PEMERIKSAAN FISIK

SISTEM PERNAPASAN

Equipment Needed

A Stethoscope
A Peak Flow Meter
Surface markings of the lobes of the lung:
(a) anterior, (b) posterior, (c) right lateral and (d) left lateral.
(UL, upper lobe; ML, middle lobe; LL, lower lobe).

ul
ll Ul
ml

ul
ml
ll

b ll
 Position/Lighting/Draping

• Position –
• patient should sit upright on the examination table.
• The patient's hands should remain at their sides.
• When the back is examined the patient is usually asked to
move their arms forward (hug themself position) so that
the scapulae are not in the way of examining the upper
lung fields.
• Lighting - adjusted so that it is ideal.
• Draping - the chest should be fully exposed. Exposure
time should be minimized.
 The basic steps of the examination

• can be remembered with the

nemonic IPPA:
• Inspection
• Palpation
• Percussion
• Auscultation
 Health History

• Any risk factors for respiratory disease

• smoking
– pack years ppd X # years
– exposure to smoke
– history of attempts to quit, methods, results
• sedentary lifestyle, immobilization
• age
• environmental exposure
– Dust, chemicals, asbestos, air pollution
• obesity
• family history
 Cough

• Type
– dry, moist, wet, productive, hoarse, hacking, barking, whooping
• Onset
• Duration
• Pattern
– activities, time of day, weather
• Severity
– effect on ADLs
• Wheezing
• Associated symptoms
• Treatment and effectiveness
 sputum
• amount
• color
• presence of blood  (hemoptysis)
• odor
• consistency
• pattern of production
Past Health History

• Respiratory infections or diseases (URI)

• Trauma
• Surgery
• Chronic conditions of other systems
• Family Health History
• Tuberculosis
• Emphysema
• Lung Cancer
• Allergies
• Asthma
 Inspection

• Tracheal deviation (can suggest of tension pneumothorax

• Chest wall deformities [
• Kyphosis - curvature of the spine - anterior-posterior
• Scoliosis - curvature of the spine - lateral
• Barrel chest - chest wall increased anterior-posterior; normal
in children; typical of hyperinflation seen in COPD
• Pectus excavatum
• Pectus carinatum
 Thoracoplasty Kyphosis
with secondary
changes in the
.spine
Pectus exacavatum
 Signs of respiratory distress

• Cyanosis - person turns blue

• Pursed-lip breathing - seen in COPD (used to
increase end expiratory pressure)
• Accessory muscle use (scalene muscles)
• Diaphragmatic paradox - the diaphragm moves
opposite of the normal direction on inspiration;
suspect flail segment in trauma
• Intercostal indrawing
 ’blue bloater‘
pink puffer’. Note the‘
showing ascites
pursed-lip
from marked cor
breathing
.pulmonale
.
 Inspection
1. Respiratory movement
– Abdominal breathing: male adult and child
– Thoracic breathing: female adult
2. Respiratory rate: 16-18 f/min
– Tachypnea: >20 f/min
– Bradypnea: <12 f/min
– Shallow and fast
• respiratory muscular paralysis, elevated intraabdominal
pressure, pneumonia, pleurisy
– Deep and fast
• Agitation, intension
– Deep and slow
• Severe metabolic acidosis (Kussmaul’s breathing)
 Inspection
3. Respiratory rhythm
• Cheyne-Stokes’ breathing
• Biot’s breathing
_____Decreased excitability of respiratory center
• Inhibited breathing
– Sudden cessation of breathing due to chest pain
• Pleurisy, thoracic trauma
• Sighing breathing
– Depression, intension
 Palpation
• Thoracic expansion
– Massive hydrothorax,
pneumonia, pleural thickening,
atelectasis
• Vocal fremitus (tactil fremitus)
• Pleural friction fremitus
– Cellulose exudation in pleura due to
pleurisy
– Holding breathing disappeared
– Tuberculous pleurisy, uremia, pulmo
embolism
.Assessing chest expansion in expiration (left) and inspiration (right)

.Percussion over the anterior chest Direct percussion of the clavicles for
disease in the lung apices
 Palpation

• Tactile fremitus
is vibration felt by palpation. Place your open palms against the
upper portion of the anterior chest, making sure that the
fingers do not touch the chest. Ask the patient to repeat the
phrase “ninety-nine” or another resonant phrase while you
systematically move your palms over the chest from the
central airways to each lung’s periphery.You should feel
vibration of equally intensity on both sides of the chest.
Examine the posterior thorax in a similar manner. The
fremitus should be felt more strongly in the upper chest with
little or no fremitus being felt in the lower chest
Tactile Fremitus
 Tactile Fremitus

• Ask the patient to say "ninety-nine" several times

in a normal voice.
• Palpate using the ball of your hand.
• You should feel the vibrations transmitted through
the airways to the lung.
• Increased tactile fremitus suggests consolidation
of the underlying lung tissues
 Auscultation

• To assess breath sounds, ask the

patient to breathe in and out slowly and
deeply through the mouth.
• Begin at the apex of each lung and
zigzag downward between
intercostal spaces . Listen with the
diaphragm portion of the
stethoscope.
• Normal breath sounds
• Note
• Pitch
• Intensity
• Quality
• Duration
 Normal Breath Sounds
• Bronchial: Heard over the trachea and mainstem bronchi (2nd-4th
intercostal spaces either side of the sternum anteriorly and 3rd-6th
intercostal spaces along the vertebrae posteriorly). The sounds are
described as tubular and harsh. Also known as tracheal breath sounds.
• Bronchovesicular: Heard over the major bronchi below the clavicles in the
upper of the chest anteriorly. Bronchovesicular sounds heard over the
peripheral lung denote pathology. The sounds are described as medium-
pitched and continuous throughout inspiration and expiration.
• Vesicular: Heard over the peripheral lung. Described as soft and low-
pitched. Best heard on inspiration.
• Diminished: Heard with shallow breathing; normal in obese patients with
excessive adipose tissue and during pregnancy. Can also indicate an
obstructed airway, partial or total lung collapse, or chronic lung disease.
Normal auscultatory
sound
Percussion
 1. Method

– Mediate
• Pleximeter: distal inter-phalangeal joint of left middle
finger
• Plexor: right middle finger tip
– Immediate
– Order
• Up to down, anterior to posterior
 Percussion
Rational
• To determine if
underlying tissue is
filled with air or solid
material
Procedure
• Pt sitting
• Tap starting at shoulder
• compare rt to lf
 Percussion: results
• Resonance – drum like
– Normal
• Hyper-resonance
– Too much air
– Emphysema
• Flatness / dull
– Fluid or solid
– Pleural effusion
– Pneumonia
– Tumor
 2. Affected factors
– Thickness of thoracic wall
– Calcification of costal cartilage
– Hydrothorax
– Containing gas in alveoli
– Alveolar tension
– Alveolar elasticity
 3. Classification
– Resonance
• Normal
– Hyperresonance
• Emphysema
– Tympany
• Cavity or pneumothorax
– Dullness
• Hydrothorax, atelectasis
– Flatness
• Massive Hydrothorax
 4. Normal sound

• Lung’s sound in percussion

• Resonance
• Slight dullness in some areas (upper,
right, back) due to thickness of muscles
and skeletons
 4. Normal sound
Border of lungs in percussion
• Apex of lungs
– Kronig’s isthmus: 5cm in width
– Narrow: TB, fibrosis
– wider: emphysema
• Anterior border
– absolute cardiac dullness area
• Lower border
– 6th, 8th, 10th intercostal space in midclavicular line, midaxillary
line, scapular line, respectively
– Down: emphysema
– Up: atelectasis, intraabdominal pressure goes up
 4. Normal sound
 Shifting range of bottom of lung
ong the scapular line
s
ercussing bottom of lung, marking
Shifting range of
bottom of lung
sking the pat. to inspire deeply and hold

ercussing bottom of lung, marking 6-8 cm

sking the pat. to expire deeply and hold

ercussing bottom of lung, marking

 Decreased: emphysema, atelactasis,
easuring the dist. between upper and lower lines fibrosis, pulmo. edema, pneumonia
 Detected impossibly: pleura adhesion,
massive hydrothorax, pneumothorax,
diaphragmatic paralysis
 5. Abnormal sound
• Dullness, flatness, hyperresonance or tympany
appear in the area of supposed resonance.

• Unchanged sound (resonance)

– The depth of the lesion > 5 cm
– The diameter of the lesion  3 cm
– Mild hydrothorax
 5. Abnormal sound
Dullness or flatness
• Decreased containing gas in alveoli
– Pneumonia
– Atelectasis?
– TB
– Pulmo. embolism
– Pulmo. edema
– Pulmo. fibrosis
• No gas in alveoli
– Tumor
– Pulmo. Hydatid ( 肺包虫 )
– Pneumocystis ( 肺囊虫 )
– Non-liquefied lung abscess
• Others
– Hydrothorax
– Pleural thickness
 5. Abnormal sound
• Hyperresonance
– Emphysema
• Tympany
– Pneumothorax
– Large cavity (TB, lung abscess, lung cyst)
• Amphorophony ( 空瓮音 )
– Large and shallow cavity with smooth wall
– Tension pneumothorax
• Tympanitic dullness ( 浊鼓音 )
– Decreased tension and gas in alveoli
• Atelectasis
• Congestive or resolution stage of pneumonia
• Pulmo. edema
 5. Abnormal sound

Garland’s triangle area

• Special areas (tympanitic dullness)

on percussion
Damoiseau’s curve
in moderate
hydrothorax

Grocco’s triangle area

(dullness)
Auscultation
 Auscultation
Purpose
• Asses air flow
through bronchial
tree
Procedure
• Diaphragm of
stethoscope
• Superior  inferior
• Compare rt to lf
 Auscultation: Results
Normal
• Vesicular
– Lung field
– Soft and low
• Bronchial
– Trachea & bronchi
– Hollow
• Bronchovesicular
– Mixed
– Between scapulae
– Side of sternum
– 1st & 2nd intercostal space
 Auscultation: Results
Adventitious
• Crackles • Fine crackles
– Rales – Air  suddenly
reinflated
– air  bronchi with
secretions • Course Crackles
– Moist
 Auscultation: Results
• Wheezes – Sibilant Wheezes
– Sonorous wheezes • High pitched
• Whistle-like
• Deep low pitched
• I&E
• Snoring
• Caused by air 
• >E
narrowed passages
• Caused by air 
• D/t constriction
narrowed passages
– Asthma
• D/t  secretions
Normal auscultatory
sound
 Auscultation: Results
• Pleural friction rub
– D/t inflammation of
pleural membranes
– Grating, creaking
– I&E
– Best heard
• Anterior, Lower,
lateral area
 Auscultation: Results
• Stridor
– Crowing
– Partial obstruction of
the larynx or trachea
Order of auscultation
 Sound of auscultation

1. Normal breath sound

2. Abnormal breath sound
3. Adventitious sound
4. Vocal resonance ( 语音共振 )
 1. Normal breath sound
• Tracheal breath sound Bronchial
• Bronchial breath sound
– Larynx, suprasternal fossa,
around 6th, 7th cervical Bronchovesicular
vertebra, 1st, 2nd thoracic
vertebra
• Bronchovesicular breath sound
– 1st, 2nd intercostal space
beside of sternum, the level of Bronchial
3rd, 4th thoracic vertebra in
interscaplar area, apex of lung
• Vesicular breath sound
Bronchovesicular
– Most area of lungs
 2. Abnormal breath sound

• Abnormal vesicular breath sound

• Abnormal bronchial breath sound

• Abnormal bronchovesicular breath sound

 Abnormal vesicular breath
sound(1)
1) Decreased or disappeared
• Movement of thoracic wall
• Respiratory muscle weakness
• Obstruction of airway
• Hydrothorax or pneumothorax
• Abdominal diseases: ascites, large tumor
2) Increased
• Movement of respiration
Abnormal vesicular breath sound
(2)

3) Prolonged expiration
• Bronchitis
• Asthma
• emphysema
4) Cogwheel breath sound
• TB
• Pneumonia
5) Coarse breath sound
• Early stage of bronchitis or pneumonia
 Abnormal bronchial breath
sound
(tubular breath sound)

 Bronchial breath sound appears in supposed

vesicular breath sound area

• Consolidation: lobar pneumonia (consolidation stage)

• Large cavity: TB, lung abscess
• Compressed atelectasis: hydrothorax, pneumothorax
 Abnormal bronchovesicular
breath sound
• Bronchovesicular breath sound appears in
supposed vesicular breath sound area

– The lesion is relatively smaller or mixed with

normal lung tissue
 3. Adventitious sound

• (moist) Crackles

• Rhonchi (wheezes)

• Pleural friction rub

 Moist crackles

Mechanism
During inspiration, air flow passes thin
secretion in the airway to rupture the
bubbles, or to open the collapse of
bronchioli due to adhesion by secretion.
 Characteristics of crackles
1. Adventitious sound
2. Intermittent
3. Appeared in phase of inspiration or early
expiration
4. Constant in site
5. Unchanged in character
6. Medium and fine crackles exist meantime
7. Less or disappeared after cough
 Classification of crackles
• According to intensity of the sound
1. Loud moist crackles
2. Slight moist crackles
• According to diameter of the airway crackles appeared
1. Coarse: trachea, main bronchi, or cavity
• Bronchiectasis, pulmo. edema, TB, lung abscess, coma
2. Medium: bronchi
• bronchitis, pneumonia
3. Fine: bronchioli
• pneumonia
4. Crepitus:
• Bronchiolitis, alveolitis, early pneumonia (pulmo. Congestion),
elder subject, pat. bed rest for long time
 Site of crackles
1. Local: local lesion
– Pneumonia, TB, bronchiectasis
2. Both bases
– Pulmo. edema, bronchopneumonia,
chronic bronchitis
3. Full fields
– Acute pulmo. edema, severe bronchopneumonia,
chronic bronchitis with severe infection
 Rhonchi (wheezes)
Mechanism
The turbulent flow is formed in trachea, bronchi or
bronchioli due to airway narrow or incomplete
obstruction.
Causes
– Congestion
– Secretion
– Spasma
– Tumor
– Foreign subject
– Compression
 Characteristics of rhonchi

1. Adventitious sound
2. High pitch
3. Dominance in phase of expiration
4. Variable intensity of character or site
5. Wheezing
 Classification of rhonchi

1. Sibilant ( 高调 )
– Bonchioli, bronchi

2. Sonorous ( 低调 )
– Trachea, main bronchi
 Site of rhonchi

1. Both fields
– Asthma
– Chronic bronchitis
– Acute left heart failure
2. Local site
– Tumor
– Endobronchial TB
 Pleural friction rub
1. Cellulose exudation in pleurisy (rough pleura)
2. Area of auscultation
– Anterolateral thoracic wall (maximal shifting area of lung)
3. Friction rub disappeared if holding breath
4. Friction rub appeared both breath and heart beat:
mediastinal pleurisy
5. Causes
– Tuberculous pleurisy
– Pulmo. embolism
– Uremia
– Pleural mesothelioma
 Vocal resonance
• Bronchophony ( 支气管语音）
– Consolidation
• Pectoriloqny ( 胸语音 )
– Massive consolidation
• Egophony ( 羊语音 )
– Upper area of hydrothorax
• Whispered ( 耳语音 )
– Consolidation
 PENGKAJIAN ASKEP SISTEM
PERNAPASAN
TES DIAGNOSTIK
1. ABGs (ARTERRIAL BLOOD GAS
ANALYSIS
2. PEMERIKSAAN SPUTUM
3. ANALYSIS CAIRAN PLEURA
4. CHEST X-RAY
5. COMPUTERIZED AXIAL TOMOGRAPHY
(CAT, CT)
6. MAGNETIC RESONANCE IMAGING (MRI)
7. PULMONARY ANGIOGRAPHY
 PENGKAJIAN ASKEP SISTEM
PERNAPASAN
TES DIAGNOSTIK
8. VENTILATION-PERFUSION (V/Q)
SCAN
9. BRONCHOSCOPY
10.LUNG BIOPSY
11.PULMONARY FUNCTION TESTS
(PFTs)
12.PULSE OXIMETRY
13.CAPNOGRAPHY