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Pulmonary Assessment
Ed Litwin, BS, RRT
Pulmonary Assessment
• ABG’s• CXR• PFT’s
Pulmonary Assessment
InspectionPalpation
PercussionAuscultation
Pulmonary Assessment:Inspection
• Respiratory Pattern
• Chest Abnormalities
• Trachea Position
• Retractions• Symmetry
• Accessory Muscle Use
• Splinting• Level of
Consciousness• Cyanosis
Respiratory Pattern
• Normal Adult Rates• 10 – 16 for quiet effortless
breathing• 20 – 30 for hypoxemia, pain, fear• RR > 30 can’t be maintained for
long• Dramatic Δ in rate may indicate
problems!
Inspection: Respiratory Pattern
• Hyperventilation• Hypoxemia• Pain, fear• Metabolic Acidosis• Hyperthermia• Midbrain lesion/trauma• Restrictive lung disease
Inspection:Respiratory Pattern
• Hypoventilation• Narcotic effects• Sedatives, alcohol• Incomplete reversal from
anesthesia• Hypothermia
Inspection:Respiratory Pattern
• COPD’ers• Lower rate• Prolonged expiration• Pursed lip expiration• Tripod position
Breathing Pattern:Cheyne-Stokes
Breathing Pattern:Biot’s/Ataxic Breathing
Breathing Pattern:Kussmaul’s
Chest Abnormalities:Pectus excavatum/carinatum
Chest Abnormalities:Scars
Chest Abnormalities:Barrel Chest
Inspection:Trachea Position
• Deviates Towards Atelectasis, Fibrosis
• Deviates Away From Pleural Effusion, Tension Pneumothorax
Inspection:Retractions
• Retractions are caused by high work of breathing or airway blockage
• Check the top of the ribcage and intercostal spaces
• Bulging between ribs may indicate a pneumothorax
Inspection:Chest Symmetry
• Are both sides of the chest moving equally?
• movement on one side:• Hemidiaphragm paralysis• Pneumothorax• Old lung resection• Fibrosis
Inspection:Accessory Muscle Use
• High WOB• Hypoxemia• Obstruction• COPD’ers
Inspection:Splinting
• Splinting –protecting or favoring a side• Trauma• Incision• Check during
palpation
Inspection:Level of Consciousness
• Decreased sensorium, somulence, confusion, or coma may be caused by hypoxia and/or PaCO2
• Get an ABG!
Inspection:Cyanosis
• Questionable indicator (late)
• Central vs. peripheral
• Cyanosis when pink before
• Can be cyanotic without being hypoxic
Palpation
• Collecting information through touch
Palpation
• Trachea• Check with fingers, should enter at
middle of the suprasternal notch• Chest Symmetry
• Position hands on both sides of the spine or sternum
• Thumbs should move equal amounts from midpoint with inspiration
• See effects of scoliosis, lordosis
Palpation:Tenderness on Palpation
• Incisional• Cracked ribs, tissue trauma –
overlooked, fall
Palpation:Crepitus
• Open chest wound
• Fresh CT’s, trache
• Pneumothorax/ tension pneumo
Palpation:Secretions
Palpation
• Tactile Fremitus• Fluid increases
sound transmission
• Used to assess consolidation, atelectasis
Percussion• Five Notes
• Flat, dull, resonant, hyperresonant, tympanic
• Uses• Diaphragm
excursion• Pleural effusion• Pneumothorax
Auscultation
• Which lobe are you listening to?
• What lung sounds are you hearing?
Auscultation:Lung Borders
• Apex rises 2 – 4 cm above inner third of clavicle
• Inferior borders at:• 6th rib mid-clavicular
line• 8th rib mid-axillary
line• 10th rib mid-scapular
line
Oblique Fissure
• Separates lower lobes from rest of lungs• Runs from T3, along lower scapular border,
just below 4th rib mid-axillary, and ends at 6th rib mid-clavicular line
• Anything below and behind this is LL’s
Horizontal Fissure
• Separates RUL from RML• Runs from ~4th rib mid-axillary line to
sternum• Usually crosses at the nipple line
Auscultation Landmarks
• Sternal angle is at the 2nd intercostal space – next rib down is 3rd
• With the patient’s neck flexed, biggest bump is C7, next T1, T2, then T3
Auscultation
Listen to anterior, posterior, and lateral surfaces. Cover all the bases!!
Listening Techniques
• Sit Patient Up• Deep Breathe Through Mouth• Stethoscope on Skin• TV, Radio, Visitors OFF!• Systematic Comparison of L and
R, and All Lobes
Normal Breath Sounds
• Vesicular
• Tracheal or Bronchial
• Bronchovesicular
Vesicular Breath Sounds
• Heard over the majority lung periphery
• Medium pitch and loudness
• Inspiration is louder and longer than expiration
Insp.
Exp.
Insp.
Tracheal/Bronchial Breath Sounds
• Heard over and around trachea
• Loud, high pitched, harsh, “tubular”
• E is louder and longer then I
• Short pause between I and E
Insp.
Exp.
Bronchovesicular• Combination of the
other 2• Heard around
sternum, between scapula, anterior RUL
• I and E are equal duration and loudness, no pause
• More muffled than Bronchial
Insp. Exp.
Adventitious (Abnormal) Breath Sounds
One Man’s Rhonchi is Another Man’s Rale
Several groups are advocating for changes in breath sound terminology. Wheezes, rhonchi, and crackles are used with descriptors of tone, pitch, and I or E. I’ll try to blend old and new terminology here.
Adventitious (Abnormal) Breath Sounds
• Bronchial or Bronchovesicular where you should hear vesicular• Indicates fluid filled or
consolidated areas• Fluid transmits vibrations better
than air• Breath sounds are “telegraphed”
from large airways to periphery
Adventitious (Abnormal) Breath Sounds
• Rhonchi/Wheezes• Continuous “musical” notes• Primarily heard on E• Large airways=low pitch=sonorous
rhonchi (“Snoring” type of sound)• Small airways=high
pitch=wheeze=sibilant rhonchi• Caused by narrowed airways from
secretions, edema, bronchospasm
Adventitious (Abnormal) Breath Sounds
• Rales/Crackles• Discontinuous notes, “bubbling”,
“pops”, “fizz”, moist or dry• Mainly heard on I, often clears
with coughing• Lg airways=low pitch=bubbling
coarse rales/crackles• Sm airways=high
pitch=fine/velcro/dry rales/crackles
Adventitious (Abnormal) Breath Sounds
• Rubs• Heard at lung apices• End of I and beginning of E• Like creaking leather or balloon• From pleural/visceral membranes
rubbing• Pleurisy, some neoplasms
Adventitious (Abnormal) Breath Sounds
• Diminished/Absent Breath Sounds• Fluid, blood, or air between lung
and chest wall• Complete airway blockage (mucus,
tumor, foreign body) causes diminished/absent breath sounds
• Pneumo, severe emphysema, resection, obesity, effusion
Extrapulmonary Signs
• Cyanosis – 5 gm of Hgb/100 ml of blood is desaturated
• Sputum - check:• Color• Amount• Thickness• Presence, color and amount of blood• odor
Extrapulmonary Signs
• Clubbing• Seen in
pulmonary, cardiovascular, and hepatobiliarydiseases
• May indicate a chronic purulent resp. disorder
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