Respiratory Assessment Supplement

Hi health assessment students, this episode will be on the respiratory supplement. And so first let's do a quick review of the anatomy and physiology of the respiratory system. So the thorax is the part of the body between the neck and the abdomen. The ribs surround most of the thorax and all the ribs are connected to the vertebrae on the back. Most of the ribs are also connected to the sternum on the front. The angle created by the lowest ribs and the vertebrae is called the costover temporal angle. The spaces in between the ribs are called intercostal spaces. Each intercostal space is numbered according to the number of the top ribs. So the space between the first and second rib is called the first in a costal space. The space inside the thorax containing the lungs and the heart is called the thoracic cavity. The large muscle called the diaphragm covers the bottom of the thoracic cavity. During inspiration the diaphragm pulls down creating negative pressure inside the thoracic cavity which draws airs into the lungs. Usually the diaphragm is the only muscle used for breathing. However when our bodies work extra hard to breathe we use other muscles on our chest walls. These are called accessory muscles for respiration. The airway begins at the mouth and it continues down the neck through the trachea. The trachea then splits into two bronchi one for each side. Those bronchi branch out into consecutively smaller airways until they eventually end up at the alveoli. The tiny sacs where gas exchange happens. There are five lung lobes, the right upper, right middle and right lower lobes on the right, and the left upper and the left lower lobe on the left. The lungs are surrounded by a thin lining called the plurée, which provide lubrication so that the lungs inhale and exhale smoothly. So to recap the thorax has the sternum in the front and the spine in the back which are connected by ribs. The spaces between ribs are called intercostal spaces and the causal vertebral angle is where the lowest ribs connect to the spine. The airway begins at the mouth, continues down the neck through the trachea, splits into bronchi, and ends at the alveoli. The space inside the thorax is called the thoracic cavity and the diaphragm at the bottom of this cavity pulls air into the lungs sometimes aided by other accessory muscles. The plurée surround the lungs. Now let's discuss the physical examination of the respiratory system. We're going to start by inspecting the client's breathing at rest, specifically we're observing the rhythm, depth, and effort of breathing, including checking to see if the client uses accessory muscles to breathe. Also observe the symmetry of the chest rise as the client breathes in and out. Note that the respiratory rhythm is not the same thing as respiratory rate. To illustrate, here's what breathing sounds like for someone with an abnormal respiratory rate and a normal respiratory rhythm. You have all breathed fast like that at some point after engaging in some kind of exhausting activity so you're all familiar with that kind of abnormal rate, but compare that with an abnormal rhythm. Here's an example. Even if the rate of that kind of breathing was within normal limits, it would still be abnormal because of the rhythm. Here is another example of an abnormal rhythm in which the abnormality is observed by comparing the respiratory and respiratory phases. Notice the prolonged respiratory phase. The depth of respirations is self-explanatory. In practice, nurses typically only report depth if their patient is breathing shallow or deep and don't mention it if the depth is normal. When observing breathing, looks specifically to see if the client is using accessory muscles to breathe. There are multiple accurate ways to describe normal breathing, including unlabored, no increased work of breathing, and relaxed. You will fairly easily recognize labored breathing. Simply imagine someone exhausted after an all-out sprint and you're probably already imagining the exhausted facial expression, the hands on their knees, the deep rapid and forceful breathing, things like that. Decreased work of breathing is a bit trickier to imagine since most nursing students have never seen it before. It isn't something that happens in normal circumstances. It happens, for example, in patients who are overdosing on opiates because opiates block the brain's ability to feel the need to breathe. Even if their body needs oxygen, the part of the brain that controls breathing doesn't get the message so breathing slows down abnormally. This is how many people die of fentanyl overdose. I dwell on this a bit because often when students read the phrase "decreased respiratory effort" in a test question or a patient's chart, they get the impression that this is a good thing since the patient has the opposite of labored breathing so be careful to avoid making this mistake. To assess the symmetry of chest expansion, ensure first that you are standing directly in front of or behind the client. This is going to be true whenever you want to determine the symmetry of a body part. You always want your eyes to be in equal distance from the two sides of the thing that you are assessing. Next, you will inspect the configuration of the chest. Since you are already standing in front of or behind the patient to assess symmetry, you can observe the width of the patient's thorax from side to side. This length is called the transverse diameter. Then look at the patient from the side and note the length from the patient's front to the patient's back. This length is called the anterior diameter. The purpose is not to perform precise measurements of these diameters, instead just roughly compare them with one another. The client's anterior diameter should be noticeably smaller than their transverse diameter. If your patient's anterior and transverse diameter are equal, this is called a barrel chest and it is caused by prolonged increased pressure inside the thoracic cavity which gradually reshapes the chest usually over several years. Because barrel chest takes so long to develop, you will only see it in people who have chronic lung problems. You may also see other abnormalities besides barrel chest, such as a crooked spine or a sunken portion of the chest. Because some of these specific abnormalities cannot be seen through clothing, you should look directly at your patient's skin when inspecting for these deformities. Since your patient's thorax is disrobbed now, you can also assess the skin over it. We already saw the patient's skin during the general survey, so here we want to confirm that there aren't any lesions that were hidden under their clothing and that their skin color is consistent. Next, you want to palpate the posterior thorax. We are only palpating the back since we will palpate the anterior thorax during the cardiovascular assessment. You first want to do a quick pass over the skin, just quickly moving your hands over the back to check for temperature and moisture and pressing to see if you feel any masses and if the patient has tenderness. It is important to understand that tenderness is defined as the patient feeling pain in response to touch. If you touch a patient and they wince and pull away from you, you can't assume that the patient felt pain because it could also be that your hands were just cold. Alternatively, you might palpate an area and the patient might not wince or pull away, but this patient may feel pain and just not show it. In both cases, asking the patient if they felt pain is helpful. Better yet, ask them beforehand to let you know if they feel pain as you touch them. If you're in a situation where your patient cannot verbalize whether they feel pain, then you may have to rely on their body language, but if you can ask, then ask. Next, palpate for symmetric chest expansion. Start by placing both hands sideways on the client's posterior thorax, one on each side, each hand a couple inches from the spine. Then try to use the entire surfaces of both hands to pull as much of the skin as possible towards the spine so that you pinch a small fold of skin in the middle of the back. Then ask the client to take a deep breath, and as they do so, you should see and feel both of your hands moving symmetrically. First, as they are pulled away from midline during inspiration, then as they come back towards midline during inspiration. This is one of those techniques that are really hard to describe in words, images, or video, so I highly encourage you to try this and ask for guidance if you aren't getting a good response. This may seem redundant since you already inspect it for symmetrical chest rise, but this technique is more sensitive to smaller changes. So in practice, if you think you see asymmetrical chest rise on inspection, but you're not sure, you can try palpating the thorax in this way to confirm your finding. Next, percussion the posterior thorax. Take a moment to eliminate any competing sounds, turn off loud televisions and ask people not to talk, whatever you need. To briefly describe the percussion technique, you will first place the middle finger of your non-dominant hand on the client and lift up the rest of your non-dominant hand so that only the most distal joint of that middle finger is touching the client. Then use your dominant hand to tap the top of that joint using a brisk wrist motion. Do this two or three times in each spot to give yourself a couple of opportunities to hear the note clearly. The quality of the sound produced by this tap will change based on the density of the underlying tissue. Start percussion at the top of the thorax. To know how high to start, try flexing your neck forward so that you are looking down at the floor and feel the back of your neck. You will feel a bony prominence there caused by the C7 vertebra. This is the level that you should begin on your client. At that level, move your hand to the side until you feel the scapula. Your first sights for percussion will be at the level of C7 as laterally as you can go without being on top of the scapula. Procuse these two sights, then move down one to two inches at a time and at each level you want to precuse just medial to the scapula. Continue down the thorax until you have reached the bottom of the scapula and then go straight down one to two inches one last time. This pattern I described is shown on the second page of the supplement. As you precuse over the lungs, the normal sound is a resonant sound, which is a hollow, low pitched note. If there is an abnormally large amount of air in the lungs, like in a patient with an abnormally expanded barrel chest, percussion will cause a booming sound. Think of a big bass drum in a marching band or orchestra. The large size of the drum gives it the bum bum bum sound. If there is an abnormally small amount of air in the lung tissue, it may be because of a collapsed lung or a lung that's infected and full of fluid. In that case, percussion will produce a third sound as when knocking on a door. If you hear this sound on your healthy lab partner, though, it's unlikely that they have any of these conditions. It is much more likely that you are precussing over a bone. So if you hear that sound, feel the tissue underneath where you are precussing and try moving to a softer spot that doesn't have bone underneath. Determining whether a sound is resonant or hyper resonant is really difficult because the sound is faint and people have a wide range of chest wall thickness which will alter the note. Three important principles apply to this and will apply to many of the other assessments moving forward. Principle number one. Assess as many people as possible. This is true whether these people have normal or abnormal lungs. It isn't enough to assess only one person's normal lungs because there's a wide range of normal lung sounds, especially based on the thickness of the chest wall. Principle number two. Compare one side of the patient with the other side of that same patient. Look at the illustration on the second page of the supplement showing the pattern for a precussion and oscillation and notice how at each level the pattern prompts you to immediately move to the corresponding location on the other side of the thorax. This allows you to compare the two sounds on either side of that same level. Even if you have never heard a single precussion note before in your life, if you follow this pattern and closely compare the sound on one side to the sound on the other side, you will often be able to pick up on an abnormality simply because you know that the two sounds should be exactly the same but they are different. Principle number three. Compare the patient with that same patient later. If you are precussing your client in the morning, precuss again in the afternoon. If you are precussing before a breathing treatment, try precussing after and try to notice any differences. This is similar to principle number two but it requires a bit more memory and a bit more careful concentration. So once you are done precussing the lung fields, you will precuss the cost of vertebral angles for tenderness. Place one hand over the cost of vertebral angle on one side and use your other hand to lightly thump your hand. Then move your hand to the other side and thump it again. Notice that when we were precussing the lung fields, the goal was to produce a sound and we will listen to that sound to learn about the density of the underlying tissue. In contrast, we are not listening for the sound when we precuss the cost of vertebral angles. Instead, we are sending vibrations into the body and discovering whether or not those vibrations cause pain. This is helpful because the kidneys are located immediately under the ribs at the cost of vertebral angle. If the client experiences pain from cost of vertebral angle percussion, this may be a sign of a kidney condition. One important implication of this difference is that we only precuss the cost of vertebral angle once per side. When precussing to produce sounds, it is helpful to tap two to three times to give yourself a few opportunities to hear the note clearly. But when you are precussing to assess for tenderness, multiple thumbs are not going to help. If it hurts the first time, it will also hurt the second time. So only thump once. Moving on, we are going to osculate the lung sounds, beginning in the posterior thorax since we are already there. Lung sounds are high pitched, so you will use the diaphragm of the stethoscope. Instructor patient to sit up, leaning slightly forward, and take deep breaths through the mouth whenever the stethoscope touches their back. Tell them that they can stop if they begin to feel dizzy. Make sure you listen to a full breath in and out before moving on to the next location. In the health assessment class, you are probably practicing with other health assessment students, and they don't really need these instructions. But part of what we are doing in our class is practicing giving clear instructions, which will be necessary when you're doing this as a practicing nurse. So make sure that you're practicing the instructions as well. For the back, follow the same pattern as percussion, beginning at the level of C7, and moving down to just above the cost of vertebral angle a little bit below the scapulae, moving from side to side to check for symmetry. For the front, start just above the clavicles. Find the middle of the collarbone on one side, and imagine a line going up and down the chest along this point. This is called the mid-clavicular line. This line has no physiological significance, but it is a valuable reference line. Move down the mid-clavicular lines on each side, down to the level of the bottom of the sternum. The lowest rib connected to the sternum is the seventh rib, just below the sixth intercostal space. Follow that sixth intercostal space laterally, and osculate there as well. There are three different types of normal breath sounds. The bronchial sounds can be heard around the trachea and larynx. This region is not included in the pattern of osculation in the illustration of the supplement, and it is not typically osculated during most nurses lung assessments, but you should practice listening to these sounds to get an idea of what they sound like. Sometimes people's bronchial sounds are really loud, and although your stethoscope is placed over lung tissue, some of what you're hearing is sound projecting from the trachea down into the chest. Being able to recognize these sounds so that you know that they're not coming from the lungs, but rather from the neck, is very helpful. The bronchial vesicular sounds are heard over the major bronchi. On the anterior side, these are heard around the upper sternum, and on the posterior side, they are heard between the scapulae and spine. Vesicular sounds are heard over the rest of the lung fields. As you move from bronchial to bronch vesicular to vesicular sounds, both the volume and pitch of the sounds will decrease. As a full disclaimer, if you ask a working nurse to describe these three different types of normal lung sounds, they probably wouldn't be able to tell you. This is because they have learned to recognize normal lung sounds across the various lung fields without consciously thinking about them. For you as a beginning nursing student, learning and recognizing these descriptions will be part of your training wheels until you build that same level of familiarity. So those are the normal lung sounds. Now I will explain a few abnormal sounds you should be listening for. One abnormality is diminished lung sounds, which can happen because something blocks air into a portion of the lungs, decreasing the volume. This is easy to understand conceptually, but can be difficult to recognize since the volume of a person's lung sounds will change based on various factors, such as the chest wall thickness and even which stethoscope you are using. Remember the three principles I mentioned earlier. Assess as many people as possible, compare one side against another, and compare the client at different times. Aside from abnormal volume, you might also hear extra sounds that shouldn't be there. These are called "adventitious lung sounds". I like to categorize the most common "adventitious lung sounds" into two broad categories. Popping and whistling. Popping and whistling are not technical terms. I chose them because they are the most helpful for describing what is causing the sound. First, I'll talk about popping sounds. When water bubbles pop, they make a soft pop sound. Similarly, when there's fluid in the lungs, bubbles are formed and popped as air moves in and out of the airways. There are many reasons why fluid would build up in the airways, such as lung infection, heart failure, or simply inhaling water. As air blows through that fluid, they may make this popping sound as when you blow bubbles into water through a straw. You will notice that these popping sounds are actually many, many small sounds happening rapidly, like the pops and crackles of food cooking in a deep fryer. If the sound is high-pitched, the technical term for that sound is crackles. These sounds typically originate from the smaller airways. If the sound is low-pitched, the technical term for this sound is ronkai. These sounds typically originate from the larger airways. In contrast, whistling sounds are caused by air being forced through a narrow passage. Think about what you must do to whistle with your mouth. You must purse your lips into a narrow opening and then quickly push air through. This same thing can happen in lungs as when the airways narrow because of inflammation or because an object partially blocks the airway. As you might guess from simply imagining what whistles generally sound like, these sounds are high-pitched and musical. Unlike the popping sounds, it is one continuous sound. The technical term for this type of sound is wheezing. Another adventitious lung sound is the plural friction rub. Remember that the purpose of the pluray is to provide lubrication and reduce friction during breathing. If the pluray are damaged, friction will occur and that will make noise. This sound is unique among the adventitious lung sounds in this list because it's actually not coming from the airways and it's not being caused by air. Instead, it's being caused by friction in the plural space. This friction will happen during both inspiration and exploration and it will sound like a rough surface being rubbed. The last adventitious lung sound mentioned in the supplement is strider, caused by an upper airway obstruction. The easiest way to learn what strider is and what it sounds like is to try it yourself. Simply press a couple fingers gently on your trachea and try breathing. Here's what that sounds like. Because you were able to produce that sound by pressing down on your trachea, it should not surprise you that this particular sound is heard with narrowing of the airway near your neck. Remember how the sound was high-pitched and only heard with inspiration. These are the two most important details to know in order to recognize strider. Also, remember how you were able to hear me make the strider sound without a stethoscope. This is the only one of these adventitious lung sounds that can be commonly heard without a stethoscope. So that's it for this supplement. I hope that this was helpful.