(CPA) respiratory exam Flashcards
what position & exposure should the patient be in for the respiratory exam?
patient should be placed at a 45-degree angle, with the anterior chest wall exposed
how is the posterior chest wall exposed?
patient leans forwards
what do you inspect for in a respiratory exam?
general appearance
gait and posture
facial appearance/expression and speech
jaundice - sclera, skin
cyanosis - skin, mucosa, tongue, lips
pallor - in anaemia – mucosa of tongue, sclera
hair distribution
body habitus
hydration - sunken eyes, dry mucosa, skin turgidity
hands – tremors, joint distortion, nails, clubbing
how is respiratory rate assessed?
visually observing the anterior wall (and abdominal walls), measure the rate of breathing for 30 seconds (then x2) BUT pretend to take the radial pulse
how is breathing rate expressed?
breaths/minute
where does the trachea bifurcate?
at the level of the sternal angle (T4/T5)
where is the trachea found?
resides in the midline of the neck and suprasternal (jugular) notch of the manubrium
where is the trachea palpable?
palpable throughout from the larynx to the suprasternal notch
explain how you would palpate the trachea
before examining the patient, warn them that this can be uncomfortable
ask the patient to lean back (lower their neck slightly so their neck is relaxed)
place forefinger of your right hand at the suprasternal notch of the patient and push to upwards and backwards until the trachea is felt
= if trachea is in the midline then finger will not be able to progress further
what is felt when the trachea is displaced?
if displaced, finger will feel only one side of the trachea instead of its middle
give three causes for tracheal deviation TOWARDS the side of the lung lesion
upper lobe collapse
upper lobe fibrosis
pneumonectomy
give three causes for tracheal deviation AWAY FROM the side of the lung lesion
extensive pleural effusion
chest expansion
tension pneumothorax
explain how anterior chest expansion is assessed
stand facing the subject
place hands on the 5th-6th ribs with the thumbs on the anterior midline, resting lightly on the chest wall
ask the patient to take a deep breath
tips of your thumbs should move apart at least 5cm in a healthy adult
explain how posterior chest expansion is assessed
place hands on approx T10 with the thumbs on the posterior midline, resting lightly on the chest wall so respiration can occur
ask the patient to take a deep breath and look for any asymmetry
where are the hands placed in anterior chest expansion?
at the level of the 5th/6th ribs in the anterior midline
where are the hands placed in posterior chest expansion?
at the level of the 10th thoracic vertebrae in the posterior midline
for females, where are the hands placed in anterior chest expansion?
hands beneath the breast
what do movements of the anterior chest wall indicate?
expansion of the upper and middle lobes
what do movements of the posterior chest wall indicate?
expansion of the lower lung lobes
what does unilateral decreased chest expansion indicate?
pneumothorax
pleural effusion
collapsed lung
consolidation
what does bilateral decreased chest expansion indicate?
asthma or COPD
what does normal chest expansion feel like?
expands symmetrically on both sides during inspiration (when lungs inflate)
healthy adults = approx 5cm
what does reduced unilateral chest wall expansion suggest?
a lesion on that side
what does a resonant/tympanic percussion sound indicate?
over air-filled spaces such as the lung
i.e. normal
what does a dull percussion sound indicate?
over solid organs such as the heart/liver
over fluid collection
what does a hyperresonant percussion sound indicate?
excessive air
e.g. percussing puffed up cheeks
describe how lung percussion is carried out
percuss anteriorly: both apices, infraclavicular regions, 3rd, 5th and 7th intercostal spaces on both LEFT and RIGHT + right mid-axillary line
percuss posteriorly: level of trapezius, level of scapular spine, 10th and 11th rib levels and laterally on right and left
give three causes of hyper-resonant percussion sounds in the lungs
pneumothorax
hollow bowels
COPD
give three causes of hypo-resonant percussion sounds in the lungs
pleural effusion (stoney dull)
lung tumour (flat dull)
consolidation (flat dull)
lung collapse (flat dull)
which areas must lung percussion include?
apices of the lungs
base of the lungs
what is auscultation?
listening to the lung sounds using a stethoscope
why are lung sounds heard?
due to air turbulence within the airways
what are the two types of normal lung sounds?
bronchial sounds
vesicular sounds
what are bronchial lung sounds?
high pitched notes
where are bronchial lung sounds heard?
anteriorly
- normally heard over trachea, suprasternal notch, manubrium, sternal angle, and sternoclavicular joints
(where alveolar tissue is absent)
posteriorly
- between C7 and T3
what are vesicular lung sounds?
low pitched notes
where are vesicular lung sounds heard?
normally heard over the rest of the chest area (where normal lung tissue is present)
describe and explain the difference between bronchial and vesicular lung sounds
bronchial sounds are from airways that are not surrounded by alvoelar tissue so the air turbulence can be heard unfiltered = HIGH PITCHED
however vesicular sounds are from alveolar tissue which filters the sounds of air turbulence = LOW PITCHED
explain how lung auscultation is carried out
lie at 45 degrees, exposed from the waist up
use the diaphragm to auscultate most areas of the chest, except the supraclavicular apical auscultation for which you will use the bell
auscultate for bronchial breathing
(!cannot auscultate over breast tissue!)
compare results both anterior and posterior
in which locations is the lung auscultated on the anterior chest wall?
supraclavicular (bell)
infraclavicular/2nd ICS (diaphragm)
3rd ICS (diaphragm)
6th ICS (diaphragm)
AXILLAE (!!)
in which locations is the lung auscultated on the posterior chest wall?
level of trapezius
level of scapular spine
level of the 10th and 11th rib
AXILLAE (!!) - only left
what must you remember when auscultating the lungs in females?
must not auscultate over the breast tissue
where is the apex of the lung auscultated?
supraclavicular region using the bell of the stethoscope
where is the superior lobe of the lung auscultated?
2nd ICS
where is the middle lobe of the lung auscultated?
4th ICS (just under the right axilla!)
= as middle lobe only present on right side
where is the inferior lobe of the lung auscultated?
6th ICS
what can you do if breath sounds are inaudible?
ask the patient to take deep breaths in and out
where are the inspiratory and expiratory components of VESICULAR breath sounds produced?
inspiratory = lobar & segmental airways
expiratory = central airways
describe the characteristics of vesicular breath sounds
low pitched
length, intensity and pitch of inspiratory phase > expiratory phase
no pause bw inspiration and expiration
give causes of the reduced intensity of vesicular breath sounds
shallow breathing
airway obstruction
hyperinflation
pneumothorax
pleural effusion
pleural thickening
obesity
(i.e. if there is poor air generation in the airways or sound transmission through the tissues)
describe the characteristics of bronchial breath sounds
high pitched, hollow
expiratory phase > inspiratory phase
distinct pause bw inspiration and expiration
which pathologies are bronchial breath sounds heard over?
consolidation
localised pulmonary fibrosis
pleural effusion
collapsed lung
when can the expiration phase become prolonged?
in obstructive lung disease e.g. asthma or chronic bronchitis
what is tactile vocal fremitus?
vibration of the chest wall during vocal sound
why does tactile vocal fremitus occur?
transmits from the larynx down the bronchial tree and into the chest wall
explain how tactile vocal fremitus is assessed
ask the patient to say ‘ninety-nine’
palpate across the posterior chest wall with your hands for changes in intensity
you should feel the vibrations equally in both hands
!! both posterior and anterior chest wall !!
what are the possible causes of decreased tactile vocal fremitus?
pneumothorax, COPD
due to decrease in density = increased/excessive air in lungs
what are the possible causes of increased tactile vocal fremitus?
consolidation in pneumonia
tumour tissue in cancer
(due to increase in density = replacement of air with another substance)
why is decreased tactile vocal fremitus caused?
decrease in density caused by an increase in distance between the chest wall and lungs
(e.g. in pleural effusion due to fluid)
how are the cervical lymoh nodes palpated?
position the patient sitting and examine from behind
use both hands to examine the lymph nodes on each side simultaneously
use the pads of the fingers in a circular motion palpate across all the cervical
lymph node groups, without lifting the fingers until the end
what is the order of cervical node palpation?
submental nodes – inferior to the chin
submandibular nodes – inferior to the angle of the mandible
preauricular/parotid nodes – anterior to the ear
postauricular nodes – posterior to the ear
occipital nods – base of the occipital
superior deep cervical nodes – superior part of the sternocleidomastoid
inferior deep cervical nodes – inferior part of the sternocleidomastoid
supraclavicular nodes – superior to the clavicle
where are the submental nodes palpated?
inferior to the chin
where are the submandibular nodes palpated?
inferior to the angle of the mandible
where are the preauricular/parotid nodes palpated?
anterior to the ear
where are the postauricular nodes palpated?
posterior to the ear
where are the occipital nodes palpated?
base of the occipital bone
where are the superior deep cervical nodes palpated?
superior part of the sternocleidomastoid
where are the inferior deep cervical nodes palpated?
inferior part of the sternocleidomastoid
where are the supraclavicular nodes palpated?
superior to the clavicle
give four possible causes of cervical lymohedenopathy
lung cancer (metastasising to the lymph nodes)
tuberculosis
sarcoidosis
respiratory tract infection
what is lung consolidation?
when air in the lungs is replaced by something else (e.g. inflammatory exudate, blood, pus, oedema)
what are the indications for a chest drain?
pleural effusion
pneumothorax
haemothorax
what is the most common position for chest drain insertion?
anterior to the mid-axillary line avoiding the long thoracic nerve lying behind the ‘safe triangle’
what are the four borders of the safe triangle for chest drain insertion?
posterior
latissimus dorsi - posterior axillary fold
anterior
pectoralis major - anterior axillary fold
inferior
5th intercostal space at mid-axillary line
superior
below apex of axilla
which ribs does the triangle of safety encompass?
overlies 2nd to 5th intercostal spaces
where can the needle be inserted for a chest drain?
once triangle of safety is marked out
= needle may be inserted in the 2nd, 3rd, 4th and 5th intercostal spaces anterior to the mid-axillary line
why is the needle for a chest drain inserted in the upper border of the rib?
to avoid injuring the neurovascular bundle
what is the purpose of a chest drain?
the remove excess fluid/air from the pleural cavity
why is a tracheostomy performed?
to create an artificial air passage into the trachea
when is a tracheostomy performed?
upper airway obstruction
respiratory failure
how is a tracheostomy performed?
opening is created on the anterior wall of the trachea between the 1st and 2nd tracheal cartilage rings
infrahyoid muscle and thyorid isthmus retracted
tracheostomy tube inserted and secured
what are the surface markings of the lungs?
long - check insendi
