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.
