UPPER AIRWAY STRUCTURES

ASSESSMENT OF THORAX

WEEK-10

Adult Physical Assessment: THORAX & LUNGS

MAJOR STRUCTURES OF THE RESPIRATORY SYSTEM

• Nasopharynx
- connect your nasal passages to the
rest of your respiratory system. This
allows air to get from your nose to
your lungs. Your nasopharynx also
helps: Control pressure between your
nasopharynx and middle ear.
• Oropharynx
- The middle part of the throat
connects to the oral cavity (mouth). It
allows air, food and fluid to pass
through.
• Larynx
- warms, filter and humidify
- helps to make sound
- sends air to lower airways

A TERMINAL BRONCHIOLE LOWER AIRWAY STRUCTURES

• Trachea
- divides into the right and left mainstem bronchi
and continues to divide into smaller passages
cross – section of lungs • Bronchioles
- terminate into the alveolar ducts and alveoli
• Alveoli
- is the gas exchanging units in the lungs

THORAX
 -
Functions of the Respiratory System Structures
• the exchange of oxygen and carbon dioxide through
respiration
• also plays a role in maintaining acid base balance
• How many? • begins at the nose continues as a series of airways or
- 2 clavicles passages extending to the alveoli where gas exchange
- 2 scapula takes place
- 1 Sternum (breast bone) • the nasal, oropharynx, and conducting airways
- 12 pair of ribs – allow chest to contract and - dead space
expand during each breath • The primary muscle of respiration is the diaphragm
- 12 thoracic vertebrae • the secondary muscles are called the accessory
muscles
RESPIRATORY MUSCLES - Anterior
- posterior
• the negative lung pressure that is needed for
breathing is maintained by the pleura

Mechanical Process
• accomplished by pulmonary ventilation
- the exchange of air between the lungs and the
atmosphere
• consists of two phases
- inspiration / inhalation
▪ during inhalation the diaphragm presses the
• Diaphragm abdominal organs downward
- The diaphragm is a muscle that helps you inhale
and forward
and exhale (breathe in and out).
• Intercostal Muscles
- muscles that present within the rib cage.
Consist of three layers of muscles external,
internal, and innermost layer they combine to
fill the space between the ribs.
- they enable forced expiration by depressing the
ribs, thus shrinking the diameter of the thoracic
cavity and pushing the air out of the lungs.
• Trapezius
- The trapezius elevates, depresses, and retracts
the scapula. The descending muscle fibers of
the trapezius muscle internally rotate the arms.
The transverse muscle fibers retract the o expiration / exhalation
scapulae, and the ascending muscle fibers ▪ during exhalation the diaphragm rises and recoils to
medially rotate the scapulae. the resting position
• Sternocleidomastoid
- The unilateral contraction of the
sternocleidomastoid muscle (SCM) determines
a triple movement, associating the rotation of
the head on the side opposite to that of its
contraction, the inclination from the side of its
contraction, and extension.
 - musculoskeletal changes (Muscles may become
rigid with age and may lose tone, even with
regular exercise. Bones become more brittle
and may break more easily. Overall height
decreases, mainly because the trunk and spine
shorten. Breakdown of the joints may lead to
inflammation, pain, stiffness, and deformity.)
- fibrotic alveoli
- decreased surface area for exchange of gases
- breathing and lung capacity decrease as a
result of muscle weakness and decreased
PHYSIOLOGICAL PROCESS
elasticity
• occurs on three levels
• and pregnancy too..
external respiration
o during pregnancy, increases in tidal volume and
- the exchange of gases (oxygen and carbon
respiratory rate allow for a 20
dioxide) between the alveoli and the blood
percent increase in oxygen consumption
through the alveolar-capillary membrane
o later in the pregnancy, the diaphragm rises and the
internal
costal angle widens to
- the exchange of gases between the systemic
accommodate the enlarging uterus
capillaries and the tissue at the cellular level
cellular
ANATOMICAL LANDMARKS
- exchange of gases within the cell
• the right lung has three lobes, and the left has two
these lobes are divided by fissures
RESPIRATIONS
-The respiration rate is the number of breaths a
person takes per minute.
- comes with age
o newborn and children
- obligatory nose breathers (they can only
breathe through their noses)
- primarily abdominal, breath
- sounds are louder, harsher, and more bronchial
- RR=irregular, with brief
- periods of apnea (Brief periods of apnea that
occur in short cycles of 5 to 10 seconds is not
pathologic and is referred to as periodic • In Front
breathing. Periodic breathing is seen - when approached anteriorly, the apices of the
predominantly during the age of two to four lungs extend about 2 cm (3⁄4 to 1inch) above
weeks and resolves by age six months. Apnea is the inner aspect of the clavicles
frequently seen in preterm infants but can - they then continue downward to the sixth
occur at any age.) Apnea is a pause in breathing. intercostal space at the midclavicular line (MCL)
It can happen quickly, without warning. Apnea
has one or more of these signs: Not breathing
for 20 seconds or longer.
- shape of the chest is more round than oval,
with the ribs in a horizontal position
o after about age 2
- the ribs become more oblique, and the
breathing pattern becomes primarily intercostal
o aging
 ASSESSMENT PROPER
• Inspection / Interview
o Normal
- Awake, alert, oriented to time, place, person
- Immediate, recent, remote memory intact
o Deviations from normal
- Early signs of hypoxia include confusion,
restlessness, irritability, short attention span
- Short-term memory may also be affected by
hypoxia
- Hypoxia is a state in which oxygen is not
• At the side available in sufficient amounts at the tissue
- laterally, the lower border of the lung is at the level to maintain adequate homeostasis; this
eighth rib at the midaxillary line can result from inadequate oxygen delivery to
the tissues either due to low blood supply or
low oxygen content in the blood (hypoxemia)
o NOTE:
▪ While doing an interview, OBSERVE AND INSPECT
PATIENT FOR SIGNS
OF HYPOXIA!
• Inspect Skin And Nails
o Normal
- Peripheral cyanosis may be normal response to
exposure to cold temperatures
- No edema
- Positive capillary refill, nailbeds pink, negative
clubbing
o Deviations from normal
• At the back ▪ Pale diaphoretic
- posteriorly, the apices of the lungs start at T1 - sympathetic response to respiratory distress
and extend to T10 and T12 on deep inspiration and hypoxia
- posterior approach affords the best access to ▪ Central cyanosis
the lungs because there are no underlying - dusky or blue buccal mucosa and tongue
organs or structures to get in the way - Po2 is less than 50
- right lung may be slightly higher because of the - respiratory failure
liver - Shock
- pulmonary edema
- airway obstruction
- ventilation-perfusion problems in vessels of
palpebral conjunctiva in end-stage COPD
▪ Peripheral cyanosis
• Blue dusky-red, purple color
- Lips
- nail beds
- tips of nose and ears
- sometimes face and cheeks
• slow or congested blood flow in peripheral vessels
or disorders with compensatory polycythemia
 - COPD, CHF(Chronic obstructive pulmonary - frequently seen in people with chronic lung
disease (COPD) and congestive heart failure disease secondary to right-side CHF
(CHF) can leave you feeling short of breath.
These two serious conditions share many
symptoms and common risk factors. But the
causes and treatments of each are very
different.)
▪ Ruddy, reddish color
- associated with polycythemia
- Polycythemia, also called erythrocytosis, refers to
increased red blood cell mass, noted on laboratory
evaluation as increased hemoglobin and hematocrit
levels.
▪ Cyanotic or dusky nails
- vasoconstriction and slowing of peripheral
blood flow also associated with central cyanosis

▪ Clubbing
- long-standing lung disease
- Clubbing is a physical sign characterized by ▪ Yellow-brown stains on nails and fingers
bulbous enlargement of the ends of one or - nicotine stains from long history of smoking
more fingers or toes

▪ Purple / dusky lower extremities

• venous stasis, especially if PO2(partial pressure of
▪ Peripheral edema
oxygen) is low
- The condition called edema arises when part of
- Leg discoloration or hyperpigmentation, when
the body becomes swollen because fluid
caused by venous disease, is also called venous
gathers in the tissue. It most commonly affects
stasis dermatitis. Leg discoloration is the
the arms and legs. That is called peripheral
appearance of dark purple and red blotches on
edema. Common early signs of peripheral
the lower legs. The skin may also appear shiny,
edema include the following: An arm or leg
irritated, and look like it has a rash.
starts feeling full or heavy.
 chest wall. This buildup of air puts pressure on
the lung, so it cannot expand as much as it
normally does when you take a breath. The
medical name of this condition is
pneumothorax.
- Tumors
- Pneumothorax- A collapsed lung occurs when
air escapes from the lung.

- Hemothorax- a collection of blood in the space

Inspect / Palpate Head & Neck
between the visceral and parietal pleura
o Normal
(pleural space). The clinical findings in such
- Trachea should arise out of sternal notch and
patients include respiratory distress and
should be midline
tachypnea.
- No
• pursed-lip breathing-Pursed lip breathing is a
technique that helps people living with asthma
or COPD when they experience shortness of
breath.
• nasal flaring-Nasal flaring occurs when the
nostrils widen while breathing. It is often a sign
of trouble breathing. Nasal flaring may be an
indication of breathing difficulty, or even
respiratory distress in infants. Check for airway ▪ Pursed-lip breathing
obstructions, and call a health care provider.
• neck vein distension-Jugular vein distention is
the bulging of the major veins in your neck. It's
a key symptom of heart failure and other heart
and circulatory problems. It's not a painful
symptom, but it can happen with conditions
that can be life-threatening.
• use of accessory muscles
- Visible neck vein in older people or those with
overdeveloped neck muscles
- No hypertrophy of neck muscles unless
occupationally related (e.g., weightlifters, • “physiological positive end expiratory pressure”
singers, professional speakers) • a compensatory mechanism
- No visible / palpable lymph nodes • used by people with COPD
o Deviations from normal - to prolong expiration
▪ Tracheal shifts (Tracheal Shift. Trachea is index of - help expel trapped air
upper mediastinal position. The pleural pressures on - keep alveoli open longer for maximum
either side determine the position of the mediastinum.) oxygenation of pulmonary blood
- collapsed lung- A collapsed lung occurs when • Nasal flaring occurs in infant and small children and
air escapes from the lung. The air then fills the indicates acute respiratory distress or cyanotic heart
space outside of the lung between the lung and disease
▪ Neck vein distention

RESPIRATION PATTERNS
• general sign of respiratory distress or air hunger • Normal / Eupnea
• elevating head and chest at 45 degrees when client - normal breathing pattern
sits - 16–20 breaths/min and regular
• neck vessels are firm and tortuous
• increased venous pressure is seen in right heart failure
and cor pulmonale • Tachypnea
• people with chronic lung disease may also develop
hypertrophied neck muscles from increased efforts to
breathe - may be a normal response to fever, anxiety, or
• Use of scalene, sternocleidomastoideus (SCM), and exercise
trapezius accessory muscles - can occur with respiratory insufficiency,
• sign of respiratory distress or COPD alkalosis, pneumonia, or pleurisy
- more than 24 breaths / min and shallow
• Auscultate / Palpate Cardiovascular • Bradypnea
o Normal - may be normal in well – conditioned athletes
- Heart, regular rate and rhythm (HRRR) - can occur with medication – induced
- no extra sounds depression of the respiratory center, diabetic
o Deviations from normal coma, neurologic damage
- Right – sided S3 and S4- The third and fourth - less than 10 breaths / min and regular
heart sound (S3 and S4) are two abnormal heart
sound components which are proved to be
indicators of heart failure during diastolic
• Hyperventilation
period.
- usually occurs with extreme exercise, fear, or
- Absent / diminished pedal pulses and ankle
anxiety
- Pedal edema- Pedal edema causes an
- causes of hyperventilation include
abnormal accumulation of fluid in the ankles,
- disorders of the central
feet, and lower legs causing swelling of the feet
o nervous system
and ankles. Two mechanisms can cause edema
o overdose of the drug salicylate
of the feet. Venous edema occurs due to
o or severe anxiety
increased capillary leakage that causes fluid to
o increased rate
leak into the interstitial space from the venous
o increased depth
system.

• Kussmaul
- a type of hyperventilation associated with
diabetic ketoacidosis
- rapid, deep, labored
 • ASSESS CHEST SHAPE
- may impede breathing because of the
anatomical discrepancy
• Hypoventilation o Barrel Chest
- Usually associated with overdose of narcotics - Most often associated with emphysema,
or anesthetics asthma
- Decreased rate, decreased depth, irregular
pattern

• Cheyne-Stokes Respiration
- May result from severe congestive heart
failure, drug overdose, increased Intracranial
pressure, or renal failure
- May be noted in elderly persons during sleep,
not related to any disease process
- Regular pattern characterized by alternating
periods of deep, rapid breathing followed by
periods of apnea or severe anxiety
- increased rate o Pectus Excavatum
- increased depth - Congenital chest wall deformity – ribs and
sternum grows abnormally producing cave-in
(concave) shape

• Biot’s Respiration
- May be seen with meningitis or severe brain
damage
- Irregular pattern characterized by varying
depth and rate of respirations followed by
periods of apnea

o Pectus Carinatum
- Deformed human chest – projecting
• Ataxic
breastbone
- A more extreme expression of Biot’s
- Defect in the connective tissue
respirations indicating respiratory compromise
- Significant disorganization with irregular and
varying depths of respiration

• Air Trapping
- In chronic obstructive pulmonary disease, air is
trapped in the lungs during forced expiration
- Increasing difficulty in getting breath out

• PALPATION OF THE CHEST

- Tracheal Position
 • Palpation may be performed with one
▪ Place your thumb and index finger on either side of
or both hands
the trachea, and note position and distance between
• Start toward the midline at the level of
trachea and sternocleidomastoid muscle
the left scapula (over the apex of the
▪ Normal
lung)
- midline
• Move your hand left to right, comparing
▪ Deviation from normal
findings bilaterally
- Tumor or thyroid enlargement may cause
• Move systematically downward and out
tracheal deviation
to cover the lateral portions of the
- Tension pneumothorax deviates trachea away
lungs at the bases
from affected lung
▪ Normal
o COLLAPSED LUNG- A collapsed lung occurs when air
- nontender
escapes from the lung. The air then fills the space
- no deformities
outside of the lung between the lung and chest wall.
- no crepitus
This buildup of air puts pressure on the lung, so it
▪ Deviations from normal
cannot expand as much as it normally does when you
-muscle soreness from exercise or the excessive work
take a breath. The medical name of this condition is
of breathing may be palpated as tenderness
pneumothorax.
-Pain/tenderness at costochondral junctions/vertebral
• In severe atelectasis, trachea may deviate toward
connections of ribs
affected lung (uneven pressure)
• may indicate fracture
-inflamed cartilage at the rib / sternal junctions
o Chest Tenderness & Crepitus
• may indicate costochondritis
- spontaneous pathological fractures:
• corticosteroid- corticosteroids are a type of
anti-inflammatory drug.
• therapy
• osteomalacia- softening of the bones. It most
often occurs because of a problem with vitamin
D, which helps your body absorb calcium.
▪ Use light palpation to assess for tenderness and
- Crepitus (subcutaneous emphysema)
crepitus
• results from air
▪ Abnormal popping or crackling sound
• leaking into
▪ Crunching sensation may be sometimes painful
• subcutaneous tissue
▪ Pathway of palpation

TACTILE FREMITUS
 breathlessness, chest tightness, and coughing at
night or early in the morning.
• pleural effusion- is a buildup of fluid between
the layers of tissue that line the lungs and chest
cavity.
• Pneumothorax- A collapsed lung occurs when
air escapes from the lung. The air then fills the
space outside of the lung between the lung and
- Place the balls of your hands with your fingers chest wall. This buildup of air puts pressure on
hyperextended or the ulnar surface of your the lung, so it cannot expand as much as it
hand on the patient’s chest normally does when you take a breath. The
- As you move your hand to each area, instruct medical name of this condition is
the client to say “99” pneumothorax.
- Assess all areas for symmetry and intensity of
• distal to airway obstruction
vibrations
- Note level where fremitus is palpable,
PERCUSSION OF THE CHEST
increased, diminished or absent
➢ Sequence for Percussing
o Normal
▪ Anterior Thorax
- symmetric easily identified in the upper regions
of the lungs
o Deviations from normal
- Increased fremitus occurs with conditions
causing fluid or exudates in lungs
• consolidating pneumonia- (pneumonia) describes the
presence of exudate in the airways and alveoli, usually
as a result of infection.
• atelectasis-is a complete or partial collapse of the
entire lung or area (lobe) of the lung.
• pulmonary fibrosis- a lung disease that occurs when ▪ Posterior Thorax
lung tissue becomes damaged and scarred. This
thickened, stiff tissue makes it more difficult for your
lungs to work properly. As pulmonary fibrosis worsens,
you become progressively more short of breath.
• pulmonary edema, or pulmonary infarction
• May also occur with lung tumor, although tumor may
stop vibrations, depending on its size and mobility
- Decreased or absent fremitus occurs where
there is: air trapping, solid tissue, decreased air
movement
• Emphysema- develops over time and involves ▪ Lateral
the gradual damage of lung tissue, specifically
the destruction of the alveoli (tiny air sacs).
Gradually, this damage causes the air sacs to
rupture and create one big air pocket instead of
many small ones.
• Asthma- Asthma is a disease that affects your
lungs. It is one of the most common long-term
diseases of children, but adults can have
asthma, too. Asthma causes wheezing,
• AUSCULTATION OF THE CHEST - sound of the voice may be heard but the actual
phrase cannot be distinguished
• abnormal findings
- words are easily understood and louder over
areas of increased density
- may indicate consolidation from pneumonia,
atelectasis or tumor
▪ EGOPHONY
- ask the client to repeat the letter “E” while you
listen over the chest wall
• normal findings
- voice transmission will be soft and muffled but
the letter “E” should be distinguishable
• abnormal findings
- over areas of consolidation or compression, the
sound is louder and sounds like “A”
▪ WHISPERED PECTORILOQUY
- ask the client to whisper the word “one-two-
three” while you auscultate the chest wall
o You’ll hear this if you auscultate..
• normal findings
- transmission of sound is very faint and muffled
- may be inaudible
• abnormal findings
- in such areas, it sounds as if clients is whispering
directly into the stethoscope

▪ BRONCHIAL (B)
- exhales – just above the clavicles on each side
of the sternum
▪ BRONCHOVESICULAR (BV)
- inhales and exhales – continous – next to the
sternum between the scapula
▪ VESICULAR (V)
- prolonged during inhalation shortened during
exhalation –remainder of the lungs
▪ TRACHEAL
- inhales or exhales above supraclavicular notch

o Vocal Fremitus
- auscultate vocal sounds
▪ BRONCHOPHONY
➢ ask the client to repeat the phrase “99” or Blue
Moon while auscultating the chest wall
• normal findings
- voice transmission is soft, muffled, and
indistinct
Normal Breath Sounds

Adventitious Breath Sounds

 • PLEURAL EFFUSION
COMMON ABNORMALITIES AND DISEASES - Chest pain
Common Signs and Symptoms : COUGH - Non productive cough
• ATELECTASIS - Decreased Chest motion
- Nonproductive cough - Dyspnea
- Pleuritic chest pain- sharp chest pain when - Tachypnea
breathing deeply. - Tachycardia
- Dyspnea- Difficult, painful breathing or - Flatness on percussion
shortness of breath. - Egophony
- Tachypnea- rapid breathing Common Signs and Symptoms : DYSPNEA
- Anxiety • ARDS
- Decreased Vocal Fremitus- suggests air or fluid - Crackles and ronchi in both lungs
in the pleural spaces or a decrease in lung tissue - Acute Dyspnea
density, which can be caused by diseases such - Tachycardia
as chronic obstructive pulmonary disease or - Tachypnea
asthma. - Anxiety
- Tracheal Deviation- happens when your trachea - Restlessness
is pushed to one side of your neck by abnormal • EMPHYSEMA
pressure in your chest cavity or neck. - Progressive exertional dyspnea
• LUNG CANCER - A history of smoking
- Productive cough with blood, streaked sputum - Barrel Chest
or frothy sputum - Accessory muscle
- Dyspnea - hypertrophy
- Anorexia- is an eating disorder characterized by • PULMONARY EMBOLISM
an abnormally low body weight, an intense fear - Pleuritic chest pain
of gaining weight and a distorted perception of - Tachycardia
weight. - Acute Dyspnea
- Fatigue - Decreased Breath sounds
- Weight Loss - Dullness on percussion
- Wheezing- breathing with a whistling or rattling - Cool, Clammy Skin
sound in the chest.
- Clubbing- bulbous enlargement of the ends of Common Signs and Symptoms : HEMOPTYSIS
one or more fingers or toes • PNEUMONIA
 - Sputum ranging in color from pink to dark - Intercostal retractions
brown - Ronchi- a rattling or whistling respiratory sound
- Productive cough resembling snoring, caused by secretions in the
- Dyspnea trachea or bronchi.
- Chest pain - Nasal Flaring
- Crackles on auscultation - Tachypnea- Rapid breathing.
- Chills • CHRONIC BRONCHITIS
- Fever - Wheezing
• PULMONARY EDEMA - Coarse crackles- louder, more low pitched and
- Frothy Bloody tinged sputum longer lasting. They indicate excessive fluid on
- Severe Dyspnea the lungs which could be caused by aspiration,
- Orthopnea pulmonary oedema from chronic heart disease,
- Gasping chronic bronchitis, pneumonia.
- Diffused crackles - Hacking cough- Dry cough: Also known as a
- Cold Clammy skin hacking cough, this cough has a consistent tone
- Anxiety because it is free from the sound of mucus. It is
• PTB caused by irritation and inflammation of the
- Blood Streaked,Blood tinged sputum airway
- Chronic productive cough - Dyspnea
- Fine crackles after coughing - Barrel Chest
- Dyspnea - Clubbing
- Dullness to percussion- reduced air in the chest - Edema- swelling caused by too much fluid
due to fluid or soft tissue. trapped in the body's tissues.
- Increased tactile fremitus- generally occurs as a
result of increased density within the lung
tissue. This commonly occurs as a result of lung
consolidation, which refers to the replacement
of the air within healthy lung tissue with
another substance; either inflammatory
exudate, blood, pus, or cells.
Common Signs and Symptoms : WHEEZING
• ASPIRATION OF FOREIGN BODY
- Sudden onset of wheezing
- Stridor- an abnormal, high-pitched, musical
breathing sound. It is caused by a blockage in
the throat or voice box (larynx). It is most often
heard when taking in a breath.
- Dry cough
- Gagging- choking or retching
- Hoarseness
- Decreased breath sounds
- Dyspnea
- Cyanosis- bluish discoloration of the skin
resulting from poor circulation or inadequate
oxygenation of the blood.
• ASTHMA
- Audible wheezing on expiration
- Prolonged expiration
- Apprehension