Pulmonary Assessment

Purposes:

 Determine a patient’s primary and secondary respiratory and ventilatory impairments and how
they limit physical function.
 Determine the adequacy of the ventilatory pump and the oxygen uptake/carbon dioxide
elimination mechanisms to meet the oxygen demands at rest and during functional activities.
 Ascertain a patient’s suitability for participation in a pulmonary rehabilitation program.
 Develop an appropriate level intervention plan for the patient.
 Establish a baseline to measure a patient’s progress and the effectiveness of the treatment.
 Determine when to discontinue specific interventions and implement a home program as a basis
for self-management.

Components of the Assessment

Analysis of Chest Shape and Dimensions
Symmetry of the Chest and Trunk

The thoracic cage should be symmetrical when observed anteriorly, posteriorly, and laterally.

Mobility of the Trunk

Check active movements in all directions and identify any restricted spinal motions, particularly in the
thoracic spine.

Shape and Dimensions of the Chest

A-P and lateral dimensions are usually 1:2. Common chest deformities include:
Barrel Chest
 The circumference of the upper chest appears larger than the lower chest. The sternum is
prominent; A-P chest diameter is greater than normal.
 Upper chest breathers, particularly patients with COPD, develop a barrel chest.
Pectus excavatum (funnel chest/funnel breast)
 The lower part of the sternum is depressed and the lower ribs flare out.
 Patients with this deformity are diaphragmatic breathers; excessive abdominal protrusion and
little upper chest movement occur during breathing.
Pectus carinatum (pigeon breast)
 The sternum is prominent and protrudes anteriorly.
Posture or Preferred Positioning
A patient who has difficulty breathing as the result of chronic lung disease often leans forward on hands
or forearms to stabilize and elevate the shoulder girdle to assist with inspiration.
It is also important to identify a patient’s preferred sleeping position. In addition, note any postural
deformities such as kyphosis and scoliosis and postural asymmetry, which could restrict chest
movements and ventilation.
Breathing Pattern
 Assess the rate, regularity, and location of ventilation at rest and with activity.
 A normal respiratory rate for a healthy adult is 12 to 20 breaths per minute.
 The normal ratio of inspiration to expiration at rest is 1:2 and with activity 1:1. A patient with
chronic obstructive pulmonary disease (COPD) may have a ratio of 1:4 at rest, which reflects
difficulty with the expiratory phase of breathing.
 To assess the breathing sequence, have the patient assume a comfortable position
(semireclining or supine). Place your hands on the patient’s epigastric region and sternum to
observe movements in these two areas.

Abnormal Breathing Patterns

 Dyspnea. Distressed, labored breathing as the result ofshortness of breath.
 Tachypnea. Rapid, shallow breathing; decreased tidal volume but increased rate; associated
with restrictive or obstructive lung disease and use of accessory muscles of inspiration.
 Bradypnea. Slow rate with shallow or normal depth and regular rhythm; may be associated
with drug overdose.
 Hyperventilation. Deep, rapid respiration; increased tidal volume and increased rate of
respiration; regular rhythm.
 Orthopnea. Difficulty breathing in the supine position.
 Apnea. Cessation of breathing in the expiratory phase.
 Apneusis. Cessation of breathing in the inspiratory phase.
 Cheyne-Stokes. Cycles of gradually increasing tidal volumes followed by a series of gradually
decreasing tidal volumes and then a period of apnea. This is sometimes seen in the patient
with a severe head injury.
Chest Mobility
Symmetry of Chest Movement

- gives information about the mobility of the thorax and also indirectly indicates what areas of the
lungs may or may not be responding

Procedure:

Place your hands on the patient’s chest and assess the excursion of each side of the thorax during
inspiration and expiration. Each of the three lobar areas can be checked.

 To check upper lobe expansion, face the patient; place the tips of your thumbs at the
midsternal line at the sternal notch. Extend your fingers above the clavicles. Have the patient
fully exhale and then inhale deeply.
 To check middle lobe expansion, continue to face the patient; place the tips of your thumbs at
the xiphoid process and extend your fingers laterally around the ribs. Again, ask the patient to
breathe in deeply.
 To check lower lobe expansion, place the tips of your thumbs along the patient’s back at the
spinous processes (lower thoracic level) and extend your fingers around the ribs. Ask the patient
to breathe in deeply.

Extent of Excursion

Method 1:

Measure the girth of the chest with a tape measure at three levels (axilla, xiphoid, lower costal).
Document change in girth after a maximum inspiration and a maximum expiration.

Method 2:

Place both hands on the patient’s chest or back as previously described. Note the distance between your
thumbs after a maximum inspiration.

Palpation
Palpation of the thorax provides evidence of dysfunction of the underlying tissues including the lungs,
chest wall, and mediastinum.

Tactile (Vocal) Fremitus

- the vibration felt while palpating over the chest wall as a patient speaks

Procedure:

Place the palms of your hands lightly on the chest wall and ask the patient to speak a few words or
repeat “99” several times. Normally, fremitus is felt uniformly on the chest wall.

Fremitus is increased in the presence of secretions in the airways and decreased or absent when air is
trapped as the result of obstructed airways.

Chest Wall Pain

Procedure:
Firmly press against the chest wall with your hands to identify any specific areas of pain potentially of
musculoskeletal origin. Ask the patient to take a deep breath and identify any painful areas of the chest
wall. Chest wall pain of musculoskeletal origin often increases with direct point pressure during
palpation and during a deep inspiration. Pain of pulmonary origin is usually localized to a region of the
chest but also may be felt in the neck or shoulder region.

Mediastinal Shift

The position of the trachea shifts as the result of asymmetrical intrathoracic pressures or lung volumes.
For example, if the patient has had a pneumonectomy (removal of a lung), the lung volume on the
operated side decreases, and the trachea shifts toward that side. Conversely, if the patient has a
hemothorax (blood in the thorax), intrathoracic pressure on the side of the hemothorax increases, and
the mediastinum shifts away from the affected side of the chest.

Procedure:

To identify a mediastinal shift, have the patient sit facing you with the head in midline and the neck
slightly flexed to relax the sternocleidomastoid muscles. With your index finger, gently palpate the soft
tissue space on either side of the trachea at the suprasternal notch. Determine whether the trachea is
palpable at the midline or has shifted to the left or right.

Mediate Percussion

- designed to assess lung density, specifically, the air-to-solid ratio in the lungs

Procedure:

Place the middle finger of the nondominant hand flat against the chest wall along an intercostal space.
With the tip of the middle finger of the opposite hand, firmly tap on the finger positioned on the chest
wall. Repeat the procedure at several points on the right and left and anterior and posterior aspects of
the chest wall. This maneuver produces a resonance; the pitch varies with the density of the underlying
tissue. The subjective determination of pitch indicates the following:

- The sound is dull and flat if there is a greater than normal amount of solid matter (tumor,
consolidation) in the lungs in comparison with the amount of air.
- The sound is hyperresonant (tympanic) if there is a greater than normal amount of air in the
area (as in patients with emphysema).
- If asymmetrical or abnormal findings are noted, the patient should be referred to the physician
for additional objective tests such as a chest radiograph.

Auscultation of Breath Sounds

Auscultation is a general term that refers to the process of listening to sounds within the body,
specifically to breath sounds during an examination of the lungs. A stethoscope is used to magnify these
sounds.

Breath sounds should be assessed to:

 Identify the areas of the lungs in which congestion exists and in which airway clearance
techniques should be performed.
  Determine the effectiveness of any airway clearance intervention.
 Determine whether the lungs are clear and whether interventions should be discontinued.

Procedure:

Follow a systematic pattern and place the stethoscope against specific thoracic landmarks (T2, T6, T10)
along the right and left sides of the chest wall. Ask the patient to breathe in deeply and out quickly
through the mouth as you move the stethoscope from point to point. Note the quality, intensity, and
pitch of the breath sounds.

Classification of Breath Sounds

Breath sounds are classified by location, pitch, and intensity as well as the ratio of sounds heard on
inspiration versus those heard on expiration. Breath sounds also are identified as normal or adventitious
(extra).

Normal breath sounds occur in the absence of pathology and are heard predominantly during
inspiration. Normal breath sounds are categorized as vesicular, bronchial, or bronchovesicular based on
the location and quality of the sound.

Adventitious breath sounds are abnormal sounds in the lungs that are heard with a stethoscope.
Adventitious breath sounds are categorized as crackles or wheezes.

Breath sounds may be totally absent or substantially diminished over a portion of the lungs. This
indicates total or partial obstruction and lack of aeration of lung tissue. The absence of air and collapse
of an area of lung tissue is known as atelectasis. Obstruction of airways may be caused by fluids, mucus,
bronchospasm, or compression by tumor.
 Normal Breath Sounds

 Vesicular. Soft, low-pitched, breezy but faint sounds heard over most of the chest except near
the trachea and mainstem bronchi and between the scapulae. Vesicular sounds are audible
considerably longer on inspiration than expiration (about a 3:1 ratio).
 Bronchial. Loud, hollow, or tubular high-pitched sounds heard over the mainstem bronchi and
trachea. Bronchial sounds are heard equally during inspiration and expiration; a slight pause in
the sound occurs between inspiration and expiration.
 Bronchovesicular. Softer than bronchial breath sounds; also heard equally during inspiration
and expiration but without a pause in the sound between the cycles. The sounds are heard in
the supraclavicular, suprascapular, and parasternal regions anteriorly and between the
scapulae posteriorly.

Adventitious Breath Sounds

 Crackles. Fine, discontinuous sounds (similar to the sound of bubbles popping or the sound of
hairs being rubbed between your fingers next to your ear). Crackles, which can be fine or
coarse, are heard primarily during inspiration as the result of secretions moving in the airways
or in closed airways that are rapidly reopening. The former term for crackles was rales.
 Wheezes. Continuous high- or low-pitched sounds or sometimes musical tones heard during
exhalation but occasionally audible during inspiration. Bronchospasm or secretions that
narrow the lumen of the airways cause wheezes. The term previously used for wheezes was
rhonchi.

Cough and Cough Production

The strength, depth, length, and frequency of a patient’s cough must be assessed. In the patient with
current or potential pulmonary dysfunction a cough can be described as weak, shallow, soft, or throaty.
A patient may have a weak, shallow cough as the result of pain or paralysis. A sudden onset of a cough
or a sustained cough often is described as paroxysmal or spasmodic.

Secretions are checked for:

 Color (clear, yellow, green, blood-stained)

 Consistency (viscous, thin, frothy)
 Amount (minimal to copious)
 Odor (no odor to foul-smelling)

Production of a small amount of clear or white secretions on a daily basis is normal. Copious but clear
secretions are common with chronic bronchitis. Yellow, green, and purulent secretions with a strong
odor are indicative of some type of infection. Blood-streaked secretions, known as hemoptysis, is
indicative of some degree of hemorrhage in the lungs. Frothy, white secretions are associated with
pulmonary edema and heart failure.