Air

Question 1

Where is the apex of the lung ?

Answer 1

2-4 centimetres above the medial part of the clavicle.

Question 2

What is the major fissure ?

Answer 2

An oblique fissure : from upper back (3rd thoracic vertebrae) to low front (tip of the scapula).
Divide the upper and lower left lungs lobes as well as the lower and middle right lungs lobes.

Question 3

What is the minor fissure ?

Answer 3

Horizontal fissure
Dividing the upper and middle right lungs lobes.

Question 4

What happen to the air flow as it progress into the lungs ?

Answer 4

The airflow become slower because the volume of air conducting system increase.

Question 5

What does an obstructive disease do ?

Answer 5

It narrows the airway therefore increase the resistance and reduce the airflow.

Question 6

What is the pleura and what is it made of ?

Answer 6

It is a double folded membrane around each of the lungs.
Composed of the parietal pleura attached to the inside of the chest wall and the visceral pleural attached to the lungs.
Both meet at the hilum and are separated by a pleural cavity filled with pleural fluids allowing them to slide against each other.

Question 7

What happen in a normal respiration at rest ? And why ?

Answer 7

Diaphragm contract and move downward during inspiration. It flattens and move up during expiration.
The lungs expand on inspiration. The intrathoracic pressure lesser than the atmospheric pressure creates an airflow towards the alveoli.
Respiratory muscle relax on expiration and contract on inspiration.

Question 8

What do you look for on inspection of the lungs and ask the patient ?

Answer 8

Cyanosis, Horner’s syndrome, SVC symptoms, clubbed fingers, nicotine stain, deviated trachea, distended jugular neck vein.
Cough, sputum (color + quantity + presence of blood = haemoptysis)), pain with deep breath.

Question 9

What do you ask the patient during inspection of the lungs ?

Answer 9

Do a little exercise to observe dyspnoea, posture, length of sentences.

Question 10

How do you palpate the lungs ?

Answer 10

Hands on both side of patient chest while they take a deep breath.
Thumbs beside the tenth rib.
Check symmetry of chest movement.

Question 11

Why do you percuss the patient in lungs and what is a normal sound ?

Answer 11

To gain information about the density of underlying tissues.
Normal lungs have a resonant sounds (low-pitched, full and last for a long time).

Question 12

Where do you find a normal dullness of sound ?

Answer 12

Anterior side of the chest (heart) : between the 3rd and 5th intercostal space
Anterior side, right midclavicular line (lungs/liver border) : around the 5th or 6th intercostal space
Posterior side (lungs border) : level of 10th thoracic vertebrae

Question 13

What are breath sound and how are they created ?

Answer 13

They are turbulence in the central airway, vibrations. What they are transmitted through healthy air filled lungs tissues to the chest wall they become softer.

Question 14

What do you asses in breath sounds ?

Answer 14

Their character : pitch/harsh, intensity, increased/decreased
The rate of inspiratory to expiratory duration.
What influence their loudness.
The type of breath sound.

Question 15

What does the rate inspiratory to expiratory duration tell about the breath sounds ?

Answer 15

Normally inspiration will sound longer than expiration because expiration is passive and you can only hear part of it.
In case of prolonged expiration, it’s a sign of obstructive disorder.

Question 16

What affect the loudness of breath sounds ?

Answer 16

The flow : more restricted => softer
The conduction by lungs tissue : better conduction => less air => louder sound
Reflection : attenuated sounds may signify a pleural effusion
Distance form the source
Patency of the airway : attenuated or no sounds signify obstruction of airway

Question 17

What are the type of breath sounds ?

Answer 17

Vesicular / normal breath sound : low-pitched, clear and soft
Bronchial breath sounds : only in the larynx, trachea and main bronchi, they are loud high pitched and harsh sound
Amphoric breath sounds : signs of tuberculosis

Question 18

What is a crackle ? What is is caused by ?

Answer 18

A discontinuous, unmusical sounds for less than 20 msec.
Caused by abrupt opening or closing of the airways => the alveolar wall are thickened and touch each other during expiration

Question 19

What is a rhonchi, what’s its cause ?

Answer 19

Continuous musical sounds longer than 250msec.
Present of mucus (viscous sputum), oscillation of the bronchial wall where the conducting airway are narrowed.

Question 20

What a squeaks and what’s its cause ?

Answer 20

Brief high pitched wheezing sounds.
Caused by brief Vigouroux vibration in stiff narrowed bronchioles during inspiration.

Question 21

What’s a stridor and what’s its cause ?

Answer 21

Can be heard without a stethoscope. Caused by obstruction in the upper airway.

Question 22

What’s a pleural sounds and what’s its cause ?

Answer 22

Sounds like walking on fresh snow. Caused by irritation or inflammation of the pleura.

Question 23

What are the ratio of inspiration to expiration ?

Answer 23

Normally : 5/6 (expiration longer)
During auscultation : 3/1 (expiration is passive so isn’t heard much)

Question 24

What do you worry about in front of a yellow discoloration of the fingers ?

Answer 24

Caused by regular nicotine use meaning increasing risk of lung cancer.

Question 25

What are the different abnormalities of the chest ?

Answer 25

Pectus carinatum : chest towards the outside.
Pectus excavatum : breastbone sunken inside the chest.

Question 26

In which patient do you see an asymmetry of the chest ?

Answer 26

Patient with pneumothorax (collapse lung), they have dyspnea with sharp stabbing pain worsening as the patient breath deeply.
It means there is a hole in the membrane of the lung which allow air to leak into the affected lung.

Question 27

What are the different type of breathing ?

Answer 27

Abdominal or diaphragmatic breathing : movement of the abdomen.
Chest or thoracic breathing : movement of the chest, more shallow associated with exertion and stress.

Question 28

What happen with lungs expansion, what should we worry about ?

Answer 28

On a maximum inspiration the chest can expand up to 5-10 cm. A lung expanding less than expected is more worry some than a lung expanding more than expected because it means a reduced elasticity of the lung.

Question 29

What is comparative percussion of the lungs, where do you do it ?

Answer 29

Used to compare the lungs fields. Can be performed in the front and back. Produced a resonant sound over all lungs fields.

For the back ask the patient to cross their arms to make lungs more accessible to percussion.
In the back start medial to the top of the scapula and go down progressively. At the end of the scapula you can percuss more caudal area. There are 7 points on each side.
Percussion of the front is performed with the patient supine.

Question 30

What is topographic percussion and where do you do it ?

Answer 30

Used to determine the location of lungs borders.

Percuss along the scapula line to determine,e the lung border on the back. The are situated around Th10-11

Percuss the front with the patient supine and only the right side because the heart affect the resonance of the left side.

Transition between lungs and liver around the 5th-6th intercostal space right midclavicular line.

Question 31

Why is the percussion transition between lung and liver not brutal ?

Answer 31

Because the diaphragm is domed shaped therefore the liver partially overlaps the right lung.

Question 32

What instruction do you give the patient for auscultation ?

Answer 32

Take slow deep breaths with your mouth open.

Question 33

What happen to the ratio of auscultation in COPD ?

Answer 33

Its an obstructive lung disease, resulting in a prolonged expiration. The airways are obstructed it takes then more time and energy to exhale.

Question 34

What are the examination on indication of the lungs ?

Answer 34

Palpation for tenderness
Bimanual palpation
Assess mobility of lung border
Voice conduction test

Question 35

Why do you palpate for tenderness ?

Answer 35

In case of possible rib fracture. Watch out for pneumothorax, haemothorax, injured spleen.

Question 36

How do you perform Bimanual palpation ?

Answer 36

Compress with one hand on the sternum and the other on spinal cord.
OR
Compress briefly with hands on the flanks.

Question 37

How do you assess lungs mobility ?

Answer 37

Assess diaphragmatic excursion on deep inspiration.
Patient takes deep breath and hold it. Percuss from the previously found lung border causally until dull.
- 4-6 cm mobile

Question 38

How do voice conduction test work ?

Answer 38

Air filled tissue conduct voice sounds to the chest wall.
Can be reduced in case of : air/fluid in pleural cavity, lung overexpansion, atelectasia with bronchial obstruction

Question 39

Technique of vocal fremitus ?

Answer 39

Feel vibration through bronchopulmonary system which ulnar side of hands while patient speaks loudly.
- phrase with low frequency vowels
- comparative between abnormal area and healthy area of other lung

Question 40

Result of vocal fremitus ?

Answer 40

Increase : lung infiltrate with patent bronchus
Decrease : conduction reduced
- obesity, pleural effusion, pneumothorax, atélectasis, lung infiltrate with closed bronchus

Question 41

Technique of bronchophony ?

Answer 41

Stethoscope on the abnormal area. Compare audible conduction of voice sound with conduction in corresponding are of healthy lung.

Question 42

Result of bronchophony ?

Answer 42

Normal air filled lung : reduced high pitches and unintelligible rumble for low frequency sounds.

Pneumonia area : stronger intelligible sound

Very important is suspicion of bronchial breath sound

Compacted area with patent : dullness, bronchial breath sound, increased bronchophony.

Question 43

Purpose of transthoracic ultrasound ?

Answer 43

Assess pneumothorax, pleural effusion, interstitial syndrome, lung consolidation.
Aid to clinical decision making and assess treatment effect

Pulmonary ultrasound takes advantages of ultrasound artefact.

Question 44

Advantages of transthoracic ultrasound ?

Answer 44

Quick, can be repeated, at the bedside.
No radiation, more accurate than x-ray for pneumonia, pleural effusion, pneumothorax.

Question 45

What are signs of respiratory insufficiency ?

Answer 45

Dyspnea, respiration alternants, agitation, central cyanosis.
Tachypnea changing on exhaustion to bradypnea and shallow breathing.
Accessory muscle use : nasal flaring
Diaphragmatic paradox : inward abdominal movement on inspiration

Question 46

What signify an abnormal lung border ?

Answer 46

Low border, bilateral limited mobility : advanced emphysema

Incipient exudative pleuritis : unilateral basal dullness, increased in axillary direction, base of lung mobility

Unilateral elevation, remains immobile on deep inspiration : phrenic nerve paralysis

Bilateral elevation : obese and pregnant patient with advanced pulmonary fibrosis

Question 47

What abnormal percussion sound can you hear ?

Answer 47

Dull sound : lung consolidation, atélectasis, pleural effusion, elevated diaphragm, lobar pneumonia

Hyper resonance : abnormal air content like pneumothorax and emphysema

Question 48

What could be dyspnea without fever ?

Answer 48

Pulmonary embolism : tachycardia, hypoxia

Unilateral, basal absent, attenuated breath sound + dullness to percussion : pleural effusion

Pneumothorax : resonant / hyper-resonant percussion

Obstructive disorder : prolonged expiration and rhonchi

Pulmonary emphysema : early inspiratory crackles

Heart failure / interstitial lung disease : mid/end inspiratory crackles

Question 49

What could be sounds associated with severe dyspnea ?

Answer 49

Silent chest : asthma attack, exhaustion, severe respiratory depression or pulmonary emphysema

Stridor : central airway obstruction, tumor, foreign body, larynx problem

Bilateral crackles : acute pulmonary edema

Coarse inspiratory and expiratory crackles : mucus in central airway or exhausted patient

Question 50

What are the causes of dyspnea with fever or chest pain ?

Answer 50

Pneumonia : abnormality in limited area with crackles and pleural rub

Pulmonary embolism : pleural rub or subtle wheezing in limited area

Question 51

Significance of coughing ?

Answer 51

Obstructive disorder : prolonged expiration or rhonchi

Stridor : central tumor, foreign bodies

Pneumonia

Heart failure or interstitial disease

Question 52

Significance of haemoptysis ?

Answer 52

Lung tumor with post obstructive infiltrate

Pulmonary embolism

Pneumonia

Question 53

What are the 6 Ps of dyspnea ?

Answer 53

Pump failure
Pulmonary embolus
Pulmonary bronchial constriction
Possible foreign object
Pneumonia
Pneumothorax