1 Cough. Do you have a cough? When did it start? Gradual or sudden?

_ How long have you had it?

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Acute cough lasts less than 2 or 3 weeks; chronic cough lasts over 2 months.

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_ How often do you cough? At any special time of day or just on arising? Cough wake you up at night?

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Conditions with characteristic timing of cough: (1) continuous throughout day—acute illness (e.g., respiratory infection); (2) afternoon/evening—may reflect exposure to irritants at work; (3) night—postnasal drip, sinusitis; (4) early morning—chronic bronchial inflammation of smokers.

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Do you cough up any phlegm or sputum? How much? What color is it?

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Chronic bronchitis presents with a history of productive cough for 3 months of the year for 2 years in a row.

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Cough up any blood? Does this look like streaks or frank blood? Does the sputum have a foul odor?

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Hemoptysis.

Some conditions have characteristic sputum production: (1) white or clear mucoid—colds, bronchitis, viral infections; (2) yellow or green—bacterial infections; (3) rust colored—tuberculosis, pneumococcal pneumonia; (4) pink, frothy—pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus.

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How would you describe your cough: hacking, dry, barking, hoarse, congested, bubbling?

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Some conditions have a characteristic cough: mycoplasma pneumonia—hacking; early heart failure—dry; croup—barking; colds, bronchitis, pneumonia—congested.

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Does the cough seem to come with anything: activity, position (lying), fever, congestion, talking, anxiety?

_ Does activity make it better or worse?

_ What treatment have you tried? Prescription or over-the-counter medications, vaporizer, rest, position change?

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Assess the effectiveness of coping strategies.

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Does the cough bring on anything: chest pain, ear pain? Is it tiring? Are you concerned about it?

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Note severity.

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2 Shortness of breath. Ever had any shortness of breath or hard-breathing spells? What brings it on? How severe is it? How long does it last?

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Determine how much activity precipitates the shortness of breath (SOB)—state specific number of blocks walked, number of stairs.

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Is it affected by position, such as lying down?

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Orthopnea

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Occur at any specific time of day or night?

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Paroxysmal nocturnal dyspnea

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Shortness of breath episodes associated with night sweats?

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Diaphoresis.

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Or cough, chest pain, or bluish color around lips or nails? Wheezing sound?

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Cyanosis signals hypoxia.

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Episodes seem to be related to food, pollen, dust, animals, season, or emotion?

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Asthma attacks may be associated with a specific allergen or extreme cold, anxiety.

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_ What do you do in a hard-breathing attack? Take a special position, or use pursed-lip breathing? Use any oxygen, inhalers, or medications?

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Assess effect of coping strategies and the need for more teaching.

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How does the shortness of breath affect your work or home activities? Getting better or worse or staying about the same?

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Assess effect on activities of daily living.

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Chest pain with breathing Any chest pain with breathing? Please point to the exact location.

`When did it start? Constant, or does it come and go?

_ Describe the pain: burning, stabbing?

_ Brought on by respiratory infection, coughing, or trauma? Is it associated with fever, deep breathing, unequal chest inflation?

_ What have you done to treat it? Medication or heat application?

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Chest pain of thoracic origin occurs with muscle soreness from coughing or from inflammation of pleura overlying pneumonia. Distinguish this from chest pain of cardiac origin (see Chapter 19) or from heartburn of stomach acid.

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History of respiratory infections. Any past history of breathing trouble or lung diseases such as bronchitis, emphysema, asthma, pneumonia?

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Consider sequelae after these conditions.

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_ Any unusually frequent or unusually severe colds?

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Because most people have had some colds, it is more meaningful to ask about excess number or severity.

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_ Any family history of allergies, tuberculosis, or asthma?

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Assess possible risk factors.

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5 Smoking history. Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long?

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State number of packs per day and the number of years smoked.

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_ Have you ever tried to quit? What helped? Why do you think it did not work? What activities do you associate with smoking?

_ Live with someone who smokes?

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Most people already know they should quit smoking. Instead of admonishing, assess smoking behavior, ways to modify daily smoking activities, identify triggers, how to manage withdrawal.

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6 Environmental exposure. Are there any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area?

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Pollution exposure.

Farmers may be at risk for grain inhalation, pesticide inhalation. People in the rural Midwest have a risk for histoplasmosis exposure; those in the Southwest and Mexico have a risk for coccidioidomycosis. Coal miners have a risk for pneumoconiosis. Stone cutters, miners, and potters have a risk for silicosis. Other irritants: asbestos, radon.

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_ Do you do anything to protect your lungs, such as wear a mask or have the ventilatory system checked at work? Do you do anything to monitor your exposure? Do you have periodic examinations, pulmonary function tests, x-ray examination?

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Assess self-care measures.

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_ Do you know what specific symptoms to note that may signal breathing problems?

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General symptoms: cough, shortness of breath. Some gases produce specific symptoms: carbon monoxide—dizziness, headache, fatigue; sulfur dioxide—cough, congestion.

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7 Self-care behaviors. Last tuberculosis skin test, chest x-ray study, pneumonia vaccine or influenza immunization?

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“Flu” vaccine is modified yearly; recommended for adults with chronic medical conditions, residents of nursing homes and group care, health care workers, and those who are immunosuppressed.

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Additional History for the Aging Adult

1 Have you noticed any shortness of breath or fatigue with your daily activities?

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Older adults have a less efficient respiratory system (decreased vital capacity, less surface area for gas exchange), so they have less tolerance for activity.

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Additional History for the Aging Adult

2 Tell me about your usual amount of physical activity.

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May have reduced exercise capacity because of pulmonary function deficits.

Sedentary or bedridden people are at risk for respiratory dysfunction.

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Additional History for the Aging Adult

`3 (For those with a history of chronic obstructive pulmonary disease [COPD], lung cancer, or tuberculosis): How are you getting along each day? Any weight change in the past 3 months? How much?

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Assess coping strategies.

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additional history for the aging adult

_ How about energy level? Do you tire more easily? How does your illness affect you at home? At work?

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Activities may decrease because of increasing shortness of breath or pain.

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additional history for the aging adult

4 Do you have any chest pain with breathing?

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Some older adults feel pleuritic pain less intensely than younger adults.

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additional history for the aging adult

_ Any chest pain after a bout of coughing? After a fall?

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Precisely localized sharp pain (points to it with one finger)—consider fractured rib or muscle injury.

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INSPECT THE POSTERIOR CHEST

Thoracic Cage

Note the shape and configuration of the chest wall. The spinous processes should appear in a straight line. The thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine. The scapulae are placed symmetrically in each hemithorax.

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Skeletal deformities may limit thoracic cage excursion: scoliosis, kyphosis (see Table 18-3, Configurations of the Thorax, p. 441).

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The anteroposterior diameter should be less than the transverse diameter. The ratio of anteroposterior to transverse diameter is from 1:2 to 5:7.

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AP = transverse diameter, or “barrel chest.” Ribs are horizontal, chest appears as if held in continuous inspiration. This occurs in chronic emphysema from hyperinflation of the lungs (see Table 18-3).

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The neck muscles and trapezius muscles should be developed normally for age and occupation.

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Neck muscles are hypertrophied in COPD from aiding in forced respirations.

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Note the position the person takes to breathe. This includes a relaxed posture and the ability to support one's own weight with arms comfortably at the sides or in the lap.

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People with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominis, intercostal, and accessory neck muscles all can aid in expiration.

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People with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominis, intercostal, and accessory neck muscles all can aid in expiration.

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Cyanosis occurs with tissue hypoxia.

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PALPATE THE POSTERIOR CHEST

Symmetric Expansion

Confirm symmetric chest expansion by placing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs (Fig. 18-13).

Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion.

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Unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion; with thoracic trauma, such as fractured ribs; or with pneumothorax.

Pain accompanies deep breathing when the pleurae are inflamed.

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Tactile Fremitus

Assess tactile (or vocal) fremitus. Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations.

Use either the palmar base (the ball) of the fingers or the ulnar edge of one hand, and touch the person's chest while he or she repeats the words “ninety-nine” or “blue moon.” These are resonant phrases that generate strong vibrations. Start over the lung apices and palpate from one side to another (Fig. 18-14).

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Fremitus varies among persons, but symmetry is most important; the vibrations should feel the same in the corresponding area on each side. However, just between the scapulae, fremitus may feel stronger on the right side than on the left side because the right side is closer to the bronchial bifurcation. Avoid palpating over the scapulae because bone damps out sound transmission.

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Fremitus varies among persons, but symmetry is most important; the vibrations should feel the same in the corresponding area on each side. However, just between the scapulae, fremitus may feel stronger on the right side than on the left side because the right side is closer to the bronchial bifurcation. Avoid palpating over the scapulae because bone damps out sound transmission.

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The following factors affect the normal intensity of tactile fremitus:

_ Relative location of bronchi to the chest wall.

_ Normally, fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as you progress down because more and more tissue impedes sound transmission.

_ Thickness of the chest wall.

_ Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration.

_ Pitch and intensity.

_ A loud, low-pitched voice generates more fremitus than a soft, high-pitched one.

Note any areas of abnormal fremitus. Sound is conducted better through a uniformly dense structure than through a porous one, which changes in shape and solidity (as does the lung tissue during normal respiration). Thus conditions that increase the density of lung tissue make a better conducting medium for sound vibrations and increase tactile fremitus.

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Decreased fremitus

Increased fremitus

Rhonchal fremitus

Pleural friction fremitus

Table 18-5 on p. 443

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Using the fingers, gently palpate the entire chest wall. This enables you to note any areas of tenderness, to note skin temperature and moisture, to detect any superficial lumps or masses, and to explore any skin lesions noted on inspection.

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Crepitus

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PERCUSS THE POSTERIOR CHEST

Lung Fields

Determine the predominant note over the lung fields. Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders (Fig. 18-15). Then, percussing in the interspaces, make a side-to-side comparison all the way down the lung region. Percuss at 5-cm intervals. Avoid the damping effect of the scapulae and ribs.

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Resonance

Fig. 18-16

Hyperresonance

A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor

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The depth of penetration of percussion has limits. Percussion sets into motion only the outer 5 to 7 cm of tissue. It will not penetrate to reveal any change in density deeper than that. Also, an abnormal finding must be 2 to 3 cm wide to yield an abnormal percussion note. Lesions smaller than that are not detectable by percussion.

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Diaphragmatic Excursion

Determine diaphragmatic excursion (Fig. 18-17, A). Percuss to map out the lower lung border, both in expiration and in inspiration. First, ask the person to “exhale and hold it” briefly while you percuss down the scapular line until the sound changes from resonant to dull on each side. This estimates the level of the diaphragm separating the lungs from the abdominal viscera. It may be somewhat higher on the right side (about 1 to 2 cm) because of the presence of the liver. Mark the spot.

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Now ask the person to “take a deep breath and hold it.” Continue percussing down from your first mark and mark the level where the sound changes to dull on this deep inspiration. Measure the difference. This diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm in adults, although it may be up to 7 to 8 cm in well-conditioned people (Fig. 18-17, B).

Note an abnormally high level of dullness and absence of excursion. These occur with pleural effusion (fluid in the space between the visceral and parietal pleura) or atelectasis of the lower lobes.

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When you are a beginning examiner, you become so involved in the subtle differences of percussion notes that you extend the patient's limits of breath-holding. Always hold your own breath when you ask your patient to. When you run out of air, the other person surely has too, especially if that person has a respiratory problem.

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AUSCULTATE THE POSTERIOR CHEST

The passage of air through the tracheobronchial tree creates a characteristic set of noises that are audible through the chest wall. These noises also may be modified by obstruction within the respiratory passageways or by changes in the lung parenchyma, the pleura, or the chest wall.

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auscultate the posterior chest

Breath Sounds

Evaluate the presence and quality of normal breath sounds. The person is sitting, leaning forward slightly, with arms resting comfortably across the lap. Instruct the person to breathe through the mouth, a little bit deeper than usual, but to stop if he or she begins to feel dizzy. Be careful to monitor the breathing throughout the examination and offer times for the person to rest and breathe normally. The person is usually willing to comply with your instructions in an effort to please you and to be a “good patient.” Watch that he or she does not hyperventilate to the point of fainting.

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auscultate the posterior chest

Clean the flat diaphragm endpiece of the stethoscope and hold it firmly on the person's chest wall. Listen to at least one full respiration in each location. Side-to-side comparison is most important.

Do not confuse background noise with lung sounds. Become familiar with these extraneous noises that may be confused with lung pathology if not recognized:

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1 Examiner's breathing on stethoscope tubing

2 Stethoscope tubing bumping together

3 Patient shivering

4 Patient's hairy chest: movement of hairs under stethoscope sounds like crackles (rales)—minimize this by pressing harder or by wetting the hair with a damp cloth

5 Rustling of paper gown or paper drapes

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While standing behind the person, listen to the following lung areas—posterior from the apices at C7 to the bases (around T10), and laterally from the axilla down to the seventh or eighth rib. Use the sequence illustrated in Fig. 18-18.

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Crackles are abnormal lung sounds (see Table 18-6, Adventitious Lung Sounds, p. 444.)

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posterior chest auscultation

Continue to visualize approximate locations of the lobes of each lung so that you correlate your findings to anatomical areas. As you listen, think (1) what AM I hearing over this spot? and (2) what should I EXPECT to be hearing? You should expect to hear three types of normal breath sounds in the adult and older child: bronchial (sometimes called tracheal or tubular), bronchovesicular, and vesicular. Study the description of the characteristics of these normal breath sounds in Table 18-1.

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posterior chest auscultation

Note the normal location of the three types of breath sounds on the chest wall of the adult and older child (Figs. 18-19 and

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Decreased

absent breath sounds

1 When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body

2 In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; also, the lungs are already hyperinflated so the inhaled air does not make as much noise

3 When anything obstructs transmission of sound between the lung and your stethoscope, such as pleurisy or pleural thickening, or air (pneumothorax) or fluid (pleural effusion) in the pleural space

A silent chest means no air is moving in or out, which is an ominous sign.

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Increased breath sounds

in

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Adventitious Sounds

Note the presence of any adventitious sounds. These are added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously deflated airways. Sources differ as to the classification and nomenclature of these sounds (see Table 18-6), but crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners.

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Study Table 18-6 on pp. 444-445 for a complete description of these abnormal adventitious breath sounds.

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In the past, persons were asked to “take a deep breath and blow it out hard” to screen for the presence of wheezing. However, this maneuver is futile because evidence shows wheezing may occur on maximal forced exhalation in healthy people

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During normal tidal flow, high-pitched wheeze occurs with asthma.

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Voice Sounds

Determine the quality of voice sounds or vocal resonance. The spoken voice can be auscultated over the chest wall just as it can be felt in tactile fremitus described earlier. Ask the person to repeat a phrase such as “ninety-nine” while you listen over the chest wall. Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Pathology that increases lung density enhances transmission of voice sounds.

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Consolidation or compression of lung tissue will enhance the voice sounds, making the words more distinct.

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Eliciting the voice sounds is not done routinely. Rather, these are supplemental maneuvers performed if you suspect lung pathology on the basis of earlier data. When they are performed, you are testing for the possible presence of bronchophony, egophony, and whispered pectoriloquy (see Table 18-7 on p. 446).

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INSPECT THE ANTERIOR CHEST

Note the shape and configuration of the chest wall. The ribs are sloping downward with symmetric interspaces. The costal angle is within 90 degrees. Development of abdominal muscles is as expected for the person's age, weight, and athletic condition.

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Barrel chest has horizontal ribs and costal angle >90 degrees.

Hypertrophy of abdominal muscles occurs in chronic emphysema.

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Note the person's facial expression. The facial expression should be relaxed and benign, indicating an unconscious effort of breathing.

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Tense, strained, tired facies accompany COPD.

The person with COPD may purse the lips in a whistling position. By exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive and fewer airways collapse.

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Assess the level of consciousness. The level of consciousness should be alert and cooperative.

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Cerebral hypoxia may be reflected by excessive drowsiness or by anxiety, restlessness, and irritability.

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Note skin color and condition. The lips and nail beds are free of cyanosis or unusual pallor. The nails are of normal configuration. Explore any skin lesions.

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Clubbing of distal phalanx occurs with chronic respiratory disease.

Cutaneous angiomas (spider nevi) associated with liver disease or portal hypertension may be evident on the chest.

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Assess the quality of respirations. Normal relaxed breathing is automatic and effortless, regular and even, and produces no noise. The chest expands symmetrically with each inspiration. Note any localized lag on inspiration.

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Noisy breathing occurs with severe asthma or chronic bronchitis.

Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or pleurisy pain.

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No retraction or bulging of the interspaces should occur on inspiration.

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Retraction suggests obstruction of respiratory tract or increased inspiratory effort is needed, as with atelectasis. Bulging indicates trapped air as in the forced expiration associated with emphysema or asthma.

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Normally, accessory muscles are not used to augment respiratory effort. However, with very heavy exercise, the accessory neck muscles (scalene, sternomastoid, trapezius) are used momentarily to enhance inspiration.

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Accessory muscles are used in acute airway obstruction and massive atelectasis.

Rectus abdominis and internal intercostal muscles are used to force expiration in COPD.

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The respiratory rate is within normal limits for the person's age (see Table 9-2), and the pattern of breathing is regular. Occasional sighs normally punctuate breathing.

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Tachypnea and hyperventilation, bradypnea and hypoventilation, periodic breathing (see Table 18-4, Respiratory Patterns, p. 442).

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PALPATE THE ANTERIOR CHEST

Palpate symmetric chest expansion. Place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process (Fig. 18-21).

Ask the person to take a deep breath. Watch your thumbs move apart symmetrically, and note smooth chest expansion with your fingers. Any limitation in thoracic expansion is easier to detect on the anterior chest because greater range of motion exists with breathing here.

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Abnormally wide costal angle with little inspiratory variation occurs with emphysema.

A lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding.

A palpable grating sensation with breathing indicates pleural friction fremitus (see Table 18-5).

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Assess tactile (vocal) fremitus. Begin palpating over the lung apices in the supraclavicular areas (Fig. 18-22). Compare vibrations from one side to the other as the person repeats “ninety-nine.” Avoid palpating over female breast tissue because breast tissue normally damps the sound.

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Palpate the anterior chest wall

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If any lumps are found in the breast tissue, refer the man to a specialist.

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PERCUSS THE ANTERIOR CHEST

Begin percussing the apices in the supraclavicular areas. Then, percussing the interspaces and comparing one side with the other, move down the anterior chest.

Interspaces are easier to palpate on the anterior chest than on the back. Do not percuss directly over female breast tissue because this would produce a dull note. Shift the breast tissue over slightly using the edge of your stationary hand. In females with large breasts, percussion may yield little useful data. With all people, use the sequence illustrated in Fig. 18-23.

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percuss anterior chest

Note the borders of cardiac dullness normally found on the anterior chest and do not confuse these with suspected lung pathology (Fig. 18-24). In the right hemithorax, the upper border of liver dullness is located in the fifth intercostal space in the right midclavicular line. On the left, tympany is evident over the gastric space.

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Lungs are hyperinflated with chronic emphysema, which results in hyperresonance where you would expect cardiac dullness.

Dullness behind the right breast occurs with right middle lobe pneumonia.

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AUSCULTATE THE ANTERIOR CHEST

Breath Sounds

Auscultate the lung fields over the anterior chest from the apices in the supraclavicular areas down to the sixth rib. Progress from side to side as you move downward, and listen to one full respiration in each location. Use the sequence indicated for percussion. Do not place your stethoscope directly over the female breast. Displace the breast and listen directly over the chest wall.

Evaluate normal breath sounds, noting any abnormal breath sounds and any adventitious sounds. If the situation warrants, assess the voice sounds on the anterior chest.

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Study Table 18-8 on pp. 447-453 for a complete description of abnormal respiratory conditions.

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Measurement of Pulmonary Function Status

The forced expiratory time is the number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction. Although the test usually is not performed in the respiratory assessment, it is useful when you wish to screen for pulmonary function.

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Ask the person to inhale the deepest breath possible and then to blow it all out hard, as quickly as possible, with the mouth open. Listen with your stethoscope over the sternum. The normal time for full expiration is 4 seconds or less.

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A forced expiration of 6 seconds or more occurs with obstructive lung disease. Refer this person for more precise pulmonary function studies.

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In an ambulatory care setting, a handheld spirometer measures lung health in chronic conditions such as asthma. Ask the patient to inhale deeply and then to exhale into the spirometer as fast as possible until the most air possible is exhaled. The forced vital capacity (FVC) is the total volume of air exhaled. The forced expiratory volume in 1 second (FEV1) is the volume exhaled in the first measured second. A normal outcome is a FEV1/FVC ratio of 75% or greater, meaning no significant obstruction of airflow is present.

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Mild obstruction of airflow is a FEV1/FCV ratio of 60% to 70%; moderate obstruction is a measure of 50% to 60%; severe obstruction is a ratio of less than 50%.

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The pulse oximeter is a noninvasive method to assess arterial oxygen saturation (Spo₂) and is described inChapter 9. A healthy person with no lung disease and no anemia normally has an Spo₂ of 97% to 98%. However, every Spo₂ result must be evaluated in the context of the person's hemoglobin level, acid-base balance, and ventilatory status.

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The 6-minute distance (6MD) walk is a safer, simple, inexpensive, clinical measure of functional status in aging adults.¹⁰,¹¹ The 6MD is used as an outcome measure for people in pulmonary rehabilitation because it mirrors conditions that are used in everyday life. Locate a flat-surfaced corridor that has little foot traffic, is wide enough to permit comfortable turns, and has a controlled environment. Ensure that the person is wearing comfortable shoes, and equip him or her with a pulse oximeter to monitor oxygen saturation. Ask the person to set his or her own pace to cover as much ground as possible in 6 minutes, and assure the person it is all right to slow down or to stop to rest at any time. Use a stopwatch to time the walk. A person who walks >300 meters in 6 minutes is more likely to engage in activities of daily living.

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Ask the person to stop the walk if you measure an Spo₂ below 85% to 88% or if extreme breathlessness occurs.

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The Pregnant Woman

The thoracic cage may appear wider and the costal angle may feel wider than in the nonpregnant state. Respirations may be deeper, although this can be quantified only with pulmonary function tests.

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The Aging Adult

The chest cage commonly shows an increased anteroposterior diameter, giving a round barrel shape, and kyphosis or an outward curvature of the thoracic spine (see Table 18-3). The person compensates by holding the head extended and tilted back. You may palpate marked bony prominences because of decreased subcutaneous fat. Chest expansion may be somewhat decreased with the older person, although it still should be symmetric. The costal cartilages become calcified with aging, resulting in a less mobile thorax.

The older person may fatigue easily, especially during auscultation when deep mouth breathing is required. Take care that this person does not hyperventilate and become dizzy. Allow brief rest periods or quiet breathing. If the person does feel faint, holding the breath for a few seconds will restore equilibrium.

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The Acutely Ill Person

Ask a second examiner to hold the person's arms and to support him or her in the upright position. If no one else is available, you need to roll the person from side to side, examining the uppermost half of the thorax. This obviously prevents you from comparing findings from one side to another. Also, side flexion of the trunk alters percussion findings because the ribs of the upward side may flex closer together.

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characteristics of normal breath sounds

BRONCHIAL (TRACHEAL)

pitch: High

amplitude: Loud

duration: Inspiration < expiration

quality: Harsh, hollow tubular

normal location: Trachea and larynx

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characteristics of normal breath sounds

BRONCHOVESICULAR

pitch: Moderate

amplitude; Moderate

duration: Inspiration = expiration

quality: Mixed

normal location:

Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in first and second intercostal spaces

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characteristics of normal breath sounds

VESICULAR

pitch: Low

amplitude: Soft

duration: Inspiration > expiration

quality: Rustling, like the sound of the wind in the trees

normal location: Over peripheral lung fields where air flows through smaller bronchioles and alveoli

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The thorax has an elliptical shape with an anteroposterior-to-transverse diameter of 1 : 2 or 5 : 7.

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Barrel Chest

`Note equal anteroposterior-to-transverse diameter and that ribs are horizontal instead of the normal downward slope. This is associated with normal aging and also with chronic emphysema and asthma as a result of hyperinflation of lungs.

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Pectus Excavatum

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A markedly sunken sternum and adjacent cartilages (also called funnel breast). Depression begins at second intercostal space, becoming depressed most at junction of xiphoid with body of sternum. More noticeable on inspiration. Congenital, usually not symptomatic. When severe, sternal depression may cause embarrassment and a negative self-concept. Surgery may be indicated.

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Pectus Carinatum

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A forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast). Less common than pectus excavatum, this minor deformity requires no treatment. If severe, surgery may be indicated.

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Scoliosis

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A lateral S-shaped curvature of the thoracic and lumbar spine, usually with involved vertebrae rotation. Note unequal shoulder and scapular height and unequal hip levels, rib interspaces flared on convex side. More prevalent in adolescent age-groups, especially girls. Mild deformities are asymptomatic. If severe (>45 degrees) deviation is present, scoliosis may reduce lung volume and then person is at risk for impaired cardiopulmonary function. Primary impairment is cosmetic deformity, negatively affecting self-image. Refer early for treatment, often surgery.

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An exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Severe deformities impair cardiopulmonary function. If the neck muscles are strong, compensation occurs by hyperextension of head to maintain level of vision.

Kyphosis has been associated with aging, especially the familiar “dowager's hump” of postmenopausal osteoporotic women. However, it is common well before menopause. It is related to physical fitness; women with adequate exercise habits are less likely to have kyphosis.

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respiratory patterns

normal adult for comparison

Rate—10 to 20 breaths per minute

Depth—500 to 800 mL

Pattern—even

The ratio of pulse to respirations is fairly constant, about 4:1. Both values increase as a normal response to exercise, fear, or fever.

Depth—air moving in and out with each respiration.

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sigh

Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction. Frequent sighs also may lead to hyperventilation and dizziness.

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Rapid, shallow breathing. Increased rate, >24 per minute. This is a normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

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Increase in both rate and depth. Normally occurs with extreme exertion, fear, or anxiety. Also occurs with diabetic ketoacidosis (Kussmaul respirations), hepatic coma, salicylate overdose (producing a respiratory alkalosis to compensate for the metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (either an increase in CO₂ or a decrease in oxygen). Hyperventilation blows off CO₂, causing a decreased level in the blood (alkalosis).

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Slow breathing. A decreased but regular rate (<10 per minute), as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.

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An irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bedrest or conscious splinting of the chest to avoid respiratory pain.

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A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and aging persons during sleep.

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Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (three to four) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.

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Normal inspiration and prolonged expiration to overcome increased airway resistance. In a person with chronic obstructive lung disease, any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping), because then the person does not have enough time for full expiration.

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Occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations (e.g., compression or consolidation [pneumonia]). There must be a patent bronchus and consolidation must extend to lung surface for increased fremitus to be apparent.

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Occurs when anything obstructs transmission of vibrations (e.g., an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema). Any barrier that gets in the way of the sound and your palpating hand decreases fremitus

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Vibration felt when inhaled air passes through thick secretions in the larger bronchi. This may decrease somewhat by coughin

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Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. Then the opposing surfaces make a coarse grating sound when rubbed together during breathing. Although this sound is best detected by auscultation, it may sometimes be palpable and feels like two pieces of leather grating together. It is synchronous with respiratory excursion. Also called a palpable friction rub.

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adventitious lung sounds

Discontinuous Sounds

These are discrete, crackling sounds.

adventitious lung sounds

Crackles

rales

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description

Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can simulate this sound by rolling a strand of hair between your fingers near your ear or by moistening your thumb and index finger and separating them near your ear

mechanism

Inspiratory crackles: inhaled air collides with previously deflated airways; airways suddenly pop open, creating explosive crackling sound

Expiratory crackles: sudden airway closing

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clinical examples

Late inspiratory crackles

occur with restrictive disease: pneumonia, heart failure, and interstitial fibrosis

Early inspiratory crackles

occur with obstructive disease: chronic bronchitis, asthma, and emphysema

Posturally induced crackles

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adventitious lung sounds

Crackles

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description

Loud, low-pitched, bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but will reappear shortly—sounds like opening a Velcro fastener

mechanism

Inhaled air collides with secretions in the trachea and large bronchi

clinical example

Pulmonary edema, pneumonia, pulmonary fibrosis, and the terminally ill who have a depressed cough reflex

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adventitious lung sounds

Atelectatic crackles

description

Sounds like fine crackles but do not last and are not pathologic; disappear after the first few breaths; heard in axillae and bases (usually dependent) of lungs

mechanism

When sections of alveoli are not fully aerated, they deflate and accumulate secretions. Crackles are heard when these sections re-expand with a few deep breaths

clinical examples

In aging adults, in bedridden persons, or in persons just aroused from sleep

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adventitious lung sounds

Pleural friction rub

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description

A very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto the chest wall; sound is inspiratory and expiratory

mechanism

Caused when pleurae become inflamed and lose their normal lubricating fluid; their opposing roughened pleural surfaces rub together during respiration; heard best in anterolateral wall where greatest lung mobility exists

clinical example

Pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae)

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adventitious lungs sounds

continuous sounds

These are connected, musical sounds.

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adventitiuous lungs sounds

Wheeze

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description

High-pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord); predominate in expiration but may occur in both expiration and inspiration

mecanism

Air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; the passageway walls oscillate in apposition between the closed and barely open positions; the resulting sound is similar to a vibrating reed

clinical example

Diffuse airway obstruction from acute asthma or chronic emphysema

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adventitious lungs sounds

Wheeze

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description

Low-pitched; monophonic single note, musical snoring, moaning sounds; they are heard throughout the cycle, although they are more prominent on expiration; may clear somewhat by coughing

mechanism

Airflow obstruction as described by the vibrating reed mechanism above; the pitch of the wheeze cannot be correlated to the size of the passageway that generates it

clinical example

Bronchitis, single bronchus obstruction from airway tumor

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adventitious lungs sounds

Stridor

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description

High-pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall

mechanism

Originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body

clinical example

Croup and acute epiglottitis in children, and foreign inhalation, obstructed airway may be life-threatening

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Normal Lung (for comparison)

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Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Atelectasis (Collapse)

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Lobar Pneumonia

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Bronchitis

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Emphysema

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Asthma (Reactive Airway Disease)

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Pleural Effusion (Fluid) or Thickening

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Condition

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Heart Failure

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Condition

Inspection

Palpation

Percussion

Auscultation

S₃

Adventitious Sounds

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Pneumothorax

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Condition

spontaneous

traumatic

tension

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Pneumocystis jiroveci (P. carinii)

Pneumonia

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Condition

P. jiroveci (P. carinii)

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Tuberculosis

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Condition

Subjective

Inspection

Palpation

Percussion

Auscultation

Adventitious Sounds

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Pulmonary Embolism

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Condition

Subjective

Inspection

₂

Palpation

Auscultation

S₂

Adventitious Sounds

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Acute Respiratory Distress Syndrome (ARDS)

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Condition

Subjective

Inspection

₂

Palpation

Auscultation

Adventitious Sounds

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Summary Checklist: Thorax and Lung Examination

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1 Inspection

Thoracic cage

Respirations

Skin color and condition

Person's position

Facial expression

Level of consciousness

2 Palpation

Confirm symmetric expansion

Tactile fremitus

Detect any lumps, masses, tenderness

3 Percussion

Percuss over lung fields

Estimate diaphragmatic excursion

4 Auscultation

Assess normal breath sounds

Note any abnormal breath sounds

If abnormal breath sounds present, perform bronchophony, whispered pectoriloquy, egophony

Note any adventitious sounds

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