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Episode 4: Lungs and Thorax
81 Plays9 months ago
Here is a brief review guide to assessment of the lungs and thorax including inspection, palpation, percussion and auscultation. Below is a link to the sources used to form this podcast as well as to a youtube video you may find helpful in learning lung sounds.
(3) Name That Lung Sound Quiz | Normal and Abnormal lung sounds, types, #respiratory - YouTube
FB group: https://www.facebook.com/groups/1415202242471170/
Dains, J., Baumann, L., & Scheibel, P. (2024). Advanced health assessment and clinical diagnosis in primary care (7th ed.). Elsevier.
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2024). Bates’ Guide to Physical Examination and history taking. Wolters Kluwer.
Global Initiative for Asthma (GINA) Report: 2023 Update. Available at: GINA Asthma Management and Prevention
National Heart, Lung, and Blood Institute (NHLBI), National Asthma Education and Prevention Program Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Available at: NHLBI Asthma Guidelines
Yawn, B.P., & Wollan, P.C. (2016). "Asthma characteristics, management, and outcomes in primary care: a report from ASPN." The Journal of Family Practice, 65(10), 699-706.
Global Initiative for Chronic Obstructive Lung Disease (GOLD) Report: 2023 Update. Available at: GOLD COPD Management Guidelines
National Institute for Health and Care Excellence (NICE) Guideline [NG115]: Chronic obstructive pulmonary disease in over 16s: diagnosis and management. Available at: NICE COPD Guidelines
Vestbo, J., et al. (2013). "Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary." American Journal of Respiratory and Critical Care Medicine, 187(4), 347-365.
Mandell, L.A., et al. (2019). "Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults." Clinical Infectious Diseases, 44(S2), S27-S72.
National Institute for Health and Care Excellence (NICE) Guideline [NG138]: Pneumonia in adults: diagnosis and management. Available at: NICE Pneumonia Guidelines
Jain, S., et al. (2015). "Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults." New England Journal of Medicine, 373(5), 415-427.
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Transcript
Introduction to the Podcast
00:00:00
shermanappel
Hello and welcome back to the advanced practice registered nursing mastery podcast with Jackson Jorgensen. I'm going to be your host again today.
Respiratory Health Assessment Overview
00:00:08
shermanappel
Um, the topic today is going to be the respiratory system and the thorax. And we're going to be talking about health assessment of those systems, uh, as well as we'll go over the three most common diagnoses of respiratory distress, uh, accompanying respiratory distress. Um, and we'll talk about, you know, signs and symptoms, accompanying each of those and the lung sounds that you'll hear. accompanying them. um We'll also talk about good ways to learn lung sounds, um and we'll talk about what average documentation might look like for your ah respiratory or thorax assessment on a soap note. So um if any of that information would be useful to you, go ahead and keep on listening. If not, no worries, move on. You have more important things to do with your time, I'm sure.
00:00:50
shermanappel
um Once again, this podcast is just a resource for me and hopefully anybody else that's starting to become a nurse practitioner or other advanced practice registered nurse. um The goal is to further my own knowledge and hopefully throughout doing that, I'm able to help you guys as well.
Thorax Assessment Techniques
00:01:05
shermanappel
So um feel free to reach out to me through email if there's any topics that you feel like I need to do better on or to discuss more. I'm more than happy to to answer any questions about this podcast. So um we'll just go ahead and dive right into the show. So introduction to respiratory system, what you're going to be looking at here is the thorax of the body. So you're going to be looking at the chest and ah very upper abdomen. So anything between the diaphragm um and the mouth, really, you can be considering as part of your respiratory assessment. So you want to include you know the trachea, the lungs, the diaphragm. um And you're going to be looking both front and back. You're going to also want to make sure that you're paying attention to the ribs as you're assessing.
00:01:49
shermanappel
um So as you walk into the room with this patient, you're doing a focused assessment on the respiratory system. Immediate signs of distress are going to be things that are going to jump out to you. You know, are they already tripoding? Are they doing purse mouth breathing? um Are they obviously red in the face, sweaty, diaphoretic, having a hard time ah breathing? Those are all things that can clue you into possible cardio or respiratory distress. um You're going to want to i make sure that you pay attention not only to those obvious and symptoms of distress, but also how fast are they breathing? um Looking for more subtle things like skin color, especially in infants. um Is their breathing audible? Can you hear wheezing as they're breathing in and out? Do they have stridor in their upper airways? Do you see ah accessory muscle use? When we say accessory muscle use, this is
00:02:43
shermanappel
you know using more than just the typical muscles that you would expect somebody to involve in breathing. okay They're having to have real retractions in their intercostal muscles to to be able to breathe in. um You're gonna be wanting to look for signs of tracheal deviation You know you'll you'll be able to notice obvious misshapen chests So you know if they have some trauma of some sort that's caused obvious damage and deformity to the chest and ribs so You'll probably be able to spot that pretty quickly But you're gonna want to make sure that you put hands on there and not just look because you could miss the way that something's expanding strangely um So yeah but once you've ah gone ahead and ah
00:03:25
shermanappel
had your once overview of the patient from you know the doorway.
Auscultation and Percussion Methods
00:03:29
shermanappel
You're going to want to go ahead and get on closer. You're going to be using, I mean, this is pretty much classic assessment for health. You're going to inspect, you're going to palpate or percuss, and you're going to auscultate. So you're going to use your eyes to observe, just like I've been talking about looking for you know signs of deformity, tracheal deviation, ah differences in skin color or tone, and also your ears. okay And I'm including ears with the inspection here because you know we're doing this without actually putting on our stethoscope yet. um Next, you're going to want to oscultate. I prefer to oscultate before palpating or percussing. I was taught in nursing school that if you palpate or percuss, you can change the ah assessment possibly, especially if you're doing an abdominal assessment. If you're moving around stuff in the stomach, you might create active bowel sounds ah super artificially.
00:04:22
shermanappel
um, rather than getting a real result. So I like to auscultate before I palpate or percuss. Um, and before auscultating, you want to ask the patient to go ahead and cough, uh, so that they're clearing any extra secretions out of their airway. Okay. You don't want to chart that they have course respiratory sounds. Um, if you were just hearing, uh, you know, they had something that they needed to cough up and after a good cough, good productive cough, they're all clear. Um, that's what you're wanting to listen to. So. Auscultate. There's eight sites on the back that you're going to auscultate over and six on the front plus the trachea. And then you've got the right middle lobe of the lung under the right arm. So the idea here is that you're listening to each individual lung lobe. So your left lung has two lobes and your like right lung has three lobes. um So to do this, you're going to start at the back just below the neck.
00:05:12
shermanappel
And you're just going to work your way down on either side of the spine. I like to go between the scapula and the spine is a nice little spot for your stethoscope. And you just work your way side to side. So left, right, down, left, right, down, left, right, down um until you're getting down almost to the lower end of the ribcage. And then that's pretty much the yeah the bottom margin of their lungs that you're going to get good lung sounds on. And then while you're listening on the back, I just like to ask the patient to lift their right arm up so that you can assess that right middle lobe. The best way to listen to the right middle lobe is to put your stethoscope right about, I think it's the third or fourth intercostal space um just underneath the axilla. That's a really great spot to listen to the right middle lung lobe. And that gives you the opportunity to listen. If you've listened on the back really thoroughly, you've hit all of the lung lobes and then you get that right middle.
00:06:07
shermanappel
And then on the front, I like to do this. You should be doing your your respiratory assessment separate from your cardiac cardiac assessment. So I like to listen up by the trachea first. um That's where you're going to hear the most obvious signs of strider ah indicating possible airway obstruction. And then you're going to go ahead and just start in the middle and work your way down and get to the sides of each of the chest. So you're auscultating on the front as well. This is especially important in patients that have been immobile for a while that you're listening on the front and the back because if they've been sedentary lying in a hospital bed, um they can have some pretty serious settling and you might get different sounds on the front than you get on the back.
00:06:51
shermanappel
Um, I wanted to mention here with, uh, our lung sounds that there are different characteristics that we use to describe them. Uh, so the million dollar word is vesicular. Like if you hear vesicular lung sounds, that's just fancy talk for clear normal to auscultation, lung sounds. After you've completed your auscultation of each of the lung lobes, you can then move on to percussion. Percussion is a really. I feel like underrated ah form of assessment, especially for registered nurses. this You probably learned how to do it in nursing school, but essentially you're putting your finger on the patient's chest or back, and then you're tapping it with your other finger from your other hand. So you know you're just making this percussing sound. That's why we call it percussion. um And the the character of the sound that you know bounces off the patient's chest from that can tell you a lot about the underlying tissues.
00:07:45
shermanappel
So if you were to have very dull lungs, very dull percussion when you're, uh, percussing the patient's lung fields, uh, that can tell you that you have some fluid buildup in there. Okay. There's something that's causing, uh, a dull, um, response with that percussion, be it fluid, be it a physical obstruction. I mean, if you have somebody that has a really nasty MPAIMA in their lungs, That'll give you really dull percussion. And then the transfer or or the the opposite of that would be hyper-resonant. So ah what when it sounds like you're almost beating on a really tympanic drum, if you're getting hyper-resonant lung sounds, the patient might be air trapping, okay? They might have an obstructive ah pathology that's preventing them from really clearing air out of their lungs. ah Maybe they've got a pneumothorax. Maybe they have really severe asthma exacerbation and they're just air trapping.
00:08:38
shermanappel
um that can cause a hyper-resonant sound. The normal sound, what you want to hear is resonant over the lungs, okay? So if you're reading somebody else's soap note or assessment and they say resonant on ah percussion, that's normal. That's good. And that, ah you kind of know it just sounds right. And if you don't know, go ahead and do it on yourself or on a friend ah that you know has good pulmonary function and go ahead and percuss their lung fields and that'll give you a good idea of what resonant should sound like. Um, and this kind of takes practice to get down and to be able to use as a good clinical evaluation tool, but it is really valuable to tell you what's going on underneath there. Um, and obviously with a percussion comes palpation. Um, you should do a palpation separate from percussion. Obviously you're going to be percussing and palpating. Um, not just using your finger to say, oh yeah, I, I palpated.
00:09:31
shermanappel
So you're going to want to fill, ah I think the most important part for me personally in my assessment when I'm palpating is I like to put my hands on the patient's back on either side of the scapula um so that my fingers, my index fingers and my thumbs are forming a little bit of a triangle or a diamond. And then I asked the patient to breathe in deeply. And then you just watch as your hands move with those, ah with the scapula. And that can tell you a lot about the patient's symmetry in their expansion. So you you can kind of look at the patient and watch them breathe and say, yeah, that's symmetrical expansion. But if you really want to be able to measure it and look for minute differences, you need to have some point point of reference. And I think that using your hands on their back in that method is
Respiratory Diseases Discussion
00:10:12
shermanappel
useful. You can do it on the front as well. I believe you just ah put your hands on their rib cage um with the thumbs ah pointing towards each other and asking them to breathe in deeply. And you just watch your thumbs move.
00:10:24
shermanappel
with the patient's chest expansion. All right. So we've talked about auscultation. We've talked about inspection. We've talked about percussion and palpation. um We talked about looking at the trachea. I just wanted to now move on to the pathologies that I wanted to talk about today. There were a couple of different ones. Uh, the three most common, um, I feel like respiratory pathologies that I see in the ICU and also in general are asthma COPD and COPD and asthma are now considered two different diseases. They used to both be bundled underneath obstructive respiratory disorders. Uh, but now they are.
00:11:04
shermanappel
separate. They have different pathologies that drive them, and it's so important to recognize that. And ah then the third one is pneumonia, so we'll talk about those three. d And I think we'll also mention ah briefly emphysema and bronchitis, but we'll focus on the big three asthma, COPD, and pneumonia. So with your asthma patients, so asthma is a chronic inflammatory disorder of the airways that causes variable recurring symptoms. You can get airflow obstruction from this chronic inflammation. Um, and that causes kind of that trademark wheezing sound. So if you've ever met many, anybody in an asthma exacerbation or done a assessment on them, you hear this very clear expiratory wheeze. Okay. They're having a hard time pushing this air out of their lungs because of this inflammation.
00:11:50
shermanappel
um Triggers for asthma and asthma exacerbations include allergens, exercise, cold air, and stress. the The triggers really vary from person to person, but it's going to be anything that causes an inflammatory response in their airways. um So symptoms that accompany asthma, you got wheezing, you got shortness of breath, ah tightness in the chest if they complain that they just feel like they can't ah relax, their chest feels so tight that they can eat you know they can't have a deep breath out. You know what we call a cleansing breath? if you If you have a patient in acute asthma exacerbation, they can't really have a cleansing breath. They don't just, you know, they don't have that moment of ah release. And then coughing, especially at night or early in the morning. ah Lung sounds, I already mentioned wheezing is that classic one. The description for that is high pitched musical sounds typically heard during expiration ah due to the narrowed airways. Wheezing can also occur on inspiration in really severe cases.
00:12:49
shermanappel
So if your patient's in such a severe asthma exacerbation that you're hearing wheezing on inspiration, that can be a pretty serious indication for you as the clinician. Moving on from asthma to COPD. COPD is a whole group of progressive lung diseases.
00:13:09
shermanappel
um But essentially with your emphysema and chronic bronchitis, ah you get similar pathway to asthma. Chronic inflammation obstructs airflow from the lungs. ah Major risk factors for developing COPD, either emphysema or chronic bronchitis, are smoking. ah You could also include long-term exposure to irritating gases or particulate matter. This is why when you're doing your general survey and social history, you want to be paying attention to what line of work was this person in. ah Were they constantly exposed to irritating gases or particulates? I mean, think about your your mechanics who maybe before they were aware about the dangers of, ah oh, what's that what's that compound that gets knocked off of breaks, break dust? it's a
00:13:56
shermanappel
but it's always in the It's always in the advertisements. Here, one second. I'm going to pause the podcast so I can look it up. It's killing me now. Asbestos. The answer is asbestos. I had to just hop on Google real quick to figure it out. Thank you for your patience with me on that one. So think about your mechanics that are constantly exposed to that through ah through work. Think about um people who work at water treatment plants, you know constantly working with certain gases. um You just want to be aware of what this person was doing because that could predispose them to COPD related pathologies. Symptoms for COPD, persistent cough with mucus, shortness of breath, especially during physical activities, frequent respiratory infections and fatigue.
00:14:40
shermanappel
And the lung sounds that you are going to be accompanying this, wheezing, similar to asthma, ah but it's simply going to be more continuous. And then ronchi. Ronchi is low-pitched, snoring-like sounds heard during both inspiration and expiration, indicating mucus secretions in larger airways. I realize that when we're talking about respiratory assessment and auscultation, it can be difficult to remember all of these lung sounds, as well as to kind of ah figure out what you're hearing when. I know a lot of nurses that, you know, they say I can recognize what's not normal, which I think is the most important part of the assessment as a registered nurse, ah being able to recognize, hey, that's not normal or that's new. But obviously now that you're moving into an advanced practice situation, you want to be able to determine what that sound is, because that's going to tell you what pathology is ah working on this patient's lungs. um So I'm going to include a link from YouTube with ah
00:15:36
shermanappel
name that lung sound quiz. You can find a lot of YouTube videos that go over the lung sounds. thatll If you have one that you're not sure about, you can look up specific videos about them. I'd really encourage you to do that. I'm not going to overplay the audio clips here just because I feel like it ah I don't have high enough fidelity in my sound system to really do it any justice or to be helpful to you guys, so I'm not going to waste your time with that. But definitely go on to YouTube and look up ah different lung sounds and help yourselves with those assessments. and Then also, just while you're at work, take any opportunity that you have to listen to a new lung sound. Like you have a patient that comes in with epiglottitis, go and ask your the nurse that's taking care of them, hey, can I take a listen to your patient's lungs? You have a patient that's coming, let's say you've never heard a what a pneumothorax feels like, or you've never felt what a pneumothorax or flow chest feels like, and you have a patient that comes in with that.
00:16:30
shermanappel
ask for the opportunity to assess that and to listen, really take ah that every chance that you're given to expose yourself because that's what really sets apart the APRN from, my I feel like medical doctors in our training is that we have that on the job throughout our entire career and even during school that we're learning and learning how to assess. So take advantage of those opportunities. um And then I wanted to also, while we're talking about COPD, parse out the differences between emphysema and ah chronic bronchitis. So emphysema, we're calling it, and this is, I should say that emphysema and COPD, while they're very similar, and some people consider emphysema ah you know a subset from COPD, you can consider them as different diseases. as they do They do present a little bit differently. So COPD, classic COPD, maybe your chronic bronchitis,
00:17:27
shermanappel
Uh, patients, they're going to be your blue bloaters. They're going to frequently be obese. They'll have a very productive cough. You'll see accessory muscle use, um, on inspiration and expiration. Uh, you'll have that runk iron wheezing on auscultation and a crude bedside test. One thing that kind of commonly gets confused between respiratory and cardiac diseases is COPD and CHF because the presentation of these two patients can be similar. um But the distinguishing test at the bedside for COPD between CHF is peak expiratory flow. So if the patients blow between 150 to 200 milliliters or less, they are probably having a COPD exacerbation, whereas higher flows than that indicate more probable CHF exacerbation. um So that'll help you determine whether we're working with a cardiac pathology or a respiratory pathology. And then for emphysema, these are going to be your pink puffers. So they're going to have the the very big barrel chest
00:18:23
shermanappel
They generally won't have a cough. They'll have pursed lip breathing, accessory muscle use, and hyper-resonant percussion. So these are your air trappers. That's why we call them pink puffers. They'll be a little bit red in the face and ah puffed up in their chest. Um, and that structural change comes from just, you know, long-term air trapping that they're just constantly having that built up pressure in their chest. Um, and then you'll have that one classic wheezing and then you may have distant heart tones just because the chest wall is further away from the heart tissue. So what you're listening to just sounds farther away. All right. And then the last one that I wanted to talk about, we would be remiss if we had a respiratory assessment podcast without talking about pneumonia.
00:19:06
shermanappel
So pneumonia is an inflection infection that inflames the air sacs in one or both lungs. Those air sacs are the alveoli is the correct term for them. um And that inflammation can cause those alveoli to fill with fluid or pus. um Get really nasty. Causes include bacterial infections, viral infections, fungal infections. um the most common bacterial cause ah of pneumonia is going to be your streptococcus pneumoniae.
00:19:40
shermanappel
um So that'll frequently be ah covered by whichever antibiotic your facility decides to start first will generally cover strep. Symptoms of pneumonia include chest pain when breathing or coughing, productive cough with phlegm or pus, ah fever, sweating and chills. okay Because it's an infection, you're going to be having a systemic response to this. It's not just localized to the lungs. And then shortness of breath. And then lung sounds include crackles, also known as rails. ah You can get fine or coarse crackling sounds heard during inspiration caused by the popping open of the small airways because you're bringing air into the lungs. Those alveoli that are collapsed with the fluid pop open during the inspiration and then they close back up on expiration. um And then you could also get bronchial breath sounds. And bronchial breath sounds, this is, you know, I said a vesicular earlier it was normal bronchial would be not
00:20:36
shermanappel
not normal. This is harsh breath sounds heard over areas of consolidation. When I say consolidation, I mean this is areas that have been closed down with that fluid or pus, um where normal air-filled lung tissue should be. um So those those are that's kind of your presentation on those. um Various sources for this material, by the way, I'm just going to mention it retroactively right now. I'm not the best at including my source as I read it. So I pulled ah data for this from the Global Initiative for Asthma ah from the National library of ah national Health Libraries. um We pulled from to to the National Institute of Health and Care Excellence guideline for pneumonia in adults. Community acquired pneumonia requiring hospitalization from the New England Journal of Medicine.
00:21:25
shermanappel
um And I'll include all these references in the in the show notes. I just want to make sure you guys understand that I'm not pulling this stuff out of my, head but, you know, I researched this. um there There is sources backing this up and also that I'm not plagiarizing.
Podcast Conclusion and Feedback
00:21:38
shermanappel
um Also, we pulled from ah the journal of family practice, asthma characteristics, management and outcomes. um So all these sources were included ah in preparation for this show. I wanted to take a moment to thank you guys for listening I ah stepped away from podcasting for about a month and a half just because I had a lot going on I had ah some in-person skills training that I had to do um and work got really busy and it was just kind of a crazy time But I'm gonna try to get back on track with releasing these podcasts and hopefully you guys find some benefit from them
00:22:09
shermanappel
um Once again, feel free to reach out to me at Jackson dot.Jorgensen.atgmail.com. That's J-A-X-O-N period. J-O-R-G-E-N-S-E-N at gmail dot.com. and There's also a Facebook group with the ah name of the show as the the group name where you guys are welcome to reach out to me as well. so Please have a great day and remember to keep your patients safe. and Thank you for listening.