Breathing Patterns, Lung Antomy And In Depth Observation Flashcards
Signs and symptoms of cardiorespiratory dysfunction -
Shortness of breath
Sputum
Cough
Wheeze
Pain
Changes in exercise tolerance
Functional ability
Psychological hangers - eg reduced self efficacy can lead to reduced motivation
Why is observation from the start so important in cardio physio?
You want to observe without the patient realising to try and make it as natural as possible
This is to attempt to see their natural breathing
Especially important with counting breaths for respiratory rate
What are the components of cardio objective assessment?
Observation
Palpation
Auscultation (listening with stethoscope)
Chest x-rays (CXR) and imaging (CT scans)
Pulse oximetry (O2 saturation)/BP/HR.
Arterial blood gases (ABG’s)
Pulmonary function tests (PFT’s)
Assessment tools
Exercise tolerance tests -
6 minute walk test (self-paced) - allowed to stop and rest if they wish within the time
Distance covered is measured in metres
Incremental shuttle walk test (externally paced) - bleep test but walking
Step test
Assessment tools
Functional ability tests -
Elderly mobility scale (EMS)
Functional independence measure (FIM)
Acute care index of function CPAx
*also use all the info on nursing charts - will find BP, rep rate etc here…
Observation
What are we looking for in their general appearance?
Is patient alert, responding to voice,pain or unresponsive (AVPU)
Are they agitated/restless
Appear breathless/distressed/confused
Face, eyes, hands, mouth, oedema
Do they look comfortable? Appear in pain?
Observation
Position -
Are there any lines, drains, evidence of surgical intervention etc.. to be aware of
If on oxygen, how much?
Observation
Chest -
What is WOB? (Definition)
Respiratory rate per min
Chest shape
Chest wall movement
Breathing pattern
WOB - the pressure required to move a volume of gas and the amount of O2 required by respiratory muscles to perform this task
Observations
Abdomen -
Distended/incisions/post op drains/feeding tube
Abdomen is in close relationship with the best, therefore important to pay attention to.
Observations
Skin colours and what they mean -
Pale or blue
Pallor (pale) - anaemia/low BP
Ruddy/plethoric - appear flushed, red skin due to increased heamoglobin in attempt to increase O2 carrying capacity. Common in COPD patients
Central cyanosed/peripheral cyanosis - central= tongue/lips peripheral = fingers and hands
Blue discolouration
Observation
What is pursed lip breathing?
Seen in patients with severe airway disease (COPD)
Opposing lips during exhalation causes airway pressure inside the chest to be maintained, preventing floppy airways from collapsing
Can be adopted naturally/physios can teach it to their patients
Observation - general appearance
What are we looking for in their eyes?
Pallor (pale) - anaemia
Redness (high BP)
Jaundice - yellow discolouration, liver diseases?biliary obstruction
Drooping of one eyelid and a constricted pupil _ aka horns syndrome
Seen in patients with lung cancer
Oedema - excess fluid in interstitial spaces
Observation
General appearance - what are we looking for in their hands?
Course flapping tremor - fingers/hands uncontrollably move up and down due to increased CO2
Fine tremor - more of a slight shake - medication related ie. Beta agonists
Wastage
Nicotine stains - sign of smoking
Cyanosis - circulation issue
Clubbing - reduced angle between nail and nail bed
Temperature feel during palpation - hot and cold or clammy
Observation
Causes of clubbing
Cardiac -
Lung disease -
Bowel disease -
Congenital heart diseases
Endocarditis
Cystic fibrosis
Infective (eg bronchiectasis)
Fibrotic lung disease
Malignant lung disease
Crohn’s disease
Ulcerative colitis
Obersvation, general appearance
What are we looking for at their mouth?
Moist or dry - if dry, secretions will stick to roof of mouth
Dehydrated? - can use wet sponges to help
Drooling? - suggests neural problem
Any swelling/abnormality?
Colour ? - ie. Central cyanosis
Hydrated
Purse lip breathing
Observation - general appearance
What are we looking for in oedema?
Peripheral - ( ankles and sacral areas)
Pitting oedema - leaves a mark once pressed - suggests it been there for a while as skin does not spring back
Observation
What are we looking for in a patients position?
In bed? - slumped, sat up or supine
In a chair?
Using a position of ease - sometimes adopted in respiratory stress. Helps reduce respiratory fixing
Fixing with upper limbs to allow accessory muscles to aid breathing
Why is it important to note how much oxygen a patient may be on?
Nasally - normally smaller amounts
Important because we need to keep track if the oxygen being given is going up or down
Going up - patient is getting worse
Going down - patient is getting better
What is the first thing to be affected when a patients breathing is deteriorating/comprimised?
Respiratory rate (RR)
Observation
Examples of different chest shapes -
Scoliosis
Kyphosis
Kyphoscoliosis
Pectus exacavatum - funnel chest
Pectus carinatum - pigeon chest
Hyperinflated/barrel chest - gas trapping in lungs , increased residual volume
How to examine a fine tremor -
Due to meds ie. Beta agonist overdose
Ask patient to extend their arms and hands out in front of them. (+) test if their is a slight controllable shaking movement of hands/fingers
How to examine a flapping tremor -
Due to increase CO2
Ask patient to put hands out in front of them, as if they are gesturing a car to stop (fingers will be pointed upwards)
Position allows u to note any flapping of hands around the wrist joint - up and down movement or fingers/hand
Relationship between volume and pressure when it comes to breathing -
Increase in volume means decreased pressure (inspiration allowing air to flood in)
Decrease in volume means increase in pressure (expiration forcing air out)
Consequences of a distended abdomen on breathing -
It inhibits diaphragmatic movement and will restrict the lungs from expanding
Therefore reduces the volume of air that can be held by the lungs at full inspiration
And also increases the WOB as diaphragm has to work harder against a greater resistance
What is seen in a normal breathing pattern?
Ratio 1:2 inspiration to expiration
Small, symmetrical coordinated increase in AP, transverse and vertical diameter of thorax
Chest movement elements moving in harmony
Abdomen - anterior abdominal wall motion
Abnormal breathing signs
What does excess negative pressure cause?
What is hoovers sign?
Flail segment -
Tracheal tube, asymmetry and paradoxical
Hoovers sign - lower ribs move in on inspiration
In drawing/recession of intercostal space
A flail segment is paradoxical movement of chest wall - inward inspiration and outward expiration
Segment of chest wall is ‘flail’ - cannot contribute to lung expansion ie flail rib fractures
What are the accessory muscles of inspiration?
Scalenes (elevate rib cage)
Sternocleidomastoid (elevate sternum)
Trapezii
Pectoralis major and minor
Serratus anterior
Latissimus Doris
What are the accessory muscles of exhalation?
Rectus abdominis
External and internal oblique
Trans versus abdominis
Internal intercostals
- contraction of abdominal muscles causes abdominal contents to push up against diaphragm
Quality of voice - what are we listening for?
Loudness
Wet sounding
Are they able to talk in full sentences
Audible sounds
Alerted breathing patterns:
Eupnoea -
Apnoea -
Eupnoea - normal breathing 12-20bpm
Apnoea - absent breathing
Altered breathing patterns
Cheyne-stokes breathing -
Biots respiration -
How are these similar?
Cheyne - due to cardiac insult (heart failure, myocardial infarction etc)
Period of apnoea followed by gradual increase and decrease of rapid breathing, and then apnoea again
Biots - due to brain insult (strokes, brain infections)
Period of apnoea followed by rapid breathing. Brain injury may cause breathing centre to be inhibited, therefore only responds to really strong stimulus eg. Increased CO2 in blood
*similar, by cheyne is a gradual increase followed by gradual decrease in breathing before apnoea, whereas biot is sudden breathing to no breathing.
Altered breathing patterns
Kussmausl respiration -
Tachypnoea -
Bradypnoea -
Kussmauls - due to asodotic states - ketones of DKA. (Anaesthesia)
Long tidal loops
Tacypnoea - rapid breathing more than 20bpm
Panic, pulmonary embolisms, myocardial infarctions
Bradypnoea - abnormally slow, less than 10bpm
Obesity, alcoholism
What is auscultation?
What is good to do prior to auscultation?
Process of listening to and interpreting the sounds produced within the thorax
Used to verify observed and palpated findings before, during and after treatment
Prior - listen at mouth
Crackles heard at the mouth should be cleared by coughing in order to prevent them from masking other sounds during auscultation
Where do the lung sit in the body?
Either side of the heart
Bases sit on the diaphragm
Apexes extend up and above the clavicle and into the root of the neck
Right lung is larger and heavier
Anatomy of lungs
Trachea and bronchi - how many and what do they do?
Trachea - divides into R and L primary bronchi
These divide into secondary bronchi - one for each lobe of lung
Right primary bronchus branches 3 times to supply 3 lobes
Left primary bronchus branches twice to supply two lobes
Secondary divide again into tertiary/segmental bronchi
Segmental bronchi lead to the different bronchopulmonary segments of each lobe
**these conducting airways do not participate in gaseous exchange, simply allow air passage
Anatomy of lungs
How are they separated into lobes?
How many lobes do R and L have?
What are the lobes separated by?
Separated into lobes by the pleura which surrounds them
R - 3 lobes, upper, middle and lower
L - 2 lobes, upper and lower, but has something similar to middle called the lingula (always listening on auscultation)
Lobes separated by fissures
Anatomy of the lungs
What are fissures?
Double fold of visceral pleura that fold back on one an another to either completely or incompletely separate lung parenchyma to help form lung lobes
Anatomy of the lungs
Fissures in the L lung -
Fissures in R lung -
L - has one fissure, the oblique fissure which separates upper and lower lobe
R - has two fissures
Oblique fissure - physically separates lower lobe from upper and middle lobe
Horizontal fissure - separates upper lobe from the middle lobe
Auscultation
What are we listening for?
The quality of the breath sounds
Intensity of the breath sounds
Presence of any added sounds
Name bony points that help identify lung placement -
2.cm above medial 1/3 clavicle on both right and left lung
4th costal cartilage/costo-sternal joint on both right and left
On the right - 6th costal cartilage/costo-sternal joint
On left - rib 6 at mid-clavicular line to avoid the heart
Rib 8 at mid axillary line on both the right and the left
T10 posteriorly on either side 2cm away from spinous process
Paradoxical breathing -
Examples of this:
Chest wall moves inward on inspiration and outward on expiration
Eg. Hoovers sign, flail chest and abdominal paradox
How are breath sounds generated?
Turbulent air in airways
Only generated in small proportion of the airways
Transmitted through lung to chest wall
Lung tissue is a good sound conductor
Air = poor sound conductor
Breath sounds - what does normal sound like? (Vesicular)
Sounds heard over entire lung fields
Muffled in quality
Normal to get quieter the further from the trachea
Inspiration, louder than expiration
Inspiration is longer than expiration
No pause between inspiration and expiration
Breath sounds -what does increased/bronchial sound like?
Due to:
Louder, coarse on expiration and inspiration, with a pause between
Normally heard over the trachea (which is not done clinically)
Due to: consolidation (pneumonia)
Collapse
Large mass
Fluid line of a pleural effusion
Breath sounds - decreased/absent, what does it sound like?
Caused by:
Either a decrease from normal or completely absent
Cause: shallow breathing/drowsiness/pain
Poor positioning
Collapse
Collapse with complete obstruction if airway
Hyperinflation eg. Emphysema
Obesity/very muscular patients
Pleural effusion
Pneumothorax/heamothrax
Added sounds
Crackles/crepitations -
Due to secretions in airways being audible as air passes through them
Two groups - coarse and fine
Can happen anywhere in respiratory cycle (inspiration/expiration/both)
Mostly indicative of sputum, however absence of crackles does not always indicate sputum absence
Can also be due to explosive sound from equalisation of pressure in an obstructed airway
Added sounds
Crackles and their timing -
Timing of when they are heard can indicate potential position in bronchial tree:
Early inspiratory crackles - proximal airways
Late inspiratory crackles - peripheral airways
Early expiratory crackles - proximal airways
Late expiratory crackles - peripheral airways
Added sounds
Wheeze -
Whistling sound causes by air passing through narrowed airway
2 types:
Monophonic - generated by one airway, single note, same position in respiratory cycle
Polyphonic - generated by several airways giving different notes
Pitch varies depending on narrowing - greater narrowing=higher pitch
Can occur in inspiration/expiration/both
Eg. Brochospasm, tumour, airway oedema, forgiven body
Added sounds
Pleural rub -
Creaky leathery sound
Pleural surfaces rubbing together
Usually heard in late inspiration and early expiration, and often identical
Eg. Inflammation of pleura
Good auscultation technique entails:
Systematic manner, comparing one side to the other whilst visualising underlying structures
Good surface anatomy to ensure correct placement
Stethoscope never placed over clothing and/or sheets
Cleaned in between patient use
Patients sit upright where they can breath through mouth to reduce nose turbulence
Auscultation, how do we assess:
Upper lobes -
Middle lobes -
Lower lobes -
Upper - anteriorly
Middle - anteriorly (males and lingula) or laterally
Lower - posteriorly
What can interfere with auscultation?
Movement of stethoscope on skin
Oral cavity sounds
Clothing/sheets
Talking
Hairy skin
Water in tubing
Shivering
External sounds
How can we find out what bronchial (increased) breath sounds sound like?
It is normal to hear this if your auscultate over the trachea
This is not done clinically, but if you are hearing the same sound in the lung fields as you hear over the trachea, this could indicate bronchial breath sounds
What does normal breathing appear quieter/louder in certain areas?
More intense closer to the trachea
Quieter the further away you get from main airways, air flow is lamina here.
Normal breath sounds: inspiration and expiration timings -
Inspiration is louder than expiration
Inspiration is longer than expiration
No pause between inspiration and expiration
What can cause abnormal quiet breath sounds?
Reduced air entry, effects ability to generate sound
- atelectasis - alveoli deflates causing partial or complete collapsed lung
Reduced chest wall movement
Reduced transmission of sound
- pleural effusion
pleural thickening
Hyperinflation - breath at small volumes
Bronchial breath sounds - inspiration and expiration timings:
Inspiration and expiration will be more equal in timing, more harsh and more intense
Due to…
Consolidation
Large collapse
Large mass in lung etc
Added sounds
What is stridor?
Caused by turbulent airflow through narrowing/obstruction in the upper airway
This is an emergency and can often be heard normally, no stethoscope needed
Eg. What happens to my throat during anaphalaxsis
Added sounds
Types of wheeze-
Monophonic - one airway, one sound eg. Tumour
Polyphonic - multiple airways, multiple sounds eg. Asthma
Added sounds
Types of crackles -
Fine - due to liquid. Can sound like twisting hair by ear
Course - sputum
What comes under the bracket of breath sounds?
What comes under the bracket of added sounds?
Breath - normal, reduced/quiet and bronchial
Added - crackles (fine/course), wheeze (mono/pol), pleural rub, stridor
management strategies to help reduced interference during auscultation:
Firm skin contract
Cough/blow nose beforehand
Place stethoscope directly on skin
Ensure patient has a way of getting your attention eg. Tapping you on the arm
