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Anterior thoracic landmarks

- Suprasternal notch
- Sternum
- Manubriosternal angle
- Costal angle

Posterior thoracic landmarks

- Vertebra prominens
- Spinous processes
- Inferior border of scapula
- Twelfth rib

Reference lines

• Midsternal line *
• Midclavicular line *
• Scapular line - posterior
• Vertebral line - posterior
• Anterior, posterior, midaxillary lines

4 functions of respiratory system

- Changing chest size during respiration
- Inspiration
- Expiration
- Control of respiration
deep breaths - in thru nose out thru mouth

health history

• Cough
• Shortness of breath = when are you experiencing this? speech? walking?
• Chest pain with breathing = when
• History of respiratory infections = pneumonia, some pre disposal once you get it once
• Smoking history
• Environmental exposure = chemicals, allergies
• Self‐care behaviors = wash hands, flu shot

cough assessment (2 & details)

- when do have? anything lead to cough? productive?
• Timing
- Continuous
- Afternoon & evening
- Night (maybe drainage)
- Morning
- 3 months per year for 2 years
• Dry vs.Moist - Hacking
- Barking
- Dry
- Moist
- Congested

sputum: white or clear

• White or clear = colds, allergies, infections, bronchitis (some bacterial)

sputum: yellow or green

bacterial infections (they sit longer in lungs)

sputum: rust colored

TB, pneumonia, blood, cancer

sputum: pink & frothy

with dyspnea = pulmonary edema (fluid overdrive)
Pink = blood
- hard to cough up b/c they are very weak. usually see when they have to be ventilated

routine techniques: general

• Inspect -general
• Inspect‐ chest
• Inspect‐color
• Respirations
• Auscultate‐BS
- Palpate & Percuss

Inspect: posterior chest

• Thoracic cage
- Shape and configuration of chest wall
- Anteroposterior/transverse diameter
- Position of person
- Skin color and condition

Inspect chest: abnormalites

1. barrel chest = emphysema, kids w/cystic fibrosis
2. look at position → tripod
3. when they are sweating, they are working harder using accessory muscles
4. skin color = blue/cyanosis (hands, around the mouth)

symmetric chest expansion

- thumbs move 5-10cm
- unilateral movement = caused by pain, fractured ribs or chest wall injury, pneumonia & atelectasis (shrunken, airless alveoli or collapse of lung tissue)

Palpate: posterior chest

• Symmetric expansion = unequal if rib fracture, bruising
• Tactile (or vocal) fremitus (non-routine) "99"
- Technique (ulnar surface of hands)
- Factors that affect normal intensity of tactile fremitus
• Palpate the entire chest wall - for discomfort

posterior chest: symmetric abnormalities

unequal if rib fracture, bruising

posterior chest: Tactile fremitus

use 2 hands & you can compare each
- if you feel stronger than pneumonia

posterior chest: percuss

• Predominant notes over lung fields

Posterior chest: Auscultate

• Breath sounds
- Technique
- Bronchial breath sounds—characteristics (anterior chest)
- Bronchovesicular breath sounds—characteristics
- Vesicular breath sounds—characteristics
* careful of patients making noise while breathing

auscultate technique

• Diaphragm of stethoscope
• Mouth open
• Breathing deeply and fairly rapidly (not too rapid)
• Systematic approach over several areas, comparing both sides


clear to auscultation

bronchial breath sounds

- heard over trachea & immediately above the manubrium
- high pitch, loud intensity
- inspiration < expiration
- 1:2
- Abnormal location = over peripheral lung fields, anywhere over the posterior or lateral thorax
Abnormal = consolidation of the lung, pneumonia

bronchovesicular breath sounds

- hear over main bronchi
location = posterior, btw scapulas
- moderate pitch, medium intensity
- inspiration = expiration
Abnormal location = over peripheral lung fields

vesicular breath sounds

- low pitch, soft intensity
- inspiration > expiration
- 2.5:1
- peripheral lung fields

Adventitious sounds

- Crackles
- Wheeze
- Atelectatic crackles

Tactile (vocal) fremitus

- say 99
- vibrations should feel equal on both sides, quality may vary from person to person
Abnormal = unequal/decrease → emphysema, pleural effusion, pulmonary edema, bronchial obstruction.
increase (rougher/coarser) → lung tissues are congested, consolidation, pneumonia, tumor

Voice sounds: bronchophony

Vocal resonance #1
= the abnormal transmission of sounds from the lungs or bronchi.
- detected by auscultation
- patient says 66 or 99 while you osculate. sound of voice becomes less distinct as you move peripherally99 or 66 should be muffled

Voice sounds: whispered pectoriloquy

Vocal resonance #2
- performed when bronchophony is positive (magnified from of bronchoscopy
- auscultate & have patient whisper
- thru stethoscope won't hear words clearly (should be muffled) unless build up of fluid in alveolar regions of the lungs (consolidation, compression, pneumonia)

voice sounds: Egophony

Vocal resonance #3
- auscultate while patient says EEE
- negative is hearing muffled EEE
- positive is hearing AAA = pneumonia, pulmonary edema, inflammatory exudate, pus, inhaled water or blood

Inspect: Anterior chest

• Shape and configuration of chest wall
• Facial expression
• Level of consciousness = changes → respiratory distress
• Skin color and condition = pale, flushed, sweaty, cyanosis
• Quality of respirations = labored or not
• Rib interspaces
• Accessory muscles = big ones in the neck

palpate: anterior chest

• Symmetric chest expansion
• Tactile fremitus = vibrations of spoken voice felt thru chest wall on palpations
• Palpate the anterior chest wall

percuss: anterior chest

• Predominant note over lung fields
• Borders of cardiac dullness

lung sound


auscultate: anterior chest

• Breath sounds
• Abnormal breath sounds
• Adventitious sounds

measurement of pulmonary function status (3)

- Forced expiratory time
- Pulse oximeter = saturation ≥ 95%
- 6‐Minute distance walk

abnormality: barrel chest

chronic overinflation, hyperinflation, emphysema, pulmonary disease

abnormality: pectus excavatum

- funnel sternum
- could be just physical abnormality or cardiac/respiratory problems

abnormality: pectus carinatum

- prominent sternum
- could be just physical abnormality or cardiac/respiratory problems

abnormality: scoliosis

- curved spine
- can effect lungs b/c not as much room.
- ↑ risk of pneumonia

abnormality: kyphosis

-spinal convexity to the right, ribs widely spaced
- ↑ risk of pneumonia

Discontinuous sounds

can't predict, intermittent

Discontinuous sounds: fine crackles

Fine (rales) = high pitched
-short crackling, sounds like popping or rub hair together or fingers rubbing together if dry
- during inspiration & expiration
- not cleared by cough
- Causes = heart failure, COPD, asthma, terminally ill

Discontinuous sounds: Course crackles

Course = low pitched
- popping, loud bubbling, gurgling sounds
- decrease w/coughing & suctioning then return
- not cleared by cough
- Causes = heart failure, COPD, asthma, terminally ill

Discontinuous sounds: Atelectatic crackles

Atelectatic crackles = either fine or course, after a few breaths or coughs the sound goes away.
Cause = collapse of small alveoli, prolonged bed rest, immobility
-sounds like popping

Continuous sounds: wheeze (sibilant)

- high pitched, similar to a squeak & musical
- inspiration & expiration (expiration=most common)
Cause= narrowing of airways, usually asthma

Continuous sounds: wheeze/Rhonchi

- sonorous
- due to passage of air thru narrowed bronchus
- lower pitched musical snoring (can be high)
- primarily on expiration but may be heard inspiration, expiration is prolonged
- coughing may clear
Causes= usually due to mucous or pneumonia. disorders causing obstruction of trachea or bronchitis

Continuous sounds: Stridor

- harsh, high pitched crowing, inspiratory sound over larynx
- usually louder in neck than the chest
- narrowing of upper airway, trachea
- can be life threatening
- often can be heard w/o stethoscope (croup, epiglottitis or post extubation laryngeal edema
Causes = aspirated foreign body, tracheal stenosis or laryngeal tumor. severe stridor is an emergency b/c airway may close

Pleural Rub

- coarse low pitched grating, "creaking of old leather
- best heard posteriorly in the lower lobes
- 2 separate phases at end inspiration & early expiration
- coughing does not affect the sound
- surfaces roughened by exudate
Cause = rubbing together of parietal & visceral pleura as seen in pleurisy

Be specific in descriptions of lung sounds

• loudness = coarse or fine?
• timing in the respiratory cycle
• location on the chest wall
• persistence of the pattern from breath to breath
• Do sounds clear after a cough or a few deep breaths?

Auscultation abnormal: Decreased or absent

= not as clear, you can hear but not as loud
• Obstruction
• Emphysema = COPD
• Pneumothorax = collapsed lung
• Pleurisy = can't take a deep breath

Auscultation abnormal: increased

= louder
• consolidation


shrunken, airless alveoli or collapse of lung tissue

trachea palpation

- should be palpable, midline & slightly movable
abnormal = if not midline → thorax mass, mediastinal shift or some degree of lung collapse.
- other findings may be dyspnea, cough & abnormal breath sounds

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