physical examination of thorax and lungs theory 1

IPPA

I: Inspection

P: Palpation

P: Percussion

A: Auscultation

sternal angle, Angle of Louis

Where the manubrium and the sternum meet,Location of the second rib, Good landmark for EKG’s

Inspection

Comfortable or needs support, coloration, configuration

coloration

White: Hypovolemia, anemia, hypothermia

 Blue: indicative of hypoxia

Red: May be indicative of hypertension, hyperthermia, or medication reaction

Barrel Chest

AP diameter is nearly equal to traverse diameter

(1:1 ratio)

 Commonly seen in COPD patients

 Makes mechanics of breathing less effective

 Ribs lose 45º angle in relation to spine

 Ribs become more horizontal

 Leads to increased accessory muscle use

Pectus Carinatum

a.k.a pigeon chest

 Anterior sternal protrusion caused by overgrowth of

cartilage in the sternum

 Makes breathing inefficient

 Leads to us of accessory muscles for respiration

Pectus excavatum

a.k.a ‘funnel chest’, cobblers chest, sunken chest

 Most common congenital deformity of the anterior

wall of the chest

 Characterized by depressed sternum

 Due to misformed ribs and sternum

Kyphoscoliosis

Combination of both kyphosis and scoliosis

Ventilatory Patterns

Eupnea, Normal breathing

 Hypopnea, Shallow breathing at a normal rate

 Hyperpnea, Deep breathing at a normal rate

 Apnea, Absence of breathing

Biot’s breathing

Definition

 Groups or clusters of quick even respirations with regular

or irregular periods of apnea

 Apnea can range from 15 to 120 seconds

 Causes

 Damage in the brain stem

 e.g. Stroke, trauma or opioid use

 Poor prognosis

Cheyne-Stokes

Definition

 Breathing pattern that starts shallow, progressively gets

deeper and then tapers, followed by an apneic period

 Subtle difference from Biot’s

 Vt remains constant in Biot’s

 Cheyne-Stokes varies

 Causes

 Strokes

 Brain injuries

 Tumors

Kussmaul’s Breathing

Definition

 hyperventilation characterized by a consistently deep and

rapid respiratory pattern

 Causes

 Diabetic ketoacidosis

 Metabolic acidosis on ABG

 Patient is attempting to blow off CO2 to correct

acidosis

Apneustic Breathing

Definition

 Prolonged inspiratory phase, followed by a pause and

then prolonged expiration

 Cause

 Brain trauma

 Damage to the Pons (respiratory center in the brain)

Paradoxical Breathing

Definition

 Discoordinated movement of chest wall

 Causes

 Chest trauma

 Flail chest

 Multiple rib fractures

cough assessment

Present without prompting

 Forceful or weak

 Non-productive

 aka ‘dry’

 Productive

 Color

Clear or white: normal Yellow: infection Green: retained mucous Red: hemoptysis Pink: pulmonary edema

palpation

Act of touching the chest wall to evaluate

underlying lung structure and function

 Evaluates

 Vocal fremitus

 Thoracic expansion

 Skin and subcutaneous tissues

Chest expansion

osterior

 Same as anterior, BUT

 Clinicians hands are at T8 on spine

 Abnormal findings

 Bilateral reduction

 Neuromuscular diseases

 COPD

 Unilateral

 Lobar consolidation

 Atelectasis

 Pleural effusion

 Pneumothorax

percussion

Act of tapping chest to assess underlying

structures

 Produces a sound and palpable vibration

 Penetrates 5cm-7cm below chest wall

 Technique

 Clinician places middle finger of left hand

firmly in intercostal space

 Clinician ‘taps’ middle finger with two fingers

of right hand

Technique of percussion

Performed systematically

 Sounds are evaluated for intensity (volume)

 Normal resonance

 Low-pitched sound, easily heard

 Increased resonance

 Louder and lower pitch

 Hyperinflation due to COPD

 Pneumothorax

Auscultation

Systematic process of listening to breath

sounds

 Performed to identify normal or

adventitious sounds

auscultation technique

Patient should be

 Upright and relaxed

 Inhale deeply

 Exhale passively

 Forceful exhalation can erroneously sound like wheezing

 Bell of stethoscope should directly touch

thorax

 Anterior, lateral and posterior thorax should be

auscultated

Breath Sounds

vary in pitch, duration, volume

 Distinct patterns dependent on where you

auscultate

normal Breath Sounds

Vesicular

 Bronchovesicular

 Bronchial

 Tracheal

Breath Sounds Adventitious (Abnormal)

Crackles (rales)

 Fine

 Coarse

 Rhonchi

 Wheeze

 Stridor

 Pleural Rub