Assessment of Thorax and Lungs

Assessment of the thorax and lungs should be completed during a comprehensive assessment or as part of a focused assessment if your patient is experiencing issues with their chest or lungs. Methods of assessing the thorax and lungs include inspection, palpation, percussion, and auscultation.

Okay, as you begin your assessment, observe your patient for indications of respiratory discomfort. These may include a distressed facial expression or other cues such as a fast respiratory rate. Then, visualize the symmetry and shape of the chest both anteriorly and posteriorly. The anterior-posterior diameter of the chest should be less than the lateral diameter. When these are equal, it's referred to as barrel chest. With a barrel chest, you may also notice the slope of the ribs will be more parallel, rather than the normal slightly downward slope, and the costal angle will be more than 90 degrees. A barrel chest can indicate a chronic respiratory condition, such as chronic obstructive pulmonary disease, or COPD for short.

You should also inspect the chest, spine, rib cage, sternum, and trachea for structural abnormalities, such as pectus carinatum, also known as pigeon chest, where the sternum bulges outward, and pectus excavatum, or funnel chest, where the sternum is depressed inward. Other structural abnormalities include scoliosis, where there's an abnormal lateral curve of the thoracic and lumbar spine; and kyphosis, or an exaggerated outward curvature of the thoracic spine.

Also observe your patient's respirations, which should typically be around 20 breaths per minute for the average healthy adult. A respiratory rate over 25 breaths per minute is generally considered tachypnea and may occur due to anxiety, pain, or infection, whereas a respiratory rate of less than 12 breaths per minute is generally considered bradypnea and may occur because of an electrolyte imbalance or the effects of sedative medications. Also remember, when you're assessing your patient's respirations, that you should keep in mind your agency's policy for normal vital sign ranges and know when you should contact the provider.

In addition to the respiratory rate, note your patient's respiratory pattern, which should be regular and nonlabored. Check for signs of acute respiratory distress, like retractions, where the chest wall "pulls in" below the sternum and between the ribs; and nasal flaring, which occurs when the nostrils widen.

Next up is palpation. First, assess for thoracic expansion while your patient breathes. To do this, place your thumbs along the level of the 10th rib on both sides of the spine and lay your palms on the patient's back, making a "W" with your hands. Ask them to take a deep breath, and as they inhale, your thumbs should symmetrically spread apart. Asymmetrical thoracic expansion may indicate a chest wall deformity.

Then, test for tactile fremitus, or the vibrations in the chest that occur when your patient speaks. To do this, ask them to say "99" repeatedly while palpating both sides of their posterior chest. Decreased or lack of fremitus can mean there's excess air in the pleural space, like with a pneumothorax; whereas increased fremitus may occur due to fluid in the lungs.

You'll also check for crepitus by palpating with the palmar surface of your hands over the anterior and posterior chest. If crepitus is present, you'll feel a bubbly or crunchy sensation that occurs when air is trapped in the subcutaneous tissues, commonly due to trauma or an underlying disease such as emphysema.

Now let's move on to percussion, which is used to determine the expansion of the lungs and check for the presence of air and fluid. To do this, percuss every 4 to 5 centimeters, or 1.5 to 2 inches, over the intercostal spaces, taking care to avoid the ribs, and comparing the anterior and posterior chest bilaterally. When percussing over the lungs, the expected sound is resonance. If instead you hear hyperresonance over the lungs, it can indicate your patient has asthma, pneumothorax, or emphysema. The expected sound over the diaphragm and bones is dullness, but if there's dullness over the lungs, it might mean your patient has atelectasis or a mass.

Lastly, there's auscultation, which is performed with the diaphragm of your stethoscope. If your patient is able, assist them to sit upright so they can take several deep breaths through their mouth. You'll begin at the bases of the lungs, since this is where most pathological conditions take place. Be sure to place the diaphragm directly on the patient's skin and remember to listen over the intercostal spaces and not bone. Listen to each side bilaterally as well as posteriorly and anteriorly.

Breath sounds are categorized as vesicular, bronchovesicular, and bronchial. Vesicular sounds are low-pitched and soft, and they're heard over the peripheral lung fields. Bronchovesicular sounds are heard around the upper sternum and between the scapulae and have a medium pitch and intensity. Lastly, bronchial sounds are high-pitched, fairly loud, and heard best over the trachea.

Adventitious, or abnormal, breath sounds include crackles, also known as rales, which are popping or crackling sounds caused by the movement of fluid through small air passages or alveoli, or when collapsed airways snap open during inspiration. Crackles are associated with pulmonary edema or pneumonia. Rhonchi are low-pitched, rumbling sounds caused by air moving over secretions in the larger airways, which can be associated with COPD. Wheezes are high-pitched musical sounds caused by airflow through small, narrowed airways, most often caused by bronchospasm.

Other abnormal breath sounds include a friction rub, which is a superficial, low-pitched grating sound that can happen with inflammation of the pleura; diminished breath sounds, associated with atelectasis or emphysema; and absent breath sounds, which are associated with pneumothorax or complete airway obstruction. If you hear any adventitious breath sounds, ask your patient to cough, and listen again.

Alright, as a quick recap…Assessment of the thorax and lungs should be completed during a comprehensive assessment or as part of a focused assessment if your patient is experiencing issues with their chest or lungs. Methods of thorax and lung assessment include inspection, palpation, percussion, and auscultation.