ASSESSMENT OF THE

THORAX AND LUNGS

ERWIN U. IMPERIO, RN
REVIEW OF ANATOMY AND
PHYSIOLOGY
ANATOMY OF THE CHEST
ANATOMY OF THE CHEST
ANATOMY OF THE CHEST
 ANATOMY OF THE CHEST
• CHEST BONES
– Sternum
• breastbone
– Manubrium
• Handlelike superior part of
the sternum that joins with
the clavicles
– Xiphoid process
– Clavicle
– 12 Pairs of ribs
– 12 Thoracic vertebrae
– Scapula
– Others
• Manubriosternal junction
(Angle Louis)
• Intercostal space
• Costal margin
• Costal angle
 CHEST LANDMARKS
• Purpose:
– To identify the position of underlying organs
(e.g. lobes of the lungs)
– To record abnormal assessment findings
• Landmarks
– Anterior
– Posterior
– Lateral
 CHEST WALL LANDMARKS
• ANTERIOR
– Midsternal line
• Vertical line running
through the center of
the sternum
– Midclavicular lines
(right and left)
• Vertical lines from the
midpoints of the clavicle
– Anterior axillary lines
(right and left)
• Vertical lines from the
anterior axillary folds
 CHEST WALL LANDMARKS
• LATERAL
– Anterior axillary line
• Vertical line from the
anterior axillary folds
– Posterior axillary line
• Vertical line from
the posterior axillary
fold
– Midaxillary line
• Vertical line from
the apex of the
axilla
 CHEST WALL LANDMARKS
• POSTERIOR
– Vertebral line
• Centered / a line along
the spinous processes
from C7 to T12
– Posterior axillary lines
(right and left)
• Vertical from the
posterior axillary fold
– Scapular lines (right
and left)
• Vertical lines from
inferior angles of the
scapulae
 ANATOMY OF THE LUNGS
• Lungs
– Right has 3 lobes
– Left has 2 lobes
– Oblique fissure divides
upper & lower lobes
• Trachea
– Anterior to esophagus
– Branches into right & left
bronchi
• Right wider, shorter, more
vertical (aspiration)
– Bronchioles
– Alveoli
 CHEST LANDMARKS
• ANTERIOR LANDMARKS
• Angle of Louis
– Starting point for locating the ribs
anteriorly
– Junction between body of sternum
and manubrium
• Superior border of the second rib
attaches to the sternum at this and
angle of louis
• Count distal ribs and intercostal
spaces (ICSs) from the second rib
• ICSs is numbered according to the
number of the rib immediately
above the space
• Only 1st – 7th ribs attaches directly
to the sternum
 CHEST LANDMARKS
• ANTERIOR
LANDMARKS
• Only 1st – 7th ribs
attaches directly to the
sternum
• 8th – 10th ribs articulate
with costal cartilages
above them
• 11th – 12th ribs “floating
ribs” have no anterior
attachments
 CHEST LANDMARKS
• ANTERIOR CHEST
LANDMARKS AND
UNDERLYING LUNGS
– Minor / horizontal fissure
• Divides the right lung into
right upper lobe and right
middle lobe
• Runs anteriorly from the
right midaxillary line at the
level of the fifth rib to the
level of the fourth rib
 CHEST LANDMARKS
• POSTERIOR
• T3
– Pertinent landmark for
identifying underlying lobes
• Spinous process of C7
– Starting point for locating T3
– A prominent process that can
be observed when the client
flexes the neck anteriorly
• Two spinous process
– Superior (C7)
– Inferior (T1)
 CHEST LANDMARKS
• POSTERIOR
• Each spinous process is
adjacent to the
corresponding rib number
(e.g., T3 is adjacent to third
rib) up to T4 only
• T5 down, spinous process is
adjacent obliquely
– Spinous process of
vertebral lie over the rib
below (e.g. T5 lies over
the body of T6 and is
adjacent to the sixth rib)
 CHEST LANDMARKS
• POSTERIOR CHEST
LANDMARKS AND
UNDERLYING LUNGS
– Oblique fissure
• Divide the lungs (right and
left) into upper and lower
lobe
• Runs from the level of the
spinous process of the third
thoracic verterbra (T3) to
the level of the sixth rib at
the midclavicular line
 CHEST LADMARKS
• LATERAL CHEST LANDMARKS AND
UNDERLYING LUNGS
 RESPIRATION
• Is the act of breathing
• Types
– Costal (thoracic breathing)
– Diaphragmatic (abdominal breathing)
 MECHANICS AND REGULATION
OF BREATHING
• INHALATION
• Diaphragm contracts
(flattens)
• Ribs move upward
and outward
• Sternum moves
outward
• Enlarging the size of
the thorax
 MECHANICS AND REGULATION
OF BREATHING
• EXHALATION
• Diaphragm relaxes
• Ribs move downward
and inward
• Sternum moves
inward
• Decreasing the size
of the thorax
 Respiratory Control Mechanisms
• Respiratory centers
– Medulla oblongata
– Pons
• Chemoreceptors
– Medulla
– Carotid and aortic bodies
• Both respond to O2, CO2, H+ in arterial
blood
 Three Processes Involved in
Respiration
• Ventilation / External respiration
– Movement of gases into and out of the lungs
– Process of taking oxygen into and eliminating CO2 in
the body
– Inspiration/inhalation (Normal: 1-1.5 sec)
– Expiration/exhalation (Normal: 2-3 sec)

Tidal Volume
- Volume of air moving in and out of the lungs
- 500mL
 Three Processes Involved in
Respiration
• Perfusion / Internal Respiration
- Process of use of oxygen; production of CO2
and exchange of these gases between the cells
and the blood
• Diffusion
– Exchange of gases from an area of greater pressure
to an area of lower pressure
– Occurs at the alveoli-capillary membrane
HEALTH HISTORY
 HEALTH HISTORY
• Common or concerning symptoms
– Chest pain
– Dyspnea
– Wheezing
– Cough
– Blood-streaked sputum (hemoptysis)
 CHEST PAIN
• Possibly due to heart disease but often
arise from structures in the thorax as well
• To assess symptom, assess dual
investigation of both thoracic and cardiac
causes
 HEALTH HISTORY
• Initial question should be:
“Do you have any
discomfort or unpleasant
feelings in your chest?”
• Use PQRSTU mnemonic
• Watch for any gestures
as the patient describes • Clenched fist over
the pain. sternum: angina
• Finger pointing to a
tender area on the chest
wall: musculoskeletal pain
• Hand moving from neck
to epigastrum: heartburn
 HEALTH HISTORY
• Lung tissue itself has no pain fibers.
– Pain in lung conditions such as pneumonia or
pulmonary infarctions usually arises from
inflammation of the adjacent pleura.
– Muscle strain from prolonged recurrent
coughing may also be responsible.
• Pericordium also has few pain fibers – the
pain stems from inflammation of adjacent
pleura.
 HEALTH HISTORY
• Sources ABNORMAL FINDINGS
– The myocardium • Angina pectoris / myocardial
infarction

– The pericardium • Pericarditis

– The aorta
– The trachea and large bronchi
– The parietal pleura
– The chest wall, including the
musculoskeletal system and
skin
– The esophagus
– Extrathoracic structures such
as the neck, gallbladder and
stomach
• Dissecting aortic aneurysm
• Bronchitis
• Pericarditis, pneumonia
• Costochondritis, herpes zoster
• Reflux esophagitis, esophageal
spasm
• Biliary colic, gastritis
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 DYSPNEA
– Is a nonpainful but uncomfortable awareness
of breathing that is inappropriate to the level
of exertion.
– Commonly results from cardiac or pulmonary
problems.
– Ask: “Have you had any difficulty breathing?”
– Use PQRSTU mnemonic
– Often experIenced with paresthesias, or
sensations of tingling or “pins and needles”
around the lips or in the extremities
HEALTH HISTORY
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HEALTH HISTORY
 WHEEZES
• Are musical • It suggests partial
respiratory sounds airway obstruction
that may be audible from secretions,
both to the patient tissue inflammation,
and others or a foreign body
 COUGH
– A reflex response to
stimuli that irritates
receptors of the
respiratory system
– May also be • It is an important symptom
cardiovascular in origin of a left-sided heart failure.
– Ask whether the cough
is productive or
nonproductive
– Use PQRST mnemonic
– Ask the patient to cough
into a tissue; inspect the
phlegm and note its
characteristics
 COUGH
• Dry hacking
– Mycoplasmal pneumonia
• Mucoid
– Translucent, white or gray
• Purulent
– Yellowish or greenish
• Foul smelling
– Anaerobic lung abscess
 HEMOPTYSIS
• Coughing up blood from the lungs
• May vary from blood-streaked phlegm to
frank blood
• Ask the volume of blood produced
• May originate from
– mouth, pharynx
– GIT: blood is darker than and may be mixed
with food particles
COUGH AND HEMOPTYSIS
 HEALTH HISTORY
• Past medical history
– Hospitalizations for respiratory condition
– Chronic pulmonary conditions, i.e., asthma,
TB, emphysema, cystic fibrosis
– Other chronic conditions, i.e., heart disease
– Allergies
– Trauma or surgery to thoracic, nose, mouth
– Medications used
– Prematurity
 HEALTH HISTORY
• Family history
– TB
– Cystic fibrosis
– Emphysema
– Allergies, asthma, atopic dermatitis
– Bronchitis
– Clotting disorders (risk of pulmonary emboli)
– Smoking
 HEALTH HISTORY
• Personal and social
– Tobacco use / exposure
– Environmental toxin exposure, i.e., air
pollution, pesticides, smoke, mold, animals
– Exposure to respiratory infections
– Occupation
– Travel
– Exercise tolerance
TECHNIQUES OF
EXAMINATION
 INITIAL SURVEY
1. Assess the following:
– Rate
– Rhythm
– Depth
– Effort of breathing
2. Assess patient’s color for cyanosis
3. Listen to the patient’s breathing
– Wheezes (heard during expiration)
– Stridor (heard during inspiration)
4. Inspect the neck (use of accessory muscle)
 Type Characteristics Pattern Possible causes

Eupnea - Normal rate and rhythm - Normal respiration

Tachypnea - Rapid, shallow -Pneumonia

- Rate rises with body temp., -Comp., respi alkalosis
about 4bpm for every degree F -Lesions of respi centers
above normal -Salicylate poisoning

Bradypnea - Slow, regular respirations of - Normal pattern during

equal depth sleep
-Conditions affecting resp
centers (tumors, metabolic d/o,
resp decompensation, use of
opiates or alcohol)
Apnea - Periodic absence of breathing - Mechanical airway
______________ obstruction
- Damage to medulla oblongata
 Type Characteristics Pattern Possible causes
Cheyne Stokes - Fast, deep - Increased ICP
respirations 30 to - Severe CHF
170 seconds - Renal failure
punctuated by
- Meningitis
periods of apnea
lasting 20 to 60 - Drug overdose
seconds - Cerebral anoxia
Kussmaul - Fast (over 20 - Renal failure
breaths/minute), - Metabolic acidosis,
labored respirations particularly DKA (diabetic
without pause ketoacidosis)

Biot Unpredictable - Respiratory depression

irregularity, may be - Brain damage typically
shallow or deep, at medullary
stop for short
periods
 EFFORT
• DYSPNEA
– Difficult and labored breathing
• ORTHOPNEA
– Can breath only in an upright position
 EFFORT
• INTERCOSTAL
– Indrawing between ribs
• SUBSTERNAL
– Indrawing between breastbone
• SUPRASTERNAL
– Indrawing above the clavicle
 DEPTH
• Hyperventilation
– Deep, rapid breathing
• Sighing respiration
– Breathing punctuated by frequent sighs
– Possible hyerventilation
– Common cause of dyspnea and dizziness

• Hypoventilation
– Shallow respiration
 EXAMINATION OF
POSTERIOR CHEST
 STEP 1
Inspect the shape and symmetry of the
thorax from posterior and lateral views.
Compare the anteroposterior diameter to
the transverse diameter.
 EXAMINATION OF POSTERIOR
CHEST
• NORMAL • ABNORMAL
FINDINGS FINDINGS
– Anteroposterior to – See the next slide for
transverse diameter the deformities of the
in ratio of 1:2 chest
– Chest symmetric – Chest assymetric
 CHEST SHAPE AND SIZE
• Oval:
– Normal shape of the
adult’s chest
• Elliptical
– Over-all shape is
(diameter is smaller at
the top than at the
base)
 CHEST SHAPE AND SIZE
• PIGEON CHEST
– Also known as pectus
carinatum
– Narrow transverse
diameter, sternum is
displaced anteriorly
increasing
anteroposterior
diameter
 CHEST SHAPE AND SIZE
• FUNNEL CHEST
– Also known as pectus
excavatum
– Opposite of the pigeon
chest in that there is a
depression of the lower
portion of the sternum is
depressed, narrowing
anteroposterior diameter
– Compression of the
heart and great vessels
may cause murmurs
 CHEST SHAPE AND SIZE
• BARREL CHEST
– Increased anteroposterior
diameter
– Ratio of the anteroposterior
to transverse diameter is
1:1
– Seen in clients:
• with thoracic kyphosis
(excessive convex
curvature of the thoracic
spine
• emphysema
– Normal during infancy
 STEP 2
Inspect the spinal alignment for deformities. Have
the client stand. From a lateral position, observe
the three normal curvatures:
cervical
thoracic
lumbar
To assess for lateral deviation of spine (scoliosis),
observe the standing client from the rear. Have the
client bend at the waist and observe from behind.
 EXAMINATION OF POSTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS
– Spine is vertically – Exaggerated spinal
aligned. curvatures (kyphosis,
lordosis)
– Spinal column is
straight, right and left – Spinal column deviates to
shoulders and hips are one side.
at the same height.
 EXAMINATION OF POSTERIOR
CHEST
• SCOLIOSIS
– Lateral deviation of the
spine
 STEP 3
• Palpate the posterior thorax.
 EXAMINATION OF POSTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL
FINDINGS
– Skin intact, uniform – Skin lesions; areas of
temperature hyperthermia
– Chest wall intact, no – Lumps, bulges,
tenderness, no depressions; areas of
masses tenderness, movable
structures
 STEP 4
• Palpate the posterior
chest for respiratory
excursion (thoracic
expansion).
• Place the palms of both
hands over the lower
thorax with thumbs
adjacent to the spine and
fingers stretched laterally.
• Ask the client to take a
deep breath while
observing movement of
hands and any lag in
movement.
 EXAMINATION OF POSTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS
– Full and symmetric – Asymmetric or decreased
chest expansion chest expansion
– Thumbs separate 3-5
cm during deep
inspiration
 STEP 5
• Palpate the chest for vocal
(tactile) fremitus, the faintly
perceptible vibration felt
through the chest wall when
the client speaks.
• Place the palmar surfaces of
your hand or closed fist on the
posterior chest, starting near
the apex of the lungs.
• Ask the client to repeat words
like:
– “blue moon”
– “one, two, three”
• Follow the right sequence in this
figure
 STEP 6
• Percuss the thorax.
• Ask the client to bend the
head and fold the arms
forward across the chest.
• Percuss in the intercostal
spaces at about 5 cm (2
in.) intervals in a
systematic sequence.
• Compare one side of the
lung with the other.
 REVIEW OF PERCUSSION
SOUNDS
SOUND INTENSITY PITCH DURATION QUALITY EXAMPLE

FLATNESS SOFT HIGH SHORT EXT. DULL MUSCLE,

(very dense) BONE
DULLNESS MEDIUM MEDIUM MOD. THUDLIKE LIVER,
(more solid) HEART
RESO- LOUD LOW LONG HOLLOW NORMAL
NANCE LUNGS
(partly air/solid)

HYPER- VERY VERY LOW VERY BOOMING EMPHYSEM

RESONANCE LOUD LONG ATOUS
(mostly air) LUNGS
TYMPANY LOUD HIGH MOD. MUSICAL STOMACH
(air)
EXAMINATION OF POSTERIOR
CHEST
• Percuss for diaphragmatic
STEP 7
excursion (movement of the
diaphragm during maximal
inspiration and expiration).
• Ask the client to take a deep
breath and hold it while you
percuss downward along
the scapular line until
dullness is produced at the
level of the diaphragm.
• Mark this point and repeat
the procedure on the other
side of the chest.
 STEP 7 (cont…)
• Ask the client to take a
few normal breaths and
then expel the last breath
completely and hold it
while you percuss upward
from the marked point to
assess and mark the
diaphragmatic excursion
during deep expiration on
each side.
• Measure the distance
between the two marks.
 EXAMINATION OF POSTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS
– Excursion is • Restricted excursion
• 3 to 5 cm bilaterally in (associated with lung
women disorder)
• 5 to 6 cm bilaterally in
men
– Diaphragm is usually
higher on the right
side.
 STEP 8
• Auscultate the chest using
the diaphragm of the
stethoscope.
• Use the systematic zigzag
procedure used in
percussion.
• Ask the client to take a
slow, deep breaths through
the mouth. Listen at each
point to the breath sounds
during a complete
inspiration and expiration.
• Compare findings at each
point on the opposite side.
NORMAL FINDINGS
NORMAL AND ABNORMAL
FINDINGS
 ABNORMAL FINDINGS
ADVENTITIOUS BREAT SOUNDS
– Fine crackles (rales)
• End inspiration, high-pitched, not cleared by cough
• Pneumonia
– Medium crackles (rales)
• Midstage inspiration, lower pitch, moist, not cleared by
cough
• Bronchiolitis (can also have wheeze)
– Coarse crackles (rales)
• Loud bubbly noise during inspiration
• Bronchitis
 ABNORMAL FINDINGS
• ADVENTITIOUS BREATH SOUNDS
– Rhonchi (gurgle)
• Loud, coarse, heard during inspiration & expiration
• May clear with cough
• URI, bronchitis
– Wheeze
• Musical noise or squeak
• Heard both on inspiration & expiration, louder expiration
• Asthma
– Pleural friction rub
• Dry, rubbing, grating sound
• Heard both on inspiration & expiration lower lateral chest
ASSOCIATED LUNG DISORDERS
ASSOCIATED LUNG DISORDERS
ASSOCIATED LUNG DISORDERS
EXAMINATION OF
ANTERIOR CHEST
 STEP 1
• Observe the shape of the • ABNORMAL FINDINGS
patient’s chest and the
movement of the chest
wall.
• Note the following:
– Deformities or asymmetry
– Abnormal retraction of the
lower interspaces during • Severe asthma, COPD
inspiration
– Local lag or impairment in • Underlying disease of lung or
respiratory movement pleura
 STEP 2
• Inspect the costal
angle (angle formed
by the intersection of
the costal margins)
and the angle at
which the ribs enter
the spine.
 EXAMINATION OF ANTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS
– Costal angle is less – Costal angle is widened
than 90o, and the ribs associated with chronic
insert into the spine at obstructive pulmonary
approximately a 45o disease (COPD).
angle.
 STEP 3
• Palpate the anterior chest
for respiratory excursion /
expansion.
• Place the palms of both
hands on the lower chest,
with the fingers laterally
along the lower rib cage
and your thumbs along
the costal margins.
• Ask the client to take a
deep breath while you
observe the movement of
your hands.
 STEP 4
• Palpate tactile
fremitus in the same
manner as for the
posterior chest and
using sequence
shown in.
– If the breasts are large
and cannot be
retracted adequately
for palpation, this part
of examination is
usually omitted.
 EXAMINATION OF ANTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS

– Same as posterior • Same as posterior fremitus.

vocal fremitus,
fremitus is normally
decreased over heart
and breast tissue.
 STEP 5
• Percuss the anterior
chest systematically.
• Begin above the clavicles
in the supraclavicular
space, and proceed
downward to the
diaphragm.
• Compare one side of the
lung to the other.
• Displace female breasts
for proper examination.
 EXAMINATION OF ANTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL
FINDINGS
Percussion notes:
– Resonate down to the – Asymmetry in
sixth rib at the level of the percussion notes.
diaphragm – Areas of dullness or
– Flat over the areas of flatness over lung
heavy muscle and bone tissue.
– Dull on areas over the
heart and the liver, and
tympanic over the
underlying stomach.
 STEP 6
• Auscultate the trachea.
 EXAMINATION OF ANTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL
FINDINGS
– Bronchial and tubular – Adventitious breath
breath sounds. sounds
 STEP 7
• Auscultate the
anterior chest. Use
the sequence used in
percussion beginning
over the bronchi
between the sternum
and the clavicles.
 EXAMINATION OF ANTERIOR
CHEST
• NORMAL FINDINGS • ABNORMAL FINDINGS

– Bronchovesicular and – Adventitious breath

vesicular breath sounds
sounds.