Lecture 5 - Respiratory System

Question 1

Which landmark is a useful place to start counting ribs? What else does this landmark represent?

Answer 1

The Sternal angle - junction of manubrium and sternal body

Corresponds with atria of heart and site of tracheal bifurcation

Question 2

What angle should the costal angle be?

Answer 2

90° or less. Increases with overinflation - such as with emphysema

Question 3

Which reference line denotes the vertical center of the anterior chest?

Answer 3

The midsternal line

Question 4

Which reference line denotes the center of the collar bone

Answer 4

The midclavicular line

Question 5

Which reference line denotes the center of the armpit vertically?

Answer 5

The midaxillary line

Question 6

Describe the Pleura

Answer 6

Pleura are a serous membrane that cover and protect the lungs. They also creates a vacuum of negative pressure that prevent lung collapse

The visceral pleura attaches to and wraps around the lungs.
The parietal pleura lines the inside of the chest wall and diaphragm.

Question 7

Describe the right lung compared the the left.
–> How much gas exchange is it responsible for?
–> How many lobes does it have an what separates them?

Answer 7

The right lung is wider and shorter than the left, sitting just above the liver.
It is responsible for 55% of gas exchange.
It has three lobes, the horizontal fissure separates the RUL and RML, and the oblique fissure separates the RML and RLL.

Question 8

Which lung is responsible for more gas exchange?

Answer 8

The right lung is responsible for 55% of gas exchange

Question 9

Describe the left lung
–> How many lobes does it have and what separates them?

Answer 9

It is narrower and longer than the right.
Oblique fissure separates LUL and LLL

Question 10

What superior tip of the lungs is called the ___
The lower tip of the lungs is called the ___

Answer 10

Apex; base

Question 11

Why is it crucial to auscultate and palpate both the anterior and posterior lungs?

Answer 11

Because the upper lobes take up the majority of anterior space, and the lower lobes take up most of the posterior space

Question 12

What is an acinus?

Answer 12

The functional unit of the lung consisting of bronchioles, alveolar ducts, alveolar sacs, and alveoli.

Question 13

How do alveoli maintain their shape and not collapse?

Answer 13

Surfactant - decreases surface tension

Question 14

Describe the process of inspiration

Answer 14

Active process involving diaphragm and external intercostals.

Accessory muscles include the scalenes and sternomastoid

Question 15

Describe the process of expiration

Answer 15

A passive process, but forced expiration might use external obliques and internal intercostals

Question 16

how do the structures in the respiratory system change with age?

Answer 16

–> Costal cartilage calcifies + decreases elastic properties within lungs
–> Decrease in surface area for gas exchange
–> Respiratory muscle strength decreases after 50’s and continuous into 70s

Question 17

What subjective data can be asked about a cough?

Answer 17

–> Provoke/palliate
–> Quality (sound, sputum colour + quantity, amount of coughing)
–> Onset and timing
–> Previous illness
–> Previous treatment + their effectiveness

Question 18

What kind of subjective data should be collected on someone with SOB?

Answer 18

–> Provokes/palliates
–> Timing/onset
–> night sweats (diaphoresis)
–> Associated symptoms (cyanosis, chest pain, cough, etc)

Question 19

What is the term for waking up with intense shortness of breath?

Answer 19

Paroxysmal Nocturnal Dyspnea

Question 20

Other than symptoms of specific complaint, what other data should be collected when doing a respiratory assessment?

Answer 20

Smoking
–>Age started, how often, how much
–> Previous attempts to quit
–> Other household members

Environment
–> workplace
–> triggers
–> breathing device

Question 21

What are some special considerations when collecting subjective data on older adults for a respiratory assessment?

Answer 21

–> SOB or fatigue during ADLs
–> Physical activity
–> History of COPD, TB, or lung cancer
–> Weight changes in last three months
–> Chest pain while breathing + recent falls.

Question 22

What should be inspected in an assessment of respiratory health?

Answer 22

–> LOC
–> facial expression (pursed lips, flaring nostrils)
–> Shape & configuration of chest wall
–> Respiration quality, use of accessory muscles, position taken to breathe,
–> Skin colour and condition

Question 23

What is Cheyne-Stokes breathing? What might cause it?

Answer 23

Regular periods of apnea followed by increased breath that comes in waves.

Could be due to heat failure, renal failure, meningitis, drug overdose, increased intracranial pressure.

Occurs normally during sleep in older adults.

Question 24

What are Biot Respiratory patterns?

Answer 24

Similar to Cheyne-Stokes, but more irregular.

Occurs due to head trauma, brain abscesses, heat stroke, spinal meningitis, stroke, encephalitis

Question 25

What is the difference between hypoventilation and bradypnea?

Answer 25

Hypoventilation - regular rate, shallow breaths (often due to pain)

Bradypnea - Regular depth, slow breath rate often accompanied by bradycardia. (due to CNS depression, intracranial pressure, diabetic coma)

Question 26

What things should be notes when palpating chest expansion with two hands?

Answer 26

Check for symmetry and note costal angle

Question 27

What is tactile fremitus

Answer 27

Vibration that can be felt by placing hand on chest/back due to speech - 99 is best word to use.

Vibration should be prominent of the top, and dissipate as you get lower (but never gone)

Question 28

What should a healthy lung sound like?

Answer 28

Should be resonant - low, clear, hollow sounding

Question 29

When is stridor and fine crackles usually heard?

Answer 29

On Inspiration

Question 30

When are wheezes and coarse crackles usually heard?

Answer 30

On expiration

Question 31

What lung sounds are heard on both inspiration and expiration?

Answer 31

Pleural friction rub

Question 32

Older adults have decreased thorax mobility and chest expansion, therefore, they are at higher risk for ____ during assessment

Answer 32

Hyperventilation and Presyncope

Question 33

A patient presents with wheezing, and labored breathing (using accessory muscles). They are coughing and have increase RR, SOB, and presyncope.

Upon assessment, tactile fremitus in decreased and the patient presents with tachycardia. Percussion is normal.

What might be happening?

Answer 33

Asthma attack - edema of bronchial mucosa with thick mucus and bronchospasm.

Question 34

A patient presents with chest pain and hacking and thick sputum. They have dyspnea, fatigue, and cyanosis with clubbing fingers.

Upon assessment, you find that tactile fremitus and percussion are normal. Auscultations presents wheezing and crackles.

What might be happening?

Answer 34

Chronic Bronchitis
–> Proliferation of mucous glands and inflammation of bronchi Might lead to distal lung obstruction + deflation.

Question 35

A patient presents with a barrel chest, cyanosis, labored breathing (Tripod seating and accessory muscle use), tachypnea, and SOB. They have a history of smoking.

Upon assessment, you find decreased tactile fremitus, hyperresonance, and decreased air entry near the base of the lungs. Heart sounds are also muffled.

What might be happening?

Answer 35

Emphysema
–> Destruction of pulmonary connective tissue that leads to permanent enlargement of air sacs

Question 36

A patient presents with increased RR and nasal flaring.

Upon inspection, you discover that chest expansion is decreased on affected side. Tactile fremitus is also decreased over affected side. Percussion sounds are dull and fine crackles are heard.

What might be happening?

Answer 36

Lobar Pneumonia
–> Alveoli fill with bacteria, cellular debris, fluid, RBCs and WBCs.
–> Decreased air exchange and possible hypoxemia

Question 37

A patient presents with chest pain that increases with deep inspiration, dyspnea, restlessness and changes in LOC. They have cyanosis, tachypnea and hemoptysis.

Upon assessment, you find that they are diaphoretic and hypotensive, with an SPO2 of less than 80%, with tachycardia. They have crackles and wheeze with expiration.

What might be happening?

Answer 37

Pulmonary embolism
–> Occlusion of pulmonary vessel, causes ischemia, increased arterial pulmonary pressure, decreased cardiac output and hypoxia

Question 38

A patient presents with increases RR, dyspnea, cyanosis, a dry cough, and accessory muscle breathing.

Upon assessment you find that tactile fremitus in decreased, tachycardia, and that the trachea has shifted towards one side. Chest expansion is decreased on the opposite side. Percussion is dull, auscultation is absent in some areas.

What might be happening?

Answer 38

Pleural Effusion
–> Excess fluid in intrapleural space, compression of underlying lung tissue

Question 39

A patient presents with increased RR, SOB, orthopnea, edema, and pallor.

Upon inspection you find that they have clammy skin. Percussion is normal, but crackles can be heart at the base of the lungs.
What might be happening?

Answer 39

Heart Failure
–> Increased cardiac overload backs up into the lungs and causes congestion and enlargement of pulmonary capillaries