Hello class. Welcome back to respiratory 108 chapter 16 lecture covering uh one of the most essential skills you'll use every single day as a respiratory therapist chest assessment. So this involves four steps. This involves inspection, palpitation, percussion, and oscultation. By mastering these four steps, you'll learn how to detect early changes in your patients respiratory status and also be able to connect what you see, feel, and hear to the underlying disease. So, some learning objectives um that we will be covering today will be to describe common signs of increased work of breathing gleaned from a physical exam of the neck and chest. We'll be able to differentiate the two archetypal breathing patterns associated with restrictive versus obstructive lung disease. We'll be describing the five abnormal breathing patterns associated with neurological disease and injury. We'll be we'll be describing how lung uh hyperinflation and diaphragmatic dysfunction are assessed during the physical examination of the chest. We'll be able to identify the three normal breath sounds and differentiate between the two main advantitious breath sounds and relate them to common pulmonary disease in which they do occur. So when we talk about lung diseases we often break them into two big categories obstructive versus restrictive. So obstructive diseases are like COPD or asthma or emphyma. All are about the difficulty getting air out due to the narrowed and damaged airways. Restrictive diseases on the other hand limit how much air can get in. So these include neurological or muscular disorders that weaken breathing muscles and interstitial lung diseases like pulmonary fibrosis where the lung tissue becomes really stiff. We also need to consider conditions that cause a ventilation to profusion mismatch or VQ mismatch. These are situations where ventilation doesn't match the blood flow such as in a plural eusion, a pneumonia, adalcttois or pneumathorax. So when we understand whether a problem is obstructive, restrictive or just a VQ mismatch, it helps us identify quickly the underlying issue and choose the right interventions to help the patient. So here, let's look at these different types of images that we have here. I have them labeled A through G and we're going to take them one at a time. Notice here for A, this is what a a normal lung would look like as far as diameter, um the space, the intercostal spaces. That was that's what the normal lung would look like. If you take a look at B and compare it, you notice that we have more of an expanded rib cage. It's actually changed shape a little bit. We call this a barrel chest. Okay. And that's from um our alvei being expanded for too long and to where it no longer snaps back like it's supposed to. It's more of what we call a floppy lung and has to do with patients with obstructive diseases or lung uh diseases. Um if you look at C here, this uh is the type of chest that they call a pectis coraninum or also known as a pigeon chest. Notice the sternum here shows an abnormal protrusion. Okay? And then if you look at letter D that this is the pectus excavatum. That's what we call a funnel chest. See this little depression here of the sternum. Uh this can produce a restrictive lung defect due to the shape of it alone. And then you move over here to E. This looks like probably a kyphoscoliosis patient. Um this can produce a severe restrictive lung defect due to poor lung expansion. F here this is just kyphosis a spinal deformity where the spine has an abnormal anterior posterior curvature. See how the curvature is is abnormal here. And then you've got G for scoliosis. Scoliosis is almost like that S in the spine. It's a spinal deformity where the spine actually has a lateral curvature. And so if you come back to E, you'll notice that um that's why we call this uh kyphoscoliosis because it's a mixture of kyphosis and scoliosis. So that get lots leaves lots of room for um difficulty in having that lung expansion properly. When you take a look at just CND, now we're just going to talk about C and D here. Um both of these are congenital um conditions that are present from birth. Um what sets them apart though are two main differences that we want to look at. We want to look at the appearance. Uh in terms of physical appearance, they're completely the opposite. Pectus excavatum makes the chest look sunken inwards while pectis corinitum makes the chest protrude outwards. Right? And the other one is the frequency. So although these two chest wall deformities are the most common, pectus excavatum is two to four times more common to happen than pectis keratanum. So pectis keratitanum is diagnosed in one out of every 1,200 births and pectis excgavatanum is diagnosed in one out of every 400 births. So how do we treat um either of these conditions? um is based on their severity levels. For um pectis corinitum, the preferred treatment is orthopedic involving the use of a chest compressor such as a brace to maintain the position of the cartilage as the patient grows. So surgery will likely be uh required depending on how severe it is. And then pectic excavatum um there's numerous different correction techniques depending on the patient's condition. Uh non-surgical methods are like the vacuum bell and increasingly less invasive and safer surgical techniques have become more and more available that people can use for those uh abnormalities. So here you've got thoracic expansion. We're going to be working on this. This is some of those um things that we're going to be working on in the lab coming up this next week. It's an important part of chest assessment because it reflects how well the lungs are actually ventilating. So the diaphragm is the primary muscle of breathing and under normal conditions the chest wall expands symmetrically both anteriorly and posteriorly. To assess chest expansion from the back you're going to place your hands on the postal chest with your thumbs positioned near that T8 vertebrae as you see the hands placed on the images here. You ask the patient to exhale completely while you keep your fingertips resting gently on the chest wall. And as they breathe out, you're going to move your thumbs so that they meet the midline. Then you have the patient take a deep breath in and watch how far your thumbs move apart. Normally both thumbs should move equally about 3 to 5 cm. Unequal movement may indicate an underlying lung problem. So here when you have diseases that affect both lungs such as an such as a lot of the neuromuscular uh disorders or with COPD you may see a bilateral reduction in chest expansion. On the other hand if only one lung or large section of it is affected such as with an ammonia a plural eusion or adalcttois the reduction in chest expansion will be unilateral. Observing these differences gives us valuable clues about underlying conditions. So let's talk about palpitation. This is basically the art of using your hands to feel the chest wall so that you get a sense of what's going on underneath. One of the things we check for is something called fmitus or it fmitus is also the vibration you feel when a patient speaks. If fmitus is increased then usually points to something like a pneumonia or an adalcttois where the lung tissue is consolidated and sound vibrations travel more easily. So on the other hand if firmus is reduced you should be thinking about conditions that block or trap air like emphyma pumothorax or a plural eusion. We also use palpitation to check for chest expansion. If both sides are reduced, it often means a systematic problem such as a neuromuscular disorder or COPD. But if only one side is reduced, that's more consistent with something more localized like a pneumonia or aumothorax. So finally, don't forget to feel for crepitus. That's when that air leaks into the tissue under the skin. It feels like little crackles or rice krispies under your fingers. It's a sign of subcutaneous emphyma. So palpitation gives us a ton of information with just a careful touch. And it's one of those skills that gets you sharper the more patients you assess with. We're going to learn exactly how to do palpitation in lab next week. Now, when it comes to percussion, this is the technique of tapping on the chest wall to get information about what's underneath. When we percuss, we're not just making noise. we're actually creating vibrations that can travel about five to seven centimeters into that lung tissue. It's not something we do on every single patient, but when we do need more information, percussion can be really valuable. The key is to work systematically, comparing one side of the chest to the other, moving across in a step-by-step fashion. What are we listening for? We're listening for resonance. A normal lung sound should sound resonant because it's filled with air. So if you hear a decreased resonance that suggests something that's more dense like a pneumonia or a plural eusion where fluid or consolidation is present. So on the flip side of that if you hear an increased resonance that points towards too much air like an emphyma or an anumothorax. So percussion gives us another way to confirm what we suspect from inspection and palpitation and it's also one more piece of the puzzle in building a complete chest assessment. So these are some great short videos. They're very helpful in being able to further connect the dots. They're going to show you an example of a percussion technique that's only 3 minutes long. Then you'll see the second one is on a percussion and oscultation demonstration. It is 4 minutes long. And then the last one is going to show you six minutes on that tactile firmus using cups. So it's pretty interesting um to see and be able to compare those three different techniques. So I encourage you to watch those more than once. Okay. So let's talk about chest oscultation. We're going to oscultate the chest listening to the lung sounds. And the lung sounds actually come in two varieties. You have normal or vicicular breath sounds and then you have abnormal or advantageous lung sounds. Okay. So, we are going to use a part of the stethoscope called a diaphragm to be able to listen to those lung sounds. So, let's talk about normal breath sounds. Those are your tracheal sounds. Tracheal sounds are heard directly over the trachea. They're very loud. created by turbulent flow and the expatory phase is about equal or even a little bit longer than inspiration. Then you have bronco vicicular sounds. Bronco vicicular sounds are a softer lower pitched sound and usually heard over the sternum and then vicular sounds. Vicular sounds are the softest very low pitched and heard out over all the lung parankma. Okay. So remember breath sounds are basically vibrations created by airflow and in the larger airways as these vibrations travel through the lung tissue and the chest wall the sounds are filtered. So what you actually hear in the periphery is softer. So normal lung tissue actually acts as a low pass filter and it lets through lower frequency sounds and dampens the higher ones. When we're talking about advantageous breast sounds, those are breath sounds that are abnormal like crackles. Crackles are discontinuous, short, crackling or bubbling sounds. Fine crackles often mean small airways popping open like in pulmonary fibrosis or adalcttois. And coarse crackles are usually secretions or fluid in the airway. And often those can be cleared after a cough or a suction. And you also have wheezes. Wheezes are continuous. So musical sounds caused by narrowed airways. If it's monoponic, it's a single note. That usually means one airway is obstructed. But if it's polyonic, those are multiple notes. That means many airways are obstructed. Like in asthma, expatory wheezing is a classic sign of an obstructive disease. So strider is another one. It's very harsh, distinct, high-pitched sound. It usually indicates an upper airway obstruction. Uh inspatory striders uh suggest narrowing above the glauus area while expatory strider points to narrowing in the lower trachea. Acute strider can be from conditions like croo while chronic strider might come from uh langomsa. Okay. So, um, we always have to be mindful of that and pay attention to that. So, here, uh, you're going to see you have bronchial breath sounds here. Um, these are normal over the trachea. Uh, but if you hear them out in the periphery, that's abnormal. It means normal vicular sounds have been replaced usually because the lung tissue has become dense with something like a pneumonia. Then you have diminished breath sounds that can happen if air flow is weak like shallow breathing or if transmission through the lung is reduced like uh with a patient with COPD or asthma. And then also you have uh plural friction rub that sounds like a creaking or grading and it happens when the inflamed plural surfaces rub together. It's really important that you learn how to identify what a plural friction rub is. um it can be a little bit tricky so you'll be practicing that in lab as well. Um on this slide here we have wheezes, strider, coarse crackles and fine crackles. I like this slide because it helps you to be able to study the characteristics that are very specific to them. What types of diseases although these are not all inclusive that they would um possibly indicate as well as what's happening inside the airways. So when you're oscultating you're not just listening you're actually translating what those sounds mean about the underlying physiology and pathophysiology. So here this should look really familiar. This is your stethoscope. Um we're going to take a look at this as a tool that we all rely on. We rely on this uh to assess our patients of all ages. Um you either have one already or you've seen them in the labs. This one happens to be a Litman. Um, it's pretty simple but incredibly powerful. So, the stethoscope has four main parts. It has this part here, which is called the bell. This part on the bottom here, the larger part, is called the diaphragm. Then you've got the tubing. And you've got ear pieces. Okay? So, that's all the parts and pieces of a stethoscope. Now, when you're oscultating the lungs, we mostly use the diaphragm because it's better at picking up high frequency sounds like breath sounds and most advantageous lung sounds. The bell, on the other hand, is useful for lower frequency sounds like certain heart murmurss, and it should be placed lightly on the chest when you use it. Technique does matter. So, make sure the earpieces are angled forward in their in your ear, just like in your ear canal. If you put your fingers in your ears, um the uh internal canal goes forward. That's the same direction that you want those earpieces to go. You're going to press the diaphragm firmly against the chest wall and always compare side to side as you listen. Uh and one very last but important point would be to always clean your stethoscope after every patient contact. So you can just use an alcohol swab. It's very easy for it to become a vehicle for microorganisms and really good hygiene here is part of infection control. So plural eusion has a direct impact on breath sounds because of the buildup of fluid in the plural space. It actually dampens or completely blocks sound transmission from the lungs on oscultation. This often presents as diminished or absent breath sounds over the affected area along with decreased tactile fminis and a dullness to percussion. So this fluid also creates significant ventilation profusion or VQ mismatch where the lung tissue may still be perused with blood but ventilation is impaired in some way because air cannot get effectively reach uh out up to that region. The result is hypoxmia due to poorly oxygenated blood continuing to circulate. So recognizing these changes in breath sounds is key to identifying a plural eusion uh and its effect on gas exchange. So here you see that this is an example of a pumothorax. Air collects in the plural space and blocks normal sound transmission. Breath sounds on the affected side are usually very faint or completely absent. When you percuss, you'll hear a hyper resonance because of the trapped air and feminis is decreased. This also causes a VQ mismatch. Blood still flows to the area but no air is getting in which lowers the oxygen levels. And in severe cases like attention pneumothorax, breast sounds actually disappear completely and the patient can quickly become unstable. In pneumonia, infection causes part of the lung to fill with fluid and become consolidated. This changes how sound travels. So breast sounds over the affected area may become bronchial instead of vicicular and you may hear crackles from fluid in the airways. Tactile feminis is usually increased because of sound vibrations and how they move more easily through dense consolidated tissue. And percussion often produces a dull sound here instead of resonance. And this concludes the rest of our chapter 16 lecture on chest assessment. Thank you.