Pulmonary

Assessme
nt
STRUCTURE AND
FUNCTION
Respiration
is a general term used to describe gas exchange within the body
and can be categorized as either external respiration or internal
respiration

External respiration
describes the exchange of gas at the alveolar-capillary membrane
and the pulmonary capillaries.
Internal respiration
describes the exchange of gas between the pulmonary
capillaries and the cells of the surrounding tissues. I
occurs when oxygen in arterial blood diffuses from red
blood cells into tissues requiring oxygen for function
reverse occurs with carbon dioxide transport
 Ventilation
as it refers to the respiratory system, is the mass exchange
of air to and from the body during inspiration and
expiration.
This cyclic process requires coordinated ventilatory muscle
activity, rib cage movements, and appropriate structure and
function of the upper and lower respiratory tracts
 Thorax and Chest Wall:
Structure and Function
The main functions of the thoracic
cage, also referred to as the chest
wall, are to:
 protect the internal organs of
respiration, circulation, and
digestion
participate in ventilation of the
lungs.
thoracic cage
provides the site of attachment for the
muscles of ventilation to mechanically
enlarge the thorax for inspiration or to
compress the thorax for expiration.
site of attachment of upper extremity
muscles, which function during lifting,
pulling, or pushing activities(activities
usually are carried out in conjunction with
inspiratory effort)
THORACIC CAGE
MECHANISM
Sternum and Ribs 8-12
Ribs 1-6 Caliper motion
Pump handle motion

Ribs 7-10 Diaphragm

Bucket handle motion Piston action
Components of the
Assessment
HISTORY AND SYSTEMS REVIEW
EXAMINATION PROCESS BEGINS WITH A PATIENT’S HISTORY
INCLUDING AN INTERVIEW WITH THE PATIENT AND SOMETIMES
FAMILY MEMBERS IF THEY ARE AVAIL ABLE. DURING THE INTERVIEW
A THERAPIST CAN IDENTIFY A PATIENT’S AND/OR FAMILY
MEMBERS’ PERCEPTION OF ANY FUNCTIONAL LIMITATIONS OR
DIS ABILITIES AND DETERMINE A PATIENT’S CHIEF COMPL AINTS
AND WHY HE OR SHE IS SEEKING TREATMENT. IN PREPARATION
FOR THE INTERVIEW, THE MEDICAL HISTORY AND ANY MEDICAL
DIAGNOSES ARE OBTAINED FROM THE PATIENT’S MEDICAL
RECORD, IF AVAIL ABLE, OR MORE GENERALLY, FROM THE PATIENT
OR FAMILY. RELEVANT OCCUPATIONAL AND SOCIAL HISTORY ARE
OBTAINED; PARTICUL ARLY IMPORTANT ARE ON-THE- JOB PHYSICAL
DEMANDS, THE ENVIRONMENT OF THE WORKPL ACE, AND SOCIAL
HABITS THAT AFFECT A PERSON’S WELL-BEING, SUCH AS TOBACCO
OR ALCOHOL USE. ASSESSMENT OF THE HOME OR FAMILY
ENVIRONMENT MIGHT INCLUDE A PATIENT’S FAMILY RESPONSIBILI
GENERAL APPEARANCE OF THE PATIENT
Analysis of Chest Shape and
Dimension
Symmetry of the Chest and Trunk
Mobility of the Trunk
Shape and Dimensions of the Chest
◦ A-P and lateral dimensions are usually 1:2
◦ Chest deformities:
1. Barrel Chest
Upper chest circumference > lower chest circumference
2. Pectus Excavatum (funnel chest/funnel breast)
The lower part of the sternum is depressed and the lower ribs flare out.
Diaphragmatic breathers
3. Pectus carinatum (pigeon breast)
The sternum is prominent and protrudes anteriorly.
Posture or Preferred Positioning
Breathing Pattern
Assess the rate, regularity, and location of ventilation at rest and with activity
(N) = 12 -20 cpm
normal ratio of inspiration to expiration at rest is 1:2 and with activity 1:1; COPD – 1:4 at rest
Abnormal Breathing Patterns
 Dyspnea. Distressed, labored breathing as the result ofshortness of breath.
 Tachypnea. Rapid, shallow breathing; decreased tidal volume but increased rate;
associated with restrictive or obstructive lung disease and use of accessory muscles of
inspiration.
 Bradypnea. Slow rate with shallow or normal depth and regular rhythm; may be
associated with drug overdose.
 Hyperventilation. Deep, rapid respiration; increased tidal volume and increased rate of
respiration; regular rhythm.
 Orthopnea. Difficulty breathing in the supine position.
 Apnea. Cessation of breathing in the expiratory phase.
 Apneusis. Cessation of breathing in the inspiratory phase.
 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.
Chest Mobility
Symmetry of Chest Movement
◦ Upper lobe expansion
◦ Middle lobe expansion
◦ Lower lobe expansion

Extent of Excursion
Method 1: use tape measure (measure at axilla, xiphoid, lower costal)
Method 2: distance between thumbs
 Palpation
Tactile (Vocal) Fremitus
- the vibration felt while palpating over the chest wall as a patient speaks
- increased in the presence of secretions; decreased or absent when air is trapped

Chest Wall Pain

Mediastinal Shift
◦ Pneumonectomy – trachea shifts on the operated side
◦ Hemothorax – mediastinum shifts away from the affected side
Mediate Percussion
- Assessment for lung density
- dull and flat if there is a greater than normal amount of solid matter
- hyperresonant (tympanic) if there is a greater than normal amount of air in the area
Auscultation of Breath Sounds
Breath sounds should be assessed to:
◦ Identify the areas of the lungs in which congestion exists and in which airway clearance techniques
should be performed.
◦ Determine the effectiveness of any airway clearance intervention.
◦ Determine whether the lungs are clear and whether interventions should be discontinued.
Classification of Breath Sounds
Normal Breath Sounds
Vesicular. Soft, low-pitched, breezy but faint sounds heard over most of the chest except near
the trachea and mainstem bronchi and between the scapulae.
Bronchial. Loud, hollow, or tubular high-pitched sounds heard over the mainstem bronchi and
trachea. Bronchial sounds are heard equally during inspiration and expiration; a slight pause in
the sound occurs between inspiration and expiration.
Bronchovesicular. Softer than bronchial breath sounds; also heard equally during inspiration
and expiration but without a pause in the sound between the cycles. The sounds are heard in
the supraclavicular, suprascapular, and parasternal regions anteriorly and between the scapulae
posteriorly.
Adventitious Breath Sounds
Crackles. Fine, discontinuous sounds (similar to the sound of bubbles popping or the sound of hairs
being rubbed between your fingers next to your ear). Crackles, which 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. The former term for crackles 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. The term previously used for wheezes was rhonchi.
Cough and Cough Production
The strength, depth, length, and frequency of a patient’s cough must be assessed.
Secretions are checked for:
◦ Color (clear, yellow, green, blood-stained)
◦ Consistency (viscous, thin, frothy)
◦ Amount (minimal to copious)
◦ Odor (no odor to foul-smelling)

Clear or white – normal

Copious but clear – chronic bronchitis
Yellow, green, purulent with strong odor – infection
Hemoptysis (blood-streaked secretions) – hemorrhage in the lungs
Frothy, white secretions – pulmonary edema and heart failure
BREATHING EXERCISES AND VENTILATORY
TRAINING
BREATHING EXERCISES:
Diaphragmatic Breathing
BREATHING EXERCISES:
Segmental Breathing
emphasize expansion of problem areas of the lungs and chest wall
Two examples of segmental breathing that target the lateral and posterior segments of the
lower lobes are described in this section. However, segmental breathing techniques also may
need to be directed to the middle and upper lobes if there is accumulation of secretions or
insufficient lung expansion in these areas.
 BREATHING EXERCISES:
Segmental Breathing
Lateral Costal Expansion
Preventing and Relieving
Episodes of Dyspnea
Pacing is the performance of functional activities, such as
walking, stair climbing, or work-related tasks, within the
limits of a patient’s ventilatory capacity

If the patient becomes slightly short of breath, he or she

must learn to stop an activity and use controlled, pursed-lip
breathing until the dyspnea subsides.