RESPIRATORY SYSTEM

• Babies are born with pink lungs but they • Mucus, secreted continuously by goblet
darken as we breathe polluted air. cells, covers the surface of the nasal mucosa
and is moved back to the nasopharynx by
• You breathe on an average of 14-20 times the action of the cilia (fine hairs).
per minute, 20K (approx.) per day, 7.8M
(approx.) per year, and breathed 468M Internal portion: hollow cavity separted into the right
(approx.) in 60 years of lifetime--- and left nasal cavities by a narrow vertical divider, the
INVOLUNTARILY. septum. Each nasal cavity is divided into 3
passageways by the projection of the turbinates from
• We lose half liter of water a day through the lateral walls.
breathing. This is the water vapor we see • Conchae – the turbinate bones, the name
when we breathe into a glass.   suggested by their shell-like appearance.
• Nasal mucosa – large surface of moist,
• It is impossible to breathe and swallow warms, highly vascular ciliated mucous
simultaneously. membrane that traps practically all of the
dust and organisms in the inhaled air.

ANATOMIC AND PHYSIOLOGIC OVERVIEW FUNCTION OF THE NOSE

• Upper Respiratory Tract • Serves as a passageway for air to pass to
• Lower Respiratory Tract and from the lungs.
• It filters impurities and humidifies and warms
Together, the two tracts are responsible for ventilation the lungs as it is inhaled.
*movement of air in and out of the airways • The air is moistened, warmed to body
temperature, and brought into contact with
The upper tract (upper airway) warms and filters sensitive nerve.
inspired air so that the lower respiratory tract (the o Detect odor (olfaction)
lungs) can accomplish gas exchange. o Provoke sneezing

GAS EXCHANGE
involves delivering oxygen to the tissues through the PARANASAL SINUSES
bloodstream and expelling waste gases, such as • 4 pairs of bony cavities that are lined with
carbon dioxide, during expiration. nasal mucosa and ciliated pseudo stratified
The respiratory system depends on the columnar epithelium.
cardiovascular system for perfusion, or blood flow • These air spaces are connected by a series
through the pulmonary system. of ducts that drain into the nasal cavity
UPPER RESPIRATORY TRACT
Upper airway structures consist of the THE SINUSES ARE NAMED BY THEIR LOCATION:
• Nose • Frontal
• Sinuses and nasal passages • Ethmoid
• Pharynx, tonsils and adenoids, • Sphenoid
• Larynx, and • Maxillary
• Trachea
FUNCTION OF PARANASAL SINUSES
• Serve as a resonating chamber in speech
THE NOSE • The sinuses are a common site of infection
• Composed of an (1) external and an (2)
internal portion.
PHARYNX, TONSILS, AND ADENOIDS
External portion: protrudes from the face and is PHARYNX (THROAT)
supported by the nasal bones and cartilage. tubelike structure that connects the nasal and oral
cavities to the larynx
The anterior nares (nostrils) are the external
openings of the nasal cavities. IT IS DIVIDED INTO THREE REGIONS:
• Nasal (Nasopharynx)
• Oral (Oropharynx)
• Nasal cavities are lined with highly vascular • Laryngeal (Laryngopharynx)
ciliated mucous membranes called the nasal • NASOPHARYNX - located posterior to the
mucosa. nose and above the soft palate.
 • OROPHARYNX - houses the faucial, or
palatine, tonsils. FUNCTION OF TRACHEA
• LARYNGOPHARYNX - extends from the Serves as the passage between the larynx and the
hyoid bone to the cricoid cartilage. right and left main stem bronchi, which enter through
an opening called the hilus.
The epiglottis forms the entrance of the larynx.
The tonsils, the adenoids, and other lymphoid
tissue encircle the throat.
ADENOIDS (PHARYNGEAL TONSILS) are located LOWER RESPIRATORY TRACT
in the roof of the nasopharynx. The lower respiratory tract consists of the lungs,
which contain the bronchial and alveolar structures
needed for gas exchange.
FUNCTION OF PHARYNX
The pharynx functions as a passageway for the
respiratory and digestive tracts. LUNGS
These structures are important links in the chain of The lungs are paired elastic structures enclosed in the
lymph nodes guarding the body from invasion of thoracic cage, which is an airtight chamber with
organisms entering the nose and the throat. distensible walls.
• Size of a football (approx.)
• The lung fill the area from the collarbone to
LARYNX the bottom of the ribs.
• Voice organ/voice box • Lung is the only organ in the body light
• Cartilaginous epithelium-lined structure that enough to float.
connects the pharynx and the trachea. Each lung is divided into lobes
• The major function of the larynx is • Right---3 lobes
vocalization. • Left---2 lobes
• It also protects the lower airway from foreign Each lobe is further subdivided into 2 to 5 segments
substances and facilitates coughing— separated by fissures, which are extesions of the
“watchdog of the lungs” pleura.

PARTS OF LARYNX The left lobe is slightly smaller than the right lobe.
• Epiglottis: a valve flap of cartilage that
covers the opening to the larynx during
swallowing PLEURA
• Glottis: the opening between the vocal Serous membrane that lined the lungs and wall of the
cords in the larynx thorax.
• Thyroid cartilage: the largest of the The visceral pleura covers the lungs; the parietal
cartilage structures; part of it forms the pleura lines the thoracic cavity, the lateral wall of
Adam’s apple the mediastinum, diaphragm, and inner aspects of
• Cricoid cartilage: the only complete the ribs.
cartilaginous ring in the larynx - the visceral and parietal pleura and the small
• Arytenoid cartilages: used in vocal cord amount of pleura fluid between these 2
movement with the thyroid cartilage membranes serve to lubricate the thorax and the
• Vocal cords: ligaments controlled by lungs & permit smooth motion of the lungs
muscular movements that produce sounds; withine the thoracic cavity during inspiration &
located in the lumen of the larynx expiration.

TRACHEA IMPORTANCE:
• AKA Windpipe You breathe 20,000 times (approx.) per day
• Composed of smooth muscle with C-shaped involuntarily
rings of cartilage at regular intervals
• The cartilaginous rings are incomplete on the MEDIASTINUM
posterior surface and give firmness to the • The mediastinum is in the middle of the
wall of the trachea, preventing it from thorax, between the pleural sacs that contain
collapsing. the two lungs.

• It extends from the strenum to the vertebral

column and contains all the thoracic tissue
 outside the lungs (heart, thymus, the aorta Type III alveolar cell macrophages are large
and vena cava, and esophagus). phagocytic cells that ingest foreign matter (mucus,
bacteria)
BRONCHI AND BRONCHIOLES • act as an important defense mechanism
There are several division of the bronchi within each
lobe of the lung FUNCTION OF THE RESPIRATORY SYSTEM
The cells of the body derive the energy they need
1. Lobar bronchi (three in the right and two in from the oxidation of carbohydrates, fats, and
the left lung) proteins, this process requires oxidation. As a result,
2. Segmental bronchi (10 on the right and 8 carbon dioxide is produced and must be removed
on the left) – these structures facilitate from the cells to prevent the buildup of acid waste
effective postural drainage in the patient. products.
3. Subsegmental bronchi – surrounded by
connective tissue that contains arteries, The respiratory system performs this function by
lymphatics, and nerves. facilitating life-sustaining processes such as:
4. Bronchioles – have no cartilage walls, their • Oxygen transport
patency depends entirely on the elastic on • Respiration and ventilation, and
the recoil of the surrounding smooth muscle • Gas exchange.
and on the alveolar pressure. Contains
submucosal glands, which produce mucus OXYGEN TRANSPORT
that covers the inside lining of the airways, • Oxygen diffuses from the capillary through
also lined with cells that have surfaces the capillary wall to the interstitial fluid.
covered with cilia (create a constant • At this point, it diffuses through the
whipping motion). membrane of tissue cells, where it is used by
5. Terminal bronchioles – do not have mitochondria for cellular respiration.
mucous glands or cilia.
6. Respiratory bronchioles – considered to be RESPIRATION
the transitional passageways between the This whole process of gas exchange between the
conducting airways contain about 150 mL of atmospheric air and the blood and between the blood
air in the tracheobronchial tree that does not and cells of the body is called respiration.
participate in gas exchange (physiologic
dead space). VENTILATION
7. Alveolar ducts and sacs - Requires movement of the walls of the thoracic
8. Alveoli cage and of its floor, the diaphragm. The effect
of these movements is alternatively to increase
ALVEOLI and decrease the capacity of the chest.
• Oxygen and carbon dioxide exchange takes - Inspiration occurs during the first third of the
place in the alveoli. respiratory cycle; expiration occurs during the
• The lung is made up of about 300 million latter two thirds.
alveoli, contituting a total surface area
2
between 50 and 100m Pysical factors that govern airflow in & out of the lungs
• Arranged in clusters of 15 to 20 are collectively reffered to as the mechanics of
ventilation and include air pressure variances,
THREE TYPES OF ALVEOLAR CELL resistance to airflow, and lung compliace.
Three types of alveolar cells---(Pneumocyte)
Type I, II, and III GAS EXCHANGE
- The air we breathe s a gaseous mixture
Type I – account for 95% of the alveolar surface area consisting mainly of nitrogen(78%), oxygen
and serve as a barrier between the air and the (21%), argon (1%), and trace amounts of other
alveolar surface. Are epithelial cells that form the gases including carbon dioxide, methane, and
alveolar walls. helium, among other gases.
Type II – account for only 5% of this area but are
responsible for producing type I cells and surfactant.
Are metabolically active; secrete surfactant a PULMONARY DIFFUSION AND PERFUSION
phospholipid that lines the inner surface and prevents • Pulmonary diffusion – gas exchange in the
alveolar collapse. alveolar-capillary membrane.
Reduces surface tension, thereby improving overall • Pulmonary perfusion – the actual blood
lung function flow through the pulmonary vasculature.
 ASSESSMENT respiratory tract and is associated with
HEALTH HISTORY multiple pulmonary disorders.
Initially focuses on the patient’s presenting problem • The cough reflex may be impaired by
and associated symptoms. weakness or paralysis of the respiratory
• Onset muscles, prolonged inactivity, presence of
• Location NG tube, or depressed function of the brain’s
• Duration medullary centers.
• Character Common causes:
• Aggravating & alleviating factors • Asthma
• Radiation (if relevant) • GI reflux disease
• Timing of the presenting problem & • Infection
associated s/s • Side effects of medications (ACE inhibitors)
Explore how these factors impact the patient’s ADL,
usual work and family activities, & quality of life. To help determine the cause of the cough, the nurse
inquires about the onset & time of coughing.
COMMON SYMPTOMS • Coughing at night – may indicate the onset
1. Dyspnea of left-sided heart failure or bronchial
• a subjective feeling of discomfort while asthma.
breathing; it causes may include multiple • Cough in the morning with sputum – may
physiologic, psychological, environmental, or indicate bronchitis.
social factors. • Cough that worsens when the pt is
• Sudden dyspnea in a healthy person may supine – suggest postnasal drip
indicate pneumothorax, acute respiratory (rhinosinusitis).
obstruction, allergic reaction, or MI. • Coughing after food intake – may indicate
• In pt’s who are immobilized, sudden dyspnea aspiration of material into the
may denote PE. tracheobronchial tree or reflux.
• Dyspnea & tachyonea accompanied by • Cough of recent onset – usually from an
progressive hypoxemia in a person who has acute infection.
recently experienced lung trauma, shock,
cardiopulmonary bypass, or multiple blood The nurse assesses the character of the cough and
transfusions may signal ARDS. associated symptoms.
• Orthopnea may be heard in patient with • Dry, irritative cough - is characteristic of an
heart disease and COPD. upper respiratory tract infection of vital origin
The high-pitched sound heard (usually on inspiration) or side effect of ACE inhibitor therapy.
when someone is breathing through a partially • Irritative, high-pitched cough – can be
blocked upper airway is called stridor. cause by laryngotracheitis.
• Is the shortness of breath related to other • Brassy cough – result of a tracheal lesion
symptoms? Is a cough present? • Severe or changing cough – may indicate
• Was the onset of shortness of breath sudden bronchogenic carcinoma.
or gradual? • Pleuritic chest pain that accompanies
• At what time of day or night does the coughing – may indicate pleural or chest
shortness of breath occur? wall (musculoskeletal) involvement.
• Is the shortness of breath worse when lying • Violent coughing – causes bronchial
flat? spasm, obstruction, & further irritation of the
• How much exertion triggers shortness of bronchi and may result in syncope.
breath? Does it occur with exercise?
Climbing stairs? At rest? A persistent cough may affect a patient’s quality of life
• How severe is the shortness of breath? On a and may produce embarrassment, exhaustion,
scale of 0 to 10, if 0 is not at all breathless inability to sleep, and pain.
and 10 is very breathless, how hard is it to
breathe?
  3. Sputum Production
• Reaction of the lungs to any constantly
2. Cough recurring irritant and often results from
persistent coughing. May also be associated
• A reflex that protects the lungs from the
accumulation of secretions or the inhalation with a nasal discharge.
of foreign bodies.
The nature of the sputum is often indicative of its
• Results from irritation or inflammation of the
cause.
mucous membranes anywhere in the
 • Profuse amount of purulent sputum (thick expiration (asthma) or inspiration
& yellow, green, rust colored) or a change (bronchitis).
in color of the sputum – common sign of a • Often the major finding in a patient with
bacterial infection. bronchoconstriction or air narrowing.
• Thin, mucoid sputum – results from viral
bronchitis.
• Gradual increase of sputum overtime –
may occur with chronic bronchitis or 6. Hemoptysis
bronchiectasis. • The expectoration of blood from the
• Pink-tinged mucoid sputum – suggests a respiratory tract.
lung tumor. • Can be present as small to moderate blood-
• Profuse, frothy, pink material, often stained sputum to a large hemorrhage and
welling up into the throat – pulmonary always warrants further investigation.
edema Common causes:
• Foul-smelling sputum & bad breath – lung ü Pulmonary infection
abscess, bronchiectasis, or an infection ü Carcinoma of the lung
caused by fusospirochetal or other anaerobic ü Abnormalities of the heart or blood vessels
organisms. ü Pulmonary artery or vein abnormalities
ü PE or infarction

4. Chest Pain The nurse must determine the source of bleesing, as

• Chest pain associated with pulmonary the term hemoptysis is reserved for bloof coming
conditions may be sharp, stabbing, and from the respiratory tract.
intermittent, or it may be dull, aching, and • Bloody sputum from the nose or the
persistent. nasopharynx – considerable sniffing, with
• The pain usually is felt on the side where the blood possibly appearing in the nose.
pathologic process is located, although it • Blood from the lung – usally bright, red,
may be reffered elsewhere. frothy, and mixed with sputum. Initial
• Lung disease does not always cause symptoms include a tickling sensation in the
thoracic pain because the lungs and the throat, a salty taste, a burning or bubbling
visceral pleura lack sensory nerves and sensation in the chest, and perhaps chest
are insensitive to pain stimuli. pain, in which case, the patient tends to
The parietal pleura have a rich supply of sensory splint the bleeding side.
nerves that are stimulated by inflammation & ü This blood has an alkaline
stretching of the membrane. Pleuritic pain from pH (greater than 7)
irritation of the pleura is sharp and seems to “catch”
on inspiration; pt’s often describe it as being “like the • Blood from the stomach – is vomited rather
stabbing of a knife”. than expectorated, may be mixed with food,
and is usually much darker and often
ü Patients are more comfortable when they lay referred to as “coffee ground emesis”.
on the affected side because this position ü This blood has an acid pH
splints the chest wall, limits expansion and (less than 7)
contraction of the lung, & reduces the friction
between the injured or diseased pleurae on
that side. PHYSICAL ASSESSMENT OF THE RESPIRATORY
SYSTEM
The nurse assesses the onset, quality, intensity, &
radiation of pain and identifies and explores GENERAL APPEARANCE
preciitating factors and their relationship to the pt’s
position. The nurse must assess the relationship of CLUBBING OF THE FINGERS
pain to the inspiratory and expiratory phases of - A change in the normal nail bed.
respiration. - It appears as sponginess of the nail bed and loss
of the nail bed angle.
- A sign of lung disease that is found in patients
with chronic hypoxic conditions, chronic lung
5. Wheezing infections, or malignancies of the lung.
• A high-pitched, musical sound which is
continuous, meaning it is heard on either In clubbing, the distal phalanx of each finger is
rounded and bulbous. The nail plate is more convex,
and the angle between the plate and the proximal nail • The frontal & maxillary sinuses can be
fold increases to 180 degrees or more. The proximal inspected by transillumination (passing a
nail fold, when palpated, feels spongy or floating. strong light through a bony area) . if the light
Among the many causes are hypoxia and lung fails to penetrate, the cavity contains fluid
cancer. or pus.

CYANOSIS
- Bluish coloring of the skin, is a very late indicator MOUTH & PHARYNX
of hypoxia. • Instruct the patient to open the mouth wide
- The presence or absence of cyanosis is and take a deep breath. This flattens the
determined by the amount of unoxygenated posterior tongue and briefly allows a full view
hemoglobin in the blood. of the anterior and posterior pillars, tonsils,
- Cyanosis appears when there is at least 5g/dL of uvula, and and posterior pharynx.
unoxygenated hemoglobin. Inspect these structures for color, symmetry, and
evidence of exudate, ulceration, or enlargement.
Cyanosis is not a reliable sign of hypoxia.

- Central cyanosis is assessed by observing the

color of the tongue and lips. This indicates a TRACHEA
decrease in oxygen tension in the blood. • Position and mobility of the trachea are
- Peripheral cyanosis results from decreased noted by direct palpation. Place the thumb
blood flow to the body’s periphery, as in and the index finger of one hand on either
vasoconstriction from exposure to cold, and side of the trachea just above the strenal
does not necessarily indicate a central systemic notch.
problem. The trachea is highly sensitive and palpating too firmly
may trigger a coughing or gagging response.

UPPER RESPIRATORY STRUCTURES Pulmonary disorders such as pneumothorax or pleural

effusion may also displace the trachea.
NOSE & SINUSES
• Inspect the external nose for lesions,
asymmetry, or inflammation and then asks
the patient to tilt the head backward. LOWER RESPIRATORY STRUCTURES &
• Gently pushing the tip of the nose upward, BREATHING
examine the internal structures of the nose,
inspecting the mucosa for color, swelling, POSITIONING
exudate, or bleeding. • Patient should be in a sitting position with
The nasal mocusa is normally redder than the oral arms crossed in front of the chest and hands
mucosa. It may appear swollen and hyperemic if the placed on the opposite shoulders.
patient has a common cold; however, in allergic • If the patient is unable to sit, with the patient
rhinitis, the mucosa appears pale and swollen. supine, roll the patient from side to side to
• Inspect the septum for deviation, perforation, complete the posterior examination. To
or bleeding. Actual displacement of the assess anterior thorax and lungs, patient
cartilage into either the right or left side of the should be either supine or sitting.
nose may produce nasal obstruction.
In chronic rhinitis, nasal polyps may develop between THORACIC INSPECTION
the inferior and middle turbinates; they are • Inspection of the thorax provides information
distinguished by their gray appearance. Unlike the about the respiratory system,
turbinates, they are gelatinous and freely movable. musculoskeletal structure, and the patient’s
• Palpate the frontal & maxillary sinuses for nutritional status.
tenderness. Using the thumbs, apply gentle • Observe the skin over the thorax for color
pressure in an upward fashion at the and turgor and for evidence of loss of
suborbital ridges (frontal sinuses) and in subcutaneous tissue. Note asymmetry, if
the cheeck area adjacent to the nose present.
(maxillary sinuses).
Tenderness in either area suggests inflammation. è CHEST CONFIGURATION
The ratio of the anteroposterior diameter to the
lateral diameter is 1:2.
 4 MAIN DEFORMITIES OF THE CHEST – • Ball of the hand – for deeper masses or
ASSOCIATED WITH RESPIRATORY DISEASE generalized flank or rib discomfort.
THAT ALTER THIS RELATIONSHIP
1. Barrel Chest – occurs as a result of Respiratory Excursion – estimation of thoracic
overinflation of the lungs, which expansion and may disclose significant information
increases the anteroposterior diameter about thoracic movement during breathing.
of the thorax. It occurs with aging and is - assess for range and symmetry of excursion.
a hallmark sign of emphysema and - For anterior assessment, place the thumbs
COPD. along the costl margin of the chest wall and
2. Funnel Chest (Pectus Excavatum) – instructs the patient to inhale deeply. (observe
results from depression in the lower movement of the thumb during inspiration &
portion of the sternum. Occurs with expiration, movement is normally symmetric.)
rickets or Marfan syndrome. - Posterior assessment, place thumbs adjacent
th
3. Pigeon Chest (Pectus Carinatum) – to the spinal column at the level of the 10 rib.
result of the anterior displacement of the Lightly grasp the lateral rib cage, sliding thumbs
sternum, which also increases the medially about 2.5cm (1inch) raises a small skin
anteroposterior diameter. Occurs with fold between thumbs. (observe for normal
rickets, Marfan syndrome, or severe flatenning of the kin fold and feels the symmetric
kyphoscoliosis. movement of the thorax.
4. Kyphoscoliosis – characterized by
elevation of the scapula and a Decreased chest excursion may be caused by chronic
corresponding S-shaped spine. Limits fibrotic disease. Assymetric excursion may be due to
lung expansion within the thorax. May splinting secondary to pleurisy, fractured ribs, trauma,
occur with osteoporosis and other or unilateral bronchial obstruction.
skeletal disorders that affect the thorax.

Tactile Fremitus – vibrations of the chest wall that

results from speech detected on palpation.
è BREATHING PATTERN & RESPIRATORY Sounds generated by the larynx travel distally along
RATES the bronchial tree to set chest wall in resonant motion.
Observation of the rate, depth, and symmetry. (most pronounced with consonant sounds)
• Normal adult at rest comfortably takes 12 t0
20 breaths/min. Factors influencing the normal tactile fremitus:
• Normal pattern associated with breathing is 1. Thickness of the chest wall
known as eupnea. Changes found during 2. Pitch
the act of breathing may be the first clinical 3. Closeness to the large bronchi
sign that the patient’s condition is
deteriorating. • The patient is asked to repeat “ninety-nine”
• Obstructive sleep apnea – episodes of or “one, one, one” as the nurse’s hands
apnea occur repeatedly during sleep, move down the patient’s thorax.
secondary to transient upper airway • The vibrations are detected with the palmar
blockage. surfaces of the hands, or the ulnar aspect of
• Apnea – temporary pauses of breathing. the extended hands, on the thorax.

Patients with emphysema exhibit almost no tactile

è USE OF ACCESSORY MUSCLES fremitus. A patient with consolidation of a lobe of the
• Observe the use of accessory muscles – lung from pneumonia has increased tactile fremitus
sternocleidomastoid, scalene, trapezius over that lobe.
muscle during inspiration. Abdominal
muscles and intercostal muscles during
expiration. THORACIC PERCUSSION
Percussion produces audible and tactile vibration and
allows the nurse to determine whether underlying
THORACIC PALPATION tissues are filled with air, fluid, or solid material.
Palpate the thorax for tenderness, masses, lesions, - healthy lung tissue is resonant.
respiratory excursions, and vocal fremitus. - Dullness over lungs occurs when air-filled lung
• Direct palpation of the fingertips – for skin tissue is replaced by fluid or solid tissue.
lesions and subcutaneous masses.
 • Percussion usually begins with the posterior Adventitious Sounds
thorax. Abnormal condition that affects the bronchial tree and
• Percussion over the anterior chest, begin in alveoli may produce adventitious (additional) sounds.
the supraclavicular area and proceeds
downward, from 1 intercostal space to the 2 categories of adventitious sounds:
next. • Crackles – nonmusical, discontinuous
Dullness noted to the left of the sternum between the sounds
rd th
3 and 5 intercostal spaces is a normal finding, • Wheezes – continuous musical sounds
because that is the location of the heart.
Rhonchi – a type of wheezing, are lower-pitched
There is a normal span of liver dullness below the continuous sounds heard over the lungs in partial
lung at the right costal margin. airway obstruction.
- depending on their location and severity,
Diaphragmatic Excursion wheezes and rhonchi may be heard with/without
- normal resonance of the lung stops at the a stethoscope.
diapgragm. - Duration of the sound is the important distinction
• Instruct patient to take a deep breath & to make in identifying the sound as
hold it while the maximal descent of the discontinuous or continuous.
diaphragm is percussed. (point at which
the percussion note at the midscapular Friction rubs mayceither be discontinuous or
line changes from resonance to continuous.
dullness is marked with a pen) Stridor is a continuous, high-pitched musical sound
• Then, instruct to exhale fully and hold it which is heard over the neck. This sound is caused by
while the nurse again percusses an interruption of airflow and indicated a narrowing of
downward to the dullness of the the upper respiratory tract. Stridor warrants
diaphgram. (point is also marked) emergent attention.
Distance between the two markings indicated the
range of motion of the diagphragm.
Voice Sounds
Maxima excursion – as much as 8-10 cm (3-4 inches) Sound heard through the stethoscope as a patient
in healthy, tall young men. speaks (vocal resonance)
5-7 cm (2-2.75 inches) for most people • Assess the voice sounds when
abnormal breath sounds are
Decreased diaphragmatic excursion = pleural effusion auscultated.
Atelectasis, diaphragmatic paralysis, or pregnancy • Voice sounds are evaluated by having
may account for a diaphragm that is positioned high in the patient repeat “ninety-nine” or “eee”
the thorax. while the nurse listens.
With normal physiology, the sounds are faint and
indistinct.
THORACIC AUSCULTATION
Assess the flow of air through the bronchial tree and Pathology that increases lung density, such as
evaluate the presence of fluid or solid obstruction in pneumonia and pulmonary edema, alters this normal
the lung. physiologic response and may result in the following
Auscultate for normal breath sounds, adventitious sounds:
sounds, and voice sounds. • Bronchophony – vocal resonance that is
more intense and clearer that normal.
- Systemic fashion from the apices to the bases • Egophony – voice sounds that are distorted.
and along midaxilliary lines. Best appreciated by having thr patient repeat
- Listen to 2 full inspirations and expirations at the letter E. The distortion produced by
each anatomic location for valid interpretation of consolidation transforms the sound into a
the sound heard. clearly heard A rather than E.
• Whispered pectoriloquy – ability to clearly
Breath Sounds and distinctly hear whispered sounds that
Normal breath sounds are distinguished by their should not normally be heard.
location over a specific area of the lung and are
identified as vesicular, bronchovesicular, &
bronchial (tubular) breath sounds.