Topic 6: Respiratory

Topic Overview

  • Lecturer: Ashley Blankenship, MSN, RN, CNE.

  • Purpose of PowerPoints: Supplemental material to enhance readings and lectures on respiratory assessment.

Landmarks of the Thorax

Anterior Thoracic Landmarks

  • Suprasternal Notch: Depressed area above the sternum where the clavicles meet.

  • Manubrium: The uppermost segment of the sternum.

  • Sternal Angle (Angle of Louis): Located at the junction of the manubrium and the body of the sternum, corresponding to the 2nd rib and the 2nd intercostal space (ICS).

  • Sternum: The central bone of the thorax.

Posterior Thoracic Landmarks

  • Clavicle: The bone connecting the arm to the body located at the top of the thorax.

  • Cervical Vertebrae: First rib is associated with the first thoracic vertebra.

  • Spinous Processes: Bony protrusions along the vertebrae; notable ones include the 7th rib, angle of the 9th rib, and 12th rib (floating ribs).

Reference Lines: Anterior Chest

  • Right and Left Lung Lobes:

    • Right Upper Lobe

    • Right Middle Lobe

    • Right Lower Lobe

    • Left Upper Lobe

    • Left Lower Lobe

  • Lines and Landmarks: Midsternal line, midclavicular line, and thyroid cartilage.

Reference Lines: Posterior Chest

  • Lung Lobes: Right Upper Lobe, Right Middle Lobe, Right Lower Lobe, Left Upper Lobe, Left Lower Lobe.

  • Spinal Processes: Reference for identifying the vertebral line.

Reference Lines: Lateral Chest

  • Lines: Anterior axillary line, midaxillary line, and posterior axillary line.

Lung Lobes

  • Lung Structure:

    • Superior Lobes

    • Middle Lobe

    • Inferior Lobes

Related Health History

Cough Assessment

  • Type: Dry, wet, productive

  • Onset: When did it start, was it sudden?

  • Duration: Acute or chronic.

  • Pattern: Consistency and frequency.

  • Severity: Impact on daily life and treatment efforts.

Sputum Production

  • Amount: How much sputum is produced.

  • Color: White/clear (mucoid), yellow/green (bacterial), rust (pneumonia), bloody (hemoptysis), black (black lung disease), pink/frothy (pulmonary edema).

  • Odor: Unusual odors may indicate infection.

Shortness of Breath (Dyspnea)

  • Onset and Severity: Identify aggressive patterns with activity.

  • Associated Symptoms: Chest pain, wheezing, etc.

  • Orthopnea: Difficulty breathing while lying flat.

  • Platypnea: Difficulty breathing while upright.

  • Paroxysmal Nocturnal Dyspnea: Episodes at night, waking the patient up.

Chest Pain

  • Assessment Criteria: Onset, duration, location, severity, etc.

  • Assessment of Influence of Activity: How activity affects pain.

Preparation of Patient and Equipment

  • Environment: Warm, quiet, well-lit, and private room.

  • Patient Preparation: Undress to the waist, provide a gown.

  • Equipment: Clean and warm stethoscope.

Preliminary Statistics to Check

  • General Observations:

    • Position of breathing.

    • Level of consciousness (LOC).

    • Skin/fingers for signs of hypoxia.

    • Respiratory rate and pulse oximetry readings.

Inspection of the Chest

Anterior Chest
General Shape and Configuration

  • Symmetry: Equal movement during breathing.

  • AP to Transverse Diameter Ratio: Normal ratio is 1:2.

  • Rib Angle: Should be less than or equal to 90 degrees.

  • Respiration Quality: Regular, even, within normal limits (WNL).

Signs of Abnormality

  • Barrel Chest: Diameter ratio deviates from 1:2.

  • Pectus Excavatum (Funnel Chest): Depression of the sternum.

  • Pectus Carinatum (Pigeon Chest): Protrusion of the sternum.

Respiratory Patterns

  • Normal Findings: Diaphragmatic breathing, thoracic breathing.

  • Respiratory Rate and Patterns: Adults normally 12-20 breaths/min.

  • Abnormal Respiratory Patterns:

    • Cheyne-Stokes: Cycles of breathing followed by apnea.

    • Biot's: Irregular breathing patterns.

    • Bradypnea: Abnormally slow breathing.

    • Tachypnea: Abnormally rapid breathing.

    • Hyperventilation: Kussmaul's breathing pattern in metabolic acidosis.

Retractions and Flail Chest

  • Retractions: Understanding retraction signs in infants, children, and adults.

  • Flail Chest:

    • Definition: Unilateral retraction due to rib fracture.

    • Signs: Dyspnea, paradoxical chest movements, crepitus, pain with breathing, and cyanosis.

Palpation of the Chest

Techniques and Observations

  • General Light Palpation: Check for temperature, tenderness, and turgor.

  • Crepitus: Presence indicates air in the subcutaneous tissues, typically abnormal.

  • Chest Expansion: Place thumbs at costal margins and assess movement with deep inhalation.

  • Tactile Fremitus: Assessing vibration with words such as “99” or “blue moon.” Abnormal findings indicate either consolidation or obstruction.

Percussion and Auscultation

Percussion

  • Techniques: Compare side to side, percussing between ribs and around breast tissue.

  • Findings:

    • Resonance: Normal low-pitched sounds.

    • Hyperresonance: Suggestive of asthma or pneumothorax.

    • Dullness: Indicates pathology like pneumonia or pleural effusions.

Auscultation

  • Normal Breath Sounds:

    • Bronchial Sounds: High pitch, loud amplitude (e.g., over trachea).

    • Vesicular Sounds: Low pitch, soft amplitude (e.g., over peripheral lungs).

    • Bronchovesicular Sounds: Moderate pitch, occurring in both phases of breathing.

  • Abnormal Sounds:

    • Crackles: Fine (not cleared by cough) and coarse.

    • Wheezes: High-pitched, musical sounds indicating obstructions.

    • Rhonchi: Low-pitched gurgles, may clear with cough.

    • Stridor: High-pitched sound indicating upper airway obstruction.

Pediatric and Older Adult Variations

Pediatric Variations

  • AP to Transverse Ratio: 1:1 in infants, normalizes by age 6.

  • Breath Sounds: Typically louder, hyperresonance is normal in children.

Older Adult Variations

  • Spinal Abnormalities: Scoliosis or kyphosis can affect breathing.

  • Chest Elasticity and Size: Barrel chest may be present in COPD.

Evaluation and Practice Questions

Evaluating Skills

  • Inspection and palpation for color, abnormalities, and breathing patterns.

  • Comparison of tactile fremitus and percussion notes.

Practice Questions for Clinical Application

  1. Which findings to expect during thorax auscultation?

  2. Conditions leading to increased tactile fremitus.

  3. Clinical manifestations in patients with COPD related to breathing patterns.

Conclusion

  • Comprehensive understanding of respiratory assessments enhances clinical skills in evaluating and managing respiratory health effectively.