CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM

I. INSPECTION A. Chest Shape/ Deformity Chest Shape/ Deformity of the Thorax (Bates) a. Normal chest b. Barrel Chest c. Pigeon Chest AKA Description Round chest; normal during infancy often accompanies aging and COPD Sternum is displaced anteriorly. The costal cartilages to the protruding sternum are depressed depression in the lower portion of the sternum; compression of blood vessels and the heart may cause murmurs Multiple rib fracture may result in paradoxical movement of thorax Diameter Lateral>AP AP=lateral diameter, 1:1 ratio Increased AP diameter

PECTUS CARINATUM PECTUS EXCAVATUM

d. Funnel Chest

e. Traumatic flail chest

On inspiration injured area caves inward, on expiration it moves outward Usual indications Severe asthma, COPD, upper airway obstruction emphysema

B. Rib cage contour Abnormalities retraction

Where to check Supraclavicular, infralavicuar, ICS Compare (B) sides

Widened ICS C.

Description Usually seen during inspiration and most apparent in the lower ICS Increased in size of spaces

Chest Symmetry Check ASYMMETRY if secondary to: LAG lesser movement on respiration of one hemithorax in contrast to the other which maybe be observed or palpated SPLINTING protective fixation of a part of the chest wall usually due to pain; commonly seen in thoracovascular surgeries where the patient splints the operative side Breathing pattern, rate and depth, rhythm Breathing pattern Diaphragmatic Thoracic Aka Abdominal breathing Description Abdominal rises in inspiration and lowers in expiration Observed in chest and upper back Seen in Infants and chidren adult

D.

RATE AND DEPTH a. Rapid and shallow breathing b. Slow and deep breathing

E.

Breathing rate and rhythm Type Tachypnea Bradypnea Hyperpnea Rate >20 cpm <12cpm Normal Characteristic Rapid, shallow Slow , shallow Laborious, rapid and deep

Abnormalities in Respiratory RATE AND RHYTHM Type Characteristic Kussmaul Deep breathing associated with Breathing fast, normal or slow rate Cheynedeep breathing pattern alternates with Stokes periods of apnea; Breathing Biots (slow) or Irregular respiration with varying depths

Indication Metabolic acidosis Heart failure, uremia, drug-induced respiratory depression, brain damage Medullary damage

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
Ataxic (fast) Breathing Apnea Stridor or Stridulous breathing Air Hunger Stertous breathing interrupted by intervals of apnea; breaths maybe shallow or deep and stop for short periods. Absence of breathing or cessation of breathing Difficult respiration with harsh, whistling sound or high pitched crowing sounds during inspiration Deep or gasping respiration Exemplified by snoring and is due to vibration of soft palate Secretion in upper respiratory passages

Obstruction on larynx or other larger air passages

F. Observe for the following: a. Prominence or use of accessory muscles of respiration (SCM, scalene, trapezius) b. Nasal flaring c. Lip pursing and cyanosis d. Nails for clubbing and cyanosis often suggest with pulmonary diseases or inflammatory bowel disease, CHD

G. Cough and Sputum check for strength, productivity and effectivity of secretions
Color Odor Consistency Quantity Red, rust, purple, yellow green, pink Foul smelling, sweet smelling Thin, watery, frothy, gritty, thick, mucus, layered mL or cupful per day

H. Note the location, size and/or length of the bruises (pasa), lesion or scar

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
II. PALPATION Check for the following: 1. Check for tenderness usually in the ribs or in the cartilages like in the case costchondritis, patient complaints of chest pain

2. Check for subcutaneous emphysema usually occurs on the chest, neck and face, where it is able
to travel from the chest cavity. Subcutaneous emphysema has a characteristic crackling feel to the touch, a sensation that been described as similar to touching RICE KRISPIES, this sensation of air under the skin is known as SUBCUTANEOUS CREPITATION

3. Lumps and masses note the location of lumps and masses

4. Pleural Friction Rub palpable coarse grating vibration usually seen in inspiration; feel of leather rubbing on leather when there is rubbing of the pleural surface against another as when it is inflamed or lacks lubricating fluid 5. Mediastinal / Tracheal shift Rationale: check if there is a collapse of the trachea Patient position: sitting Procedure: 1. Slightly flex the neck to the relax SCM, chin should be in midline 2. Place the index fingers medial to suprasternal notch 3. Push inward to the cervical spine Tracheal deviation can occur towards: Ipsilateral or affected side Normal side Atelectasis pneumothorax Agenesis of lung Pleural effusion Pneumonectomy Large mass Pleural fibrosis Lobectomy 6. Respiratory Excursion / Chest expansion (Bates) Rationale: To assess if there is asymmetry in the chest expansion during respiration To check if there lagging or splinting during respiration Patients position: sitting Procedure: done in 3 levels (angle of Louis, xiphoid process, 10th rib done posteriorly) 1. Place your thumbs at about the level, with your fingers loosely grasping and parallel to the lateral rib cage. 2. As you position your hands, slide them medially just enough to raise a loose fold of skin on each side between your thumb and the spine 3. Ask the patient to inhale deeply. 4. Watch the distance between your thumbs as they move apart during inspiration and feel for the range and symmetry of the rib cage as it expands and contracts 7. Fremitus refers to the palpable vibrations that arise in the respiratory tract that are transmitted to the chest wall when speaking Three types: Vocal due to spoken sound usually tres, tres or ninety nine Whispered produced by whispering Tussive produced by coughing Rationale: To determine if there is excessive air or solid mass in the lungs Procedure: Place the palm of the hand or the ulnar border of the hand on the different areas Ask the patient to repeat the words tres, tres or ninety nine Note if fremitus is decreased or increased The palpation maybe done with one hand or alternating both hands or simultaneously with both hands General Indication: increased (d/t presence of fluid or mass in the lungs) Decreased (d/t excess air in the lungs)

1.
2.

3. 4.

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
Areas for Fremitus: ANTERIOR CHEST (preferably in supine but maybe performed in side lying) Above the breast Medial sides of the nipple Lateral sides of the nipple (B) anterior segment of t he upper lobe Medial segment of the right middle lobe and left upper lobe Lateral segment of middle lobe and left upper lobe

Areas for Fremitus: POSTERIOR CHEST (done in sitting wit hands across the chest) Medial to the superior angle of the scapula (L) apicoposterior segment and ( R ) apical segment upper lobe Medial to the scapular spine Posterior segment of the (R) upper lobe Below the inferior angle of the scapula (B) posterior segments of the lower lobe 10th ribs slightly lateral (B) lateral segments of the lower lobe 8. Chest Expansion Measurement (using tape measure) - generally used for pt that can follow instruction otherwise we make use of chest excursion Rationale: check for limited chest or lung expansion Landmarks Resting Expiration Maximal Inspiration Angle of Louis Xiphoid process 10th rib ***Significant Value: < 2cm limited chest expansion Difference

Procedure: 1. Position the tape measure (in centimeters) in the above mentioned landmarks 2. For each of the mentioned landmark, ask the patient to inspire and expire normally but before the 3rd inspiration take the reading of the resting expiration, then ask the patient to inhale deeply. Take the measurement of maximal inspiration 3. Record the difference between the resting expiration and maximal inspiration 4. Repeat the same procedure for the two other landmarks 5. Give rest periods to avoid hyperventilation of the patient. 9. Presence of Rib fracture Rationale: to check for possible rib fracture Pt Position: sitting/standing Procedure: compress the sternum and the spine wit two hands, a (+) c/o is indicative rib fracture.

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
III. PERCUSSION 1. Types of Percussion tones: PERCUSSION TONE Resonance Flat Dull Tympanic Hyperresonance STRUCTURE Lung Muscles, bones Heart, liver Stomach Emphysematous lung

Rationale: to assess lung density Patients position: Anterior chest supine Posterior chest sitting with arms folded in front Procedure: 1. Hyperextend the middle finger of your left hand (pleximeter finger). Press the DIP joint firmly on the surface to be percussed. All the other fingers are not touching the chest surface. 2. Position right forearm quite close to the surface with the hand cocked upward. The middle finger should be partially flexed relaxed and poised to strike 3. With a quick sharp but relaxed wrist motion, strike the pleximeter. Aim at the DIP of the middle finger. Strike using the tip of the finger and not on the pad 4. Withdraw the striking hand quickly to avoid damping the vibrations created Important percussion Notes: 1. A thick wall requires heavier percussion than a thin one 2. If a louder note is needed, apply more pressure with the pleximeter finger 3. When percussing the lower posterior chest, stand at the side rather directly behind the patient 4. When comparing two areas, use the same percussion technique in both areas. It is easier to detect differences in percussion by comparing one area to the opposite of that area 5. Distinguish the difference in the basic quality of sound; intensity, pitch and duration 6. Normal lungs are resonant 7. The thickness of the muscle and bones alter the percussion notes over the lungs 8. Dullness replaces resonance when fluid or slid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers 9. Hyperresonance may be heard over the hyperinflated lungs of emphysema or asthma. Unilateral hyperresonance suggest a large pneumothorax or possibly a large air-filled bulla in the lung 2. Diaphragmatic Excursion (you can also use the video for reference) - limitation may suggest pathologic processes like abdominal ascites, emphysema, pain. Procedure: 1. Ask the pt to take a deep breath and hold it. 2. Percuss along the scapular line until you locate the lower border (point marked by a tone from resonance to dullness) 3. Mark the point and allow pt to breath normally. 4. Ask pt to exhale as much and continue percussing from the 1st marking going up to the point of resonance (change in tone from dullness to resonance) 5. Measure the distance of the two points 6. Repeat and compare on the other side. 7. Normal difference should be 3-6cm

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
IV. AUSCULTATION GUIDELINES DURING EXAMINATION 1. Bell is for low pitched sounds, diaphragm is for high pitched 2. Pressing too hard on the skin can obliterate sound 3. Avoid holding either side of the stethoscope with the thumb 4. Last to administer: IPPA

A.

Normal breath sounds B. Adventitious sounds Normal breath sounds: Duration of sound Vesicular I>E Bronchovesicular I=E Bronchial Tracheal E>I I=E Intensity of expiratory sound Soft Intermediate Loud Very loud Heard during Inspiration Both Both Inspiration Both Pitch of expiratory sound Low Intermediate High Very high Locations normally heard lungs 1st and 2nd ICS and in between scapula manubrium Trachea

Adventitious Sound Adventitious sound Rales or crackles Rhonchi Wheezes Stridor Pleural rub

Description Crackling, noncontinuous Continuous, high pitched and musical Non-continuous, whistling Louder in the neck than the chest wall Sounds like rales

indication CHF, bronchitis, pneumonia, pulmonary fibrosis Asthma, COPD, chronic bronchitis

Laryngeal or tracheal obstruction Inflamed pleura

RATIONALE: To check for breath sounds Patient position: Anterior chest sitting / supine position Posterior chest sitting with arms folded in front PROCEDURE: 1. Place the diaphragm of the stethoscope at the skin of the patient 2. Follow the systematic pattern based on the table below REMEMBER: always start with the POSTERIOR CHEST Left side then on the ANTERIOR CHEST Right side) 3. Ask the patient to breath in slowly, deeply 4. Note the equality pitch and intensity BREATH ODORS POSSIBLE CAUSES PTB DIABETIC KETOACIDOSIS HALITOSIS FOUL SMELLING SCENT CINNAMON SWEET, FRUITY LUNG INFECTION EMPHYSEMA, LUNG ABSCESS

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CHEST AND LUNG ASSESSMENT REVISIONS MADE FOR AY12-13 PT EVALUATION TEAM
AREAS OF PERCUSSION AND AUSCULTATION a. POSTERIOR CHEST Medial to the superior angle of the scapula Medial to the scapular spine Medial to the vertebral border of the spine Below the inferior angle of the scapula 10th rib just below the inferior angle of the scapula Lateral side - inferior angle of the scapula Lateral side 10Th rib b. ANTERIOR CHEST Above clavicle Below clavicle Slightly above the nipple Medial side of the nipple Lateral side of the nipple Below the breast (in line with the lateral side of the nipple) ***see the diagram for Locations of PERCUSSION AND AUSCULTATION (Bates) (L) apicoposterior segment and right apical segment upper lobe Posterior segment of the upper lobe (B) superior or apical segment of the lower lobe (B) posterior segment of the lower lobe (B) posteromedial segments of the lower lobe (B) lateral segments of the lower lobe

(B) anterior segment of t he upper lobe Medial segment of the right middle lobe and left upper lobe Lateral segment of middle lobe and left upper lobe

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