Physical Assessment of the Respiratory Tract II: Inspection

Physical assessment of the respiratory tract through inspection is a crucial step in understanding the patient's respiratory health. It provides insights into the functioning of the respiratory system, the musculoskeletal structure, and even the patient's nutritional status. This comprehensive approach involves observing several vital aspects: chest configuration, breathing patterns, respiratory rates, skin color, and use of accessory muscles.

Chest Configuration

The chest configuration can reveal a lot about the patient's respiratory health. Typically, the ratio of the anteroposterior diameter to the lateral diameter is 1:2. However, certain deformities associated with respiratory diseases can alter this relationship. These include the barrel chest, funnel chest (pectus excavatum), pigeon chest (pectus carinatum), and kyphoscoliosis.

Barrel chest, characterized by an increased anteroposterior diameter due to lung overinflation, is often seen in patients with emphysema and COPD. A funnel chest is a depression in the lower portion of the sternum that can compress the heart and great vessels, possibly leading to murmurs. The pigeon chest is an anterior sternum displacement, increasing the anteroposterior diameter. Kyphoscoliosis is defined by an elevated scapula and an S-shaped spine, limiting lung expansion.

When inspecting the posterior chest, any spinal curvatures such as kyphosis, scoliosis, and kyphoscoliosis should be noted, as they can affect breathing.

Breathing Patterns and Respiratory Rates

Breathing patterns and respiratory rates provide vital information about a patient's respiratory health. The average adult at rest takes 12 to 20 breaths per minute. In older adults, it is between 16 to 25 breaths/minute. The length of inspiration should be half as long as expiration (a ratio of 1:2). However, pathologic conditions may alter these patterns. For example, wheezing is common in patients with asthma, while irregular breathing patterns can indicate Kussmaul, Cheyne-Stokes, or Biot's respirations.

• • Kussmaul Respiration: Characterized by deep, rapid breathing, often seen in diabetic ketoacidosis or severe metabolic acidosis. It helps the body expel carbon dioxide to reduce acidosis.

• • Cheyne-Stokes Respiration: Involves a cycle of increasing and decreasing breathing depth, leading to temporary apnea, and can indicate heart failure, stroke, or brain injury.

• • Biot's Respiration: Marked by quick, shallow breaths followed by periods of apnea, often associated with medulla oblongata damage, stroke, or opioid use.

Skin Color

The color of the patient's skin can provide clues about their respiratory status. Cyanosis, a late sign of hypoxemia, is best observed in the conjunctivae, lips, palms, and under the tongue. It can be caused by hypoxemia or decreased cardiac output. Long-standing hypoxemia may lead to nail clubbing, which increases the angle between the base of the nail and its tip to 180 degrees or more.

Use of Accessory Muscles

During periods of exertion or specific disease conditions, accessory muscles like the sternocleidomastoid, scalene, and trapezius during inspiration, and the abdominal and internal intercostal muscles during expiration, can provide additional support to assist the breathing effort. Observing how the patient uses these muscles can provide important information about the patient's respiratory health.

In conclusion, physical assessment of the respiratory tract through inspection is a comprehensive approach that provides vital insights into a patient's respiratory health. By carefully observing the chest configuration, breathing patterns and rates, skin color, and use of accessory muscles, healthcare professionals can more effectively diagnose and treat respiratory diseases.