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RSPT 2210 – Cardiopulmonary Disease
Advanced Assessment in Respiratory Disease
Lecture Notes
Reference: Des Jardins Chapters 3, 7, & 8
The basic assessment provides a great amount of information for us as practitioners. It is essential that
practitioners master the bedside assessment so that signs and symptoms of acute changes can be
recognized.
I.
Basic Assessment is vital and is the first indication of any type of disease process as well as
any acute changes in you patient.
A. Patient Hx – Obtaining a patient’s history through an interview not only tells the
practitioner about the patient’s present health. By knowing the past medical history
we can be keen on any new ailments especially if there is a history of or a chronic
illness.
B. Physical Assessment – With every treatment or procedure that a respiratory
practitioner performs requires some form of physical assessment:
1. Vital Signs – HR, RR, BP
2. Inspection
 Thoracic configuration – barrel chest, scoliosis, kyphoscoliosis,
kyphosis. Pectus excavatum, pectus carinatum
 Color – Cyanosis, Digital clubbing
3. Palpation
 Tactile fremitus
 Vocal fremitus
 Subcutaneous emphysema
4. Percussion
5. Auscultation – Bilateral breath sounds are a keen indicator of respiratory
anomalies
 Wheezes
 Coarse
 Crackles
 Diminished
 Pleural Rub
II.
Along with the basic assessment, there are other adjuncts to recognizing certain and/or
classifying, respiratory disease.
1. Test and diagnostic procedures
2. Chest Radiography
3. Pulmonary Function Tests
III.
Additional Tests and Procedures
A. Sputum Examination – By simply examining expectorated sputum can be an early
indication, but not definitive, of what the patient could be suffering from. Some
characteristics that are examined include: color, volume, odor and components can be
examined either at the bedside or microscopically.
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1.
Color
Color/Description
Yellow
Green
Green & foul smelling
Brown
Bright Red
Pink & frothy
2.
Association
Normal
Bronchial Asthma
Acute
Retained secretions
Pseudomonas
Old Blood
Fresh Blood
Pulmonary edema
Microscopic examination can help determine the microbes that are causing
the infection. The organism can be identified and therapy adjusted to treat
the infection. The most common organisms associated with respiratory
disorders in listed. (pp. 105, Box 7-1)
B. Skin Tests - There are several different types of skin tests. A positive result indicates
that the patient has been exposed (but does not mean the disease is present) to the
antigen. A negative test result means the patient has not been exposed to the antigen.
Common tests include:
1. TB skin test – Identifies if the patient has been exposed to Tuberculosis
Bacilli
2. Sweat Chloride test – Presence of increased sodium (Na+) in a sweat test is
an indication for Cystic Fibrosis
3. Allergy Test – Performed to determine what allergens a patient will react
to.
C. Bronchoscopy – This procedure can be diagnostic or therapeutic. The flexible
bronchoscope is more commonly used because there is minimal risk to the patient
and usually does not interrupt a patient’s ventilation.
1. During a bronchoscopy the following can be directly visualized
 Upper airways (nose, oral cavity, pharynx)
 Larynx
 Vocal cords
 Subglottic area
 Trachea
 Carina
 Bronchi
 Lobar bronchi
 Segmental bronchi (down to 3rd and 4th generations)
2.
Diagnostic bronchoscopy – A bronchoscopy is used diagnostically with a
patient has a suspected (undiagnosed) infectious disease or to obtain a lung
biopsy that is located on or near the bronchi. There are multiple
indications for a diagnostic bronchoscopy (refer to pp. 106). Images can be
taken while performing a diagnostic bronchoscopy as a record for any
abnormalities that are found.
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3.
Therapeutic bronchoscopy – The therapeutic bronchoscopy is used to
perform procedures such as bronchial lavage, removing foreign objects,
managing life-threatening hemoptysis. *Note: Routine procedures (CPT,
deep breathing/cough techniques, postural drainage, etc.) should be the
first line of defense in preventing/treating atelectasis.
D. Lung Biopsy - performed to diagnose abnormalities that have been found by some
other means of investigation, for example an abnormal CXR, or CAT scan.
1. Although many abnormalities can be reached with a bronchoscopy, a lung
biopsy is obtained for abnormalities usually found in the periphery of the
lung.
2. Tissues collected from a lung biopsy are sent to pathology to be analyzed
for any type of malignancy or to determine the presence and origin of an
infection.
3. A lung biopsy can be collected two ways:
 Transbronchial lung biopsy: Utilizing a bronchoscope, forceps or a
needle is guided to obtain a sample
 Open-lung biopsy: An open-lung biopsy is a surgical procedure and
the patient must undergo general anesthesia.
a. An incision is made and varies according to the suspected
problem area.
b. Because it is a thoracic surgery, a chest tube is required for 7
– 14 days. There are also larger risks in this procedure, for
example pneumothorax, bleeding, infection etc. (pp.106)
c. Open lung biopsies are usually performed when a
transbronchial biopsy is unsuccessful or a larger tissue
sample is required.
d. There are contraindications to this type of biopsy including
cor pulmonale, pulmonary hypertension, etc. (pp.106-107).
E. Thoracentesis – also known, as a thoracocentesis is a procedure used to remove excess
or collected fluid in the pleural space. A thoracentesis can be performed diagnostically
or therapeutically.
1. Diagnostic thoracentesis – Performed to diagnose the origin of a
malignancy and especially pleural effusion. Once the fluid is collected it
can be sent to pathology to determine the diagnosing and/or staging of a
malignancy.
2. Therapeutic thoracentesis is usually performed to relieve an increased
WOB or pain from a pleural effusion, to administer medication to treat
fluid accumulation or cancer.
3. The fluid that is in the pleural space can be classified as transudate or
exudate.
 Transudate: fluid from the capillaries spill into the pleural space,
usually thin and watery, has a low WBC and protein level
a. Usually not caused by pleural surfaces, but can be caused by
left ventricular failure, peritoneal dialysis, cirrhosis
 Exudate: can be caused by a variety of states including infection,
cancer, chest trauma etc (pp.108). Each condition will have different
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protein, WBC and enzyme levels, along with other components such
as cellular debris, and blood (pp.108).
F.
IV.
Hematology, Blood Chemistry, and Electrolytes
1. Hematology – The most common blood test is the CBC (Complete Blood
Count). Include: (refer to table 7-1, and box 7-2 for normal values and
etiology)
 Red Blood Count (RBC) – The larger portion of the blood. Helps in
assessing the patient’s overall oxygen-carrying capacity
 Hematocrit (Hct) – the volume of RBCs in 100 mL of blood.
 Hemoglobin (Hb) – oxygen that passes into the pulmonary capillary
bed attaches to Hb.
 White Blood Cell Count (WBC) – WBCs function to fight infection,
defend the body using phagocytosis, and produce antibodies in the
immune response.
2. Blood chemistry – The RCP should be aware of and have basic knowledge
of blood chemistry is important in patient assessment.
 Refer to table 7-2 for blood chemistry that RCPs should have some
knowledge on.
a. Glucose – increased glucose indicates that the body is
undergoing stress
b. Bilirubin – especially in newborns is monitored closely.
c. Blood Urea Nitrogen (BUN) – increased levels indicate
acute or chronic renal failure
3. Electrolytes-Variances in electrolyte levels can be indications for
impending failure, the source of cardiac arrhythmias or in diagnosing
diseases (Table 7-3)
 Sodium (Na+) – increased levels can indicate dehydration
 Potassium (K+) – increased or decreased levels can lead to cardiac
arrest
 Chloride (Cl-) – related to metabolic acidosis (increased) and
alkalosis (decreased)
 Calcium (Ca+) – Changes in the level of Ca+ can directly affect a
patient’s EKG
Radiologic Examination of the Chest - Radiography plays an important role in assessing,
diagnosis, and evaluating the present state of a patient. An X-ray is an image of internal
body structures by passing x-rays through the body to and x-ray film. The most common
type of radiographs that a practitioner will be utilizing is the chest x-ray.
A. Standard Positions for Chest X-Rays (CXR)
1. Posteranterior (PA) – The image is captured by the patient standing (or
sitting) with the film on the anterior portion of his chest and the x-ray
apparatus facing his posterior approximately 6 feet away
2. Anteroposterior (AP) – This type of radiograph is utilized most often when
a patient is debilitated or unable to stand or sit for the CXR. The film is
place against the patient’s back the x-ray source is placed in front of the
patient.
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3.
Lateral: Used to complement the PA film. The film is pressed against the
side of the chest. To see the right lung and heart the right side is on the
film. When placed on the left the left lung and heart is captured.
4. Lateral Decubitus: Similar to the lateral film, but the patient is lying on her
left or right side. When the image is named it is referring to which side
the patient is lying. Example: “Left lateral decubitus” means – patient with
left side down. This film is helpful in the diagnosis of pleural effusion, or
free air in the abdomen or thorax. Fluid will accumulate in gravity
dependant areas, free air will rise to top of the film. Right lateral decubitus
with pleural effusion.
B. Radiologic terminology (Table 8-1)
1. Radioluency – describes darker areas (air - black)
2. Radiodensity - appear white on x-ray (dense areas – white)
3. Consolidation – becoming solid; areas of the lung that are solidifying
because of pathologic engorgement.
4. Bleb – superficial air cyst
5. Infiltrate – poorly defined radiodensity
C. Assessing quality of an X-ray – An x-ray that is properly taken by the technician, will
include:
1. Proper position – When the image is captured the patient should be in
proper position. The spine should be in the center of the chest with the
distance between the costophrenic angles equal. Any rotation could result
in false diagnosis i.e. – tracheal deviation, cardiac enlargement.
2. Exposure – Normal exposure is determined by the ability to visualize to the
5th or 6th thoracic vertebrae. Degree of exposure can be determined by
examining heart and lung fields
 Overexposed films – the heart and lungs will be more radiolucent
with more exposure
 Underexposed films – the heart and lungs will appear dense (white).
The lungs may have erroneous infiltrates and little to no
visualization of the vertebrae.
3. Level of Inspiration – the film should be captured at full inspiration if
possible. The diaphragm should be at the level of the 9 th or 10th rib. When
a film is taken on exhalation the lungs are denser, diaphragm is elevated
and heart looks larger and wider.
D. Examining a Chest Radiograph – The best approach to examining a Chest X-ray is to
use a systematic approach. The most common is an “inside-out approach.”
1. Mediastinum – Any shifts from midline or increase/decrease in size of the
anatomical portions of the mediastinum should be noted.
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
2.
3.
4.
5.
6.
Trachea – The trachea is a translucent column that lies on top of the
spinal column. The trachea can be shifted by certain conditions. In
collapse (atelectasis) the trachea will shift toward the affected area.
With fluid or gas accumulation the trachea will shift away from the
affected area.
 Heart – The size of the heart should take no more than half of the
chest on the film. When it is larger it is known as an “enlarged
heart” and be investigated.
 Hilar region – The hilar region includes the major vasculature from
the heart. Increased density indicates engorgement which is usually
related to increase pulmonary vascular resistance.
Lung Parenchyma (Tissue) – The lungs should be examined systematically
from top to bottom. There are some normal lung tissue markings, but
when absent there is a possibility of a pneumothorax, overinflation or
overexposure of the film.
Pleura – the periphery of the lungs should be examined for fluid (pleural
effusion), air (pneumothorax) or lesions in the pleural space.
Diaphragm – Right and left hemidiaphragms should be in a dome-shaped
contour. The right is usually higher because of the liver.
Gastric Air Bubble – Located under the left hemidiaphragm.
Bony Thorax – Includes inspection of the ribs, vertebrae, clavicles,
sternum, and scapulae.
E. Other Radiologic Exams
1. Computed Tomography (CT Scan) – Uses beams of x-ray that rotate in a
continuous 360-degree mothion to provide cross-sectional images of the
patient.
2. Magnetic Resonance Imaging – Uses magnetic resonance for its source of
energy to capture cross-sectional images. Much better than CT scan
because the high-contrast images that MRIs show more subtle lesions that
would of otherwise been overlooked on a CT scan.
3. Pulmonary Angiography – helps identify pulmonary emboli or AV
malformations. Radiopaque contrast is injected through the right side of
the heart and into the pulmonary artery to follow pulmonary circulation.
4. Ventilation/Perfusion Scan (V/Q Scan) – Also used in the detection of a
pulmonary embolism.
 Perfusion scan involve the injection of albumin in combination with
a radioactive material and distributed by the pulmonary arteries.
The lungs are scanned with a gamma camera, dark areas = good
blood flow, white or opaque areas = decreased or absent blood flow.
 Ventilation Scan the patient breathes a radioactive gas, scanned by
the gamma camera to display distribution of the gas. Dark areas =
good ventilation, light/white areas = decreased or absence of
ventilation.
 If results indicate normal ventilation scan, but abnormal perfusion
scan then a pulmonary emboli is present.
5. Bronchography – used in diagnosis or extent of bronchiectasis; the film is
called a bronchogram.
 Radiopaque contrast is instilled into tracheobronchial tree.
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V.
Identifying location of involved areas will allow better
administration of postural drainage in bronchiectasis.
Pulmonary Function Testing (PFT) – Indicated any time that an assessment of the
respiratory system is required or desired
A. PFTs will evaluate:
1. Presence of lung disease
2. Extent of abnormal lung function
3. Amount of disability due to dysfunction
4. Progression of the disease
5. Nature of the dysfunction or type of disease
6. Course of therapy for the dysfunction
B. Lung Volumes and Capacities
1. LUNG VOLUMES – There are 4 lung volumes that can be measured in a
PFT:
 Tidal volume (Vt) – the amount of gas that is inhaled and exhaled on
a normal, daily basis. 10% of the total lung capacity
 Inspiratory Reserve volume (IRV) – the maximum volume of air
inhaled after a normal inspiration. 50% of TLC
 Expiratory Reserve volume (ERV) – the volume of air that can be
exhaled from the end of a normal exhalation. 20% of TLC
 Residual volume (RV) – the volume remaining after a maximal
exhalation. 20% of TLC
2.
LUNG CAPACITIES – By adding 2 or more of the lung volumes, 4 lung
capacities are formed
 Total Lung Capacity (TLC) is the maximal amount of air that the
lungs can accommodate. It is the sum of all four volumes:
TLC =
100%=

IRV +
50% +
ERV + RV
20% + 20%
Inspiratory Capacity (IC) is the volume of gas found in the lung that
can be inhaled from a normal resting end exhalation. It is the sum
of Vt and IRV:
IC =
60% =

Vt +
10% +
Vt +
10% +
IRV
50%
Vital Capacity (VC) is the largest volume of gas that can be moved in
or out of the lung, represents all the air that can be inhaled and
exhaled forcibly leaving only the RV in the lung. It is the sum of
the Vt, IRV and ERV:
VC =
80% =
Vt+
10%
IRV+
50%
ERV
20%
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Functional Residual Capacity (FRC) is the volume of gas that is left
in the lung at the end of a normal exhalation. It is the sum of RV
and ERV:
FRC =
40%
3.
RV+
20%+
ERV
20%
Pulmonary disorders will change the volumes of the patient to be:
 Obstructive: INCREASED RV, Vt, FRC; VC, IC, IRV and ERV are
DECREASED
 Restrictive: VC, IC, RV, FRC, Vt are all DECREASED
 Obstructive and Restrictive: DECREASED flows and DECREASED
volumes
C. Expiratory Flow Measurements
1. Vital Capacity – There are two types of Vital capacity:
 Slow Vital Capacity – used to measure restrictive disease; decreased
volumes will indicate restrictive disease
 Forced Vital Capacity – the volume that can be exhaled as forcefully
and as rapidly as possible after a maximum inspiration
2. Forced Vital Capacity – the patient is instructed to take a maximal
inspiration followed by a maximal expiration as forcefully and rapidly as
possible. The FVC will provide the important flow rates used to measure
obstructive disease. The following values can be measured:
 FEV1: Forced Expiratory Volume in 1 second; Volume of gas expired
over a given time (@0.5, 1.0, 2.0, 3.0 seconds); FEV1 is best indicator
of obstructive disease.
 FEF200-1200: Forced Expiratory Flow 200-1200 is the average flow
during the first 1000 mL after 200 mL have been exhaled. Decreased
values are associated with large airway obstruction.
 FEF25-75: Forced Expiratory Flow 25%-75% is the average flow rate
during the mid-portion of the FVC. Decreased values are found in
the early stages of obstructive disease and associated with small
airway obstruction.
 FEV/FVC ratio: FEV for a given interval expressed as a % of FVC;
Decreased values indicate obstructive disease; can have normal
values, but may be restrictive.
Measurement
Min Acceptable
FEV 0.5/FVC
60%
FEV1/FVC
75%
FEV2/FVC
94%
FEV3/FVC
97%
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PEFR - Peak Expiratory Flow Rate is patient effort dependant, may
appear normal in abnormal patients, sometimes used to evaluate
asthmatic patients (pre & post bronchodilator)
D. MVV – Maximum volume ventilation is the largest volume and rate that can be
breathed per minute by voluntary effort for usually about 12-15 seconds.
 Decreased values are associated with obstructive disease; increased
Raw, muscle weakness, decreased compliance, or poor pt effort.
E. Pre and Post Bronchodilator PFT testing: performed to measure the reversibility of an
obstructive pattern. An increase of 15% or more is considered significant. ALL
bronchodilator therapy should be held 8 hours prior to testing.
F.
FRC Measurement (RV, TLC): There are several methods available:
1. He dilution – A % of He is inhaled and diluted by the patient’s FRC the
change in He% is used to determine the FRC.
2. N2 wash out – The FRC is washed out of the lung by having the patient
inhale 100% O@ to replace the N2 from FRC. The amount of N2 is used to
calculate FRC.
3. Plethysmograph/Body Box- uses Boyle’s law to determine total thoracic gas
volume at FRC.
G. Flow-Volume Loops – Measures the volumes and flow rates of the FVC
1. The patient performs a FEV followed by a FIV.
2. Flow rates are measured directly on the vertical axis. Expiratory flows are
above baseline, inspiratory flows are below the baseline
3. Volume is measure directly on the horizontal axis
4.
The shape of the flow-volume loop is diagnostic
 Obstructive – short and wide - Figure 3-10
 Restrictive – tall and skinny - Figure 3-11
 Flow-volume loops can also help evaluate partial vocal cord paralysis
– appears like a large obstruction
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H. Gas Diffusion (DLCO) – Measures all the factors that affect the diffusion of a gas across
the A-C membrane. The CO single breath technique is the most common.
1. The patient inhales a VC of gas containing a known amount of CO, He, and
air.
2. Holds breath for 10 seconds, then exhales in to the machine where the gas
concentrations are analyzed.
3. The amount of CO that diffuses across the A-C membrane is equal to the
toal amount of CO used, minus the amount returned plus the amount
remaining in residual volume.
 Normal DLCO is 25 mL CO/min/mmHg
 Decreases in DLCO are lung disorders that affect the A-C membrane
such as pulmonary fibrosis, scardosis, ARDS.
 Emphysema is the only obstructive disease that has a decreased D LCO
because of the destructive nature of the disease.