Physical Exam: Lungs

I. History: smoking, infections, pain, discomfort, dyspnea, activity intolerance, fever
II. Inspection


General Appearance: Respiration

• Breathing should be quiet and easy
• Respiration involves ventilation, diffusion, and perfusion of gases
• Factors influencing respirations: exercise, pain, anxiety, stress, anemia, posture, drugs (narcotics, amphetamine)
• Normal Rates of Respiration: Newborn - 35 to 40 breaths/minute; Infant - 30 to 50 breaths/minute; Toddler - 25 to 35 breaths/minute; Schoolage - 20 to 30 breaths/minute; Adolescent - 14 to 20 breaths/minute; Adult - 12 to 20 breaths/minute
• Depth: deep, normal, shallow
• Rhythm: regular, irregular; Normal Finding: regular
• Skin color
• Chest wall configuration: Normal Findings - symmetrical with bilateral muscle development; A-P Transverse Ration = 1-5:2-7

III. Palpation

• Feel for abnormalities such as masses, lesions, scars, swelling, crepitus, asymmetry
• Crepitus indicates air in subcutaneous space (in thoracic area, usually due to pneuomothorax)
• Vocal fremitus: Vibration felt when patient speaks; Increased over areas of consolidation

IV. Percussion

• Normal findings: resonance heard throughout lung fields

V. Auscultation

• Normal findings: quiet breathing throughout all lung fields
• Whispered pectoriloquy:

1. Client whispers "One, two, three" 
2. Over normal areas of the lung, only faint sounds are heard
3. Over consolidated areas, the words are more distinct

• Egophony:

1. Client says "E"
2. Over consolidated areas, the sound is a nasal "A"

VI. Alterations in Lung Function

• Cough
• Expectoration
• Dyspnea
• Bradypnea
• Tachypnea
• Hyperpnea
• Apnea
• Cheyne-Stoke respiration
• Kussmaul's breathing
• Biot's breathing
• Grunting
• Retractions
• Hemoptysis
• Pain
• Accessory muscle use
• Cyanosis
• Adventitious sounds
• Pursed-lip breathing:

1. Prolonged exhalation
2. Breathing out through puckered lips

• Pleural friction rub:

1. Grating sound produced by inflamed pleura rubbing together
2. Usually heard loudest over lower lateral anterior chest at end of inspiration

VII. Pediatric Differences

• Smaller, shorter, more pliable airways
• Underdeveloped supporting cartilage
• Above two factors increase the risk of obstruction due to mucus, edema or foreign body
• Flexible larynx more susceptible to spasm
• Immature immune system
• Incomplete myelinization
• Increased basal metabolic rate
• Decreased ability to mobilize secretions
• Less forceful cough

POINTS TO REMEMBER:

• Anemic patients may never become cyanotic
• Polycythemic patients may become cyanotic, even when oxygenation is normal
• Cough results from stimulation of irritant receptors, with implications of either acute or chronic etiology
• Cyanosis indicates decreased available oxygen. Etiology can be either peripheral or central in origin
• Wheezes indicates narrowing/inflammatory process of lower airways
• Stridor harsh sound produced near larynx by vibration of structures in upper airway. Classic "barky cough"
• Crackles or rales adventitious sounds, usually on inspiration and indicating inflammation