Lung Assessment; More than just listening!

1. Lung Assessment; More than just listening! Suzey Delger RN FNP

2. History….most important! • Hx: congenital lung problem? RSV? Cystic Fibrosis? • Asthma, Reactive Airway Disease? • Pneumonia? • Ask if they take any “inhalers”. • Allergic reactions: significance of respiratory distress.

3. Thorax Review

4. Don’t forget Right Middle Lobe Koenig's space AAL MCL MSL Rt.mid lobe

5. Inspection • Deformities, retractions, rate, & rhythm? • Kyphosis, scoliosis, deviated trachea • Tracheal tug, capillary refill • Schamroth sign: index fingers together, checks for true clubbing.

6. Palpation • Overall palpation: pain? Masses? Pulmonary excursion…place on costal margins with big breath, should be equal inflation. Repeat at xyphoid process. • Vocal/tactile fremitus. Have pt. say “99”, “99” while you are palpating with ball of your hand, area at base of fingers. Check side to side for bilaterally equal. If not equal & is > in one side vs. other= consolidation.

7. Auscultation • 1. Quality/intensity. • Vesicular: insp.>exp. Heard over most of lung. • Broncho-Vesicular: Insp.=exp. Heard over main stem bronchi, below clavicles between scapula esp. over right side. • Bronchial: exp.>insp., heard over trachea.

8. Normal vs. adventious breath sounds. • With stethoscope, listen side to side comparing bilateral symmetry don’t forget Koenigs space. • Use both bell and diaphragm. Start Anterior then to Posterior. Listen carefully for Right middle lobe and posterior lower lobes. • With greatly diminished breath sounds for asthmatics, when you cannot hear insp. OR exp. wheezing, there is NO AIR EXCHANGE. Serious situation.

9. Rales, Rhonchi, Friction rubs. • Rales, fine rales in smaller air passages, sounds like a lock of hair between your fingers near you ear. Louder, coarse rales originate in larger bronchi. Character may change with coughing. • Rhonchi (low pitched sd.)/wheezes(high pitched sds) are continuous sounds produced by air flow across narrowed passages. Insp./exp. Can be more prominent in expiration. • Pleural friction rubs: crackling or grating sounds originating in an inflamed pleura. Not affected by coughing. Usually very painful.

10. Bronchial breath sounds • listen

11. Crackles • listen

12. Wheezing • listen

13. Pertussis, whooping cough • listen

14. Pertussis

15. One more pertussis, whoop. • listen

16. Bronchophony, Egophony, & Whispered Pectoriloquy! • Bronchophony: increase in intensity and clarity of spoken voice sounds c steth. • Egophony: have the pt. say “E-E-E-E”, and if it sounds like ‘A-A-A-A’, then it is ABNL. • Whispered Pectoriloquy: describes an unusually clear transmission of whispered words. • All indicate: pulmonary consolidation.

17. For fun!

18. Percussion • Percussion tells you about the underlying structures approx. 5-7cm deep. Start at Koenig's space and work your way down comparing sides. • Keep finger flat on the surface and use wrist action….PRACTICE MAKES PERFECT! Measure Diaghragmatic excurtion posterior, 4-5cm wnl. Practice, mark spaces.

19. Percussion Tones • Flatness: soft, short duration, thigh. • Dullness: medium, medium duration, liver. • Resonance: loud, long duration, normal lung. • Hyper resonance: very loud, longer duration, Emphysematous lung. • Tympany: very loud, long duration, gastric bubble, puffed out cheek.

20. Let’s practice. • Be sure to have a method to your exam, always start the same way. • Hold hand away from surface of skin. • Hit hard! • Be quiet so all can hear.

21. Neck-agility. • Sometimes, I have to be hit over the head many times to “get it”….my take home message, don’t just listen to lungs with a stethoscope anymore….do it all!

23. Thanks so much for having me!

24. School Nurse’s Rock • Suzey_Delger@ncsd.k12.wy.us • Web site: • http://depts.washington.edu/physdx/pulmonary/tech.html