ELASTICITY/RECOIL- return to original/resting volume
ANATOMY AND PHYSIOLOGY OF REPIRATORY SYSTEM RESPIRATION REGULATION
OXYGENATION- dynamic interaction of gases to give adeq O2 for cellular survival.
I. NEUROCHEMICAL CONTROL
I. UPPER AIRWAYS MEDULLA OBLONGATA- resp center; initiate each breath by sending message to primary
1. NOSE 2. PHARYNX (Nasopharynx, Oropharynx, Laryngopharynx) resp muscles over phrenic nerve
3. LARYNX- connect upper & lower airways PONS- w/2 resp centers working w/inspiration center to make normal breathing rate
Fx: Warm, humidify, and filter inhaled air • Apneustic center – prolongs inhalation
Help make sound and send air to lower airways
• Pneumotaxic center – limit air volume inspired; produce abn inhalation.
-> Epiglottis – valve flap; covers opening to larynx during swallowing
CHEMORECEPTORS- responds to changes in PH (↑PACO2 = ↑ RR)
• Central (Medulla)
• Peripheral (Carotid & Aortic bodies) – monitor blood levels of CO2, O2, pH
II. NEURAL CONTROL
DORSAL RESPIRATORY GROUP (INSPIRATORY CENTER) (DRG)
- @medulla; sends stimulatory signals to diaphragm thru phrenic nerve
VENTRAL RESPIRATORY GROUP
• VRG Expiratory Center (Apneustic)- stimulates expiratory muscles
• VRG Inspiratory Center (Pneumotaxic) – stimulates inspiratory muscles other than diaphragm
PERIPHERAL CHEMORECEPTORS
- carotid + aortic bodies send signals to DRG via glossopharyngeal nerve
- ↑CO2, ↓O2 (↑O2 = inhibit respiration)
STRETCH RECEPTORS
• Inflation reflex – ↑lung volume stimulates apneustic center thru vagus nerve
• Deflation reflex – ↓ “ “ “ pneumotaxic center thru vagus nerve
LUNG RECEPTORS
• Stretch R.= Hering-Breurer reflexes (baroreceptors in lung tissue detect stretching & send
impulses to medulla to depress inspiration center)
• Irritant R= Sighing & yawning
• Juxtacapillary/J receptors= Lung congestion
III. VOLUNTARY CONTROL
HYPOTHALAMUS – Modifies output from medulla (Anger = ↑RR; Fright = gasp)
CEREBRAL CORTEX –voluntarily change breathing rate/rhythm (Talking, singing)
H-B Reflex (LUNG VOLUMES)
• TIDAL VOLUME (TV)- air volume inhaled & exhaled w/each breath (500 ml)
• RESIDUAL VOLUME (RV)- After exhalation, 1200 ml of air remains in lungs
• INSPIRATION RESERVE VOLUME (IRV)- air # that can be inhaled forcibly over TV (3000 ml)
• EXPIRATORY “ “ (ERV)- air # that can be forcibly exhaled (1200 ml)
LUNG CAPACITY
II. LOWER AIRWAYS
1. TRACHEA • VITAL CAPACITY (TV+IRV+ERV = 4,600 ml)
- between larynx & primary bronchi; 10-13 cm (4.5 in) long; 2.5cm wide - Maximum air volume exhaled from point of maximum inspiration
- supported by 16-20 c-shaped cartilage rings • INSPIRATORY C. (TV+IRV = 3,500 ml)
- Carina (where trachea divides into 2 primary bronchi) - Maximum air volume inhaled after normal expiration
2. BRONCHI • FUNCTIONAL RESIDUAL C. (ERV+RV = 2,300 ml)
- RIGHT MAINSTEM BRONCHI (larger + straighter; divides to 3 lobar branch) - air volume remaining in lungs after normal expiration
- LEFT “ “ (smaller + curvier; divides to upper & lower “ “ ) • TOTAL LUNG C. (5,800 ml)
primary -> secondary (lobar) - > tertiary (segmental) - air volume in the lungs after maximum inspiration
3. LUNGS VENTILATION PERFUSION RATIO
- main resp organs; base (broad, rest on diaphragm) apex (narrow superior part @clavicle
• NORMAL RATIO = 1:1 VP ratio
- mediastinum (thorax midline)
• LOW VENTILATION-PERFUSION RATIO= Shunt (P exceeds V)
Membranes: Visceral (covers lungs) Parietal (covers thorax)
- blood will bypass alveoli w/o gas exchange (common in pneumonia, atelectasis)
Pleural Fluid (lubricate lungs + thorax for smooth motion during breathing
(5-15 ml) • HIGH VP RATIO= Dead Space (V exceeds P)
4. ALVEOLI- 300 mil arranged in clusters of 15-20 - alveoli don’t have adeq blood supply for gas exchange to occur (common in pulmonary embolism)
Alveolar cells: Type I= epithelial cells forming walls; for structure to alveoli squamous • SILENT UNIT
Type II= metabolically active; form surfactant (prevent alveolar collapse) - Absence of V & P /decrease in both V&P; common in pneumothorax.
Type III= macrophage; destroy foreign materials/bacteria
OXYHEMOGLOBIN DISSOCIATION CURVE
Three levels: NORMAL = PaO2 >70 mm HG RELATIVELY SAFE= PaO2 45-70 mm Hg
DANGEROUS= PaO2 < 40 mm Hg
• The normal (middle) curve (N) = 75% saturation occurs at PaO2 40 mm Hg
Resp Muscle: DIAPHRAGM + EXTERNAL INTERCOSTAL MUSCLE (primary) • curve shifts to right (R) = 75% sat occurs at higher PaO2 57mm Hg.
• curve shifts to left (L)= 75% saturation occurs at PaO2 25 mm Hg
GAS EXHANGE
1. VENTILATION- in & out of lungs (inspiration + expiration)
2. DIFFUSION- O2 & CO2 exchanged air-blood interface
3. RESPIRATION- external (bw alveoli & pulmonary capillaries)
internal (bw blood & systemic capillaries + tissue)
4. PERFUSION- Systemic Circulation (blood flow to oxygenate body) (heart + body)
Pulmonary Circulation (heart + lungs)
COMPLIANCE- expand d/t pulling action of pleural memb; aided by surfactant
, • Peripheral– d/t ↓ blood flow to a certain area of body
- Vasoconstriction of nailbeds/earlobes from cold exposure
III. PHYSICAL ASSESSMENT (I, P, P, A)
ASSESSMENT OF RESPIRATORY STATUS 1. INSPECTION
I. COMPLETE HISTORY = External nose – lesions, asymmetry, or inflammation
A. Family history = Mucosa – for color, swelling, exudate, or bleeding
B. Past medical history Steps:
- Childhood/ infectious diseases - Respiratory immunization • Start w/nose (symmetry, swelling, others)
- Major illnesses/ hospitalizations - Medications - Allergies • Observe for dyspnea, use of accessory muscles during breathing
C. Psychosocial history • Watch for chest wall symmetry, note any paradoxical chest wall movement
- Family relationship - Employment status • Count RR for a full minute (longer if with abnormalities)
• Inspect the tongue, mouth, fingers and nail beds
D. Present health history
- Biographic data - Nutrition - Lifestyle (LOWER RESPIRATORY STRUCTURES)
- Chief complaint presenting problem (Dyspnea, Cough) → “WHAT’S UP” & “COLDSPAA” TRACHEA = (N) middle deviated by masses in neck/mediastinum.
(Abn) Displace d/t Pleural or pulmonary disorders (pneumothorax)
(WHAT’S UP?)
• Where is it? (Not applicable) THORAX= inspect: Color & turgor, loss of subcutaneous tissue, asymmetry
• How does it feel? Does breathing feel tight, gasping, suffocating? CHEST CONFIGURATION= (N) ratio of anteroposterior diameter : lateral diameter = 1:2
• Aggravating and alleviating factors? • Barrel chest – lung Overinflation → ↑thorax anteroposterior diameter
How much activity cause SOB? = EMPHYSEMA
Does anything else aggravate it? What do you do to lessen SOB?
• Timing? When did you first experience SOB?
Does it happen more at any particular time of the day or year?
• Severity? Rate SOB 0 to 10 (0=easy breathing, 10= worst SOB you can imagine)
• Useful other data? Do you have any other symptoms that occur along with SOB?
•Patient’s perception? What do you think is causing your shortness of breath?
2. Funnel Chest (Pectus Excavatum)
- depression in lower portion of sternum; Compress heart & great vessels
= RICKETS / MARFAN’S SYNDROME
SMOKING – single most important contributor to lung disease 3. Pigeon Chest (Pectus Carinatum)- sternum Displacement = ↑anteroposterior diameter
smoking history formula: Years of smoking x packs/day = PACK YEARS = RICKETS / MARFAN’S SYNDROME /SEVERE KYPHOSCOLIOSIS
(15 years of smoking x 2 packs/day = 30 packs years)
4. Kyphoscoliosis – scapula Elevation into S-shaped spine; limits lung expansion in thorax
= OSTEOPOROSIS
II. PRIMARY INDICATORS OF RESPIRATORY DISORDERS
1. DYSPNEA – difficult or labored breathing, SOB
Types: a. Exertional
b. Orthopnea
c. Paroxysmal nocturnal dyspnea
RESPIRATORY RATE/BREATHING/RESP PATTERN
- inspect rate, rhythm, depth
• EUPNEA – normal rate + rhythm • TACHYPNEA – increased respiratory rate
2. COUGH – d/t irritation of mucous membranes anywhere in the respiratory tract
Character: Dry – URTI Severe changing – carcinoma
Time: AM– bronchitis PM – asthma • BRADYPNEA – slow but regular respirations • APNEA – absent breathing (may be periodic)
3. SPUTUM PRODUCTION – lung reax to any constantly recurring irritant
- associated w/ nasal discharge
• Bacterial infection – thick yellow/rust-colored sputum • HYPERVENTILATION – deeper respirations; normal rate
• Viral bronchitis – thin, mucoid sputum frequent
• Chronic bronchitis – a gradual ↑sputum
• Lung Tumor= Pink-tinged mucoid sputum
• Pulmonary edema – profuse, frothy, pink material • CHEYNE-STROKES –gradually become faster & deeper than normal, then slower;
• Lung abscess – foul-smelling sputum & bad breath - alternates w/periods of apnea
4. CHEST PAIN
• r/t pulmonary conditions = sharp, stabbing, intermittent/ dull, aching, persistent.
• may occur w/ pneumonia, pulmonary embolism w/lung infarction, pleurisy. • BIOT’S – faster & deeper resp than normal, w/abrupt pauses between; breaths have equal depth
5. WHEEZING- major finding in Bronchoconstriction/ airway narrowing.
6. CLUBBING OF THE FINGERS- sign of lung dse w/ chronic hypoxic conditions
• KUSSMAUL’S – faster & deeper respirations w/o pauses
2. PALPATION
7. HEMOPTYSIS- Expectoration of blood from resp tract = Palpate sinuses using thumbs
- Blood from lung is usually bright red, frothy, mixed w/sputum = Use palms to palpate chest crepitus, tenderness, alignment, bulging, retractions
d/t: Pulmonary infection, lung Carcinoma Palpate: tactile fremitus, crepitus Assess: chest wall symmetry & expansion
• Thoracic Palpation- tenderness, masses, lesions, crepitus
8. CYANOSIS - bluish coloring of skin (very late indicator of hypoxia)
- appears if unoxygenated Hbg = 5 g/dL • Respiratory Excursion (Tactile Fremitus)
- diaphragm movement during breathing
• Central– tongue & lips ↓ oxygen tension in blood.
, - Place both hands posteriorly at level of T9/ T10. Slide hands medially to pinch a small
amount of skin between your thumbs. Observe for symmetry.
ABNORMAL / ADVENTITIOUS BREATH SOUNDS
3. THORACIC PERCUSSION
– tapping on anterior & posterior chest
- tip of other hand strikes quick taps over middle finger of 1 hand placed firmly against skin
Sound Where Characteristic Significance
I: loud L: long
RESONANCE Over lungs NORMAL lung tissue
P: Low Q: hollow
(N) children, very thin adults
HYPER- I: Very loud L: long (Abn)
Areas of ↑ air
RESONANCE P: low Q: Booming hyperinflated lungs, COPD,
asthma, pneumothorax
Over stomach (N) stomach (gastric bubbles)
I: Loud L: Moderate
TYMPANY (but not normal (Abn) excess air in chest,
P: High Q: Drum-like
chest sound) pneumothorax
Fluid-filled/solid tissue replace
Dense areas
I: Medium L: Moderate air-filled lung tissue
DULLNESS (liver, heart, FINE CRACKLES COARSE CRACKLES
P: Medium Q: Thud-like (pneumonia, tumor, pleural
diaphragm) Occur when stops inhaling Occurs when starts to inhale
effusion)
Solid areas Heard at lung bases Heard throughout lungs
FLATNESS/ I: Soft L: Short Sound like: hair rubbed between fingers Sound like: bubbling or gurgling
(bone, muscle,
STONY DULL P: High Q: Flat Unaffected by coughing Usually clear/diminish after coughing
sternum, thigh)
WHEEZES
• Sibilant rhonchi – High-pitched, squeaking sound
• Sonorous rhonchi – Low-pitched, musical snoring, moaning sound
→ MORE ON BACK PART !!!
Vocal Resonance
EGOPHONY- distorted voice sound
• Say prolonged “e”
• Auscultated as “a” indicating consolidation
BRONCHOPHONY – more intense & clearer than normal
• Say “ninety-nine”
• Consolidation results in words are heard clearly
• Diaphragmatic Excursion
- thoracic diaphragm movement during breathing WHISPERED PECTORILOQUY
- vertical distance from baseline to highest point of inspiration (how far diaphragm move) • Whisper “1,2,3”
• (N) auscultated as muffled 1,2,3 = must be non-distinct
• (consolidation) = If words are distinct
4. THORACIC AUSCULTATION
- assess airflow thru bronchial tree to eval presence of fluid/ solid obstruction in lung structures.
NORMAL BREATH SOUND
TRACHEAL BRONCHIAL BRONCHOVESICULAR VESICULAR
INTENSITY Very loud Loud Moderate Soft
Low
Very high,
PITCH High Moderate
high-pitched
DESCRIPTION Harsh Tubular Rustling, tubular Gentle rustling
Extra- Over mainstem bronchi Most of
Manubrium in large peripheral lung
LOCATION thoracic (1st & 2nd intercostal
tracheal airway (lung bases)
trachea space of anterior chest
ANATOMY AND PHYSIOLOGY OF REPIRATORY SYSTEM RESPIRATION REGULATION
OXYGENATION- dynamic interaction of gases to give adeq O2 for cellular survival.
I. NEUROCHEMICAL CONTROL
I. UPPER AIRWAYS MEDULLA OBLONGATA- resp center; initiate each breath by sending message to primary
1. NOSE 2. PHARYNX (Nasopharynx, Oropharynx, Laryngopharynx) resp muscles over phrenic nerve
3. LARYNX- connect upper & lower airways PONS- w/2 resp centers working w/inspiration center to make normal breathing rate
Fx: Warm, humidify, and filter inhaled air • Apneustic center – prolongs inhalation
Help make sound and send air to lower airways
• Pneumotaxic center – limit air volume inspired; produce abn inhalation.
-> Epiglottis – valve flap; covers opening to larynx during swallowing
CHEMORECEPTORS- responds to changes in PH (↑PACO2 = ↑ RR)
• Central (Medulla)
• Peripheral (Carotid & Aortic bodies) – monitor blood levels of CO2, O2, pH
II. NEURAL CONTROL
DORSAL RESPIRATORY GROUP (INSPIRATORY CENTER) (DRG)
- @medulla; sends stimulatory signals to diaphragm thru phrenic nerve
VENTRAL RESPIRATORY GROUP
• VRG Expiratory Center (Apneustic)- stimulates expiratory muscles
• VRG Inspiratory Center (Pneumotaxic) – stimulates inspiratory muscles other than diaphragm
PERIPHERAL CHEMORECEPTORS
- carotid + aortic bodies send signals to DRG via glossopharyngeal nerve
- ↑CO2, ↓O2 (↑O2 = inhibit respiration)
STRETCH RECEPTORS
• Inflation reflex – ↑lung volume stimulates apneustic center thru vagus nerve
• Deflation reflex – ↓ “ “ “ pneumotaxic center thru vagus nerve
LUNG RECEPTORS
• Stretch R.= Hering-Breurer reflexes (baroreceptors in lung tissue detect stretching & send
impulses to medulla to depress inspiration center)
• Irritant R= Sighing & yawning
• Juxtacapillary/J receptors= Lung congestion
III. VOLUNTARY CONTROL
HYPOTHALAMUS – Modifies output from medulla (Anger = ↑RR; Fright = gasp)
CEREBRAL CORTEX –voluntarily change breathing rate/rhythm (Talking, singing)
H-B Reflex (LUNG VOLUMES)
• TIDAL VOLUME (TV)- air volume inhaled & exhaled w/each breath (500 ml)
• RESIDUAL VOLUME (RV)- After exhalation, 1200 ml of air remains in lungs
• INSPIRATION RESERVE VOLUME (IRV)- air # that can be inhaled forcibly over TV (3000 ml)
• EXPIRATORY “ “ (ERV)- air # that can be forcibly exhaled (1200 ml)
LUNG CAPACITY
II. LOWER AIRWAYS
1. TRACHEA • VITAL CAPACITY (TV+IRV+ERV = 4,600 ml)
- between larynx & primary bronchi; 10-13 cm (4.5 in) long; 2.5cm wide - Maximum air volume exhaled from point of maximum inspiration
- supported by 16-20 c-shaped cartilage rings • INSPIRATORY C. (TV+IRV = 3,500 ml)
- Carina (where trachea divides into 2 primary bronchi) - Maximum air volume inhaled after normal expiration
2. BRONCHI • FUNCTIONAL RESIDUAL C. (ERV+RV = 2,300 ml)
- RIGHT MAINSTEM BRONCHI (larger + straighter; divides to 3 lobar branch) - air volume remaining in lungs after normal expiration
- LEFT “ “ (smaller + curvier; divides to upper & lower “ “ ) • TOTAL LUNG C. (5,800 ml)
primary -> secondary (lobar) - > tertiary (segmental) - air volume in the lungs after maximum inspiration
3. LUNGS VENTILATION PERFUSION RATIO
- main resp organs; base (broad, rest on diaphragm) apex (narrow superior part @clavicle
• NORMAL RATIO = 1:1 VP ratio
- mediastinum (thorax midline)
• LOW VENTILATION-PERFUSION RATIO= Shunt (P exceeds V)
Membranes: Visceral (covers lungs) Parietal (covers thorax)
- blood will bypass alveoli w/o gas exchange (common in pneumonia, atelectasis)
Pleural Fluid (lubricate lungs + thorax for smooth motion during breathing
(5-15 ml) • HIGH VP RATIO= Dead Space (V exceeds P)
4. ALVEOLI- 300 mil arranged in clusters of 15-20 - alveoli don’t have adeq blood supply for gas exchange to occur (common in pulmonary embolism)
Alveolar cells: Type I= epithelial cells forming walls; for structure to alveoli squamous • SILENT UNIT
Type II= metabolically active; form surfactant (prevent alveolar collapse) - Absence of V & P /decrease in both V&P; common in pneumothorax.
Type III= macrophage; destroy foreign materials/bacteria
OXYHEMOGLOBIN DISSOCIATION CURVE
Three levels: NORMAL = PaO2 >70 mm HG RELATIVELY SAFE= PaO2 45-70 mm Hg
DANGEROUS= PaO2 < 40 mm Hg
• The normal (middle) curve (N) = 75% saturation occurs at PaO2 40 mm Hg
Resp Muscle: DIAPHRAGM + EXTERNAL INTERCOSTAL MUSCLE (primary) • curve shifts to right (R) = 75% sat occurs at higher PaO2 57mm Hg.
• curve shifts to left (L)= 75% saturation occurs at PaO2 25 mm Hg
GAS EXHANGE
1. VENTILATION- in & out of lungs (inspiration + expiration)
2. DIFFUSION- O2 & CO2 exchanged air-blood interface
3. RESPIRATION- external (bw alveoli & pulmonary capillaries)
internal (bw blood & systemic capillaries + tissue)
4. PERFUSION- Systemic Circulation (blood flow to oxygenate body) (heart + body)
Pulmonary Circulation (heart + lungs)
COMPLIANCE- expand d/t pulling action of pleural memb; aided by surfactant
, • Peripheral– d/t ↓ blood flow to a certain area of body
- Vasoconstriction of nailbeds/earlobes from cold exposure
III. PHYSICAL ASSESSMENT (I, P, P, A)
ASSESSMENT OF RESPIRATORY STATUS 1. INSPECTION
I. COMPLETE HISTORY = External nose – lesions, asymmetry, or inflammation
A. Family history = Mucosa – for color, swelling, exudate, or bleeding
B. Past medical history Steps:
- Childhood/ infectious diseases - Respiratory immunization • Start w/nose (symmetry, swelling, others)
- Major illnesses/ hospitalizations - Medications - Allergies • Observe for dyspnea, use of accessory muscles during breathing
C. Psychosocial history • Watch for chest wall symmetry, note any paradoxical chest wall movement
- Family relationship - Employment status • Count RR for a full minute (longer if with abnormalities)
• Inspect the tongue, mouth, fingers and nail beds
D. Present health history
- Biographic data - Nutrition - Lifestyle (LOWER RESPIRATORY STRUCTURES)
- Chief complaint presenting problem (Dyspnea, Cough) → “WHAT’S UP” & “COLDSPAA” TRACHEA = (N) middle deviated by masses in neck/mediastinum.
(Abn) Displace d/t Pleural or pulmonary disorders (pneumothorax)
(WHAT’S UP?)
• Where is it? (Not applicable) THORAX= inspect: Color & turgor, loss of subcutaneous tissue, asymmetry
• How does it feel? Does breathing feel tight, gasping, suffocating? CHEST CONFIGURATION= (N) ratio of anteroposterior diameter : lateral diameter = 1:2
• Aggravating and alleviating factors? • Barrel chest – lung Overinflation → ↑thorax anteroposterior diameter
How much activity cause SOB? = EMPHYSEMA
Does anything else aggravate it? What do you do to lessen SOB?
• Timing? When did you first experience SOB?
Does it happen more at any particular time of the day or year?
• Severity? Rate SOB 0 to 10 (0=easy breathing, 10= worst SOB you can imagine)
• Useful other data? Do you have any other symptoms that occur along with SOB?
•Patient’s perception? What do you think is causing your shortness of breath?
2. Funnel Chest (Pectus Excavatum)
- depression in lower portion of sternum; Compress heart & great vessels
= RICKETS / MARFAN’S SYNDROME
SMOKING – single most important contributor to lung disease 3. Pigeon Chest (Pectus Carinatum)- sternum Displacement = ↑anteroposterior diameter
smoking history formula: Years of smoking x packs/day = PACK YEARS = RICKETS / MARFAN’S SYNDROME /SEVERE KYPHOSCOLIOSIS
(15 years of smoking x 2 packs/day = 30 packs years)
4. Kyphoscoliosis – scapula Elevation into S-shaped spine; limits lung expansion in thorax
= OSTEOPOROSIS
II. PRIMARY INDICATORS OF RESPIRATORY DISORDERS
1. DYSPNEA – difficult or labored breathing, SOB
Types: a. Exertional
b. Orthopnea
c. Paroxysmal nocturnal dyspnea
RESPIRATORY RATE/BREATHING/RESP PATTERN
- inspect rate, rhythm, depth
• EUPNEA – normal rate + rhythm • TACHYPNEA – increased respiratory rate
2. COUGH – d/t irritation of mucous membranes anywhere in the respiratory tract
Character: Dry – URTI Severe changing – carcinoma
Time: AM– bronchitis PM – asthma • BRADYPNEA – slow but regular respirations • APNEA – absent breathing (may be periodic)
3. SPUTUM PRODUCTION – lung reax to any constantly recurring irritant
- associated w/ nasal discharge
• Bacterial infection – thick yellow/rust-colored sputum • HYPERVENTILATION – deeper respirations; normal rate
• Viral bronchitis – thin, mucoid sputum frequent
• Chronic bronchitis – a gradual ↑sputum
• Lung Tumor= Pink-tinged mucoid sputum
• Pulmonary edema – profuse, frothy, pink material • CHEYNE-STROKES –gradually become faster & deeper than normal, then slower;
• Lung abscess – foul-smelling sputum & bad breath - alternates w/periods of apnea
4. CHEST PAIN
• r/t pulmonary conditions = sharp, stabbing, intermittent/ dull, aching, persistent.
• may occur w/ pneumonia, pulmonary embolism w/lung infarction, pleurisy. • BIOT’S – faster & deeper resp than normal, w/abrupt pauses between; breaths have equal depth
5. WHEEZING- major finding in Bronchoconstriction/ airway narrowing.
6. CLUBBING OF THE FINGERS- sign of lung dse w/ chronic hypoxic conditions
• KUSSMAUL’S – faster & deeper respirations w/o pauses
2. PALPATION
7. HEMOPTYSIS- Expectoration of blood from resp tract = Palpate sinuses using thumbs
- Blood from lung is usually bright red, frothy, mixed w/sputum = Use palms to palpate chest crepitus, tenderness, alignment, bulging, retractions
d/t: Pulmonary infection, lung Carcinoma Palpate: tactile fremitus, crepitus Assess: chest wall symmetry & expansion
• Thoracic Palpation- tenderness, masses, lesions, crepitus
8. CYANOSIS - bluish coloring of skin (very late indicator of hypoxia)
- appears if unoxygenated Hbg = 5 g/dL • Respiratory Excursion (Tactile Fremitus)
- diaphragm movement during breathing
• Central– tongue & lips ↓ oxygen tension in blood.
, - Place both hands posteriorly at level of T9/ T10. Slide hands medially to pinch a small
amount of skin between your thumbs. Observe for symmetry.
ABNORMAL / ADVENTITIOUS BREATH SOUNDS
3. THORACIC PERCUSSION
– tapping on anterior & posterior chest
- tip of other hand strikes quick taps over middle finger of 1 hand placed firmly against skin
Sound Where Characteristic Significance
I: loud L: long
RESONANCE Over lungs NORMAL lung tissue
P: Low Q: hollow
(N) children, very thin adults
HYPER- I: Very loud L: long (Abn)
Areas of ↑ air
RESONANCE P: low Q: Booming hyperinflated lungs, COPD,
asthma, pneumothorax
Over stomach (N) stomach (gastric bubbles)
I: Loud L: Moderate
TYMPANY (but not normal (Abn) excess air in chest,
P: High Q: Drum-like
chest sound) pneumothorax
Fluid-filled/solid tissue replace
Dense areas
I: Medium L: Moderate air-filled lung tissue
DULLNESS (liver, heart, FINE CRACKLES COARSE CRACKLES
P: Medium Q: Thud-like (pneumonia, tumor, pleural
diaphragm) Occur when stops inhaling Occurs when starts to inhale
effusion)
Solid areas Heard at lung bases Heard throughout lungs
FLATNESS/ I: Soft L: Short Sound like: hair rubbed between fingers Sound like: bubbling or gurgling
(bone, muscle,
STONY DULL P: High Q: Flat Unaffected by coughing Usually clear/diminish after coughing
sternum, thigh)
WHEEZES
• Sibilant rhonchi – High-pitched, squeaking sound
• Sonorous rhonchi – Low-pitched, musical snoring, moaning sound
→ MORE ON BACK PART !!!
Vocal Resonance
EGOPHONY- distorted voice sound
• Say prolonged “e”
• Auscultated as “a” indicating consolidation
BRONCHOPHONY – more intense & clearer than normal
• Say “ninety-nine”
• Consolidation results in words are heard clearly
• Diaphragmatic Excursion
- thoracic diaphragm movement during breathing WHISPERED PECTORILOQUY
- vertical distance from baseline to highest point of inspiration (how far diaphragm move) • Whisper “1,2,3”
• (N) auscultated as muffled 1,2,3 = must be non-distinct
• (consolidation) = If words are distinct
4. THORACIC AUSCULTATION
- assess airflow thru bronchial tree to eval presence of fluid/ solid obstruction in lung structures.
NORMAL BREATH SOUND
TRACHEAL BRONCHIAL BRONCHOVESICULAR VESICULAR
INTENSITY Very loud Loud Moderate Soft
Low
Very high,
PITCH High Moderate
high-pitched
DESCRIPTION Harsh Tubular Rustling, tubular Gentle rustling
Extra- Over mainstem bronchi Most of
Manubrium in large peripheral lung
LOCATION thoracic (1st & 2nd intercostal
tracheal airway (lung bases)
trachea space of anterior chest
