Symmetry of the chest and trunk. Observe anteriorly, posteriorly, and laterally; the thoracic cage should be symmetrical.

Mobility of the trunk. Check active movements in all directions and identify any restricted spinal motions, particularly in the thoracic spine.

Shape and dimensions of the chest. The anteroposterior (AP) and lateral dimensions are usually 1:2. Common chest deformities include:

• Barrel chest. The circumference of the upper chest appears larger than that of the lower chest. The sternum appears prominent, and the AP diameter of the chest is greater than normal. Many patients with chronic obstructive pulmonary disorders, who are usually upper chest breathers, develop a barrel chest.

• Pectus excavatum (funnel breast). The lower part of the sternum is depressed and the lower ribs flare out. Patients with this deformity are diaphragmatic breathers; excessive abdominal protrusion and little upper chest movement occur during breathing.

• Pectus carinatum (pigeon breast). The sternum is prominent and protrudes anteriorly.

Posture or Preferred Positioning
Identify a patient’s preferred sitting or standing posture. A patient who has difficulty breathing as the result of chronic lung disease often leans forward on hands or forearms to stabilize and elevate the shoulder girdle to assist with inspiration. This position increases the effectiveness of the pectoralis and serratus anterior muscles to act as accessory muscles of inspiration by reverse action. It is also important to identify a patient’s preferred sleeping position. A patient with cardiopulmonary dysfunction often prefers to sleep in a head-up rather than a fully recumbent position. Assuming a horizontal position may result in shortness of breath.

In addition, note any postural deformities such as kyphosis and scoliosis and postural asymmetry from thoracic surgery, which could restrict chest movements and ventilation.

Breathing Pattern
Assess the rate, regularity, and location of ventilation at rest and with activity. A normal respiratory rate for a healthy adult is 12 to 20 breaths per minute. This is most accurately determined when a patient is unaware that his or her respiratory rate is being measured, as when taking the pulse rate. The normal ratio of inspiration to expiration at rest is 1:2 and with activity 1:1. A patient with chronic obstructive pulmonary disease (COPD) may have a ratio of 1:4 at rest, which reflects difficulty with the expiratory phase of breathing.

The normal sequence of inspiration at rest is (1) the diaphragm contracts and descends and the abdomen (epigastric area) rises; (2) this is followed by lateral costal expansion as the ribs move up and out; and finally (3) the upper chest rises. The neck muscles that act as accessory muscles of inspiration should be inactive during relaxed inspiration.

To assess the breathing sequence, have the patient assume a comfortable position (semireclining or supine). Place your hands on the patient’s epigastric region and sternum to observe movements in these two areas.

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