History and Physical Exam of the Pulmonary System Flashcards
Air conduction tract
Upper: nasopharynx, oropharynx, larynx
Lower: trachea, primary bronchial tree bifurcation
Respiratory Tract
Smallest bronchioles and alveoli–gaseous exchange, mucous secreting cells
Physiology of movement of air into lungs
Inhaled air is hydrated, putting it into solution
Air is heated by underlying blood vessels
Air cells surrounded by capillaries allow for rapid diffusion of gases
Mucous secreting goblet cells excrete mucous that traps particular matter; mucociliary escalator move it up toward glottis
Mechanics of Respiration
Inspiration is active, controlled largely by diaphragm
Expiration is passive
When under stress, intercostals and abdominal muscles are recruited to assist
Amount of air moved in quiet breathing
500mL
Dyspnea
Subjective description of difficult, labored, or uncomfortable breathing
“Shortness of breath”
“Breathlessness”
“Not getting enough air”
Dyspnea is not dianosis of itself, should be considered a significant sx of another dx
Orthopnea
Dyspnea in the recumbant position
Most often the result of volume overload, PE, COPD
Documented in terms of number of pillows
Progression is of particular importance
Paroxysmal Nocturnal Dyspnea (PND)
Orthopnea that wakes the patient from sleep
May be associated with left sided heart failure (early pulmonary edema that comes on quickly)
AKA “cardiac asthma”
Wheezing
Musical respiratory sound that may be audible to patient and others
Suggestive of partial airway obstruction from:
**secretions
tissue inflammation
foreign body **
Tachypnea
Rapid breathing
May or may not be associated with dysnpea
RR >20
Bradypnea
Slow breathing
RR<12
Platypnea
Dyspnea in the upright position
Hyperpnea
Hyperventilation (basically)
Minute ventilation in excess of metabolic demand
Rapid and deep respirations; can lead to respiratory alkalosis
Carpopedal spasm
Associated with:
Hyperventilation (psychologic)
Hypocalcemia (physiologic)
Tactile Fremitus
Palpable vibrations transmitted through the bronchopylmonary tree to the chest wall when pt speaks (99)
Bronchophony/Egophony
The phenomena of increased volume and clarity of sounds transmitted through a solid or liquid opposed to through air
Chest Wall Expansion
Normal, symmetricular upward and outward movement of the ribs and chest wall during inspiration
Diaphragmatic Excursion
Movement of the diaphragm from its high resting position to its lower, flattened position when it is flexed in inspiration
Normal: 5-6cm on either side
Hypoxia
Inadequate oxygenation of the blood
Cyanosis
Bluish discoloration of the skin secondary to hypoxia or to inadequate peripheral circulation
Carboxyhemoglobin
Stable complex of CO and hemoglobin in RBCs
Pulse Oximetry
SaO2
Oxygenated hemoglobin absorbs more infrared light and allows more red light to pass through.
Deoxygenated (or reduced) hemoglobin absorbs more light adn allows more infrared light to pass through
Vesicular
Soft and low pitch.
Heard throughout inspiration, continue without pause throughout expiration, and then fade away about one third of the way through expiration
Bronchovesicular
Inspiratory and expiratory sounds are about equal length, sometimes with silent interval in between
Detecting differences in intensity and pitch is often easier during expiration
Louder because no compliance of these airways
Bronchial
Louder and higher in pitch, with short silence between inspiratory adn expiratory sounds
Expiratory sounds last longer than inspiratory sounds
Normal breath sounds
Vesicular
Bronchovesicular
Bronchial
*Tracheal
Adventitious Breath Sounds
Wheezing
Rales/Crackles
Rhonchi
Crackles/Rales
Intermittent, non-musical, brief sounds
Usually higher pitched and brief
Usually occur first in inspiration adn later in both inspiration and expiration
Described as fine or coarse
Rhonchi
Relatively low pitched nad may be described as snoring
Suggestive of secretions in larger airways
May be inspiratory or expiratory (or both)
Wheezing
Relatively high pitched with a musical quality
Usually begin as an expiratory but with increasing severity can span entire respiratory cycle
Questions related to Pulmonary Hx
Identify alarming symptoms such as associated chest pain.
Acute or chronic?
ROS: Pay particular attention to upper and lower respiratory tract, CV, and GI
Ask about smoking, environmental, and occupational exposures
Review current and prior medications and medication and environmental allergies.
PMSoHx including previous history of similar complaints, asthma, sinusitis, recent respiratory infections, TB exposure, CAD, and esophageal disease.
Family history of pulmonary disease like asthma, COPD and any exposure to second hand smoke.
Pulmonary Risk Factors
SMOKING!
Aspiration –
stroke, NG tube, trouble protecting airway (i.e. alcoholic), dysphagia.
Debilitation –
alcohol misuse, extremes of age, immunosupression.
Chronic disease –
DM, renal failure, CHF, neuromuscular disorders like Guillian Barre’ or Myasthenia Gravis.
Pulmonary diseases –
Emphysema, Chronic Bronchitis, Asthma, Cystic Fibrosis, Hereditary A1 Antitrypsin deficiency.
Inspection
Observe the shape of the chest and the movement of the chest wall
Asymmetry or obvious deformities
Retractions in ICS
Inspect skin for cyanosis
Nails for cyanosis or clubbing
Variations in Chest Wall Shape
Barrell Chest
Traumatic Flail Chest
Funnel Chest (Pectus Excavatum)–depression in lower portion of sternum
Pigeon Chest (Pectus Carinatum)–anteriorly displaced sternum
Thoracic Kyphoscoliosis
Palpation
Assess for tenderness, instability, or crepitus in trauma
Assess for chest expansion
Assess vocal fremitus
- Increased fremitus–consolidated fluid magnifies vibration
- Decreased fremitus–space b/w lung and chest wall magnified vibration
Auscultation
Pt breathing with mouth open, somewhat more deeply than normal
Note intensity of breath sounds and any variations from normal vesicular breathing
- Breath sounds are usually louder in the upper, anterior chest
- Bronchovesicular breath sounds may be heard over the large airways, especially on the right
Identify any adventitious sounds, noting:
- Timing in respiratory cycle
- Location on chest wall
- Do they clear with coughing?
Percussion
Percuss in the same areas as auscultation
The heart produces areas of dull left of the sternum from the 3rd to 5th ICS
Percuss diaphragmatic excursion
History: Evaluation of common or concerning respiratory complaints
Cough
Dyspnea
Hemoptysis
Wheezing
Chest Pain
Cough
A mechanical reflex that involves a deep inspiration, which increases lung volume; followed by muscle contraction against a closed glottis; and then sudden opening of the glottis
Protective and helps clear mucus, secretions, and foreign objects from airway
Acute Cough
Lasts less than 3 weeks
Usually self-limiting
Most common causes:
- URI
- Lower respiratory tract infections
- Acute exacerbation of chronic COPD
- Allergic rhinitis
- Rhinitis due to irritants
- Irritants to the respiratory tree
Chronic Cough
Persistent cough lasting longer than 3 weeks
Most common causes:
- COPD
- Chronic sinus drainage
- Asthma
- GERD
- Meds
- Psychiatric
Triggers of irritant receptors
Irritant–dust
Allergens–ragweed, pollen
Toxic substances–gastric acid
Inflammation–asthma
Cold air
Smoke
Rapid change in humidity or temperature
Infection–viral vs. bacterial
Acute causes of cough
URI, sinusitis
LRI, bronchitis, pneumonia
Allergic rxn
Asthma
Environmental
Foreign body
Chronic/Common Causes of Cough
Smoking
Postnasal discharge
Asthma
GE Reflux
ACE Inhibitors/ARBs
Chronic/Uncommon Causes of Cough
CHF
bronchiectasis
Lung CA
Emphysema
Occupational
Recurrent aspiration
CF, interstitial
Characteristics of a smoking induced cough
Usually worse in the AM, productive
Characteristics of chronic bronchitic cough
usually productive
Characteristics of rhinitis associated cough
associated with PND, nasal mucous drainage, often a hx of seasonal allergies
Characteristics of an asthma related cough
Worse at night or after exercise
Associated with episodic wheezing
Characteristics of a cough associated with meds
beta blocker–makes asthma worse
ACEI
Characteristics of GE Reflux Associated Cough
H/o heartburn
Worse in supine position
Improves with antacids
Alarming Symptoms
Cough with hemoptysis
Cough, fever, and purulent sputum production
Cough with excessive sputum production
Cough with wheezing and dyspnea
Cough with CP
Cough with unintentional weight loss
Cough, dyspnea, and lower extremity edema
Dyspnea
Rule out the bad stuff
MI
PE
significant infections
CHF
Dyspnea Hx Questions
Was the onset acute?
- airway obstruction
- PE
- angioedema
- allergic reaction
Was the onset gradual?
- CHF
- AECB
- Anemia
Any current or previous diseases that may be an exacerbation of?
Any recent periods of immobility (surgery)?
Differential Diagnosis of Acute Dyspnea
Pulmonary
- CHF, pulmonary edema
- Exacerbation of COPD
- PE
- Aspiration/foreign body
- Acute infections
- Spontaneous pneumothorax
Cardiac
- Cardiac tamponade
- Myocardial ischemia
- Pericarditis/endocarditis
- Mitral valve prolapse
Miscellanceous
- Anaphylaxis
- Metabolic acidosis
- Guillain Barre
- Myasthenia Gravis
Psych
- Panic attack
- Hyperventilation
DDX of Chronic Dyspnea
Pulmonary
- Asthma
- COPD
- Interstitial lung disease
- Chronic pneumonia
- Chronic pulmonary emboli
- Pulmonary neoplasia
- Pleural effusions
Cardiac
- Cardiomyopathies
- CHF
- Myocardial ischemia
- Primary pulmonary HTN
- Pericardial dz
Miscellaneous
- Deconditioning
- Anemia
- Neuromuscular dz
Psychiatric
Most immediately life threatening causes of dyspnea
Upper airway obstruction, foreign body, angioedema, hemorrhage
Tension pneumothorax
Pulmonary embolism
Neuromuscular (MG, GB)
Anaphylaxis
Alarming Symptoms
Chest pain
Pink, frothy sputum
Swelling, hives, or wheezing
Fever and sputum production
Weakness/fatigue
Signs to promptly identify imminent respiratory failure
How to respond to these signs
Tachypnea, stridor, accessory muscle use.
Inability to speak because of breathlessness (3-word dysnpnea)
Agitation or lethargy as consequence of hypoxia
Paradoxical abdominal wall movement due to diaphragmatic fatigue
**What to do: **
Give oxygen
Anticipate need for airway control and mechanical ventilation
Hemoptysis Hx
Amount of hemoptysis
Associated sxs
Recent illnesses
PMH
Meds and Drugs
Smoking
Travel
Occupational exposure
Hemoptysis DDx
Infectious – bronchitis, pneumonia, TB
Neoplastic – lung CA
CV – PE, CHF, pulmonary HTN
Hematologic - ↓ platelets, anticoagulant Rx
Traumatic – foreign body, ruptured bronchus
Iatrogenic – lung bx., bronchoscopy
Inflammatory – bronchiectasis, cystic fibrosis
GI- esophageal varicies
ENT- following nasal trauma
Alarming Sxs of Hemoptysis
Massive or severe hemoptysis is considered life threatening
Chest imaging indicated
Massive hemoptysis carries a mortality rate of 13-58%
Wheezing History
Timing and details of onset
Any previous attacks?
Risk factors and associated disease
- Occupational exposure
- Immobility
- PMH, asthma, CHF, smoking
- FHx-atopy
- Allergies
- Medication
Compare severity to baseline
Modifying factors
Associated sxs
DDx of Wheezing
Asthma
COPD, especially emphysema
PE
Anaphylaxis
Infection: viral or bacterial
Tumors
Aspiration
Mitral valve disease
CHF
Initial questions for pts with CP
PQRSTA
Rule out the bad stuff:
- MI
- PE
- TAA
- Pneumothorax
Chest pain alarming sxs
Diaphoresis
Dyspnea with hemotysis, fever, syncope, or paplpitations
Tearing or ripping sensation radiating to the back
CP with N/V
Radiating to arms, shoulders, or jaw
Sudden onset
Sense of impending doom
Chest Pain DDx
Heart disease
Structures of the thorax
Lungs: PE, pneumothorax, pneumonia, pleuritis
GI causes
Musculoskeletal causes
