MU PT 7890, Case Management I
Chest Examination & Breathing Re-training
DeTurk C.9: Pulmonary Eval
Components of a Physical Therapy Chest Examination
1. Results of Pulmonary Function Laboratory and other Medical Tests
a. chest radiograph
b. pulmonary function tests
c. arterial blood gas studies
d. pulmonary and blood cultures
e. graded exercise test
2. Physical Therapy Examination Components
a. inspection
b. palpation
c. auscultation
d. mediate percussion (not the same as percussion with postural drainage)
Anatomical Landmarks
1. Skeletal
a.
Sternal angle (angle of Louis) is the joint between manubrium and sternum: marks the bifurcation
of trachea into L and R mainstem bronchi (therefore at the level of the carina – cough reflex). Also
at the level of 2nd rib.
b.
Attachments of ventilatory diaphragm – have a mental image. DeTurk p.79
2. Surface projections of lung segments: DeTurk p.81
a.
mediate percussion locates diaphragm posteriorly
b.
T4 (or T3) = medial end of scapular spine = upper height of lower lobes from post view. ·
Landmarks post: T3-4 = medial spine of scapula = upper/lower lobe division
c.
4 Upper Lobe Segments: ant (below clavicle) ant-apical, (above clavical), post-apical (upper trap
zone), post (under clavicles)
d.
Lower Lobe: extends to diaphragm. T10 = “4 fingers below scapular inferior angle]
e.
3 Lower Lobe Segments: post, lateral, anterior (ant. is actually lateral at the mid axillary line)
Kinesiology of Ventilation
Gas transport = Heart + Lung + Vascular system
Lungs provide VENTILATION of the alveoli … Gases DIFFUSE back and forth across alveolar-capillary interface
… Heart and Vascular systems move gases to the cells [98% of O2 is bound to Hgb (SaO2), and 2% of O2 is
dissolved in plasma (PaO2)… at the Capillaries gases PERFUSE in and out of Cells (oxygen dissociates from Hgb)
… Cellular RESPIRATION uses O2 and produces CO2
1. Muscles of ventilation Coffman p.3 (normal vs. accessory, etc)
a. Inspiration (inhalation)
a. Diaphragm & External intercostals (normal / relaxed breathing) 1:2 inspiration:expiration is normal
b. Accessory mm use = increased aerobic demand (normal) OR chronically increased Work of
Breathing “WOB” (pathological)
b. Expiration (exhalation) normally, during quiet breathing, exhalation is normally passive (elastic recoil of
lungs and relaxation of diaphram) . Forced exhalation by abdominals and internal intercostals
2. Rib movement: DeTurk p.78
a. bucket handle: lower ribs increase transverse diameter
b. pump handle – upper ribs increase A-P diameter
Specific Examination Methods available to the physical therapist
1. Inspection DeTurk p.224-5
a. General appearance: orientation, attitude, skin, scars, nail bed color/refill, mucous membranes (lip
color), speech
b. Posture and chest wall conformation. Intercostal retractions?
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c. Head and neck: hypertrophy of SCM, Scalenes, Upper Traps? Supraclavicular retraction?
d. Breathing pattern: is diaphragm working? Belly should move out with resting inspiration.
e. Cough and sputum production: document productive or non-productive cough. Document color,
viscosity, and amount (teaspoons) of sputum
2. Palpation
a. Mediastinal shift? This would be indicated by a deviation of the trachea to one side. Exam by bending
head forward for slack and use 2nd and 3rd fingers to lightly trace along trachea (careful not to overmassage and trigger a vasovagal response in the carotid bodies). Coffman p.21; DeTurk p.228
b. Chest wall compliance (flexibility)
c. Chest wall motion (symmetry, superior vs. A/P & Lat motion)
 Place thumbs (while slightly gathering the skin) at the following positions: midsternal notch,
zyphoid (thumbs horizontal), and posteriorly at T8 level
 Inspiration Girth Measurement: tape measure placed around chest at: axilla, zyphoid, lower costal
margin. Patient performs maximal expiration, then max inspiration. Normal = 2-3” or 6-8cm
d. Tactile fremitus: vibration from chest wall during speech. Patient says “99”. If vibration feels
stronger over a given area it may indicate consolidation: pneumonia, atelectasis
e. Scalene muscle action (upward movement of first rib) Hypertrophy? First find both parts of SCM,
(elbow must be resting on desk to relax muscles) then posterior to clavicular portion of SCM are
Scalenes, and then go inferior to the attachment at the first rib. Try alternating belly breath with upper
chest breath. Make a very rapid inhale while palpating.
f. Chest wall pain (differentiate cardiac from intercostals, pleurisy)
i. Intercostal m. pain = pain with respiration cycle; unilateral splinting, tender to palpation,
stretching, worse with deep breath
ii. Parietal plurae innervated by intercostal n (referred to chest wall) Pleural inflammation,
pleurisy, causes dyspnea and “stabbing” pain on affected side with breath cycle, restricted
breathing on the affected side with splinting.
iii. Angina: usually related to aerobically taxing activity. A big meal, emotional stressors can
also trigger. Stable angina (predictable at a certain MET level / activity level) vs. Classic
angina (present at rest and worse with activity). Prinzmetal / Variant angina: not due to
coronary occlusion, rather cold air vasospasm / emotion.
iv. Liver problem can refer to R shoulder
3. Auscultation: Be sure bell is “clicked”. Ear tips point toward your eyes. Go under clothing.
DeTurk p.227-228
a. normal vs. adventitious sounds with respiratory cycle
b. transmitted voice sounds: Bronchophony: “99” clearly audible; Egophony: “e” sounds like “a”;
Whispered Pectoriloquy: whispered “99” is audible
c. listen particularly to lung bases posteriorly (early clue to pneumonia, CHF exacerbation)
d. tracheal, bronchovesicular, vesicular sounds (all in the right places!)
e. posterior: don’t auscultate over scapula. Have patient slump so scapula move laterally.
4. Mediate Percussion
a. finger tip(s) on intercostals space and then tap fingertip(s) with 1-2 fingers of opposite hand
b. four normal sounds: resonant (lung), dull (heart), flat (liver or spleen), tympanic (gas bubble in
fundus of stomach)
c. Task: with subject prone, mark excursion of the diaphragm at: highest (normal breathing) and at
lowest (maximal inhalation and hold). Slightly higher on the R, over the liver. Normal = 1-2 “
Breathing Retraining
1. What, why, and who
2. Conditions that cause air trapping, inability to fully expire gases = obstructive, COPD: flattened diaphragm and
contracted, shortened external intercostals + increased lung compliance  hyperinflation.
3. Conditions that limit the volume of air able to be inspired = restrictive, RLD
Diaphragmatic Breathing Training
1. Goal: relax accessory mm with COPD. EB info: slows RR, but no change in VO2.
2. Components
Kisner & Colby p.750Page 2 of 3
a. Positioning, relaxation
b. Pursed lip breathing. Careful not to force expiration, as that can cause turbulence and bronchiole
constriction.
c. Focus on movement below rib cage
d. Hints: hand placement on tummy can give feedback as diaphragm descends, and hand rise.
a. Use of weights on abdomen to give resistance to the descent of the diaphagm (by weighting the
viscera) during inspiration is not well established. If used be very sure the weight does NOT
activate the abdominals to contract during inspiration since they should be relaxed then.
b. Abdominal strengthening, e.g. for a patient with a SCI, can be useful for generating a more forceful
expiration and a more effective cough, thereby provide improved airway protection. Puffing will
begin to trigger abdominal contraction, and a mirror can be put under mouth for feedback.
2. Progression
a. start in a semi-Fowler position, then progress to:
1. hooklying,
2. sitting,
3. standing,
4. walking
5. stairs (try paced breathing with a stop and rest)
3. Huff coughing: is performed by forcefully exhaling through an open airway after taking in a fairly large
inspiration. You take in a slow, deep breath and hold this breath for a count of three. You then perform short, quick,
forced exhalations with your airways open. Say the word “huff” during the exhalation. Younger children may be
taught to flap their arms to the sides of their chests as they perform the “huff” cough. This technique is sometimes
referred to as the “chicken breath”. This activity may help the child to focus on the forced exhalation and add
enjoyment to the technique.
4. Self-Assisted cough: Heimlich-type maneuver with patient’s hands doubled over abdomen and pulling in during
Huff. Splinting before coughing: squeeze pillow to area; wrap towel around abdomen; do a “self hug” before a
sneeze.
5. Pursed Lip Breathing: PLB : EB = decreases dyspnea, increases gas exchange (often instinctually adapted).
6. Paced Breathing: lengthen expiration time (with pursed lips) compared to inspiration phase
 Incorporate PNF patterns while semi-supine (inspiration on UE D-2 extension)
 Walking rhythm: Inhale on “one-two”; Exhale on “three-four-five-six-seven…”
 Add a rest period if necessary.
Segmental Breathing
1. Performed on a segment of lung, or a section of chest wall that needs increased ventilation or movement, e.g.
post thoracotomy, trauma to chest wall, pneumonia, post mastectomy scar, post chest radiation-fibrosis. Use of
imagery is helpful.
a. Lateral and lower costal (hands placed anterior / lateral)
b. apical (fingers placed below clavicle)
2. Tactile Cues (patient may be able to self-facilitate)
a. PNF for the ribs (gently push down during exhale, then a quick stretch at start of inhale)
b. terry cloth towel or belt for resistance around lower ribs
c. postural and trunk shifts. Elevate UE and sidebend away from restriction
Chest Wall mobilization / Stretching
Especially useful for patients with SCI and resulting Restrictive Lung Disease (RLD)
Glossopharyngeal Breathing
MSH_EP MUPT 04,06
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