Ch.1-6 Flashcards
What is the purpose of the patient history?
To gather pertinent historical subjective and objective data.
The ___________ is a meeting between the respiratory care practitioner and the patient.
Interview
What are the most important components of a successful interview?
Communication and understanding
What is the art of viewing the world from the patient’s point of view while remaining separate from it?
Empathy
___________ is defined as the patient’s capacity to obtain, process and understand basic health information and services and needed to make appropriate health decisions and follow instructions for treatment.
Health Literacy
During the interview, what should the examiner observe?
- Patient’s body language
- Note patient’s facial expressions
- Eye movement
- Pain grimaces
- Restlessness and sighing
Explain “white coat syndrome”
Anxiety patients get from simply being in the hospital and interacting with various professional staff members about health issues, test results and medical procedures. The patient can be intimidated to the point of shutting down and fail to ask questions or learn from the interview.
What can be defined as the values, beliefs and practices shared by the majority in a group of people?
Culture
What refers to a formalized system of belief and worship?
Religion
_______ entails the spirit, or soul, and is an element of religion.
Spirituality
__________ involves the knowledge of the patient’s history and ancestry and an understanding of the patient’s beliefs, artistic expressions, diets, celebrations and rituals.
Cultural awareness
_______________ refers to refraining from using offensive language, respecting accepted and expected ways to communicate, and not speaking disrespectfully of a person’s cultural beliefs.
Cultural sensitivity
_____________ refers to knowing the health care practitioner’s own values, attitudes, beliefs and prejudices, while at the same time, keeping an open mind and trying to view the world through the perspective of culturally diverse groups and people.
Cultural competence
It is estimated that more than ___% of adults in the United States have basic or below acceptable basic health literacy. In other words, nearly 9 in 10 adults lack the skills needed to manage their health and prevent disease.
85
What is used to echo the patient’s words?
Reflection
The _____________ is the final overview of the examiner’s understanding of the patient’s statements.
Summary
What is used when the patient’s choice of words is ambiguous or confusing?
Clarification
To enhance the accuracy of written and oral information, what is the best strategy?
Plain language approach
What type of question asks the patient to provide narrative information?
Open-ended questions
_________ encourages patients to say more, to continue the story.
Facilitation
____________ is affective after an open-ended question.
Silent attentiveness
_______________ is the use of impersonal conversation that places space between a frightening topic and the speaker.
Distance
When are open-ended questions commonly used?
- To begin interview
- Introduce a new section of questions
- To gather further information whenever the patient introduces a new topic
What type of question is unbiased and allows the patient to answer in any way?
Open-ended questions
What type of question asks the patient for specific information?
Closed or direct questions
What type of questions speed up the interview process and are often useful in emergency situations when the patient is unable to speak in complete sentences?
Closed or direct questions
__________ is defined as the identification of oneself with another and the resulting capacity to feel or experience sensations, emotions or thoughts similar to those being experienced by another person.
Empathy
What are some examples of facilitating responses?
“Mm hmm”, “Go on”, “Continue”, “Uh huh”
Nonverbal cues such as maintaining eye contact and shifting forward in the seat.
_________ communicates that the patient has time to think and organize what he or she wishes to say without interruption by the examiner.
Silence
In using ___________, the examiner notes a certain action, feeling, or statement made by the patient and focuses the patient’s attention on it.
Confrontation
Nonverbal techniques include:
- Physical appearance
- Posture
- Gesture
- Facial expressions
- Eye contact
- Voice and touch
What type of position sends a defensive and anxious message?
Closed position, with arms and legs crossed
An open position shows ____________________.
relaxation, physical comfort and willingness to share information
Slow speech with long and frequent pauses, combined with a weak and monotonous tone voice suggests ___________.
Depression
What are the four major vital signs?
- Body Temperature
- Pulse
- Respiratory Rate
- Blood Pressure
In many patient care settings, what is considered to be the “fifth vital sign”?
Oxygen saturation as measured by pulse oximetry (SpO2)
Body temperature is routinely measured to assess for signs of what?
Inflammation or Infection
The temperature inside the body, the core temperature remains relatively constant - what is the temperature?
37°C (98.6°F)
What is the average cardiac output in the resting adult?
Approximately 5 L/min
Fast, deep respirations with (abrupt, irregular) pauses
Biot’s respirations
When the chest is percussed over areas of trapped gas, what type of sound is heard?
Hyperresonant note
A decrease in body temperature causes ____________, which works to keep warmed blood closer to the center of the body, thus working to maintain the core temperature.
Vasoconstriction
According to estimates, for every 1°C increase in the body temperature, the patient’s oxygen consumption increases about ______%
10
A patient who has a temperature within the normal range is said to be ______________.
Afebrile
A body temperature above normal range is called ______________.
Pyrexia or hyperthermia
When the body temperature rises above the normal range, the patient is said to have a ______________.
Fever, or they’re febrile
An exceptionally high temperature, such as 41°C (105.8°F) is called what?
Hyperpyrexia
What are the four common types of fevers?
- Intermittent fever
- Remittent fever
- Relapsing fever
- Constant fever
When the patient’s body temperature alternates at regular intervals between periods of fever or normal below-normal temperatures. What type of fever is this?
Intermittent fever
The patient has marked peaks and valleys (more than 2°C [3.6°F]) over a 24-hour period, all of which are above normal. What type of fever is this?
Remittent fever
This fever is present when the patient’s body temperature remains above normal with minimal or no fluctuation. What type of fever is this?
Constant fever.
When short febrile periods of a few days are interspersed with 1 or 2 days of normal temperature. What type of fever is this?
Relapsing fever
Hypothermia may occur as a result of what?
- Excessive heat loss
- Inadequate heat production to counteract heat loss
- Impaired hypothalamic thermoregulation
Describe the diaphragm when severe alveolar hyperinflation is present.
It is low and flat in position and has minimal excursion.
What are some clinical signs of hypothermia?
(Up to 11 answers)
- Below normal body temperature
- Decreased pulse and respiratory rate
- Severe shivering
- Patient indicating coldness and presence of chills
- Pale or bluish, cool waxy skin
- Hypotension
- Decreased urinary output
- Lack of muscle coordination
- Disorientation
- Coma
- Drowsiness or unresponsiveness
Accidental hypothermia is commonly seen in what type of patients?
- Those who have been immersed in a cold liquid environment for a prolonged time
- Those who have had an excessive exposure to a cold environment
- Has inadequate clothing, shelter or heat.
In clinical settings the pulse is usually assessed by what?
Palpatation
The characteristics of the pulse are described in terms of what?
Rate, rhythm and strength
What are the nine common pulse sites?
- Temporal
- Carotid
- Apical
- Brachial
- Radial
- Femoral
- Popliteal
- Pedal (Dorsalis pedis)
- Posterior tibial area
What is the normal pulse rate for an adult?
60-100 BPM
What is the primary muscle of respiration?
Diaphragm
What is defined as a systolic blood pressure that is more than 10 mmHg lower on inspiration than on expiration?
Pulsus paradoxus
What is used to establish an immediate baseline SpO2 value?
Oxygen saturation
Tachycardia may occur as a result of what?
- Hypoxemia
- Anemia
- Fever
- Anxiety
- Emotional stress
- Fear
- Hemorrhage
- Hypotension
- Dehydration
- Shock
- Also a common side effect in patient receiving certain medications such as sympathomimetic agents
Normally, the ventricular contraction is under the control of the ___________, which generates a normal rate and regular rhythm.
Sinus node in the atrium
In child and young adults, it is not uncommon for the heart rate to increase during inspiration and decrease during exhalation. What is this called?
Sinus arrhythmia
The quality of the pulse reflects the strength of what?
The left ventricular contraction and volume of blood flowing to the peripheral tissues
Pulsus paradoxus is common among patients experiencing what?
Severe asthmatic episodes
Where can bradycardia be seen?
- Patients with hypothermia
- In physically fit athletes
- It also may be lower than expected when the patient is at rest or asleep as a result of head injury, drugs such as beta- blockers, vomiting or advanced age.
What are some things that can cause the heart to beat irregularly?
Inadequate blood flow and oxygen supply to the heart or an electrolyte imbalance can cause heart to beat irregularly
Clinically, the strength of the pulse may be recorded on a scale of ________.
0 to 4+
What may be used for peripheral pulses that are difficult to detect by palpation?
ultrasonic Doppler device
Under normal conditions, ___________ is a passive process.
Answer choices:
1. Inspiration
2. Expiration
Expiration
Inspiration is an active process whereby the diaphragm contracts and causes ____________ to decrease.
Intrathoracic pressure
What happens at the end of inspiration?
Diaphragm relaxes and the natural lung elasticity causes the pressure in the lung to increase. This action causes air to flow out of the lung.
What is the normal RR for an adult?
12-20 breaths per min
Where is tachypnea commonly seen?
- Fever
- Metabolic acidosis
- Hypoxemia
- Pain
- Anxiety
Bradypnea may occur with what?
- Hypothermia
- Head injuries
- Drug overdose
What is the force exerted by the circulating volume of blood on the walls of the arteries?
Arterial blood pressure
The blood pressure measured during ventricular contraction (cardiac systole) is the ________________.
Systolic blood pressure
Blood flow is equal to _______________.
Cardiac output
During ventricular relaxation, blood pressure is generated by the elastic recoil of the arteries and arterioles. What is this called?
Diastolic blood pressure
Label the scale to rate pulse quality
0: Absent or no pulse detected
1+: Weak, thready, difficult to feel
2+: Pulse difficult to palpate
3+: Normal pulse
4+ Bounding, easily palpated and difficult to obliterate
Respirations that progressively become faster and deeper, followed by respirations that progressively become slower and shallower and ending with a period of apnea.
Cheyne-Stokes respiration
What is the normal systolic blood pressure range for an adult?
110-140 mmHg
The numeric difference between the systolic and diastolic pressure is called the ________________________.
Pulse pressure
Blood pressure is the function of:
1. _________________________
2. _________________________
- The blood flow generated by ventricular contraction
- The resistance to blood flow caused by the vascular system
Cardiac output is equal to the product of what?
The volume of blood ejected from the ventricles during each heartbeat (stroke volume) multiplied by the heart rate.
CO=SV x HR)
Decreased rate and depth, which decreases alveolar ventilation and leads to an increased PaCO2
Hypoventilation
Increased rate and depth, which increases alveolar ventilation and leads to an decreased PaCO2
Hyperventilation
Increased depth and rate of breathing. Commonly considered normal during periods of exercise to meet metabolic needs.
Hyperpnea
Friction between the blood components and the vessel walls is inversely related to ____________________.
The dimensions of the vessel lumen (size).
What happens when the vessel lumen narrows or constricts?
Vascular resistance increases
An elevated blood pressure of an unknown cause is called ___________.
Primary hypertension
What are some factors associated with hypertension?
- Arterial disease
- Obesity
- High serum sodium level
- Pregnancy
- Obstructive sleep apnea
- Family history of high blood pressure
An elevated blood pressure with a known cause is called ___________.
Secondary hypertension
Hypertension may lead to what?
Congestive Heart Failure
Hypotension is said to be present when the patient’s blood pressure falls below _________.
90/60 mmHg
What is hypotension associated with?
- Peripheral vasodilation
- Decreased vascular resistance
- Hypovalemia
- Left ventricular failure
_____________ occurs when blood pressure quickly drops as the individual rises to an upright position or stands.
Orthostatic hypotension or postural hypotension
What are some signs and symptoms of hypotension?
- Pallor
-Skin mottling - Clamminess
- Blurred vision
- Confusion
- Dizziness
- Syncope
- Chest pain
- Increased heart rate
- Decreased urine output
What is orthostatic hypotension associated with?
- Decreased blood volume
- Anemia
- Dehydration
- Prolonged bed rest
- Antihypertensive medications
What is normal SpO2 range values?
95-99%
What is mild hypoxemia SpO2 range values?
91-94%
What is moderate hypoxemia SpO2 range values?
86-90%
What is severe hypoxemia SpO2 range values?
85% or LOWER!
Anteriorly, the first rib attached to the manubrium just beneath the ______________.
Clavicle
The __________ and its cartilage are attached to the sternum just above the xiphoid process.
sixth rib
What equally divides the anterior chest into the left and right hemithoraces?
The vertical midsternal line
________ runs parallel to the sternum, traditionally down through the male nipple.
Midclavicular lines
Posteriorly, the ___________ runs along the spinous processes of the vertebrae.
Vertebral line, also called the midspinal line
Anteriorly, the apex of the lung extends approximately _______ above the medial third of the clavicle.
2-4 cm
Under normal conditions the lungs extend down to about the level of the __________.
sixth rib
The right lung is separated into the upper, middle, and lower lobes by what?
- Horizontal fissure
- Oblique fissure
The left lung is separated into the upper and lower lobes by the _________.
Oblique fissure
The ______________ of the patient is an ongoing observational process that beings with the history and continues throughout the patient interview, taking vital signs and physical examination.
Inspection
_____________ is the process of touching the patient’s chest to evaluate the symmetry of chest expansion, the position of the trachea, skin temperature, muscle tone, areas of tenderness, lumps, depressions and tactile fremitus and vocal fremitus.
Palpation
What are some abnormal pulmonary conditions that may cause the trachea to deviate from its normal position?
May push trachea to unaffected side:
- Tension pneumothorax
- Pleaural effusion
- Tumor mass
May push trachea towards affected side:
- Atelectasis
- Pulmonary fibrosis
The symmetry of chest expansion is evaluated by lightly placing each hand over the patient’s posterolateral chest so that the thumbs meet at the midline at about __________________.
the T-8 to T-10 level.
With chest excursion, each thumb tip normally moves equally about _________ from the midline.
3-5 cm
Vibration that can be perceived by palpation over the chest is called _________.
Tactile fremitus, also known as rhonchial fremitus
Bilaterally decreased chest expansion may be caused by what?
Both an obstruction and restrictive lung disorder
An unequal chest expansion may occur when one or more of the following develop in or around one lung only:
- Alveolar consolidation
- Lobar atelectasis
- Pneumothorax
- Large pleural effusions
- Chest trauma
___________ over the chest wall is performed to determine the size, borders and consistency of air, liquid or solid material in the underlying lung.
Percussion
What is generated through the vascular system with each ventricular contraction of the heart (systole)?
A pulse
What are some factors that affect body temperature?
- Age
- Environment
- Time of day
- Exercise
- Stress
- Hormones
What are some common therapeutic interventions for hypothermia?
- Remove wet clothing
- Provide dry clothing
- Place patient in warm environment (slowly increase room temperature)
- Cover patient with warm blankets or electric heating blanket
- Apply warming pads
- Keep patient’s limbs close to body
- Cover patient’s head with cap or towel
- Supply warm oral or IV fluids
What is the term used to describe a core temperature below the normal range?
Hypothermia
_________________ refers to the intentional lowering of a patient’s body temperature to reduce the oxygen demand of the tissue cells.
Induced hypothermia
What is heard when the chest is percussed over areas of pleural thickening, pleural effusion, atelectasis and consolidation?
Dull percussion note
What is the other name for subcutaneous emphysema?
Crepitus
What are the three normal breath sounds called?
- Bronchial breath sounds
- Bronchovesicular breath sounds
- Vesicular breath sounds
What are some factors that affect blood pressure?
- Age
- Exercise
- Autonomic nervous system
- Stress
- Circulating blood volume
- Medications
- Normal fluctuations
- Race
- Obesity
- Diurnal - BP is usually lowest in the morning, when the metabolic rate is lowest.
____________ of the chest provides information about the heart, blood vessels, and air flowing in and out of the tracheobronchial tree and alveoli.
Auscultation
Abnormal lung sounds are also called ____________________.
Adventitious lung sounds
What type of breath sounds are auscultated directly over the trachea and are caused by the turbulent flow of gas through the upper airway?
Bronchial breath sounds
What type of breath sound are normal sounds of gas rustling or swishing through the small bronchioles and the alveoli?
Vesicular breath sounds
An increase in body temperature causes the blood vessels near the skin surface to dilate. What is this process called?
Vasodilation
When is induced hypothermia usually indicated?
- Before certain surgeries, such as heart or brain surgery or after ROSC after a cardiac arrest
Body temperature normally varies throughout the day, this phenomenon is called ___________.
Diurnal variation
What are the 4 commonly used sites for BP?
- Oral (Mouth)
- Rectum
- Axillary
- Tympanic (Ear)
Before taking an oral temperature, how long should the practitioner wait after a patient has ingested ice water?
15 minutes
Drinking ice water may lower a patient’s oral temperature by how much?
0.2 to 1.6°F
In patients with irregular, abnormally slow, or fast cardiac rhythms, the pulse rates should be counted for how long?
1 minute
A increased heart rate combined with a large blood volume will generate what type of pulse?
Full, bounding pulse
A weak ventricular contraction combined with an inadequate blood volume will result in what type of pulse?
Weak, thready pulse
A normal left ventricular contraction with an inadequate blood volume will generate what type of pulse?
Strong, throbbing pulse
When the strength of a pulse varies every other beat while the rhythm remains regular. What is this called?
Pulsus alternans
During normal sinus rhythm, the heart rate can be obtained through auscultation by placing the stethoscope over ________________.
The apex of the heart
What monitors and regulates vascular tone?
Autonomic nervous system
The physical examination of the chest and lungs should be performed in a systemic and orderly fashion. What’s the common sequence?
- Inspection
- Palpation
- Percussion
- Auscultation
To evaluate the position of the trachea, the examiner places an index finger over the ___________ and gently moves it from side to side.
Sternal notch
What condition is commonly caused by gas flowing through thick secretions that are partially obstructing the large airways?
Tactile fremitus
Where is fremitus sounds most promininent?
Between the scapulae and around the sternum, sites where the bronchi are closest to the chest wall
Which abnormal percussion note is similar to the sound produced by knocking on a full barrel?
A dull percussion note
Which type of note is elicited from air trapping in the patient with chronic obstructive pulmonary disease or pneumothorax?
Remember air trapping!!
- Lung hyperinflation (COPD)
- Lung collapse (pneumothorax)
- Air trapping (asthma)
Hyperresonant note
What would happen to the diaphragm in a patient with lobar collapse of one lung?
Diaphragm would be pull up affected side and reduce excursion.
What would happen to the diaphragm in a patient with a neuromuscular disease?
Diaphragm would be elevated and immobile
Where is the location of bronchial breath sounds?
Over the trachea
Pitch: High
Intenstity: Loud
Where is the location of bronchovesicular breath sounds?
Upper portion of anterior sternum, between scapulae
Pitch: Moderate
Intenstity: Moderate
Where is the location of vesicular breath sounds?
Peripheral lung regions
Pitch: High
Intenstity: Low
What type of breath sounds are auscultated directly over the mainstem bronchi and do not have a pause between the inspiratory and expiratory phase?
Bronchovesicular
Are vesicular breaths sounds heard primarily during inspiration or expiration?
Inspiration
What should be included when documenting ALS (abnormal lung sounds)?
- For intensity or loudness, use words like faint, soft, moderate or loud
- The part of the respiratory cycle
- Document the magnitude (small, scant or profuse crackles)
- Always include the precise location over the chest
What does stridor indicate?
Swollen larynx or airway
What does pleural friction rub indicate?
Inflammation of pleural membranes (pleurisy)
What does coarse crackles indicate?
Airway secretions
Associated with the following pathologic conditions:
- Severe COPD
- CF
- Bronchiectasis
- CHF (Pulmonary edema)
What does fine crackles indicate?
- Atelectasis (Loss of lung volume)
- Alveolar fluid
- Interstitial fibrosis (asbestosis)
- Early stage of CHF
- Interstitial edema (early pulmonary edema)
What does diminished breath sounds indicate?
Alveolar hyperinflation
What does wheezes indicate?
Smooth muscle constriction
What does bronchial breath sounds indicate?
Alveolar consolidation and/or collapse (atelectasis)
Voluntary decrease in tidal volume to decrease pain on chest expansion. What is this called?
Splinting
Leaning forward with arms and elbows supported on overbed table. What is this called?
Tripod position; inability to lie flat
An individual’s normal breathing pattern is composed of:
(3 things)
- Tidal Volume (VT)
- Ventilatory rate
- I:E ratio
In normal adults, tidal volume is about _____________.
500 mL (7 to 9 mL/kg)
In normal adults, the ventilatory rate is about ____.
15 breaths per minute. (with a range of 12-18)
In normal adults, the I:E ratio is ______.
1:2
________ is defined as the “breathlessness” or “shortness of breath” or the “labored or difficult breathing” felt and described only by the patient.
Dyspnea
What are some signs of dyspnea?
- Audibly labored breathing
- Hyperventilation
- Tachypnea
- Retractions of intercostal spaces
- Use of accessory muscles
- Distressed facial expression
- Flaring of nostrils
- Paradoxical movements of the chest and abdomen
- Gasping
Dyspnea that occurs only when the patient is in the reclining position.
Positional dyspnea, also called orthopnea
Labored breathing caused by heart disease. What type of dyspnea is this?
Cardiac dyspnea
Dyspnea that is provoked by physical exercise or exertion
Exertional dyspnea
Difficulty breathing as a result of kidney disease
Renal dyspnea
A form of respiratory distress related to posture (especially reclining while sleeping) and is usually associated with CHF with pulmonary edema
Paroxysmal nocturnal dyspnea
What is the Modified (British) Medical Research Council Questionnaire used for?
Assessing the severity of breathlessness in those who can speak
What is the Borg Dyspnea scale used for?
Assessing the severity of breathlessness in those who cannot speak because of mouthpieces, endotracheal tubes, tracheostomies, etc
The ease with which the elastic forces of the lungs accepts a volume of inspired air is known as ________________.
Lung compliance
____________________ is defined as the pressure difference between the mouth and the alveoli divided by the flow rate.
Airway resistance
What determines how much air in liters the lungs will accommodate for each centimeter or water pressure change in distending pressure?
Compliance
A rapid rate of breathing and reduced tidal volume is commonly seen during ________ when the alveoli are overinflated.
Early stages of an acute asthmatic attack
Under normal conditions, what is the airway resistance (Raw) in the tracheobronchial tree?
About 1.0 to 2.0 cmH2O/L/s
In large airway obstructive diseases (e.g., bronchitis, asthma), is airway resistance high or low?
Extremely high
Even the slightest reduction in airway diameter can have a remarkable effect on the patient’s ability to move in and out of the lungs. According to whose law?
Poisueille
In physics, work is defined as the force multiplied by _________.
The distanced moved. (work= force x distance)
In respiratory physiology, what may be used to quantify the work of breathing?
The change in pulmonary pressure (force) multiplied by the change in lung volume (distance)
work= pressure x volume
What is a major cause of dyspnea?
Hypoxemia and the stimulation of the peripheral chemoreceptors (also called carotid or aortic bodies)
In respiratory disease, a decrease arterial oxygen level is the result of what?
- Ventilation-perfusion ratio
- Pulmonary shunting
- Venous admixutre
Although the peripheral chemoreceptors are stimulated whenever the PaO2 is less than normal, they are generally most active when the PaO2 falls below _____.
60 mmHg (SaO2 <88%)
Suppression of peripheral chemoreceptors are seen when PaO2 falls below ____.
30 mmHg
Which two groups are responsible for coordinating respiration?
- Dorsal respiratory group (DRG)
- Ventral respiratory group (VRG)
It should be noted that in patients who have a ____________, the peripheral chemoreceptors are the primary receptor sites for the control of ventilation.
- Chronically high PaCO2
- Low PaO2
Both DRG and VRG are stimulated by an increase of ________________.
H+ concentration in the cerebrospinal fluid.
What is the H+ concentration monitored by?
Central chemoreceptors
When the lungs are compressed or deflated (atelectasis), what type of breathing is seen?
increased rate of breathing
When the lungs are compressed, deflated or exposed to noxious gases, which receptor is stimulated?
Irritant receptors
Fever is commonly associated with infectious diseases such as:
- Pneumonia
- Lung abscess
- TB
- Fungal disease
When the irritant receptors are activated, a reflex causes the ventilatory to increase or decrease?
Increase
May also cause a cough and bronchoconstriction
Stimulation of which receptors triggers raid, shallow breathing?
Juxtapulmonary-Capillary Receptors - J receptors
Abnormal ventilatory patterns that occur suddenly (minutes to hours maximum) are classified as ____________.
Acute onset conditions
Abnormal ventilatory conditions that develop slowly (days to months) are classified as _________.
Chronic conditions
What is the function of aortic and carotid sinus baroreceptors?
- Decrease heart rate and ventilatory rate in response to increased systemic BP
- Increase heart rate and ventilatory rate in response to decreased systemic BP
An increased RR may result from chest pain or fear and anxiety associated with _________________.
Inability to breathe
The Hering-Breur reflex does NOT occur when the bronchi and bronchioles are below what temperature?
8°C (46.4°F)
What are the major muscles of inspiration?
- Scalenes
- Sternocleiodomastoid
- Pectoralis major muscle groups
- Trapezius muscle groups
During the advanced stages of chronic obstructive pulmonary disease, the diaphragm ____________________.
Explain what happens to the diaphragm
The diaphragm becomes significantly depressed by the increased lung volumes. (RV, TLC and FRC)
_________ assist or largely replace the diaphragm in creating subatmospheric pressure in the pleural space during inspiration.
The accessory muscles of inspiration
When they are used as accessory muscles, their primary role is to elevate the first and second ribs and flex the neck.
Scalene muscles
What are the major accessory muscles of expiration?
- Rectus abdominis
- External oblique
- Internal oblique
- Tranversus abdominis
The ______________ are located on each side of the neck, where they rotate and support the head.
Sternocleidomastoids
Which muscle rotates the scapula, raises the shoulders and abducts and flexes the arm?
Trapezius
Pulling the upper part of the arm to the body in a hugging position is a function of the ________________.
Pectoralis major muscles
When used as an accessory muscle of inspiration, the _________ helps elevate the thoracic cage.
Trapezius
What are often recruited when airway resistance become significantly elevated?
Accessory muscles of expiration
When __________ is activated, the muscles assist in compressing the abdominal contents, which in turn push the diaphragm into the thoracic cage.
- Rectus abdominis
- Internal oblique
- External oblique (during exhalation)
Which muscle is the longest and most superficial of all the anterolateral muscles of the abdomen?
External Obliques
What happens when all four accessory muscles of expiration contract?
The abdominal pressure increases and drives the diaphragm into the thoracic cage. As the diaphragms moves during inhalation, the intrapleural pressure increases and enhances expiratory gas flow.
Pursed-lip breathing occurs in patients during _____________.
The advances stages of obstructive pulmonary disease
Where is nasal flaring commonly seen?
In infants experiencing respiratory distress
_______ is usually described as a sudden, sharp or stabbing pain.
Pleuritic chest pain
In an effort to overcome the low lung compliance, the patient must generate a greater-than-normal negative intrapleural pressure during inspiration.
Substernal and Intercostal retractions
Where is substernal and Intercostal retractions commonly seen?
Newborns with respiratory disorder like:
- RDS
- Meconium aspiration syndrome
- Transient tachypnea of newborn
- Bronchopulmonary dysplasia
- Congenital diaphragmatic hernia
When activated, the _______ pulls the alae laterally and widens the nasal aperture, providing a larger orifice for gas to enter the lungs during inspiration.
dilator naris
What is one of the most common complaints among patients with cardiopulmonary issues?
Chest pain
Severe resistance to taking a deep breath is called _____________.
Splinting
________________ is described as a constant pain that is usually located centrally.
Nonpleuritic chest pain
Nonpleuritic chest pain is associated with the following disorders:
- Myocardial ischemia
- Pericardial inflammation
- Pulmonary hypertension
- Esophagitis
- Local trauma or inflammation of the chest cage, muscles, bones or cartilage
When the normal 14-15 g/dL of hemoglobin is fully saturated, the PaO2 is about _________.
97-100 mmHg and about 20 mL/dL of O2 in the blood
In a typical cyanotic patient with one-third (5g/dL) of the hemoglobin reduced, the PaO2 is about _______.
30 mmHg and there is about 13 mL/dL of O2 in the blood
The recognition of cyanosis depends on:
- The acuity of the observer
- Light conditions in the examining room
- Pigmentation of the patient
Pleuritic chest pain is a characteristic feature of which respiratory diseases?
- Pneumonia
- Pleural effusion
- Pneumothorax
- Pulmonary infarction
- Lung cancer
- Pnuemoconiosis
- Fungal diseases
- TB
In a patient with polycythemia, cyanosis may be present at a PaO2 well above 30 mmHg because _________________________.
The amount of reduced hemoglobin is often greater than 5 g/dL in these pts, even when their oxygen content is within normal limits.
In respiratory diseases, cyanosis is the result of what?
- A decreased V/Q
- Pulmonary shunting
- Venous admixture
- Hypoxemia
What are some things associated with digital clubbing?
- Circulating vasodilators
- Chronic infection
- Unspecified toxins
- Arterial hypoxemia
- Local hypoxia
- Capillary stasis
Where is bilateral, dependent pitting edema commonly seen?
Patients with CHF, cor pulmonale and hepatic cirrhosis
The wall of the tracheobronchial tree is composed of what three layers?
- An epithelial lining
- Lamina propria
- Cartilaginous layer
What covers the epithelial lining of the tracheobronchial tree?
A mucous layer, commonly referred as the mucous blanket
How would a health care practitioner assess the presence and severity of pitting peripheral edema?
By placing a finger or fingers over the tibia or medial malleolus (2 to 4 inches above the foot), firmly depress the skin for seconds and then release. Normally there should be no indentation, but a pit may be seen if the person has been standing all day or is pregnant.
What scale is peripheral pitting edema measured on?
1+ (mild, slight depression) to 4+ (severe, deep depression)
The epithelial lining is separated from the lamina propria by a ____________________.
Basement membrane
What is the epithelial lining predominantly composed of?
Psuedostratified, ciliated columnar epithelium
The mucous blanket is ____% water.
95
The mucous blanket is produced by what?
Goblet cells and the submucosal, or bronchial glands
_________ is the coughing up of blood or blood-tinged sputum from the tracheobronchial tree.
Hemoptysis
A sudden, audible expulsion of air from the lungs
Cough
The ________ is an important cleansing mechanism of the tracheobroncial tree.
Mucous blanket
The submucosal glands are particularly numerous in the medium-sized bronchi and disappear in the _____________.
Bronchioles
The submucosal glands are innervated by parasympathetic nerve fibers and normally produced how much of clear, thin bronchial secretions per day?
100 mL
Sputum analysis: Brown/Dark
Old blood
Sputum analysis: Bright red (hemoptysis)
Fresh blood (bleeding tumor, tuberculosis)
Sputum analysis: Clear and translucent
Normal
Sputum analysis: Frank hemoptysis
Massive amount of blood
Sputum analysis: Green
Stagnant sputum or gram-negative bacteria
Sputum analysis: Pink and frothy
Pulmonary edema
Sputum analysis: Yellow or opaque
Presence of WBCs, bacterial infection
Sputum analysis: Viscous
Thick, sticky or glutinous
Sputum analysis: Mucoid (white/gray)
Asthma, chronic bronchitis
Sputum analysis: Green and foul smelling
Pseudomonas or anaerobic infection
Sputum analysis: Tenacious
Secretions that are sticky or otherwise tend to hold together.
The submucosal layer of the tracheobronchial tree is the ______________.
Lamina propria
Where is repeated expectoration of blood-streaked sputum seen?
- Chronic bronchitis
- Bronchiectasis
- CF
- PE
- Lung cancer
- Necrotizing infections
- TB
- Fungal diseases
A cough is preceded by:
- Deep inspiration
- Partial closure of glottis
- Forceful contraction of accessory muscles of expiration to expel air from lungs.
What is defined as coughing up to 400 to 600 mL of blood within a 24-hour period?
Massive hemoptysis
Blood that originates from the upper gastrointestinal tract, usually dark coffee-ground appearance
Hematemesis
A brassy cough may indicate what?
Tumor
A hoarse cough indicates what?
Croup
What are some common causes of NPC?
- Irritation of airway
- Inflammation of airway
- Mucous accumulation
- Tumors
- Irritation of pleura
What is the protective mechanism that clears the lungs, bronchi, or trachea of irritants and also prevents aspiration of foreign materials into the lungs?
Cough!
Cough is commonly seen in respiratory disease, especially in disorders that cause ______________.
Inflammation of the tracheobronchial tree
What should be apart of the objective finding in a good SOAP note?
Sputum volume, appearance, viscosity and odor
Where are irritant receptors located?
In the pharynx, larynx, trachea and large bronchi
Gas in the lungs is divided into how many volumes and capacities?
- 4 volumes
- 4 capacities
When the alveoli become overdistended with gas, what is this condition called?
Air trapping
Which lung volume cannot be exhaled?
RV - Residual volume.
The volume of gas that normally moves into and out of the lungs in one quiet breath.
Tidal Volume (500 mL)
The volume of air that can be exhaled after a maximal inspiration
Vital Capacity (4800 mL)
The maximal amount of air that the lungs can accommodate.
Total Lung Capacity (6000 mL)
The amount of air remaining in the lungs after a forced exhalation
Residual Volume (1200 mL)
The volume of air that can be forcefully exhaled after a normal tidal volume exhalation
Expiratory Reserve Volume (1200 mL)
The volume of air that can be forcefully inspired after a normal tidal volume
Inspiratory Reserve Volume (3100 mL)
The lung volume at rest after a normal tidal volume exhalation
Functional Residual Capacity (2400 mL)
The volume of air that can be inhaled after a normal exhalation
Inspiratory Capacity (3600 mL)
______________________ are associated with pathologic conditions that alter the anatomic structures of the lungs distal to the terminal bronchioles.
Restrictive lung volumes and capacities
How can residual volume and the lung capacities that contain RV be obtained?
Measured indirectly by:
- Open circuit nitrogen washout
- Closed circuit helium dilution
- Body plethysmography
The total volume of gas that can be exhaled as forcefully and rapidly as possible after a maximal inspiration.
Forced Vital Capacity - FVC
The maximum volume of gas that can be exhaled over a specific period of time
Forced Expiratory Volume Timed (FEVT)
What is the total expiratory time necessary to perform an FVC in a healthy individual?
4-6 seconds
The maximum flow rate generated during an FVC maneuver
Peak Expiratory Flow Rate - PEFR
10 L/s (600 L/min)
The largest volume of gas that can be breathe voluntarily in and out of the lungs in 1 minute.
Maximum Voluntary Ventilation - MVV
170 L/min
In the normal individual the FVC equals the _____________.
Vital capacity
Clinically, the lungs are considered normal if the FVC and VC are within _______ of each other.
200 mL
What test is most commonly used to evaluate the patient’s respiratory muscle strength at the bedside?
MIP, MEP, FVC and MVV
The maximum inspiratory pressure the patient is able to generate against a closed airway
Maximum inspiratory pressure
What is the MIP in a normal healthy adult?
-80 to -100 cmH2O
Ideally, the MIP should be measured at the patient’s ______.
Residual volume - RV
The percentage of TLC occupied by the RV.
RV/TLC ratio
1200/6000 = 20% (approx)
Pathological conditions that alter the tracheobronchial tree
Obstructive lung disorders
Gas that enters the alveoli during inspiration is prevented from leaving the alveoli during expiration.
Obstructive lung disorders
What is the most precise method for measuring FRC and RV?
Body box
What can the body box measure?
- RV
- FRC
- Airway resistance
- Airway conductance
In a patient with an obstructive lung disorder, the FVC is lower than VC because of what?
Increased airway resistance and air trapping associated with maximal effort
Question from the back of the book:
What is the normal average compliance of the lungs and chest wall combined?
0.1 L/cmH2O
Series of discontinuous, short crackling and popping sounds, high-pitched sounds heard just before the end of inspiration.
Fine crackles
Continuous high-pitched whistling sound caused by rapid vibration of bronchial walls. First evident on expiration but also possibly evident on inspiration as obstruction of airway increases.
Wheezes
Series of discontinuous short, low-pitched bubbling or gurgling sounds caused by air passing through intermittently occluded by mucus, unstable bronchial wall, or fold of mucosa.
Similar to blowing through a straw under water
Coarse crackles
Medium-pitched sounds over areas that usually produce a resonant sound on chest percussion.
Dullness/flatness
What are some possible causes of digital clubbing?
- Chronic hypoxemia
- CF
- Lung cancer
- Bronchiectasis
What are possible causes of dull/flat percussion note?
Increased density: Pneumonia, large atelectasis
Increased pleural space fluid: pleural effusion
What are some causes of increased and decreased tactile fremitus?
Increased
- Pneumonia
- Atelectasis
- Pulmonary edema
Decreased
- Pleural effusion
- Lung hyperinflation
- Absent in pneumothorax
In which of the following pathological conditions is transmission of the whispered voice of a patient through a stethoscope usually unclear?
- Alveolar consolidation
- Atelectasis
In what pathologic conditions would you hear diminished breath sounds?
- COPD
- Drug overdose
- Major sedation
- Neuromuscular disease
- Flail chest
- Pleural effusion
- PTX
What are some possible causes of pleural friction rub?
- Pleurisy
- Pneumonia
- Pulmonary fibrosis - PE
- Thoracic surgery
What is hypoxemia?
PaO2 ≤ 60 mmHg or SaO2 ≤88%
The inspection of a patient’s extremities should include the following:
- Altered skin color
- Presence or absence of digital clubbing
- Presence or absence of peripheral edema
- Presence or absence of distended neck veins
Wheezing is the characteristic sound produced by _________________.
Airway obstruction
What abnormal breath sound is a cardinal finding of bronchial asthma?
Wheezing
A harsh, hollow or tubular breath sound. They are loud, high in pitch and about equal duration during inspiration and expiration.
Bronchial breath sounds
Under normal conditions, what is the average DLCO value for a resting man?
25 mL/min/mmHg
A simple, noninvasive, effort independent test that applies oscillating pressure impulses to the lungs during normal passive breathing.
Impulse oscillosmetry (IOS)
The highest pressure that can be generated during a forceful expiratory effort against an occluded airway and is recorded as a POSITIVE number in either centimeters of water or millimeters of mercury.
Maximum expiratory pressure (MEP)
An MIP of ______ or greater (less negative) is a strong indicator of ventilatory support.
-20 cmH2O
Where are reduced MIP values commonly seen?
- Patients with neuromuscular disease
- Chest wall deformities
- Chronic Obstructive Pulmonary Disease (COPD)
Ideally, the MEP is measured at _____________.
Maximal inspiration (near total lung capacity)
It should be noted that a low MEP is associated with ________________.
Poor or inadequate cough effort
What measures the amount of carbon monoxide that moves across the alveolar capillary membrane?
Pulmonary Diffusion Capacity of Carbon Monoxide - DLCO
______________ result in a increased lung rigidity, which in turn decreases lung compliance.
Restrictive lung disorders
What are the most common measurements obtained from an FVC manuever?
- FEVT
- FEV1/FVC ratio
- FEF 200-1200
- FEF 25-75%
- PEFR
What are the most common measurements obtained from an FVC manuever?
- FEVT
- FEV1/FVC ratio
- FEF 200-1200
- FEF 25-75%
- PEFR
In obstructive lung disorders, why is the FEVT decrease?
The time necessary to exhale a certain volume forcefully is increased
What compares the amount of air exhaled in 1 second with the total amount exhaled during an FVC maneuver?
FEVT/FVC ratio
Because the FEV1/FVC ratio is expressed as a percentage, it is commonly referred as ________________.
Forced expiratory flow in 1 second percentage (FEV1%)
Airway obstruction is said to be present when the FEV1/FVC ratio is less than ______.
70%
What are commonly used to assess the severity of a patient’s pulmonary disorder and determine whether has an obstructive or restrictive lung disorder?
- FVC
- FEV1
- FEV 1%
When the patient has a normal hemoglobin concentration, pulmonary capillary blood volume, and ventilatory status, the only limiting factor to the diffusion of carbon monoxide is the _____________.
Alveolar-capillary membrane
Graphic representation of both a forced vital capacity maneuver and a forced inspiratory volume (FIV) maneuver.
Flow-volume loop
What measurements are increased in a restrictive lung disorder?
- FEV1/FVC (Normal or increased)
- FEV 1% (Normal or increased)
What measurements are decreased in a restrictive lung disorder?
And what’s normal?
Volumes
- VT (Normal or decreased)
- IRV
- ERV
- RV
- MVV (Normal or decreased)
- FEF 25%-75% (Normal or decreased)
- FEF 50% (Normal or decreased)
- FEV1/FVC
- PEFR (Normal or decreased)
- FEF 200-1200 (Normal or decreased)
- FEVT (Normal or decreased)
Capacities
- VC
- IC
- TLC
- FRC
- FVC
NORMAL: RV/TLC
What measurements are decreased in a obstructive lung disorder?
Volumes
- IRV (Normal or decreased)
- ERV (Normal or decreased)
- MVV
Capacities
- IC (Normal or decreased)
- VC
- FVC
- FEF 50%
- FEVT
- FEF 200-1200
- PEFR
- FEV/FVC
- FEF 25-75%
What measurements are increased in a obstructive lung disorder?
Volumes
- VT (Normal or increased)
- RV/TLC ratio (Normal or increased)
- RV
Capacities
- FRC
- TLC (Normal or increased)
What is used to evaluate the status of medium to small airways in obstructive lung disorders?
FEF 25%-75%
4.5 L/s (270L/min)
Normal FEF 200-1200 value for the average healthy man
8 L/s (480 L/min)
_______ provides a good assessment of the large upper airways.
Peak Expiratory Flow Rate
PEFR can be measure easily with what?
At the patient’s bedside with a hand-held peak flowmeter
________ is the average flow rate generated by the patient during the middle 50% of an FVC measurement.
FEF 25-75%
4.5L/s (270 L/min)
What measures the average flow rate between 200 and 1200 mL of an FVC.
Forced Expiratory Flow 200-1200
What does MIP primarily measure?
Inspiratory muscle strength — that is, the power of the diaphragm and external intercostal muscles
An MIP of -25 cmH2o or less (more negative) usually indicates _____________________.
Adequate muscle strength to maintain spontaneous breathing
What does MEP primarily measure?
Strength of the abdominal muscles — that is, the rectus abdominis muscles, external abdominis oblique muscles and internal abdominis oblique muscles, transversus abdominis muscles and internal intercostal muscles
The adult MEP is greater than ______ in males and greater than ______ in females
Males - 100 cm H2O
Females - 80 cm H2O
Where are unsatisfactory MEP values commonly seen?
- Patients with neuromuscular disease
- High cervical spine fractures
- COPD
________ involves treadmill or victor ergometer testing while a variety of physiologic parameters are measured and/or calculated.
Cardiopulmonary Exercise Test (CPET)
What are some useful ways of confirming diagnosis of asthma?
- Inhaled methacholine or histamine
- Indirect challenge test to inhaled mannitol
- Exercise or cold air challenge
Inhalation challenge tests can be performed only when the patient has a FEV1 of ___________, to avoid inducing asthma symptoms in an already compromised patient.
80% or greater
Impulse oscillometry is used to assess ______________________.
- Large and small airway obstructions
- Bronchodilator response
- Bronchoprovocation tesing
IOS can be performed in patients on ventilators and during sleep. T or F?
True
What are the two ways oxygen is carried in the blood?
- Dissolved oxygen in the blood plasma
- Oxygen bound to hemoglobin
In the healthy individual, over ________ of the oxygen that diffuses into the pulmonary capillary blood chemically combines with hemoglobin.
98 percent
What is the normal hemoglobin value for men?
14-16 g/dL
What is the normal hemoglobin value for women?
12-15 g/dL
Each gram of hemoglobin is capable of carrying about _______ of oxygen.
1.34 mL
Define (P[A-a]O2).
The oxygen tension difference between the alveoli and arterial blood.
Also known as the alveolar-arterial tension gradient.
_____________ is an S-shaped curve on a nonogram that illustrates the percentage of hemoglobin that is saturated with oxygen related to oxygen at a specific oxygen partial pressure.
Oxyhemoglobin dissociation curve, also called oxyhemoglobin equilibrium curve
a PO2 increase from 60 to 100 mm Hg only increases the total saturation of hemoglobin by ____.
7 percent
_________ is the ratio of carbon dioxide production divided by oxygen consumption.
RQ, the respiratory quotient
Under normal circumstances, about ______ of oxygen per minute is consumed by tissue cells.
250 mL
Under normal circumstances, about _____ of carbon dioxide is excreted in the lung per minute.
200
The normal P(A-a)O2 on room air at sea level ranges from _______ and should not exceed 30 mm Hg.
7-15 mm Hg
The normal value for P(A-a) O2 on 100% oxygen is between _____________.
What is the critical value?
25 and 65 mm Hg.
The critical value is greater than 350 mm Hg
P(A-a) O2 is normal when __________ is the cause of patient’s hypoxemia.
Alveolar hyperventilation
P(A-a) O2 increases in response to -
- Oxygen diffusion disorders
- Ventilation perfusion mismatching
- Right-to-left intracardiac shunting
- Age
What reflects the amount of alveolar oxygen that moves into the arterial blood?
PaO2/PAO2 ratio
What is the normal range for arterial-alveolar pressure ratio, for a young adult?
0.75 and 0.95
The critical value is less than 0.75
When is PaO2/PAO2 most reliable?
- When ratio is less than 0.55
- FiO2 greater than 0.30
- PaO2 less than 100 mm Hg
What is useful in determining the extent of lung diffusion defects?
PaO2/FiO2 ratio
___________ is the amount of oxygen delivered to the peripheral tissue cells
Total oxygen delivery (DO2)
__________ is the amount of oxygen consumed by the tissue cells divided by the total amount of oxygen delivered.
Oxygen extraction ratio
Normally, the oxygen consumption (VO2) is about _________ of oxygen per minute.
250 mL
Normally, the SVO2 (mixed venous oxygen saturation) is about _______.
75%
What type of hypoxia is this?
Inadequate oxygen at the tissue cell caused by low arterial oxygen tension (PaO2)
Hypoxic hypoxia
What type of hypoxia is this?
PaO2 is normal, but the oxygen-carrying capacity and thus the oxygen content of the blood is inadequate
Anemic hypoxia
What type of hypoxia is this?
Impaired ability of the tissue cells to metabolize oxygen
Histotoxic hypoxia
What type of hypoxia is this?
Blood flow to the tissue cells is inadequate; therefore adequate oxygen is not available to meet tissue needs
Circulatory hypoxia, also called stagnant or hypoperfusion hypoxia
An increased level of red blood cells is called ______________.
Polycythemia
What is defined as an inadequate level of tissue oxygenation?
Hypoxia
What is useful in assessing the patient’s cardiopulmonary status?
Arterial-venous oxygen content difference
(C[a-v]O2)
__________ is a good indicator of the patient’s oxygenation status
Arterial oxygen tension - PaO2
Normally, the DO2 is about ______ of oxygen per minute.
1000 mL
Normally, the VO2 (oxygen consumption) is about _________ of oxygen per minute.
250 mL
What is defined as an abnormally low arterial oxygen tension?
Hypoxemia
Hypoxia is characterized by:
- Tachycardia
- Hypertension
- Peripheral vasoconstriction
- Dizziness
- Mental confusion
Normally, the C(a-v)O2 is about _______.
5 mL/dL
______ is a term used to denote pulmonary arterial hypertension, right ventricular hypertrophy, increased right ventricular work and ultimately right ventricular failure.
Cor polmonale
When hypoxia exists, alternative anaerobic mechanisms are activated in the tissues that produce dangerous metabolites like _________.
Lactic acid
Clinically, the presence of mild hypoxemia generally stimulated the oxygen peripheral chemoreceptors to ____________.
Increase the patient’s breathing rate and heart rate
Red blood cell production is known as what?
Erythropoiesis
When pulmonary disorders produce chronic hypoxia, the renal cells release higher than normal amounts of the hormone erythropoietin which in turn stimulates __________.
The bone marrow to increase red blood cell production
At normal body temperature about _____ of oxygen will dissolve in each 100 mL of blood for every 1 mm Hg of PO2.
0.003 mL
Decrease DLCO is a hallmark clinical manifestation in ___________.
Emphysema
