Assessment of the respiratory system

Physical Therapy Year 3

BY: S.KIPLAGAT
MSc PT
Anatomy and physiology
The respiratory tract extends from the nose to the
alveoli and includes not only the air-conducting
passages also but the blood supply

The primary purpose of the respiratory system is gas

exchange, which involves the transfer of oxygen and
carbon dioxide between the atmosphere and the
blood.

The respiratory system is divided into two parts:

a) The upper respiratory tract
b) The lower respiratory tract
 The upper respiratory tract
includes

The nose
 pharynx
larynx,
and trachea.
The lower respiratory tract consists
of:
the bronchi,
Bronchioles
 alveolar ducts
 and alveoli
 With the exception of the right and left main-stem
bronchi, all lower airway structures are contained
within the lungs.
 Anatomy of Respiratory System
The lung is a two cone-shaped, elastic structure suspended within
the thoracic cavity.
Lungs are paired, they are not completely symmetrical, the right

lung contains three lobe, whereas the left lung contains only two
lobes.
The apex of each lung extended slightly above the clavicle,

where the base is at the level of diaphragm

The thoracic cavity contains the nasopharynx, larynx, trachea,

bronchi, bronchioles, alveoli.

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 The thoracic cavity is lined by a thin, double- layered serous
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The right lung is divided into three lobes (upper,
middle, and lower)
 the left lung into two lobes (upper and lower)
The structures of the chest wall
(ribs, pleura, muscles of respiration) are also essential
Muscles of inspiration
The diaphragm-innervated by the phrenic nerve (C3-5)
External intercostals-elevate anterior position of the
ribcage (T1-T11)
 Muscles of expiration
Internal intercostal muscles (T1-L1)
Abdominal muscles-powerful expiratory muscles –
increases the abdominal pressure and displaces the
diaphragm upward.
Accessory muscles-Become active during vigorous
activities i.e exercises or during labored breathing i.e
asthma
Example of Accessory muscles- SCM, scalenes, pectoral
muscles, trapezius, abdominals, platysma

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Assessment of respiratory system
Subjective data: the PT must ask the client about:-
Coughing (productive, non productive)
Sputum (type, amount, color, presence of blood
(hemoptysis), Odor, Consistency, pattern of production)
 Allergies, dyspnea or SOB (at rest or on exertion).

Chest pain, history of asthma, bronchitis, emphysema,

tuberculosis.
Exposure to environmental inhalants (chemicals, fumes).

History of smoking (amount and length of time)

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 Technique for Respiratory Exam
Before beginning, if possible:

Quiet environment

Proper positioning (patient sitting for posterior thorax exam,

supine for anterior thorax exam)

Expose skin for auscultation

Patient comfort, warm hands and diaphragm of stethoscope, be

considerate of women (drape sheet to cover chest)

After that apply the four techniques; Inspection,

12 Palpation, Percussion and Auscultation
Initial Respiratory Survey (Inspection)
Observe the patient’s breathing pattern
Rate (normal vs. increased/decreased)
Depth (shallow vs. deep)
Effort (any sign of accessory muscle use, inspect neck)
Signs of distress:
 Dysnoea
 Intercostal recession
 Nasal flaring
 Grunting
 Cyanosis of toes and fingertips
 Tachypnoea
 Sternal retraction in infants

Finger clubbing: filling of the angle between the skin and the
base of a nail. It is associated with bronchiectasis, cystic fibrosis,
bronchial tumors, chronic aseptic conditions.
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 Assess the patient’s color
Normal, pale, cyanosis

Pink puffers-in early stages of Chronic Obstructive

Airway Disease (COAD) patient attempts to compensate
for changes in level of blood gases by increasing the RR
resulting in a pink flush in the face.

Blue bloaters-when compensatory mechanisms are not

effective, patients become hypoxic and the R side of the
heart fails rapidly. There is visible central cyanosis and
bloating oedema
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 ’blue bloater‘
pink puffer’. Note the‘
showing ascites
pursed-lip
from marked cor
breathing
.pulmonale
.
Inspection and assessment of respiration patterns
Assess the skin and overall symmetry and integrity of the
thorax.

Assess thoracic configuration.

Client must be uncovered to the waist, and in sitting position

without support.
Normal Respiratory Rates
Infant 30-40
Toddler 24-40
Preschooler 22-34
School-age child 18-30
Adolescent 12-16
Adult 16-20
Assess pattern of respiration
Normally: ratio I:E-1:2

Tachypnea: respiratory rate over than 20/m for adult.

Bradypnea: respiratory rate less than 10/m.

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 Cont.
Observation of skin may give you knowledge about
nutritional status of the client.

Assess for abnormality of configuration, e.g. pigeon

chest, funnel chest, spinal deformities.

Assess ribs and inter spaces on respiration – may give

information about obstruction in air flow e.g. bulging
of inter spaces on expiration may be from obstruction
to air out flow “tumor, aneurysm, cardiac enlargement”

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 Inspect the chest shape
Normal
Barrel shaped: Increased AP diameter, dorsal kyphosis,
neck appears short due to raised ribs, common in
COAD: asthma, chronic bronchitis, emphysema
Congenital
 Funnel shaped (pectus excavatum)- sternum depressed
at lower end, usually associated with kyphosis
 Pigeon shaped (Pectus carinatum)-Sternum projects
forward, severe asthmatics
 Others: Scoliosis, kyphosis, kyphoscoliosis

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 Barrel shape Pigeon shape

20 Kyphosis
 Palpation
palpate areas of chest especially areas of
abnormalities.
If patient complains: all chest areas must palpated
carefully for tenderness, bulges, or any movements
Skin temperature-normal; hot; cold
*done with dorsal aspect of the arm
Oedema: absent, Generalized/localized;peripheral;
pitting/non/pitting
Pitting –skin remains dented for a few minutes
Secretions- usually palpable through the chest wall

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 Assess thoracic expansion:
It is possible to estimate the extend and nature of
movements of the thorax and the condition of the
lungs by placing the hands on the chest wall.
Place hands over the main areas where movement
occurs so as to compare both sides:
a. On either side of the manubrium sterni to assess the
degree of apical movement.
b. Nipple line T4 –mid thoracic zone
c. Over the lateral aspects of the ribcage –lower costal
movement
d. Below the scapula to assess posterior thoracic movt
e. Across the costal arch to assess movement of the
diaphragm
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By these ways you feel amount of thoracic expansion
during quiet and deep breathing, and symmetry of
respiration between left and right hemi thoraces.

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 Chest expansion measurement
These are quantitative means of assessing movement
of the thoracic cage.

Measurements are done using a tape measure at three

levels.
Common landmarks:-
At the level of axilla and sternal angle
At the level of xiphoid process
At the level of tenth costal cartilage

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 Ensure the patient is supported in sitting with the arms
Procedure
by his side and accessory muscles relaxed.
The patient should be alert and able to follow
instructions.
Instruct the patient fully before any measurements.
Take the resting measurement.
Ask the patient to breath in fully. Do not record this
Ask him to breath out fully. Record this measurement
Ask him to breath in again. Record this measurement
Repeat the procedure three times at each level.
Calculate the difference between the two
measurements and record the amount of expansion.

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 Calculate the mean values at each level and record.

Measurements Axilla Xiphoid process 10th costal

cartilage
RESTING
EXPIRATION
INSPIRATION
EXPANSION

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 Normal chest expansion: 2-3cm in healthy people
-Athletes-expansion up to 5cm
-Diseased lungs: less than 2cm
Inequality of bilateral expansion may be caused by:
a) Consolidation/collapse (atelectasis) of a lobe or
bronchopulmonary segment, common in conditions
like:*pneumothorax, pleurisy with effusion, lobar
pneumonia, TB
b) Fibrosis or neoplastic growths
c) Pain: after thoracic or high abdominal surgical
incision, trauma i.e fractured rib

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Tactile Fremitus
 Assessment of fremitus: which is vibration perceptible on
palpation"
 In subcutaneous emphysema: you must palpate the tissue,
audible cracking sounds are heard – these sounds are
termed Crepitation
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
Percussion of chest:
 Done to determine relative amounts of air, liquid, or solid material
in the underlying lung, and to determine positions and boundaries
of organs.
 Percussion done for posterior, anterior and lateral aspects of chest
with all directions, and with about “5”cms intervals.

Percussion over the anterior chest Direct percussion of the

clavicles to assess for
disease
in the lung apices
 The normal sound expected is resonance

Resonant sounds: Are low pitched, hollow sounds

heard over normal lung tissue

Hyper resonant sounds indicates emphysema and is

similar to the sound of puffed cheeks

Dullness on percussion suggests pleural effusion.

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 Auscultation:
To obtains information about the function of the
respiratory system & to detect any obstruction in
the passages.
Instruct the patient to breathe through the mouth
more deeply and slowly than in usual respiration
and then to hold the breath for a few seconds at the
end of inspiration to increase intrapleural pressure
and reopen collapsed alveoli.
Auscultate all areas of chest for at least one
complete respiration: 12 anterior locations and 14
posterior locations
Auscultate symmetrically: Should listen to at least

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6 locations anteriorly and posteriorly
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 Areas to be auscultated
Upper lobes: Beneath clavicles anteriorly
-In the supraspinous fossae posteriorly
Middle Lobe/Lingula:T4
All lobes: Axillae
Lower lobes: Lower ribs 7-10 at the back.

Note: When auscultating with the patient in side-lying

the effect of posture must be taken into consideration.
Breath sounds are decreased in the underneath lung.
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 Breath sounds
Breathe sounds: are analyzed according to pitch,
intensity, quality, and relative duration of
inspiratory and expiratory phases.

Normal breath sounds are distinguished by their

location over a specific area of the lung and are
identified as tracheal, vesicular, bronchovesicular, and
bronchial (tubular) breath sounds as the next:

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 1. Tracheal
Very loud, high pitched sound
Inspiratory = Expiratory sound duration
Heard over trachea in the neck

2. Bronchial
Loud, high pitched sound
Expiratory sounds > Inspiratory sounds
Heard over manubrium of sternum
If heard in any other location suggestive of consolidation

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 3. Broncho vesicular
Intermediate intensity, intermediate pitch
Inspiratory = Expiratory sound duration
Heard best 1st and 2nd ICS anteriorly, and between scapula
posteriorly
If heard in any other location suggestive of consolidation

4. Vesicular
Soft, low pitched sound
Inspiratory > Expiratory sounds
Major normal breath sound, heard over most of lungs

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 Patterns of consolidation
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Adventitious Breath Sounds
An abnormal condition that affects the bronchial tree and alveoli
may produce adventitious (abnormal= additional) sounds.
Adventitious sounds are divided into two categories: discrete,
non continuous sounds (crackles) and continuous musical
sounds (wheezes) as the next:

1. Crackles (Rales)
Discontinuous, intermittent, nonmusical, brief sounds. Heard
more commonly with inspiration
Classified as fine or coarse
Its is associated with Prolonged recumbency
Crackles caused by air moving through secretions and collapsed
alveoli and associated with the following conditions: pulmonary
edema, bronchitis, early CHF, and pneumonia
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 2. Wheeze
Continuous, high pitched, musical sound, longer than
crackles
Whistle quality, heard during expiration, however, can be
heard on inspiration
Produced when air flows through narrowed airways
Associated conditions: asthma, chronic bronchitis, and
COPD

3. Rhonchi
Similar to wheezes (subtype of wheeze)
Low pitched, snoring quality, continuous, musical sounds
Implies obstruction of larger airways by secretions
Associated condition: acute bronchitis
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4. Stridor
 Inspiratory musical wheeze
 Loudest over trachea
 Suggests obstructed trachea or larynx
 Medical emergency requiring immediate attention
 Associated condition
 inhaled foreign body

5. Pleural Friction Rub

 Pleural friction rubs are specific examples of crackles.
Discontinuous or continuous brushing sounds
 It is a loud dry, cracking or grating sound indicating of pleural
irritation, heard over lateral and anterior lung in sitting position that
heard during both inspiratory and expiratory phases
 Occurs when pleural surfaces are inflamed and rub against each
other
 Associated conditions as pleural effusion, Pneumonothorax
Medical conditions associated with decreased or absent of
breath sounds
Asthma
COPD
Pleural Effusion: fluid accumulating within the pleural space
Pneumothorax: caused by accumulation of air or gas in the
pleural space.
ARDS( adult respiratory distress syndrome)
Atelectasis : is defined as a state in which the lung, in whole
or in part, is collapsed or without air entry

Five Main Symptoms of Respiratory Disease

Cough Sputum Pain
Breathlessness Wheeze
 Respiratory defense mechanisms
1. Mucociliary blankets
2. Cough mechanism
3. Cellular and immunological mechanisms

A. Mucociliary blankets
Nose, trachea, bronchi and bronchiole are lined with
-Mucous membrane* consists of mucous secreting
goblet cells produce mucous which traps foreign
particles.
-Ciliated epithelial cells-cilia move the mucous upwards
towards the pharynx.
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 *ciliary action is depressed by cold, increased with
temp rise
Increase in viscousity of mucous decreases the rate and
force of ciliary action

B. Cough mechanism
Sneezing is stimulated by large foreign particles in the
nose.
Coughing is the main way in which the lungs are kept
clean.
Cough reflex is stimulated by irritation of the mucous
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membrane anywhere in the respiratory tract.
 Causes of cough failure:-
• Local airway anaesthesia
• CNS depression i.e coma, after using depressant drugs
such as heroin, codeine
• Neurological diseases affecting abdominal muscles i.e
poliomyelitis
• Weakness of expiratory muscles i.e spinal cord lesions
• Lung diseases: decreased expiratory flow rate due to
loss of elastic recoil and airway obstruction e.g chronic
bronchitis, emphysema

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 C. Cellular and immunological defenses
Alveolar macrophages and leucocytes-ingest foreign
particles
B lymphocytes-responsible for humoral immunity.
Most are effective against bacterial infections caused
by streptococci, pneumococci, influenza bacilli.
Produce immunoglobulins against specific antigens.
T lymphocytes are for cell mediated immunity-active
in combating chronic bacterial infections i.e TB
Immunoglobulins(circulating plasma proteins) assist to
reduce the harm done by foreign materials(antigens)
Interferons (proteins) assist in defense by viral
infections.

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 CHEST RADIOGRAPHS
Importance:-
1. Accurate diagnosis of thoracic diseases
2. Localization of thoracic diseases
3. Exclude presence of diseases in patients with
respiratory diseases
However, X-ray findings lag behind other measurements
i.e pyrexia-an early indication of chest infection
X-ray signs of pneumonia present weeks or months after
resolution of the disease.

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 VIEWS
• PA(Posterioranterior)
Standard film
Patient positioned so that anterior chest is against the
film cassette and back to the xray tube. Arms
abducted; scapula protracted. Xray centered at T4
spinous process
• AP (Anteriorposterior)
Portable film. For less mobile pts. Back against film
cassette. Lung fields are partly obscured by scapula,
raised diaphragm and magnified heart.

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 • Lateral
Patient at 90 degrees to film cassette. Side of interest
placed against film cassette, arms extended forward.
• Decubitus
Xray beam horizontal to the floor patient lying in a PA
position. Useful in identifying pleural effusion, lung
abcess.
Colour
Any dense tissue;-bones, malignancies
Fluid is opaque (white)
Air presents black/translucent-lungs

decubitus
50 position
 Analysis-XRAY
1. Patient’s name
2. Date of film
3. View
4. Quality/exposure-distinguished through heart
shadow
5. Posture-Symmetrical if medial ends of clavicles are
equidistant from spinous processes. Signs of
asymmetry;-trunk side flexion, depressed/elevated
clavicles & scapulae, kyphosis, lordosis, scoliosis
6. Trachea- dark column of air, inclines slightly to the
right before branching to main stem bronchi (T5)
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 Heart
-Less than ½ diameter of internal diameter of the chest
on PA film, 15.5cm in adult.
Hila
-Pulmonary vessels and lymph nodes make up hilar
shadows. Left hilum slightly higher than right. The hila
are of equal density and size.
Diaphragm
-Dome shaped. On full inspiration-height is level of 6th
rib anteriorly and 10th rib posteriorly.
-Left side lower-pushed down by heart; Right side
higher-presence of liver.
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 Low diaphragm-emphysema
Flat diaphragm-hyperinflation
If one side of diaphragm is raised than usual-
atelectasis, paralyzed hemi diaphragm, excess gas in
stomach
Lung fields-Normal lung contains air and is
dark/translucent
With pathology present, lung fields are generally
/partially opaque (white) or very dark.

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 Ribs
Posterior horizontal; anterior ends pass in-and
downward if no pathology present.
Chest shape affected by chronic pulmonary conditions-
barrel; funnel shaped-ribs more horizontal.
On full inspiration -9 ½ ribs observed
Hyperinflation-more than the above, flattened
diaphragm

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55 Normal Lung X-RAY
 Management-Chest physiotherapy
Breathing exercises
1. Diaphragmatic breathing
Aim
• To encourage relaxed breathing with less emphasis on
the upper chest.
• Minimizes the work of breathing
• Helps to relieve breathlessness at rest and on exertion
• Improves ventilation of the bases of the lungs

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 2. Localized breathing exercises
 Localized basal expansion
Aim
• To assist in the loosening of excess bronchial
secretions
• To assist in the removal of secretions
• To improve movement of the thoracic cage
• Aid re-expansion of lung tissue
• Improve ventilation

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 3. Relaxed positions for the breathless patient
Aim
To encourage a patient to control his breathing during an
attack of dyspnea.
• High side lying
• Forward lean sitting
• Relaxed sitting
• Forward lean standing
• Relaxed standing

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 4. Forced expiratory techniques
5. Active cycle of breathing techniques(ACBT)
6. Manual secretion removal techniques-percussion,
shaking and vibration.
7. Postural drainage
8. Agility exercises

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 Underwater seal drainage
Also known as intercostal chest drain (ICD)
Indications
• Haemothorax-as a result of trauma i.e gunshot or stab
wounds.
• Pneumothorax
1. Trauma
2. Spontaneous pneumothorax-surgical i.e aspiration, biopsy,
rapture of bullae- violent exercises, underwater diving
3. Tension pneumothorax-when the pleural surface is torn
causing pressure build up after each breath. This causes
compression of the heart, large blood vessels and lungs. Causes
death if pressure is not relieved.
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 Incision is made in midaxillary line between 5th and 6th
intercostal space.
Chest tube with holes at end placed inside pleural
cavity
Tube is connected to rigid transparent tube inside
bottle that is below water level-underwater seal
Bottle consist of a vent/open tube to allow
displacement of air.

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 Patency of UWCD
Observations:
 Bubbling
Air in the pleural cavity-unresolved pneumothorax
There is an air leakage arising from a hole in the tubing
if: bubbles continue after lung has re-expanded.
Patient is asked to take a deep breath and cough and
bubbles appear.
 Oscillation of fluid level-rises on inspiration: falls
with expiration
No oscillation –possible blockage or kinking of tube

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 Cont’
Management: undo kinking, milking of tube, physician
intervention
 Colour of fluid
 Amount of fluid drained.
Precautions and contraindications
1. UWCD always below level of chest tubing (siphoning)
2. If bottle breaks, clamp tube immediately and report to
nurse
3. If tube comes off the chest, seal wound with hand
immediately and report to nurse.

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 Problems of patients with UWCD
a. Pain
b. Poor/asymmetrical posture
c. Decreased chest expansion
d. Decreased/added breath sounds
e. Decreased mobility; general, shoulder, trunk
f. Retention of pulmonary secretions
g. Ineffective cough
h. Accumulation of air/fluid in pleural cavity

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 Aims of PT treatment
Decrease pain: talk to nursing staff to provide
analgesics
Correct posture
Improve chest expansion
Improve breath sounds
Improve mobility: general, shoulder and trunk
Removal of pulmonary secretions
Teach /facilitate effective cough
Facilitate drainage of air/fluid from pleural cavity

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