Assessment of Respiratory System PDF

# Assessment of respiratory system ## Anatomic and physiologic overview * The respiratory system is composed of the upper and lower respiratory tracts. * The two tracts are responsible for ventilation (movement of air in and out of the airway). * The upper tract, known as the upper airway, warms...

# Assessment of respiratory system ## Anatomic and physiologic overview * The respiratory system is composed of the upper and lower respiratory tracts. * The two tracts are responsible for ventilation (movement of air in and out of the airway). * The upper tract, known as the upper airway, warms and filters inspired air so that the lower respiratory tract (the lungs) can accomplish gas exchange. * Gas exchange involves delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as carbon dioxide, during expiration. ### Upper airways - The upper airways include the nasopharynx (nose), oropharynx (mouth), laryngopharynx, and larynx. - These structures warm, filter, and humidify inhaled air. ### Lower airways - The lower airways begin with the trachea, or windpipe, which extends from the cricoid cartilage to the carina. - The trachea then divides into the right and left mainstem bronchi, which continue to divide all the way down to the alveoli, the gas-exchange units of the lungs. ## Oxygen transport: * Oxygen is supplied to and Carbon Dioxide is removed from cells by way of the circulating blood. * Cells are in close contact with capillaries, whose thin walls permit easy passage or exchange of Oxygen and Carbon Dioxide. * Oxygen diffuses from the capillary, through the capillary wall to the interstitial fluid, and then through the membrane of tissue cells, where it can be used by the mitochondria for cellular respiration. * The movement of Carbon Dioxide also occurs by diffusion and proceeds in the opposite direction, from cell to blood. ## Gas exchange: * After these tissue capillary exchange, blood enters the systemic veins (where it called venous blood) and travels to the pulmonary circulation. * The Oxygen concentration in the blood within the capillaries of the lungs is lower than it is in the lung's air sacs, which are called alveoli. * As a result of this concentration gradient, oxygen diffuses from the alveoli to the blood. * Carbon Dioxide, which has a concentration in the blood higher than that in the alveoli, diffuses from the blood into the alveoli. * Movement of air in and out of the airways (called Ventilation) continually replenishes the Oxygen and removes the Carbon Dioxide from the airways in the lung. * This whole process of gas exchange between the atmospheric air and the blood and between the blood and the cells of the body is called Respiration. ## Characteristics of Normal Breathing * **Normal rate and depth**: 12 - 24 * **Regular inhalation and exhalation pattern** * **Audible on each side of chest** * **Equal rise and fall of each side** ## Sign of abnormal breathing * **Rate slower than 8 per minute or faster than 24 per minute** * **Pale or cyanotic skin** * **Shallow or irregular** * **Pursed lips** ## Poeus assessment * You should ask the patient some information and focus on what you are asking in order to direct them to the right place to get treated. ## Assessment of the respiratory system: ### 1-Chief reason for seeking health care: * **Dyspnea:** difficoltà respiratoria * **Pain:** (quality, intensity, onset) * **Wheezing:** (is a high-pitched musical sound heard mainly on expiration) * **Hemoptysis:** (is the expectoration of blood from the respiratory tract) bleeding **The questions that should be asked** * When the symptoms are started? * How long it is lasted? ### 2- History: * **Allergies** * **Smoking history** * **Nature of any cough** (dry, productive) * **Sputum production** * **Dyspnea** * **Respiratory treatments or medications** * **Last pulmonary tests e.g. chest radiograph.** * **Occupation** * **Exercise tolerance.** ### 3- Examination of the Chest and Lungs #### Inspection * **Observe the rate, rhythm, depth, and effort of breathing**. Rate in adult is 14–24 c\m, may arrive to 40 c/m in the infant. * **Note whether the expiratory phase is prolonged.** * **Observe the chest for asymmetry, deformity. Note masses or scars that indicate trauma or surgery.** #### Palpation * **Identify any areas of pain, tenderness or deformity by palpating the ribs and sternum.** * **Assess expansion and symmetry of the chest** by placing hands on the patient's back, thumbs together at the midline, and ask them to breathe deeply. #### Percussion * **Posterior Chest** * **Percuss from side to side and top to bottom.** Omit the areas covered by the scapulae. * **Compare one side to the other looking for asymmetry.** * **Note the location and quality of the percussion sounds you hear.** * **Find the level of the diaphragmatic dullness on both sides.** * **Anterior Chest** * **Percuss from side to side and top to bottom using the pattern shown in the illustration.** * **Compare one side to the other looking for asymmetry.** * **Note the location and quality of the percussion sounds you hear.** **The examiner uses percussion to:** * **Determine whether or not the underlying tissues are filled with air, fluid, or solid material.** * **Estimate the size and location of certain structures within the thorax** (e.g. heart, liver, diaphragm). | Sound | Description | Clinical significance | |--------------|------------------------------------------------------------------------------------|-----------------------------------------------------------------------------------------| | **Flat** | Short, soft, high-pitched, extremely dull, as found over the thigh | Consolidation, as in atelectasis and extensive pleural effusion | | **Dull** | Medium in intensity and pitch, moderate length, thudlike, as found over the liver | Solid area, as in lobar pneumonia | | **Resonant** | Long, loud, low-pitched, hollow | Normal lung tissue; bronchitis | | **Hyperresonant** | Very loud, lower-pitched, as found over the stomach | Hyperinflated lung, as in emphysema or air pneumothorax | | **Tympanic** | Loud, high-pitched, moderate length, musical, drumlike, as found over a puffed-out cheek | Air collection, as in a large pneumothorax | **Auscultation: Auscultation is useful in assessing:** * The flow of air through the bronchial tree * The presence of fluid or solid obstruction in the lung structure #### Auscultation * Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration. * The best position to listen to lung sounds is with the patient sitting upright; however, if the patient is acutely ill or unable to sit upright, turn them side to side in a lying position. * Avoid listening over bones, such as the scapulae or clavicles or over the female breasts to ensure hearing adequate sound transmission. * Listen to sounds from side to side rather than down one side and then down the other side. This side-to-side pattern allows you to compare sounds in symmetrical lung fields. | Breath sound | Quality | Inspiration-expiration (I:E) ratio | Location | |-----------------|-------------|-----------------------------------|-----------------------------------------------------------------------------| | **Tracheal** | Harsh, high-pitched | I=E | Above supraclavicular notch, over the trachea | | **Bronchial** | Loud, high-pitched | I<E | Just above clavicles on each side of the sternum, over the manubrium | | **Bronchovesicular** | Medium In loudness and pitch | 1=E | Next to sternum, between scapulae | | **Vesicular** | Soft, low-pitched | 1>E | Remainder of lungs | ### Abnormal respiratory sounds: * **Crackles:** Also called rales, crackles tend to sound like discontinuous clicking, rattling, or bubbling when the person inhales. Crackling breath sounds may sound wet or dry, and doctors might describe them as either fine or coarse. It commonly happens as a result of fluid accumulation in the lungs. Conditions such as pneumonia or left-sided heart failure may cause this buildup. * **Wheezing:** Wheezing noises are high-pitched and continuous and may sound like a breathy whistle. Sometimes, wheezing can be loud enough to hear without a stethoscope. A squawk is a short version of a wheeze that occurs during inhalation. It is a common symptom of conditions that narrow the small airways in the lungs, such as asthma and COPD. * **Rhonchi:** Rhonchi are continuous, lower-pitched, rough sounds that many people compare to snoring. It occurs due to conditions that block airflow through the large airways, including the bronchi. There may also be inflammation and fluid in these airways. Conditions such as acute bronchitis and COPD may cause rhonchi. * **Stridor:** Stridor is a harsh, high-pitched, wheeze-like sound. It occurs in people who have a blocked upper airway, usually when they are breathing in. It occurs in people with an upper airway blockage. A blockage may occur if a person breathes in a foreign object, chemical, or other harmful substance. A traumatic neck or chest injury involving the upper airway could result in a blockage too. Stridor can also be a symptom of inflammatory conditions, such as tonsillitis, epiglottitis, or croup (laryngotracheitis). ### Abnormalities in chest wall: * **Barrel chest:** Increased anteroposterior diameter * **Funnel chest (pectus excavatum):** Depressed lower sternum * **Pigeon chest:** Anteriorty displaced sternum * **Thoracic kyphoscollosis:** Raised shoulder and scapula, thorax convexity, and flared interspaces **Barrel chest:** is usually caused by lung conditions. When the lungs overfill with air, they push out the ribs, chest, and bones in the upper back. Over time, barrel chest develops. The medical conditions that cause barrel chest as Asthma, COPD, emphysema, cystic lung fibrosis. **In Funnel chest (congenital):** the depression of the sternum causes cardiac compression and lung capacity restriction. When severe, patients may experience shortness of breath, chest. **Pigeon chest:** may be associated with disorders including heart disease, scoliosis, kyphosis and musculoskeletal defects. ## Abnormal respiratory patterns * **Tachypnea:** Increased respiratory rate * **Bradypnea:** Decreased rate but regular breathing * **Apnea:** Absence of breathing; may be periodic * **Hyperpnea:** Increased depth of breathing ## Diagnostic Tests: * **Arterial blood gases:** It is an arterial blood sample to assess the degree to which the lungs are able to provide adequate oxygen and remove carbon dioxide. * **Pulse oximetry:** Is a non-invasive method of continuously monitoring the oxygen saturation of hemoglobin * **Sputum studies:** Sputum is obtained for study to identify pathological organisms * **Radiographic examination of the chest:** Radiographic examination of the chest includes chest X-ray studies, computed tomography, and angiographic studies of pulmonary vessels. * **Thoracentesis:** Thoracentesis is the aspiration of pleural fluid from the pleural cavity for diagnostic or therapeutic purposes by means of needle biopsy * **Lung and lymph node biopsy:** It is an excision of tissue from a lung, or lymph nodes for microscopic examination. * **Thorascopy:** Thorascopy is a diagnostic procedure in which the pleural cavity is examined with endoscope * **Endoscopic procedures:** Bronchoscopy is the direct inspection and examination of the larynx, trachea, and bronchi through either a flexible fiber-optic bronchoscope or a rigid bronchoscope * **Pulmonary function test:** Pulmonary function tests are performed to assess respiratory function and to detect and determine the extent of the abnormality. * **Tidal volume (TV):** Volume of air inhaled and exhaled with each breath * **Expiratory reserve volume (ERV):** Additional air that can be forcefully exhaled after normal exhalation is complete * **Inspiratory reserve volume (IRV):** Maximum volume of air that can be inhaled forcefully after normal inhalation. * **Residual volume (RV):** Amount of air remaining in the lungs after forced expiration * **Total lung capacity (TLC):** Maximum volume of air that lungs can contain * **Vital capacity (VC):** Maximum volume of air that can be exhaled after maximum inspiration