Lower Respiratory Flashcards
Hypopnea
decreased depth (shallow) and rate (slow) of respiration
Bradypnea
regular rhythm but slower than normal rate (<14 bpm)
Hyperpnea
increases depth (deep) breathing and rate of respiration
Tachypnea
rapid breathing (>20-25 bpm)
Hypoxia
deficiency in amount of O2 reaching tissues
Hypoxemia
oxygen deficiency in arterial blood
atelectasis
collapse of lung tissue that affects the alveoli from normal O2 absorption
Pleximeter finger
hyperextended middle finger of non-dominant hand in percussion
plexor finger
“tapping” finger, dominant hand, for percussion
Needle thoracentesis (decompression)
2nd intercostal space, midclavicular line
Chest tube insertion
4th intercostal space at mid or anterior axillary line in the 4th intercostal space just superior to margin of the 5th rib
Neurovascular bundle
- runs along inferior margins of each rib
- chest tubes and needles need to be placed over the superior margin of the rib to avoid the bundle
What marks the lower margin of the endotracheal tube on a chest xray?
T4
What is the landmark for thoracentesis?
7th intercostal space
Order for exam
Vital signs (RR, HR, temp, O2 sat) Inspection Palpation Percussion Auscultation
Pulse Ox
- measures peripheral arterial O2 sat
- improper placement, hypoperfusion, hypothermia, motion artifact may all cause bad waveform
Capnogrpahy
-non invasive measurement of the partial pressure of CO2 in exhaled breath as the CO2 concentration over time
EtCO2 (end tidal CO2)
concentration of CO2 in exhaled air at the end of respiration
What is the significance of CO2 being only a trace gas in the air?
CO2 detected in exhaled air is produced by the body and delivered to the lungs by the blood correlates with PaCO2
normal PETCO2
35-40 mmHg (partial pressure of exhaled carbon dioxide)
Normal PaCO2
35-45 mmHg (partial pressure of CO2 in arterial blood)
physical exam
1) sitting position and breathing pattern
2) use of accessory muscles
3) color of fingers and lips; shape of nails
4) breathing through pursed lips
5) ability to speak
6) chest deformities
7) spinal deformities
8) is the trachea midline
9) chest excursion
10) tactile fremitus
11) percussion
12) lung sounds
13) lymphadenopathy
Signs of Hypoxia
- nail bed blue, clubbing
- perioral blue tint
Clubbing
- bulbous sweating 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
- causes: congenital heart disease, interstitial lung disease, bronchiectasis, pulm fibrosis, cystic fibrosis, lung abcess, malignancy, IBS
Normal shape of chest
thorax wider than it is deep, lateral diameter is larger than AP diameter
Tracheal deviation
- pneumothorax
- pleural effusion
- atelectasis
- mass
Pectus Excavatum
- funnel chest
- depression in lower portion of the sternum
- can compress heart and great vessels
- cause murmurs
Pectus Carinatum
- pigeon chest
- sternum displaced anteriorly
- increased AP diameter
- adjacent costal cartilages are depressed
Barrel Chest
- increased AP diameter resembling a barrel
- seen in COPD
- some increase in AP diameter can come with aging
- can be normal in infancy
Signs of chronic bronchitis
- blue bloater
- daily productive cough for more than 3 months in at least 2 consecutive years
- overweight and cyanotic
- elevated hemoglobin
- peripheral edema
- rhonchi and wheezing
Signs of emphysema
- pink puffer
- permanent enlargement and destruction of air spaces distal to the terminal bronchiole
- older and thin
- severe dyspnea
- quiet chest
- XR shows hyperinflation with flattened diaphragms
Traumatic flail chest
- multiple rib fractures may result in paradoxical movements of the thorax
- on inspiration the injured areas cave inward, and on expiration it moves outward
Accessory muscle use
- scalenes, SCM, traps
- sign of respiratory distress
- seen in asthma, COPD, airway obstruction, viral illness (RSV)
Tactile fremitus
- palpable vibrations
- decreased or absent may be COPD or pleural changes (effusions, fibrosis, air, infiltrating tumor)
- increased may indicate pneumonia
OS structural exam
Viscerosomatics: T2-7
doming of the diaphragm, rib raising, tapotement, thoracic pump (helps with atelectasis)
Percussion tones
- helps to determine if underlying structures are air filled, fluid filled, or solid
- only penetrates 5-7 cm, so can’t detect deep seated lesions
- flat over spinous process, scapula, heavy muscles, bones
- resonance in lungs
- cardiac and liver dullness
- visceral flatness
- stomach tympany
Dullness replaces resonance
-fluid or solid tissue replaces air-containing lung or occupies space beneath percussing fingers
-lobar pneumonia
pleural accumulations
Generalized hyperresonance
- heard over hyperinflated lungs
- COPD
- asthma
Unilateral hyperresonance
- large pneumothorax
- large air filled bulla in lung
- COPD/emphysema
Tympanic
abdominal percussion
Healthy lung sound
resonant
Sound of lungs with effusion/emphysema
dull
sounds of lungs with pneumothorax
hyperressonant
Diaphragmatic excursion
- mark areas between full exhalation and inhalation for diaphragm
- normal distance = 3-5.5cm
- asymmetry with one side higher can be the sign of pleural effusion
- high diaphragm secondary to atelectasis or phrenic paralysis
Auscultation
- diaphragm of stethoscope
- pt breathe through OPEN mouth
- 2 spots anterior
- 4 spots posterior
- listen throughout complete inhale and exhale
Most important technique for assessing air flow
- listen to sounds generated by breathing (normal)
- listening for adventitious (added) sounds
- if abnormalities, listen for vocal resonance
Normal breath sounds
-vesicular, bronchovesicular, bronchial, tracheal
Adventitious (added) breath sounds
-stridor, wheezes, crackles
Common causes of stridor
-croup, epiglottitis, upper airway foreign body, anaphylaxis
Common causes of wheezing
- reactive airway disease (RAD), asthma, COPD
- generally an expiratory sound
- caused by rapid airflow through a narrowed bronchial airway
Crackles
- an inspiratory sound
- continuous musical sounds
- thought to be caused by small airway closed during expiration, “popping” open during inspiration
- common causes: pneumonia, CHF, atelectasis, pulm fibrosis, COPD, asthma
Atelectasis
- loss of lung volume due to collapse of lung tissue
- can be post surgery
- incentive spirometer for treatment
Normal Vocal Resonance
- words muffled and indistinct in auscultation
- whispered words are faint and indistinct if heard at all
- when pt says “ee”, hear a muffled long E on auscultation
Abnormal vocal resonance
- distinctness increases with lung consolidation
- bronchophony, whispered pectoriloquy, egophony
PFT
- non invasive
- show how well the lungs are working
- diagnose certain lung disorders
Spirometry
- measures lung function
- amount and speed of air inhaled and exhaled
- diagnose conditions
Chest X Ray Interpretation (A)
A- adequate assessment of quality
- position
- exposure
- inspiration
- rotation
Chest X Ray Interpretation (A)
A- Airway
-trachea midline, carina
Chest X Ray Interpretation (B)
B- bones and soft tissue
- osteopenia
- fractures
- metastatic lesions
- subcutaneous emphysema
Chest X Ray Interpretation (C)
C- cardiac size
- normal = <50% of chest diameter of PA films and <60% on AP films
- check for shape of heart, calcifications, and prosthetic valves
Chest X Ray Interpretation (D)
D- diaphragms
-round? flat?
Chest X Ray Interpretation (E)
E- effusions, endotracheal tube, ekg
Chest X Ray Interpretation (F)
F- field and fissures
-infiltrates, masses, consolidation, air bronchogram, pneumothorax, vascular markings
Chest X Ray Interpretation (F)
F- foreign body
-piercings, bullet fragments, central line
Chest X Ray Interpretation (G)
G- great vessels
-aortic size and shape
Chest X Ray Interpretation (G)
G- gastric bubble
-nasogastric tube?
Chest X Ray Interpretation (H)
H- hilar masses
-lymphadenopathy, widening (aortic dissection), mass
Chest X Ray Interpretation (I)
I- impression
-what are your overall findings
