Head & Neck

  • Introduction
  • Palp/Percus
  • Auscultation

Palpation/Percussion

Thoracic expansion:.

  • Is used to evaluate the symmetry and extent of thoracic movement during inspiration.
  • Is usually symmetrical and is at least 2.5 centimeters between full expiration and full inspiration.
  • Can be symmetrically diminished in ankylosing spondylitis .
  • Can be unilaterally diminished in chronic fibrotic lung disease , extensive lobar pneumonia, large pleural effusions, bronchial obstruction and other disease states.

Percussion:

Percussion is the act of tapping on a surface, thereby setting the underlying structures in motion, creating a sound and palpable vibration. Percussion is used to determine whether underlying structures are fluid-filled, gas-filled, or solid. Percussion:

  • Penetrates 5 - 6 centimeters into the chest cavity.
  • May be impeded by a very thick chest wall.
  • Produces a low-pitched, resonant note of high amplitude over normal gas-filled lungs.
  • Produces a dull, short note whenever fluid or solid tissue replaces air filled lung (for example lobar pneumonia or mass) or when there is fluid in the pleural space (for example serous fluid, blood or pus).
  • Produces a hyperresonant note over hyperinflated lungs (e.g. COPD ).
  • Produces a tympanitic note over no lung tissue (e.g. pneumothorax ).

Diaphragmatic excursion:

  • Can be evaluated via percussion.
  • Is 4-6 centimeters between full inspiration and full expiration.
  • May be abnormal with hyperinflation , atelectasis , the presence of a pleural effusion , diaphragmatic paralysis, or at times with intra-abdominal pathology.

The Lung Exam

  • Inspection and Observation
  • Auscultation

Sample Lung Sounds

The 4 major components of the lung exam (inspection, palpation, percussion and auscultation) are also used to examine the heart and abdomen. Learning the appropriate techniques at this juncture will therefore enhance your ability to perform these other examinations as well. Vital signs, an important source of information, are discussed elsewhere.

Inspection/Observation:

A great deal of information can be gathered from simply watching a patient breathe. Pay particular attention to:

  • General comfort and breathing pattern of the patient. Do they appear distressed, diaphoretic, labored? Are the breaths regular and deep?
  • Use of accessory muscles of breathing (e.g. scalenes, sternocleidomastoids). Their use signifies some element of respiratory difficulty.

chest excursion

  • Breathing through pursed lips, often seen in cases of emphysema.
  • Ability to speak. At times, respiratory rates can be so high and/or work of breathing so great that patients are unable to speak in complete sentences. If this occurs, note how many words they can speak (i.e. the fewer words per breath, the worse the problem!).
  • Any audible noises associated with breathing as occasionally, wheezing or the gurgling caused by secretions in large airways are audible to the "naked" ear.
  • The direction of abdominal wall movement during inspiration. Normally, the descent of the diaphragm pushes intra-abdominal contents down and the wall outward. In cases of severe diaphragmatic flattening (e.g. emphysema) or paralysis, the abdominal wall may move inward during inspiration, referred to as paradoxical breathing. If you suspect this to be the case, place your hand on the patient's abdomen as they breathe, which should accentuate its movement.

chest excursion

Review of Lung Anatomy:

Understanding the pulmonary exam is greatly enhanced by recognizing the relationships between surface structures, the skeleton, and the main lobes of the lung. Realize that this can be difficult as some surface landmarks (eg nipples of the breast) do not always maintain their precise relationship to underlying structures. Nevertheless, surface markers will give you a rough guide to what lies beneath the skin. The pictures below demonstrate these relationships. The multi-colored areas of the lung model identify precise anatomic segments of the various lobes, which cannot be appreciated on examination. Main lobes are outlined in black. The following abbreviations are used: RUL = Right Upper Lobe; LUL = Left Upper Lobe; RML = Right Middle Lobe; RLL = Right Lower Lobe; LLL = Left Lower Lobe.

chest excursion

Palpation plays a relatively minor role in the examination of the normal chest as the structure of interest (the lung) is covered by the ribs and therefore not palpable. Specific situations where it may be helpful include:

lung excursion

Pathologic conditions will alter fremitus. In particular:

  • Lung consolidation: Consolidation occurs when the normally air filled lung parenchyma becomes engorged with fluid or tissue, most commonly in the setting of pneumonia. If a large enough segment of parenchyma is involved, it can alter the transmission of air and sound. In the presence of consolidation, fremitus becomes more pronounced.
  • Pleural fluid: Fluid, known as a pleural effusion, can collect in the potential space that exists between the lung and the chest wall, displacing the lung upwards. Fremitus over an effusion will be decreased.

In general, fremitus is a pretty subtle finding and should not be thought of as the primary means of identifying either consolidation or pleural fluid. It can, however, lend supporting evidence if other findings (see below) suggest the presence of either of these processes.

chest excursion

  • Investigating painful areas: If the patient complains of pain at a particular site it is obviously important to carefully palpate around that area. In addition, special situations (e.g. trauma) mandate careful palpation to look for evidence of rib fracture, subcutaneous air (feels like your pushing on Rice Krispies or bubble paper), etc.

Percussion:

This technique makes use of the fact that striking a surface which covers an air-filled structure (e.g. normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound. If the normal, air-filled tissue has been displaced by fluid (e.g. pleural effusion) or infiltrated with white cells and bacteria (e.g. pneumonia), percussion will generate a deadened tone. Alternatively, processes that lead to chronic (e.g. emphysema) or acute (e.g. pneumothorax) air trapping in the lung or pleural space, respectively, will produce hyper-resonant (i.e. more drum-like) notes on percussion. Initially, you will find that this skill is a bit awkward to perform. Allow your hand to swing freely at the wrist, hammering your finger onto the target at the bottom of the down stroke. A stiff wrist forces you to push your finger into the target which will not elicit the correct sound. In addition, it takes a while to develop an ear for what is resonant and what is not. A few things to remember:

lungs-posterior

  • If you're percussing with your right hand, stand a bit to the left side of the patient's back.
  • Ask the patient to cross their hands in front of their chest, grasping the opposite shoulder with each hand. This will help to pull the scapulae laterally, away from the percussion field.
  • Work down the "alley" that exists between the scapula and vertebral column, which should help you avoid percussing over bone.
  • Try to focus on striking the distal inter-phalangeal joint (i.e. the last joint) of your left middle finger with the tip of the right middle finger. The impact should be crisp so you may want to cut your nails to keep blood-letting to a minimum!
  • The last 2 phalanges of your left middle finger should rest firmly on the patient's back. Try to keep the remainder of your fingers from touching the patient, or rest only the tips on them if this is otherwise too awkward, in order to minimize any dampening of the perucssion notes.

Percussion

  • The goal is to recognize that at some point as you move down towards the base of the lungs, the quality of the sound changes. This normally occurs when you leave the thorax. It is not particularly important to identify the exact location of the diaphragm, though if you are able to note a difference in level between maximum inspiration and expiration, all the better. Ultimately, you will develop a sense of where the normal lung should end by simply looking at the chest. The exact vertebral level at which this occurs is not really relevant.
  • "Speed percussion" may help to accentuate the difference between dull and resonant areas. During this technique, the examiner moves their left (i.e. the non-percussing) hand at a constant rate down the patient's back, tapping on it continuously as it progresses towards the bottom of the thorax. This tends to make the point of inflection (i.e. change from resonant to dull) more pronounced.

Practice percussion! Try finding your own stomach bubble, which should be around the left costal margin. Note that due to the location of the heart, tapping over your left chest will produce a different sound then when performed over your right. Percuss your walls (if they're sheet rock) and try to locate the studs. Tap on tupperware filled with various amounts of water. This not only helps you develop a sense of the different tones that may be produced but also allows you to practice the technique.

Auscultation:

Prior to listening over any one area of the chest, remind yourself which lobe of the lung is heard best in that region: lower lobes occupy the bottom 3/4 of the posterior fields; right middle lobe heard in right axilla; lingula in left axilla; upper lobes in the anterior chest and at the top 1/4 of the posterior fields. This can be quite helpful in trying to pin down the location of pathologic processes that may be restricted by anatomic boundaries (e.g. pneumonia). Many disease processes (e.g. pulmonary edema, bronchoconstriction) are diffuse, producing abnormal findings in multiple fields.

Superficial Abdominal Anatomy

  • Put on your stethoscope so that the ear pieces are directed away from you. Adjust the head of the scope so that the diaphragm is engaged. If you're not sure, scratch lightly on the diaphragm, which should produce a noise. If not, twist the head and try again. Gently rub the head of the stethoscope on your shirt so that it is not too cold prior to placing it on the patient's skin.

normal auscultation

  • The lingula and right middle lobes can be examined while you are still standing behind the patient.
  • Then, move around to the front and listen to the anterior fields in the same fashion. This is generally done while the patient is still sitting upright. Asking female patients to lie down will allow their breasts to fall away laterally, which may make this part of the examination easier.

Thoughts On "Gown Management" & Appropriately/Respectfully Touching Your Patients:

There are several sources of tension relating to the physical exam in general, which are really brought to the fore during the chest examine. These include:

  • Area to be examined must be reasonably exposed - yet patient kept as covered as possible
  • The need to Palpate sensitive areas in order to perform accurate exam - requires touching people w/whom you've little acquaintance - awkward, particularly if opposite gender
  • As newcomers to medicine, you're particularly aware that this aspect of the exam is "unnatural" & hence very sensitive.. which is a good thing!

Keys to performing a sensitive yet thorough exam:

  • Explain what you're doing (" why) before doing it → acknowledge "elephant in the room"!
  • Expose the minimum amount of skin necessary - this requires "artful" use of gown & drapes (males & females)
  • Ask pt to remove bra prior (you can't hear the heart well thru fabric)
  • Expose the chest only to the extent needed. For lung exam, you can listen to the anterior fields by exposing only the top part of the breasts (see picture below).
  • Enlist patient's assistance, asking them to raise their breast to a position that enhances your ability to listen to the heart
  • Don't rush, act in a callous fashion, or cause pain
  • It reflects Poor technique
  • You'll miss things
  • You'll lose points on scored exams (OSCE, CPX, USMLE)!

exam reminders

A few additional things worth noting.

  • Ask the patient to take slow, deep breaths through their mouths while you are performing your exam. This forces the patient to move greater volumes of air with each breath, increasing the duration, intensity, and thus detectability of any abnormal breath sounds that might be present.
  • Sometimes it's helpful to have the patient cough a few times prior to beginning auscultation. This clears airway secretions and opens small atelectatic (i.e. collapsed) areas at the lung bases.
  • If the patient cannot sit up (e.g. in cases of neurologic disease, post-operative states, etc.), auscultation can be performed while the patient is lying on their side. Get help if the patient is unable to move on their own. In cases where even this cannot be accomplished, a minimal examination can be performed by listening laterally/posteriorly as the patient remains supine.

What can you expect to hear? A few basic sounds to listen for:

  • A healthy individual breathing through their mouth at normal tidal volumes produces a soft inspiratory sound as air rushes into the lungs, with little noise produced on expiration. These are referred to as vessicular breath sounds.
  • Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction, secretions, and/or associated mucosal edema. As this most commonly occurs in association with diffuse processes that affect all lobes of the lung (e.g. asthma and emphysema) it is frequently audible in all fields. In cases of significant bronchoconstriction, the expiratory phase of respiration (relative to inspiration) becomes noticeably prolonged. Clinicians refer to this as a decrease in the I to E ratio. The greater the obstruction, the longer expiration is relative to inspiration. Occasionally, focal wheezing can occur when airway narrowing if restricted to a single anatomic area, as might occur with an obstructing tumor or bronchoconstriction induced by pneumonia. Wheezing heard only on inspiration is referred to as stridor and is associated with mechanical obstruction at the level of the trachea/upper airway. This may be best appreciated by placing your stethescope directly on top of the trachea.
  • Rales (a.k.a. crackles) are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Pulmonary edema is probably the most common cause, at least in the older adult population, and results in symmetric findings. This tends to occur first in the most dependent portions of the lower lobes and extend from the bases towards the apices as disease progresses. Pneumonia, on the other hand, can result in discrete areas of alveolar filling, and therefore produce crackles restricted to a specific region of the lung. Very distinct, diffuse, dry-sounding crackles, similar to the noise produced when separating pieces of velcro, are caused by pulmonary fibrosis, a relatively uncommon condition.
  • Dense consolidation of the lung parenchyma, as can occur with pneumonia, results in the transmission of large airway noises (i.e. those normally heard on auscultation over the trachea... known as tubular or bronchial breath sounds) to the periphery. In this setting, the consolidated lung acts as a terrific conducting medium, transferring central sounds directly to the edges. It's very similar to the noise produced when breathing through a snorkel. Furthermore, if you direct the patient to say the letter 'eee' it is detected during auscultation over the involved lobe as a nasal-sounding 'aaa'. These 'eee' to 'aaa' changes are referred to as egophony. The first time you detect it, you'll think that the patient is actually saying 'aaa'... have them repeat it several times to assure yourself that they are really following your directions!
  • Secretions that form/collect in larger airways, as might occur with bronchitis or other mucous creating process, can produce a gurgling-type noise, similar to the sound produced when you suck the last bits of a milk shake through a straw. These noises are referred to as ronchi.
  • Auscultation over a pleural effusion will produce a very muffled sound. If, however, you listen carefully to the region on top of the effusion, you may hear sounds suggestive of consolidation, originating from lung which is compressed by the fluid pushing up from below. Asymmetric effusions are probably easier to detect as they will produce different findings on examination of either side of the chest.
  • Auscultation of patients with severe, stable emphysema will produce very little sound. These patients suffer from significant lung destruction and air trapping, resulting in their breathing at small tidal volumes that generate almost no noise. Wheezing occurs when there is a superimposed acute inflammatory process (see above).

Most of the above techniques are complimentary. Dullness detected on percussion, for example, may represent either lung consolidation or a pleural effusion. Auscultation over the same region should help to distinguish between these possibilities, as consolidation generates bronchial breath sounds while an effusion is associated with a relative absence of sound. Similarly, fremitus will be increased over consolidation and decreased over an effusion. As such, it may be necessary to repeat certain aspects of the exam, using one finding to confirm the significance of another. Few findings are pathognomonic. They have their greatest meaning when used together to paint the most informative picture.

(courtesy of Dr. Michael Wilkes, MD-- UC Davis and UCLA Schools of Medicine)

  • Bronchial Breath Sounds
  • Vesicular Breath Sounds
  • Normal Voice E

pulse oxymeter

Oftentimes, a patient will complain of a symptom that is induced by activity or movement. Shortness of breath on exertion, one such example, can be a marker of significant cardiac or pulmonary dysfunction. The initial examination may be relatively unrevealing. In such cases, consider observed ambulation (with the use of a pulse oxymeter, a device that continuously measures heart rate and oxygen saturation, if available) as a dynamic extension of the cardiac and pulmonary examinations. Quantifying a patient's exercise tolerance in terms of distance and/or time walked can provide information critical to the assessment of activity induced symptoms. It may also help unmask illness that would be inapparent unless the patient was asked to perform a task that challenged their impaired reserves. Pay particular attention to the rate at which the patient walks, duration of activity, distance covered, development of dyspnea, changes in heart rate and oxygen saturation, ability to talk during exercise and anything else that the patient identifies as limiting their activity. The objective data derived from this low tech test can aid you in determining disease and symptom severity, helping to create a list of possible diagnoses and assisting you in the rational use of additional tests to further delineate the nature of the problem. This can be particularly helpful in providing objective information when symptoms seem out of proportion to findings. Or when patients report few complaints yet seem to have a cosiderable amount of disease. It will also generate a measurement that you can refer back to during subsequent evaluations in order to determine if there has been any real change in functional status.

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Pulmonary Exam: Percussion & Inspection

The pulmonary exam is one of the most important and often practiced exam by clinicians. While auscultation is most commonly practiced, both percussion and inspection are equally valuable techniques that can diagnose a number of lung abnormalities such as pleural effusions, emphysema, pneumonia and many others.

Introduction to the Pulmonary Exam

Though taught extensively in early medical training the pulmonary exam is often neglected apart from auscultation.

Percussion During the Pulmonary Exam

The "5-7-9 rule".

  • The upper border of liver dullness is defined by:
  • 5th intercostal space in the midclavicular line
  • 7th intercostal space in the midaxillary line
  • 9th intercostal space in the scapular line
  • Note: 9th intercostal space is located approximately at the inferior border of the scapula
  • Hyperresonance that continues below these boundaries can be suggestive of hyperinflation (e.g. emphysema)

Cardiac dullness

Be able to outline the area of "absolute" cardiac dullness— a fist sized area just to the left of the sternum. If it is not there it suggests emphysema.

Traube's space

  • Superiorly: Left 6th rib
  • Inferiorly: Left costal margin
  • Laterally: Anterior axillary line
  • Left pleural effusion (however NOT in left lower lobe pneumonia without effusion as it is the effusion that falls into the costophrenic recess that is above the gastric bubble)
  • Splenomegally (less reliable compared to Castell’s Sign)
  • Very full colon
  • Recently eaten (i.e. stomach is full)

Click here to read an article on the Ludwig Traube.

Tidal Percussion

  • Percuss down the back until the normal hyperresonance of the lungs becomes dull over the diaphragm. Then simply have the patient breath in and out deeply while continuing to percuss. The sound should wax and wane.
  • Pleural effusion
  • Hyperinflation such as emphysema from a maximally contracted diaphragm

Major and Minor Fissures of the Lung

  • The major fissure can be located by drawing a line from the T2 spinous process to where the 6th rib meets the sternum. The minor fissure can be approximated by drawing a horizontal line from the 4th rib attachment of the sternum to the major fissure.
  • Easier method: Simply ask the patient to put their hands over their head. The scapula will rotate externally and its medial border will outline the major fissure (see figure below).

Historical Perspective of the Pulmonary Exam

Percussion was first described by  Dr. Josef Leopold Auenbrugger , an Austrian physician who first observed his father tapping on wine barrels in the cellar of his hotel to determine how much wine was left. The son applied this technique to patients when he became a physician. He is credited with bringing the technique of percussion to the field of medicine. Much of his work occurred around 1760 where he described that by percussing the thorax he could accurately predict the contents of what was inside, as confirmed with post-mortum studies he conducted.

Inspection During the Pulmonary Exam

Signs of copd.

  • Inspiratory descent of trachea.
  • Use of accessory muscles.
  • Pursed lips on exhalation (provides a small amount of PEEP).
  • Normal in infancy and increased with aging.
  • Prominent angle of Louis (or sternal angle).
  • Flaring of the lower costal margins.
  • Dahl Sign: Above the knee, patches of hyperpigmentation or bruising caused by constant 'tenting' position of hands or elbows.
  • The "subcostal angle" is the angle between the xiphoid process and the right or let costal margin. Normally, during inhalation the chest expands laterally, increasing this angle. When the diaphragms are flattened (as in COPD), inhalation paradoxically causes the angle to decrease.
  • Harrison's sulcus: a horizontal grove where the diaphragm attaches to the ribs; associated with chronic asthma, COPD, & Rickets.

REMEMBER : "The side that moves less, is the side of disease!"

Look for signs of volume loss (or gain) on the side that moves less (hollow supraclavicular fossae, intercostal spaces prominent, shoulder droopy, scapula outline more prominent).

Consult the Expert

Dr. Peadar Noone

Dr. Peadar Noone

Dr. Peadar Noone  trained in Galway, Dublin, Boston, the UK and Chapel Hill, where he is now Associate Professor of Medicine and Medical Director of the Lung Transplant Program at the University of North Carolina, Chapel Hill.

Clinical Pearl

Insert (in a normal individual) three fingers vertically in the space under the cricoid cartilage, and above the sternal notch. As the person breathes in, the space may reduce to two fingers at most (i.e. the fingers get "squeezed" as the sternum rises with inspiration). In a patient with severe hyperinflation, the crico-sternal distance is much shorter (because the sternum is elevated), maybe 1-2 fingers at most. With inspiration one's fingers get "squeezed" out as the already "high" sternum rises up to the level of the cricoid, thus, in many cases, obliterating the crico-sternal distance altogether. Some clinicians label this sign "tracheal shortening" but strictly speaking, the actual tracheal length does not get shorter. Classically this is seen with severe emphysema / hyperinflation, or severe air trapping. Often accompanied by reduced hepatic and cardiac dullness on percussion, a widened / flared costal angle, and Hoover's sign.

Other Findings in the Chest

  • Pectus Excavatum (Funnel Chest) : depression of sternum; in severe cases may compress heart and great vessels.
  • Pectus Carinatum (Pigeon chest) : anterior displacement of sternum, usually benign.
  • Flail Chest:  secondary to multiple rib fractures, depression of diaphragm causes injured area to cave inward producing a "paradoxical thoracic movement" in breathing.

Key Learning Points

  • Percussion of the lung exam
  • Inspection of the lung exam

Related to Pulmonary Exam: Percussion & Inspection

  • Precordial Movements
  • Cardiac Second Sounds
  • Neck Veins & Wave Forms
  • BP & Pulsus Paradoxus

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Normal Chest Excursion

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Betty Carlson, Normal Chest Excursion, Physical Therapy , Volume 53, Issue 1, January 1973, Pages 10–14, https://doi.org/10.1093/ptj/53.1.10

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Nineteen normal adults were studied to establish a chest excursion norm based on a clinically practical standardized method of measurement. The factors influencing accurate measurement such as type of tape measure used, patient position, room temperature, and underclothing are discussed. A normal circumferential measurement of three and one-fourth inches (8.48 cm) is explained. The importance of this chest excursion measurement in the respiratory portion of the patient's evaluation is related to his treatment program and activity goal. The mean and standard deviations of age, vital capacity, and excursion according to the groups of men and women, active and sedentary, are included.

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10.3: Respiratory Assessment

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  • Ernstmeyer & Christman (Eds.)
  • Chippewa Valley Technical College via OpenRN

With an understanding of the basic structures and primary functions of the respiratory system, the nurse collects subjective and objective data to perform a focused respiratory assessment.

Subjective Assessment

Collect data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data. The information discovered during the interview process guides the physical exam and subsequent patient education. See Table \(\PageIndex{1}\) for sample interview questions to use during a focused respiratory assessment. [1]

Table \(\PageIndex{1}\): Interview Questions for Subjective Assessment of the Respiratory System

Life Span Considerations

Depending on the age and capability of the child, subjective data may also need to be retrieved from a parent and/or legal guardian.

  • Is your child up-to-date with recommended immunizations?
  • Is your child experiencing any cold symptoms (such as runny nose, cough, or nasal congestion)?
  • How is your child’s appetite? Is there any decrease or change recently in appetite or wet diapers?
  • Does your child have any hospitalization history related to respiratory illness?
  • Did your child have any history of frequent ear infections as an infant?

Older Adult

  • Have you noticed a change in your breathing?
  • Do you get short of breath with activities that you did not before?
  • Can you describe your energy level? Is there any change from previous?

Objective Assessment

A focused respiratory objective assessment includes interpretation of vital signs; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds using a stethoscope. For more information regarding interpreting vital signs, see the “ General Survey ” chapter. The nurse must have an understanding of what is expected for the patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that is being collected.

Evaluate Vital Signs

The vital signs may be taken by the nurse or delegated to unlicensed assistive personnel such as a nursing assistant or medical assistant. Evaluate the respiratory rate and pulse oximetry readings to verify the patient is stable before proceeding with the physical exam. The normal range of a respiratory rate for an adult is 12-20 breaths per minute at rest, and the normal range for oxygen saturation of the blood is 94–98% (SpO₂) [3] . Bradypnea is less than 12 breaths per minute, and tachypnea is greater than 20 breaths per minute.

As a general rule of thumb, respiratory rates outside the normal range or oxygen saturation levels less than 95% indicate respiration or ventilation is compromised and requires follow-up. There are disease processes, such as chronic obstructive pulmonary disease (COPD), where patients consistently exhibit below normal oxygen saturations; therefore, trends and deviations from the patient’s baseline normal values should be identified. A change in respiratory rate is an early sign of deterioration in a patient, and failing to recognize such a change can result in poor outcomes. For more information on obtaining and interpreting vital signs, see the “ General Survey ” chapter.

Inspection during a focused respiratory assessment includes observation of level of consciousness, breathing rate, pattern and effort, skin color, chest configuration, and symmetry of expansion.

  • Assess the level of consciousness. The patient should be alert and cooperative. Hypoxemia (low blood levels of oxygen) or hypercapnia (high blood levels of carbon dioxide) can cause a decreased level of consciousness, irritability, anxiousness, restlessness, or confusion.
  • Obtain the respiratory rate over a full minute. The normal range for the respiratory rate of an adult is 12-20 breaths per minute.
  • Observe the breathing pattern, including the rhythm, effort, and use of accessory muscles . Breathing effort should be nonlabored and in a regular rhythm. Observe the depth of respiration and note if the respiration is shallow or deep. Pursed-lip breathing, nasal flaring, audible breathing, intercostal retractions , anxiety, and use of accessory muscles are signs of respiratory difficulty. Inspiration should last half as long as expiration unless the patient is active, in which case the inspiration-expiration ratio increases to 1:1.
  • Observe pattern of expiration and patient position. Patients who experience difficulty expelling air, such as those with emphysema, may have prolonged expiration cycles. Some patients may experience difficulty with breathing specifically when lying down. This symptom is known as orthopnea . Additionally, patients who are experiencing significant breathing difficulty may experience most relief while in a “tripod” position. This can be achieved by having the patient sit at the side of the bed with legs dangling toward the floor. The patient can then rest their arms on an overbed table to allow for maximum lung expansion. This position mimics the same position you might take at the end of running a race when you lean over and place your hands on your knees to “catch your breath.”
  • Observe the patient’s color in their lips, face, hands, and feet. Patients with light skin tones should be pink in color. For those with darker skin tones, assess for pallor on the palms, conjunctivae, or inner aspect of the lower lip. Cyanosis is a bluish discoloration of the skin, lips, and nail beds, which may indicate decreased perfusion and oxygenation. Pallor is the loss of color, or paleness of the skin or mucous membranes and usually the result of reduced blood flow, oxygenation, or decreased number of red blood cells.
  • Chest movement should be symmetrical on inspiration and expiration.
  • Observe the anterior-posterior diameter of the patient’s chest and compare to the transverse diameter. The expected anteroposterior-transverse ratio should be 1:2. A patient with a 1:1 ratio is described as barrel-chested . This ratio is often seen in patients with chronic obstructive pulmonary disease due to hyperinflation of the lungs. See Figure \(\PageIndex{2}\) [5] for an image of a patient with a barrel chest.
  • Older patients may have changes in their anatomy, such as kyphosis , an outward curvature of the spine.
  • Inspect the fingers for clubbing if the patient has a history of chronic respiratory disease. Clubbing is a bulbous enlargement of the tips of the fingers due to chronic hypoxia. See Figure \(\PageIndex{3}\) [6] for an image of clubbing.

Photo showing Landmarks of the Anterior, Posterior, and Lateral Thorax on human male

  • Palpation of the chest may be performed to investigate for areas of abnormality related to injury or procedural complications. For example, if a patient has a chest tube or has recently had one removed, the nurse may palpate near the tube insertion site to assess for areas of air leak or crepitus. Crepitus feels like a popping or crackling sensation when the skin is palpated and is a sign of air trapped under the subcutaneous tissues. If palpating the chest, use light pressure with the fingertips to examine the anterior and posterior chest wall. Chest palpation may be performed to assess specifically for growths, masses, crepitus, pain, or tenderness.
  • Confirm symmetric chest expansion by placing your hands on the anterior or posterior chest at the same level, with thumbs over the sternum anteriorly or the spine posteriorly. As the patient inhales, your thumbs should move apart symmetrically. Unequal expansion can occur with pneumonia, thoracic trauma, such as fractured ribs, or pneumothorax.

Auscultation

Using the diaphragm of the stethoscope, listen to the movement of air through the airways during inspiration and expiration. Instruct the patient to take deep breaths through their mouth. Listen through the entire respiratory cycle because different sounds may be heard on inspiration and expiration. As you move across the different lung fields, the sounds produced by airflow vary depending on the area you are auscultating because the size of the airways change.

Listen to normal breath sounds on inspiration and expiration.

Query \(\PageIndex{1}\)

Correct placement of the stethoscope during auscultation of lung sounds is important to obtain a quality assessment. The stethoscope should not be performed over clothes or hair because these may create inaccurate sounds from friction. The best position to listen to lung sounds is with the patient sitting upright; however, if the patient is acutely ill or unable to sit upright, turn them side to side in a lying position. Avoid listening over bones, such as the scapulae or clavicles or over the female breasts to ensure you are hearing adequate sound transmission. Listen to sounds from side to side rather than down one side and then down the other side. This side-to-side pattern allows you to compare sounds in symmetrical lung fields. See Figures \(\PageIndex{4}\) [7] and \(\PageIndex{5}\) [8] for landmarks of stethoscope placement over the anterior and posterior chest wall.

Photo showing Anterior Auscultation Areas

When assessing patients who are experiencing shortness of breath (or fatigue easily), it may be helpful to begin auscultation in the bases and progress upward to other lung fields as tolerated by the patient. This ensures that assessment of the vulnerable lower lobes is achieved prior to patient fatigue.

Expected Breath Sounds

It is important upon auscultation to have awareness of expected breath sounds in various anatomical locations.

  • Bronchial breath sounds are heard over the trachea and larynx and are high-pitched and loud.
  • Bronchovesicular sounds are medium-pitched and heard over the major bronchi.
  • Vesicular breath sounds are heard over the lung surfaces, are lower-pitched, and often described as soft, rustling sounds.

Adventitious Lung Sounds

Adventitious lung sounds are sounds heard in addition to normal breath sounds. They most often indicate an airway problem or disease, such as accumulation of mucus or fluids in the airways, obstruction, inflammation, or infection. These sounds include rales/crackles, rhonchi/wheezes, stridor, and pleural rub:

  • Fine crackles , also called rales , are popping or crackling sounds heard on inspiration that occur in association with conditions that cause fluid to accumulate within the alveolar and interstitial spaces, such as heart failure or pneumonia. The sound is similar to that produced by rubbing strands of hair together close to your ear.

Listen to fine crackles:

Query \(\PageIndex{2}\)

  • Wheezes are whistling-type noises produced during expiration (and sometimes inspiration) when air is forced through airways narrowed by bronchoconstriction or associated mucosal edema. For example, patients with asthma commonly have wheezing.

Listen to wheezes:

Query \(\PageIndex{3}\)

  • Stridor is heard only on inspiration. It is associated with mechanical obstruction at the level of the trachea/upper airway.

Listen to stridor:

Query \(\PageIndex{4}\)

  • Pleural rub may be heard on either inspiration or expiration and sounds like the rubbing together of leather. A pleural rub is heard when there is inflammation of the lung pleura, resulting in friction as the surfaces rub against each other. [9]

There are various respiratory assessment considerations that should be noted with assessment of children.

  • The respiratory rate in children less than 12 months of age can range from 30-60 breaths per minute, depending on whether the infant is asleep or active.
  • Infants have irregular or periodic newborn breathing in the first few weeks of life; therefore, it is important to count the respirations for a full minute. During this time, you may notice periods of apnea lasting up to 10 seconds. This is not abnormal unless the infant is showing other signs of distress. Signs of respiratory distress in infants and children include nasal flaring and sternal or intercostal retractions.
  • Up to three months of age, infants are considered “obligate” nose-breathers, meaning their breathing is primarily through the nose.
  • The anteroposterior-transverse ratio is typically 1:1 until the thoracic muscles are fully developed around six years of age.

Older Adults

As the adult person ages, the cartilage and muscle support of the thorax becomes weakened and less flexible, resulting in a decrease in chest expansion. Older adults may also have weakened respiratory muscles, and breathing may become more shallow. The anteroposterior-transverse ratio may be 1:1 if there is significant curvature of the spine (kyphosis).

Percussion is an advanced respiratory assessment technique that is used by advanced practice nurses and other health care providers to gather additional data in the underlying lung tissue. By striking the fingers of one hand over the fingers of the other hand, a sound is produced over the lung fields that helps determine if fluid is present. Dull sounds are heard with high-density areas, such as pneumonia or atelectasis , whereas clear, low-pitched, hollow sounds are heard in normal lung tissue.

  • Because infants breathe primarily through the nose, nasal congestion can limit the amount of air getting into the lungs.
  • Attempt to assess an infant’s respiratory rate while the infant is at rest and content rather than when the infant is crying. Counting respirations by observing abdominal breathing movements may be easier for the novice nurse than counting breath sounds, as it can be difficult to differentiate lung and heart sounds when auscultating newborns.
  • Auscultation of lungs during crying is not a problem. It will enhance breath sounds.
  • The older patient may have a weakening of muscles that support respiration and breathing. Therefore, the patient may report tiring easily during the assessment when taking deep breaths. Break up the assessment by listening to the anterior lung sounds and then the heart sounds and allowing the patient to rest before listening to the posterior lung sounds.
  • Patients with end-stage COPD may have diminished lung sounds due to decreased air movement. This abnormal assessment finding may be the patient’s baseline or normal and might also include wheezes and fine crackles as a result of chronic excess secretions and/or bronchoconstriction. [10] , [11]

Expected Versus Unexpected Findings

See Table \(\PageIndex{2}\) for a comparison of expected versus unexpected findings when assessing the respiratory system. [12]

Table \(\PageIndex{2}\): Expected Versus Unexpected Respiratory Assessment Findings

Query \(\PageIndex{5}\)

  • This work is a derivative of Clinical Procedures for Safer Patient Care by British Columbia Institute of Technology and is licensed under CC BY 4.0 ↵
  • Massey, D., & Meredith, T. (2011). Respiratory assessment 1: Why do it and how to do it? British Journal of Cardiac Nursing, 5( 11), 537–541. https://doi.org/10.12968/bjca.2010.5.11.79634 ↵
  • This work is a derivative of Nursing Pharmacology by Open RN licensed under CC BY 4.0 ↵
  • "Anterior_Chest_Lines.png," "Posterior_Chest_Lines.png," and "Lateral_Chest_Lines.png" by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
  • “Normal A-P Chest Image.jpg" and "Barrel Chest.jpg" by Meredith Pomietlo for Chippewa Valley Technical College are licensed under CC BY 4.0 ↵
  • “ Clubbing of fingers in IPF.jpg ” by IPFeditor is licensed under CC BY-SA 3.0 ↵
  • "Anterior Respiratory Auscultation Pattern.png" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
  • "Posterior Respiratory Auscultation Pattern.png" by Meredith Pomietlo for Chippewa Valley Technical College is licensed under CC BY 4.0 ↵
  • Honig, E. (1990). An overview of the pulmonary system. In Walker, H. K., Hall, W. D., Hurst, J. W. (Eds.), Clinical methods: The history, physical, and laboratory examinations (3rd ed.). Butterworths. www.ncbi.nlm.nih.gov/books/NBK356/↵
  • Hill, B., & Annesley, S. H. (2020). Monitoring respiratory rate in adults. British Journal of Nursing, 29 (1), 12–16. doi.org/10.12968/bjon.2020.29.1.12↵

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Chest Expansion

How to assess.

  • While the patient is in maximal expiration, place your palms over the patient's posterolateral ribs with your thumbs touching in the midline. Ask the patient to take a deep breath in and measure the distance that the thumbs move apart.

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What Is Paradoxical Breathing?

  • Infants and Children

Paradoxical breathing occurs when the chest wall or the abdominal wall moves in when taking a breath and moves out when exhaling. This is the opposite of normal breathing movement . Seen in children and adults, it is a sign of respiratory distress associated with damage to the structures involved in breathing.

Paradoxical breathing, also called paradoxical respiration, can be a symptom of trauma or a medical condition. It can also lead to other symptoms, like shortness of breath, weakness, rapid heart rate, and dizziness. Treatment may vary but typically involves managing the underlying condition.

Learn more about the symptoms, causes, diagnosis, and treatment of paradoxical breathing.

When you're breathing normally, your chest rises when you inhale and contracts when you exhale. In paradoxical breathing, your chest contracts while inhaling and expands while exhaling. 

If you have paradoxical breathing you may also have other symptoms, including:

  • Feeling short of breath or like you can't breathe deeply
  • Involuntary gasping
  • Feeling dizzy or weak
  • Difficulty talking
  • Pain in the neck, shoulders, or chest 
  • Weakness in the chest muscles
  • Faster than normal heartbeat

Always seek immediate medical attention for chest pain.

The presence of paradoxical breathing points to various types of respiratory distress or respiratory failure. Almost any cause of shortness of breath , if severe enough, can lead to paradoxical breathing.

A blunt injury to the chest can cause a condition known as " flail chest ." Flail chest occurs when multiple rib fractures cause pieces of broken rib to detach from the chest wall and interfere with normal breathing. In flail chest, a minimum of two or more consecutive ribs are broken in two or more places.

Flail chest is a very rare condition. In one study of 25,467 trauma patients admitted over a six-year period, only 85 patients had flail chest, or about 1/3 of a percent.

The movement of a large detached section of bone makes it difficult for the chest to move air in. This is because the segment moves in and reduces the change in overall chest volume. The same thing happens during exhalation.

The amount of force needed to cause flail chest is significant. Such force is likely to damage much more than just the chest wall. Many people with flail chest also have associated internal injuries.

With flail chest, paradoxical breathing can lead to complications such as pneumothorax and pneumonia.

The larger an area the section of bone covers, the more severe the patient's shortness of breath will be.

Nerve or Muscle Problems

Damage to nerves or weakened muscles can disrupt your breathing. This can happen through trauma or because of a medical condition such as:

  • Multiple sclerosis
  • Muscular dystrophy
  • Guillain-Barre syndrome
  • Lung cancer

The diaphragm is the muscle most involved in expanding and contracting the chest cavity to change volume with inhalation or exhalation. When the diaphragm is weak, the muscles of the chest wall must do all the work of breathing.

If the diaphragm is too weak, chest movement can pull abdominal organs toward the chest when you inhale and push them away from the chest when you exhale.

Paradoxical breathing from a weak diaphragm is often most noticeable when you lie flat on your back (supine).

Paradoxical breathing during weakness or paralysis of the diaphragm is described as a "seesaw" motion between the chest wall and the abdominal wall.

Obstructive Sleep Apnea

People with this condition have a blockage in the airway that causes them to stop breathing during sleep. The condition is characterized by many breathing stops and starts during the night. Over time, it can cause the chest wall to turn inwards, leading to paradoxical breathing. 

Electrolyte Disorders

Electrolyte disorders can also cause paradoxical breathing. Electrolytes are important minerals such as potassium, magnesium, and calcium that your body needs to perform certain functions.

You may develop an electrolyte imbalance if you are severely dehydrated from vomiting or diarrhea, if you are taking certain medications, or if you have chronic health conditions such as kidney disease. Malnourishment can also cause an electrolyte imbalance.

A deficiency in electrolytes such as potassium can cause muscle weakness, including weakness in the respiratory muscles. This can lead to dysfunction of the diaphragm and paradoxical breathing.

Hormonal Imbalance

Certain hormones help regulate your respiration. Thyroid hormone, for example, affects lung strength and function. When you have hypothyroidism, you have lower-than-normal amounts of thyroid hormone. This can lead to weakness in the respiratory muscles.  

Deficiencies in parathyroid hormone can also lead to paradoxical breathing. Parathyroid hormone helps regulate the amount of calcium in your blood. 

Blockage of the Airway

When you have an airway blockage, inhaling creates negative pressure that pulls your chest wall inward. This causes your abdomen to rise and your chest to fall as you attempt to breathe.

Causes of airway blockage include severe allergic reactions, severe respiratory infection, or choking.

Respiratory Failure

If you have severe shortness of breath for long enough, fatigue of the intercostal muscles or diaphragm can lead to the seesaw type of paradoxical breathing.

Respiratory failure is defined as fatigue from shortness of breath. It is also known as respiratory distress. Without treatment, respiratory failure is likely to worsen. Paradoxical breathing develops as one of many signs of increased work to breathe and decreased effectiveness of breathing.

It's crucial to get medical care when you recognize these symptoms so a proper diagnosis can be made and the underlying condition can be treated.

Paradoxical Breathing in Infants and Children

Infants often breathe paradoxically, especially during REM sleep. This is because the rib cage is still soft and can pull in when a baby inhales.  

An infant's breathing may look different than an adult's because the chest moves more easily. As long as the stomach expands as the lungs fill with air, they are breathing normally.

If your child has paradoxical breathing, look for other signs of respiratory distress such as:

  • Difficulty breathing or very rapid breathing
  • Grunting or wheezing
  • Blue skin color

If your child has any of these symptoms, contact a healthcare provider right away. Seek emergency medical care if your child's chest contracts into the ribs while breathing or they appear to be struggling to breathe.

Paradoxical respiration can usually be spotted visually and recognized by its characteristic opposition to normal breathing patterns. You can see the chest/stomach move in or toward the body upon inhalation, and out or away from the body upon exhalation.

Your healthcare provider may order tests to help find the underlying cause of your paradoxical breathing. These may include:

  • Pulmonary function test to see how well your lungs are working
  • Maximal static inspiratory pressure, to measure the strength of your diaphragm
  • Sniff nasal inspiratory pressure, which measures pressure in your nostril when you sniff
  • Vital capacity test, which measures the amount of air you can exhale
  • Blood tests to look for hormone or electrolyte imbalances
  • Imaging tests such as ultrasound, chest X-ray, CT scan, or MRI
  • Fluoroscopy, an X-ray that produces multiple images of your chest movement
  • Electromyography, which records the electrical activity in your diaphragm

How Is Paradoxical Breathing Treated?

Paradoxical breathing can be corrected by treating the underlying condition. For example, broken ribs may need to be surgically repaired. If you have a weakened or paralyzed diaphragm, you may need a type of surgery called surgical plication. During this procedure, your diaphragm is flattened so your lungs can expand more easily.

You may also be given treatments that will help you take in oxygen. Ventilation or continuous positive airway pressure (CPAP) can help you breathe better while you are sleeping.

If you are put on a ventilator, you may also benefit from a phrenic pacing machine, which sends signals to the nerves that contract your diaphragm.

Paradoxical breathing happens when your chest contracts when you inhale and expands as you exhale. It is a sign of respiratory distress.

Paradoxical breathing can have a number of causes, including trauma and weakness of the diaphragm from a medical condition such as multiple sclerosis or muscular dystrophy. It is diagnosed through physical exam, imaging tests, and/or breathing tests. Treating the underlying cause is the only way to correct paradoxical breathing.

Anahana Wellness. Paradoxical breathing .

Schuurmans J, Goslings JC, Schepers T. Operative management versus non-operative management of rib fractures in flail chest injuries: a systematic review .  Eur J Trauma Emerg Surg . 2017;43(2):163–168. doi:10.1007/s00068-016-0721-2

Veysi VT, Nikolaou VS, Paliobeis C, Efstathopoulos N, Giannoudis PV. Prevalence of chest trauma, associated injuries and mortality: a level I trauma centre experience .  Int Orthop . 2009;33(5):1425–1433. doi:10.1007/s00264-009-0746-9

Tuinman PR, Jonkman AH, Dres M, et al. Respiratory muscle ultrasonography: methodology, basic and advanced principles and clinical applications in ICU and ED patients-a narrative review . Intensive Care Med . 2020;46(4):594-605. doi:10.1007/s00134-019-05892-8

Supinski GS, Morris PE, Dhar S, Callahan LA. Diaphragm dysfunction in critical illness . Chest. 2018;153(4):1040-1051. doi:10.1016/j.chest.2017.08.1157

Shrestha GS, Rajbhandari S. Ultrasound of the diaphragm in severe hypokalemia induced diaphragmatic dysfunction . Lung India . 2017;34(6):552-554. doi:10.4103/lungindia.lungindia_4_17

Sagmen SB, Gokkaya N. Respiratory muscle strength in Hashimoto's disease . J Clin Med Kaz . 2020;6(60):63-7. doi:10.23950/jcmk/9264

Lencu C, Alexescu T, Petrulea M, Lencu M. Respiratory manifestations in endocrine diseases . Clujul Med . 2016;89(4):459-463. doi:10.15386/cjmed-671

Chandra A, Ray AK, Hati A. 237 Clinical signs of diaphragm dysfunction . In: Medicine Update . Evangel; 2021:754-761.

Shah PL, Hull JH, Hind M.  Upper airway obstruction . In: Firth J, Conlon C, Cox T, eds.  Oxford Textbook of Medicine . Oxford; 2020.

Kaditis A, Gozal D. Sleep studies for clinical indications during the first year of life: Infants are not small children . Children (Basel) . 2022;9(4):523. doi:10.3390/children9040523

American Academy of Pediatrics. Newborn reflexes and behaviors .

Sweet LR, Keech C, Klein NP, et al. Respiratory distress in the neonate: Case definition & guidelines for data collection, analysis, and presentation of maternal immunization safety data . Vaccine . 2017;35(48 Pt A):6506-6517. doi:10.1016/j.vaccine.2017.01.046

Chapman EB, Hansen-Honeycutt J, Nasypany A, Baker RT, May J. A clinical guide to the assessment and treatment of breathing pattern disorders in the physically active: Part 1 .  Int J Sports Phys Ther . 2016;11(5):803–809.

By Rod Brouhard, EMT-P Rod Brouhard is an emergency medical technician paramedic (EMT-P), journalist, educator, and advocate for emergency medical service providers and patients.

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Chapter 5: The Respiratory System

Learning Objectives

After completing this chapter, the learner should be able to explain and discuss:

  • General pulmonary anatomy and physiology
  • Data collection, tests and measures for respiratory conditions
  • General signs, symptoms, and effects of pulmonary and respiratory disease
  • Explain effects, pathophysiology, and likely outcomes of pneumonia
  • Explain effects, pathophysiology, and likely outcomes of tuberculosis
  • Describe chronic obstructive pulmonary disease
  • Compare causes, chronic bronchitis and emphysema
  • Explain effects, pathophysiology, and likely outcomes of restrictive lung disease
  • Give examples of restrictive lung disease

Cystic fibrosis

  • Lung cancer
  • Medications commonly used to treat pulmonary conditions
  • The role of the physical therapist assistant in pulmonary conditions

Chapter Contents

5.0 general anatomy and physiology review, 5.1 breathing.

  • 5.2 Pulmonary Capacity

5.3 Respiratory Rates

5.4 general signs of pulmonary system condition or disease.

  • 5.5 Data Collection, Tests and Measure
  • 5.6.1 General

5.6.1.1 Pneumothorax

5.6.1.2 atelectasis, 5.6.1.3 pleural effusion, 5.6.1.4 pulmonary embolism, 5.6.1.5 respiratory acidosis, 5.6.1.6 respiratory alkalosis, 5.6.1.7 bronchiectasis, 5.6.2 infectious lung diseases, 5.6.2.1 pneumonia, 5.6.2.2 tuberculosis, 5.6.3 chronic obstructive pulmonary disease (copd), 5.6.3.1 chronic bronchitis, 5.6.3.2 emphysema, 5.6.4 restrictive lung disease, 5.6.5 other pulmonary conditions, 5.6.5.1 asthma, 5.6.5.2 cystic fibrosis.

  • 5.6.5.3 Lung Cancer
  • 5.7 Medications Commonly Used to Manage Pulmonary Conditions

5.8 Pulmonary Conditions and the PTA

The pulmonary, or respiratory system, is a vital body system. The pulmonary and cardiovascular systems work together to bring oxygen into the body and distribute it throughout the body, and then release carbon dioxide and water from the body. The main components of the upper and lower respiratory tracts are shown below. The upper respiratory tract consists of all structures above the vocal folds: the nose and mouth, paranasal sinuses, pharynx, and larynx. The lower respiratory tract includes all those below the vocal folds: the trachea, bronchi, bronchioles, and alveoli.

The illustration shows the following groups

  • Nasal cavity
  • Nasal conchae
  • Nasal vestibule
  • Thyroid cartilage
  • Cricoid cartilage
  • Vocal folds
  • Carina of trachea
  • Main bronchi
  • Lingular division bronchi
  • Superior lobe
  • Horizontal fissure
  • Oblique fissure
  • Middle lobe
  • Inferior lobe
  • Capillary beds
  • Connective tissue
  • Alveolar sacs
  • Alveolar duct
  • Mucous gland
  • Mucosal lining
  • Pulmonary artery
  • Pulmonary vein
  • Tracheal and bronchi rings
  • Apex of left lung
  • Cardiac notch
  • Lingula of lung
  • Oral cavity

For a review of the pulmonary system, please watch the following video.

5.0 – Resource 02 –  “The lungs and pulmonary system | Health & Medicine | Khan Academy” by Khan Academy is licensed under Fair Use

Breathing is accomplished by a combination of muscle activity and pressure gradients. When the diaphragm contracts, it pulls downward, elongating the pleural space. When the intercostal muscles contract, they pull the pleural cavity upward and outward. The result of this muscle action is that the pleural space and lung volume increase. This increase in volume creates a decrease of pressure inside the lungs relative to the air pressure outside the body. Since gasses always flow from an area of greater pressure to an area of lower pressure, air flows into the lungs. This is inspiration.

During expiration, the diaphragm returns to its upward position, and the relaxing intercostal muscles allow the ribs and lungs to return to the resting position. This decreases the lung volume, thereby increasing the pressure in the lungs, so the air rushes out to an area of lower pressure outside the body. For a good video explanation of this activity, watch this:

5.1 – Resource 01 – The Mechanisms of Breathing 

To watch a real time video of breathing visualized through MRI , check out the link below:

real time video of breathing

5.2 Pulmonary Capacity and Volume

Refer to the chart below for a visual representation of breathing and lung capacities.

A black and white graph of a sound wave

Graph of lung volumes.

A graph shows Lung Volumes where the Y axis is Volume in milliliters per kilogram and goes from 0 to 80 with horizontal lines at 15, 30 and 37. The X axis has no units. A sinusoidal curve oscillates 4 times between 30 and 37, then has a larger oscillation between 15 and 80 then has 2 more between 30 and 37.

Sections of the graph:

  • 0 to 80: Total lung capacity (TLC)
  • 15 to 80: Vital capacity (VC)
  • 0 to 15: Residual volume (RV)
  • 30 to 80: Inspiratory capacity (IC)
  • 0 to 30: Functional residual capacity (FRC)
  • 37 to 80: Inspiratory reserve volume (IRV)
  • 30 to 37: Tidal volume (TV) or (V sub T)
  • 15 to 30: Expiratory reserve volume (ERV)

Regular relaxed breathing is the tidal volume of breathing. It includes gentle inspiration and expiration. If you take a really big breath in, the volume of air above the normal tidal volume inspiration is the inspiratory reserve volume . If you include the inspiratory volume that is part of the tidal volume, the total amount of inspiration is the inspiratory capacity . The amount of air that you are able to exhale after your normal expiration phase of the tidal volume is the expiratory reserve volume . As long as we are alive, there is a small amount of air that stays in the lungs, so that they do not deflate completely. This is the residual volume . If the expiratory reserve volume is added to the residual volume, the result is the functional residual capacity . The vital capacity includes the inspiratory capacity and expiratory reserve volume, which means a maximal inspiration plus a maximal expiration. If you add the reserve volume to the vital capacity, the result is the total lung capacity . The chart below will be helpful to refer to when learning about some pulmonary conditions and diseases.

Respiratory rates are counted in breaths per minute (bpm) during times of quiet respiration. During infancy and childhood, normal respiratory rates are considerably higher than for an adult. If the pulmonary system is working well, the chest and abdomen should gently rise and fall in a rhythmic pattern. The shoulders should remain level, and there should be no signs of stress or strain with breathing.

Normal Respiratory Rates (bpm) for various ages

5.3 – Resource 01 – Normal Respiratory Rates (bpm) for various ages

  • Sneeze: irritation or inflammation of nasal passages
  • Irritation due to nasal discharge
  • Inflammation, foreign material, or tumor in lower respiratory tract
  • Effectiveness is determined by strength of respiratory muscles
  • Productive or unproductive
  • Dyspnea: Subjective feeling in which the patient feel unable to inhale enough air
  • Orthopnea: dyspnea in supine
  • Tachypnea: breathing at a faster rate than expected
  • Bradypnea: breathing at a slower rate than expected
  • Chest pain: may radiate to shoulder or arm
  • Central: mucous membranes of mouth, lips
  • Peripheral: nail beds, nose, ends of fingers, toes
  • Altered or irregular breathing patterns
  • Clubbing of fingernails: shape of nailbed changes; angle is flattened out (> 180 degrees); seen in pulmonary and cardiovascular disorders; can be hereditary; associated with enlarged capillary bed

Photo of a hand with bluish tint and wrinkles

5.4 – Resource 01 – Cyanosis of the fingers

Photo showing a person's hands from the knuckle side, who has Cyanosis of the fingers

5.4 – Resource 02 – Clubbing Fingers or Acopaquia

5.4 – resource 03 – clubbing in the fingernails. note the change in angle of the nailbed. –, 5.5 data collection, tests and measures.

There are many tests and measures to help determine the state of the pulmonary system. Some can be observed or performed during a physical therapy treatment session, while others are performed by other health care professionals. PTAs should be aware of the many tests and the implications of the results for PT interventions.

  • Dyspnea: patient’s complaint of feeling short or breath
  • Tachypnea: breathing is at a higher rate than expected
  • Bradypnea: breathing is at a lower rate than expected
  • Diaphragmatic: normal use of diaphragm and intercostals, contractions for inspiration, relaxation for expiration
  • Accessory muscle use: Patients might use accessory muscles in the chest and neck to help with breathing. Common accessory muscles used for inspiration are the sternocleidomastoids, scalenes, pectoralis major and minor, trapezius, erector spinae, and latissimus dorsi. The abdominal muscles can be used for forced expiration.
  • Apnea: absence of breathing
  • Hypopnea: shallow breathing
  • Hyperpnea: fast, deep breathing (normal during exercise)
  • Paradoxical breathing: occurs in multiple rib fractures, such that a portion of the rib cage is separated; associated with flail chest; part of the rib cage is sucked inward during inspiration, as the diaphragm pulls downward; during expiration the same part distends
  • Indrawing/intercostal indrawing: lower ribs pulled in with inspiration; seen in pneumonia and other pulmonary conditions
  • Ataxic: uncoordinated breathing pattern
  • Apneustic: abnormal breathing pattern characterized by a deep, gasping inspiration, followed by a short pause and then a short incomplete expiration; associated with brain damage
  • Cheyne-Stokes: patterns of quick breaths followed by periods of apnea, associated with brain damage or heart failure.(This term is used interchangeably with Biot’s respiration in some sources.)
  • Biot’s respiration: groups of shallow, quick breaths followed by periods of regular or irregular apnea; occurs with brain damage as in head injury or stroke, or as a result of opioid overdose
  • Kussmaul breathing: Deep labored, gasping breathing associated with metabolic acidosis
  • Effective or ineffective
  • Productive or non-productive for sputum
  • Insidious or acute onset
  • Chronic, frequent, infrequent
  • Sounds: dry, barking,
  • Assessed for amount produced, color, consistency
  • Clear, translucent: normal
  • Purulent: greenish; large numbers of white blood cells, as in infection
  • Blood-tinged/ hemoptysis: associated with TB, lung cancer, or irritated pulmonary structures
  • Gray in smokers
  • Black in coal miners
  • Heart rate: most likely to increase in association with pulmonary disorders. This is a compensatory strategy for the body to get more oxygen distributed
  • Crackles (rales): fine, rattling, or crackling noises heard through auscultation; associated with alveoli that are closed due to fluid, mucous, or lack of aeration “popping open” during inhalation; heard in many pulmonary conditions
  • Wheeze: course, whistling sound heard on inspiration and/or expiration; associated with obstruction or narrowing of any part of the bronchial tree; may be heard with or without stethoscope
  • Stridor: high-pitched sound associated with obstruction in the larynx or lower bronchial tree; associated with croup in children, epiglottitis, foreign body aspiration, and tumor obstruction
  • Pleural rub: squeaking sound heard through auscultation; associated with pleural effusion
  • Absent: no breath sound heard on auscultation; associated with collapsed lung due to atelectasis or pneumothorax

an illustration of a doctor measuring a patients back width with a measuring tape.

5.5 – Resource 01 – Chest Excursion /Expansion –

  • Measurement is taken with tape measure around the level of the 6th rib. Positive result yields < 2.5 cm, or 1 inch, excursion from maximal exhalation to maximal inhalation; associated with restrictive lung disease, or other lung condition; also seen in ankylosing spondylitis.
  • chest expansion test

5.5 – Resource 02 – Alternate Measure for Chest Excursion

  • Tactile fremitus: patient repeated says “99” as clinician places hands on various areas of the posterior thorax; clinician assess vibrations; helpful in identification of obstruction or pulmonary edema
  • Barrel: chest extends in an anterior-posterior direction, causing a circular, or barrel-shaped appearance; occurs in COPD, cystic fibrosis, and other conditions that cause air to remain trapped in the lungs
  • Flared: inferior rib widening secondary to long-term distension of the lower lobes of the lungs; occurs in COPD, cystic fibrosis, and other conditions that cause air to remain trapped in the lungs

photo of someone with pectus carinatum. His chest protrudes further than normal.

Pectus excavatum (Funnel chest): depression of the sternum and chest; seen in genetic conditions, such as Noonan syndrome and Marfan’s syndrome; respiratory and cardiac function can be severely affected by pectus excavatum

Photo of someone with Pectus excavatum (Funnel chest): a depression of the sternum and chest

  • Hypoxemia: diminished PaO2; result of hypoventilation
  • Hypercapnia: excessive PaCO2; result of hypoventilation

photo of the saturometre attached to a finger.

  • < 7.35 pH: respiratory acidosis (increased PaCO2)
  • >7.45 pH: respiratory alkalosis (decreased PaCO2)
  • Chest radiographs, CT scans, MRI : all used to image alterations in the internal structures; can be used with our without contrast materials; useful for visualizing masses or nodules on or in the lungs, bony changes in the ribs, sternum, vertebrae, hypertrophy or atrophy of structures (heart and lungs and structures with them), displacement of organs
  • Arteriography (Angiography): contrast medium injected into blood supply and radiography used to visualize blood flow through the area
  • Bronchoscopy: tube with a small camera inserted through the trachea and into the lungs to “see” abnormalities within the trachea, bronchi, and bronchioles

5.6 Pulmonary Diseases and Conditions

5.6.1 general conditions.

An intact and efficient pulmonary system is essential to health and well-being. When people have difficulty with the mechanisms of breathing, it is often given the general term “respiratory distress.”

Read this article for a great lesson on the signs, symptoms, and reasons for respiratory distress

A pneumothorax is often referred to as a “collapsed lung” because it allows a lung to decrease in volume. In a pneumothorax, air accumulates between the lung and the chest wall which presses inward on the spongy lung tissue. This can occur as a result of trauma to the lung, as an associated disorder with other pulmonary conditions (asthma, emphysema, TB, pneumonia, history of smoking), or spontaneously for no apparent reason. When there is no trauma or underlying pathology, the pneumothorax is labeled “primary.” If there is an associated condition or disease, it is labeled “secondary.” If the pneumothorax is associated with an injury or medical procedure, it is labeled “traumatic.”

Signs and symptoms of a pneumothorax include sharp, one-sided chest pain and shortness of breath. A small, primary pneumothorax may require monitoring only as the body heals itself. For a larger pneumothorax, especially in the presence of chronic disease, the excess air is often removed with a syringe or chest tube. Surgery may be required to repair a large pneumothorax. If left untreated, a large pneumothorax can lead to respiratory distress or death. In the infrequent case of tension pneumothorax , a one-way movement of air out of the lung and into the pleural space exists, and lung expansion is impossible. This is a true medical emergency.

An illustration of atelectasis shows normal bronchiole and blocked bronchiole in the area of the collapsed lung.

Atelectasis, like pneumothorax, is often referred to as “collapsed lung,” although the pathology is quite different. In atelectasis, the alveoli collapse and gasses are not able to be exchanged through these structures. This can be caused by a blockage in a bronchiole from a mucous plug or other material inside the bronchiole, or from pressure outside the bronchiole, perhaps from a tumor or fluid. In premature infants, the lack of surfactant surrounding the lung tissue can cause atelectasis. Poor production of or distribution of surfactant can also lead to atelectasis in adults. Smoking and underlying pulmonary disease are significant risk factors. Most cases of atelectasis occur during surgical recovery.

Physical therapy can be useful in the treatment of atelectasis. Deep breathing exercises and ambulation activities can help prevent atelectasis. Breathing exercises, coughing, percussion and postural drainage can help loosen and remove mucous plugs associated with atelectasis.

an illustration of atelectasis. it shows normal bronchiole and blocked bronchiole in the area of the collapsed lung.

If fluid accumulates in the pleural space, the condition is called pleural effusion. This can occur because of chronic illnesses such as heart failure, kidney failure, or liver cirrhosis. When the normal air space of the lung is compromised by fluid accumulation, there is less space for the lung to expand and move air in and out of the body. This can cause shortness of breath, coughing, and fatigue for the patient. Chest expansion may be diminished over the area of effusion. A pleural rub (squeaking or grating sound) or other abnormal breath sounds may be appreciated through auscultation.

In the case of pleural effusion, the fluid is usually collected via needle biopsy and then tested for infectious agents. The fluid can be drained using a chest tube, if necessary. If infection is present, antimicrobial medications are prescribed.

an illustration showing pleural effusion, with a normal lung, compressed lung, and Pleura.

A pulmonary embolism (PE) occurs when a piece of a thrombus in the venous system (most often a DVT) breaks off and is carried back to the heart in the blood. Since the veins become larger as they approach the heart, the embolism is carried in the bloodstream through the heart and becomes lodged in a small pulmonary artery in the lung. For a PE to become symptomatic, the embolism must either be very large, or consist of several thrombi that have broken free from venous walls and formed a large blockage in the pulmonary circulation. A PE causes damage to lung tissue by occluding blood flow to the area supplied by a vessel, producing ischemia and tissue death. This dead tissue is unable to perform important gaseous exchanges, and less oxygen is available for circulation throughout the body.

The most important risk factor for PE is DVT. Other risk factors include recent immobilization or surgery, obesity, pregnancy, inherited blood conditions, smoking, estrogen replacement therapy, and heart disease. Signs and symptoms of a PE include dyspnea, chest pain, coughing, and hypoxia. The signs and symptoms can be very similar to those of a heart attack, and either diagnosis should receive immediate attention. Other signs and symptoms may include hemoptysis, lower extremity edema, cyanosis, wheezing, diaphoresis, syncope, and weak, rapid pulse.

Anticoagulation medications, such as heparin and coumadin, are the treatment of choice for patients experiencing PE and/or DVT. Supplemental oxygen may also be required.

The normal pH of blood is 7.35-7.45. If the pH is below 7.35, and the blood is too acidic, the condition is called acidosis. This can occur because of hypoventilation, in which case it is termed respiratory acidosis . If a patient’s breathing is too slow (bradypnea) or shallow, or breathing is suppressed because of disease or drugs, the lungs are unable to remove adequate amounts of CO2. The CO2 builds up in the blood, which is a state of hypercapnia. The excessive CO2 causes bicarbonate (HCO3-) levels to decrease, and the kidneys try to compensate by releasing extra bicarbonate into the blood.

Respiratory acidosis can be an acute or chronic condition and is a symptom of many different etiologies. Acute respiratory acidosis a medical emergency that is associated with head trauma, cerebral disease, neuromuscular disease, drugs, or airway obstruction, as in COPD or an acute asthma attack. Chronic respiratory acidosis is a secondary condition caused by several conditions, including COPD, neurological disease, interstitial lung disease, pneumonia, obesity, and severe scoliosis.

Treatment of respiratory acidosis is directed at treating the underlying condition causing the acidosis.

If the pH of the blood is greater than 7.45, a state of alkalosis exists. Hyperventilation is the most common cause of respiratory alkalosis . Hyperventilation (tachypnea) causes too much CO2 to be released through the pulmonary system, causing a state of hypocapnia. Hydrogen (H+) levels also decrease in this condition. Respiratory alkalosis can occur secondary to many conditions, such as COPD, asthma, pulmonary embolism, hyperthyroidism, and sepsis. It can also be a response to living at high altitudes or as a CNS response to fever, anxiety, pain, or trauma.

Respiratory alkalosis can be an acute or chronic condition. Both types require treatment of the primary source of the hyperventilation.

Complete the following chart for Respiratory Alkalosis and Respiratory Acidosis.

Bronchiectasis is a condition in which the airways of the lungs are permanently widened. It occurs in association with pneumonia, tuberculosis, lung cancer, immunosuppressive disorders, and cystic fibrosis. The breakdown of the airway walls is caused by continual excessive inflammatory responses in the lungs, and the expansion of the airways causes excessive mucus production. This mucus presents fertile ground for infection, especially for bacteria. Patients with bronchiectasis have frequent lung infections and can cough up copious amounts of purulent sputum. This disorder can be categorized as an obstructive disease, but since it is a condition associated with other lung and systemic conditions, it is categorized as a general condition here.

Signs and symptoms of bronchiectasis include cough with mucus production, shortness of breath, coughing up blood (hemoptosis), fatigue, fever and chills during exacerbations. Wheezing, chest pain, and clubbing of the fingers are also possible signs. The progression of bronchiectasis is marked by periods of exacerbation, when symptoms can be more pronounced and  hospitalization may be necessary.

Treatment includes pulmonary physical therapy (percussion and postural drainage, breathing exercises, postural correction) and medications. Antibiotics, mucus-thinning medications, and mucus thinning devices, such expiratory pressure devices or Flutter devices (see section on Cystic Fibrosis below), are also useful in eliminating excess mucus. Lung transplantation surgeries are performed in severe cases. It is important that patients with bronchiectasis avoid smoking and are regularly vaccinated for flu and pneumonia.

illustration of A: the lungs, B: tube-like normal airway, C: airway with bronchiectasis shows mucus in the airway.

Review Exercise

Pneumonia is a condition that causes inflammation of one or both lungs, mainly in and about the alveoli. Many different infectious agents can cause pneumonia. Viral and bacterial infections are most common, but fungal and mycoplasma microbes can all cause pneumonia. Pneumonia can be the result of these organisms entering the lungs through inhalation of germs spread through coughing, sneezing, or speaking (community acquired), through insertion of ventilator tubes or other medical instruments (nosocomial). S ome forms of pneumonia (histoplasmosis, for example) are acquired from breathing in microbes from soil infected with fungal agents associated with bird or bat droppings. In addition, pneumonia can be an effect of aspiration of food, liquids, or other substances or items.

Patients with pneumonia will most often exhibit a cough, chest pain, shortness of breath, and fever. Pneumonia can be relatively mild or very serious, depending upon the infectious agent and overall health of the individual. In Pneumonia, fluid collects in the areas of infection in the alveoli, which makes it difficult for the O2 and CO2 transfers to occur. The people who are at greatest risk for developing pneumonia are those with weakened immune systems due to comorbities, immobility, poor nutrition, advanced age, and inadequate medical care. A weak or absent gag reflex is also a significant risk factor for aspiration pneumonia. Anytime a breathing tube is inserted, as in surgery, also places a patient at risk for developing pneumonia.

Treatment for pneumonia includes medications directed at eliminating the inciting infection and decreasing the lung inflammation. Percussion and postural drainage may be useful in assisting patients to clear areas of mucous and fluid retention in the lungs. In addition, general mobility and breathing and coughing exercises can be incorporated to help with lung function.

Click this link to watch a video on pneumonia.

Test Your Knowledge

  • What are the two most common types of community acquired pneumonia, and what can we do to help prevent them?
  • Is pneumonia primarily a problem of obstruction, restriction, ventilation, or perfusion? (Hint: You might want to look back on the Kahn Academy video of Respiratory Distress.)

Tuberculosis (TB) is a disease that has been targeted by the CDC to be eliminated by 2100. Unfortunately, efforts toward eradication are behind schedule, and reducing the number of cases in the US and around the world is proving to be challenging. Health care workers are considered an at-risk population because of the possibility of exposure to TB, and the communicability of the disease in the active form. The populations most at-risk for developing TB include those born outside of the US in countries with high incidence of TB and those living in congregate settings (correctional institutions, long-term care facilities, homeless shelters). TB is also more common in people who have diabetes or AIDS, or those whoabuse drugs or alcohol. World-wide, one-quarter of the population is infected with TB, and it is the leading cause of death due to infectious disease. ( CDC statistics, obtained August 12, 2018. )

TB is caused by the bacterium Mycobacteruim tuberculosis . It is communicable in the active state through airborne transmission, as in coughing, sneezing, or talking. It most often affects the lungs, but can also affect the kidneys, bone, CNS, lymphatic system, and genito-urinary system. The most common signs and symptoms of the active form of the disease include coughing, hemoptysis (blood-tinged sputum), weight loss, fever, and night sweats. Lung tissue infected with TB will develop areas of caseous necrosis called “granulomas.”

An image of a lung with tuberculosis

The initial exposure to the TB bacterium is considered the primary infection. Following the primary infection, the bacterium could cause a progressive primary infection, in which the patient would exhibit the signs and symptoms of TB and would be at risk for lung damage or even death. More often, the TB bacterium exists in a latent state (90% of US cases are latent). A person who has the latent form is more likely to develop a reactivation of TB, often called the secondary progressive state, if they experience a depression of the immune system. This might include HIV/AIDs, diabetes, or auto-immune disease. The signs and symptoms of the secondary progressive infection are the same as for the primary progressive infection, at in this state, the affected person is highly contagious.

The Mantoux tuberculin skin test detects the presence of latent or active forms of TB. A positive result on the skin test will be followed up with blood work, which can detect the presence of the TB bacterium. If active TB is suspected, chest x-rays and sputum sample testing are used to determine active disease. TB is only communicable in the active state.

Vaccination is available for prevention of some forms of TB and is routinely given to children in high-risk populations. It is not used in most US-born infants because it can lead to false positive results on the skin test, making that screening tool less valuable.

Treatment of TB includes many months of anti-microbial medications for the patient and family members and caretakers. Some strains of TB are resistant to the most commonly used medications and require very expensive medication regimes, with less optimistic prognoses than the non-resistant forms.

Kahn academy video on TB:

5.6 – Resource 06 – Primary and Secondary TB – Khan Academy

Watch the video on chronic bronchitis:

5.6 – Resource 07 – Chronic Bronchitis – Khan Academy

Chronic bronchitis is a pulmonary condition that affects people who smoke or who are exposed to smoke, air pollution, coal dust, asbestos, or have allergies that constantly irritate the lungs. A diagnosis of chronic bronchitis is given when a person has a productive cough for 3 consecutive months for 2 consecutive years. The hallmark of this condition is excessive mucous production that is a response to irritation of the bronchioles, which are inflamed. Because of this over-production of mucous, airways can become plugged with mucous and breathing becomes difficult. Expiration is more difficult than inspiration and the residual volume of the lungs increases, while the tidal volume and inspiratory volumes decrease. Also, air exchange is less efficient, so the amount of oxygen in the blood will be less than optimal (hypoxia), and the amount of CO2 will be higher than normal. The oxygen saturation deficiency will show up in pulse oximetry and the nailbeds and lips can take on a bluish tone (cyanosis). Air is trapped in the lungs because of the mucous plugs, so over time, the chest can become larger, and take on a barrel shape. Because of the bluish coloration and the enlarged chest, patients with chronic bronchitis are often referred to as “blue bloaters.”

Chronic bronchitis is a chronic disease, but acute episodes are not uncommon. These episodes include increased mucous production and coughing and can be caused by further irritation of the bronchioles from a cold, allergies, or other increased irritation.

The most important treatment for chronic bronchitisis to decrease the source of irritation. If the patient is a smoker, they should stop smoking. Exposure to other allergens or environmental irritants should be avoided, if possible. Corticosteroids (e.g. Prednisone) are prescribed to decrease the swelling and inflammation of the bronchiole walls and bronchodilators are employed to open the bronchioles. Sometimes, supplemental oxygen therapy is used to help raise the oxygen saturation rates. During acute attacks, antibiotics are prescribed to decrease the risk of developing pneumonia. All patients with chronic bronchitis should receive flu and pneumonia vaccines. Percussion and postural drainage may be useful in clearing mucous plugs. Patients also can benefit from breathing exercises and general physical conditioning.

Watch the following video on emphysema.

5.6 – Resource 08 – What is Emphysema – Khan Academy

The other pulmonary disorder that is included in every COPD discussion is emphysema . Emphysema is similar to chronic bronchitis in that the main problem is one of obstructed breathing and air exchange. Both are highly associated with smoking, but the pathophysiology is quite different. Emphysema is the result of the loss of elastin in the alveoli structures. This causes these important structures to collapse, making oxygen and carbon dioxide exchange very difficult. Air pockets, known as blebs, form between the alveolar spaces. Air pockets can also form in the lung parenchyma; these are called bullae.

The oxygen delivery into the lung is less affected than the removal of the CO2, so people with emphysema do not tend to be cyanotic. They develop coping mechanisms, which include increasing breathing rate, but not depth of breathing. Over time, they develop a barrel chest, and they will often assume a pursed-lip breathing pattern. Because of these characteristics, people with emphysema are sometimes referred to as “pink puffers.” People with emphysema also develop wheezing, dyspnea, and centralized chest pain, and they can develop right-sided heart failure as congestion backs up from the lungs to the right side of the heart.

A section of a deceased person's lung that shows severe emphysema. The black "bubbles" are emphysemous alveoli that have expanded and become filed with black carbon that is from smoking

Gross pathology of lung showing centrilobular emphysema characteristic of smoking. Closeup of fixed, cut surface shows multiple cavities lined by heavy black carbon deposits.

Risk factors for emphysema include smoking or exposure to second hand smoke, chronic bronchitis, respiratory infections, and genetic factors. Environmental factors, such as exposure to coal dust, asbestos, or air pollution also contribute to the development of emphysema. Treatment of emphysema includes smoking cessation and daily use of bronchodilators. During acute exacerbations, antibiotics and steroids are used. Supplemental oxygen might be beneficial, also. All patients with chronic bronchitis should receive flu and pneumonia vaccines. Percussion and postural drainage may be useful in clearing mucous plugs. Patients also can benefit from breathing exercises and general physical conditioning.

Restrictive lung disease is a condition in which lung expansion is limited, most often because of infiltration of fibrotic tissue in the lungs. Specific conditions that can cause scaring and fibrosis include Idiopathic pulmonary fibrosis, sarcoidosis, adult respiratory distress syndrome (ARDS), infant respiratory distress syndrome (IRDS), radiation fibrosis, and pneumoconiosis (long term exposure to irritants, such as coal dust, asbestos). Structural problems, such as scoliosis, kyphosis, and obesity can also lead to restrictive lung disease. Inspiration is a greater problem than expiration in restrictive lung disease and total lung capacity is decreased. Forced vital capacity and forced expiratory volume are also decreased. Symptoms of the disorder include dyspnea and coughing.

Treatment for restrictive lung disease focuses on the source of the problem. For infections causing restriction, antimicrobial medications can be utilized. For structural or postural issues, postural training, muscular training, and orthopedic surgeries can be helpful. Most patients with restrictive lung disease will benefit from breathing exercises and general conditioning. For some patients, lung transplantation or heart-lung transplantation is a good option.

Asthma is a common disorder that can be quite variable in severity. Asthma attacks can occur with extreme variation in frequency. Most people who have asthma can manage the chronic illness with lifestyle modifications and medications, but sometimes attacks can be acute and severe with life-threatening symptoms.

The cause of asthma is not known, but the incidence of asthma in the US has risen steadily in the past 50 years. There are some common triggers for asthma attacks: smoke, pollen, dust, perfumes or other chemicals, animal dander, mold, air pollution, aspirin, certaon foods, exercise, and stress are among the most common. When a person is exposed to a trigger or allergen, the body produces a strong immune reaction, mobilizing large numbers of mast cells containing histamine to the lungs. The smooth muscle in the bronchioles constricts and the mucosal layer of the inner walls of the bronchioles swells, narrowing the lumen. Extra fluid and mucous are released into the bronchioles, which narrows the lumen even more. Breathing becomes difficult and the irritated airways cause coughing. Wheezing, generally on exhalation, can be heard through auscultation, and even sometimes without the use of a stethoscope. Asthma is a disorder of obstruction, so exhalation is affected more acutely than inspiration, and CO2 builds up in the lungs and in the blood.

Asthma attack: illustration with normal airway, and airway during asthma attack.

Asthma attack

The illustration shows 3 parts.

  • Airways and lungs are labelled;
  • Muscle and airway walls are labelled;
  • The airway is extremely reduced from mucus.
  • narrowed airway (limited air flow);
  • tightened muscles constrict airway;
  • inflamed/thickened airway wall; mucus.

Microscopic image shows obstruction of the lumen of the bronchiole by mucoid exudate, goblet cell metaplasia, epithelial basement membrane thickening and severe inflammation of bronchiole.

Asthma is managed through avoidance of known triggers and preventive measures. Many patients have inhalers or nebulizers which deliver inhaled steroids or bronchodilators, such as albuterol. These are useful prior to exercise (think physical therapy) to prevent attacks. Patients use some medications for short term relief from attacks. Some patients also use longer-acting medications for management of the chronic condition. There is no cure for asthma, although some children “outgrow” the condition. Medications are useful in treating the symptoms. There are rare times when a patient is non-responsive to the usual medications and they can enter a life-threatening state of acute severe asthma attack (previously called status asthmaticus).  This is a medical emergency, and large amounts of medications are administered to decrease the pulmonary edema and mucous production, reduce the bronchospasm, and improve O2 levels in the blood.

5.6 – Resource 13 – What is Asthma? Khan Academy

5.6 – resource 14 – asthma pathophysiology – khan academy.

Cystic fibrosis (CF) is a genetic disorder that affects many parts of the body, but its most devastating effects are on the lungs. The disease is an autosomal recessive gene, so a child of two carrier parents (they do not actually have, or express, the disease) has a 25% chance of actually being affected by CF, a 50% chance of being a carrier, and a 25% chance of being completely free of the gene.

Autorecessive

Illustration with human stick figures labelled and connected by arrows. 2 parents are shown: an unaffected carrier father and mother. Below each is a blue R and a red R. Below the parents are 4 children. Child 1 is labelled “Unaffected, 1 in 4 chance” and has 2 blue R’s, 1 from dad and 1 from mom. Child 2 is labelled “Unaffected carrier: 2 in 4 chance” and has 1 blue R from dad and 1 red r from mom. Child 3 is also labelled “Unaffected carrier: 2 in 4 chance” and has has 1 blue R from mom and 1 red r from dad. Child 4 is labelled “Affected: 1 in 4 chance” and has 2 red R’s, 1 from dad and 1 from mom.

People with CF have abnormalities with their lungs, pancreas, kidneys, liver, and intestines. Almost all males with CF are sterile. The problem is with a protein involved with the creation of sweat and mucous throughout the body. The sweat and skin are very salty and the mucous is very thick in people with CF. The thick mucus affects the pulmonary, digestive, renal, and reproductive systems. The most profound symptoms are generally associated with lung function: respiratory infections, coughing up mucous, barrel chest, clubbing of the fingers and toes, difficulty breathing, wheezing, and in later stages, right-sided heart failure.

Figure A shows the organs that cystic fibrosis can affect. Figure B shows a cross-section of a normal airway. Figure C shows an airway with cystic fibrosis. The widened airway is blocked by thick, sticky mucus that contains blood and bacteria.

Illustration with 3 sections – A: Organs affected by cystic fibrosis. B: Normal airway. C: Airway with cystic fibrosis.

  • Sinuses: sinusitis (infection) infection, and widened airways
  • Skin: sweat glands produce salty sweat.
  • Liver blocked biliary ducts
  • Pancreas: blocked pancreatic ducts
  • Intestines: cannot fully absorb nutrients
  • (male and female) complications
  • (Airway in cross section)
  • Airway wall
  • Airway lined with a thin layer of mucus
  • Bacterial infection
  • Thick, sticky mucus blocks airway
  • Widened airway , blood in mucus

The disorder is often diagnosed in infancy or early childhood. There is no cure for the disease, but it can be managed. The life expectancy for a person with CF is now 40-50 years, which marks a huge improvement in the past 30 years. The disorder can be managed through various medications and procedures, which focus on improving the quality of life for most patients.

Since the thick, sticky mucous in the lungs is such a rich environment for bacterial infection, patients take antibiotics almost all the time. Health care workers need to be very careful regarding transmission of bacteria and other organisms to and from CF patients. Medications to thin mucus secretions, replace pancreatic enzymes, reduce inflammation, and assist with breathing are also employed. Chest physical therapy is useful in providing percussion, postural drainage, vibration, breathing and assisted coughing techniques, and ventilatory muscle training. Other areas of PT that should be included are postural training, mobilization of the thorax, and breathing exercises. General cardiovascular conditioning is also helpful. There are several devices that can provide mechanical assistance in moving the mucus into larger airways. These include autogenic drainage devices, such as positive expiratory pressure (PEP) devices or Flutter valve therapy devices, and mechanical percussion devices. Patients with CF need to use these devices and/or manual methods for moving secretions in the lungs several times each day.

As the disease progresses and lung function diminishes, some patients are the recipients of lung or heart-lung transplantations, which can extend life. Gene therapy is in the experimental stages and shows promise as an effective cure for this disease.

For some really cool research going on to help people with CF, read this short article .

Watch the video on cystic fibrosis .

5.6 – Resource 17 – What is Cystic Fibrosis? – Khan Academy

5.6.5.3 lung cancer.

The lung can be a primary site for cancer, or a secondary site for cancers that have metastasized. The strongest risk factor for primary lung cancer is smoking. Other risk factors include genetic factors, exposure to asbestos, coal dust, air pollution, or radon gas. Genetic factors also play a role; 10-15% of lung cancers occur in individuals who have never smoked.

In lung cancer, the epithelial cells lining the lungs are damaged and undergo many generations of mutations. In the mutations, DNA can be damaged, creating abnormal cancer cells that proliferate and grow without control. From the lung, tumors can metastasize and colonize in any part of the body. One reason lung cancer remains the deadliest cancer in the US for both men and women is that lung cancer tends to grow and metastasize very quickly. The tumors in the lungs take up space normally occupied by functioning lung parenchyma, and they can obstruct air passageways in the lung. Symptoms include dyspnea, wheezing, coughing, hemoptysis, chest pain, weight loss, fever, clubbing of the fingernails, and fatigue.

X-rays, CT scans, MRIs, tissue biopsies, and sputum sample testing are used to diagnose lung cancer. Treatment for this condition includes chemotherapy, radiation therapy, and surgical resection of part of or of an entire lung.

Gross appearance of the cut surface of a pneumonectomy specimen containing a lung cancer, here a Squamous cell carcinoma (the whitish tumor near the bronchi).

Think about this….

  • Why would a patient who is having difficulty breathing lean forward and support themselves with their arms on a walker or countertop? Why would this position help them to breath more easily?
  • One recommendation PTAs can make for patients who have pulmonary difficulties, particularly COPD, is to employ pursed-lip breathing. In this breathing pattern, the patient purses their lips on expiration. Why is this helpful?
  • If a patient experiences long-standing pulmonary dysfunction, are they more likely to have associated right-sided or left-sided heart failure? Why?
  • Respiratory alkalosis
  • Respiratory acidosis

5.7 Medications Commonly Used to Manage or Treat Pulmonary Conditions

Bronchodilators, inhaled: most often used to treat asthma and COPD; can be used in other conditions that obstruct the pulmonary system

Short-acting beta-2-adrenergic agonists : quickly decrease bronchial constriction and open airways in the case of asthma attack or respiratory distress due to obstructed breathing, as in COPD or CF; can be used 20 minutes before an exercise session to prevent an asthma attack (example: salbutamol)

Long-acting beta-2-adrenergic agonists : act to maintain open airways and prevent bronchoconstriction; used mainly for asthma (examples: salmeterol, salbutermol (albuterol), and formoterol, corticosteroids)

Anticholinergics : used to improve lung function and prevent exacerbations; used for asthma and COPD (examples: tiotropium (Spiriva) and ipratropium bromide)

Side effects of bronchodilators: dry mouth, tremor, headache, palpitations, muscle cramps, coughing, nausea, vomiting, diarrhea)

Antibiotics: used to treat pulmonary bacterial infections, such as pneumonia or infections associated with CF (examples: Levofloxacin (Levaquin), Clindamycin (Cleocin), Piperacillin-tazobactam (Zosyn)

Side effects of antibiotics: nausea, vomiting, diarrhea, increased sun sensitivity, yeast infections

Antivirals: used to treat pulmonary viral infections, such as pneumonia (examples: oseltamivir (Tamiflu), zanamivir (Relenza), or peramivir (Rapivab))

Side effects of antivirals: nausea, vomiting, diarrhea, headache

Antifungals; used to treat pulmonary lung infections, especially fungal pneumonias, including histoplasmosis; (examples: amphotericin B, amphotericin, itraconazole)

Side-effects of antifungals: can cause life-threatening allergic reactions

Expectorants (Mucus-thinning drugs): these drugs thin the mucus and lubricate the airway; assists patients to mobilize secretions out of airways where they obstruct airflow; (example: guaifenesin/hydrocodone)

Side effects of expectorants: headache, dizziness, sedation, nausea, diarrhea, decreased blood pressure

Flu and pneumonia vaccines are very important preventative measures for people with chronic pulmonary conditions. They are also important for anyone in an immunocompromised state, including autoimmune disease or other chronic condition, in chemo- or radiation therapy, elderly, or affected by other cormorbitidies, such as diabetes, heart failure, kidney disease, or liver disease. Flu and pneumonia vaccines can help prevent dangerous pulmonary infections from occurring in those at risk.

Many patients seen in physical therapy will be affected by some sort of pulmonary condition. Asthma is very common, and attacks are often triggered by exercise. Many patients will have had recent surgery and are at risk for pneumonia and pulmonary emboli. Smoking and exposure to asbestos, coal or air pollution are common risk factors, as well. The PTA needs to have a working knowledge of the pulmonary system and conditions. Patient education regarding smoking cessation and avoidance of substances or situations that put patients at risk for pulmonary conditions needs to be addressed in physical therapy sessions. The PTA needs to be vigilant regarding signs of respiratory difficulties and needs to be able to react quickly and appropriately if signs become evident. Familiarity with and confidence in taking vital signs are extremely important for the PTA.

Here are a few questions for a quick review:

The Pulmonary System Resources

Section 5.0

Resource 01 – The Respiratory Complete System

Resource 02 –  “The lungs and pulmonary system | Health & Medicine | Khan Academy” by Khan Academy is licensed under Fair Use

Section 5.1

Resource 01 – The Mechanisms of Breathing

Section 5.2

Resource 01 – Breathing and Lung Capacities

Section 5.3

Resource 01 – Normal Respiratory Rates (bpm) for various ages

Section 5.4

Resource 01 – Chest Excursion /Expansion

Resource 02 – Clubbing Fingers or Acopaquia

Resource 03 – – Clubbing illustration

Section 5.5

Resource 01 – Chest Excursion/Expansion

Resource 02 – Alternate Measure for Chest Excursion

Resource 03 –  Pigeon chest/pigeon breast/pectus carinatum

Resource 04 – Pectus excavatum (Funnel chest)

Resource 05 – Spirometry (Incentive inspiratory spirometry)

Resource 06 – Spirometry (Incentive inspiratory spirometry)

Resource 07 – Pulse oximeter

Section 5.6

Resource 01 – Pneumothorax

Resource 02 – Atelectasis

Resource 03 – Pleural Effusion

Resource 04 – Bronchiectasis

Resource 05 – Tuberculosis

Resource 06 – Primary and Secondary TB – Khan Academy

Resource 07 – Chronic Bronchitis – Khan Academy

Resource 08 – What is Emphysema? – Khan Academy

Resource 09 – Gross Pathology of lung showing centrilobular emphysema characteristics of smoking

Resource 11 – Asthma

Resource 12 – Asthma

Resource 13 – What is Asthma? – Khan Academy

Resource 14 – Asthma pathoshysiology – Khan Academy

Resource 15 – Cystic Fibrosis

Resource 16 – Cystic Fibrosis

Resource 17 – What is Cystic Fibrosis? – Khan Academy

Resource 18 – Lung Cancer

Section 5.7

Section 5.8

Pathophysiology for Physical Therapist Assistants Copyright © 2020 by rlb18 is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Respiratory chest excursion: what is how to measure, the norm.

In order to correctly collect an anamnesis, students learn for years learn to interview, examine and measure a patient. It's a whole art - quickly and qualitatively fill the primary card so that even a doctor who has never met your patient was immediately clear. One of the stages in the history of anamnesis is anthropometric research, which includes determining the size of the chest, the volume of respiratory movements, their symmetry and frequency, participation in the act of breathing muscles.

Chest shape

What does the doctor seek during the examination? First of all, this is to reveal the characteristics of the chest at rest and during movement, along with spirometry indicators, for example, such as inspiratory volume, speed and expiratory volume, and many others. Their relationship will help differentiate pulmonological pathology from neurological, from trauma or pulmonary edema.

First of all, with a visual examination, we can look at the shape of the chest. Distinguish right or wrong variations. Next, look at the symmetry of both of its halves and the uniformity of respiratory movements.

In the clinical anatomy, the following possible variants of the development of events are distinguished:

  • Normostenic, when the ratio of width and depth is correct, the supra- and subclavian fossa are moderately impressed, the ribs go obliquely, the distance between them remains normal, the scapula is loosely pressed to the thorax, and the epigastrium angle is straight.
  • The asthenic type most often happens in slender people. Size, representing the depth of the chest is smaller, due to this is created by the impression that it has an elongated shape. Most often, the pits near the clavicle are expressed sharply, the skin over them sinks. The ribs are located more vertically than at an angle, the angle formed by the xiphoid process is acute. In such people, the muscles of the shoulder and back are usually weakly developed, and the lower edge of the ribs is easily palpated.
  • Hypersthenic type, corresponds to the same type of physique. The thorax is slightly similar to the cylinder, the depth and width are the same, the intervals between the ribs are narrow, they are almost parallel. Supra- and subclavian fossa are slightly prominent, the epigastric angle is blunt.
  • Emphysiematous thorax occurs in patients with COPD and bronchial asthma. It is similar to hypersthenic, but it has rather wide intercostal spaces, the course of the ribs is horizontal, practically without a slope, the scapulas are closely located with respect to the ribs, there is no obvious selection of supra- and subclavian pits.
  • The paralytic chest is outwardly similar to an asthenic one. It occurs in patients with tuberculosis, chronic lung diseases, pleura, in severely malnourished, cachectic people and in genetic pathology - Morphan syndrome.
  • Rickets, or keeled thorax - occurs mainly in children. Its distinctive features are an impression in the central part in the area of the xiphoid process of the sternum. And also the presence of the symptom of the beads, thickening at the site of the transition of the osseous part of the rib into the cartilaginous part due to incorrect osteogenesis.

Method of breathing

Excursion of the chest depends not only on its type and shape, but also on how a person breathes: mouth or nose. In this connection, different types of breathing are distinguished.

Breast - occurs mainly in women. In this type, the main load falls on the intercostal muscles and the diaphragm. Abdominal breathing is more common in men. They have an active abdominal wall in the act of breathing.

There is also a rhythm of breathing (rhythmic or arrhythmic), depth (deep, middle depth or superficial) and frequency (the number of respiratory movements per minute).

The respiratory excursion of the thorax is normally symmetrical. In order to check this sign, you need to look at the movement of the lower angles of the blades during a deep inspiration and exhalation. If one of the scapulae does not succeed in another, it indicates a violation of the function of external respiration and may indicate inflammatory processes, such as pleurisy. In addition, asymmetry can be observed after surgery on the chest, with the wrinkling of the lung due to malignant neoplasms or necrosis.

Another case where a chest excursion can be disturbed is a pathological increase in the lung. This situation can be observed with emphysema, bronchoectatic disease, exudative or exudative pleurisy, closed pneumothorax.

Measurement technique

How to determine the chest excursion? Quite simply: by measuring and simple calculations.

The examinee is asked to stand facing the doctor and spread his hands to the sides. It is desirable that the upper part of the trunk at the same time be freed from clothing. Then the doctor takes a centimeter tape and places it so that it passes through the corners of the scapula. The researcher is invited to take a deep breath and hold his breath. At this time, the first measurement is made. Then the patient can exhale and again hold his breath, so that the doctor can again measure the circumference of the chest. Actually, this was the excursion of the chest. How to measure the frequency of breaths or their depth in liters? Too simple enough if there is additional equipment, such as a clock and a picofluometer.

Deformation of the chest

A chest excursion should normally be symmetrical over all areas, but sometimes uneven resistance of its walls to air pressure is observed. And then protrusions or retractions are formed. Retraction is usually a consequence of fibrosis or lung atelectasis. A one-sided swelling of the chest can indicate the accumulation of fluid or air in this place.

To check the symmetry, the doctor must put his hands to the back of the patient on either side of the spinal column and ask for a few deep breaths. The lag of one of the halves can tell the doctor that a person develops pleurisy or pneumonia, and a uniform decrease or absence of a lung excursion may lead to an idea of emphysema.

Normal performance

In fact, there are no clear criteria, which should be a tour of the chest. The norm (cm) is quite relative and depends on the age, physique, sex of the person. On average, it ranges from one to three centimeters. Circumference of the chest - also a relative value, only for children there are special tables that reflect the dynamics and harmony of their development.

Breathing rate

When the chest excursion is determined, the doctor is engaged in counting the breaths-exhalations. At this moment it is important to distract the patient to something else, otherwise it can distort the results, breathe more often or, conversely, less often.

Therefore, unnoticed for the patient, the specialist has a hand on the surface of the chest. This is convenient when you count the pulse and count the number of movements per minute. A normal chest excursion involves twelve or twenty respiratory movements. If the patient does not reach the lower limit of the norm, then most likely, he will soon show neurologic symptoms, but if the frequency is much higher, then the probable diagnosis is associated with pathologies that prevent a person from breathing deeply (fluid, fracture of ribs, neuralgia, etc.) .). In addition, the rapidity of breathing can be observed because of the labile psychoemotional state, at the height of the fever, or in pre-teaching.

Excursion of the chest (the difference in its circumference between inspiration and exhalation) is not always included in the priority study of emergency physicians or somatic hospitals. This is considered a routine activity, although it is not deserved. Earlier, when ultrasound, MRI and CT machines were not widely used, doctors could reveal a hidden pathology, simply putting a hand to the patient's breast.

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Things to Do in Elektrostal, Russia - Elektrostal Attractions

Things to do in elektrostal.

  • 5.0 of 5 bubbles
  • 4.0 of 5 bubbles & up
  • Good for a Rainy Day
  • Good for Kids
  • Good for Big Groups
  • Adventurous
  • Budget-friendly
  • Hidden Gems
  • Good for Couples
  • Honeymoon spot
  • Good for Adrenaline Seekers
  • Things to do ranked using Tripadvisor data including reviews, ratings, photos, and popularity.

chest excursion

1. Electrostal History and Art Museum

chest excursion

2. Statue of Lenin

chest excursion

3. Park of Culture and Leisure

4. museum and exhibition center.

chest excursion

5. Museum of Labor Glory

chest excursion

7. Galereya Kino

8. viki cinema, 9. smokygrove.

chest excursion

10. Gandikap

11. papa lounge bar, 12. karaoke bar.

  • Statue of Lenin
  • Electrostal History and Art Museum
  • Park of Culture and Leisure
  • Museum and Exhibition Center
  • Museum of Labor Glory

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  • Elsevier - PMC COVID-19 Collection

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Diaphragmatic excursion: A possible key player for predicting successful weaning in patients with severe COVID-19

To the Editor,

The medical community is suffering from Coronavirus disease 2019 (COVID-19) pandemic. The cardinal cause of death in patients with COVID-19 is respiratory failure; therefore, respiratory support represents the mainstay of their management. Weaning of critically ill patients from mechanical ventilation (MV) is a critical decision for intensivists especially within a pandemic with a shortage of ventilators and an urge need for successful and timely patient disconnection from ventilatory support. Furthermore, failure of patient disconnection and subsequent re-intubation are independent causes of patient mortality. Thus, it is essential to reach adequate criteria for weaning with precise cut-off values. There is mounting evidence for the value of diaphragmatic excursion during weaning [1] , [2] . However, no data are available for its accuracy in patients with COVID-19. This study evaluates the accuracy of diaphragmatic excursion in predicting weaning outcomes.

A prospective observational study was conducted in a University Hospital after approval of the institutional research ethics board (N-3-2021) and obtainment of informed consents from the participants’ next-of-kin. The study included 22 patients with severe COVID-19 who were invasively mechanically ventilated for 2 days or more. Patients were included when they met the basic criteria for weaning from invasive MV: resolution of the primary pathology, adequate cough, minimal tracheobronchial secretions, PaO 2 /fraction of inspired oxygen ratio (P/F ratio) > 200 with positive end expiratory pressure ≤ 8 cmH 2 O, respiratory rate < 30/min, appropriate p H for patients’ baseline values, and stable haemodynamic profile on no/minimal vasopressor therapy. Patients with history of diaphragmatic pathology or recent thoracic or upper abdominal surgery were not included.

Ultrasound examination of the diaphragm ( Fig. 1 ) was performed by an expert, using a Samsung HS60 ultrasound machine with a 3−5 MHz curvilinear probe in the semi-recumbent position 15 min after initiation of the SBT.

Fig. 1

Ultrasound examination of the diaphragm.

The probe was placed over one of the lower intercostal spaces in the right anterior axillary line for the right diaphragm, and the left mid axillary line for the left diaphragm. The ultrasound beam was directed to the hemi-diaphragmatic domes at an angle ≥ 70° and M-mode tracing was initiated. Diaphragmatic excursion was measured as the vertical distance from the baseline to the highest point of inspiration. Three measurements were obtained, and their average was used in data analysis. The data collectors were blinded to the results of ultrasound examination.

Patients were subjected to a spontaneous breathing trial (SBT) on pressure support mode (pressure support 5 cmH2o, positive end-expiratory pressure 5 cmH2O) for 120 min and by its end the patient was extubated if the respiratory and haemodynamic parameters were stable. After extubation, the patients were followed up and divided into successful weaning group (patients who did not require any ventilatory support 72 h after extubation) and failed weaning group (patients who were re-intubated within 72 h after extubation and those who failed by the end of the SBT). The primary outcome of the study was the accuracy of diaphragmatic excursion to predict successful weaning. Other outcomes included: respiratory rate, P/F ratio, rapid-shallow breathing index (RSBI), vasopressor use, acute kidney injury, laboratory investigations, and Acute Physiology and Chronic Health Evaluation (APACHE) score.

The SPSS 21 (Chicago, IL) and MedCalc software were used for analyses. The data were checked for normality using the Shapiro-Wilk test. Data were presented as the means (standard deviations), medians (quartiles), and frequencies (%) as appropriate; and were compared using the Unpaired Student’s t test, Mann-Whitney U test, or Fisher’s exact test as appropriate. The area under receiver operating characteristic curve (AUC) (95% confidence interval [CI]) was calculated for predictors of successful weaning. The best cut-off values were determined using the Youden index. The level of significance was set at p  ≤  0.05.

Twenty-two patients were included in the study. Nine patients were successfully weaned, and 13 patients failed, either by the end of the SBT or after extubation. The successful weaning group had lower age, body mass index, APACHE score, and RSBI; and higher P/F ratio, and diaphragmatic excursion compared to the failed weaning group ( Table 1 ).

Baseline characteristics and weaning predictors. Data are presented as means (standard deviations), medians (quartiles), and frequencies (%).

APACHE: Acute Physiology and Chronic Health Evaluation, MV: mechanical ventilation, RSBI: rapid shallow breathing index, P/F ratio: PaO 2 /fraction of inspired O 2 .

The AUC for predicting successful weaning was highest for the diaphragmatic excursion (right side: AUC [95% CI]: 0.996 [0.838–1.000], sensitivity: 100%, specificity: 92%, cut-off value: 11 mm; left side: AUC [95% CI]: 1.000 [0.846–1.000], sensitivity: 100%, specificity: 100%, cut-off value: 12 mm) followed by the RSBI (AUC [95% CI]: 0.782 [0.557−0.927], sensitivity: 100%, specificity: 54%, cut-off value: ≤ 97) and the P/F ratio (AUC [95% CI]: 0.774 [0.547−0.992], sensitivity: 78%, specificity: 77%, cut-off value: 281) ( Fig. 2 ).

Fig. 2

Area under receiver operating characteristic curve (AUC) for predicting successful weaning.

Legend: Summarised results. Upper left panel: receiver operating characteristic curves for predicting successful weaning. Upper right panel: individual readings of the RSBI. Lower left panel: individual readings of the DE, individual readings of the P/F ratio. AUC: area under the curve, CI: confidence interval, DE: diaphragmatic excursion, P/F ratio: PaO2/fraction of inspired oxygen, RSBI: rapid shallow breathing index.

We report that diaphragmatic excursion can perfectly predict successful weaning in patients with COVID-19. The diaphragm is the key respiratory muscle, which is responsible for ≈ 70% of the tidal volume during inspiration [1] . Diaphragmatic dysfunction is common in critically ill patients and a pivotal factor in failure of weaning from MV. Ultrasonographic evaluation of diaphragmatic dysfunction had gained interest as a simple and accurate measure for respiratory workload during MV. Diaphragmatic excursion is positively correlated with lung inspiratory volumes and can accurately reflect the muscle strength and function [2] , [3] . Furthermore, diaphragmatic excursion is an index for respiratory muscle fatigue during the SBT. Some authors had reported a lower accuracy for diaphragmatic excursion compared to most of the available data and suggested that this lower accuracy is due to the heterogeneity of the patients included in the meta-analyses [4] , [5] . Therefore, separate evaluation of different groups of patients is essential to find the validity of this useful measure during weaning. Our study is the first to evaluate the value for diaphragmatic indices in patients with COVID-19. We found an outstanding value for diaphragmatic evaluation during the SBT and none of the patients whose diaphragmatic excursion exceeded 12 mm were re-intubated.

The pandemic pattern of COVID-19 resulted in overwhelming number of patients that exceeded, sometimes, the hospital capacities and ended with collapse of the healthcare system in some countries. Thus, proper and timely weaning would help in faster discharge and subsequent bed clearance.

In conclusion, diaphragmatic excursion has an excellent ability for predicting weaning outcome in COVID-19 patients. A patient with diaphragmatic excursion > 12 mm during the SBT is unlikely to be re-intubated.

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors

Registration

This study was not registered in a trials register; however, study protocol and any data related to this study can be available upon request from the corresponding author.

Conflict of interests

The authors declare that they have no conflict of interest with this work.

Acknowledgments

The authors would like to acknowledge all the residents and assistant lecturers in their department.

chest excursion

Strange Glow Over Moscow Skies Triggers Panic as Explosions Reported

B right flashes lit up the night sky in southern Moscow in the early hours of Thursday morning, new footage appears to show, following reports of an explosion at an electrical substation on the outskirts of the city.

Video snippets circulating on Russian-language Telegram channels show a series of flashes on the horizon of a cloudy night sky, momentarily turning the sky a number of different colors. In a clip shared by Russian outlet MSK1.ru, smoke can be seen rising from a building during the flashes lighting up the scene.

Newsweek was unable to independently verify the details of the video clips, including when and where it was filmed. The Russian Ministry of Emergency situations has been contacted via email.

Several Russian Telegram accounts said early on Thursday that residents of southern Moscow reported an explosion and a fire breaking out at an electrical substation in the Leninsky district, southeast of central Moscow.

Local authorities in the Leninsky district told Russian outlet RBC that the explosion had happened in the village of Molokovo. "All vital facilities are operating as normal," Leninsky district officials told the outlet.

The incident at the substation in Molokovo took place just before 2 a.m. local time, MSK1.ru reported.

Messages published by the ASTRA Telegram account, run by independent Russian journalists, appear to show residents close to the substation panicking as they question the bright flashes in the sky. One local resident describes seeing the bright light before losing access to electricity, with another calling the incident a "nightmare."

More than 10 villages and towns in the southeast of Moscow lost access to electricity, the ASTRA Telegram account also reported. The town of Lytkarino to the southeast of Moscow, lost electricity, wrote the eastern European-based independent outlet, Meduza.

Outages were reported in the southern Domodedovo area of the city, according to another Russian outlet, as well as power failures in western Moscow. Electricity was then restored to the areas, the Strana.ua outlet reported.

The cause of the reported explosion is not known. A Telegram account aggregating news for the Lytkarino area described the incident as "an ordinary accident at a substation."

The MSK1.ru outlet quoted a local resident who speculated that a drone may have been responsible for the explosion, but no other Russian source reported this as a possible cause.

Ukraine has repeatedly targeted Moscow with long-range aerial drones in recent months, including a dramatic wave of strikes in late May.

On Sunday, Moscow Mayor Sergei Sobyanin said the region's air defense systems had intercepted an aerial drone over the city of Elektrostal, to the east of Moscow. No damage or casualties were reported, he said.

The previous day, Russian air defenses detected and shot down another drone flying over the Bogorodsky district, northeast of central Moscow, Sobyanin said.

There is currently no evidence that an aerial drone was responsible for the reported overnight explosion at the electrical substation in southern Moscow.

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Stills from footage circulating on Telegram early on Thursday morning. Bright flashes lit up the night sky in southern Moscow, new footage appears to show, following reports of an explosion at an electrical substation on the outskirts of the city.

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40 facts about elektrostal.

Lanette Mayes

Written by Lanette Mayes

Modified & Updated: 02 Mar 2024

Jessica Corbett

Reviewed by Jessica Corbett

40-facts-about-elektrostal

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

  • Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
  • With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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IMAGES

  1. Chest Wall Excursion

    chest excursion

  2. PPT

    chest excursion

  3. PPT

    chest excursion

  4. PPT

    chest excursion

  5. PPT

    chest excursion

  6. PPT

    chest excursion

VIDEO

  1. Secondary Chest Day... Pause Reps??

  2. Chest exercises are the best effective exercises to expand the chest quickly🤸

  3. Inspection:Impaired chest expansion-video only

  4. Chest and back

  5. Fix Your UNEVEN IMBALANCE CHEST! IN FEW DAYS

  6. Chest Expansion Exercise 1

COMMENTS

  1. Diaphragmatic excursion

    Diaphragmatic excursion is the movement of the thoracic diaphragm during breathing. ... If it is less than 3-5 cm the patient may have a pneumonia or a pneumothorax in which a chest x-ray is diagnostic for either. References This page was last edited on 14 August 2020, at ...

  2. Thorax & Lungs: Palpation/Percussion

    Palpation of the chest includes evaluation of thoracic expansion, percussion, and evaluation of diaphragmatic excursion. These techniques may be used to evaluate suspected abnormalities. ... May be impeded by a very thick chest wall. Produces a low-pitched, resonant note of high amplitude over normal gas-filled lungs. Produces a dull, short ...

  3. UC San Diego's Practical Guide to Clinical Medicine

    Detecting Chest Excursion. Tactile Fremitus: Normal lung transmits a palpable vibratory sensation to the chest wall. This is referred to as fremitus and can be detected by placing the ulnar aspects of both hands firmly against either side of the chest while the patient says the words "Ninety-Nine."

  4. Pulmonary Exam: Percussion & Inspection

    Learn how to perform percussion and inspection of the chest to diagnose lung abnormalities such as pleural effusions, emphysema, pneumonia and more. Find out the stigmata of chronic obstructive pulmonary disease, the 5-7-9 rule, the major and minor fissures of the lung, and the historical perspective of the pulmonary exam.

  5. Thoracic Excursion Is a Biomarker for Evaluating Respiratory Function

    Thoracic excursion is estimated by measuring chest expansion. It is known to correlate with maximal inspiratory volume and is used as an outcome in respiratory rehabilitation. We aimed to determine the usefulness of thoracic excursion as an alternative to PFT in patients with ALS.

  6. Normal Chest Excursion

    A normal circumferential measurement of three and one-fourth inches (8.48 cm) is explained. The importance of this chest excursion measurement in the respiratory portion of the patient's evaluation is related to his treatment program and activity goal. The mean and standard deviations of age, vital capacity, and excursion according to the ...

  7. Pulmonary Examination Technique

    When the patient inspires, each hand should rotate away from the midline equally. Unequal movement, or a minute amount of movement, indicates asymmetry and poor diaphragmatic excursion, respectively. Crepitus is the sensation of crackles under the fingertips during superficial palpation of the chest wall.

  8. 10.3: Respiratory Assessment

    Chest movement should be symmetrical on inspiration and expiration. Observe the anterior-posterior diameter of the patient's chest and compare to the transverse diameter. The expected anteroposterior-transverse ratio should be 1:2. A patient with a 1:1 ratio is described as barrel-chested. This ratio is often seen in patients with chronic ...

  9. Ultrasonographic Assessment of Diaphragmatic Excursion and its

    Movement of diaphragm during breathing is called diaphragm mobility. Movement of diaphragm from end-expiration to full inspiration is known as diaphragm excursion. Diaphragmatic mobility has been found to be lower in patients with COPD than in healthy elderly individuals due to hyperinflated chest. COPD patients with thoracic hyperkyphosis have ...

  10. Reliability of Chest Wall Mobility and Its Correlation with Lung

    Chest wall circumference measurements are common evaluation methods in clinical settings by therapists in order to obtain chest wall mobility. Previous published results have been conflicting, and there is a lot of variability in the method of testing, which needs testing in different conditions. ... Weedon J. Measuring thoracic excursion ...

  11. Performing a respiratory assessment : Nursing2020 Critical Care

    Uncover his chest and inspect the shape and configuration. Normally, the thorax is symmetrical and the anterior-posterior diameter is less than the transverse diameter. (Equal diameters may signal chronic obstructive pulmonary disease in an adult.) ... Measure the distance between the marks to determine diaphragmatic excursion, normally 5 to 6 ...

  12. Chest Expansion

    Assessing for chest expansion (symmetric or asymmetric) provides clues regarding the presence of chest wall pathology, lung volume loss or obstruction. How to Assess; While the patient is in maximal expiration, place your palms over the patient's posterolateral ribs with your thumbs touching in the midline. Ask the patient to take a deep breath ...

  13. Respiratory rate 4: breathing rhythm and chest movement

    Abstract Breathing rhythm and chest movement provide key information on a patient's condition. The fourth article in this five-part series on respiratory

  14. Paradoxical Breathing: Symptoms, Causes, and Treatment

    Paradoxical breathing, also called paradoxical respiration, can be a symptom of trauma or a medical condition. It can also lead to other symptoms, like shortness of breath, weakness, rapid heart rate, and dizziness. Treatment may vary but typically involves managing the underlying condition. Learn more about the symptoms, causes, diagnosis, and ...

  15. Chest Retractions While Breathing: Symptoms, Causes, and Types

    Croup, swelling in a baby 's upper airways. Respiratory distress syndrome, breathing trouble in newborns. Bronchiolitis, or swelling in the smallest airways of the lungs. Buildup of infected pus ...

  16. Chapter 5: The Respiratory System

    5.5 - Resource 01 - Chest Excursion /Expansion - Measurement is taken with tape measure around the level of the 6th rib. Positive result yields < 2.5 cm, or 1 inch, excursion from maximal exhalation to maximal inhalation; associated with restrictive lung disease, or other lung condition; also seen in ankylosing spondylitis. chest ...

  17. Chest Examination

    The pulmonary examination consists of inspection, palpation, percussion, and auscultation. The inspection process initiates and continues throughout the patient encounter. Palpation, confirmed by percussion, assesses for tenderness and degree of chest expansion. Auscultation, a more sensitive process, confirms earlier findings and may help to ...

  18. Respiratory chest excursion: what is how to measure, the norm

    Chest excursion is the movement of the thorax when a person inhales and exhales. It can be influenced by chest shape, type, size, breathing method and frequency. The normal range is one to three centimeters for adults. The web page explains how to measure chest excursion with a tape and a clock, and what factors can affect its symmetry and quality.

  19. THE 10 BEST Things to Do in Elektrostal

    1. Electrostal History and Art Museum. 2. Statue of Lenin. 3. Park of Culture and Leisure. 4. Museum and Exhibition Center. 5.

  20. Elektrostal

    Elektrostal, city, Moscow oblast (province), western Russia.It lies 36 miles (58 km) east of Moscow city. The name, meaning "electric steel," derives from the high-quality-steel industry established there soon after the October Revolution in 1917. During World War II, parts of the heavy-machine-building industry were relocated there from Ukraine, and Elektrostal is now a centre for the ...

  21. Diaphragmatic excursion: A possible key player for predicting

    Diaphragmatic excursion is positively correlated with lung inspiratory volumes and can accurately reflect the muscle strength and function , . Furthermore, diaphragmatic excursion is an index for respiratory muscle fatigue during the SBT. Some ... Chest. 2017; 152:1140-1150. ...

  22. Strange Glow Over Moscow Skies Triggers Panic as Explosions Reported

    B right flashes lit up the night sky in southern Moscow in the early hours of Thursday morning, new footage appears to show, following reports of an explosion at an electrical substation on the ...

  23. 40 Facts About Elektrostal

    Known as the "Motor City of Russia." Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname "Motor City" due to its significant involvement in the automotive industry.. Home to the Elektrostal Metallurgical Plant. Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.