MARIE AGNES BANIWAS

PROFESSOR
ASSESSMENT OF THE CHEST AND LUNGS
 REVIEW OF THE ANATOMY

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 REVIEW OF THE ANATOMY
Respiratory assessment landmarks

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 Auscultation assessment landmarks

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 ASSESSMENT
 Begin your respiratory assessment by first observing the patient’s general appearance.
 Then use inspection, palpation, percussion, and auscultation to perform a physical
examination.
 Examine the back of the chest first, comparing one side with the other.
 Then examine the front of the chest using the same sequence.
 Observe the chest from the side as well.
 The diameter of the thorax should be greater from side-to-side than from front-to-back.

Inspecting the LANDMARK LINE KEYS

chest Axillary line
Inspect for chest-wall
Midclavicular line
symmetry. Note masses
or Midsternal line
scars that indicate trauma Scapular line
or surgery Vertebral line
Respiratory rate and pattern
Count the number of breaths for a full
minute. Adults normally breathe at a rate of
12 to 20 breaths/minute. An infant’s breathing rate
may reach 40 breaths/minute. The respiratory pattern
should be even, coordinated, and regular, with
occasional sighs (long, deep breaths).
Accessory muscle use Observe the diaphragm and the
intercostal muscles with breathing. Frequent use of
accessory muscles may indicate a respiratory problem,
particularly when the patient purses his lips and flares
his nostrils when breathing.
 While Memory board
Men, children,
inspecting the Chest-wall asymmetry
infants, athletes, and
chest, look Respiratory rate and
singers Usually use
for these pattern(abnormal)
abdominal, or
characteristics Accessory muscle use
diaphragmatic,
that may put Masses or scars
breathing. Most
a CRAMP in Paradoxical movement
women, however,
usually use chest, or your patient’s
intercostal, respiratory
breathing. system.

This Photo
by
Unknown
Palpating the chest
The chest wall should feel smooth, warm, and dry. Gentle palpation
shouldn’t cause the patient pain. Pain may be caused by
costochondritis, rib or vertebral fractures, or sore muscles as a result of
protracted coughing. Crepitus, which feels like puffed-rice cereal
crackling under the skin, indicates that air is leaking from the airways
or lungs. Also palpate for tactile fremitus, palpable vibrations caused
by the transmission of air through the bronchopulmonary system.
Then evaluate chest-wall symmetry and expansion.
Assessing voice sounds
Check the patient for vocal fremitus —voice sounds resulting
from chest vibrations that occur as the patient speaks. Abnormal
transmission of voice sounds may occur over consolidated areas.
The most common abnormal voice sounds are bronchophony,
egophony, and whispered pectoriloquy.
Assessing vocal fremitus
■ Ask the patient to repeat the words below while you listen.
■ Auscultate over an area where you heard abnormally located bronchial
breath sounds to check for abnormal voice sounds.

“ninety-nine”
Bronchophony
■ Ask the patient to say,
“ninety-nine.”
■ Over normal lung tissue, the
words sound muffled.
■ Over consolidated areas, the
words sound unusually loud
Whispered pectoriloquy
■ Ask the patient to
Egophony
whisper,“1, 2, 3.”
■ Ask the patient to say, “E.”
■ Over normal lung tissue,
■ Over normal lung tissue, the
the numbers will be almost
sound is muffled.
indistinguishable.
■ Over consolidated lung tissue,
■ Over consolidated lung
it will sound like the letter a.
tissue,the numbers will be
loud and clear.
Evaluating chest-wall symmetry and expansion
Place your hands on the front of the chest wall with
your thumbs touching each other at the second intercostal What the results mean
space. As the patient inhales deeply, watch your thumbs. They Vibrations that feel more
should separate simultaneously and equally to a distance intense on one side than
several centimeters away from the sternum. Repeat the the other indicate tissue
measurement at the fifth intercostal space. The same consolidation on that side.
measurement may be made on the back of the chest near the Less intense vibrations may
indicate emphysema, pneumo
tenth rib. The patient’s chest may expand asymmetrically if he
thorax, or pleural effusion.
has pleural effusion, atelectasis, pneumonia, or pneumothorax. Faint or no vibrations in the
upper posterior
thorax may indicate bronchial
obstruction or a
fluid-filled pleural space.
Percussing the chest
Chest percussion reveals the boundaries of the lungs and helps to
determine whether the lungs are filled with air or fluid or solid material.

Place your nondominant hand over

the chest wall, pressing firmly with
your middle finger.
■ Position your dominant hand over
your other hand.
■ By flexing the wrist (not the elbow
or upper arm) of your dominant hand,
tap the middle finger of your
nondominant hand with the middle
finger of your dominant hand (as
shown).
■ Follow the standard percussion
sequence over the front and back
chest walls.
 Percussion sounds
Sound Description Clinical
significance
flat Short, soft, high-pitched, extremely Consolidation, as in
dull, as found over atelectasis and
the thigh extensive pleural effusion
dull Medium in intensity and pitch, Solid area, as in
moderate length, thud like, as lobar pneumonia
found over the liver
Resonant Long, loud, low pitched, hollow Normal lung tissue;
bronchitis

Hyperresonant Very loud, lower pitched, as found Hyperinflated lung, as in

over the stomach emphysema or
pneumothorax
Tympanic Loud, high-pitched, moderate length, Air collection, as in
musical, drumlike, a large pneumo thorax
as found over a puffed-out cheek
 AUSCULTATING THE CHEST
As air moves through the bronchi, it creates sound waves that travel to the chest
wall. The sounds produced by breathing change as air moves from larger airways
to smaller airways. Sounds also change if they pass through fluid, mucus, or
narrowed airways. Auscultation of these sounds helps you to determine the
condition of the alveoli and surrounding pleura. Classify each sound you hear
according to its intensity, location, pitch, duration, and characteristic. Note
whether the sound occurs when the patient inhales, exhales, or both.
To distinguish between
normal and adventitious
breath sounds in the
patient’s lungs, press
the diaphragm of the
stethoscope firmly
against the skin. Listen
to a full inspiration and
a full expiration at each
site in the sequence
shown. Remember to
compare sound variations from one side to
the other. Document Listen to these auscultation tips
adventitious sounds ■ Have the patient breathe through his
that you hear and mouth; nose breathing alters the pitch of
include their locations. breath sounds.
Auscultation sequence ■ If the patient has abundant chest hair,
mat it down with a damp washcloth so the
hair doesn’t make sounds like crackles.
 Assessment: NORMAL FINDINGS

 The thorax is normally symmetric, it moves easily and without impairment

on respiration. there are no bulges or retractions of the intercostal spaces.
 The anteroposterior diameter of the thorax in relation to the lateral
diameter is approximately 1:2 ( the lateral diameter is wider than the AP
diameter.
 On palpation of the posterior chest, there should be no tenderness; chest
movement should be symmetric and without lag or impairment.
 Percussion normally reveals resonance over symmetric areas of the lungs
 On auscultation, breath sounds are louder and coarse near the large rhonchi
and over the anterior chest. softer and much finer ( vesicular) at the
periphery over the alveoli.
 The Normal breaths sounds are as follows:
VESICULAR- heard in most areas of the lungs
BRONCHOVESICULAR – heard near the main stem bronchi
BRONCHIAL- Heard over the trachea
 ABNORMAL FINDINGS
 Cough
 Hemoptysis- coughing out of blood
 Orthopnea- difficulty breathing when supine
 Paroxysmal Nocturnal Dyspnea ( PND) – Is awakening from sleep with
shortness of breath ( SOB) and needing to be upright to achieve comfort
 Unequal chest expansion
 Decreased fremitus – occurs when anything obstruct transmission of
vibrations
 Increased fremitus- occurs with compression or consolidation of lung tissue
 Crepitus- is a coarse crackling sensation palpable over the skin surface, it
occurs when air escapes from the lung and enters the subcutaneous tissue.
 Hyperresonance- a low pitched, booming sound on percussion of the chest,
when too much air is present in the lungs
 Dullness- soft, muffled thud, which signals abnormal density in the lungs
 Atelectasis- collapse lungs
 Unequal chest expansion- occurs when part of the lung is obstructed or
collapsed
 Retractions- indentions at the intercostal spaces, these suggest obstruction of
respiratory tract.
 Tachypnea- rapid, shallow breathing
 Hyperventilation- deep rapid breathing, also called kussmaul’s
breathing
 Hypoventilation- slow, shallow breathing
 Barrel chest – alteration in thoracic anatomy it’s a result of
hyperinflation of the lungs
 Pectus Excavatum- the sternum is markedly sunken
 Pectus carinatum ( Pigeon's chest )- there is forward protrusion of
the sternum
 Scoliosis – a lateral S shaped curvature of the thoracic and lumbar
spine
 Kyphosis- an exaggerated posterior curvature of the thoracic spine
 Chest pain with breathing
 Decreased or absent breath sounds