Air Flashcards
Where is the apex of the lung ?
2-4 centimetres above the medial part of the clavicle.
What is the major fissure ?
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.
What is the minor fissure ?
Horizontal fissure
Dividing the upper and middle right lungs lobes.
What happen to the air flow as it progress into the lungs ?
The airflow become slower because the volume of air conducting system increase.
What does an obstructive disease do ?
It narrows the airway therefore increase the resistance and reduce the airflow.
What is the pleura and what is it made of ?
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.
What happen in a normal respiration at rest ? And why ?
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.
What do you look for on inspection of the lungs and ask the patient ?
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.
What do you ask the patient during inspection of the lungs ?
Do a little exercise to observe dyspnoea, posture, length of sentences.
How do you palpate the lungs ?
Hands on both side of patient chest while they take a deep breath.
Thumbs beside the tenth rib.
Check symmetry of chest movement.
Why do you percuss the patient in lungs and what is a normal sound ?
To gain information about the density of underlying tissues.
Normal lungs have a resonant sounds (low-pitched, full and last for a long time).
Where do you find a normal dullness of sound ?
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
What are breath sound and how are they created ?
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.
What do you asses in breath sounds ?
Their character : pitch/harsh, intensity, increased/decreased
The rate of inspiratory to expiratory duration.
What influence their loudness.
The type of breath sound.
What does the rate inspiratory to expiratory duration tell about the breath sounds ?
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.
What affect the loudness of breath sounds ?
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
What are the type of breath sounds ?
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
What is a crackle ? What is is caused by ?
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
What is a rhonchi, what’s its cause ?
Continuous musical sounds longer than 250msec.
Present of mucus (viscous sputum), oscillation of the bronchial wall where the conducting airway are narrowed.
What a squeaks and what’s its cause ?
Brief high pitched wheezing sounds.
Caused by brief Vigouroux vibration in stiff narrowed bronchioles during inspiration.
What’s a stridor and what’s its cause ?
Can be heard without a stethoscope. Caused by obstruction in the upper airway.
What’s a pleural sounds and what’s its cause ?
Sounds like walking on fresh snow. Caused by irritation or inflammation of the pleura.
What are the ratio of inspiration to expiration ?
Normally : 5/6 (expiration longer)
During auscultation : 3/1 (expiration is passive so isn’t heard much)
What do you worry about in front of a yellow discoloration of the fingers ?
Caused by regular nicotine use meaning increasing risk of lung cancer.
What are the different abnormalities of the chest ?
Pectus carinatum : chest towards the outside.
Pectus excavatum : breastbone sunken inside the chest.
In which patient do you see an asymmetry of the chest ?
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.
What are the different type of breathing ?
Abdominal or diaphragmatic breathing : movement of the abdomen.
Chest or thoracic breathing : movement of the chest, more shallow associated with exertion and stress.
What happen with lungs expansion, what should we worry about ?
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.
What is comparative percussion of the lungs, where do you do it ?
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.
What is topographic percussion and where do you do it ?
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.
Why is the percussion transition between lung and liver not brutal ?
Because the diaphragm is domed shaped therefore the liver partially overlaps the right lung.
What instruction do you give the patient for auscultation ?
Take slow deep breaths with your mouth open.
What happen to the ratio of auscultation in COPD ?
Its an obstructive lung disease, resulting in a prolonged expiration. The airways are obstructed it takes then more time and energy to exhale.
What are the examination on indication of the lungs ?
Palpation for tenderness
Bimanual palpation
Assess mobility of lung border
Voice conduction test
Why do you palpate for tenderness ?
In case of possible rib fracture. Watch out for pneumothorax, haemothorax, injured spleen.
How do you perform Bimanual palpation ?
Compress with one hand on the sternum and the other on spinal cord.
OR
Compress briefly with hands on the flanks.
How do you assess lungs mobility ?
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
How do voice conduction test work ?
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
Technique of vocal fremitus ?
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
Result of vocal fremitus ?
Increase : lung infiltrate with patent bronchus
Decrease : conduction reduced
- obesity, pleural effusion, pneumothorax, atélectasis, lung infiltrate with closed bronchus
Technique of bronchophony ?
Stethoscope on the abnormal area. Compare audible conduction of voice sound with conduction in corresponding are of healthy lung.
Result of bronchophony ?
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.
Purpose of transthoracic ultrasound ?
Assess pneumothorax, pleural effusion, interstitial syndrome, lung consolidation.
Aid to clinical decision making and assess treatment effect
Pulmonary ultrasound takes advantages of ultrasound artefact.
Advantages of transthoracic ultrasound ?
Quick, can be repeated, at the bedside.
No radiation, more accurate than x-ray for pneumonia, pleural effusion, pneumothorax.
What are signs of respiratory insufficiency ?
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
What signify an abnormal lung border ?
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
What abnormal percussion sound can you hear ?
Dull sound : lung consolidation, atélectasis, pleural effusion, elevated diaphragm, lobar pneumonia
Hyper resonance : abnormal air content like pneumothorax and emphysema
What could be dyspnea without fever ?
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
What could be sounds associated with severe dyspnea ?
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
What are the causes of dyspnea with fever or chest pain ?
Pneumonia : abnormality in limited area with crackles and pleural rub
Pulmonary embolism : pleural rub or subtle wheezing in limited area
Significance of coughing ?
Obstructive disorder : prolonged expiration or rhonchi
Stridor : central tumor, foreign bodies
Pneumonia
Heart failure or interstitial disease
Significance of haemoptysis ?
Lung tumor with post obstructive infiltrate
Pulmonary embolism
Pneumonia
What are the 6 Ps of dyspnea ?
Pump failure
Pulmonary embolus
Pulmonary bronchial constriction
Possible foreign object
Pneumonia
Pneumothorax
