Pulmonary Assessment

Ed Litwin, BS, RRT

Pulmonary Assessment

• ABG’s
• CXR
• PFT’s
Pulmonary Assessment

Inspection
Palpation
Percussion
Auscultation
Pulmonary Assessment:
Inspection
• Respiratory • Accessory
Pattern Muscle Use
• Chest • Splinting
Abnormalities • Level of
• Trachea Consciousness
Position • Cyanosis
• Retractions
• Symmetry
 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?
• Ð 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 Ï 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
Exp.
majority lung
Insp.
periphery
I
n
s
• Medium pitch
p
. and loudness
• Inspiration is
louder and
longer than
expiration
 Tracheal/Bronchial
Breath Sounds
• Heard over and
Insp.
around trachea
Exp.
• Loud, high
pitched, harsh,
“tubular”
• E is louder and
longer then I
• Short pause
between I and E
 Bronchovesicular
• Combination of the
other 2
• Heard around
Insp. Exp. sternum, between
scapula, anterior
RUL
• I and E are equal
duration and
loudness, no pause
• More muffled than
Bronchial
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
hepatobiliary
diseases
• May indicate a
chronic purulent
resp. disorder