Chest examination

Syeda Afsheen daud

Lecturer IPMR KMU
A = Airway
This component of the objective
assessment is concerned with collecting
information regarding upper airway
patency.
 Establishing patency of the upper airway
is the most important component of
performing a respiratory examination.
Obstruction of the airway will ultimately
lead to hypoxia and death
Airway – Observation
Is the patient self-ventilating or requiring
the assistance of an artificial airway to
ensure airway patency?
Forms of artificial airways include: a
nasopharyngeal airway; an oropharyngeal
airway; an endotracheal tube or
tracheostomy tube.
Self-ventilatingpatients should be asked to open their
mouth so a visual inspection can be made.
Visual inspection will determine whether there is
swelling or abnormality of the mouth, teeth, tongue or
soft palate.
The colour of the oral mucosa, lips and facial skin should
be noted.
 Central cyanosis, seen on examination of the tongue and
mouth, is caused by hypoxia.
The blueness is related to the quantity of unbound
haemoglobin.
Cyanosisis a late sign of airway obstruction.
Airway – Feel
Air movement into and out of a natural or
artificial airway can be assessed by
placing your hand to feel the flow of
warm air against your skin during
expiration.
Simultaneous observation of chest rise
and fall with air flow through an airway
will assist in the determination of airway
patency.
Airway – Listen
Is the airway clear? Can you hear any airway sounds?
Normal quiet unobstructed breathing is almost
inaudible at the mouth.
 Abnormal sounds heard at the mouth include
gurgling, when there is fluid in the upper airway
wheezing, with obstruction of the lower airways
stridor, with obstruction of the upper airway
crowing, caused by laryngeal spasm
 grunting caused by a flail chest
 snoring, caused when there is pharyngeal obstruction
by the tongue.
B = Breathing
The breathing component of the objective
assessment relates to examination of the
anatomical and physiological features
which contribute to the process of
breathing.
To be able to examine breathing it is
important to know the surface landmarks
of the lungs
The oblique fissure, dividing the upper
and middle lobes from the lower lobes,
runs from the spinous process of T2/3
posteriorly around the chest to the sixth
costochondral junction anteriorly.
The horizontal fissure on the right,
dividing the right upper lobe from the
right middle lobe, runs from the fourth
intercostal space at the right sternal edge
horizontally to the mid-axillary line,where
it joins the oblique fissure.
The diaphragm sits at approximately the
sixth rib anteriorly, the eighth rib in the
mid-axillary line and the 10th rib
posteriorly.
The trachea bifurcates just below the level
of the manubriosternal junction.
The apical segment of both upper lobes
extends 2.5 cm above the clavicles.
Breathing – Observation
Observation of the breathing component of
objective assessment begins from initial
patient contact.
Does the patient appear short of breath, sitting
on the edge of the bed or distressed?
Is he able to speak; if so howlong are his
sentences? When he moves around or
undresses, does he become distressed?
Is the patient producing sputum; what is the
colour, consistency andquantity of sputum?
Chest Shape
The chest should appear symmetrical with
the adult rib descending at approximately
45 degrees from the thoracic spine.
 The transverse diameterof the chest
should be greater than the anteroposterior
(AP) diameter.
The thoracic spine should have a slight
kyphosis.
Common abnormalities of chest wall
shape include.
Kyphosis: An increase in thoracic spine
flexion.
Scoliosis: An excessive lateral curvature
of the
spine with vertebral rotation.
Kyphoscoliosis: Scoliosis and an element
of kyphosis. Kyphoscoliosis can cause a
restrictive lung defect which may lead to
respiratory failure.
Pectus excavatum
Pectus excavatum or ‘ funnel’ chest: Is
where part of the sternum is depressed
inwards.
This rarely effects lung function but may
be corrected surgically for cosmetic
reasons.
Pectus carinatum
Pectus carinatum or ‘pigeon’ or ‘chicken’
chest: Is where the sternum protrudes
anteriorly.This may be present in children
with severe asthma and rarely effects lung
function.
barrel chest
Hyperinflation or ‘ barrel chest’: Is where
the ribs lose their normal 45-degree angle
with the thoracic spine and become
almost horizontal.
The AP diameter of the chest increases to
almost equal the transverse diameter.
 This is commonly seen in severe
emphysema.
Normal quiet inspiration is characterized
by small coordinated symmetrical
increases in the AP, transverse and
vertical diameters of the thorax.
Asymmetry
When one side of t he chest has reduced
(or excessive) movement compared to the
other.
This can occur in acute lung collapse,
haemothorax and simple and tensio
pneumothorax.
Abdominal distension:
Will impede descent of the diaphragm
during inspiration and limit increases in
the vertical diameter of the thorax.
Abdominal distension may result from
obesity, ascites, pregnancy, abdominal
surgery and constipation.
 Intercostal indrawing
Occurs where t he skin between the ribs is drawn
inwards during inspiration.
It may be seen in patients with severe inspiratory
air flow resistance. Large negative pressures during
inspiration suck the soft tissues inwards.
 Intercostal indrawing can be an important sign of
respiratory distress in children.
Supraclavicular indrawing
Occurs when the skin above the clavicle
is drawn inwards during inspiration.
It is also seen in patients with severe air
flow resistance who generate high
negative pressures during inspiration; for
example, acute asthma.
Flail chest
Flail chest: Occurs wit h multiple rib
fractures when two or more breaks in
each rib result In loss of integrity of the
thoracic cage.
During inspiration the loose segment is
drawn inwards as the rest of the chest wall
moves out. In expirationthe reverse
occurs.
Paradoxical breathing
Paradoxical breathing: Is where the
entire chest wall moves inwards on
inspiration and outwards on expiration.
Chest wall paradox occurs in bilateral
diaphragm weakness or paralysis as
observed in the patient with high cervical
spinal cord injury.It is most apparent
when the patient is supine.
Hoover sign
Hoover sign: Is paradoxical movement of
t he lower chest wall and occurs in
patients with severe chronic air flow
limitation who are extremely
hyperinflated.
As the dome of the flattened diaphragm
cannot descend further, diaphragm
contraction during inspiration pulls the
lower ribs inwards.
Hoover’s sign
Normal quiet breathing should occur with
a regular rhythm and rate. The ratio of
inspiratory to expiratory time (I : E ratio)
is 1 : 2.
An increased effort to breathe is
characterized by the following
observations.
Tachypnoea
Accessory muscle use
Active expiration
Prolonged expiration
Pursed lip breathing
Breathing – Feel
This action requires the examiner to
palpate the structures and movement of
the thorax.
Using the surfaces of the fingers and
hands the examiner can feel for areas of
tenderness, skin temperature changes,
swelling or masses.
Tracheal Position.
The trachea is palpated to assess its
position in relation to the sternal notch.
Tracheal deviation indicates underlying
mediastinal shift.
 The trachea may be pulled towards a
collapsed or brosed upper lobe, or pushed
away from a pneumothorax orlarge
pleural effusion.
Chest Expansion.
The examiner’s hands are placed
spanning the anterior segments of the lung
bases, with the thumbs touching in the
midline anteriorly.
The patient is instructed to inspire slowly
several times whilst the displacement of
the thumbs is observed.
Both sides should move equally, with a 3–
5 cm displacement.
Fremitus

Fremitus is a vibration felt on the body

during palpation. Vocal or tactile fremitus
is the palpation of speech vibrations
transmitted through the chest wall to the
examiner’s hands.
Vocal fremitus is increased when the lung
underneath is consolidated, as solid tissue
transmits sound better.
Vocal fremitus is decreased with
pneumothorax or a pleural effusion since
the physical interface between the lung
and examiners hands is increased
Breathing – Listen
This action requires the examiner to focus
on the sounds associated with breathing.
The examiner may have already noted
breathing sounds when assessingthe
airway.
Speech
Speech. What is the speech pattern – long
fluent paragraphs without discernable
pauses for breath, quick sentences, just a
few words or is the patient too breathless
to speak?
Quality of Cough
Instruct the patient to cough to assess the
quality of their performance.
Can the patient cough? Is the patient
afraid to cough? Is the cough inhibited? Is
the cough painful? Is the cough strong,
tight, wheezy, productive or dry?
 A weak ineffective cough places the
patient at risk of retained
secretions,hypoxia and respiratory failure.
Percussion Note
Percussion is a method of tapping over the
surface of the chest to determine the nature
of the underlying structures. It is performed
by placing the left hand firmly on the chest
wall over an intercostal space.
The distal interphalangeal joint of the
middle finger on the left hand is tapped
with the middle finger of the right hand
using a wrist action
Aerated lung will sound resonant, whilst
consolidated lung sounds dull, and a
pleural effusion sounds ‘stony dull’.
 Increased resonance is heard when the
chest wall is free to vibrate over an air-
lled space, such as a pneumothorax.
Chest Auscultation.
Normal breath sounds
Represent sound generated by turbulent
air flow in the trachea and large airways
which is attenuated (or altered) by lung
tissue in the periphery. Normal breath
sounds vary according to stethoscope
location.
Bronchial Sounds heard over the trachea
and large bronchi have a loud, harsh, high
pitched tubular quality that can be heard
throughout inspiration and expiration and
are called ‘tracheal’ or ‘bronchial’ sounds.
Bronchovesicular Sounds heard over the
hilar lung regions are softer bronchial
sounds which may be louder during
inspiration than expiration and are known
as ‘bronchovesicular’ sounds.
Vesicular Sounds heard over the
periphery have a low pitched, soft
blowing or rustling quality heard through
inspiration but almost inaudibl during
expiration and are known as ‘vesicular’
sounds.
Reduced breath sounds
Decreased intensity of breath sounds occurs for a
number of reasons. Since breath sounds are generated
by flow turbulence, a reduction in flow causes less
sound.
Patients who cannot breathe deeply will have globally
diminished breath sounds.
Similarly, reduced breath sounds may be heard when
there is an increased sound attenuation in the periphery
due to destruction of lung tissue or hyperinflation or an
increase in the distance of the lung to the chest surface
such as in obesity, pneumothorax or pleuraleffusion.
Absent breath sounds
Breath sounds may be absent when
localized accumulation of air or fluid in
the pleural space blocks sound
transmission from the large airways.
Similarly if the bronchus supplying an
area of lung is obstructed (e.g. carcinoma,
large sputum plug) sound transmission to
the periphery will be blocked.
Bronchial breath sounds
Normal tracheal or bronchial sounds that
are heard at the lung periphery. Any
increase in airway fluid or lung tissue
density will allow better sound
transmission from the large airways.
Consequently thesounds heard over an
area of consolidated lung are similar to
those heard over the trachea.
Wheeze
Continuous high-pitched musical tones
produced by air vibrating in a narrowed
airway heard during late inspiration and
expiration.
Airway diameter decreases during
expiration but any cause of additional
narrowing (bronchospasm, mucosal
oedema, sputum, foreign bodies), will
elicit wheeze.
The pitch of the wheeze is related to the
degree of narrowing. High-pitched wheezes
indicate near total obstruction.
A fixed, monophonic (single pitch) wheeze is
caused by a single obstructed airway.
Polyphonic (multiple pitch) wheeze is due to
widespread airway narrowing.
Localized wheeze may be caused by
sputumretention and can change or clear after
coughing.
Crackles
Discontinuous explosive popping or
clicking sounds more commonly heard
during inspiration than expiration, caused
by the opening of previously closed small
airways during inspiration causing
transient airway vibration.
Airway closure may occur due to fluid or
exudate accumulation, low lung volumes
or abnormalities of lung tissue
Pleural rub
Creaking, squeaking, grating or rubbing
sounds that occur during inspiration and
expiration caused by friction between the
pleural surfaces. The pleura may be
roughened by inflammation, infection or
neoplasm.
Lung Sounds (Normal) Bronchial Bronchovesicular Vesicular _ Breath Respiratory Sounds.mp4