Respiratory

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Respiratory Assessment

MS. Dominguez and MR. Dave!

Subjective

Shortness of breath

Difficulty in drawing sufficient breath: labored breathing

Dyspnea

Same as shortness of breath

Painful respirations

Compare to see if it is inspiratory or expiratory, maybe both

Orthopnea

Difficulty in breathing that occurs when lying down and is relieved upon changing to an upright position (as in congestive heart failure)

Productive cough

Raising mucus or sputum (as from the bronchi) a productive cough

Nonproductive cough

The opposite

Hemoptysis

Expectoration of blood from some part of the respiratory tract

Respiratory Assessment

MS. Dominguez and MR. Dave!

Objective

Eupnea

Apnea

Normal respiration

Transient cessation of respiration—sleep apnea

Bradypnea

Abnormally slow breathing

Tachypnea

Increased rate of respiration

Kussmaul’s

Abnormally slow deep respiration characteristic of air hunger and occurring especially in acidotic states -- called also Kussmaul respiration

Kussmaul, Adolf (1822-1902), German physician. Kussmaul made notable contributions to clinical medicine. In 1873 he introduced the concept of paradoxical pulse in a clinical description of obstructive pericarditis. The following year he described the labored breathing in diabetic coma that is now known as Kussmaul breathing.

Cheyne-Stokes

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MS. Dominguez and MR. Dave!

This is an abnormal pattern of respiration, characterized by alternating periods of apnea and deep, rapid breathing. The breathing gradually becomes slower and shallower and is followed by 10 to 20 seconds of apnea before the cycle is repeated.

Cyanosis

This is a bluish or purplish discoloration (as of skin) due to deficient oxygenation of the blood

Acrocyanosis

This is a blueness or pallor of the extremities usually associated with pain and numbness and caused by vasomotor disturbances (as in Raynaud's disease); specifically : a disorder of the arterioles of the exposed parts of the hands and feet involving abnormal contraction of the arteriolar walls intensified by exposure to cold and resulting in bluish mottled skin, chilling, and sweating of the affected parts

Circumoral cyanosis

This is cyanosis surrounding the mouth

Respiratory Assessment

MS. Dominguez and MR. Dave!

Crackles

This is an abnormal respiratory sound consisting of discontinuous bubbling noises heard on auscultation of chest heard during inspiration

Fine crackles-have a popping sound produced by air entering distal bronchioles or alveoli that contain serous secretions

Coarse crackles-may originate in the bronchi or trachea an have a lower pitch

Wheezes

A high pitch or low pitch musical sound. It is caused by a high-velocity flow of air through a narrow airway

Friction rub

Stridor

A dry, grating sound heard on auscultation

A harsh vibrating sound heard during respiration in cases of obstruction of the air passages

Sputum

Color and consistency

Example: green and thick

1) Are the breath sounds increased, normal, or decreased?

2) Are there any abnormal or adventitious breath sounds?

Respiratory Assessment

MS. Dominguez and MR. Dave!

B. Auscultation

To assess the posterior chest, ask the patient to keep both arms crossed in front of his/her chest, if possible.

Auscultate using the diaphragm of your stethoscope. Ask the patient not to speak and to breathe deeply through the mouth. Be careful that the patient does not hyperventilate.

You should listen to at least one full breath in each location. It is important that you always compare what you hear with the opposite side. eg If you are listening to the left apex, you should follow through by comparing what you heard with what you hear at the right apex.

There are 12 and 14 locations for auscultation on the anterior and posterior chest respectively. Generally, you should listen to at least 6 locations on both the anterior and posterior chest. Begin by ausculating the apices of the lungs, moving from side to side and comparing as you approach the bases. Making the order of the numbers in the images below a ritual part of your pulmonary exam is a way of ensuring that you compare both sides every time and you'll begin to know what each area should sound like under normal circumstances. If you hear a suspicious breath sound, listen to a few other nearby locations and try to delineate its extent and character.

Respiratory Assessment

MS. Dominguez and MR. Dave!

C. Breath Sounds

Breath sounds can be divided and subdivided into the following categories:

Normal tracheal vesicular bronchial bronchovesicular

Abnormal Adventitious absent/decreased crackles (rales) bronchial wheeze rhonchi stridor pleural rub mediastinal crunch

(Hamman's sign)

1. Normal Breath Sounds

These are traditionally organized into categories based on their intensity, pitch, location, and inspiratory to expiratory ratio. Breath sounds are created by turbulent air flow. In inspiration, air moves into progressively smaller airways with the alveoli as its final location. As air hits the walls of these airways, turbulence is created and produces sound.

In expiration, air is moving in the opposite direction towards progressively larger airways. Less turbulence is created, thus normal expiratory breath sounds are quieter than inspiratory breath sounds.

Respiratory Assessment

MS. Dominguez and MR. Dave! i. Tracheal Breath Sound

Tracheal breath sounds are very loud and relatively high-pitched. The inspiratory and expiratory sounds are more or less equal in length. They can be heard over the trachea which is not routinely auscultated. ii. Vesicular Breath Sound

The vesicular breath sound is the major normal breath sound and is heard over most of the lungs. They sound soft and low-pitched. The inspiratory sounds are longer than the expiratory sounds. Vesicular breath sounds may be harsher and slightly longer if there is rapid deep ventilation (eg post-exercise) or in children who have thinner chest walls. As well, vesicular breath sounds may be softer if the patient is frail, elderly, obese, or very muscular. iii. Bronchial Breath Sound

Bronchial breath sounds are very loud, high-pitched and sound close to the stethoscope.

There is a gap between the inspiratory and expiratory phases of respiration, and the expiratory sounds are longer than the inspiratory sounds. If these sounds are heard anywhere other than over the manubrium, it is usually an indication that an area of consolidation exists (ie space that usually contains air now contains fluid or solid lung tissue). iv. Bronchovesicular Breath Sound

These are breath sounds of intermediate intensity and pitch. The inspiratory and expiratory sounds are equal in length. They are best heard in the 1st and 2nd ICS

(anterior chest) and between the scapulae (posterior chest) - ie over the mainstem bronchi. As with bronchial sounds, when these are heard anywhere other than over the mainstem bronchi, they usually indicate an area of consolidation.

2. Abnormal Breath Sounds

i. Absent or Decreased Breath Sounds

There are a number of common causes for abnormal breath sounds, including:

ARDS : decreased breath sounds in late stages

Asthma : decreased breath sounds

Atelectasis : If the bronchial obstruction persists, breath sounds are absent unless the atelectasis occurs in the RUL in which case adjacent tracheal sounds may be audible.

Respiratory Assessment

MS. Dominguez and MR. Dave!

Emphysema : decreased breath sounds

Pleural Effusion : decreased or absent breath sounds. If the effusion is large, bronchial sounds may be heard.

Pneumothorax : decreased or absent breath sounds ii. Bronchial Breath Sounds in Abnormal Locations

Bronchial breath sounds occur over consolidated areas. Further testing of egophony and whispered petroliloquy may confirm your suspicions.

3. Adventitious Breath Sounds

i. Crackles (Rales)

Crackles are discontinuous, nonmusical, brief sounds heard more commonly on inspiration. They can be classified as fine (high pitched, soft, very brief) or coarse (low pitched, louder, less brief). When listening to crackles, pay special attention to their loudness, pitch, duration, number, timing in the respiratory cycle, location, pattern from breath to breath, change after a cough or shift in position. Crackles may sometimes be normally heard at the anterior lung bases after a maximal expiration or after prolonged recumbency.

The mechanical basis of crackles: Small airways open during inspiration and collapse during expiration causing the crackling sounds. Another explanation for crackles is that air bubbles through secreations or incompletely closed airways during expiration.

Conditions:

ARDS asthma bronchiectasis chronic bronchitis consolidation early CHF

Respiratory Assessment

MS. Dominguez and MR. Dave! interstitial lung disease pulmonary edema ii. Wheeze

Wheezes are continuous, high pitched, hissing sounds heard normally on expiration but also sometimes on inspiration. They are produced when air flows through airways narrowed by secretions, foreign bodies, or obstructive lesions.

Note when the wheezes occur and if there is a change after a deep breath or cough. Also note if the wheezes are monophonic (suggesting obstruction of one airway) or polyphonic

(suggesting generalized obstruction of airways).

Conditions: asthma

CHF chronic bronchitis

COPD pulmonary edema iii. Rhonchi

Rhonchi are low pitched, continous, musical sounds that are similar to wheezes. They usually imply obstruction of a larger airway by secretions. iv. Stridor

Stridor is an inspiratory musical wheeze heard loudest over the trachea during inspiration.

Stridor suggests an obstructed trachea or larynx and therefore constitutes a medical emergency that requires immediate attention. v. Pleural Rub

Pleural rubs are creaking or brushing sounds produced when the pleural surfaces are inflammed or roughened and rub against each other. They may be discontinuous or continuous sounds. They can usually be localized a particular place on the chest wall and are heard during both the inspiratory and expiratory phases.

Conditions: pleural effusion pneumothorax

Respiratory Assessment

MS. Dominguez and MR. Dave! vi. Mediastinal Crunch (Hamman’s sign)

Mediastinal crunches are crackles that are synchronized with the heart beat and not respiration. They are heard best with the patient in the left lateral decubitus postion. As with stridor, mediastinal crunches should be treated as medical emergencies.

Conditions: pneumomediastinum

Summary

The following table has been adapted from A Guide to Physical Exam and History Taking by Barbara Bates.

Type

Normal

Characteristic Intensity Pitch tracheal loud high vesicular soft low bronchial very loud high

Description harsh; not routinely auscultated

Location over the trachea

.

most of the lungs sound close to stethoscope; gap between over the manubrium

Abnormal

Adventitious

Respiratory Assessment

MS. Dominguez and MR. Dave! insp & exp sounds bronchovesicular absent/decreased bronchial crackles (rales) wheeze rhonchi stridor pleural rub mediastinal crunch .

.

.

medium soft (fine crackles) or loud (coarse crackles) high low

.

.

medium .

(normal) or consolidated areas normally in 1st

& 2nd ICS anteriorly and between scapulae posteriorly; other locations indicate consolidation

.

.

heard in ARDS, asthma, ateletasis, emphysema, pleural effusion, pneumothorax indicates areas of consolidation

.

.

high (fine crackles ) or discontinuous, nonmusical, brief; more commonly heard on inspiration; assoc. w/ low (coarse crackles) may sometimes be normally heard at ant. lung bases after

ARDS, asthma, max. expiration bronchiectasis, bronchitis, or after consolidation, early CHF, interstitial lung disease prolonged recumbency expiratory continuous sounds normally heard on expiration; note if monophonic (obstruction of 1 airway) or polyphonic (general obstruction); assoc. w/ asthma, CHF, chronic bronchitis, COPD, pulm. edema can be anywhere over the lungs; produced when there is obstruction expiratory continuous musical sounds similar to wheezes; imply obstruction of larger airways by secretions

.

inspiratory insp. & exp.

musical wheeze that suggests obstructed trachea or larynx; medical heard loudest over trachea in inspiration emergency creaking or brushing sounds; continuous or discontinuous; assoc. w/ pleural effusion or pneumothorax usually can be localized to particular place on chest wall not crackles synchronized w/ synchronized heart beat; medical w/ respiration emerg.; assoc. w/ pneumomediatstinum best heard w/ patient in left lateral decubitus position

Respiratory Assessment

MS. Dominguez and MR. Dave!

The Lung Exam

The 4 major components of the lung exam (inspection, palpation, percussion and auscultation) are also used to examine the heart and abdomen. Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. Vital signs, an important source of information, are discussed elsewhere.

Inspection/Observation: A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to:

1.

General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep?

2.

Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies some element of respiratory difficulty.

3.

Color of the patient, in particular around the lips and nail beds. Obviously, blue is bad!

4.

The position of the patient. Those with extreme pulmonary dysfunction will often sit up-right. In cases of real distress, they will lean forward, resting their hands on their knees in what is known as the tri-pod position.

Patient with emphysema bending over in Tri-Pod Position

Respiratory Assessment

MS. Dominguez and MR. Dave!

5.

Breathing through pursed lips, often seen in cases of emphysema.

6.

Ability to speak. At times, respiratory rates can be so high and/or work of breathing so great that patients are unable to speak in complete sentences. If this occurs, note how many words they can speak (i.e. the fewer words per breath, the worse the problem!).

7.

Any audible noises associated with breathing as occasionally, wheezing or the gurgling caused by secretions in large airways are audible to the "naked" ear.

8.

The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.

9.

Any obvious chest or spine deformities. These may arise as a result of chronic lung disease (e.g. emphysema), occur congenitally, or be otherwise acquired. In any case, they can impair a patient's ability to breathe normally. A few common variants include: o Pectus excavatum: Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat "hollowed-out" appearance. The x-ray shows a subtle concave appearance of the lower sternum.

Respiratory Assessment

MS. Dominguez and MR. Dave! o Barrel chest: Associated with emphysema and lung hyperinflation.

Accompanying xray also demonstrates increased anterior-posterior diameter as well as diaphragmatic flattening.

Respiratory Assessment

MS. Dominguez and MR. Dave! o Spine abnormalities:

 Kyphosis: Causes the patient to be bent forward. Accompanying

X-Ray of same patient clearly demonstrates extreme curvature of the spine.

 Scoliosis: Condition where the spine is curved to either the left or right. In the pictures below, scoliosis of the spine causes right shoulder area to appear somewhat higher than the left. Curvature is more pronounced on x-ray.

Respiratory Assessment

MS. Dominguez and MR. Dave!

Review of Lung Anatomy: Understanding the pulmonary exam is greatly enhanced by recognizing the relationships between surface structures, the skeleton, and the main lobes of the lung. Realize that this can be difficult as some surface landmarks (eg nipples of the breast) do not always maintain their precise relationship to underlying structures.

Respiratory Assessment

MS. Dominguez and MR. Dave!

Nevertheless, surface markers will give you a rough guide to what lies beneath the skin.

The pictures below demonstrate these relationships. The multi-colored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black. The following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper Lobe; RML =

Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.

Anterior View

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Posterior View

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Right Lateral

View

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MS. Dominguez and MR. Dave!

Left Lateral

View

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MS. Dominguez and MR. Dave!

Palpation: Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable.

Specific situations where it may be helpful include:

1.

Accentuating normal chest excursion: Place your hands on the patient's back with thumbs pointed towards the spine. Remember to first rub your hands together so that they are not too cold prior to touching the patient. Your hands should lift symmetrically outward when the patient takes a deep breath. Processes that lead to asymmetric lung expansion, as might occur when anything fills the pleural space (e.g. air or fluid), may then be detected as the hand on the affected side will move outward to a lesser degree. There has to be a lot of plerual disease before this asymmetry can be identified on exam.

Detecting Chest Excursion

Respiratory Assessment

MS. Dominguez and MR. Dave!

2.

Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine." This maneuver is repeated until the entire posterior thorax is covered. The bony aspects of the hands are used as they are particularly sensitive for detecting these vibrations.

Assessing Fremitus

Pathologic conditions will alter fremitus. In particular:

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MS. Dominguez and MR. Dave!

A.

Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced.

B.

Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

In general, fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. It can, however, lend supporting evidence if other findings (see below) suggest the presence of either of these processes.

Respiratory Assessment

MS. Dominguez and MR. Dave!

Effusions and infiltrates can perhaps be more easily understood using a sponge to represent the lung.

In this model, an infiltrate is depicted by the blue coloration that has invaded the sponge itself

(sponge on left). An effusion is depicted by the blue fluid upon which the lung is floating

(sponge on right).

3.

Investigating painful areas: If the patient complains of pain at a particular site it is obviously important to carefully palpate around that area. In addition, special situations (e.g. trauma) mandate careful palpation to look for evidence of rib fracture, subcutaneous air (feels like your pushing on Rice Krispies or bubble paper), etc.

Percussion: This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound. If the

Respiratory Assessment

MS. Dominguez and MR. Dave! normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone.

Alternatively, processes that lead to chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyperresonant (i.e. more drum-like) notes on percussion. Initially, you will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not. A few things to remember:

1.

If you're percussing with your right hand, stand a bit to the left side of the patient's back.

2.

Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field.

3.

Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone.

4.

Try to focus on striking the distal inter-phalangeal joint (i.e. the last joint) of your left middle finger with the tip of the right middle finger. The impact should be crisp so you may want to cut your nails to keep blood-letting to a minimum!

5.

The last 2 phalanges of your left middle finger should rest firmly on the patient's back. Try to keep the remainder of your fingers from touching the patient, or rest only the tips on them if this is otherwise too awkward, in order to minimize any dampening of the perucssion notes.

Respiratory Assessment

MS. Dominguez and MR. Dave!

6.

When percussing any one spot, 2 or 3 sharp taps should suffice, though feel free to do more if you'd like. Then move your hand down several inter-spaces and repeat the maneuver. In general, percussion in 5 or so different locations should cover one hemi-thorax. After you have percussed the left chest, move yours hands across and repeat the same procedure on the right side. If you detect any abnormality on one side, it's a good idea to slide your hands across to the other for comparison. In this way, one thorax serves as a control for the other. In general, percussion is limited to the posterior lung fields. However, if auscultation (see below) reveals an abnormality in the anterior or lateral fields, percussion over these areas can help identify its cause.

Percussion Technique

7.

The goal is to recognize that at some point as you move down towards the base of the lungs, the quality of the sound changes. This normally occurs when you leave the thorax. It is not particularly important to identify the exact location of the diaphragm, though if you are able to note a difference in level between maximum inspiration and expiration, all the better. Ultimately, you will develop a sense of where the normal lung should end by simply looking at the chest. The exact vertebral level at which this occurs is not really relevant.

8.

"Speed percussion" may help to accentuate the difference between dull and resonant areas. During this technique, the examiner moves their left (i.e. the nonpercussing) hand at a constant rate down the patient's back, tapping on it continuously as it progresses towards the bottom of the thorax. This tends to make the point of inflection (i.e. change from resonant to dull) more pronounced.

Practice percussion! Try finding your own stomach bubble, which should be around the left costal margin. Note that due to the location of the heart, tapping over your left chest will produce a different sound then when performed over your right. Percuss your walls

Respiratory Assessment

MS. Dominguez and MR. Dave!

(if they're sheet rock) and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only helps you develop a sense of the different tones that may be produced but also allows you to practice the technique.

Auscultation: Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.

1.

Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.

2.

The upper aspect of the posterior fields (i.e. towards the top of the patient's back) are examined first. Listen over one spot and then move the stethoscope to the same position on the opposite side and repeat. This again makes use of one lung as a source of comparison for the other. The entire posterior chest can be covered by listening in roughly 4 places on each side. Of course, if you hear something abnormal, you'll need to listen in more places.

Lung Auscultation

3.

The lingula and right middle lobes can be examined while you are still standing behind the patient.

Respiratory Assessment

MS. Dominguez and MR. Dave!

4.

Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright. Asking female patients to lie down will allow their breasts to fall away laterally, which may make this part of the examination easier.

A few additional things worth noting.

1.

Don't get in the habit of performing auscultation through clothing.

2.

Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.

3.

Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.

4.

If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side.

Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.

5.

Requesting that the patient exhale forcibly will occasionally help to accentuate abnormal breath sounds (in particular, wheezing) that might not be heard when they are breathing at normal flow rates.

The Auscultation Assistant -- A limited sampling of lung sounds can be found at this site.

Listen to lungs sounds at an excellent link through this site at UC Davis.

Listen to more lungs sounds from Rales Repository of Lung Sounds.

What can you expect to hear? A few basic sounds to listen for:

1.

A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs, with little noise produced on expiration. These are referred to as vessicular breath sounds.

2.

Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction, secretions, and/or associated mucosal edema. As this most commonly occurs in association with diffuse processes that affect all lobes of the lung (e.g. asthma and emphysema) it is frequently audible in all fields. In cases of significant bronchoconstriction, the expiratory phase of respiration (relative to inspiration) becomes noticeably prolonged. Clinicians refer to this as an increased I to E ratio.

Respiratory Assessment

MS. Dominguez and MR. Dave!

Normal is approximatley 1:2 (i.e. expiration twice as long as inspiration) though actual timed measurements are neither practical nor reliable. Focus instead on simple observation, noting whether E seems >> I. The greater the difference, the worse the obstruction. Occasionally, focal wheezing can occur when airway narrowing if restricted to a single anatomic area, as might occur with an obstructing tumor or bronchoconstriction induced by pneumonia. Wheezing heard only on inspiration is referred to as stridor and is associated with mechanical obstruction at the level of the trachea/upper airway. This may be best appreciated by placing your stethescope directly on top of the trachea.

3.

Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Pulmonary edema is probably the most common cause, at least in the older adult population, and results in symmetric findings. This tends to occur first in the most dependent portions of the lower lobes and extend from the bases towards the apices as disease progresses. Pneumonia, on the other hand, can result in discrete areas of alveolar filling, and therefore produce crackles restricted to a specific region of the lung. Very distinct, diffuse, dry-sounding crackles, similar to the noise produced when separating pieces of velcro, are caused by pulmonary fibrosis, a relatively uncommon condition.

4.

Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea… known as tubular or bronchial breath sounds) to the periphery. In this setting, the consolidated lung acts as a terrific conducting medium, transferring central sounds directly to the edges. It's very similar to the noise produced when breathing through a snorkel. Furthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation over the involved lobe as a nasal-sounding 'aaa'. These 'eee' to 'aaa' changes are referred to as egophony. The first time you detect it, you'll think that the patient is actually saying 'aaa'… have them repeat it several times to assure yourself that they are really following your directions!

5.

Secretions that form/collect in larger airways, as might occur with bronchitis or other mucous creating process, can produce a gurgling-type noise, similar to the sound produced when you suck the last bits of a milk shake through a straw.

These noises are referred to as ronchi.

6.

Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation, originating from lung which is compressed by the fluid pushing up from below. Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest.

7.

Auscultation of patients with severe, stable emphysema will produce very little sound. These patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise.

Wheezing occurs when there is a superimposed acute inflammatory process (see above).

Respiratory Assessment

MS. Dominguez and MR. Dave!

Most of the above techniques are complimentary. Dullness detected on percussion, for example, may represent either lung consolidation or a pleural effusion. Auscultation over the same region should help to distinguish between these possibilities, as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. Similarly, fremitus will be increased over consolidation and decreased over an effusion. As such, it may be necessary to repeat certain aspects of the exam, using one finding to confirm the significance of another. Few findings are pathognomonic. They have their greatest meaning when used together to paint the most informative picture.

The Dynamic Lung Exam:

Pulse Oxymeter

Oftentimes, a patient will complain of a symptom that is induced by activity or movement. Shortness of breath on exertion, one such example, can be a marker of significant cardiac or pulmonary dysfunction. The initial examination may be relatively unrevealing. In such cases, consider observed ambulation (with the use of a pulse oxymeter, a device that continuously measures heart rate and oxygen saturation, if available) as a dynamic extension of the cardiac and pulmonary examinations.

Quantifying a patient's exercise tolerance in terms of distance and/or time walked can provide information critical to the assessment of activity induced symptoms. It may also help unmask illness that would be inapparent unless the patient was asked to perform a task that challenged their impaired reserves. Pay particular attention to the rate at which the patient walks, duration of activity, distance covered, development of dyspnea, changes in heart rate and oxygen saturation, ability to talk during exercise and anything else that the patient identifies as limiting their activity. The objective data derived from this low tech test can aid you in determining disease and symptom severity, helping to create a list of possible diagnoses and assisting you in the rational use of additional tests to further delineate the nature of the problem. This can be particularly helpful in providing objective information when symptoms seem out of proportion to findings. Or

Respiratory Assessment

MS. Dominguez and MR. Dave! when patients report few complaints yet seem to have a cosiderable amount of disease. It will also generate a measurement that you can refer back to during subsequent evaluations in order to determine if there has been any real change in functional status.

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