Thorax and lungs

1. Cough. Do you have a cough? When did it start? Gradual or sudden?

• How long have you had it?

Acute cough lasts less than 2 or 3 weeks; chronic cough lasts over 2 months.

• How often do you cough? At any special time of day or just on arising? Cough wake you up at night?

Conditions with characteristic timing of cough: (1) continuous throughout day—acute illness (e.g., respiratory infection); (2) afternoon/evening—may be exposure to irritants at work; (3) night—postnasal drip, sinusitis; (4) early morning—chronic bronchial inflammation of smokers.

• Do you cough up any phlegm or sputum? How much? What color is it?

Chronic bronchitis has a history of productive cough for 3 months of the year for 2 years in a row.

• Cough up any blood? Does it look like streaks or frank blood? Does the sputum have a foul odor?

Hemoptysis. Some other conditions have characteristic sputum production: (1) white or clear mucoid—colds, bronchitis, viral infections; (2) yellow or green—bacterial infections; (3) rust colored—TB, pneumococcal pneumonia; (4) pink, frothy—pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus.

• How would you describe your cough: hacking, dry, barking, hoarse, congested, bubbling?

Some conditions have a characteristic cough: mycoplasma pneumonia—hacking; early heart failure—dry; croup—barking; colds, bronchitis, pneumonia—congested.

• Does the cough seem to come with anything: activity, position (lying down), fever, congestion, talking, anxiety?

• Does activity make it better or worse?

• Which treatment have you tried? Prescription or over-the-counter medications, vaporizer, rest, position change?

Assess effectiveness of coping strategies.

• Does the cough bring on anything: chest pain, ear pain? Is it tiring? Are you concerned about it?

Note severity.

2. Shortness of breath. Are you having any shortness of breath now? Within the last day, have you been short of breath?

• Ever had any shortness of breath or hard-breathing spells? When did it start? What brings it on? How severe is it? How long does it last?

Determine how much activity precipitates the shortness of breath (SOB)—state specific number of blocks walked, number of stairs. Chronic dyspnea is SOB lasting >1 month and may have neurogenic, respiratory, or cardiac origin. It also occurs with anemia, anxiety, and deconditioning (see Table 19.7, p. 443, for the differential diagnosis of dyspnea and its findings).

• Is it affected by position such as lying down?

Orthopnea is difficulty breathing when supine. State number of pillows needed to achieve comfort (e.g., “two-pillow orthopnea”).

• Occur at any specific time of day or night?

Paroxysmal nocturnal dyspnea is awakening from sleep with SOB and needing to be upright to achieve comfort.

• SOB episodes associated with night sweats?

Diaphoresis.

• Cough, chest pain, or bluish color around lips or nails? Wheezing sound?

Cyanosis signals hypoxia.

• Episodes seem to be related to food, pollen, dust, animals, season, emotion, or exercise?

Asthma attacks may occur with a specific allergen or extreme cold, anxiety. Asthma often described as “chest tightness.”

• What do you do in a hard-breathing attack? Take a special position or use pursed-lip breathing? Use any oxygen, inhalers, or medications?

Assess effect of coping strategies and the need for more teaching.

• How does the SOB affect your work or home activities? Getting better or worse or staying about the same?

Note to examiner: For people with a smoking history, dyspnea, and cough, consider referral to screen for chronic obstructive pulmonary disorder (COPD). Asymptomatic individuals should not be screened for COPD.28

Assess effect on activities of daily living.

3. Chest pain with breathing. Any chest pain with breathing? Please point to the exact location.

Chest pain of thoracic origin occurs with muscle soreness from coughing or from inflammation of pleura overlying pneumonia. Distinguish this from chest pain of cardiac origin (see Chapter 20) or heartburn of stomach acid.

• When did it start? Constant, or does it come and go?

• Describe the pain: burning, stabbing?

• Brought on by respiratory infection, coughing, or trauma? Is it associated with fever, deep breathing, unequal chest inflation?

• What have you done to treat it? Medication or heat application?

4. History of respiratory infections. Any past history of breathing trouble or lung diseases such as bronchitis, emphysema, asthma, pneumonia?

Consider sequelae after these conditions.

• Any unusually frequent or unusually severe colds?

Because most people have had some colds, it is more meaningful to ask about excess number or severity.

• Any family history of allergies, tuberculosis, or asthma?

Assess possible risk factors.

5. Smoking history. Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long?

Calculate pack-years of smoking by multiplying packs per day by number of years smoked.

• Have you ever tried to quit? What helped? Why do you think it did not work? What activities do you associate with smoking?

• Live with someone who smokes?

Note to examiner: Depending on the person’s stage of readiness to quit smoking, you can offer counseling and encouragement using the five As25:

Ask about his or her tobacco use status at every visit and record the person’s response.

Advise Give clear, nonjudgmental, and personalized suggestions for quitting. “I understand that quitting is difficult and challenging, but it is the most important thing you can do for your own health and for your family.”

Assess each person’s readiness for and interest in quitting. The response will affect the next step. If he or she is willing to quit, you’ll offer resources and assistance. If not, you’ll help the person determine the barriers to cessation.

Assist each person with a specific cessation plan that includes medications, behavioral modification, exercise programs, or referrals. Encourage to pick a quit date and give support and feedback.

Arrange follow-up visits. If relapse occurs, state that you are there to help start over again. Remind that quitting takes practice and often does not happen in the first attempt.25

Most people already know they should quit smoking. Instead of admonishing, assess smoking behavior and ways to modify daily smoking activities, identify triggers, and how to manage withdrawal.

Most (but not all) cases of COPD are caused by smoking. For patients who currently smoke or have a history of smoking, ask about symptoms of COPD, such as shortness of breath with exertion, frequent productive cough, wheezing, and history of repeated respiratory infections. If patients report these symptoms, refer for COPD screening with pulmonary function testing.

6. Environmental exposure. Are there any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area?

Have you been exposed to asbestos? Do you have pets in the home?

Traffic-related air pollution increases risk of allergic rhinitis and asthma.Farmers may be at risk for grain or pesticide inhalation. People in rural Midwest have risk for histoplasmosis exposure; those in Southwest and Mexico have risk for coccidioidomycosis. Coal miners have risk for pneumoconiosis. Stone cutters, miners, and potters have risk for silicosis. Other irritants: asbestos, radon, certain pets (e.g., birds).

• Do you do anything to protect your lungs such as wear a mask or have the ventilatory system checked at work? Do you do anything to monitor your exposure? Do you have periodic examinations, pulmonary function tests, x-ray image?

Assess self-care measures.

• Do you know which specific symptoms to note that may signal breathing problems?

General symptoms: cough, SOB. Some gases produce specific symptoms: carbon monoxide—dizziness, headache, fatigue; sulfur dioxide—cough, congestion.

7. Patient-centered care. Last TB skin test, chest x-ray study, pneumonia vaccine, or influenza immunization?

Have you received the COVID-19 vaccine? The boosters? Have you previously had COVID-19? (Consider asking about symptoms related to COVID-19: Have you been exposed to anyone with COVID-19? Have you experienced any fever, cough, shortness of breath, fatigue, loss of appetite, or changes in taste or smell?)a

“Flu” vaccine is modified annually. The CDC recommends annual flu vaccine for everyone age 6 months or older, especially important for those at high risk of flu complications, including pregnant people, older adults and young children, those with chronic medical conditions, residents of nursing homes and group care, health care workers, and those who are immunosuppressed.

Additional History for Infants and Children

1. Has the child had any frequent or very severe colds?

Limit of 4 to 6 uncomplicated upper respiratory infections per year is expected in early childhood.

2. Is there any history of allergy in the family?

Consider new foods or formula as possible allergens. Exclusive breastfeeding ≥6 months protects against a variety of respiratory infections.

• For child younger than 2 years: At what age were new foods introduced? Was the child breastfed or bottle-fed?

3. Does the child have a cough? Seem congested? Have noisy breathing or wheezing? (Further questions similar to those listed in the section on adults.)

Screen for onset and follow course of childhood chronic asthma, bronchitis.

4. Which measures have you taken to child-proof your home? Yard? Is there any possibility of the child inhaling or swallowing toxic substances? Has anyone reviewed with you the small things that are choking hazards (e.g., nuts, pins, seed, beans, corn, pen cover, toy pieces, hard candy, paper clip)?

Young children, especially <3 years, are at risk for foreign body aspiration, poisoning, and injury.

• Has anyone taught you emergency care measures in case of accidental choking or a hard-breathing spell?

Assess knowledge level of parent and caregivers.

5. Any smokers in the home or in the car with child? If so, insist that they not smoke in the house or car or anywhere near the child. Do not go to restaurants or other indoor places where there is smoking.

Postnatal SHS exposure increases risk for acute and chronic ear and respiratory infections in children.5

Additional History for the Aging Adult

1. Have you noticed any shortness of breath or fatigue with your daily activities?

Older adults have a less efficient respiratory system (decreased vital capacity, less surface area for gas exchange); thus they have less tolerance for activity.

2. Tell me about your usual amount of physical activity.

May have reduced exercise capacity because of pulmonary function deficits.Sedentary or bedridden people are at risk for respiratory dysfunction.

3. For those with a history of COPD, lung cancer, or TB: How are you getting along each day? Any weight change in the past 3 months? How much?

Assess coping strategies.

• How about energy level? Do you tire more easily? How does your illness affect you at home? At work?

Activities may decrease because of increasing shortness of breath or pain.

4. Do you have any chest pain with breathing?

• Any chest pain after a bout of coughing? After a fall?

Some older adults feel pleuritic pain less intensely than younger adults.Precisely localized sharp pain (points to it with one finger)—consider fractured rib or muscle injury.

Normal Range of Findings Abnormal Findings

Inspect the Posterior Chest

Thoracic Cage

Note the shape and configuration of the chest wall. The spinous processes should appear in a straight line. The thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine. The scapulae are placed symmetrically in each hemithorax. Skeletal deformities may limit thoracic cage excursion: scoliosis, kyphosis (see Table 19.3, Configurations of the Thorax, p. 437).

The anteroposterior (AP) diameter should be less than the transverse diameter. The ratio of AP to transverse diameter is about 0.70 to 0.75 in adults, and it increases with age. AP = transverse diameter, or “barrel chest.” Ribs are horizontal, chest appears as if held in continuous inspiration. This occurs in COPD from hyperinflation of the lungs (see Table 19.3).

The neck and trapezius muscles should be developed normally for age and occupation. Neck muscles are hypertrophied in COPD from aiding in forced respirations across the obstructed airways.

Note the position the person takes to breathe. This includes a relaxed posture and the ability to support one’s own weight with arms comfortably at the sides or in the lap. People with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so the abdominal, intercostal, and neck muscles all can aid in expiration.

Assess the skin color and condition. Color should be consistent with person’s genetic background, with allowance for sun-exposed areas on the chest and the back. No cyanosis or pallor should be present. Note any lesions. Inquire about any change in a nevus on the back (e.g., where the person may have difficulty monitoring) (see Chapter 13). Cyanosis occurs with tissue hypoxia.

Palpate the Posterior Chest

Symmetric Expansion

Confirm symmetric chest expansion by placing your warmed hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs (Fig. 19.14).

19.14

Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion.

Unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma such as fractured ribs, or pneumothorax.

Pain accompanies deep breathing when the pleurae are inflamed.

Tactile Fremitus

Assess tactile (or vocal) fremitus. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall, where you feel them as vibrations.

Use either the palmar base (the ball) of the fingers or the ulnar edge of one hand and touch the person’s chest while he or she repeats the words “ninety-nine” or “blue moon.” These are resonant phrases that generate strong vibrations. Start over the lung apices and palpate from one side to the other (Fig. 19.15).

19.15

The rear view of a patient for tactile fremitus. The right hand of a nurse is placed on the top left side, just below the neck. Numbers from 1 through 4 are marked vertically downwards on both left and right sides. Number 5 is marked on respective ends of number 4. On the left side, arrow marks are drawn from numbers 2 to 3. On the right side, arrow marks are drawn from numbers 1 to 2 and 3 to 4. A horizontal dotted line is drawn connecting the 5's. Horizontal lines from left to right side and from right to left side are marked alternatively between numbers.

Symmetry is most important; the vibrations should feel the same in the corresponding area on each side. Avoid palpating over the scapulae because bone damps out sound transmission. Asymmetric findings suggest dysfunction that you can assess further with the stethoscope.

The following factors affect the intensity of tactile fremitus:

• Fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. It normally decreases as you progress down because more and more tissue impedes sound transmission.

• Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration.

• A loud, low-pitched voice generates more fremitus than a soft, high-pitched one.

Note any areas of abnormal fremitus. Sound is conducted better through a uniformly dense structure than through a porous one, which changes in shape and solidity (as does the lung tissue during normal respiration). Thus conditions that increase the density of lung tissue make a better conducting medium for sound vibrations and increase tactile fremitus.

Decreased fremitus occurs with obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema. Any barrier that comes between the sound and your palpating hand decreases fremitus.

Increased fremitus occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect it.

Using the fingers, gently palpate the entire chest wall. This enables you to note any areas of tenderness, to note skin temperature and moisture, to detect any superficial lumps or masses, and to explore any skin lesions noted on inspection.

Rhonchal fremitus is palpable with thick bronchial secretions.

Pleural friction fremitus is palpable with inflammation of the pleura (see Table 19.5, Abnormal Tactile Fremitus, p. 440).Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as in tension pneumothorax or after open thoracic injury or surgery.

Percuss the Posterior Chest

Lung Fields

Determine the predominant note over the lung fields. Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders (Fig. 19.16). Then, percussing in the interspaces, make a side-to-side comparison all the way down the lung region. Percuss at 5-cm intervals. Avoid the damping effect of the scapulae and ribs.

19.16 Sequence for percussion.

The rear view of a patient for the different lung fields. The lung fields are numbered from 1 through 9 within individual circles. Number 1 is marked at the top on either sides. Two other circles are left blank on both sides. Numbers from 2 through 5 are mentioned vertically downwards. Numbers 6 and 7 are mentioned little side-wards. Number 8 is marked a little up, parallel to the number 6 and 9 is mentioned below 8. On the left side, arrow marks are drawn from numbers 2 to 3, 4 to 5, 6 to 7, and 8 to 9. On the right side, arrow marks are drawn from numbers 3 to 4, 5 to 6, 7 to 8. A horizontal dotted line is drawn connecting the 8's. Horizontal lines from left to right side and from right to left side are marked alternatively between numbers.

Resonance is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult (Fig. 19.17). However, resonance is a relative term and has no constant standard. The resonant note may be duller in the athlete with a heavily muscular chest wall and in the heavily obese adult in whom subcutaneous fat produces scattered dullness.

19.17Expected percussion notes.

The rear view of a patient for the different range of findings. An outline of the ribs on both sides are drawn. A flat over the scapula is visible at the top right side. The resonance is marked at the top and at the space between the ribs. The liver dullness is marked on the right side at the last three ribs, where as, visceral dullness is marked on the left side at the last three ribs.

Asymmetry is important: one side with prominent dullness or marked hyperresonance indicates underlying disease.

Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax.

A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.

The depth of penetration of percussion has limits. Percussion sets into motion only the outer 5 to 7 cm of tissue. It does not penetrate to reveal any change in density deeper than that. In addition, an abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Lesions smaller than that are not detectable by percussion.a

Auscultate the Posterior Chest

The passage of air through the tracheobronchial tree creates a characteristic set of sounds that are audible through the chest wall. Breath sounds are changed by obstruction in the passageways or by disease in the lung parenchyma, the pleura, or the chest wall.

Breath Sounds

Evaluate the presence and quality of normal breath sounds. The person is sitting, leaning forward slightly, with arms resting comfortably across the lap. Instruct the person to breathe through the mouth, a little bit deeper than usual, but to stop if he or she begins to feel dizzy. Be careful to monitor the breathing throughout the examination, and offer times for the person to rest and breathe normally. The person is usually willing to comply with your instructions in an effort to please you and be a “good patient.” Watch that he or she does not hyperventilate to the point of fainting.

Clean the flat diaphragm endpiece of the stethoscope and hold it firmly on the person’s chest wall. Listen to at least one full respiration in each location. Side-to-side comparison is most important.

Do not confuse background noise with lung sounds. Become familiar with these extraneous noises that may be confused with lung pathology if not recognized:

1. Examiner’s breathing on stethoscope tubing

2. Stethoscope tubing bumping together

3. Patient shivering

4. Patient’s hairy chest: movement of hairs under stethoscope sounds like crackles (rales)—minimize this by pressing harder or by wetting the hair with a damp cloth

5. Rustling of paper gown or paper drapes

6. Sounds transmitted from other connected tubes, lines, or devices

Crackles are abnormal lung sounds (see Table 19.6, Adventitious Lung Sounds, p. 441).

While standing behind the person, listen to the following lung areas: posterior from the apices at C7 to the bases (around T10) and laterally from the axilla down to the 7th or 8th rib. Use the sequence illustrated in Fig. 19.18.

19.18

The rear view of a patient for the different locations of lobes of lungs. The lobes of lungs are represented by numbers from 1 through 9. Numbers from 1 through 5 are mentioned vertically downwards. Numbers 6 and 7 are mentioned little side-wards. Number 8 is marked a little up, parallel to the number 6 and 9 is mentioned below 8. On the left side, arrow marks are drawn from numbers 2 to 3, 4 to 5, 6 to 7. On the right side, arrow marks are drawn from numbers 1 to 2, 3 to 4, 5 to 6. A horizontal dotted line is drawn connecting the 8's. Also, a pointed line is drawn from the number 6 on the right side to the number 6 on the left side. Similarly, a pointed line is drawn from the number 7 on the left side to the number 7 on the right side. Horizontal lines from left to right side and from right to left side are marked alternatively between numbers.

Continue to visualize approximate locations of the lobes of each lung so you correlate your findings to anatomic areas. As you listen, think (1) what AM I hearing over this spot? and (2) what should I EXPECT to be hearing? You should expect to hear three types of normal breath sounds in the adult and older child: bronchial (sometimes called tracheal or tubular), bronchovesicular, and vesicular. Study the description of the characteristics of these normal breath sounds in Table 19.1.

TABLE 19.1

Characteristics of Normal Breath Sounds

PITCH AMPLITUDE DURATION QUALITY NORMAL LOCATION

BRONCHIAL (TRACHEAL)A table presents characteristics of normal breath sounds are as follows : 1. Bronchial (Tracheal) (it is depicted with an upward arrow and a downward arrow which resembles 7) - pitch = high, amplitude = loud, Duration = Inspiration < expiration, Quality = harsh, hollow tubular and the Normal location = Trachea and larynx. 2. Bronchovesicular (it is depicted with an upward arrow and a downward arrow which resembles a mountain line diagram) - pitch = moderate, amplitude = moderate, Duration = Inspiration = expiration, Quality = Mixed, Normal location = over major bronchi where fewer alveoli are located : posterior, between scapulae especially on right ; anterior, around upper sternum in 1st and 2nd intercostal spaces. 3. Vesicular (it is depicted with an upward arrow and a downward arrow which resembles an inverted 7) - pitch = low, amplitude = soft, Duration = Inspiration > expiration, Quality = rustling, like the sound of the wind in the trees, Normal location = over peripheral lung fields where air flows through smaller bronchioles and alveoli. High Loud Inspiration < expiration Harsh, hollow tubular Trachea and larynx

BRONCHOVESICULARA table presents Apgar scoring system are as follows : 2 indicates that heart rate = over 100, Respiratory effort = good, sustained cry; regular respirations, Muscle tone = Active motion, spontaneous flexion, Reflex irritability (response to catheter in nares) = sneeze, cough, cry, color = completely pink. 1 indicates that heart rate = slow (below 100), Respiratory effort = slow, irregular, shallow, Muscle tone = some flexion of extremities; some resistance to extension, Reflex irritability (response to catheter in nares) = Grimace, frown, color = body pink, extremities pale. 0 indicates that heart rate = absent, Respiratory effort = absent, Muscle tone = Limp, flaccid, Reflex irritability = No response, color = cyanotic, pale. Moderate Moderate Inspiration = expiration Mixed Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces

VESICULAR Low Soft Inspiration > expiration Rustling, like the sound of the wind in the trees Over peripheral lung fields where air flows through smaller bronchioles and alveoli

Note the normal location of the three types of breath sounds on the chest wall of the adult and older child (Figs. 19.19 and 19.20).

19.19

The rear view of a patient highlights the normal range of findings of breath sounds. The breath sounds are classified into vesicular and bronchovesicular breath sounds. An outline of the ribs and lungs are drawn. The bronchovesicular, B V sounds are marked between the spaces of the upper ribs. The vesicular, V breath sounds are heard throughout the lungs and hence marked on both the lungs.

Decreased or absent breath sounds occur:

1. When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body

2. In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; the lungs also are already hyperinflated, so the inhaled air does not make as much noise

3. When anything obstructs transmission of sound between the lung and your stethoscope such as pleurisy or pleural thickening or air (pneumothorax) or fluid (pleural effusion) in the pleural space

A silent chest means that no air is moving in or out; an ominous sign.

19.20

The front view of a patient highlights the normal range of findings of breath sounds. The breath sounds are classified into vesicular, bronchial and bronchovesicular breath sounds. An outline of the ribs and lungs are drawn. The bronchial breath sounds are heard along the trachea or windpipe within the neck. The bronchovesicular, B V sounds are marked between the spaces of the upper ribs. The vesicular, V breath sounds are heard throughout the lungs and hence marked on both the lungs.

Increased breath sounds mean that sounds are louder than they should be (e.g., bronchial sounds are abnormal when they are heard over an abnormal location, the peripheral lung fields). They have a high-pitched, tubular quality, with a prolonged expiratory phase and a distinct pause between inspiration and expiration. They sound very close to your stethoscope, as if they were right in the tubing close to your ear. They occur when consolidation (e.g., pneumonia) or compression (e.g., fluid in the intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchi. When the inspired air reaches the alveoli, it hits solid lung tissue that conducts sound more efficiently to the surface.

Adventitious Sounds

Note the presence of any adventitious sounds. These are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously deflated airways. Sources differ as to the classification and nomenclature of these sounds (see Table 19.6, p. 441), but crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners. If you hear adventitious sounds, describe them as inspiratory versus expiratory, loudness, pitch, and location on the chest wall. Crackles are discontinuous popping sounds heard over inspiration; wheezes are continuous musical sounds heard mainly over expiration. Study Table 19.6 for a complete description of these and other abnormal adventitious breath sounds.

One type of adventitious sound, atelectatic crackles, is not pathologic. Atelectatic crackles are short, popping, crackling sounds that last only a few breaths. When sections of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.

Voice Sounds

The spoken voice can be auscultated over the chest wall just as it can be felt in tactile fremitus described earlier. Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Pathology that increases lung density enhances transmission of voice sounds. Consolidation or compression of lung tissue will enhance the voice sounds, making the words more distinct.

Voice sounds are not elicited routinely. Rather these are supplemental maneuvers performed if you suspect lung pathology on the basis of earlier data. When they are performed, you are testing for the possible presence of bronchophony, egophony, and whispered pectoriloquy (see Table 19.8, p. 444).

Inspect the Anterior Chest

Note the shape and configuration of the chest wall. The ribs are sloping downward with symmetric interspaces. The costal angle is within 90 degrees. Development of abdominal muscles is as expected for the person’s age, weight, and athletic condition.

Barrel chest has horizontal ribs and costal angle >90 degrees.

Hypertrophy of abdominal muscles occurs in chronic emphysema.

Note the person’s facial expression. The facial expression should be relaxed and benign, indicating an unconscious effort of breathing. Tense, strained, tired facies and purse-lipped breathing (the lips in a whistling position) accompany COPD. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse.

Assess the level of consciousness. The level of consciousness should be alert and cooperative. Cerebral hypoxia may be reflected by excessive drowsiness or anxiety, restlessness, and irritability.

Note skin color and condition. The lips and nail beds are free of cyanosis or unusual pallor. The nails are of normal configuration. Explore any skin lesions. Clubbing of distal phalanx occurs with COPD because of growth of vascular connective tissue.

Cutaneous angiomas (spider nevi) associated with liver disease or portal hypertension may be evident on the chest.

Assess the quality of respirations. Normal relaxed breathing is automatic and effortless, regular and even, and produces no noise. The chest expands symmetrically with each inspiration. Note any localized lag on inspiration.

Noisy breathing occurs with severe asthma or chronic bronchitis.

Unequal chest expansion occurs when part of the lung is obstructed (pneumonia) or collapsed or when guarding to avoid postoperative or pleurisy pain.

No retraction or bulging of the interspaces should occur on inspiration. Retraction suggests obstruction of respiratory tract or that increased inspiratory effort is needed, as with atelectasis. Bulging indicates trapped air as in the forced expiration associated with emphysema or asthma.

Normally accessory muscles are not used to augment respiratory effort. However, with very heavy exercise the accessory neck muscles (scalene, sternomastoid, trapezius) are used momentarily to enhance inspiration.

Accessory muscles are used in acute airway obstruction and massive atelectasis.

Rectus abdominis and internal intercostal muscles are used to force expiration in COPD.

The respiratory rate is within normal limits for the person’s age (see p. 145), and the pattern of breathing is regular. Occasional sighs normally punctuate breathing. Tachypnea and hyperventilation, bradypnea and hypoventilation, periodic breathing (see Table 19.4, Respiratory Patterns, p. 438).

Palpate the Anterior Chest

Palpate symmetric chest expansion. Place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process (Fig. 19.21).

19.21

Abnormally wide costal angle with little inspiratory variation occurs with emphysema.

Ask the person to take a deep breath. Watch your thumbs move apart symmetrically and note smooth chest expansion with your fingers. Any limitation in thoracic expansion is easier to detect on the anterior chest because greater range of motion exists with breathing here.

A lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding.

A palpable grating sensation with breathing indicates pleural friction fremitus (see Table 19.5, p. 440).

Assess tactile (vocal) fremitus. Begin palpating over the lung apices in the supraclavicular areas (Fig. 19.22). Compare vibrations from one side to the other as the person repeats “ninety-nine.” Avoid palpating over female breast tissue because breast tissue normally damps the sound.

19.22 Assess tactile fremitus.

The front view of a patient for the palpation of vocal fremitus. The right hand of a nurse is placed on the top left side, just below the neck. Numbers from 1 through 4 are marked vertically downwards on both left and right sides. On the left side, arrow mark is drawn from number 2 to 3 and on the right side arrow marks are drawn from 1 to 2 and 3 to 4. Horizontal lines from left to right side and from right to left side are marked alternatively between numbers.

Palpate the anterior chest wall to note any tenderness (normally none is present) and detect any superficial lumps or masses (again, normally none are present). Note skin mobility and turgor and skin temperature and moisture. If any lumps are found in the breast tissue, refer the patient to a specialist.

Percuss the Anterior Chest

Begin percussing the apices in the supraclavicular areas. Then, percussing the interspaces and comparing one side with the other, move down the anterior chest.

Interspaces are easier to palpate on the anterior chest than on the back. Do not percuss directly over female breast tissue because this would produce a dull note. Shift the breast tissue over slightly, using the edge of your stationary hand. In females with large breasts, percussion may yield little useful data. With all people use the sequence illustrated in Fig. 19.23.

19.23 Sequence for percussion and auscultation.

The front view of a patient for the number sequence for percussion and auscultation. Numbers from 1 through 4 are marked vertically downwards on both left and right sides from the neck towards the upper chest. Number 5 is marked on respective ends of number 4. On the left side, arrow marks are drawn from numbers 2 to 3 and 4 to 5. On the right side arrow marks are drawn from 1 to 2 and 3 to 4. Horizontal lines from left to right side and from right to left side are marked alternatively between numbers.

Note the borders of cardiac dullness normally found on the anterior chest, and do not confuse these with suspected lung pathology (Fig. 19.24). In the right hemithorax, the upper border of liver dullness is located in the 5th intercostal space in the right midclavicular line. On the left, tympany is evident over the gastric space.

19.24 Expected percussion notes.

The front view of a patient for the different range of findings. An outline of the ribs on both sides are drawn. A flat over the muscle and bone are visible just below the neck on both sides. The resonance is marked at the side to the right neck of the patient and also between the third and fourth rib. The liver dullness is marked from the center half of the ribs towards the right lung. The stomach tympany is marked on the center of the left lower lung.

Lungs are hyperinflated with chronic emphysema, which results in hyperresonance where you would expect cardiac dullness.

Dullness behind the right breast occurs with right middle lobe pneumonia.

Auscultate the Anterior Chest

Breath Sounds

Auscultate the lung fields over the anterior chest from the apices in the supraclavicular areas down to the 6th rib. Progress from side to side as you move downward and listen to one full respiration in each location. Use the sequence indicated for percussion. Do not place your stethoscope directly over the female breast. Displace the breast and listen directly over the chest wall.

Evaluate normal breath sounds, noting any abnormal breath sounds and adventitious sounds. If the situation warrants, assess the voice sounds on the anterior chest. Study Table 19.9, p. 445, for a complete description of abnormal respiratory conditions.

Measurement of Pulmonary Function Status

The forced expiratory time is the number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction. Although the test usually is not performed in the respiratory assessment, it is useful when you wish to screen for pulmonary function.

Ask the person to inhale as deeply as possible and then to blow all out hard, as quickly as possible, with the mouth open. Listen with your stethoscope over the sternum. The normal time for full expiration is 4 seconds or less. A forced expiration of 6 seconds or more occurs with obstructive lung disease. Refer this person for more precise pulmonary function studies.

In an ambulatory care setting, a handheld spirometer measures lung health in chronic conditions such as asthma. Ask the patient to inhale deeply and then to exhale into the spirometer as fast as possible until the most air possible is exhaled. The forced vital capacity (FVC) is the total volume of air exhaled. The forced expiratory volume in 1 second (FEV1) is the volume exhaled in the first measured second. A normal outcome is a FEV1/FVC ratio of 75% or greater, meaning that no significant obstruction of airflow is present. An FEV1/FVC ratio less than 70% indicates obstructive lung disease. Obstructive disease severity is classified using predicted FEV1. Mild obstruction = FEV1 >80% predicted; moderate obstruction = FEV1 of 50%-79% predicted; severe obstruction = FEV1 30%-49% predicted; very severe = FEV1 <30% predicted.24

The pulse oximeter is a noninvasive method to assess arterial oxygen saturation (SpO2) and is described in Chapter 10. A healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 99%. However, every SpO2 result must be evaluated in the context of the person’s hemoglobin level, acid-base balance, and ventilatory status.

The 6-minute walk test (6 MWT) is a safer, simple, inexpensive, clinical measure of functional status in persons with a variety of pulmonary and cardiac disorders. The 6 MWT is used as an outcome measure for people in pulmonary rehabilitation because it mirrors conditions that are used in everyday life. Locate a flat-surfaced corridor that has little foot traffic, is wide enough to permit comfortable turns, and has a controlled environment. Ensure that the person is wearing comfortable shoes and equip them with a pulse oximeter to monitor oxygen saturation. Ask the person to set their own pace to cover as much ground as possible in 6 minutes, and assure the person it is all right to slow down or to stop to rest at any time. Use a stopwatch to time the walk. A person who walks more than 300 meters in 6 minutes is more likely to engage in activities of daily living.