Chest and Lungs Assessment Flashcards
What is the initial step in the physical assessment of an infant’s lungs?
a through review of the infant’s history
What factors can create a wide range of variability in the physical presentation of clinical findings in the lung assessment of an infant?
GA, time elapsed since delivery, prenatal/intrapartum history and postnatal history
What factors should be investigated in the review of an infant’s prenatal/intrapartum history?
GA, maternal drug ingestion, fetal distress, maternal health status, PROM, med stained fluids, mode of delivery and APGAR scores
What factors should be investigated in the review of an infant’s postnatal history?
corrected age, duration of mechanical ventilation, history of RDS or BPD, h/o pneumonia, difficulty feeding and apnea
Physical examination of the chest generally begins with what assessment skill?
observation so as not to disturb the infant before assessing breath sounds
How will cold stress affect respiratory status?
precipitate of further aggravate respiratory distress
What structures create the chest cavity?
the chest cavity is bounded by the sternum, 12 thoracic vertebrae and 12 pairs of ribs
Describe the 12 pair of ribs that are included in the chest cavity.
7 true vertebrocostal pairs and 5 false (or vertebrochondral) dyads
How do neonate ribs differ from the ribs of an adult?
they are more cartilaginous
How does the cartilaginous make up of neonatal ribs affect the respiratory system?
increased chest wall compliance and permits more obvious retractions (as seen w/ RDS)
What creates the lower boundary of the thorax?
the diaphragm
What is the normal presentation of the diaphragm?
a convex muscular sheath
Where is the diaphragm inserted in the chest cavity?
insertion points on the sternum, the first 3 lumbar vertebra and the lower 6 ribs
What are palpable landmarks in the physical assessment of the chest?
ribs, vertebrae, suprasternal notch, xiphoid process, clavicles and scapulae
Where is the suprasternal notch located?
on the upper aspect of the sternum
What three potential spaces comprise the chest cavity?
the mediastinum and the right and left pleural cavities
What structures are contained within the mediastinum?
heart, esophagus, trachea, main stem bronchi, thymus and major blood vessels
What encases the right and left pleural tissues?
the three lobes of the right lung and two lobes of the left lung are encased in serous membranes, which make up the visceral and parietal pleura
Where is the anterior axillary reference line?
extends from the anterior axillary fold
Where is the midclavicular reference line?
vertical line draws through the middle of the clavicle
Where is the midsternal reference line?
bisects the suprasternal notch
Where is the nipple reference line?
horizontal line drawn through the nipples
What is included in the initial general inspection of the neonate?
an overall assessment of the infant’s color, tone and activity
What can an overall assessment of the infant’s color, tone and activity indicate?
these find gins provide clues to oxygenation and respiratory status
Where should a clinician assess an infant for color?
infant’s skin and mucous membranes
What is the normal presentation of the lips and mucous membranes in a neonate?
are pink and well perfused
What is acrocyanosis and how long may it persist following birth?
a bluish coloration of the hands and feet; may persist during transition up to 24h postnatally
What color deviations may be observed?
cyanosis (either generalized or central), acrocyanosis, mottling, paleness or ruddiness
What is central cyanosis?
bluish coloration of the lips, tongue and mucous membranes
What is the normal presentation of tone and activity in a neonate?
normal findings include flexed posture and active movements of all 4 extremities when awake
How is tone affected by prematurity?
the ability to attain and maintain flexion is decreased with prematurity
What tone deviations may be observed?
hypotonia and inactivity
What is the normal range of an infant’s RR?
30-60bpm with wide range of variability
What is the impact of temperature stress on an infant’s RR?
if the ambient temp is either very warm or cool, the RR will vary; usually will p/w tachypnea, occasional bradypnea
What is typical of infants delivered via CSX for the first 12-24h postnatally?
increased likelihood for retained fetal lung fluid and will p/w tachypnea
When might tachypnea in the neonate indicate an underlying pathology?
persistent tachypnea beyond 2 hours of life
Persistent tachypnea beyond 2 hours of life may be indicative of which pathologic states?
TTNB, RDS, MAS, pneumonia, hyperthermia or pain
What is a/w bradypnea and/or shallow breathing?
CNS depression secondary to factors such as maternal drug ingestion, asphyxia or birth injury
What is the primary muscle of respiration of the newborn?
the diaphragm
What is required for the diaphragm to function effectively?
the rib cage must be stabilized by the intercostal muscles and the abdomen by the abdominal muscles
What can occur during REM sleep in preterm infants?
respiratory instability secondary to uncoordinated diaphragmatic breathing
How is the diaphragm situated in the neonate to compensate for chest wall instability?
the diaphragm is higher in the chest and is more concave in shape than in adults, allowing for more efficient ctx
What occurs during regular, relaxed, symmetric respiratory efforts in infants?
the lower thorax pulls in and the abdomen bulges with each respiration
What respiratory effort deviations can be observed?
asymmetric chest movement, excessive thoracic expansion and paradoxical respirations
What is suggested by paradoxical respirations?
seesaw respirations (the chest wall collapses and the abdomen bulges on inspiration) suggests poor lung compliance and the loss of lung volume.
What might mild nasal flaring, grunting and substernal.intercostal rtx immediately after birth indicate?
the infant is attempting to clear fetal lung fluid from the lungs
What might G/F/R suggest if observed beyond the immediate postnatal period?
TTNB, pneumonia, RDS or atelectasis
What is indicated by suprasternal rtx, especially if p/w gasping or stridor?
an upper airway obstruction (laryngeal web or cyst, tumors or vascular rings
What pathologies may result in asymmetric chest wall movement?
CDH, cardiac lesions inducing failure, pneumo or phrenic nerve damage
How should sneezing be interpreted in a newborn?
a common finding bc it helps to clear the nasal passages
How should coughing be interpreted in a newborn?
always abnormal
What is the normal newborn pattern of respirations?
irregular; varies with environmental temperature, sleep and state following a feed
What is the effect of prematurity on the pattern of respiration?
the less mature the infant, the more likely the breathing pattern is to be irregular
Define periodic breathing.
vigorous breaths followed by up to a 20 second pause
When is periodic breathing a common pattern of respiration?
in preterm infants and may persist for up to several days after birth
How long does periodic breathing persist in the preterm infant?
until they approach term
Define apnea.
a lapse of 15 seconds or more between respiratory cycles (one inspiration and one expiration)
What indicates an apneic event?
a lapse of 15 seconds or more between respiratory cycles p/w bradycardia or color change
What is apnea typically a function of?
prematurity; is gradually outgrown as the infant approaches term
In the term or late preterm infant, what might apnea be indicative of?
and underlying pathology; sepsis, hypoglycemia, CNS injury or abnormality, seizures or factors such as maternal drug ingestion
What percentage does the resistance to airflow in the nasal passages contribute to the total pulmonary resistance?
1/3
How does the pharyngeal component of the airway system in the newborn compare to an adult?
it is much shorter and very compliant
What effect can poor muscle tone have on the tongue?
the tongue can fall back against the soft palate and obstruct the airway, a process accentuated by neck flexion
What infants are at increased risk for upper airway obstruction?
infants with poor tone, macroglossia or micrognathia
Name the tracheal cartilages.
hyoid, thyroid and cricoid
What supports the tracheal cartilages in the newborn?
superficial fascia
What effect does prematurity have on the superficial fascia of the trachea?
the fascia is less well developed which increases the risk for airway obstruction
What supports the trachea and bronchi?
cartilaginous rings
How do the cartilaginous rings of the trachea and bronchi differ in the newborn as compared to an adult?
are less well developed, which can lead to an increased risk of airway collapse and air trapping
What do chemoreceptors in the larynx trigger?
reflex apnea to prevent the entry of foreign substances into the airway
What changes can newborns elicit with active movement of the vocal cords with breathing?
to alter laryngeal airway diameter
What is an infant with respiratory distress attempting to achieve with expiratory grunting?
to increase laryngeal airway resistance and to ultimately increase FRC
What may be indicated by trachea deviation?
penumothorax, a space occupying lesion or significant atelectasis
What is the average chest circumference in a term infant?
30-36cm or 2cm less than the normal OFC
What can cause a greater discrepancy between OFC and chest circumference?
prematurity, IUGR
How does the shape of the thorax of a newborn differ from older children?
in newborns is normally rounded (rather than dorsoventrally flattened) and ribs are oriented horizontally (which limits the potential for rib cage expansion)
In the presence of decreased lung compliance, what effect do the soft cartilaginous structures of the newborn’s chest result in?
the tendency for the chest wall to collapse inward
How will a neonate attempt to preserve positive end-expiratory lung volume?
compensates by increasing the RR, shortening the Itime and closing the larynx
How does the AP diameter compare to the transverse diameter?
the AP diameter of the thorax is approximately equal to the transverse diameter
In what pathologic state does a short thorax present?
pulmonary hypoplasia
In what pathologic state does a bell shaped thorax present?
neurologic abnormalities or dwarfing syndrome
In what pathologic state does a barrel chest, characterized by an increased AP diameter, present?
characteristic of air trapping as seen with TTNB, MAS and over mechanical ventilation
Of what clinical significance is pectus excavatum and pectus carinatum?
rarely clinically significant, may be seen with rickets or Marfan syndrome
What is Harrison’s groove?
flaring of the lower ribs, may be normal or a/w rickets
How does hyperinflation affect abdominal shape?
creates abdominal dissension as the diaphragm is pushed downward by air trapped in the lungs
What muscular deviations may be observed in the chest assessment?
bulges or masses, atrophy, agenesis and hypertrophy
What are features of Poland syndrome?
unilateral hypoplasia or absence of the pectoralis major muscle, rib defects and upper limb hypoplasia
In examining an infant’s nipples, what features should be noted?
number, placement, shape, pigmentation, the presence of fissures and/or secretions
How do nipples typically present in term infants?
the areolae are normally raised and stippled, with 0.75-1cm palpable breast tissue
How are nipples typically positioned?
the distance from the outside of one areola to the outside of the other should be less than one quarter of the chest circumference
What effect can maternal estrogen have on the newborn?
results in breast tissue enlargement and engorgement with a milky secretion- witch’s milk
How long will witch’s milk and infant great enlargement persist?
secretion may last 1-2 wks and the enlargement several months
What s/s are indicative of newborn mastitis?
rare; redness, tenderness, breast enlargement and discharge of pus
What syndrome are wide spaced nipples a feature of?
Turner’s syndrome; associated findings include lymphedema and neck webbing
How do supernumerary nipples typically present?
most commonly seen as raised or pigmented areas 5-6cm below the normal nipple but can be located anywhere on a vertical line drawn through the true nipple
In what ethnic group are supernumerary nipples commonly seen?
African American infants
What is the appearance of normal oral and nasal secretions?
usually clear to white frothy mucus; oral secretions will also reflect the stomach contents swallowed during delivery and therefore may be yellow or green
What does excessive frothy oral secretions indicate?
esophageal atresia
What does nasal stuffiness indicate?
may indicate maternal drug use
What do “snuffles” indicate?
may be found with congenital syphilis
What do thick yellow secretions indicate?
may be seen in the presentation of a respiratory infx
What do copious white nasal secretions indicate?
may indicate RSV
Why are breath sounds louder and coarser in the neonate than in the adult?
because the infant has less subcutaneous tissue to muffle transmission
Why are sounds readily referred in the neonate?
because of the small size of an infant’s chest, therefore localization of adventitious sounds becomes difficult
In what situations are breath sounds less readily transmitted?
seldom absent; 1) the pleural space contains fluid or air, 2) a bronchus contains secretions or foreign bodies, or 3)the lungs are hyperinflated
In what situation are breath sounds more readily transmitted?
in the presence of consolidation (ex: pneumonia)
In what location can the breath sounds of the lower lobes of the lung be adequately assessed?
only through the infant’s back; perform systematic auscultation of both the anterior and posterior chest and compared
What qualities should be assessed for in the auscultation of breath sounds?
pitch, intensity and duration
Describe vesicular breath sounds.
soft, short and low pitched during expiration and louder, longer and higher pitched during inspiration
Where can vesicular breath sounds be auscultated?
normally found over the entire chest except over the manubrium and trachea
Describe bronchial breath sounds.
the loudest of the breath sounds, characterized by a short inspiration and a loud, longer expiration
Where can bronchial breath sounds be auscultated?
seldom heard in neonates; only over the trachea
Describe bronchovesicular breath sounds.
I=E in quality, intensity, pitch and duration; medium pitch
Where can bronchovesicular breath sounds be auscultated?
over the manubrium and intrascapular regions
Auscultation of a newborn’s lung fields shortly after birth may yield what observation?
adventitious sounds resulting from the presence of fetal lung fluid
Adventitious lung sounds appreciated at the onset of inspiration are most likely resultant from what?
secretions in the larger airways
Adventitious lung sounds appreciated at the end of inspiration are most likely resultant from what?
most likely represent distal disease
Describe what is meant by crackles.
defined as a series of brief (noncontinuous) crackling or bubbling sounds arising from a sudden release of energy- either from an airway popping open or a liquid film breaking
Where do fine crackles originate and when are they usually heard?
commonly originate in the alveoli in the dependent lobes of the lung and are usually heard at the end of inspiration
When fine crackles are appreciated after an elapsed postnatal period, what should be included in the diff dx?
RDS or BPD; think inflammation or congestion
Where do medium crackles originate and when are they usually heard?
lower, moister sound heard during midstage of inspiration; originate in the bronchioles; a/w the passage of air through sticky surfaces (pneumonia, pulmonary congestion or TTNB)
Where do coarse crackles originate and when are they usually heard?
loud, bubbly noise heard during inspiration; a/w significant accumulations of mucus or fluid in the larger airways
Describe rhonchi.
loud, low, coarse sound like a snore heard at any point of inspiration or expiration; seldom appreciated in newborns
In what conditions might rhonchi present?
may be heard when either secretions or aspirated foreign matter is present in the large airways
When might wheezes be appreciated in the newborn?
may be heard on inspiration of expiration, but are usually louder on expiration; seldom heard in the newborn
By what mechanism might wheezing sounds be appreciated in the assessment of an infant with BPD?
narrowing of the airways or presence of bronchospasm
In the neonate, what are rubs typically a/w?
inflammation of the pleura; more frequently used to described during mechanical ventilation
Describe the presentation of stridor in the neonate.
high-pitched, hoarse sound produced during inspiration or expiration at the larynx or upper airways
What might stridor indicate in the neonate?
a partial obstruction; or upper airway edema in the recently extubated infant
What should be suspected of persistently appreciated bowel sounds in the chest, especially on the left side?
CDH
What are possible causes of absence of air entry in a mechanically ventilated infant?
pneumo, blocked ETT, accidental extubation, space occupying lesion
What are possible causes of decreased or unequal air entry in a mechanically ventilated infant?
atelectasis, pneumo, right main stem intubation
What are possible causes of asymmetric chest movement in a mechanically ventilated infant?
pneumo, right main stem intubation
What are possible causes of increased chest excursion in a mechanically ventilated infant?
change in compliance resulting in overventilation
What are possible causes of decreased chest excursion in a mechanically ventilated infant?
underventilation, blocked ETT, accidental extubation, air leak
Why is an infant’s chest typically hyper resonant?
because of the thin chest wall
When performing percussion, what might a change in resonance indicate?
a change in consistency of the underlying tissue
What bone is commonly fractured during delivery?
clavicle; 1.9-2.9% of term deliveries
When should a clavicle fracture be suspected?
if crepitus, swelling or tenderness is present; may also demonstrate an incomplete Moro reflex on the affected side
If crepitus is palpated on the sternum or ribs, what is typically suspected?
subcutaneous air from an underlying pulmonary air leak
If a lump or mass is palpated on the sternum or ribs, what is typically suspected?
the presence of an underlying fracture
The overall structure and cartilage should be assessed for what pathologic finding?
hypertrophy
How does rickets present in the costal cartilages?
enlarged and can be palpated as a series of small lumps down the side of the sternum (‘rachitic rosary”)
What is the correct way to perform a transillumination of an infant’s chest?
place a high-density fiberoptic light source perpendicular to the chest, move the light back and forth from side to side; compare the ant of transillumination bw the L and R, lower and upper aspects of the chest
What condition might generate a false positive in a transillumination of the chest wall?
subcutaneous edema
What conditions might generate a false negative in a transillumination of the chest wall?
chest wall edema, dark skin, tape and equipment
How are breath sounds altered in the intubated patient?
the ETT effectively narrows the airway, and by which the flow of gases from the ventilator, which may create turbulence
What adventitious sounds are typical of an intubated RDS infant?
harsh or sandpaper breath sounds resulting from the forceful opening of atelectatic alveoli
What sounds are typical of an air leak from around an ETT?
high-pitched inspiratory sound
What do ventilators that measure tidal volume allow the clinician to assess?
the infant’s ability to generate spontaneous breaths and to determine the relative size of that breath compared with the size of breath generated by the ventilator
What will indicate the improvement of an intubated infant’s lung disease?
will generate larger tidal volumes suggesting a readiness for weaning
What will indicate an improvement in lung compliance of an intubate infant?
less PIP is required to deliver the same amount of volume
What are typical breath sounds appreciated in an infant on HFOV?
high-pitched with a jackhammer quality
What might variations in breath sounds in the infant on HFOV indicate?
higher pitched or musical sounds may indicate the presence of secretion; decreases in pitch may indicate the presence of a pneumo
