College of medicine and health science

School of nursing
Department of medical nursing
Respiratory system assessment
By : Chilot K
September 17/09/2019

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 Objectives
 At the end of this session the students are expected
to:-
• List some of the general guidelines to examine lung
and thorax.
• Identify important land mark on the surface of the
chest and thorax.
• Locate finding based on land marks.
• Identify basic technique to examine lung and thorax
• Assess lung and interpret findings.
• Assess chest expansion, & tactile fremitus
• Identify the level of diaphragmatic dullness.
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The six cardinal symptoms of chest diseases are

1- Cough
2- Expectoration (sputum)
3- Hemoptysis-coughing up blood
4- Chest pain
5- Dyspnea
6- Wheezes

04-04-2011 E.C 3
 Cough
• Onset – sudden, gradual
• Duration- acute or chronic
• Nature – dry, productive
• Sputum – amount, color, odor
• Severity – disrupts activities
• Associated symptoms – sneezing, dyspnea, fever,
chills,
• What makes it better?
• What has been tried? – medications/ treatments
• Anything similar complaint in the past?

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 Guideline in chest and thorax examination
• Expose the part that you need to examine.
• Position the patient.
• Use an orderly fashion
• Compare one side to another side/symmetrically.
• Move from the apex to the base.
• Do not auscultate the chest through gown, cloth
etc
• Instruct person to sit upright and breathe in and
out slowly through the mouth.
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 MANUBRIUM
BODY OF ANGLE OF
STERNUM LUIS

XYPHOID
PROCESS 2ND ICS

COSTAL ANGLE

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 locating findings along the vertical axis on the chest
Anterior Landmarks
1. Suprasternal Notch: “U” shaped depression
above sternum-between clavicles.

2. “Angle of Louis” marks site of tracheal

bifurcation into right and left main bronchi.
Approximately 5 cm below sternal notch.

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 Anterior Landmarks…
• The angle of Louis also termed as sternal angle,
is the best guide.

• Place your finger in the hollow curve of the

suprasternal notch, then move your finger down
about 5 cm to the horizontal bony ridge joining
the manubrium to the body of the sternum.
Then move your finger laterally to find the
adjacent 2nd rib and costal cartilage.

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 Anterior Landmarks (Cont).
3. Costal Angle:
• Right and Left costal margins form an angle
where they meet at the Xiphoid Process. Usually
90 degrees or less.

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 Posterior Landmarks
1. The spinous process of the 7th cervical
vertebrae
when a person flexes neck forward, the most
prominent process is usually that of the
seventh cervical vertebrae, when two process
appear equally they are of the 7th cervical and
1st thoracic vertebrae these help to locate
finding posteriorly.

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Posterior Landmarks Cont’d
2. The 12th rib give another possible starting point
for counting the ribs and interspaces, this is
usually important when anterior land mark is
unsatisfactory.

3. The inferior angle of the scapula lies at the

level of the seventh rib or interspaces.

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 12

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 Lung boarder
 Anteriorly, the apex of each lung rises about
2-4cm above the clavicle.

 The lower border/base of the lung crosses the

6th rib at the midclavicular line and the 8th rib
at the mid axillary line.

 Posteriorly, the lower border of the lung lies at

about the level of the T10 spinous process.
On inspiration, it descends farther.
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 Anterior and posterior view of
the lobes of the lung

LUL RUL
RUL
LUL

RML
LLL RLL
RLL LLL T 10

T 12

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 Lung and chest examination
Inspect

Palpate

Percuss (normal note is resonance)

Auscultate (normal is clear and equal bilaterally)

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 Equipment and Techniques
• Equipment
– Stethoscope
• Techniques
– Inspection
– Palpation
– Percussion
– Auscultation

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 Inspection
General Appearance
 Restless or agitated
 Flaring nostrils
 Supraclavicular retractions
 Intercostals retractions
 Subcostal retractions
 Use of accessory muscles

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 Inspection
From a midline position behind the patient, note
 Shape of the chest
 Breathing pattern
 Deformities or asymmetry.
 Abnormal retraction of the interspaces during
inspiration./sever asthma, sever pneumonia, COPD or
upper airway obstruction/.

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 Tracheal shift to right

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 Inspection cont…
Tracheal Position:
 Normally trachea is central in the mediastinum
 Any deviation of the trachea is abnormal
 Lateral shift: the mediastinum can be either
pulled or pushed away from the lesion
 Pull: Loss of lung volume
(Atelectasis, surgical resection, pleural fibrosis…)
 Push: Space occupying lesions
(pleural effusion, pneumothorax, large mass lesions)
20

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 Clubbing of nails

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 Inspection (cont).
Cyanosis: bluish discoloration of the skin.
• Central Cyanosis: Circumoral (around mouth),
cheek, lips, tongue & buccal mucosa.
• Peripheral Cyanosis: check nail beds and
extremities.
Symmetry:
Check symmetrical expansion of chest wall.
– Bilateral diminished expansion may be due to
acute pleurisy, pleural fibrosis, atelectasis.
– Unilateral diminished expansion may be due to
pneumothorax.
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 Cont’d
Causes of unilateral decrease or delay in chest
expansion include:
 Pleural effusion.
 Lobar pneumonia.
 Pleural pain and
 Unilateral bronchial obstruction.

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 Inspection…
Check abnormal anterior chest
• Barrel chest-enlarged and rounded cross-section
to chest associated with COPD and some times
asthma.
• Funnel chest-compression of the lower part of
the sternum/pectus excavatum /sunken

• Pigeon chest-characterized by a protruding

sternum /pectus carinatum

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 Barrel chest

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 Funnel chest
Pigeon chest

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 Abnormal posterior chest
Kyphosis = accentuated thoracic curve /hunch
back/ may impended respiratory muscles

Scoliosis = lateral ‘S’ deviation/curvature of the

spine.

Lordosis = accentuated lumbar curve or a

forward curvature of the lumbar spine associated
with kyphosis.
-This is normal only in pregnancy.

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 Lordosis
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 Palpation
• Palpation has 4 potential uses:

1. Identification of tender areas

2. Assessment of observed abnormalities

3. Further assessment of chest expansion

4. Assessment of tactile fremitus

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 Palpation…
As you palpate the chest focus on area of
tenderness and abnormality in the overlying
skin.
• Identify tender areas carefully and palpate any
area where pain has been reported
• Lymph nodes-infra &supraclavicular , axilary LN
• Thorax: Check for crepitus, tenderness.

• Check for chest wall expansion/ chest lag

• Check for tactile or vocal fremitus.
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 Palpation…
Chest Expansion
Posterior chest expansion
• Place both thumbs at about
the level of 10th rib
posteriorly along the spinal
process.
• As you position your hands,
slide them medially just
enough to raise a loose fold of
skin on each side between
your thumb and the spine.
 Chest expansion…..
 Extend the fingers of both hands outward over
the posterior chest wall
 Have the person to inhale deeply and exhale
fully and observe for bilateral outward
movement of thumbs or
 Watch the distance between your thumbs as
they move apart during inspiration.

• Normal: bilateral symmetric expansion

• Abnormal: unilateral or unequal

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 chest Expansion

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 Cont…
 Asymmetrical chest expansion is
abnormal

– The abnormal side expands less and lags

behind the normal side.

– Any form of unilateral lung or pleural disease

can cause asymmetry of chest expansion.

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 Tactile or vocal fremitus
• This refers to the palpable vibrations as sound is
transmitted through the bronchopulmonary tree
to the chest wall when the patient speaks.
• To detect fremitus, use either the ball (the bony
part of the palm at the base of the fingers) or
the ulnar surface of your hand to optimize the
vibratory sensitivity of the bones in your hand.

• Ask the patient to repeat the words “ninety-

nine” or “one-two-three” or “forty four”.
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 Technique of appreciating tactile
fremitus

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 Tactile fremitus (cont).
Normal finding is a mild purr like sensation.
– Increased tactile fremitus occurs in conditions
where solid conducts vibrations better than air.
Ex. Pneumonia and pulmonary fibrosis.
– Decreased tactile fremitus occurs when there
is increased distance that sound has to travel
before it reaches chest wall.
Ex. Pleural Effusion, pneumothorax, COPD,
obstructed bronchus, pleural thickening, and
also a very thick chest wall.
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 Fremitus …
• Tactile fremitus is a relatively rough
assessment tool, but as a scouting
technique it directs your attention to
possible abnormalities.

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 Percussion
• Percussion helps you establish whether the
underlying tissues are air-filled, fluid-filled, or
solid.

• It penetrates only about 5 cm to 7 cm into the

chest, therefore it will not help you to detect
deep-seated lesions.

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 Percussion……
• Hyperextend the middle finger
of your left hand, known as the
pleximeter finger.
• Press its distal
interphalangeal joint firmly on
the surface to be percussed.
• Avoid surface contact by any
other part of the hand,
because this dampens out
vibrations.
• Note that the thumb, 2nd, 4th,
and 5th fingers are not
touching the chest.

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 Percussion…….
• With a quick sharp but relaxed
wrist motion, strike the
pleximeter finger with the right
middle finger, or plexor finger.
• Strike using the tip of the plexor
finger, not the finger pad.
• Your finger should be almost at
right angles to the pleximeter.
• A short finger nail is
recommended to avoid self-
injury.

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 Percussion…
Percuss: Anterior, lateral, posterior chest
Normal:
• Resonance
Abnormal:
• Dullness - consolidation, atelectasis, pleural
effusion.
• Hyper-resonance- pneumothorax, emphysema,
asthma.

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 Diaphragmatic Excursion
• This is the ROM of the diaphragm
Procedure:
Patient sits in up right
Tell patient to exhale and hold it.

Percuss down ward posterior chest at scapular

line, continue until tone changes from
resonance to dullness, and mark with a parker.

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 Diaphragmatic Excursion…
• Tell pt to take a deep inhalation and hold it
• Continue percussion from first mark until
change from resonance to dullness
• Mark with marker, then measure findings.
• DON’T FORGET TO TELL Pt TO BREATH
• Repeat on other side.
• Normal finding 4-6 cm.
NB: An abnormally high level suggests pleural
effusion.
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 Diaphragmatic Excursion…

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 Auscultation of the lung
• Auscultation of the lungs is the most important
examination technique for assessing air flow
through the tracheo-bronchial tree.

• Together with percussion, it also helps the

clinician to assess the condition of the
surrounding lungs and pleural space.

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 Auscultation involves
1. Listening to the sounds generated by breathing.

2. Listening for any adventitious (added) sounds, &

3. If abnormalities are suspected, listening to the

sounds of the patient’s spoken or whispered
voice as they are transmitted through the chest
wall.

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 Breath Sounds
• Auscultate using diaphragm, use a systematic
approach, compare side to side, document when
and where sounds are heard.
• Normal breath sounds:
1. Vesicular breath sound.
2. Bronchial breath sound and
3. Broncho-vesicular breath sound.
4. Tracheal breath sound
Patterns of breath sounds identified by their
intensity, their pitch, and the relative duration of
their inspiratory and expiratory phases.
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 Symmetrical Auscultation of chest

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 Breath Sounds…..
Bronchovesicular Breath Sounds
• Combination of vesicular and bronchial sounds
represent a mixture of sounds produced by
bronchial and alveoli vibrations.
• No pause between inspiration and expiration
• Inspiration = Expiration
• Heard best anteriorly at 1&2 ICS, posteriorly
between scapula.
• Anywhere else = consolidation

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 BRONCHO
VESICULAR VESICULAR

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 Cont …

• If Broncho-vesicular or bronchial breath sounds

are heard in locations distant from those listed,
suspect that air-filled lung has been replaced by
fluid-filled or solid lung tissue…………dullness on
percussion !!!

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 Abnormal Breath Sounds
Abnormal breath sounds are called adventitious
/added/sounds
1. Rales (Crackles):
• Discontinuous and non musical high pitched
sound and brief—like dots in time.
• Sounds like hair being rubbed together
• Sound produced by air passing through fluid in
air spaces (CHF, pneumonia).
• Usually on inspiration / not expiration
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 Adventitious Sounds (cont).
2. Rhonchi: continuous snoring sound.
• Low pitched, snoring quality
• Greater pronounced during expiration.
• Etiology: larger airways are obstructed with
mucus or tumor.
• Rhonchi suggest secretions in large airways.

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 Adventitious Sounds (cont).
3. Wheezing:
High pitched, continuous musical, whistling
sounds.
Produced by narrowed airway.
Related to broncho-spasm, asthma, tumor,
foreign body.
Can occur during inspiration or expiration.
Wheezes suggest narrowed airways, as in
asthma, COPD, or bronchitis.
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 Adventitious Sounds (cont).

4. Stridor: increased musical wheeze heard over

trachea on inspiration.
Cause: Laryngeal obstruction
=
MEDICAL EMERGENCY

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 Adventitious Sounds (cont).
5. Friction (Pleural) Rub: Course, dry, grating sound
heard only with stethoscope.
Etiology: Inflamed pleural surfaces rub.
 Sounds similar to cupping hand over ear,
scratching back of hand with other hand.
 Usually heard anterio-lateral chest wall
 Continuous during inspiration and expiration.

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 Summery
Increased TVF Decreased TVF

 Consolidation  Thick chest wall

 Collapse with patent main  Pleural effusion

bronchus  Pleural fibrosis

 Pneumothorax

 Emphysema

 Collapse

04-04-2011 E.C 60
 Summery…
Pleural effusion Consolidation
• reduced tactile vocal • increased tactile vocal
fremitus fremitus
• reduced chest expansion • reduced expansion
• stony dull • dull percussion
• reduced air entry • bronchial breathing
• no added sounds • coarse creps
• reduced vocal resonance • increased vocal resonance
• whispering pectoriloquy

04-04-2011 E.C 61
 Tests of Vocal Resonance

-BRONCHOPHONY

-EGOPHONY

-WHISPERED PECTORILOQUAY

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 Thank you
Any Questions

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