Abnormal Breathing patterns

Dyspnea- distressed, labored breathing as the result

of shortness of breath
Tachypnea- rapid, shallow breathing; decreased TV
but increased rate; associated with restrictive or
obstructive lung disease and use of accessory
muscle of inspiration
Bradypnea- slow rate with shallow or normal depth
and regular depth rhythm; may be associated with
drug overdose
Hyperventilation- deep rapid respiration; increased
TV and increased rate of respiration; regular rhythm

 Orthopnea- difficulty in breathing in supine

position
Apnea- cessation of breathing in the expiratory
phase
Apneusis- cessation of breathing in the
inspiratory phase
Cheyne stokes- cycles gradually increasing tidal
volume, followed by a series of gradually
decreasing tidal volume, and then a period of
apnea. This is sometimes seen the patient with
a severe head injury

Chest Mobility
Symmetry of chest movement
Place your thumbs along each costal
margin, your hands along the lateral rib
cage
Slide hands medially; to raise loose skin
folds between your thumbs.
Ask the patient to inhale deeply.
Observe how far your thumbs diverge as
the thorax expands, and feel for the extent
and symmetry of respiratory movement.

 Lag
Movement of 1
hemithorax lesser
than the other

Splinting
Protective fixation
of the chest 2 to
pain or surgery

Extent of excursion
Can also be measured in three levels:
under the axillae for apical expansion
nipple line or xiphisternal junction for
midthoracic expansion,
TIO rib level for lower thoracic
expansion.

The normal difference between

inspiration and expiration is 3 to 7.5
cm(1 to 3 inches)

Palpation
Tactile fremitus
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.
Fremitus is increased in the presence of
secretions in the airways and decreased or
absent when air is trapped as the result of
obstructed airways.

 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.
Hyperresonant (tympanic) if there is a
greater than normal amount of air in the
area (as in patients with emphysema).
If asymmetrical or abnormal findings are
noted, they should be referred to the
physician for additional objective tests such
as a chest radiograph.

Chest wall pain

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

Mediastinal Shift
Position of the trachea centrally
The position of the trachea shifts as the
result of asymmetrical intrathoracic
pressures or lung volumes.
pneumonectomy (removal of a lung), the lung
volume on the operated side decreases, and the
trachea shifts toward that side.
Hemothorax (blood in the thorax), intrathoracic
pressure on the side of the hemothorax increases,
and the mediastinum shifts away from the affected
side of the chest.

Ipsilateral

Contralateral

(To pull)

( To push)

Collapse
Fibrosis

Apical mass
Pleural effusion
Pneumothorax

Mediate Percussion
Technique to assess lung density,
specifically, air-to-solid ratio in the
lungs.

 Hyperextend the middle finger of one

hand and place the distal
interphalangeal joint firmly against
the patient's chest.
With the end (not the pad) of the
opposite middle finger, use a quick
flick of the wrist to strike first finger.
Categorize what you hear as normal,
dull, or hyperresonant.

 Dull and Flat solid > air (tumor,

consolidation)
Hyperresonant air > solid
(emphysema)

Auscultation of breathe
sounds
Purpose:
identify congested lungs and
effectiveness or discontinue of
pulmonary drainage

Auscultation of breathe sounds

Classification of breath sounds

Normal breathing sounds
Vesicular
soft low pitched
breezy but faints sounds heard over most of
the chest except near the trachea and
mainstem bronchi and between the
scapulae.
Audible considerably longer on inspiration
than expiration (3:1)

 Bronchial
loud, hollow, or tubular, high pitched sound heard over
the mainstem bronchi and trachea.
Bronchial sounds heard equally during inspiration and
expiration
a slight pause in the sounds occurs between inspiration
and expiration

Bronchovesicular
softer than bronchial breath sounds
also heard equally during inspiration aand expiration but
without a pause in the between cycles.
Heard in the supraclavicular, suprascapular, and para
sternal regions anteriorly and between the scapulae
posteriorly

Adventitious breath sounds

Crackles
fine discontinues sounds
Can be fine or coarse, are heard primarily during
inspiration as the result of secretions moving in the
airways or in closed airways that are rapidly reopening.
Former term was rales.

Wheezes
continuous high or low pitched sounds or sometimes
musical tones heard during exhalation but occasionally
audible during inspiration.
Bronchospasm or secretions that narrow the lumen of the
airways cause wheezes.
Former termed as rhonchi.

 Breathe sounds may also be totally

absent or substantially diminished over a
portion of the lungs.
This indicated total or partial obstruction
and lack of aeration of lung tissue.
Atelectasis - Absence of air and collapse
of an area of lung tissue is known due to
obstruction of airways, by fluids, mucus,
bronchospasm, or compression by tumor.

Cough and cough production

Strength, depth, length and
frequency of patients cough must be
assessed. An effective cough is sharp
and deep.
In the patient with current or
potential pulmonary dysfunction a
cough can be described as weak,
shallow soft, or throaty.

 Clear but copious chronic bronchitis

Pink/ white, frothy - pulmonary edema, CHF
Green, purulent, foul smell - acute infection
/ pus
Yellow - infection starting to clear
Gray - abcess / emphysema
Rust - pneumonia
Purple - neoplasm
Blood streaked - hemorrhage in the lungs

Other areas of examination

ROM, particularly of the shoulders
and trunk
MMT
General endurance and graded
exercise testing
Functional abilities or limitations
Use of assistive respiratory
equipment

Breathing Exercise and

Ventilatory training
Improve or redistribute ventilation
Increase the effectiveness of the cough
mechanism and promote airway
clearance
Prevent postoperative pulmonary
complications
Improve strength, endurance, and
coordination of the muscles ventilation.

 Maintain or improve chest and thoracic

spine mobility.
Correct inefficient or abnormal breathing
patterns and decrease the work of breathing
Promote relaxation and relive stress
Tech the patient how to deal with episodes
of dyspnea
Improve a patients overall functional
capacity for daily living, occupational, and
recreational activities.

Guidelines for teaching

breathing exercise
Choose a quiet area for instruction in which you can
interact with the patient with minimal distraction
Explain to the patient the aims and rationale of
breathing exercises or ventilatory training specific to
his or her particular impairments and functional
limitations
Position the patient in a semi fowler position with the
head and trunk elevated approximately 45 degrees.
Other positions such as supine sitting, or standing
may be used initially or as the patient progress the
treatment
Observe and asses the patients spontaneous
breathing pattern while at rest and later with activity

 Determine whether or not ventilatory training

is indicated
Establish a baseline for assessment of change,
progress, and outcomes of intervention.
If necessary, teach the patient relaxation
techniques.
Depending on the patients underlying
pathology and impairments determine whether
to emphasize the inspiratory or expiratory
phase of ventilation.
Demonstrate the desired breathing pattern to
the patient
Have the patient practice the correct breathing
pattern in a variety of positions at rest and with
activity

Precautions
Never allow a patient to force expiration
Do not allow a patient to take a very
prolonged expiration
Do not allow the patient to initiate
inspiration with the accessory muscles and
the upper chest
Allow the patient to perform deep
breathing for only three or four inspirations
and expirations at a time to avoid
hyperventilation

Diaphragmatic breathing
Improve the efficiency of ventilation
Decreases the work of breathing,
Increases the excursion of the
diaphragm
Improves gas exchange and
oxygenation
Mobilize lung secretions during
postural drainage

 Position the patient in a semi fowlers

position
If you have noted in the examination that
the patient initiates the breathing pattern
with the accessory muscles of inspiration,
start instruction by teaching the patient
how to relax those muscles.
Place your hand 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 and upper chest quiet, allowing
the abdomen to rise. Then tell the patient to
slowly let all the air out using controlled
expiration.

 Have the patient practice the practice this three or

four times and then rest.
If the patient is having difficulty using the diaphragm
during inspiration, have the patient inhale several
times in succession through the nose by using a
sniffing action
Have the patient place his or her own hand below the
anterior costal margin and feel the movement. The
patients hand should rise during inspiration and fall
during expiration. By placing one hand on the
abdomen, the patient can also feel the contraction of
the abdominal muscles, which occurs with controlled
expiration or coughing.
After the patient understands is able to control
breathing using a diaphragmatic pattern, keeping the
shoulders relaxed, practice diaphragm breathing in a
variety positions