aspect of the
lung. The established sequence
for palpating the anterior thorax
serves as a guide for positioning
your hands.

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Palpate for tenderness at Palpation does not elicit
costochondral junctions of ribs. tenderness.
Palpate for crepitus as you
would on the posterior thorax
( described previously).
Palpate for any surface masses
or lesions.
Palpate fremitus. Using the
sequence for the anterior chest
described previously, palpate for
fremitus using the same technique
same as for the posterior thorax.
Palpate anterior chest
expansion. Place your hands on
the client’s antero-lateral wall with
your thumbs along the costl
margins and pointing toward the
xiphoid process. As the client
takes a deep breath, observe the
movement of your thumbs.
Tenderness or pain at the
constochondral junction of the ribs
is seen with fractures especially in
older clients with osteoporosis.
No crepitus is palpated. In areas of extreme congestion or
consolidation, crepitus may be
palpated, particularly in clients
with lung disease.
No unusual surface Surface masses or lesions may
massess or lesions are indicare cysts or tumors.
palpated.
Fremitus is symmetric Diminished vibrations even with a
and easily identified in the loud spoken voice, may indicate
upper regions of the an obstruction of the
lungs. A decreased tracheobronchial tree. Clients with
intensity of fremitus is emphysema may have
expected toward the base considerably decreased fremitus
of the lungs. However, as a result of air trapping.
fremitus should be
symmetric bilaterally.
Thumbs move outward in Unequal chest expansion can
a symmetric fashion from occur with severe atelectasis,
the midline. pneumonia, chest trauma, pleural
effusion, or pneumothorax.
Decreased chest excursion at the
base of the lungs is seen with
COPD.

PERCUSSION
Percuss for tone
Percuss the apices above the Resonance is the Hyperresonance is elicited in
clavicles. Then percuss the percussion tone elicited cases of trapped air such as in
intercostal spaces across and over normal lung tissue. emphysema or pneumothorax.
down, comparing sides. Depicts normal tones and Dullness may characterize areas if
their locations. increased density such as
consolidation, pleural, effusion or
Percussion elicits tumor.
dullness over breast
tissue, the heart, and the
liver. Tympany is
detected over the
stomach and flatness is
detected over the
muscles and bones.

THORAX AND LUNGS 14

 AUSCULTATION
Auscultation for anterior breath
sounds, adventitious sounds
and voice sounds. Place the
diaphragm of the stethoscope
firmly and directly on the anterior
chest wall.
Auscultate from the apices of
the lungs slightly above the
clavicles to the bases of the
lungs at the sixth rib. Ask the
client to breathe deeply through
the mouth in an effort to avoid
transmission of sounds that may
occur with nasal breathing. Be
alert to the client’s comfort and
offer times for rest and normal
breathing if fatigue is becoming a
problem, particularly for the older
client.
Listen at each site for at least one
complete respiratory cycle. Follow
the sequence for anterior
auscultation.
NORMAL ABNORMAL FINDINGS
Voice transmission is Refer to adventitious breath
soft, muffled, and sounds.
indistict. The sound of theDiscontinuous sounds:
voice may be heard but 1. Crackles (fine)
the actual phrase cannot 2. Crackles (coarse)
be distinguished. Continuous sounds:
1. Pleural friction rub
Voice transmission will be 2. Wheeze (sibilant)
soft and muffled but the 3. Wheeze (sonorous)
letter “E” should be
distinguishable.
Transmission of sound is
very faint and muffled. It
may be inaudible.
The words are easily understood
and louder over of increased
density. This may indicate
consolidation from pneumonia,
atelectasis or tumor.
Over areas of consolidation or
compression the sound is louder
and sound like “ A.”
Over areas of consolidation or
compression, the sound is
transmitted clearly and distinctly.
In such areas, it sounds as if the
client is whispering directly into the
stethoscope.
THORAX AND LUNGS 15
 Table 1
NORMAL BREATH SOUNDS

Type Pitch Quality Amplitude Duration Location

Bronchial High Harsh or Loud Short during Trachea and
hollow inspiration long thorax
in expiration.
Bronchovesicular Moderate Mixed Moderate Same during Over the
inspiration and major bronchi-
expiration. posterior
between
scapulae;
anterior
around the
upper sternum
in the first and
second
intercostal
spaces
Vesicular Low Breezy Soft Long in Peripheral
inspiration lung fields.
short in
expiration.

Table 2
ADVENTITIOUS BREATH SOUNDS

Abnormal sounds Characteristics Source Associated

Conditions
Discontinuous
sounds
Crackles (fine)

High-pitched, short, Inhaled air suddenly

popping sounds opens the small, Crackles occurring
heard during deflated air passages late in inspiration are
inspiration and not that are coated and associated with
cleared with sticky with exudate. restrictive diseases
coughing; sounds are such as pneumonia
discontinuous and and congestive heart
can be stimulated by failure. Crackles
rolling a strand of hair occurring early in
between your fingers inspiration are
near your ear. associated with
obstructive disorder
such as bronchitis,
asthma or
emphysema.

THORAX AND LUNGS 16

Crackles Low-pitched, Inhaled air comes May indicate pneumonia,
(coarse) bubbling, moist into contact with pulmonary edema, and
sounds that may secretions in the pulmonary fibrosis. Velcro
persist from early large bronchi and rales of pulmonary fibrosis
inspiration to early trachea. are heard louder, and closer
expiration; also to stethoscope, usually do not
described as softly change location, and are
separating Velcro. more common in clients with
long-term COPD.
Continuous
Sounds
Pleural friction Low-pitched, dry, Sound is the result Pleuritus
rub grating sound; sound of rubbing of two
like crackles, only inflamed pleural
more superficial and surfaces.
occurring during both
inspiration and
expiration.
Wheeze High-pitched, Air passes through Sibilant wheezes are often
(Sibilant) musical sounds constricted heard in cases of acute
heard primarily passages (caused asthma or chronic
during expiration but by swelling, emphysema.
may also be heard secretions or
on inspiration. tumor.
Wheeze Low-pitched snoring Same as sibilant Sonorous wheezes are often
(Sonorous) or moaning sounds wheeze. The pitch heard in cases of bronchitis
heard primarily of the wheeze or single obstruction and
during expiration but cannot be snoring before an episode of
may be heard correlated to the sleep apnea. Stridor is a
throughout the size of the harsh, honking, wheeze with
respiratory cycle. passageway that severe
These wheezes may generates it. broncholaryngospasm such
clear with coughing. as occurs with croup.

THORAX AND LUNGS 17

 Table 3
RESPIRATORY PATTERNS

Type Description Clinical indication

Normal 12-20 bpm Normal breathing pattern
Tachypnea More than 24 breaths Maybe be normal response to fever,
per/min and shallow anxiety or exercise can occur with
respiratory insufficiency, alkalosis,
pneumonia or pleurisy.
Bradypnea Less than 10 BPM and May be normal in well-continued
regular athletes. Can occur with medication-
induced depression of the respiratory
center, diabetic coma, neurologic
damage.
Hyperventilation Increased rate and Usually occurs with extreme
increased depth. exercise, fear or anxiety. Cause of
hyperventilation include disorders of
the CNS, an overdose of the drug
salicylate or severe anxiety.
Kussmaul Rapid, deep, labored A type of hyperventilation associated
with diabetic ketoacidosis.
Hypoventilation Decreased rate, Usually associated with overdose of
decreased depth, narcotics or anesthetics.
irregular pattern.
Cheyne-Stokes Regular pattern May result from severe congestive
respiration characterized by heart failure, drug overdose,
alternating periods of increased intracranial pressure or
deep, rapid breathing renal failure. May be noted in elderly
followed by periods of persons during sleep, not related to
apnea. any disease process.

Biot respiration Irregular pattern Meningitis or severe brain damage.

characterized by varying
depth and rate of
respirations followed by
periods of apnea.
Ataxic Significant A more extreme expression of Biot
disorganization with respirations indicating respiratory
irregular and varying compromise.
depths of respiration.
Air trapping Increasing difficulty in In chronic obstructive pulmonary
getting breath out. disease, air is trapped in the lungs
during forced expiration.

THORAX AND LUNGS 18