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Physical Assessment > Chest and Lungs Assessment > Flashcards

Chest and Lungs Assessment Flashcards

1
Q

What is the initial step in the physical assessment of an infant’s lungs?

A

a through review of the infant’s history

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2
Q

What factors can create a wide range of variability in the physical presentation of clinical findings in the lung assessment of an infant?

A

GA, time elapsed since delivery, prenatal/intrapartum history and postnatal history

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3
Q

What factors should be investigated in the review of an infant’s prenatal/intrapartum history?

A

GA, maternal drug ingestion, fetal distress, maternal health status, PROM, med stained fluids, mode of delivery and APGAR scores

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4
Q

What factors should be investigated in the review of an infant’s postnatal history?

A

corrected age, duration of mechanical ventilation, history of RDS or BPD, h/o pneumonia, difficulty feeding and apnea

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5
Q

Physical examination of the chest generally begins with what assessment skill?

A

observation so as not to disturb the infant before assessing breath sounds

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6
Q

How will cold stress affect respiratory status?

A

precipitate of further aggravate respiratory distress

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7
Q

What structures create the chest cavity?

A

the chest cavity is bounded by the sternum, 12 thoracic vertebrae and 12 pairs of ribs

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8
Q

Describe the 12 pair of ribs that are included in the chest cavity.

A

7 true vertebrocostal pairs and 5 false (or vertebrochondral) dyads

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9
Q

How do neonate ribs differ from the ribs of an adult?

A

they are more cartilaginous

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10
Q

How does the cartilaginous make up of neonatal ribs affect the respiratory system?

A

increased chest wall compliance and permits more obvious retractions (as seen w/ RDS)

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11
Q

What creates the lower boundary of the thorax?

A

the diaphragm

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12
Q

What is the normal presentation of the diaphragm?

A

a convex muscular sheath

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13
Q

Where is the diaphragm inserted in the chest cavity?

A

insertion points on the sternum, the first 3 lumbar vertebra and the lower 6 ribs

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14
Q

What are palpable landmarks in the physical assessment of the chest?

A

ribs, vertebrae, suprasternal notch, xiphoid process, clavicles and scapulae

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15
Q

Where is the suprasternal notch located?

A

on the upper aspect of the sternum

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16
Q

What three potential spaces comprise the chest cavity?

A

the mediastinum and the right and left pleural cavities

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17
Q

What structures are contained within the mediastinum?

A

heart, esophagus, trachea, main stem bronchi, thymus and major blood vessels

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18
Q

What encases the right and left pleural tissues?

A

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

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19
Q

Where is the anterior axillary reference line?

A

extends from the anterior axillary fold

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20
Q

Where is the midclavicular reference line?

A

vertical line draws through the middle of the clavicle

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21
Q

Where is the midsternal reference line?

A

bisects the suprasternal notch

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22
Q

Where is the nipple reference line?

A

horizontal line drawn through the nipples

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23
Q

What is included in the initial general inspection of the neonate?

A

an overall assessment of the infant’s color, tone and activity

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24
Q

What can an overall assessment of the infant’s color, tone and activity indicate?

A

these find gins provide clues to oxygenation and respiratory status

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25
Q

Where should a clinician assess an infant for color?

A

infant’s skin and mucous membranes

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26
Q

What is the normal presentation of the lips and mucous membranes in a neonate?

A

are pink and well perfused

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27
Q

What is acrocyanosis and how long may it persist following birth?

A

a bluish coloration of the hands and feet; may persist during transition up to 24h postnatally

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28
Q

What color deviations may be observed?

A

cyanosis (either generalized or central), acrocyanosis, mottling, paleness or ruddiness

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29
Q

What is central cyanosis?

A

bluish coloration of the lips, tongue and mucous membranes

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30
Q

What is the normal presentation of tone and activity in a neonate?

A

normal findings include flexed posture and active movements of all 4 extremities when awake

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31
Q

How is tone affected by prematurity?

A

the ability to attain and maintain flexion is decreased with prematurity

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32
Q

What tone deviations may be observed?

A

hypotonia and inactivity

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33
Q

What is the normal range of an infant’s RR?

A

30-60bpm with wide range of variability

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34
Q

What is the impact of temperature stress on an infant’s RR?

A

if the ambient temp is either very warm or cool, the RR will vary; usually will p/w tachypnea, occasional bradypnea

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35
Q

What is typical of infants delivered via CSX for the first 12-24h postnatally?

A

increased likelihood for retained fetal lung fluid and will p/w tachypnea

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36
Q

When might tachypnea in the neonate indicate an underlying pathology?

A

persistent tachypnea beyond 2 hours of life

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37
Q

Persistent tachypnea beyond 2 hours of life may be indicative of which pathologic states?

A

TTNB, RDS, MAS, pneumonia, hyperthermia or pain

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38
Q

What is a/w bradypnea and/or shallow breathing?

A

CNS depression secondary to factors such as maternal drug ingestion, asphyxia or birth injury

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39
Q

What is the primary muscle of respiration of the newborn?

A

the diaphragm

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40
Q

What is required for the diaphragm to function effectively?

A

the rib cage must be stabilized by the intercostal muscles and the abdomen by the abdominal muscles

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41
Q

What can occur during REM sleep in preterm infants?

A

respiratory instability secondary to uncoordinated diaphragmatic breathing

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42
Q

How is the diaphragm situated in the neonate to compensate for chest wall instability?

A

the diaphragm is higher in the chest and is more concave in shape than in adults, allowing for more efficient ctx

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43
Q

What occurs during regular, relaxed, symmetric respiratory efforts in infants?

A

the lower thorax pulls in and the abdomen bulges with each respiration

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44
Q

What respiratory effort deviations can be observed?

A

asymmetric chest movement, excessive thoracic expansion and paradoxical respirations

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45
Q

What is suggested by paradoxical respirations?

A

seesaw respirations (the chest wall collapses and the abdomen bulges on inspiration) suggests poor lung compliance and the loss of lung volume.

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46
Q

What might mild nasal flaring, grunting and substernal.intercostal rtx immediately after birth indicate?

A

the infant is attempting to clear fetal lung fluid from the lungs

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47
Q

What might G/F/R suggest if observed beyond the immediate postnatal period?

A

TTNB, pneumonia, RDS or atelectasis

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48
Q

What is indicated by suprasternal rtx, especially if p/w gasping or stridor?

A

an upper airway obstruction (laryngeal web or cyst, tumors or vascular rings

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49
Q

What pathologies may result in asymmetric chest wall movement?

A

CDH, cardiac lesions inducing failure, pneumo or phrenic nerve damage

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50
Q

How should sneezing be interpreted in a newborn?

A

a common finding bc it helps to clear the nasal passages

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51
Q

How should coughing be interpreted in a newborn?

A

always abnormal

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52
Q

What is the normal newborn pattern of respirations?

A

irregular; varies with environmental temperature, sleep and state following a feed

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53
Q

What is the effect of prematurity on the pattern of respiration?

A

the less mature the infant, the more likely the breathing pattern is to be irregular

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54
Q

Define periodic breathing.

A

vigorous breaths followed by up to a 20 second pause

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55
Q

When is periodic breathing a common pattern of respiration?

A

in preterm infants and may persist for up to several days after birth

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56
Q

How long does periodic breathing persist in the preterm infant?

A

until they approach term

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57
Q

Define apnea.

A

a lapse of 15 seconds or more between respiratory cycles (one inspiration and one expiration)

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58
Q

What indicates an apneic event?

A

a lapse of 15 seconds or more between respiratory cycles p/w bradycardia or color change

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59
Q

What is apnea typically a function of?

A

prematurity; is gradually outgrown as the infant approaches term

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60
Q

In the term or late preterm infant, what might apnea be indicative of?

A

and underlying pathology; sepsis, hypoglycemia, CNS injury or abnormality, seizures or factors such as maternal drug ingestion

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61
Q

What percentage does the resistance to airflow in the nasal passages contribute to the total pulmonary resistance?

A

1/3

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62
Q

How does the pharyngeal component of the airway system in the newborn compare to an adult?

A

it is much shorter and very compliant

63
Q

What effect can poor muscle tone have on the tongue?

A

the tongue can fall back against the soft palate and obstruct the airway, a process accentuated by neck flexion

64
Q

What infants are at increased risk for upper airway obstruction?

A

infants with poor tone, macroglossia or micrognathia

65
Q

Name the tracheal cartilages.

A

hyoid, thyroid and cricoid

66
Q

What supports the tracheal cartilages in the newborn?

A

superficial fascia

67
Q

What effect does prematurity have on the superficial fascia of the trachea?

A

the fascia is less well developed which increases the risk for airway obstruction

68
Q

What supports the trachea and bronchi?

A

cartilaginous rings

69
Q

How do the cartilaginous rings of the trachea and bronchi differ in the newborn as compared to an adult?

A

are less well developed, which can lead to an increased risk of airway collapse and air trapping

70
Q

What do chemoreceptors in the larynx trigger?

A

reflex apnea to prevent the entry of foreign substances into the airway

71
Q

What changes can newborns elicit with active movement of the vocal cords with breathing?

A

to alter laryngeal airway diameter

72
Q

What is an infant with respiratory distress attempting to achieve with expiratory grunting?

A

to increase laryngeal airway resistance and to ultimately increase FRC

73
Q

What may be indicated by trachea deviation?

A

penumothorax, a space occupying lesion or significant atelectasis

74
Q

What is the average chest circumference in a term infant?

A

30-36cm or 2cm less than the normal OFC

75
Q

What can cause a greater discrepancy between OFC and chest circumference?

A

prematurity, IUGR

76
Q

How does the shape of the thorax of a newborn differ from older children?

A

in newborns is normally rounded (rather than dorsoventrally flattened) and ribs are oriented horizontally (which limits the potential for rib cage expansion)

77
Q

In the presence of decreased lung compliance, what effect do the soft cartilaginous structures of the newborn’s chest result in?

A

the tendency for the chest wall to collapse inward

78
Q

How will a neonate attempt to preserve positive end-expiratory lung volume?

A

compensates by increasing the RR, shortening the Itime and closing the larynx

79
Q

How does the AP diameter compare to the transverse diameter?

A

the AP diameter of the thorax is approximately equal to the transverse diameter

80
Q

In what pathologic state does a short thorax present?

A

pulmonary hypoplasia

81
Q

In what pathologic state does a bell shaped thorax present?

A

neurologic abnormalities or dwarfing syndrome

82
Q

In what pathologic state does a barrel chest, characterized by an increased AP diameter, present?

A

characteristic of air trapping as seen with TTNB, MAS and over mechanical ventilation

83
Q

Of what clinical significance is pectus excavatum and pectus carinatum?

A

rarely clinically significant, may be seen with rickets or Marfan syndrome

84
Q

What is Harrison’s groove?

A

flaring of the lower ribs, may be normal or a/w rickets

85
Q

How does hyperinflation affect abdominal shape?

A

creates abdominal dissension as the diaphragm is pushed downward by air trapped in the lungs

86
Q

What muscular deviations may be observed in the chest assessment?

A

bulges or masses, atrophy, agenesis and hypertrophy

87
Q

What are features of Poland syndrome?

A

unilateral hypoplasia or absence of the pectoralis major muscle, rib defects and upper limb hypoplasia

88
Q

In examining an infant’s nipples, what features should be noted?

A

number, placement, shape, pigmentation, the presence of fissures and/or secretions

89
Q

How do nipples typically present in term infants?

A

the areolae are normally raised and stippled, with 0.75-1cm palpable breast tissue

90
Q

How are nipples typically positioned?

A

the distance from the outside of one areola to the outside of the other should be less than one quarter of the chest circumference

91
Q

What effect can maternal estrogen have on the newborn?

A

results in breast tissue enlargement and engorgement with a milky secretion- witch’s milk

92
Q

How long will witch’s milk and infant great enlargement persist?

A

secretion may last 1-2 wks and the enlargement several months

93
Q

What s/s are indicative of newborn mastitis?

A

rare; redness, tenderness, breast enlargement and discharge of pus

94
Q

What syndrome are wide spaced nipples a feature of?

A

Turner’s syndrome; associated findings include lymphedema and neck webbing

95
Q

How do supernumerary nipples typically present?

A

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

96
Q

In what ethnic group are supernumerary nipples commonly seen?

A

African American infants

97
Q

What is the appearance of normal oral and nasal secretions?

A

usually clear to white frothy mucus; oral secretions will also reflect the stomach contents swallowed during delivery and therefore may be yellow or green

98
Q

What does excessive frothy oral secretions indicate?

A

esophageal atresia

99
Q

What does nasal stuffiness indicate?

A

may indicate maternal drug use

100
Q

What do “snuffles” indicate?

A

may be found with congenital syphilis

101
Q

What do thick yellow secretions indicate?

A

may be seen in the presentation of a respiratory infx

102
Q

What do copious white nasal secretions indicate?

A

may indicate RSV

103
Q

Why are breath sounds louder and coarser in the neonate than in the adult?

A

because the infant has less subcutaneous tissue to muffle transmission

104
Q

Why are sounds readily referred in the neonate?

A

because of the small size of an infant’s chest, therefore localization of adventitious sounds becomes difficult

105
Q

In what situations are breath sounds less readily transmitted?

A

seldom absent; 1) the pleural space contains fluid or air, 2) a bronchus contains secretions or foreign bodies, or 3)the lungs are hyperinflated

106
Q

In what situation are breath sounds more readily transmitted?

A

in the presence of consolidation (ex: pneumonia)

107
Q

In what location can the breath sounds of the lower lobes of the lung be adequately assessed?

A

only through the infant’s back; perform systematic auscultation of both the anterior and posterior chest and compared

108
Q

What qualities should be assessed for in the auscultation of breath sounds?

A

pitch, intensity and duration

109
Q

Describe vesicular breath sounds.

A

soft, short and low pitched during expiration and louder, longer and higher pitched during inspiration

110
Q

Where can vesicular breath sounds be auscultated?

A

normally found over the entire chest except over the manubrium and trachea

111
Q

Describe bronchial breath sounds.

A

the loudest of the breath sounds, characterized by a short inspiration and a loud, longer expiration

112
Q

Where can bronchial breath sounds be auscultated?

A

seldom heard in neonates; only over the trachea

113
Q

Describe bronchovesicular breath sounds.

A

I=E in quality, intensity, pitch and duration; medium pitch

114
Q

Where can bronchovesicular breath sounds be auscultated?

A

over the manubrium and intrascapular regions

115
Q

Auscultation of a newborn’s lung fields shortly after birth may yield what observation?

A

adventitious sounds resulting from the presence of fetal lung fluid

116
Q

Adventitious lung sounds appreciated at the onset of inspiration are most likely resultant from what?

A

secretions in the larger airways

117
Q

Adventitious lung sounds appreciated at the end of inspiration are most likely resultant from what?

A

most likely represent distal disease

118
Q

Describe what is meant by crackles.

A

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

119
Q

Where do fine crackles originate and when are they usually heard?

A

commonly originate in the alveoli in the dependent lobes of the lung and are usually heard at the end of inspiration

120
Q

When fine crackles are appreciated after an elapsed postnatal period, what should be included in the diff dx?

A

RDS or BPD; think inflammation or congestion

121
Q

Where do medium crackles originate and when are they usually heard?

A

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)

122
Q

Where do coarse crackles originate and when are they usually heard?

A

loud, bubbly noise heard during inspiration; a/w significant accumulations of mucus or fluid in the larger airways

123
Q

Describe rhonchi.

A

loud, low, coarse sound like a snore heard at any point of inspiration or expiration; seldom appreciated in newborns

124
Q

In what conditions might rhonchi present?

A

may be heard when either secretions or aspirated foreign matter is present in the large airways

125
Q

When might wheezes be appreciated in the newborn?

A

may be heard on inspiration of expiration, but are usually louder on expiration; seldom heard in the newborn

126
Q

By what mechanism might wheezing sounds be appreciated in the assessment of an infant with BPD?

A

narrowing of the airways or presence of bronchospasm

127
Q

In the neonate, what are rubs typically a/w?

A

inflammation of the pleura; more frequently used to described during mechanical ventilation

128
Q

Describe the presentation of stridor in the neonate.

A

high-pitched, hoarse sound produced during inspiration or expiration at the larynx or upper airways

129
Q

What might stridor indicate in the neonate?

A

a partial obstruction; or upper airway edema in the recently extubated infant

130
Q

What should be suspected of persistently appreciated bowel sounds in the chest, especially on the left side?

A

CDH

131
Q

What are possible causes of absence of air entry in a mechanically ventilated infant?

A

pneumo, blocked ETT, accidental extubation, space occupying lesion

132
Q

What are possible causes of decreased or unequal air entry in a mechanically ventilated infant?

A

atelectasis, pneumo, right main stem intubation

133
Q

What are possible causes of asymmetric chest movement in a mechanically ventilated infant?

A

pneumo, right main stem intubation

134
Q

What are possible causes of increased chest excursion in a mechanically ventilated infant?

A

change in compliance resulting in overventilation

135
Q

What are possible causes of decreased chest excursion in a mechanically ventilated infant?

A

underventilation, blocked ETT, accidental extubation, air leak

136
Q

Why is an infant’s chest typically hyper resonant?

A

because of the thin chest wall

137
Q

When performing percussion, what might a change in resonance indicate?

A

a change in consistency of the underlying tissue

138
Q

What bone is commonly fractured during delivery?

A

clavicle; 1.9-2.9% of term deliveries

139
Q

When should a clavicle fracture be suspected?

A

if crepitus, swelling or tenderness is present; may also demonstrate an incomplete Moro reflex on the affected side

140
Q

If crepitus is palpated on the sternum or ribs, what is typically suspected?

A

subcutaneous air from an underlying pulmonary air leak

141
Q

If a lump or mass is palpated on the sternum or ribs, what is typically suspected?

A

the presence of an underlying fracture

142
Q

The overall structure and cartilage should be assessed for what pathologic finding?

A

hypertrophy

143
Q

How does rickets present in the costal cartilages?

A

enlarged and can be palpated as a series of small lumps down the side of the sternum (‘rachitic rosary”)

144
Q

What is the correct way to perform a transillumination of an infant’s chest?

A

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

145
Q

What condition might generate a false positive in a transillumination of the chest wall?

A

subcutaneous edema

146
Q

What conditions might generate a false negative in a transillumination of the chest wall?

A

chest wall edema, dark skin, tape and equipment

147
Q

How are breath sounds altered in the intubated patient?

A

the ETT effectively narrows the airway, and by which the flow of gases from the ventilator, which may create turbulence

148
Q

What adventitious sounds are typical of an intubated RDS infant?

A

harsh or sandpaper breath sounds resulting from the forceful opening of atelectatic alveoli

149
Q

What sounds are typical of an air leak from around an ETT?

A

high-pitched inspiratory sound

150
Q

What do ventilators that measure tidal volume allow the clinician to assess?

A

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

151
Q

What will indicate the improvement of an intubated infant’s lung disease?

A

will generate larger tidal volumes suggesting a readiness for weaning

152
Q

What will indicate an improvement in lung compliance of an intubate infant?

A

less PIP is required to deliver the same amount of volume

153
Q

What are typical breath sounds appreciated in an infant on HFOV?

A

high-pitched with a jackhammer quality

154
Q

What might variations in breath sounds in the infant on HFOV indicate?

A

higher pitched or musical sounds may indicate the presence of secretion; decreases in pitch may indicate the presence of a pneumo

Physical Assessment (11 decks)

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