Lectures 9-10 Flashcards
What is problem oriented approach
- Get data- history, PE, tests
- Problem prioritization
- Plans- diagnostic, therapeutic, client education
- Follow up
What are some “big picture” things to look at during your physical exam
Rate
Effort
Patient position and attitude
Audible or auscultable sounds
What are some details to look for during physical exam
Inspiration vs expiration (timing, effort, sounds)
Body wall movements
Auscult full lung fields and large airways
Define: Eupnea Tachypnea Bradypnea Hyperpnea Hypopnea Apnea Dyspnea
- Normal breathing
- Increased rate/frequency (hyperventilation)
- Decreased rate/frequency (hypoventilation)
- Increased depth/airflow (hyperventilation)
- Decreased depth/airflow (hypoventilation)
- Cessation of breathing
- Difficult/labored breathing (need to further describe besides just “dyspnea”)
What is orthopnea
Dyspnea while lying down but is corrected when upright
What is ataxic/agonal
Continuous irregular shifts of hyperventilation, hypoventilation, and apnea
What is paradoxic breathing
Abdomen and thorax moving in opposite directions
What is flail chest
One segment of chest wall moves differently
What are bronchial sounds
Normal, airflow through trachea (mid height, mid width of chest)
What are vesicular sounds
Normal airflow through large airways
What is stertor and what does it mean
Snoring sounds produced by partial obstruction of upper airway
Means a problem somewhere between nose or nasopharynx
Abnormal
What is stridor and what does it mean
High pitched, harsh, vibratory sound caused by partial upper airway obstruction
Usually means problem in the larynx
What are crackles and what causes it
Discontinuous bubbling/popping sounds caused by air passing through fluid or when air forces collapsed airway/alveolar walls open
What are wheezes and what causes it
Continuous whistling sounds caused by air turbulence in narrowed lower airwars
What does an end expiratory grunt indicate
Bronchoconstriction or air trapping
What does a pleural rub indicate
Irregular pleural surface
Similar to crackles but is very focal (same place and time in breath)
What does it mean if you can hear lung sounds dorsally but not ventrally
Fluid line usually means pleural space disease or consolidation
what are signs the problem is nose/nasopharynx specific
Nasal discharge, epistaxis, sneezing
Nasal passage occlusion, stertor, mouth breathing, facial asymmetry or deformity, ocular signs, anorexia (cats)
What are signs the problem is upper airway below the nose?
Stridor, coughing, altered breathing pattern (posture, I>E, paradoxic breathing), exercise intolerance, hyperthermia, tachypnea, panting, dyspnea, distress
What are signs the problem is lower airways
Couging, wheezing, altered breathing (I
What are signs the problem is pleural space?
Altered breathing (I>E), tachypnea, dyspnea, distress, exercise intolerance, decreased lung sounds on auscultation
What are other things that can determine your differential diagnoses
Cats vs dogs
Breed specifics
Age
What are important things to gather in your history
Confirm and characterize principal clinical signs Preventative care protocol Prior treatment, response to treatment Other concurrent signs or diseases Environment
What is coughing?
Where are cough receptors located?
A symptom, NOT a disease
Receptors are located in upper respiratory tract and large airways
Basic approach for nasal disease
Start with less invasive tests- blood work, infectious disease screening, cytology
Next step is imaging- oropharyngeal exam, nasal rads, dental rads, CT/MRI, rhinoscopy
Next step is more invasive tests- nasal flush, biopsy
What type of information does imaging give you about nasal disease
Give you information of localization, but generally doesn’t give you definitive diagnose UNLESS it’s:
- foreign body
- tooth root abscess
- mites
- anatomic/structural abnormalities
Which diagnostic test will provide the highest diagnostic yield?
Blind nasal biopsies. Don’t technically need imaging so it can be done for clients with low budgets
Basic approach for upper airway problems?
Still start with less invasive tests (blood work, infectious disease screening, cytology, imaging)
Next visualization and imaging (oropharyngeal exam, CT/MRI, endoscopy)
More invasive tests (brush cytology, biopsies)
What will imaging tell you about upper airway problems
Can localize, but will not provide definitive diagnoses UNLESS it is:
- laryngeal paralysis
- cervical tracheal collapse
- foreign body
- other anatomic/structural abnormalities
Basic approach for lower airway/ lung problems
Less invasive tests (infectious disease screening, blood gas analysis, cytology, imaging)
More invasive tests (transthoracic FNA, airway washes, biopsies)
Fecal testing for parasites- when should you do it? What test should you do if looking for resp parasites?
Do this diagnostic for all patients with cough!
Baermann is resp parasite check, but in practice you should also do float and sediment
What signs clue you in to a lower airway/lung problem
Cough, tachypnea, expiratory distress
What signs clue you in to upper airway problems?
Stridor, tachypnea, inspiratory distress, cough
What signs clue you in to nasal problems?
Stertor, discharge, sneezing, open mouth breathing
What can the blood gas help you determine?
Severity
Differentiate between pulmonary disease from hypoventilation
Monitor response to treatment
What does pulse oximetry tell you
Measure saturation of hemoglobin, NOT the total content
*need to make sure the number fits with HR, RR, and breathing effort
What is the FIO2: PIO2 ratio
Percentage of oxygen patient is breathing in to percentage of oxygen in their blood
Expect it to be 400 or more
Can’t use this for oxygen cages or nasal cannulas
What is the hemoglobin dissociation curve
Sigmoid shape with a plateau at higher PaO2
What does imaging tell you about lower airway/lung problems
Only definitive diagnosis unless it is tracheal/bronchial collapse, foreign bodies, anatomic/structural abnormalities
What are differentials for alveolar pulmonary patterns
Fluid or tissue within alveolar spaces
Pneumonia, effusion, neoplasia
What are differentials for interstitial pulmonary pattern
Increased tissue in interstitium
Fibrosis, neoplasia, inflammatory infiltrates
What are differentials for bronchial pulmonary pattern
Bronchitis, asthma
What would you use a trans-thoracic aspiration for?
What are complications?
Cytology and/or culture- mainly in patients with mass lesions or diffuse disease
Most patients will get a pneumothorax
What are other very specific tests for lower airway/lung problems
Pulmonary function testing
Angiography
Scintigraphy
What is a tracheal wash
Sample for large airways
Two main techniques- TTW and endotracheal lavage
Doesn’t require anesthesia
Limited use in cases of interstitial or focal disease
What is a bronchoalveolar lavage
Two main techniques- bronchoscopy guided and endotracheal
Sample from small airways and alveoli
Limited use in cases of interstitial disease
Anesthesia required
What should all airway washing techniques do?
What may they result in?
Bypass normal flora/debris from oral and pharyngeal cavities
May cause transient hypoxemia and crackles
What cells should predominate in normal secretions
Large mononuclear cells
What signs clue you in to a pleural space problem?
Tachypnea, inspiratory distress
What diagnostics are available for pleural disease?
Imaging (rads, CT)
Thoracocentesis
Thoracoscopy/thoracotomy
If a dog is coughing, what two thing do you need to differentiate between?
Heart disease or resp disease
*no murmur and no tachycardia prob means coughing is not cardiac related
What are components of adequate oxygen delivery
Oxygen in air Enough air getting to lungs Air can move from inside lung to blood Blood is able to hold enough oxygen Blood can get to tissues
