Beruflich Dokumente
Kultur Dokumente
RESPIRATORY
SYSTEM
Functions:
Gas Exchange
Regulation of blood pH
Voice production
Olfaction
Innate Immunity
Lungs tendency to
recoil:
Elastic fibers
Surface tension
Is prevented from
collapsing:
Surfactant
Pleural Pressure
Atelectasis (collapsed lung)
10
Ribs
Air-filled
lung
Position
of
the heart
Position of the diaphragm
Diseased lung
atelectasis
tuberculosis
12
Respiratory Membrane
Thickness
Surface Area
Partial Pressure
Gas Exchange
Breathing/Ventilation
process by which gases are
exchanged between the
atmosphere & alveoli
Inspiration air moves into
the lungs
Expiration air moves out
of the lungs
External Respiration
exchanges of gases
between the lungs & blood
Internal Respiration
exchange of gases between
blood & cells
Ventilatory Principles
INSPIRATION
stimulation of respiratory center
Phrenic nerve
Impulse
intercostal nerve
Diaphragm
intercostal muscle
CONTRACTION
Downward movt
Top to bottom
Thoracic cavity
enlargement
lung stretched
lowering of pressure in the cavity
lung pressure < atmospheric pressure
air enters lungs
lung pressure = atmospheric pressure
BREATHING
Enlarges the
Chest wall &
lungs recoil, the thoracic cavity, and
pushes the
diaphragm rises,
abdominal wall
and air flows
outward, and
outwards
causes a decrease
in thoracic pressure
19
GENERAL APPROACH
Arrange
GENERAL APPROACH
Skeletal landmarks
Sternal angle
Spinous process
subscapular angle
xiphoid
Intercostal space
Costalspinal angle
22
Supraclavicular fossa
Infraclavicular fossa
Sternal line
Sternal angle
Parasternal line
Anterior midline
Midclavicular line
epigastric angle
23
24
Interscapular region
Infrascapular region
Scapular line
Posterior midline
25
26
27
28
29
Anterior Chest
Sternum
Angle
Louis
Intercostal
space
xiphoid
clavicle
Posterior Chest
Scapula
Subscapular
Angle/
Infrascapular
region (7th
ICS)
Spine /
vertebra
Costalspinal angle
Remember???
Focused Interview
Questions
Questions
Environmental factors?
Taking any meds? Rx ? OTC ? Herbal ?
Any respiratory illnesses in the past?
INSPECTION
Patient Position: sit upright with arms relaxed
at the sides
Observe the rate, rhythm, and effort of
breathing
Normal VS
Neonate, Infant
RR 30-60/min PR 110-160/min
PR 90-130/min
PR 100/min
Adult
16-20/min
PR 60-100/min
Normal Breathing
Tachypnea
Hyperventilation
Bradypnea
Cheyne-Stokes
Biots
Obstructive
Breathing
38
INSPECTION
Patient Position: sit upright with arms relaxed
at the sides
Observe the rate, rhythm, and effort of
breathing
Check for cyanosis
Check for retractions
Listen to patients breathing
Observe the shape of the chest
39
Central cyanosis
Peripheral cyanosis
40
Clubbing
41
Schamroths Technique
42
Nasal flaring
43
Intercostal retractions
Sternal retractions
Subcostal
45
46
Thoracic Configuration
Anteroposterior (AP) diameter to
transverse diameter (T)
> AP: T = 1:2
> Increases slightly with age
> Increases prematurely
with COPD
47
Barrel chest
Kyphosis
Scoliosis
Pectus Carinatum
(pigeon chest)
49
Pectus Excavatum
(sunken/funnel chest)
50
Inspection
51
Shifts toward:
Collapsed lung
Atelectasis
Pneumonectomy
Shifts away:
Increased air ( tension
penumothorax)
Increased fluid ( pleural
effusion)
Increased tissue (tumor)
53
PALPATION
May be
Increased
Atelectasis
Pneumonia
Decreased
Soft voice
Pneumothorax
Pleural effusion
Emphysema
Obesity
Muscular
Or Absent
Soft voice
Pneumothorax
Pleural effusion
56
Percussion
To determine tissue
density
Percuss in between
ribs (ICS)
TECHNIQUE OF
PERCUSSION
Position your right
hand with middle
finger partially
flexed, relaxed &
poised to strike
Hyperextend the
middle finger of
your left hand
(pleximeter)
PERCUSSION NOTES
Intensity
Pitch
Duration Location
FLAT
Soft
High
Short
Dullness
Medium
Medium Medium
Liver
Resonance
Loud
Low
Lung
Simple Chronic
Long
Thigh
Pleural effusion
Lobar pneumonia
Bronchitis
Hyperresonance Very
loud
Tympany
Loud
Lower
High
Longer
-
COPD
None
(emphysema,
normally
Pneumothorax)
Gastric air
Large
bubble/
puffed
pneumothorax
out cheek
Auscultation
Listening for
Most important
breath
sounds
Listen
for
examining
adventitious
technique
for
Listen
to
sounds
assessing
air flow
transmitted
sounds
Auscultation
Diaphragm of
stethoscope placed firmly
& directly on the chest
wall
Ask patient to deep
breath through the mouth
Listen for at least once, a
complete respiratory
cycle
Watch out for patients
comfort
General Approach
63
Order of auscultation
64
BREATH SOUNDS
Bronchial
Vesicular
E>I
I>E
Loud
Soft
Relatively
Low High
Quality:breezy
tubular
Quality:
Tracheal
I<E
Bronchovesicular
Very
I = loud
E
Relatively
high
Intermediate
Quality:
tubular
Intermediate
Quality: tubular
w/ rustling of
leaves
Intensity of
Expiratory
Sound
Pitch of
Expiratory
Sound
Locations
Where
Heard
Normally
Clinical
Significanc
e
Vesicular
Inspiratory
sounds last
longer than
expiratory
ones
Soft
Relatively
Low
Over most of
both lungs
Regional
ventilation
Bronchovesicular
Inspiratory &
expiratory
sounds are
about equal
Intermediate
Intermediate
Often in the
1st & 2nd
interspaces
anteriorly &
between the
scapulae
Large airway
patency
Bronchial
Expiratory
sounds lasts
longer than
inspiratory
ones
Loud
Relatively
High
Over the
manubrium,
if
heard at all
Patency of
large
airways
Tracheal
Expiratory
sounds lasts
longer than
Very loud
Relatively
high
Over the
trachea in
the neck
Patency of
airway
Discontinuous Sounds
DISCONTINUOUS
FINE
CRACKLES
Intermittent
COARSE
CRACKLES
Soft
pitched, brief
Non-musical
Louder, lower pitched
Quality:
Loudness,
pitch,
duration
rolling
strand
Quality: bubbling or
of hairNumber
b/w fingers
velcro
Clinical
Timing
Significance:
Clinical Significance:
Location
opening
of collapsed
secretions
in airways
Changes
alveoliafter coughing or
changing position
Continuous Sounds
Continuous
Sounds
Wheezes (sibilant)
>
Longer
than crackles
High
pitched
Wheezes
(sonorous)/Ronchi
Stridor
Do
not
persist
throughout
low-pitched
Heard primarily
during
snoring
Friction
Rubor
A
wheeze
that
is
entirely
the respiratory
cycleor
moaning
sounds
expiration
low-pitched,
dry, grating
predominantly
inspiratory
Clinical
Significance:
heard
duringairway
Musical
occursprimarily
during
inspiration
&
obstruction
louder in the neck than chest
expiration ( bronchospasm)
wall
may clear
with coughing
Significance:
pleurisy
Clinical
Clinical
Significance:
Clinical Significance: Upper
airway
airway obstruction
obstruction ( airway
secretions)
68
TRANSMITTED SOUNDS
Sounds are normally muffled &
indistinct
When the patient
says ee, youll
Louder
&muffled
clearer long
voiceee
sounds
are
hear
a
sound.
Ask called
the patient
to whisper ninetyBRONCHOPHONY
When
ee
is
heard
as ayisits
called
nine. Whispered voice
usually
EGOPHONY
faint
and indistinct.
Louder clearer sounds are called
WHISPERED PECTORILOQUY
Case Scenarios
70
Case Scenarios
Inspection: dyspnea, RR,
use of accesory muscles,
audible wheezes, anxiety
Palpation:
tactile fremitus
Percussion: Resonance to
hyperresonance
Ausculation: wheezes
ASTHMA
71
Case Scenarios
Inspection: tachypnea,
productive cough, chills
Palpation: tactile fremitus,
chest expansion
Percussion: dull
Auscultation: bronchophony,
egophony, whispered
pectoriloquy, bronchial breath
sounds and crackles
PNEUMONIA
72
Case Scenarios
Inspection: dyspnea,
productive cough, tachypnea,
use of accessory muscles
Palpation: normal tactile
fremitus
Percussion: resonance
Auscultation: wheezes and
ronchi
CHRONIC BRONCHITIS
73
Case Scenarios
Inspection: dyspnea, tracheal
shift to unaffected side
(severe)
Palpation: tactile fremitus &
chest expansion on affected
side
Percussion: dullness over fluid
Auscultation: or absent breath
& voice sounds, possible
pleural rub
PLEURAL EFFUSION
74
Case Scenarios
Inspection: tachypnea,
tracheal shift
Palpation:
tactile fremitus
Percussion: hyperresonance
Auscultation: or absent
breath & voice sounds
PNEUMOTHORAX
75
Case Scenrios
ATELECTASIS
CONGESTIVE HEART
FAILURE
76
DOCUMENTATION
RR 18/min, relaxed &
(normal findings)
even. AP less than
No dyspnea, cough, or
chest pain with
breathing, at rest or
with activity. No past
history or family history
of respiratory diseases.
Has never smoked &
works in well-ventilated
factory. Reports one
or two colds per year.
No known allergies
Subjective Data
transverse diameter.
Chest expansion
symmetric. No retractions
or bulging of intercostal
spaces. Tactile fremitus
symmetric. Percussion
tones resonant over all
lung fields. Vesicular
breath sounds
auscultated over lung
fields. No adventitious
sound present
Objective Data
77
DOCUMENTATION
Shortness of breath
with chest pain and
cough that gets worse
at night as verbalized
Subjective Data
Objective Data
78
79