CARDIOPULMONARY

ASSESSMENT
 INTRODUCTION
• The aim of assessment is to define the patient’s problems accurately.
• It is based on both a subjective and an objective assessment of the patient.
• The system of patient management is based on the problem oriented
medical system (POMS) first described by Weed in 1968.
• The POMR is now widely used as the method of recording the assessment,
management and progress of a patient. It is divided into five sections:
 Initial data from medical notes 1. Database

Subjective assessment

Objective assessment

Problem list 2. Problem list

Goal
-Short term 3. Initial plan
-Long term
No
Yes
Treatment plan
4. Progress note
Assess outcome of treatment

Is current Any further goal to

goal is met? address? 5. Discharge
summary
Discharge
DATABASE
• The database contains a concise summary of the relevant information about
the patient taken from the medical notes, together with the subjective and
objective assessment made by the physiotherapist.

• The first part contains the patient's personal details including name, date of
birth, sex, occupation, address, hospital number, patient number, and
referring doctor. It may also contain the diagnosis and reason for referral.

• The second part summarizes the history from the medical notes and the
physiotherapy assessment.
 Medical notes/records
• The first patient contact can be indirect, through the medical chart, or
direct, through patient interview.
• In the inpatient setting, a chart review is the first point of contact,
whereas in the outpatient population, the information may be only what is
obtainable from the patient.
• Important items to note within the medical record include the following:
1. Medical problems, past medical history, social history, accommodation,
physician’s examination
2. Medications, including type, dosage, and schedule
3. Other disorders requiring physiotherapy
 4. Conditions requiring precautions in relation to certain treatments, e.g. light-
headedness, bleeding disorder, history of falls, swallowing difficulty/tendency
to aspirate
5. Relevant investigations: chest x-ray, ECGs, ETT, cardiac catheterization, surgical
reports, hemodynamic monitors (e.g., pressure readings from central line and/
or arterial line)
6. Response to medical treatment
7. Recent cardiopulmonary resuscitation (requiring close X-ray examination in
case of gastric aspiration or fracture)
8. Possibility of bony metastases
9. Long-standing steroid therapy, leading to a risk of osteoporosis
10. History of radiotherapy over the chest.
Note: The last three findings contraindicate percussion or vibrations over the ribs.
• Laboratory tests:
• Blood tests for specific cardiac enzymes that may indicate an MI has
occurred, such as a positive CK-MB or troponin level
• Electrolytes, including potassium, and magnesium and calcium if
ventricular arrhythmias are present
• Complete blood count (CBC), which may indicate the presence of anemia
via the hemoglobin and hematocrit values
• Status of the kidney (BUN and creatinine) and liver function (liver function
tests)
• Presence of CAD risk factors, such as elevated lipid values (e.g., total
cholesterol, low-density lipoproteins [LDLs], triglyceride), and elevated
blood sugars (glucose)
• Arterial blood gases (ABGs)
SUBJECTIVE
ASSESSMENT
 Chief complaint
• Subjective assessment is based on an interview with the patient.
• Each chief complaint should be carefully explored. Supplementary
questions should be nonleading, using words the patient can easily
understand. This allows the interviewer to determine the significance of
the complaint.
• The four cardinal symptoms of chest disease are:
I. Breathlessness
II. Wheeze
III. Pain
IV. Cough (with or without sputum).
• With each of these symptoms, enquiries should be made concerning:
i. Duration - both the absolute time since first recognition of the symptom
(months, years) and the duration of the present symptoms (days, weeks)
ii. Severity - in absolute terms and relative to the recent and distant past
iii. Pattern - seasonal or daily variations
iv. Associated factors - including précipitants, relieving factors, and
associated symptoms, if any.

• The patient should describe, in his or her own words, the quality and
location of the symptom for which medical attention is being sought.
 I. Breathlessness (dyspnoea)
• Dyspnoea, breathlessness or shortness of breath, can be defined as the
sensation of difficulty in breathing (George, 1990). It is one of the most
common reasons that patients seek medical attention.
• It can also said to be the subjective awareness of an increased work of
breathing.
• It is, the predominant symptom of both cardiac and respiratory disease.
• It also occurs in anaemia where the oxygen-carrying capacity of the blood is
reduced, in neuromuscular disorders where the respiratory muscles are
affected, and in metabolic disorders where there is a change in the acid-
base equilibrium or metabolic rate (e.g. hyperthyroid disorders).
Breathlessness is also found in hyperventilation syndrome where it is due
to psychological factors (e.g. anxiety).
• The duration and severity of breathlessness is most easily assessed through
enquiries about the level of functioning in the recent and distant past.
• Patients may deny breathlessness if it has developed gradually.
• Significant breathlessness is indicated by a need to pause during undressing
or talking, or an inability to walk and talk at the same time.
• The time course of the appearance and progression of dyspnoea should be
identified.
• Dyspnea may also be related to body position. Therefore when evaluating
dyspnea, the patient should be asked if he or she has difficulty breathing
when reclining horizontally.
 Acute Dyspnea
• Acute dyspnea is common in pulmonary embolism, pneumothorax, acute
asthma, pulmonary congestion related to congestive heart failure (CHF),
pneumonia, and upper airways obstruction. Most of these conditions
require immediate physician evaluation of the acute problem before physical
therapy intervention.
• The therapist should ask several important questions to address the possible
causes of acute dyspnea:
• Are you short of breath at rest? If the answer is yes, it suggests a severe
physiological dysfunction. The patient likely needs prompt evaluation by a
physician if this is of recent onset and has not had a medical workup.
• Do you have chest pain'? If so what part of your chest? Unilateral localized chest
pain raises the possibility of spontaneous pneumothorax, pulmonary embolism,
or chest trauma.
 • What were you doing immediately before or at the time of onset of shortness of
breath? Approximately 75% of spontaneous pneumothoraces occur during
sedentary activity, 20% during some strenuous activity, and 5% are related to
coughing or sneezing.
• Do you have any major medical or surgical conditions? Cystic fibrosis, chronic
obstructive pulmonary disease (COPD), interstitial lung disease, and
malignancies are important causes of secondary spontaneous pneumothorax.

Dyspnea on Exertion (DOE)

• Subacute or chronic progression of dyspnea generally presents as
increasingly severe dyspnea with exertion over time.
• Dyspnea on exertion is a common complaint of patients with
cardiopulmonary dysfunction. Dyspnea during exercise or exertion usually
precedes dyspnea at rest. It most often is a result of chronic pulmonary
disease or CHF.
• It is important to establish the amount of activity required to produce
dyspnea. Various scales have been developed to categorize the level of
dyspnea and impairment present in patients:
• Diseases that involve the lungs or thoracic cage generally prevent external
respiration (ventilation) from keeping pace with internal respiration (in the
cells). In other words, patients outwalk or outrun their lungs during
activities or exertion.
• Hence, dyspnea on exertion in pulmonary patients is usually related to
hypoxic or hypercapnic stimuli.

Dyspnea in Cardiac Patients

• The cause of dyspnea in cardiac patients depends on whether an associated
stiffness of the lungs (fall in compliance) is also present.
• Dyspnea is the primary symptom of a decompensating left ventricle. As the
ventricle fails to eject the normal volume of blood, it produces chronic
pulmonary venous hypertension, congestion, and pulmonary edema,
resulting in stiff or less compliant lungs.
• Tachypnea is often seen at rest. Exercise exaggerates the pulmonary
congestion and edema, promotes arterial and mixed venous hypoxemia,
which also increases the amount of dyspnea and tachypnea manifested.
Fatigue, resulting from low cardiac output, also affects the respiratory
muscles, further increasing the sensation of breathlessness.

Orthopnea
• If breathlessness increases in supine it is called orthopnoea. It is dyspnea
brought on in the recumbent position.
• The patient may state the need for two or three pillows under the head to
rest at night.
• This symptom is commonly associated with CHF but may also be associated
with severe chronic pulmonary disease.
• In lung disease this is caused by pressure on the diaphragm from the
abdominal viscera.
• In heart disease a poorly functioning left ventricle is unable to tolerate the
increased volume of blood returning to the heart in supine.

Paroxysmal Nocturnal Dyspnea

• Paroxysmal nocturnal dyspnea (PND) is an important type of shortness of
breath. This symptom has strong predictive value as a sign of CHF.
• The patient usually falls asleep in the recumbent position, and 1 or 2 hours
later, awakens from sleep with acute shortness of breath. The patient sits
upright on the side of the bed or goes to an open window to breathe "fresh
air" to get relief from shortness of breath.
• Classic PND cannot usually be eliminated by only elevating the trunk
without lowering the legs. The patient must pool blood in the extravascular
tissues of the legs to get adequate relief, which usually takes at least 30
minutes. This is why the patient must sit up or stand up, and ambulate.

Platypnea
• Platypnea is the onset of dyspnea when assuming the sitting position from
the supine position.
• This unusual phenomenon is often found in patients with basilar pulmonary
fibrosis or basilar arteriovenous malformation. It can be related to the
redistribution of blood flow to the lung bases in the sitting position with
resultant ventilation-perfusion mismatching and hypoxemia.
 Trepopnea
• Trepopnea refers to dyspnea in one lateral position but not the other.
• It is often produced by unilateral respiratory system pathology such as
lung disease, pleural effusion, or airway obstruction.
• It also is commonly seen in patients with mitral stenosis. Occasionally it
may be the result of a fall in blood pressure in the left lateral decubitus
position.

Functional Dyspnea
• Functional dyspnea is defined as shortness of breath at rest but not during
exertion.
• The physical examination and pulmonary function tests are negative.
• Reassurance is usually all that is necessary.
 II. Wheeze
• Wheeze is a whistling or musical sound produced by turbulent airflow
through narrowed airways.
• These sounds are generally noted by patients when audible at the mouth.
• The feeling should be explained to patients as tightness of the chest on
breathing out, not just noisy, laboured or rattly breathing. Is the wheeze
aggravated by exertion or allergic factors, suggesting asthma?
• Patients that complain of wheezing associated with dyspnea may have
pulmonary or cardiac disease.
• This symptom, if first reported in patients over age 40, is often related to
heart failure. When confirmed that the wheezing is because of heart
disease, the patient is said to have cardiac asthma.
• However, if patients have a history of episodes of wheezing and dyspnea
since childhood, COPD, or asthma is the likely cause.
• Chronic pulmonary patients may also develop heart conditions, so it is
good to remember patients that complain of wheezing may have both
cardiac and pulmonary disease.
III. Pain
• Chest pain may be musculoskeletal, cardiac, alimentary or respiratory in
origin.
• Pleuritic pain:
• this denotes the nature of the pain rather than the pathology.
• It is sharp, stabbing and worse on deep breathing, coughing, hiccuping, talking
and being handled.
• It is not reproduced by palpation.
• Causes include pleurisy, some pneumonias, pneumothorax, fractured ribs or
pulmonary embolism.

• Tracheitis generally causes a constant burning pain in the centre of the

chest aggravated by breathing.
• Musculoskeletal (chest wall) pain may originate from the muscles, bones,
joints or nerves of thoracic cage.
• It is usually well localized and exacerbated by chest and/or arm movement.
• Palpation will usually reproduce the pain.

• Angina pectoris is a major symptom of cardiac disease.

• The classical presentation of angina is substernal chest pressure accompanied by
the Levine sign (the patient clenching his or her fist over the sternum). The
Levine sign has a high diagnostic accuracy for ischemia.
• Myocardial ischaemia characteristically causes a dull central retrosternal
gripping or band-like sensation which may radiate to either arm, neck or jaw.
• Pericarditis may cause pain similar to angina or pleurisy.
• The patient is often asked to rank his or her discomfort on the Angina Scale.
IV. Cough
• Coughing is a protective reflex which rids the airways of secretions or
foreign bodies. Any stimulation of receptors located in the pharynx, larynx,
trachea, or bronchi may induce cough.
• Cough is abnormal if it is persistent, painful or productive of sputum. It is
caused by inflammation, irritation, habit or excess secretions.
• Smokers may discount their early morning cough as being 'normal' when in
fact it signifies chronic bronchitis.
• A loud, barking cough, which is often termed 'bovine', may signify
laryngeal or tracheal disease.
• Interstitial lung disease is characterized by a persistent dry cough.
• A chronic productive cough every day is a fundamental feature of chronic
bronchitis and bronchiectasis.
• Nocturnal cough is an important symptom of asthma, in children, and young
adults, but in older patients—it is more commonly due to cardiac failure.
• Stress incontinence is a common complication of chronic cough, especially in
women. As this subject is often embarrassing to the patient, specific
questioning may be required.
• Sputum
• In a normal adult, approximately 100 ml of tracheobronchial secretions are
produced daily and cleared subconsciously.
• It may contain mucus, cellular debris, microorganisms, blood and foreign
particles.
• Questioning should determine the colour, consistency and quantity of sputum
produced each day. This may clarify the diagnosis and the severity of disease.

• Haemoptysis
• It is the presence of blood in the sputum It may range from slight streaking of
the sputum to frank blood.
• Isolated haemoptysis may be the first sign of bronchogenic carcinoma, even
when the chest radiograph is normal.
• Patients with chronic infective lung disease often suffer from recurrent
haemoptysis.
 OBJECTIVE
ASSESSMENT
• Objective assessment is based on examination of the patient, together with
the use of tests such as spirometry, arterial blood gases and chest
radiographs.

• A good examination will provide an objective baseline for the future

measurement of the patient's progress.

• By developing a standard method of examination, the findings are quickly

assimilated, and the physiotherapist remains confident that nothing has
been omitted.
 Vital Signs
• HR
• BP
• oxygen saturation (SaO2)
• respiratory rate
• Temperature
• and presence of pain (usually associated with SOB) should be examined
and documented.
 Physical examination
• The traditional components of a chest assessment are:
1. Visual inspection
2. Auscultation
3. Percussion
4. Palpation
 1. Visual inspection
Before each individual component of the assessment is discussed, a review
of the pertinent anatomical landmarks and topographical lines is to be
discussed.
TOPOGRAPHICAL ANATOMIC LANDMARKS
Key anatomical structures include the following:
• Sternum
• Clavicles
• Suprasternal notch
• Sterno-manubrial angle (angle of Louis)
• Costal angle
• Vertebra prominens
• Imaginary topographical lines are
used to more clearly describe any
physical findings (e.g., location of
surgical incisions, abnormal breath
sounds, etc).
 General Appearance
• Level of awareness (level of consciousness): alert, responsive, or cooperative
versus lethargic, disoriented, or inattentive
• Body type: normal, obese, or cachectic
• Color: cyanosis (bluish appearance) peripherally (nailbeds) or centrally (lips)
• Facial signs or expressions: focused or dilated pupils, nasal flaring, sweating,
or distressed appearance
• Jugular vein engorgement: visualization of the jugular venous pulse with the
patient supine and the head and neck on pillows at a 45 angle
• Hypertrophy of or use at rest of accessory muscles of ventilation: SCM, upper
trapezius
• Supraclavicular or intercostal retractions occurring with inspiration
• Use of pursed lip breathing (usually with expiration)
• Clubbing of digits: loss of angle between the nail bed and DIP joint
• Peripheral edema
 Skin
• Does the skin have a pink, healthy color versus a pallor?
• Is cyanosis present?
• Are any scars, bruises or ecchymoses observed?
• Are there reddened areas suggestive of prolonged pressure anywhere?
• Do the bony landmarks appear more prominent than usual?
• Are there any signs of trauma to the thorax or any other body parts?
• Does the skin appear edematous? Does this edema appear to limit joint
motion?
• Are there any surgical incisions, new and old?
• Do these incisions appear to be healed or seem reddened and swollen?
• Is there evidence of clubbing of the digits?
• The first sign of clubbing is the loss
of the angle between the nail bed
and the nail itself. Later, the finger
pad becomes enlarged.
• The nail bed may also become
'spongy', but this is a difficult sign to
elicit.
 Neck
• Are the accessory muscles of respirations being recruited for a resting
breathing pattern?
• Do the sternocleidomastoid or trapezius muscles appear prominent?
• This is an early sign of obstructive lung disease.
• Jugular venous distension
• The more superficial external jugular veins may be seen superior to the clavicles;
the internal jugular veins, though larger, lie deep beneath the
sternocleidomastoids and are less visible.
• Jugular venous distention (JVD) can be best seen when the patient lies with the
head and neck at an optimal angle of 45 degrees.
• Symmetry of JVD should be noted.
• The veins are distended bilaterally if there is a cardiac cause such as congestive
heart failure (CHF). A unilateral distention is an indication of a localized problem.
 Chest wall configuration
• The thorax should be observed both anteriorly and posteriorly.
• The symmetry of the thoracic cage should be noted.
• Any asymmetry should be observed from both anterior and posterior views.
• The anteroposterior (AP) and lateral dimensions are usually 1:2. Destruction
of the lung parenchyma results in an increase in the AP diameter and a
reduction of this ratio (up to 1:1). Common chest deformities include:
Barrel chest: The circumference of the upper chest appears larger than that
of the lower chest. The sternum appears prominent, and the AP diameter of
the chest is greater than normal.
Pectus excavatum (funnel breast): The lower part of the sternum is
depressed and the lower ribs flare out. Patients with this deformity are
diaphragmatic breathers.
Pectus carinatum (pigeon breast): The sternum is prominent and protrudes
anteriorly.
Flail chest: the chest wall moves inward with inspiration, such as with
multiple rib fractures.
 Breathing pattern
• Respiratory rate normally ranges between 12 and 20 breaths per minute
(bpm).
• Eupnea: normal breathing cycle
• Apnea: temporary halt in breathing
• Dyspnea describes the sensation of breathlessness or shortness of breath.
• Tachypnea: rapid, shallow breathing pattern ( >20 bpm); this is an indicator
of respiratory distress.
• Bradypnea exists when respiration is slowed, less than 12 bpm.
• Kussmaul's breathing is an increased rate and depth of respirations and is
associated with metabolic acidosis.
• Hyperventilation: Deep, rapid respiration; increased tidal volume and
increased rate of respiration; regular rhythm.
• Apneusis: Cessation of breathing in the inspiratory phase. Apneustic
breathing is characterized by prolonged inspiration, and is usually the result
of brain damage.
• Cheyne-Stokes: Cycles of gradually increasing tidal volumes followed by a
series of gradually decreasing tidal volumes and then a period of apnea.
This is sometimes seen in the patient with a severe head injury.
• Ataxic breathing consists of haphazard, uncoordinated deep and shallow
breams. This may be found in patients with cerebellar disease.
• The "normal" ratio of inspiratory time to expiratory time is 1:2. As the
respiratory rate increases this ratio decreases to 1: 1.
 2. Auscultation
• Auscultation is the art of listening to sounds produced by the body.
• Skill in auscultation is dependent on the following four factors:
1. A functional stethoscope
2. Proper technique
3. Knowledge of the different categories of lung sounds
4. Knowledge of the different categories of heart sounds and murmurs

STETHOSCOPE
• Any extraneous noises should be minimized or eliminated. This is especially
important when auscultation is a new technique for the therapist.
• The patient should be positioned sitting, if possible, for lung sounds.
• The anterior, lateral, and posterior aspects of the chest should be auscultated
both craniocaudally (apices to bases) and side to side.
• The PT places the diaphragm on the patient’s skin so that it lies flat.
• The patient is instructed to breath in and out through the mouth. A slightly
deeper breath than tidal breathing is suggested.
• A minimum of one breath per bronchopulmonary segment allows for a
comparison of the intensity, pitch, and quality of the breath sounds.
• Clothing should be removed and/or draped so that it does not interfere in
the assessment of the breath sounds.
 CHEST SOUNDS
I. Breath sounds- normal, abnormal, adventitious
II. Voice sounds- egophany, bronchophany, whispered pectoriloquy
III. Extrapulmonary sounds-pleural or friction rubs
IV. Heart sounds

V. Breath sounds
A. Normal breath sounds
• Therapist auscultates from top to bottom, the breath sounds are quieter at
the bases than at the apices.
• Infants and small children have louder, harsher breath sounds. This is as
result of the thinness of the chest wall and the airways being closer to its
surface.
• Inhalation and the beginning of
exhalation normally produce a
soft rustling sound. The end of
exhalation is normally silent.

• This characteristic of a normal

breath sound is termed
vesicular.

• When a louder, more hollow,

and echoing sound occupies a
larger portion of the
ventilatory cycle, the breath
sounds are referred to as
bronchial.
B. Abnormal breath sounds

• Abnormal sounds can be divided into three types: bronchial, decreased, and
absent.
• Bronchial (eg. Consolidated pneumonia): Sound from the adjacent bronchi
is enhanced and becomes more high-pitched and the expiratory component
louder and more pronounced.
• Decreased breath sounds are when the normal vesicular sounds are further
diminished.
• Absent sounds are when no sounds are audible.
• Decreased or absent sounds can be caused by an internal pulmonary
pathology or can be secondary to an initially non-pulmonary condition.
C. Adventitious breath sounds

• Adventitious sounds are classified as crackles (rales), rhonchi, and wheezes.

• Crackles (rales) are described as discontinuous, low-pitched sounds. sound
like the “rustling of cellophane” and have a multitude of potential causes
(tissue fibrosis, secretions in the airways, and so forth). They occur
predominantly during inspiration. Crackles usually indicate a peripheral
airway blockage.
• Rhonchi are low pitched but continuous sounds. These occur both in
inspiration and expiration. “Snoring” is a term used to describe its quality.
Rhonchi are attributed to an obstructive process in the larger, more central
airways.
• Wheezes are continuous but high-pitched. A “hissing or whistling” quality is
present. Wheezes predominantly occur during expiration and are an
indication of bronchospasm (i.e., asthma).
 II. Voice Sounds

• Voice sounds are vibrations produced by the speaking voice as it travels down the
tracheobronchial tree and through the lung parenchyma when heard with a
stethoscope.
• These sounds, over the normal lung, are low-pitched and have a muffled or
mumbled quality.
• Bronchophany describes the phenomenon of increased vocal transmission.
• Egophany is also described when there is increased transmission of the vocal
vibrations. In this case, the patient is asked to say “eeee”.
• Whispered pectoriloquy describes when whispered voice sounds become distinct
and clear; "one, two, three" or "ninety-nine" are used to evaluate this sound.
 III. Extrapulmonary Sounds

• An adventitious sound that is nonpulmonary is the friction rub.

• It can be described as a rubbing or leathery sound and occurs during both
inspiration and expiration.
• The sound is produced by the visceral (inner) pleural lining rubbing against the
parietal (outer) pleura.
 IV. Heart sounds

There are four reference areas for cardiac auscultation:

• Aortic: 2nd ICS, at right sternal border (RSB)
• Pulmonic: 2nd ICS, at left sternal border (LSB)
• Tricuspid: 4th-5th lCS, LSB
• Mitral: cardiac apex 5th ICS, Midclavicular line (MCL).
• Normal heart sounds are identified as S1 (lub), which occurs at the time of the
closure of the mitral (and tricuspid) valve and marks the beginning of systole.
• S2 (dub), which occurs at the time of aortic (and pulmonic) valve closure and
marks the end of systole.
• Murmurs are abnormal heart sounds commonly the result of valvular
disorders due to the changes in blood flow around and through the altered
valve.
• A systolic murmur will present as audible turbulence between S1 and S2, and
a diastolic murmur as turbulence between S2 and S1.
• Other abnormal sounds are S3 and S4. S3, also known as a ventricular gallop,
occurs after S2 and is clinically associated with LV failure. S4, also known as
an atrial gallop, occurs before S1 and is clinically associated with an MI or
chronic HTN.
 Technique:
• Positions used for cardiac auscultation include the following: supine-used for
all areas; left lateral decubitus (side lying)-listening to cardiac apex or mitral
area, bell usually used; and sitting used for all the areas.

• The first heart sound (S1) signifies the closing of the atrioventricular valves.
Its duration is 0.10 seconds; it is heard the loudest at the cardiac apex.

• S2: The pulmonic component is best heard at the LSB, in the second to
fourth ICS.

• S3 (gallop): The ideal position to hear S3 would be left side lying; the bell
would be placed over the cardiac apex. "Ken-TUCK' -y“

• S4: "TENN'-ess-ee“. Location of S4 is similar to S3.

 3. Mediate Percussion
• Mediate percussion is an examination technique designed to assess lung
density, specifically, the air-to-solid ratio in the lungs.
• Striking the chest wall produces vibrations in the underlying structures
which, in turn, gives rise to sound waves or percussion tones.

• These tones are described by the following terms:

• Resonant: loud or high amplitude, low-pitched, longer duration, heard over air-
filled organs such as the lungs
• Dull: low amplitude, medium to high-pitched, short duration, heard over solid
organs such as the liver
 • Flat: high-pitched, short duration, heard over muscle mass
such as the thigh
• Tympanic: high-pitched, medium duration, heard over
hollow structures such as the stomach
• Hyper-resonant: very low-pitched, prolonged duration,
heard over tissue with decreased density (increased air:
tissue ratio); abnormal in adults; heard over lungs with
emphysema.

Technique:
• Place the middle finger of the nondominant hand flat
against the chest wall along an intercostal space. With
the tip of the middle finger of the opposite hand, firmly
tap on the finger positioned on the chest wall.
• Repeat the procedure at several points on the right and left and anterior and
posterior aspects of the chest wall, remembering that the upper lobe
predominates anteriorly and lower lobe posteriorly.

• The subjective determination of pitch indicates the following.

• The sound is dull and flat if there is a greater than normal amount of solid matter
(tumor, consolidation) in the lungs in comparison with the amount of air.
• The sound is hyperresonant (tympanic) if there is a greater than normal amount of air
in the area (as in patients with emphysema, pneumothorax, bulla).
• In situations where the chest wall is unable to move freely, as may occur in obese
patients, the percussion note may sound dull, even if the underlying lung is normal.

• This technique is not usually used in infants, since percussion is too easily
transmitted by a small chest.
 Diaphragmatic Excursion
• Assessment of diaphragmatic movement can be made with mediate
percussion.
• The patient is asked to breathe deeply and hold that breath. The lowest
level of the diaphragm on maximal inspiration coincides with the lowest
point where a resonant tone is heard.
• The patient is then asked to exhale, and mediate percussion is repeated.
The lowest area of resonance now moves higher, as the diaphragm ascends
with relaxation.
• The distance between these two points is described as the diaphragmatic
excursion; normal is 3-5 cm.
• Diaphragmatic movement is decreased in patients with COPD.
 4. Palpation
• Palpation of the thorax provides evidence of dysfunction of the underlying
tissues including the lungs, chest wall, and mediastinum.
I. Breathing sequence
• To assess the breathing sequence, have the patient assume a comfortable
position (semireclining or supine). Place your hands on the patient’s
epigastric region and sternum to observe movements in these two areas.
• The normal sequence of inspiration at rest is
(1) the diaphragm contracts and descends and the abdomen (epigastric
area) rises;
(2) this is followed by lateral costal expansion as the ribs move up and out;
and finally
(3) the upper chest rises.
 II. Chest mobility
• This can be assessed by observation, but
palpation is more accurate.
Procedure:
• Place your hands on the patient’s chest and
assess the excursion of each side of the
thorax during inspiration and expiration.
Each of the three lobar areas can be checked.
i. To check upper lobe expansion, face the
patient; place the tips of your thumbs at
the midsternal line at the sternal notch.
Extend your fingers above the clavicles.
Have the patient fully exhale and then
inhale deeply.
ii. To check middle lobe expansion, continue to face the patient; place the
tips of your thumbs at the xiphoid process and extend your fingers laterally
around the ribs. Again, ask the patient to breathe in deeply.
iii. To check lower lobe expansion, place the tips of your thumbs along the
patient’s back at the spinous processes (lower thoracic level) and extend
your fingers around the ribs. Ask the patient to breathe in deeply.
III. Extent of excursion
The extent of chest mobility can be measured by two methods.
i. Chest wall excursion can be determined by circumferential chest
measures using a tape measure at specific bony landmarks. Three
common landmarks for circumferential chest measures are: (1) the
sternal angle of Luis; (2) the xiphoid process; and (3) midway between
the xiphoid process and the umbilicus.
ii. Place both hands on the patient’s chest or back as previously described.
Note the distance between your thumbs after a maximum inspiration.

• Symmetry and extent of movement are both noted.

• Normal chest wall excursion is about 3.25 inches (8 cm) in a young adult
between 20 to 30 years of age.
IV. Tactile (vocal) fremitus
• Tactile fremitus is the vibration felt while palpating over
the chest wall as a patient speaks.
Procedure:
• Place the palms of your hands lightly on the chest wall
and ask the patient to speak a few words or repeat “99”
several times. The sequence is, again cephalocaudal and
side to side.
• Normally, fremitus is felt uniformly on the chest wall.
• Fremitus is increased in the presence of secretions in the
airways (consolidation) and decreased or absent when air
is trapped as the result of obstructed airways
(pneumothorax, pleural effusion).
 V. Mediastinal shift
• The position of the trachea normally is oriented centrally in relation to the
suprasternal notch indicating symmetry of the mediastinum.
• The position of the trachea shifts as the result of asymmetrical intrathoracic
pressures or lung volumes (pneumonectomy, haemothorax).
Procedure:
• To identify a mediastinal shift, have the patient sit facing you with the head
in midline and the neck slightly flexed to relax the sternocleidomastoid
muscles.
• With your index finger, gently palpate the soft tissue space on either side of
the trachea at the suprasternal notch.
• Determine whether the trachea is palpable at the midline or has shifted to
the left or right.
VI. Chest wall pain
• Specific areas or points of pain over anterior, posterior, or lateral aspects of
the chest wall can be identified with palpation.
Procedure:
• Firmly press against the chest wall with your hands to identify any specific
areas of pain potentially of musculoskeletal origin. Ask the patient to take a
deep breath and identify any painful areas of the chest wall.
• Chest wall pain of musculoskeletal origin often increases with direct point
pressure during palpation and during a deep inspiration.
• Pain in the anterior, posterior, or lateral region of the chest can be of
musculoskeletal, pulmonary, or cardiac origin.
 CHEST RADIOGRAPHY
• The chest X-ray provides a unique insight into the state of the lungs and
chest wall.
• For an optimum view of the lungs, the patient is taking a deep breath in
the standing position with shoulders abducted, so that the medial borders
of the scapulae do not obscure the lungs.
• The erect position ensures that gas passes upwards, so that a
pneumothorax is easier to detect, and fluid passes downwards, so that a
pleural effusion is easier to see.
 • Preliminary checks
✔ The patient's name
✔ Date
✔ View: PA, AP, Lateral etc.
✔ Exposure
✔ Symmetry: Symmetry is correct if the
spinous processes, which appear as
teardrop shapes down the spine, are
midway between the medial ends of
the clavicles.
 Trachea
• The dark column of air overlying the upper vertebrae represents the
trachea, which is in the midline down to the clavicles and is then displaced
slightly to the right by the aortic arch before branching into the main
bronchi.
• It may move with the mediastinum if the heart is displaced.
 Heart
• Size: The transverse diameter is normally less
than half the internal diameter of the chest in the
PA film.
• An apparently big heart could be the result of
ventricular enlargement, pulmonary hypertension
or poor inspiratory effort.
• A narrow heart is caused by hyperinflation, when
the diaphragm pulls down the mediastinum.
• Shape : In right ventricular hypertrophy, the
heart is boot-shaped, i.e. enlarged with the apex
lifted off the diaphragm.
• A rounded heart might indicate pericardial effusion.
• Position: The heart is normally extended slightly left of
midline.
• If pushed away from, indicates a large pleural effusion, or
tension pneumothorax and if pulled towards, indicates a
significant unilateral collapse, resection or fibrosis.
• Borders: These are obscured (silhouette sign) if there is a
lesion abutting the heart, e.g. in middle lobe consolidation
or collapse.
• Specific lobes are collapsed or consolidated if the following
borders are obscured:
• LLL: left hemidiaphragm
• RLL: right hernidiaphragm
• LUL: aortic arch
• RUL: right upper mediastinum
• lingula: left heart border
• middle lobe: right heart border.
 Diaphragm
• Height : On full inspiration, the diaphragm should be level with the 6th rib
anteriorly, 8th laterally and 1 0th posteriorly, with the right side about 2 cm
higher than the left because it is pushed up by the liver. A low, flat
diaphragm suggests hyperinflation.
• An elevated diaphragm could be:
- positional as in an AP film
- physiological due to lack of a full Inspiration
- pathological due to pressure from below
• If one side of the diaphragm is raised, this could be due to lower lobe
atelectasis, paralysed hemidiaphragm or, on the left, excess gas in the
stomach.
• Shape : The diaphragm should be domeshaped and smooth. Flattening is
caused by hyperinflation. Tenting is caused by fibrotic lungs pulling
upwards.
• Costophrenic angles: The normal acute angle may be obliterated by the
patchy shadow of consolidation or the meniscus of a small pleural effusion.

Lung field
• Lungs that are too dark suggest hyperinflation. Lungs that are too white
usually indicate infiltrates or consolidation.
• Vascular markings: The fine white lines fanning out from the hila are blood
vessels.
• Diffuse shadowing:
• ground glass appearance, a hazy density like a thin veil
over the lung, suggesting alveolar pathology
• reticular or a coarser honeycomb pattern, representing
progressive damage in interstitial disease.
• Localized opacities and unilateral white-out
• Ring shadows. These represent:
• A bulla
• Abscess
• Cyst
 Bones
• The bones are examined with care following
cardiopulmonary resuscitation or other trauma,
or if the patient is suspected of having
osteoporosis or malignant secondary deposits.
• A fresh rib fracture is seen as a discontinuation
of the border of the rib, to be distinguished
from overlapping structures that can be
misleading.
• Old fractures are identified by callous
formation.
• Bony secondaries may appear as densities.
 REFERENCES
• Jennifer A Pryor et al. Physiotherapy for respiratory and cardiac problems. 2 nd ed. Churchill
livingstone.

• Donna Frownfelter et al. Principles and practice of cardiopulmonary physical therapy.Third edition.
Mosby.

• Alexandra Hough. Physiotherapy in respiratory care. 3rd ed.

• Carolyn Kisner and Lynn Allen Colby. Therapeutic exercise foundations and techniques. F i f t h e d i t
i o n. F. A. Davis company

• Susan B. O’Sullivan et al. Physical rehabilitation. 6th ed. F.A. Davis company.
TREATMENT PLANS
 BREATHING EXERCISES AND
VENTILATORY TRAINING
• Breathing exercises and ventilatory training can take on many forms
including:
1. diaphragmatic breathing,
2. segmental breathing,
3. inspiratory resistance training,
4. incentive spirometry, and
5. breathing techniques for the relief of dyspnea during exertion.
 1. Diaphragmatic Breathing
• Controlled breathing techniques, which emphasize diaphragmatic
breathing, are designed to improve the efficiency of ventilation, decrease
the work of breathing, increase the excursion (descent or ascent) of the
diaphragm, and improve gas exchange and oxygenation.
Procedure
• Prepare the patient in a relaxed and comfortable position in which gravity
assists the diaphragm, such as a semi- Fowler’s position.
• Instruct the patient to relax the accessory muscles of inspiration (shoulder
and neck musclulature)e.g., shoulder rolls or shrugs coupled with
relaxation.
• Place your hand(s) on the rectus abdominis just below the anterior costal
margin. Ask the patient to breathe in slowly and deeply through the nose.
Have the patient keep the shoulders relaxed and upper chest quiet, allowing
the abdomen to rise slightly.
• Then tell the patient to relax and exhale slowly (not forcefully) through the
mouth.
• To learn how to self-monitor this sequence, have the patient place his or her
own hand below the anterior costal margin and feel the movement. The
patient’s hand should rise slightly during inspiration and fall during
expiration.
• Repeat 3-4 times, then rest (do not allow the patient to hyperventilate).
 2. Segmental breathing
• In this breathing technique patient is taught to expand localized areas of
the lungs while keeping other areas quiet.
• Two examples of segmental breathing that target the lateral and posterior
segments of the lower lobes are described in here.

i. Lateral Costal Expansion

• Lateral costal expansion, sometimes called lateral basal expansion, can be
carried out unilaterally or bilaterally.
• This technique is particularly important for the patient with a stiff lower rib
cage, as is often seen with chronic bronchitis, emphysema, or asthma.
 Procedure
• Have the patient begin in a hook-lying position; later progress to a sitting
position. Place your hands along the lateral aspect of the lower ribs to
direct the patient’s attention to the areas where movement is to occur.
• Ask the patient to breathe out, and feel the rib cage move downward and
inward.
• Just prior to inspiration, apply a quick downward and inward stretch to the
chest. This places a quickstretch on the external intercostals to facilitate
their contraction.
• Apply light manual resistance to the lower ribs to increase sensory
awareness as the patient breathes in deeply and the chest expands and
ribs flare.
• Then, as the patient breathes out, assist by gently squeezing the rib cage in
a downward and inward direction.
 ii. Posterior Basal Expansion
• Deep breathing emphasizing posterior basal expansion is important for
the postsurgical patient who is confined to bed in a semireclining position
for an extended period of time because secretions often accumulate in the
posterior segments of the lower lobes.
Procedure
• Have the patient sit and lean forward on a pillow, slightly bending the hips.
• Place your hand over posterior aspect of lower ribs then perform the same
procedure as lateral costal expansion.
 3. Pursed-Lip Breathing
• Pursed-lip breathing is a strategy that involves lightly pursing the lips
together during controlled exhalation. This breathing pattern often is
adopted spontaneously by patients with COPD to deal with episodes of
dyspnea.

4. Preventing and Relieving Episodes of Dyspnea

• It is helpful to teach a patient how to monitor his or her level of shortness
of breath and to prevent episodes of dyspnea by controlled breathing
techniques, pacing activities, and becoming aware of what activity or
situation precipitates a shortness of breath attack.
 Procedure
• Have the patient assume a relaxed,
forward-bent posture. Have the patient
gain control of his or her breathing and
reduce the respiratory rate by using pursed-
lip breathing during expiration.
• After each pursed-lip expiration, teach the
patient to use diaphragmatic breathing and
minimize use of accessory muscles during
each inspiration.
• Have the patient remain in a forward-bent
posture and continue to breathe in a slow,
controlled manner until the episode of
dyspnea subsides.