ASSESSMENT OF THE CHEST AND LUNGS
I. FUNCTIONS
A. Breathing
1. Oxygen In
a) 21% of oxygen in room air
2. CO2 Out
II. ANATOMY AND PHYSIOLOGY
A. Skeletal Framework
1. Ribs
a) Protect the lungs and the heart
b) First rib is identified directly below the clavicle
c) Lower ribs protect the stomach
2. Sternum
3. Clavicle
4. Thoracic Vertebrae
B. Muscles
1. Diaphragm
a) Located underneath the rib
b) Major muscle that drives breathing
2. Intercostal Muscles
a) Muscles between the ribs that assist in breathing
b) Highly present in Respiratory Distress
C. Spaces
1. Intercostal
a) Spaces between the ribs
D. Structures
1. Trachea
a) Flexible structure that lies anterior to the esophagus
b) Made up of C-shaped rings of hyaline cartilage
c) Begins at the level of the cricoid cartilage in the neck
d) 10-12 cm long in adults
2. Right Mainstem Bronchus
a) Contains three lobar bronchi
b) Shorter and more vertical
c) More likely to have aspirated objects enter the right lung
3. Left Mainstem Bronchus
a) Contains two lobar bronchi
4. Terminal Bronchioles
a) Terminate at the alveolar ducts
b) Channel air into alveolar sacs
5. Alveoli
a) Increase surface area available for gas exchange
6. Medulla and Pons
a) Trigger breathing
b) Structures are triggered by the need to expel CO2
E. Respiration
1. Process that facilitates gas exchange
2. Ventilation
a) Process of breathing in oxygen and breathing out CO2
F. Landmarks
1. Lobes sit sideways
2. Right lateral lobe is the easiest to access
III. AGE AND CONDITION VARIATIONS
A. Infants and Children
1. Lung Maturity
a) Achieved at 38 weeks
b) Last organ to mature
2. Cord Cutting
a) Delayed, 1 minute after arrival
3. APGAR Scoring
a) Measures how much organ function a baby has at birth
4. Acrocyanosis
a) Babies turn blue very quickly
5. Respiratory Rate
a) Normal range is 30-60 breaths per minute
6. Hypothermia
a) Leads to cold stress, resulting in respiratory compromise
B. Pregnancy
1. Respiratory Rate Increases
2. Shallow Breathing
3. Oxygen Consumption Increases
4. Dyspnea on Exertion
a) Shortness of breath with activity
5. Respiratory Congestion
a) Extra blood flow to the upper respiratory region
C. Older Adults
1. Posture Changes
2. Weaker Muscles
3. Kyphosis
a) Outward curve of the spine
4. Gibbus
a) Sharp curve of the spine
5. Decreased Mobility
6. Hyperresonance
7. Typically on multiple medications
8. Common Illnesses
a) COPD, Emphysema
9. Smoking History
IV. HISTORY
A. Chief Complaint (CC)
1. Shortness of Breath
a) Dyspnea
2. Cough
a) Productive
b) Fluid production
c) Sputum characteristics
3. Pain
4. Trauma/Injury
B. History of Present Illness (HPI)
1. Onset
2. Location
3. Duration
4. Character
5. Aggravating Factors
6. Relieving Factors
7. Timing
8. Severity
C. Past Medical History (PMH)
1. Respiratory Illnesses
a) Tuberculosis, Pneumonia, Asthma, COPD, Cystic Fibrosis, Emphysema
2. Cancer
a) Lung or Esophageal cancer
3. Trauma/Injuries
a) Broken ribs
4. Upper Respiratory Infection (URI)
a) Sinus infection
5. Allergies/Sinus Problems
6. Cardiovascular Diagnosis
a) Interlinked with lung conditions
D. Family History (FH)
1. Cystic Fibrosis
a) 100% genetic condition
2. Asthma
3. Allergies
E. Current Health Status (CHS)
1. Exercise/Activity Intolerance
a) Without shortness of breath
2. Working Conditions/Exposure to Irritants
3. Hobbies
a) Example: wood turning
4. Air Quality in Home Environment
5. Pets/Animals
6. Number of Pillows Used for Sleeping
a) Specifically under the head
7. Smoking History
a) Cigarettes (Pack years)
(1) Pack years: Number of years smoked multiplied by the number of packs smoked per day
b) Marijuana
c) Hookah
8. Vaping
F. Review of Systems (ROS)
1. Chest Pain
2. Snoring/Sleep Apnea
3. Night Sweats
4. Frequent Upper Respiratory Infections
5. Sputum Production/Character
6. Regular Wheezing
7. Regular Sneezing
8. Allergies
V. PHYSICAL EXAMINATION
A. Inspection
1. Shape
a) Anterior/Posterior diameter should be less than transverse diameter
b) Assessing for barrel chest
(1) A/P diameter equals transverse diameter
(a) Squares chest shape
2. Symmetry
a) Expect symmetry bilaterally: Right/Left posterior and anterior
b) Conditions producing asymmetry
(1) Kyphosis
(a) Outward curve of the spine
(2) Lordosis
(a) Inward curve of the spine
(3) Gibbous
(a) Sharp angle of the spine
(4) Scoliosis
(a) Spinous processes that deviate laterally in the thoracic area
(5) Pectus Carinatum (Pigeon Chest)
(a) Chest protrudes outwards
(6) Pectus Excavatum (Funnel Chest)
(a) Chest is sunken inwards
3. Color of Skin, Lips, Nailbeds
a) Should be pink
b) Assessing for oxygenation
4. Nasal Flaring, Clubbing, Retractions, Use of Accessory Muscles
a) Signs of forced breathing/impaired breathing
5. Respiratory Rates
6. Presence of Cough
a) Is it productive?
7. Sputum Production
a) A description of the sputum appears
8. Descriptors of Respiration
a) Eupnea – normal breathing
b) Tachypnea – increased breathing rate
c) Bradypnea – decreased breathing rate
d) Dyspnea – defined as shortness of breath
e) Apnea – absence of breathing
f) Hyperpnea – hyperventilating; rapid breathing
g) Cheyne-Stokes – breathing pattern characterized by alternating periods of deep and shallow breaths, often associated with end-of-life
h) Kussmaul – deep, rapid breathing
i) Sighs – longer breath out, infrequent
j) Stridor – a high-pitched breathing sound resulting from narrowing of the upper airway, often associated with choking
9. Alterations in Respiratory Drive
a) Acid-Base Imbalance
b) Medications
c) Neurological Issues
B. Palpation
1. Palpation of the Front of the Chest or Over Ribcage
2. Check for Bulges, Masses, Tenderness
3. Crepitus
a) Air caught in subcutaneous tissue, typically related to trauma
4. Tracheal Position
a) Must be midline
5. Thoracic Expansion (A/P)
a) Palpate at the 6th rib (T10)
b) Should be symmetrical/equal expansion
6. Tactile Fremitus (A/P)
a) Assess how much air can flow in the spaces
b) Tactile vibrations detected
C. Percussion
1. Technique
a) Percuss indirectly in between intercostal spaces
b) Document findings based on lobe
2. Tones
a) Resonance – expected/healthy lung sound
b) Hyperresonance – echo, indicative of COPD
c) Dullness – indicates presence of other organs (ex. Liver)
d) Flatness – over bone
e) Tympany – abnormal sound associated with pneumothorax (air inside of lungs)
D. Auscultation
1. Procedure
a) Listen directly on the skin during inspiration and expiration
b) One inspiration and one expiration = one breath
2. Normal Breath Sounds
a) Vesicular – soft, low-pitched sounds over peripheral lung fields
b) Bronchovesicular – medium-pitched sounds over R/L main bronchi
c) Bronchial – loud, high-pitched sounds heard over trachea
d) Can document findings as clear
3. Adventitious Breath Sounds
a) Crackles – “bubbling” sounds that are high or low pitched and discontinuous, heard predominantly during inspiration
b) Rhonchi – “snoring” sounds that are loud, often continuous, may clear with cough
c) Wheezes – “musical” high-pitched sounds, continuous, typically louder on expiration, commonly associated with bronchitis
d) Rubs – “grating” sounds that are low-pitched, dry, continuous, often associated with pleurisy
4. Vocal Resonance
a) Expected findings should be negative
b) Bronchophony – increased clarity of spoken words during auscultation (ask patient to say words in sequence)
c) Whispered Pectoriloquy – softly spoken words should still sound like whispers
d) Egophony – upon auscultation of the letter “E”, “A” sound is heard instead during patient speech
VI. FINDINGS
A. Pneumonia
1. Dull percussion sound, bronchial sounds noted
B. Pleurisy
C. Bronchitis
D. Pneumothorax
1. Findings on Palpation
a) Shifted trachea
b) Unequal chest expansion
c) Crepitus
d) Absence of sounds upon auscultation
e) Tympanic percussion sound detected
E. Hemothorax
1. Presence of blood in the lungs noted
F. Emphysema
1. Leads to wheezing, barrel chest, hyperresonance, clubbing in nails
G. Respiratory Distress
1. Signs include not speaking in full sentences
2. Respiratory rate exceeding 20+ breaths per minute
3. Observable body positioning — often hunched over
4. Presence of adventitious sounds noted
5. Retractions and use of accessory muscles
6. Skin Color
a) Appearance may be pale or blue
7. Presence of panic noted
8. Observe how hard the patient is working to breathe
9. Treatments options include
a) Nebulizer/breathing treatment
b) Oxygen therapy
c) Steroid use
VII. SUMMARY
A. Sequence of IPPA (Inspection, Palpation, Percussion, Auscultation)
B. Importance of systematic assessment
C. Familiarization with respiratory assessment findings
D. Knowledge of anatomical landmarks