Lab - Respiratory Exam Flashcards
Respiratory Physical Exam: Inspection. What do you look at first?
Assess for Respiratory Distress:
- Tachypnea
- (>25 breaths/minute)
- Cyanosis (Blue in color) or Pallor (Pale in color)
- Audible sounds of breathing Using accessory muscle to breathe (SCM, Scalenes, intercostal)
Deviated Trachea
Increased AP chest diameter (Seen in COPD)
Tripod Posture : Patient with obstructive lung disorders
will tend to sit leaning forward with
shoulders elevated
Respiratory Physical Exam - landmarks to look for?
-
Anterior/mid/posterior-axillary line:
The anterior and posterior axillary lines drop vertically from the anterior and posterior axillary folds. The mid-axillary line drops from the apex of the axilla -
Mid-sternal line & Midclavicular line:
Mid-sternal line drops from suprasternal notch. Midclavicular line drops vertically from the midpoint of the clavicle
Resp Physical Exam Inspection: Digital Clubbing
Digital Clubbing: swelling of soft tissue at nail base. Loss of normal angle between nail and proximal nail fold (>180 degrees) leading to a spongy or floating feeling.
- Can be seen in:
Congenital heart disease, Interstitial lung disease, Bronchiectasis, Pulmonary fibrosis, Lung abscess, Inflammatory Bowel Disease (IBD), Malignancies (lung cancer, and cystic fibrosis
Resp Physical Exam : what do you look for to evaluate Respiration
Rate, Rhythm, Depth, Effort (Look for sternal retractions and use of accessory muscles)
Resp Physical Exam : Palpation - TART
· Trachea
· Lymph nodes
· Thoracic Muscles
· T-spine
o Viscerosomatics T1-7
· Landmarks:
o Suprasternal Notch
o Xyphoid process
o Sternal Angle (Angle of Louis)
§ Where 2nd rib meets with
the manubrium and the
body of sternum ·
Resp Physical Exam - Ribs: TART
Ribs
o Thoracic Expansion
o Chapmans points:
§ Upper lung 3rd Intercostal space
§ Lower Lung 4th intercostal space
Somatic Dysfunction
Resp Physical Exam: Percussion establishes whether underlying tissues are _____
· Air-filled
· Fluid-filled
· Solid
Percussion of the chest - where?
Pathologic examples of when dullness replaces resonance (percussion)
· Lobar pneumonia (alveoli filled with fluid and blood cells)
· Pleural accumulations
· Effusion (serous fluid)
· Hemothorax (blood)
· Empyema (pus)
Fibrous tissue or tumor
Pathologic examples of generalized hyperresonance (percussion)
· COPD/Emphysema
· Asthma
Pathologic examples of unilateral hyperresonance (percussion)
· Large pneumothorax
· Large air-filled bulla in lung
Resp Physical Exam: auscultation
Listen with the diaphragm of the stethoscope:
· Instruct pt to breath deeply through an open mouth
· Compare sides in a ladder like fashion
Normal Breath Sounds: Vesicular
-
Vesicular
- Soft and low pitched
- Heard through inspiration and about 1/3 of expiration
- Heard over most of lungs (parenchyma)
Normal Breath Sounds: Bronchovesicular
-
Bronchovesicular
- Intermediate in intensity and pitch
- Heard equally in inspiration and expiration
- Heard best in 1st and 2nd interspaces anteriorly and between the scapulae
Normal Breath Sounds: Bronchial
-
Bronchial
- Loud and high pitched
- Expiratory sounds heard longer than inspiratory
- Heard best over manubrium (larger proximal airways)
Normal Breath Sounds: Tracheal
- Tracheal
- Very loud and high pitched
- Heard equally in inspiration and expiration
- Heard best over trachea in neck
Adventitious (added) Breath Sounds:
- Superimposed on the usual breath sounds
Adventitious (added) Breath Sounds: Crackles (rales)
-
Crackles (rales)
- Discontinuous; intermittent, nonmusical and brief.
- Defined by the following:
- Fine crackles: soft, high-pitched, very brief (5-10msec) - (sometimes likened to sounding like “velcro”)
- Coarse crackles: louder, lower in pitch, brief (20-30msec)
- Timing in respiratory cycle: Inspiratory, expiratory or mid-inspiratory/expiratory
- Crackles in dependent portions of the lungs may occur after prolonged recumbency; also seen in pneumonia, fibrosis, early heart failure, bronchitis, bronchiectasis
Adventitious (added) Breath Sounds: Wheezes
-
Wheezes
- Continuous; musical quality and prolonged (not necessarily the entire respiratory cycle)
- Wheezes: Relatively high pitched, musical, hissing or shrill quality
- Suggest narrowed airways (asthma, COPD, bronchitis, heart failure)
Adventitious (added) Breath Sounds:
- Rhonchi
-
Rhonchi
- Rhonchi: Relatively low-pitched, snoring quality
- Suggest secretions in large airways
- Rhonchi: Relatively low-pitched, snoring quality
Adventitious (added) Breath Sounds: Stridor
-
Stridor
- High pitched wheeze that is entirely or predominantly inspiratory in nature.
- Often louder in neck than over chest wall.
- Indicates partial obstruction of larynx or trachea (medical emergency: immediate attention needed)
Adventitious (added) Breath Sounds: Pleural friction rub
-
Pleural friction rub
- Inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction.
- Sounds like “creaking”, usually during expiration but can occur in both phases of respiration.
Usually confined to a relatively small area of the chest wall.
Resp Physical Exam: Special Tests
Tactile fremitus
Diaphragmatic Excursion
Transmitted Voice Sounds (Bronchophony, Egophony, Whispered pectoriloquy)
Tactile fremitus:
palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks.
- Perform on anterior and posterior chest. Use ball or ulnar surface of hands
- Patient says “Ninety-nine” or “One-one-one”.
- Often more prominent in the interscapular area than in the lower lung fields, and is more prominent on the right than the left. Disappears below the diaphragm.
Decreased/absent fremitus: sign of _______
Increased fremitus: sign of _______
Decreased/absent fremitus:
COPD, pleural effusions, fibrosis, pneumothorax, thick chest wall, or an infiltrating tumor.
Increased fremitus:
Pneumonia – increased transmission through consolidated tissue
Diaphragmatic Excursion
- Determine the distance between the level of dullness on full expiration and the level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm).
- Normal excursion = 3 to 5.5 cm.
- Dullness at a level higher than expected suggests a pleural effusion or a high diaphragm (as in atelectasis, or phrenic nerve paralysis)
Bronchophony
- Patient says “ninety-nine” while doc listens to lungs.
- Normally sounds transmitted through healthy lungs are muffled and indistinct. (*Remember: can also palpate for tactile fremitus while patient is speaking)
- Bronchophony: Spoken words become louder and clearer (indicates consolidation)
Egophony
- Patient says “ee”.
- Normally you will a hear a muffled long E sound
-
Egophony: the “ee” sounds like “A”. The “A” has a nasal bleating quality and should be localized.
- Note: In patients with fever and cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia.
Pectoriloquy
- Patient whispers “ninety-nine” or “one-two-three”.
- Normally a whispered voice is faint and indistinct or not heard at all.
- Whispered pectoriloquy: whispers are heard louder and clearer during auscultation.
Accessory Muscles of Respiration:
Scalene (1-2)
Pectoralis (3-5)
Serratus Anterior (6-8)
Latissimus dorsi (9-10)
Quadratus lumborum (11-12)
Scalene muscle contraction elevates ______
Contraction elevates ribs 1 and 2
“ Woke up at 1AM 2P ”
- Rib 1**: _A_nterior and **Middle Scalenes
- Rib 2**: **Posterior Scalenes
Pectoralis muscles (mainly pectoralis minor) contraction can cause _________
Ribs 3-5
Contraction can cause anterior (inhalation) rib dysfunction
Engaging pec minor can help treat exhalation rib dysfunctions
Serratus anterior muscle can be an accessory muscle of inhalation when _______________
Accessory muscle of inhalation when scapula is fixed in place (Ex: COPD patient grasping bedrail)
