L6: Pulmonary & Chest Assessment Flashcards
Chest Anatomical Terms
- Supraclavicular
- Infraclavicular
- Interscapular
- Infrascapular
- Upper, middle and lower lung fields
- Apex of the lungs
- Bases of the lungs
- Supraclavicular: above clavicle
- Infraclavicular: below clavicle
- Interscapular: between scapulae
- Infrascapular: below scapulae
- Upper, middle and lower lung fields
- Apex of the lungs: most superior portion of the lungs
- Bases of the lungs:lowest portion of lungs
Vertical Axis Landmarks (anterior)
Angle of Louis
2nd Rib
-
Sternal angle (aka Angle of Louis)
- Bony ridge that joins the manubrium and sternal body
- Located approximately 5cm below the suprasternal notch
- Bony ridge that joins the manubrium and sternal body
-
2nd rib
- located lateral to sternal angle
Counting Ribs (anterior)
Counting ribs: how?
Intercostal spaces: define
-
Counting ribs
- Walk fingers laterally from sternal angle to the 2nd rib
- Continue walking fingers down, at an angle, to count ribs and intercostal spaces
-
Intercostal spaces
- Space between two ribs, numbered by rib above:
- 2nd left intercostal space (2nd LICS) is below the 2nd rib
- Space between two ribs, numbered by rib above:
Vertical axis landmarks (posterior)
12th rib
Inferior tip of scapula
Spinous process of C7
-
12th rib
- Start here and walk up the interspaces to count ribs/interspace
-
Inferior tip of scapula
- Correlates with 7th rib/intercostal space
-
Spinous process of C7
- Count down from C7: T1 = first rib
Circumferential Landmarks
What are the anterior landmarks?
What are the axillary landmarks?
- Anterior circumferential landmarks
- Midsternal line (MSL) - precise
- Midclavicular line (MCL) - estimated
- Anterior axillary line (AAL) - estimated
- Axillary circumferential landmarks
- Posterior axillary line (PAL)
- Drops from posterior axillary fold
- Midaxillary line (MAL)
- Drops from apex of axilla
- Anterior axillary line (AAL)
- Drops from anterior axillary fold
- Posterior axillary line (PAL)
Lung basics
R & L long lobes
Lung apices: location
Lower lung borders
-
Right lung
- 3 lobes: RUL, RML, RLL
-
Left lung
- 2 lobes: LUL, LLL
-
Lung apices
- ~2-4cm above clavicle
-
Lower lung borders
- 6th rib midclavicular line
- 8th rib midaxillary line
- T10 posteriorly
Lung basics
Major & minor fissures
What are the other names for these fisures?
Location?
-
Major (Oblique) fissure
- Divides each lung in half
- From T3 spinous process obliquely around chest to 6th rib at midclavicular line
-
Minor (Horizontal) fissure
- R lung only
- Runs close to 4th rib, meeting major fissure at midaxillary line near 5th rib
Trachea & Major Bronchi
Trachea: location
Bronchi: where does it bifurcate
- Trachea
- Normal position: midline
- Bifurcates into R & L mainstem bronchi at the level of the sternal angle (anteriorly) and T4 (posteriorly)
- NOTE: breath sounds over trachea and bronchi are different than breath sounds over lung parenchyma.
Respiration
What is the normal respiration rate?
Sounds?
What occurs during inspiration and expiration?
- Normal rate: 12-20 breaths/min
- Quiet, slight thorax movement, more prominent abdominal movement
- Inspiration – diaphragm contracts, chest wall expands, negative intrathoracic pressure draws air into lungs
- Expiration – diaphragm relaxes, chest wall contracts, intrathoracic pressure normalizes, air leaves lungs
Neck Abnormalities
What are the common neck abnormalities?
- Stridor
- Tracheal deviation
- Accessory muscle use
Stridor
What does it sound like?
What does it indicate?
Cause?
What can it lead to in kids?
- High-pitched usually inspiratory wheeze
- Indicates obstruction in trachea or larynx
- Foreign body or airway disease
- Croup in kiddos
- Displacement of the trachea from midline
- Causes: Large pleural effusion, large pneumothorax, mass/tumor
Tracheal Deviation
What is tracheal deviation?
Causes?
- Displacement of the trachea from midline
- Causes:
- Large pleural effusion
- Large pneumothorax
- Mass/tumor
Accessory Muscle Use
What is this a sign of?
What to look for?
What illnesses is it comonly seen in?
- Sign of respiratory distress
- Look for sternocleidomastoid, scalene, supraclavicular contraction
- Seen with COPD, asthma…
Thorax Abnormalities
Pectus excavatum
Pectus Excavatum (Funnel Chest)
Concave anterior chest
Depression of distal sternum
Thorax Abnormalities
Pectus Carinatum
Pectus Carinatum (Pigeon Chest)
- Convex anterior chest
- Anterior displacement of sternum
Thorax Abnormalities
Barrel chest
Barrel Chest: Increased A-P (anteroposterior) diameter
- Seen in aging, COPD
Thorax Abnormalities
Flail Chest
Flail Chest: rib fractures cause paradoxical movement of chest wall
Thorax Abnormalities
Kyphosis
Kyphosis: abnormal forward curvature of spine
Thorax Abnormalities
Scoliosis
Scoliosis: abnormal lateral curvature of the spine
Bradypnea vs. Tachypnea
Fast/slow?
Breaths/min?
Commonly seen in what medical conditions?
-
Normal:
- 14-20 breaths/min
-
Bradypnea: slow
- <12 breaths/min
- Diabetic coma, drug-induced respiratory depression
-
Tachypnea: rapid, shallow depth
- >20 breaths/min
- Restrictive lung disease, elevated diaphragm, pain
Hyperventilation vs. sighing
What are they commonly seen in?
-
Hyperventilation: faster, deeper respiration
- Metabolic acidosis (Kussmaul breathing)
- Sighing: periodic deeper breaths
Obstructive Breathing
What is it?
What conditions is it commonly seen in?
- Prolonged expiration and increased airway resistance
- Asthma, chronic bronchitis, COPD
Kussmaul Breathing
What is it?
What is it a sign of?
Rapid & deep respiration
Sign of metabolic acidosis
Cheyne-Stokes Breathing
What is it?
Causes?
- Periods of gradually increasing and decreasing depth of respirations with periods of apnea (no breathing)
- Can be normal in sleeping children, elderly
- Causes include
- Heart failure
- Uremia
- Brain damage
- Drug-induced
Biot’s Breathing
What is it?
Cause?
Irregular, unpredictable, shallow or deep, with intermittent apnea
Respiratory depression, brain damage
Apnea
What is it?
The absence of spontaneous respiration
Crepitus
What condition is it usually seen in?
Palpation Abnormality
- Crepitus: crackling/grating feeling or sound
- Rib movement from fracture (bone crepitus)
- Subcutaneous emphysema (subQ crepitus) – feels like “Rice Krispies” under the skin
Limited chest excursion
Palpation Abnormalities
Limited chest excursion: Unilaterally from chronic lung/pleural fibrosis, pleural effusion, lobar pneumonia, pain/splinting
Subcutaneous Emphysema
What is it?
What can it cuse?
What is it seen in?
Air from lung/chest tracks along tissue planes
Can cause: “swelling” of eyelids, cheeks, lips, neck, chest
Seen w/lung injury (rib fx), postop thoracic surgery, etc.
Fremitus
Define
Fremitus: Palpable vibrations transmitted through bronchiopulmonary tree to chest wall with patient verbalization
Abnormal Tactile Fremitus
What are the cause(s) of:
Decreased fremitus
Increased fremitus
-
Decreased fremitus (vibration)
- Obstructed bronchus
- COPD
- Pleural effusion
- Lung fibrosis
- Pneumothorax
-
Increased fremitus (vibration)
- Pneumonia/consolidation
Percussion
Purpose
Technique
-
Purpose:
- Determine if underlying tissues are air-filled, fluid-filled, or solid (up to 7cm deep into chest)
- Detect areas of tenderness (spine, ribs, etc) Technique:
-
Technique:
- Finger of one hand strikes the finger of the other hand, not striking the patient directly
- For louder notes, apply more pressure to finger on chest wall
What are the locatoins for chest perucssion & ascultation
Anteriorly
Posteriorly
Note: Required for Exam - 3 levels anteriorly, 4 levels posteriorly, plus 1 lateral site on each side
Chest Percussion Tones
Resonant
Dull
Flat
Tympanic
Resonant over air (lungs)
Dull over solid (liver)
Flat over fluid-filled areas/bone/muscle
Tympani over hollow areas (stomach)
Normal Percussion Tones
Abnormal percussion tones
What conditions might be associated with the following tones?
Hyper-resonant
Resonant
Tympanic
Dull
Flat
-
Hyper-resonant
- COPD
- Pneumothorax (PTX)
-
Resonant
- Chronic bronchitis
-
Tympanic
- Large pneumothorax
-
Dull
- Pneumonia
- Pleural effusion
-
Flat
- Pleural effusion
Characteristics of Breath Sounds
Adventitious Sounds
What are adventitious sounds?
Crackles
Rhonchi
Wheezes
-
Adventitious Sounds: Sounds are superimposed on usual breath sounds
- “Adventitious” = added
- Crackles: discontinuous sounds
- Rhonchi: continuous, low-pitched
- Wheezes: continuous, high-pitched
Crackles
Continuous or discontinuous?
Sound?
Conditions where these sounds may be present
Fine vs. coarse crackles: sound/pitch/duration?
- Adventitious Sounds: Discontinuous
- Intermittent, nonmusical, brief, velcro-like sounds
- Heard when small airways pop open during inspiration or when air bubbles flow through secretions or closed airways
- Bronchitis, pulmonary fibrosis, CHF
- Fine crackles: soft, high pitched, very brief (5-10msec)
- Coarse crackles: louder, lower pitch, brief (20-30msec)
Rhonchi & Wheezes
Continuous or discontinuous?
What are they?
Duration?
Pitch?
Seen in what conditions?
- Adventitious Sounds: Continuous
- Longer (≥250 msec), musical
-
Rhonchi – suggest secretions in larger airways, often clear with cough
- Low pitched, snoring “wheeze”
- Large airway secretions (chronic bronchitis)
-
Wheeze – rapid airflow through narrowed (almost closed) bronchi
- High-pitched, hissing, shrill, whistling
- Asthma, COPD, chronic bronchitis, bronchus obstruction,
- Stridor – inspiratory wheeze (larynx/tracheal obstruction)
Pleural friction rub
What is it?
Cause?
Adventitious Sound
- Pleural Friction Rub – crackle-like creaking sounds
- Inflamed pleural surfaces rubbing together
- Recent URI, pneumonia, etc.
Mediastinal crunch
What is it also called?
What is it?
Cause?
Where/how is it best heard?
- Mediastinal Crunch aka “Hamman’s Sign”– precordial crackles in sync with heartbeat, not respiration
- Mediastinal emphysema (pneumomediastinum)
- Best heard in left lateral position
Specialized Exam
Respiratory Expansion
How to test?
How to test
- Place your thumbs at the level of the 10th ribs, your fingers parallel to lateral rib cage
- Slide your hands medially to loosen skin folds
- Ask the patient to inhale deeply
- Make note of how your thumbs diverge as the thorax expands – distance and symmetry
Specialized Exam
Tactile Fremitus
How to test?
Normal/abnormal
How to test: Place ulnar side of hand against chest wall and ask patient to say “99”, feeling for vibrations
Normal: Palpable vibrations
Abnormal: increased or decreased vibrations
Specialized Exam
Diaphragmatic Excursion
What is it?
How to test?
Normal?
-
What is it: the movement of the thoracic diaphragm during breathing
- Measures the contraction of the diaphragm.
- How to test:
- Normal: 3 - 5.5 cm
Specialized Exam
Bronchophony
What is it?
Purpose?
How to test?
Normal/abnormal?
-
What is it:
- abnormal transmission of sounds from the lungs or bronchi
- Transmitted voice sound
- Presence indicates lung consolidation/collapse
- e.g. pneumonia, atelectasis, tumors
- Purpose: Assess underlying lung tissue for collapse/consolidation
- How to test: Ask patient to say “99” while auscultating lung fields
- Normal lung: spoken words are muffled & indistinct
- Abnormal lung: louder voice sounds, called bronchophony
Specialized Exam
Egophony
What is it?
Purpose?
How to test?
Normal/abnormal?
-
What is it:
- increased resonance of voice sounds heard when auscultating the lungs
- Presence indicates lung consolidation/collapse
- e.g. pneumonia, atelectasis, tumors
- Purpose: Assess underlying lung tissue for collapse/consolidation
-
How to test: Ask patient to say “EE” while auscultating lung fields
- When patient says “EE”, it sounds like nasally “AAY” during auscultation
- “E-A change” present
- Normal lung: muffled long “EE” sound
- Abnormal: if “EE” sound changes to “AAY”, Egophony is present
Specialized Exam
Whispered Pectoriloquy
Purpose?
How to test?
Normal/abnormal?
-
Purpose:
- Assess underlying lung tissue for collapse/consolidation
-
How to test:
- Ask patient to whisper “1-2-3” while auscultating lung fields
-
Normal lung:
- whispered words inaudible/barely audible
-
Abnormal:
- Louder, clearer whispered sounds are called Whispered Pectoriloquy
Pleural Effusion
What is it?
Pleural Effusion: fluid collection within the chest but outside the lung, causing lung compression
Pneumothorax
What is it?
Pneumothorax: air collection within the chest but outside the lung, causing lung compression
COPD
What does it stand for?
What is it?
COPD (Chronic Obstructive Pulmonary Disease): over-distention of distal airspaces, resulting in limited expiratory flow and lung hyperinflation
Consolidation/infiltrate
What is it?
Consolidation/infiltrate: alveoli filled with fluid/blood/pus increasing the density and opacity of the lung tissue
Normal, Air-Filled Lung
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
Percussion: Resonant
Breath sounds: Mostly vesicular except over large bronchi (bronchovesicular) and trachea (bronchial)
Transmitted voice sounds: Normal
Tactile fremitus: Normal
Pneumonia (consolidation)
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
- Percussion: Dull over affected area
- Breath sounds: Bronchial over involved area, crackles
-
Transmitted voice sounds: Increased
- Bronchophony: Present (spoken words are louder, clearer)
- Egophony: Present (“EE” to “AAY” change present)
- Whispered Pectoriloquy: Present (whispers sound loud)
- Tactile fremitus: Increased
Infintrate vs. Effusion
Pleural Effusion
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
- Percussion: Dull to flat over fluid
-
Breath sounds: Decreased or absent over fluid
- Possible pleural rub
- Transmitted voice sounds: Decreased to absent
- Tactile fremitus: Decreased to absent
Pneumothorax
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
- Percussion: Hyperresonant or tympanic over pleural air pocket
-
Breath sounds: Decreased to absent over pleural air pocket
- possible pleural rub
- Transmitted voice sounds: Decreased to absent over air pocket
- Tactile fremitus: Decreased/absent over pleural air pocket
COPD
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
Inspection
- COPD = Chronic Obstructive Pulmonary Disease
- Percussion: Resonant to diffusely hyperresonant
- •Breath sounds: Obscured by high pitched wheezes, possible crackles
- Transmitted Voice Sounds: Decreased
- Tactile fremitus: Decreased
- Inspection: Possible accessory muscle use
Asthma
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
Inspection
- Percussion: Resonant to diffusely hyperresonant
- Breath sounds: Obscured by high pitched wheezes, possible crackles
- Transmitted voice sounds: Decreased
- Tactile fremitus: Decreased
- Inspection: Possible accessory muscle use
Chronic Bronchitis
Percussion
Breath sounds
Transmitted voice sounds
Tactile fremitus
Percussion: Resonant (normal)
Breath sounds: Vesicular (normal), possible crackles, wheezes, or rhonchi
Transmitted voice sounds: Normal
Tactile fremitus: Normal
What is the breath pattern?
