Assessment of the Chest – Advanced

by Stephen Holt, MD, MS

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    00:00 Next up, we're going to do the respiratory exam.

    00:03 And like examination of many systems, it starts with inspection.

    00:06 So, I don't know about you, but I've taken care of a number of patients, who tell me that they're unable to breathe and having significant respiratory distress and they can go into great detail about that, without even taking a breath.

    00:17 In reality, a person who is legitimately having respiratory distress, should typically have a problem, where they can't say more than a few words at a time.

    00:27 So, just looking at our patient right now, he looks comfortable and if I asked him to tell me how he was feeling, as long as he can get out a few words, a full sentence, etc., then I know that he's not in significant respiratory distress.

    00:38 It's worth documenting that on your physical exam, your patient can speak, in only one word or three-word sentences, to really get at that picture very quickly.

    00:47 In addition, patients who are in respiratory distress, oftentimes, use accessory muscles of respiration.

    00:53 So, remember that, normally if you're just breathing, standard tidal volumes at rest, you only need one muscle to do that and that's your diaphragm.

    01:01 So, just looking at our patient relaxing right now, taking normal tidal breaths of inhalation and exhalation, the only muscle that's working, is his diaphragm, which right now is up, now it's going down, then it goes up, it's going down to draw air into his chest, and then it relaxes.

    01:25 And it's actually for inhalation, that's the only time the diaphragm is doing anything, during exhalation, it's simply the elastic recoil of the ribcage, that is expelling air from your lungs.

    01:38 In contrast, a person who's in respiratory distress, is going to use extra muscle groups to help with both inhalation and exhalation.

    01:46 So, let's first look at the muscles of inhalation, the accessory muscles, of inhalation.

    01:50 So, what I'm going to have you do Sean, is, I want you to take a full deep breath, as big as you can, go ahead.

    01:58 You'll note, you can see right here what happened, his sternocleidomastoids and his scalene muscles pulled up his clavicles as well as his first rib and by doing so, he's increasing the amount of space in his chest cavity, so, he can accommodate more air coming in.

    02:14 So, that's one of the first signs that you'll see, for inhalation in terms of accessory muscle use.

    02:19 And now what I’m going to have you do Sean, is, completely exhale completely empty your chest of air.

    02:29 Great. So, you can see right here he's contracting his abdominal muscles, because by contracting his abdominal muscles, he is squeezing his abdominal cavity, which pushes the diaphragm upwards and allows, extra ability to expel air from the lungs.

    02:44 In addition, you may have noticed a subtle change where he leaned forward, just a little bit.

    02:49 What that was, was his intercostal muscles of his rib cage also contracting, which basically, just closes the cage to again, assist with expelling air from the lungs.

    03:00 Other findings that particularly you might see in a person with a COPD exacerbation, is, "Pursed lipped breathing." When patients have emphysema, there's a loss of the architecture that supports the patency of small airways.

    03:16 So, when they're trying to expel air, the airways are collapsing, when you do pursed lip breathing, just basically push your lips and try and breathe out.

    03:32 With pursed lip breathing, he's creating a back pressure, so-called, “Positive End Expiratory Pressure” that basically tense open, those smaller airways to allow that air to get out more effectively, in the setting of emphysema.

    03:49 The next thing that you might see in a patient with emphysema, is the tripoding position.

    03:53 So, this is known as the tripoding position and the patient is essentially using his arms, to prop up his upper thorax, which allows him to still keep that ribcage very open, but reduces the work of the accessory muscles of respiration in the process.

    04:08 So, this is another thing that you may find in patients who particularly have emphysema, who are in respiratory distress.

    04:14 And perhaps the last and perhaps most significant finding, that you'll see in a person who is legitimately in respiratory distress, is, “Cyanosis” and we know this from literature and movies and everything else, that the patients get blue lips and this is a very real finding, with really exceptional likelihood ratios as well.

    04:31 So, for a person who has an oxygen saturation of less than 80%.

    04:40 So, we'd be looking at his oxygen saturation to tell us what his O2 sat is, but even before we have an O2 sat monitor, I'm just going to basically take a look at his lips.

    04:49 In a patient with cyanosis, they should have a clear bluish discoloration and Sean, can you open your mouth for me, the tongue, would also be somewhat bluish in color and lifting up your tongue, underneath those mucous membranes, beneath the tongue is where you're most likely to see, evidence of this bluish discoloration, that is evidence of deoxyhemoglobinemia.

    About the Lecture

    The lecture Assessment of the Chest – Advanced by Stephen Holt, MD, MS is from the course Assessment of the Respiratory System: Theory (Nursing).

    Included Quiz Questions

    1. The diaphragm
    2. Intercostal muscles
    3. Abdominal muscles
    4. Sternocleidomastoid muscle
    1. The client is leaning forward with their hands on their knees.
    2. The client purses their lips when exhaling.
    3. The client can only speak in 15–20 word sentences before taking a breath.
    4. The nurse can see the client’s diaphragm move during inspiration.
    5. The nurse can see the client's neck muscles move during inspiration.

    Author of lecture Assessment of the Chest – Advanced

     Stephen Holt, MD, MS

    Stephen Holt, MD, MS

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