Chest and Respiratory Assessment Jane Hansen APN

Anatomy Know the names of the major landmarks: suprasternal notch, sternal angle (Angle of Louis), xyphoid process, manubrium, etc

Anatomy Note locations of lobes Where do you listen to the right middle lobe? Pleurae Visceral pleurae cover the surfaces of the two lungs Parietal pleura cover the surfaces of the inner rib cage and upper surface of the diaphragm

Use broad questions Do you have any discomfort or unpleasant feelings in your chest? Use PQRST in doing pain assessment Chest pain can arise from a range of conditions – respiratory, cardiac, GI, Musc/skel, skin, anxiety Lung tissue has no pain fibers “lung” pain usually arise in the parietal pleura Other surrounding structures can irritate the parietal pleura Assess dyspnea based on activity levels Also ask about wheezing and cough (dry, productive, characteristics of sputum) Use OLDCARTS History

Assess for all types of tobacco/nicotine use If cigarette smoker, get an estimate of pack years Always advise cessation & offer help Remember the Five “A’s” Ask about smoking at each visit Advise patients regularly to stop smoking using a clear, personalized message Assess patient readiness to quit Assist patients to set stop dates and provide educational materials for self-help Arrange for follow-up visits to monitor and support patient progress Tobacco Cessation

Inspect, palpate, percuss, auscultate Practice percussion in lab – key skill in low resource setting Vocab: flat, dull, resonant, hyperresonant, tympanic Technique: press the DIP into an intercostal space and percuss with tip of finger in other hand Be able to estimate diaphragmatic excursion – s/b 5-6 cm What do you expect to hear at the left sternal border between the 3rd and 5th rib? Chest & Lung Exams

Know technique “Deep breaths through an open mouth” Be able to recognize normal breath sounds Vesicular, bronchial, bronchial-vesicular Be able to recognize abnormal breath sounds crackles (rales), wheezes, rhonchi, pleural rubs and note location For crackles – have pt cough and listen after coughing May need to perform whispered pectoriloquy Auscultation

Observe directly Look for quantity, color, turbidity, viscosity, presence of blood, froth, odor Blood streaked sputum often from upper airway Nose, nasopharynx, gums, larynx, bronchi Pink sputum – blood mixes with respiratory secretions in alveoli. Pneumonia & pulmonary edema. Massive bleeding – erosion of bronchial artery – many causes, all dire. Bloody gelatinous sputum (“currant jelly”) – pneumonia (two specific types) Assess Sputum

Rusty sputum – degraded blood pigment – usually pneumococcal pneumonia Frothy sputum – pulmonary edema due to injury or CHF Purulent sputum – lower airway infection. Yello, green, dirty gray, scant or copious. Stringy mucoid – formation of plugs occurs in asthma Broncholiths – calcified particles in sputum More on Sputum

Pain – take a careful history Be alert for non-cardiac causes Be alert for cardiac causes in non-typical populations e.g. young women Deep retro-sternal or pre-cordial pain can arise from any area served by nerve fibers entering the spinal column along T1-T6 All thoracic viscera, thoracic walls, diaphragm, gallbladder, pancreas, duodenum, stomach Pain will be deep, visceral and poorly localized This pain can have a wide range of causes Abnormals

Pain on inspiration – “intercostal neuralgia” Deep stabbing pain along nerve route Worsened by deep breath, chest movement, cold Palpate along nerve course from spinal outlet to sternal margin. Palpate in axilla. Tenderness along the nerve is diagnostic. Causes include Herpes zoster, DM, neoplasm, neurofibroma, TB, obesity with nerve stretching Respiratory Pain

Hard to sort out all the different ‘chest pain’ types Always rule out chest wall or skin etiology of pain by careful inspection and palpation Costochondritis – dull, worsened by respiration and shoulder movement. Pain which can be produced by physical movements of arms, extension of neck is diagnostic Rib fractures – compress chest wall; produce pain in untouched area Chest Wall Pain

Careful history At rest? Exertion? Sleeping position (orthopnea)? OLDCARTS Look for tachypnea, use of accessory muscles, sternal retractions, forward lean position, nasal flares Assess O2 saturation Emergent conditions: blocked airway, trauma, anaphylaxis, CO poisoning, other signs of cyanosis Dyspnea

Acute vs chronic; productive vs dry Variants: brassy (strident, from narrowed airway) Check out sounds: http://children.webmd.com/pertussis-whooping-cough-10/coughing-sounds Whoop – long strident inspiratory noise (pertussis) http://www.whoopingcough.net/cough-child-muchwhooping.wav Many causes COPD, asthma, infection, abscess, smoking, allergies, ACE inhibitors, aspiration, neoplasm, GERD, CHR, vasculitis, aortic aneurysm, PE, and more Chronic Look for post-nasal drip, GERD, chronic bronchitis or cough-variant asthma Cough

Hiccups –variety of causes. Note duration and if sleep is disturbed. Hemoptysis Snoring Stridor – high pitched whistling through partially closed glottis. Look for foreign body. May signal impending airway closure. http://upload.wikimedia.org/wikipedia/commons/b/ba/Stridor_NP_OGG_2.ogg Other findings

Pectus excavatum, carinatum Barrel chest – COPD Flail chest – paradoxical chest wall movements Usually due to fractures of contiguous ribs Soft tissue crepitus – air in thoracic wall, subcutaneous tissues – usually trauma Fluctuant masses – usually abscesses Rib masses – old fractures, neoplasm, granulomas, neurofibroma. Need imaging to dx. Chest Abnormalities

Abnormal Sounds on Percussion

Whispered Pectoriloquy Consolidated lung transmits whispered syllables distinctly – even when other breath sounds are normal Detects early pneumonia, infarction, pulmonary atelectasis Bronchophony Spoken syllables are normally heard indistinctly. If distinct, then think consolidation. Egophony A form of bronchophony. Spoken ‘Eee’ comes out a nasal sounding ‘Ay’. Look for underlying lung compression, below a pleural effusion, or consolidation. Auscultation of Breath Sounds

Crackles – sounds of aveoli opening in presence of fluid. Think interstitial fluid. Rhonchi – gurgles – liquid in larger airways. Often clears after effective cough. Think inflammatory states, drowning, agonal states. Cavernous breathing – low pitched, hollow. Think large empty superficial cavity or open pneumothorax Rubs – pleura rub against each other. “creaking of new leather” Abnormal Breath Sounds

Pleural effusion Fluid in the pleural space Pleural thickening – pleural membranes thicken Atelectasis – alveoli collapse Conditions

Consolidation –alveoli fill with fluid or pus Pulmonary emphysema – loss of alveolar walls Thick-walled cavity – abscess within the lung parenchyma Pneumothorax – open or closed and/or tension – air in pleural space more

Peak Flow Meters Simple test for use in asthma - “fast blast” of air out Variety of types Correct use & interpretation important See Required Reading on how to use it See Required Reading on chart of normal adult values See this link for a calculator: http://www.asthma.partners.org/Applets/PeakFLowPredicted.html Tests

As asthma mgmt tool, divide the person’s expected volume into Green, Yellow, Red zones Green – 80-100% of expected (good control) Yellow – 50-79% of expected (need intervention) Red - <50% of expected (emergency!) Create maintenance/intervention plan for each zone Peak Flow Meter - Interpretation

Office procedure Need age, race, sex Need pt able to cooperate (min. age ~ 6 years) Need good coaching to get best effort Watch video See link in Content – Req Read. http://www.youtube.com/watch?v=dMkQsxn5Hgk&feature=related Spirometry

Anyone with dyspnea Pts age 45 & older who are current or former smokers Pts with prolonged or progressive cough or sputum production Pts with hx of exposure to lung irritants Prior to starting certain meds that can affect lung function Assess pre-op risk Indications for Spirometry

Forced Vital Capacity – FVC – full amount of air that can be blown out Forced expiratory volume at 1 second – FEV 1 – amount of air blown out in 1 second Forced Expiratory Flow - FEF 25-75% - the rate of flow over the middle 50% of the expiration period Key Results from Spirometry

Key Value #1 is FEV1 as percent of predicted FVC <70% is indicative of obstructive airway disease May need albuterol challenge to distinguish asthma (reactive) disease from COPD (non-reactive airway disease) Key Value #2 is actual FVC vs predicted FVC Diminished actual FVC indicates restrictive lung disease (e.g. fibrosis). Ratio of FEV1/FVC may be normal Key Results from Spirometry

Assess inspiration and expiration More elaborate equipment Interpretation more complex See diagrams like this: Full Pulmonary Function Tests

Questions?