seidel chap9

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CHAPTER

9 Chest and Lungs

EQUIPMENT

◆ Drape◆ Skin-markingpencil◆ Rulerandtapemeasure◆ Stethoscopewithbellanddiaphragm

EXAMINATION

Havepatientsit,disrobedtowaist.

TECHN IQUE F IND INGS

CHEST AND LUNGS

Inspect front and back of chest

Seethoraciclandmarks.■ Size/shape/symmetry■ Landmarks EXPECTED: Supernumerary

nipplespossible(canbecluetoothercongenitalabnormalities,particularlyinwhites).

■ Compare anteroposterior diameter with transverse diameter

EXPECTED: Ribsprominent,claviclesprominentsuperiorly,sternumusuallyflatandfreeofabundanceofoverlyingtissue.Chestsomewhatasymmetric.Anteroposteriordiameteroftenhalfoftransversediameter.UNEXPECTED: Barrelchest,posteriororlateraldeviation,pigeonchest,orfunnelchest.

Seidel_5405_Chapter 9_main.indd 98 12/1/2009 10:34:49 AM

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CHAPTER 9 ChestandLungs 99

Thoracic landmarks. A, Anterior thorax. B, Right lateral thorax. C, Posterior thorax.

Rightupper lobe

Right middlelobe

Rightlowerlobe

Thyroid cartilage

Trachea

Suprasternal notch

Rightmidclavicularline

Right anterioraxillary line

A

C

BMidsternalline

First rib

Angle ofLouis

Leftupper lobe

Leftlowerlobe

Posterioraxillaryline

Anterior axillary line

Mid-axillaryline

Vertebralline

Scapularline

Rightupper lobe

Scapula

Rightmiddlelobe

Rightlowerlobe

Leftlowerlobe

Leftupperlobe

Spinalprocesses


■ Assess nails, lips, nares UNEXPECTED: Clubbedfingernails(usuallysymmetricandpainless;mayindicatedisease,maybehereditary),pursedlips,flaredalaenasi.


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100 CHAPTER 9 ChestandLungs


■ ColorAssessskin,lips,andnails.

UNEXPECTED: Superficialvenouspatterns.Cyanosisorpalloroflipsornails.

■ Breath UNEXPECTED: Malodorous.

Evaluate respirations

■ Rhythm or pattern and rateSeepatternsofrespirationinfigurebelow.

EXPECTED: Breathingeasy,regular,withoutdistress.Patterneven.Rate12to20respirationsperminute.Ratioofrespirationstoheartbeatsabout1:4.UNEXPECTED: Dyspnea,orthopnea,paroxysmalnocturnaldyspnea,platypnea,tachypnea,hypopnea.Useofaccessorymuscles,retractions.

Patterns of respiration. The horizontal axis indicates the relative rates of these patterns. The vertical swings of the lines indicate the relative depth of

respiration.

Normal

Bradypnea

Slower than 12 breathsper minute

Regular and comfortable ata rate of 12-20 per minute

Faster than 20 breathsper minute

Faster than 20 breathsper minute, deep breathing

Frequently intersperseddeeper breath

Varying periods ofincreasing depthinterspersed with apnea

Increasing difficulty ingetting breath out

Rapid, deep, labored

Irregularly interspersedperiods of apnea in a disorganized sequenceof breaths

Significant disorganizationwith irregular and varyingdepths of respiration

Tachypnea

Hyperventilation(hyperpnea)

Sighing

Airtrapping

Cheyne-Stokes

Kussmaul

Biot

Ataxic


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■ Inspiration/expiration ratio UNEXPECTED: Airtrapping,prolongedexpiration.

Inspect chest movement with breathing

■ Symmetry EXPECTED: Chestexpansionbilaterallysymmetric.UNEXPECTED: Asymmetry.Unilateralorbilateralbulging.Bulgingonexpiration.

Listen to respiration sounds audible without stethoscope

EXPECTED: Generallybronchovesicular.UNEXPECTED: Crepitus,stridor,wheezes.

Palpate thoracic muscles and skeleton

■ Symmetry/condition EXPECTED: Bilateralsymmetry.Someelasticityofribcage,butsternumandxiphoidrelativelyinflexibleandthoracicspinerigid.UNEXPECTED: Pulsations,tenderness,bulges,depressions,unusualmovement,unusualpositions.

■ Thoracic expansionStandbehindpatient.Placepalmsinlightcontactwithposterolateralsurfacesandthumbsalongspinalprocessesattenthrib,asshowninfigureatright.Watchthumbdivergenceduringquietanddeepbreathing.Facepatient;placethumbsalongcostalmarginandxiphoidprocesswithpalmstouchinganterolateralchest.Watchthumbdivergenceduringquietanddeepbreathing.

EXPECTED: Symmetricexpansion.UNEXPECTED: Asymmetricexpansion.

Palpating thoracic expansion. The thumbs are at the level of the

tenth rib.


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■ Sensations EXPECTED: Nontendersensations.UNEXPECTED: Crepitusorgratingvibration.

■ Tactile fremitusAskpatienttorecitenumbersorwordswhilesystematicallypalpatingchestwithpalmarsurfacesoffingersorulnaraspectofclenchedfist,usingfirm,lighttouch.Assesseacharea,fronttoback,sidetoside,lungapices.Comparesides.

EXPECTED: Greatvariability;generally,fremitusismoreintensewithmales(lower-pitchedvoice).UNEXPECTED: Decreasedorabsentfremitus;increasedfremitus(coarser,rougher);orgentle,moretremulousfremitus.Variationbetweensimilarpositionsonrightandleftthorax.

Note position of trachea

Usingindexfingerorthumbs,palpategentlyfromsuprasternalnotchalongupperedgesofeachclavicleandinspacesabove,toinnerbordersofsternocleidomastoidmuscles.

EXPECTED: Spacesequalsidetoside.Tracheamidlinedirectlyabovesuprasternalnotch.Possibleslightdeviationtoright.UNEXPECTED: Significantdeviationortug.Pulsations.

Perform percussion on chest

Percussasshowninfigurebelow.Compareallareasbilaterally,followingasequencesuchasshowninfiguresonp.103Seetableonp.103forcommontones,intensity,pitch,duration,quality.

Method for percussion.


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Suggested sequence for systematic percussion and auscultation of the thorax. A, Posterior thorax. B, Right lateral thorax. C, Left lateral thorax. D,

Anterior thorax. The pleximeter finger or the stethoscope is moved in the numeric sequence suggested; however, other sequences are possible.

13

16

1 2

4 3

5 6

8 7

9 10

11

14

15

18

17

12

19

22

23

26 25

24

21

20

A B

C D

Percussion Tones Heard Over the Chest

Type of Tone Intensity Pitch Duration Quality

Resonant Loud Low Long HollowFlat Soft High Short Extremely

dullDull Medium Medium-high Medium ThudlikeTympanic Loud High Medium DrumlikeHyperresonant* Very loud Very low Longer Booming

* Hyperresonance is unexpected in adults. It represents air trapping, which occurs in obstructive lung diseases.

From Thompson et al, 1997.


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■ ThoraxHavepatientsitwithheadbentandarmsfoldedinfrontwhilepercussingposteriorthorax,thenwitharmsraisedoverheadwhilepercussinglateralandanteriorchest.Percussat4-to5-cmintervalsoverintercostalspaces,movingsuperiortoinferior,medialtolateral.Thefemalebreastmayobscurefindings.Youorthepatientmayneedtoshiftthebreast,butpaycarefulattentiontomodesty.

EXPECTED: Resonanceoverallareasoflungs,dulloverheartandliver,spleen,areasofthorax.UNEXPECTED:Hyperresonance,dullness,orflatness.

■ Diaphragmatic excursionAskpatienttobreathedeeplyandholdbreath.Percussalongscapularlineononesideuntiltonechangesfromresonanttodull.Markskin.Allowpatienttobreathenormally,thenrepeatonotherside.Havepatienttakeseveralbreaths,thenexhaleasmuchaspossibleandhold.Oneachside,percussupfrommarktochangefromdulltoresonant.Tellpatienttoresumebreathingcomfortably.Measureexcursiondistance.

EXPECTED: 3to5cm(higheronrightthanleft).UNEXPECTED: Limiteddescent.

Measuring diaphragmatic excursion. Excursion distance is usually 3 to 5 cm.


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Auscultate chest with stethoscope diaphragm, apex to base■ Intensity, pitch, duration, and

quality of breath soundsHavepatientbreatheslowlyanddeeplythroughmouth.Followsetauscultationsequence,holdingstethoscopeasshowninfigurebelow.Askpatienttositupright(1) withheadbentandarms

foldedinfrontwhileauscultatingposteriorthorax,

(2) witharmsraisedoverheadwhileauscultatinglateralchest,

(3) witharmsdownandshouldersbackwhileauscultatinganteriorchest.

Listenduringinspirationandexpiration.Auscultatedownwardfromapextobaseatintervalsofseveralcentimeters,makingside-to-sidecomparisons.

EXPECTED: Seeexpectedbreathsoundsintableonp.106.UNEXPECTED: Amphoricorcavernousbreathing.Soundsdifficulttohearorabsent.Crackles,rhonchi,wheezes,orpleuralfrictionrub,asdescribedinboxonp.107.

Auscultation with a stethoscope.


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■ Vocal resonanceAskpatienttorecitenumbersorwords.

EXPECTED: Muffledandindistinctsounds.UNEXPECTED:Bronchophony,whisperedpectoriloquy,oregophony.

Characteristics of Expected Breath Sounds

Sound Characteristics Findings

Vesicular Heard over most of lung fields; low pitch; soft and short expirations; will be accentuated in a thin person or a child and diminished in overweight or very muscular patient

Bronchovesicular Heard over main bronchus area and over upper right posterior lung field; medium pitch; expiration equals inspiration

Bronchotracheal (tubular)

Heard only over trachea; high pitch; loud and long expirations, often somewhat longer than inspiration

Modified from Thompson et al, 1997.


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Adventitious Breath Sounds

Fine crackles: High-pitched, discrete, discontinuous crackling sounds heard during end of inspiration; not cleared by cough

Medium crackles: Lower, more moist sound heard during midstage of inspiration; not cleared by cough

Coarse crackles: Loud, bubbly noise heard during inspiration; not cleared by cough

Rhonchi (sonorous wheeze): Loud, low, coarse sounds, like a snore, most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)

Wheeze (sibilant wheeze): Musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; usually louder during expiration

Pleural friction rub: Dry rubbing or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface

Modified from Thompson et al, 1997.


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AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMAL I T Y DE SCR I P T ION

Pleuraleffusion Subjective Data: Coughwithprogressivedyspneaisthetypicalpresentingconcern.Pleuriticchestpainoccurswithaninflammatoryeffusion.Objective Data: Findingsonauscultationandpercussionvarywiththeamountoffluidpresentandwiththepositionofthepatient.Theseincludedullnesstopercussionandtactilefremitus,whicharethemostusefulfindingsforpleuraleffusion.Whenthefluidismobileitwillgravitatetothemostdependentposition.Theaffectedareas,thebreathsoundsaremutedandthepercussionnoteisoftenhyperresonantintheareaabovetheperfusion.

Lungcancer Subjective Data: Cough,wheezing,avarietyofpatternsofemphysemaandatelectasis,pneumonitis,andhemoptysis.Peripheraltumorswithoutairwayobstructionmaybeasymptomatic.Objective Data: Findingsarebasedontheextentofthetumorandthepatternsofitsinvasionandmetastasis.Withairwayobstructionapostobstructivepneumoniacandevelopwithconsolidation.Amalignantpleuraleffusionmaydevelopwithcorrespondingfindings.


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Pneumonia Subjective Data: Rapidonset(hourstodays)ofcough,pleuriticchestpainanddyspnea.Sputumproductioniscommonwithbacterialinfection(seetableonp.110).Chills,fever,rigors,andnonspecificabdominalsymptomsofnauseaandvomitingmaybepresent.Involvementoftherightlowerlobecanstimulatethetenthandelevenththoracicnervestocauserightlowerquadrantpainandsimulateanabdominalprocess.Objective Data: Febrile,tachypneic,andtachycardic.Cracklesandrhonchiarecommonwithdiminishedbreathsounds.Egophony,bronchophony,andwhisperpectoriloquy.Dullnesstopercussionoccursovertheareaofconsolidation.

Asthma Subjective Data: Episodesofparoxysmaldyspneaandcough.Chestpainiscommonand,withit,afeelingoftightness.Episodesmaylastforminutes,hours,ordays.Maybeasymptomaticbetweenepisodes.Objective Data: Tachypneawithwheezingonexpirationandinspiration.Expirationbecomesmoreprolongedwithlaboredbreathing,fatigue,andanxiousexpressionasairwayresistanceincreases.Hypoxemiabypulseoximetry.


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Chronicbronchitis Subjective Data: Dyspneamaybepresentalthoughnotsevere.Coughandsputumproductionareimpressive.Objective Data: Wheezingandcrackles.Hyperinflationwithdecreasedbreathsoundsandaflatteneddiaphragm.Severechronicbronchitismayresultinrightventricularfailurewithdependentedema.

Emphysema Subjective Data: Dyspneaiscommonevenatrest.Coughisinfrequentwithoutmuchproductionofsputum.Objective Data: Chestmaybebarrelshaped,andscatteredcracklesorwheezesmaybeheard.Overinflatedlungsarehyperresonantonpercussion.Inspirationislimitedwithaprolongedexpiratoryeffort(i.e.,longerthan4or5seconds)toexpelair.

Assessing Sputum

Cause Possible Sputum Characteristics

Bacterial infection Yellow, green, rust-colored (blood mixed with yellow sputum), clear, or transparent; purulent; blood streaked; mucoid, viscid

Viral infection Mucoid, viscid; blood streaked (not common)

Chronic infectious disease

All of the above; particularly abundant in early morning; slight, intermittent blood streaking; occasionally large amounts of blood

Carcinoma Slight, persistent blood streakingInfarction Blood clotted; large amounts of bloodTuberculous cavity Large amounts of blood


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Pediatric Variations

EXAMINATION


CHEST AND LUNGS

Inspect front and back of chest■ Compare anteroposterior

diameter with transverse diameter

EXPECTED: Infant’schestisexpectedtomeasure2to3cmlessthanheadcircumference.

Evaluate respirations

■ Rhythm or pattern and rate EXPECTED:Age Respirations per Minute

Newborn 30-801year 20-403years 20-306years 16-2210years 16-2017years 12-20

Perform direct or indirect percussion on chest

■ Thorax EXPECTED: Hyperresonancemaybeheardinchildren.

Auscultate chest with stethoscope diaphragm, apex to base

■ Intensity, pitch, duration, and quality of breath sounds

EXPECTED: Ininfantsandchildren,expecttransmittedbreathsoundsthroughoutchest.Vesicularsoundisaccentuatedinachild.Absentordiminishedbreathsoundsarehardertodetect.


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SAMPLE DOCUMENTATION

Subjective. A45-year-oldwomancomplainingofcoughandfeverfor4days.Coughisnonproductive,persistent,andworsewhensheliesdown.Shefeelsillandshortofbreath.Herchestfeels“heavy.”Feverupto38.3°C(101°F).Takingacetaminophenandnonprescriptioncoughsyrupwithoutrelief.Objective. Pulse104perminute,temperature38.2°C,bloodpressure122/82,respirations32perminuteandsomewhatlabored;noretractionsorstridor.Minimalincreaseinanteroposteriordiameterofchest,withoutkyphosisorotherdefect.Tracheainmidlinewithouttug.Thoracicexpansionsymmetric.Nofrictionrubsortendernessoverribsorotherbonyprominences.Overposteriorleftbase,diminishedtactilefremitus,dullpercussionnote,andonauscultation,cracklesthatdonotclearwithcough,diminishedbreathsounds.Remaininglungfieldsareclearandfreeofadventitioussounds,withresonantpercussiontones.Diaphragmaticexcursion3cmbilaterally.


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