Chest assessment

Original Editor - Mandeepa Kumawat Top Contributors - Mandeepa Kumawat, Adam Vallely Farrell and Kim Jackson

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Respiratory Assessment

Respiratory conditions can affect breathing either through damage to the lungs or excess secretions. To ensure that the correct treatment is implemented a thorough respiratory assessment is undertaken and should include both a comprehensive subjective and objective component to get a complete understanding of the client's function and baseline.


CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

•Site , intensity , type , aggrevating factor and relieving factor (SITAR)

•Onset - sudden or gradual

•Location - radiating

•Duration - frequency or chronology ( seasonal or daily variations )

•Characteristics - quality or severity

•Current situation - improving or deteriorating

•Effect on activity of daily living (ADL)

•Previous diagnosis of similar episodes

•Previous treatment and efficacy

SUBJECTIVE ASSESSMENT

Cardinal signs and symptoms :-

1.Cough : onset - sudden or gradual

duration - Acute < 3 weeks

Chronic - >3 weeks

Nature - Dry : irritation

Wet : signs of infection

Type - Mucoid

Mucopurulent : TB

Froathy : pulmonary oedema

Rusty ( blood ) : TB , lobar pneumonia

Odour - foul : infection


2) sputum : Amount (tea spoon , table spoon , cup )

Normal - 100 ml of tracheobronchial secretions are produced daily and cleared subconsciously


Color :

• Blood streaked sputum : inflammation of throat ( larynx , trachea ) or bronchi , lung cancer , ulcers

•Pink sputum : sputum and blood formed from alveoli and small peripheral bronchi

•Massive blood : cavitary TB , lung abscess ,bronchieactasis , lung infarction , pulmonary embolism

•Green or greenish coloured infection : pneumonia , cystic fibrosis ( green from degenerative changes in cell debris )

•Rust colored - pneumococcal bacteria , pulmonary TB

•Brownish - chronic bronchitis ( greenish / yellowish / brown ) , chronic pneumonia ( whitish - brown )

•Yellowish purulent - pus - haemophilus

Yellowish - green ( mucopurulent ) - treatment with antibiotics that reduce symptoms - bronchiectasis , cystic fibrosis , pneumonia

• Whitish grey - chronic allergic bronchitis ( no. of eosinophilis )

•White , milky or opaque (mucoid) - viral infection or allergy ( asthma )

•Foamy white - earlier phase - pulmonary edema

•Froathy pink - severe pulmonary edema

•Black - black specks in mucoid secretions - smoke inhalation ( fires , tobacco , heroine ) , coaldust


3) Breathlessness-

The physiotherapist should always relate breathlessness to the level of function that the patient can achieve

  • Exercise tolerance ( no. of stairs client can climb or can walk )
  • Shortness of breath at rest
  • Association of paraoxysmal nocturnal dyspnea (PND)
  • Associated swelling of ankles or recent weight gain
  • Activities : Sudden ( pneumothorax , pulmonary embolism , DVT )

Always ( fibrosis , fluid )

SCALES -

A.NYHA ( New York Heart Association )

Grade 1 - no symptoms and limitation in ordinary physical activity

Grade 2 - mild symptoms , angina and slight limitation in ordinary activities

Grade 3 - marked limitation in activity due to symptom , even during less than ordinary activity .

Grade 4 - severe limitation , experience symptoms even at rest mostly bed bound patient .

B. MMRC ( Modified Medical Research Council )

Grade 0 - no dyspnea except with strenous exercise

Grade 1- dyspnea when walking up on the hill or hurrying on the level

Grade 2 - walks slower than most on the level or stops after 15 minutes of walking on the level.

Grade 3 - stops after few minutes of walking on the level.

Grade 4- dyspnea with minimal activity such as getting dressed or too dyspneic to leave the house.

C. ATS (AMERICAN THORACIC SOCIETY)

Grade 0- none - no trouble of dyspnea on level / uphill

Grade 1 - mild - dyspnea on at level / uphill.

Grade 2 - moderate - walks slower than person of same age

Grade 3 - severe - stops after 100 yards

Grade 4 - very severe - breathlessness

4. CHEST PAIN -

Chest pain in respiratory patients usually originate from musculoskeletal , pleural or tracheal inflammation as lung parenchyma and small airways contain no pain fibres.

Example : Pleuritic chest pain

Tracheitis

Musculoskeletal (chest wall) pain

Angina pectoris

Pericarditis


Efforts to treat - Heat , Splinting , Pain medication


INCONTINENCE - Coughing and huffing increases intra - abdominal pressure which may precipitate urinary leakage

5. OTHER SYMPTOMS:

Fever (pyrexia) - TB

Headache - morning headache - nocturnal CO2 retention

Peripheral oedema - right heart failure

Shivering

Weight loss

Palpitations

Vomiting and nausea

Gastro intestinal reflex


Past medical history- •Thoracic , nasal , pharyngeotracheal , trauma or surgery , hospitalisation for pulmonary disorders.


•Use of ventilation - assisting devices


•COPD- TB , bronchitis , emphysema , etc


•Other chronic disorders - cardiac , cancer , blood clotting disorders


•Allergy


•Immunization (pneumococcal , influenza )


•DM / TB / BP / asthma


Surgical history -

Endoscopy , tracheostomy , lobectomy


Personal and social history -

Sleep

Appetite / bowel , bladder / nutrition

Smoking

Exercise tolerance

Home environment

Economic condition - poor / fair / good


OBJECTIVE ASSESSMENT


General examination

Vital sign :

Temperature

Pulse

Respiratory rate

Blood pressure

Spo2


General appearance- Ectomorph

                                  Mesomorph
                                  Endomorph


Body weight - BMI - weight in kg

                               Height in meter square 

Nails - Clubbing


Eyes - pallor (anaemia)

           Plethora (high haemoglobin)
           Jaundice (yellow color due to liver or blood disturbance)


Tongue and mouth - Cyanosis - hypoxemia


Jugular venous pressure - increased in right heart failure , chronic lung disease , dehydrated patient


Peripheral oedema - seen in decreased albumin level , impaired venous or lymphatic function , increased steroids

   In bedbound patients , check the sacrum.


Observation of chest-

Transverse diameter > A P Diameter


Abnormalities - •Kyphosis


•Kyphoscoliosis - restrictive lung defect


•Pectus carinatum - pigeon chest


•Hyperinflation or barrel chest - AP = transverse - ribs horizontal


Breathing pattern -

12 to 16 breath per minute

Inspiratory : expiratory = 1:1.5 to 1:2

Check for bradypnea , tachypnea , hyperventilation

Prolonged expiration - 1:3 to 1:4

•Pursed lip breathing


•Apnoea


•Hypopnea


•Kaussamaul ‘s respiration - metabolic acidosis


•Cheyne strokes respiration - drugs ( narcotics) , heart failure , neurological disturbances


•Ataxic breathing - cerebellar disease


•Apneutic breathing - brain damage


•Thoracoabdominal - female ; abdominothoracic


• ICU Patients - mode of ventilation ( supplemental oxygen , intermitent positive pressure ventilation)


•Route of ventilation (mask , endotracheal tube , tracheostomy )


•Level of consciousness (glasgow coma scale)


•Central venous pressure (CVP) , pulmonary artery pressure (PAP)


PALPATION :

TRACHEA - tracheal deviation indicates underlying mediasternal shift . trachea may be pulled towards in collapsed or fibrosed upper lobe or pushed away from pneumothorax or large pleural effusion .


CHEST EXPANSION - BY TAPE :

Supramammary - 1.5cm

Mammary - 1.5 cm

Inframammary - 1cm


   Technique : at residual volume , the examiner ‘s hands are placed spanning the posterolateral segment of both bases , with the thumbs touching in the midline posteriorly . both the sides should move  equally with 3 - 5 cm being the normal displacement.


Hoover’s sign :
      Paradoxical movement of the lower chest can occur in patients with severe chronic airflow limitation who are extremely hyperinflated . as the dome of the diaphragm cannot descend any further diaphragm contraction during inspiration pulls the lower ribs inwards. This is called hoover’ s sign.


Vocal fremitus -

    It is the measure of speech vibrations transmitted through the chest wall to the examiner’ s hands .It is the measure by asking the patient to repeatedly say ‘ggg’ or 111 whilst the examiner`s hands are placed flat on both sides of the chest .
  Increase in patient whose lung underneath is relatively solid ( consolidated)

Decrease in patient - pneumothorax or pleural effusion.


PERCUSSION -

It is performed by placing the left hand firmly on the chest wall so that the finger have good contact with the skin . the middle finger of the left hand is struck over the DIP joint with the middle finger of the right hand . for all the positions , percuss at 4 to 5 cm intervals over the intercostal spaces , moving systematically from superior to inferior and medial to lateral .


Resonance - the expected sound can usually be heard over all areas of the lungs.

Hyper resonance - associated with hyperinflation may indicate emphysema , pneumothorax or asthma.

Dullness or flatness - pneumonia , atelactasis , pleural effusion , pneumothorax or asthma.

Tympany - sound usually associated with percussion over the abdomen .


AUSCULTATION :

Auscultation with the stethscope provides important clues to the condition of the lungs and pleura . all sounds can be characterized in the same manner as the percussion notes , intensity , pitch , quality and duration. 

1.Breath sound : normal - bronchial , vesicular


   Abnormal - crackels, rhonchi ,wheeze , pleural friction rub.


2. Vocal resonance :

Transmission of voice through the airway and lung tissue to the chest wall where it is heard through a stethscope . it is usually tested by instructing the patient to say ‘99’ repeatedly .

  Decrease in resonance - emphysema , pneumothorax , pleural thickening or pleural effusion .


3. Heart sound :

1st - closure of mitral and tricuspid valve.

2nd - closure of pulmonary and aortic valves.

3rd - cardiac failure

4th - heart failure , hypertension , aortic valve disease


TEST RESULTS : 1.SPIROMETRY - The forced expiratory volume in 1 second (FEV) , the forced vital capacity ( FVC ) and peak expiratory flow rate (PEFR) are important measures of ventilatory function.


2.ARTERIAL BLOOD GASES - ABG provide an accurate measure of O2 uptake and CO2 removal by the respiratory system as a whole


             Normal values :
                 pH : 7.35 TO 7.45
           PaO2: 10.7 to 13.3 kPa ( 80 - 100 mmHg)
         PaCO2: 4.7 TO 6.0 KPa (35 to 45 mm hg)
          HCO3: 22 - 26 MMOL / L 
Base excess : -2 to +2 


3. Chest radiograph