Lower Respiratory Competency Flashcards
What are the special landmarks/anatomy that you should look at when inspecting the chest/back during a lower respiratory exam?
Sternal angle (where 2nd rib meets the manubrium)Suprasternal notchXiphoid processScapulaThoracic vertebrae
Where would you insert a chest tube after performing a needle decompression of a pneumothorax?
4th intercostal space at mid or anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib
What level of the T spine is the lower margin of the endotracheal tube on a chest X-ray?
T4
What is the landmark for thoracentesis?
7th intercostal space
What can pursed lips while breathing indicate?
Obstructive lung disease (COPD)
When assessing a patients posture and postion, what is indicative of obstructive lung disorders?
Sit leaning forward with shoulders elevated (tripod position)
When inspecting the neck during a lower respiratory exam, what are you looking for?
Contraction of accessory muscles (sternomastoid, scalenes or supraclavicular retraction) -> could indicate pathology Tracheal position -> should be midline
What are signs of clubbing of the fingernails?
- Bulbous swelling of soft tissue at nail base. Loss of normal angle between anil and proximal nail fold leading to a spongy or floating feel
How should you assess thoracic expansion when performing a lower respiratory exam?
Place thumbs about the level of the 10th ribs, with fingers loosely grasping and parallel to the lateral rib cage. Ask pt to inhale deeply. Watch the distance between thumbs as they move apart during inspiration and feel for the range and symmetry of the rib cage as it expands and contracts
How do you perform a tactile fremitus test?
Perform on anterior and posterior chest. Pt says 99 or 111. On back there are 3 interclavicular places you feel starting near neck and working toward apex then the 4th place is at lateral inferior edge of scapula (all of these are bilateral. On chest you there are 2 places at top and bottom of sternum bilaterally and the 3rd is near the midclavicular line on each side
What are the 4 normal breath sounds?
Vesicular Bronchovesicular BronchialTracheal
Explain vesicular breath sounds
Soft and low pitchedHeard through inspiration and about 1/3 of expiration Heard over most of lungs (parenchyma)
Explain bronchovesicular sounds
Intermediate in intensity and pitchHeard equally in inspiration and expiration Heard best n 1st and 2nd interspaces anteriorly and between the scapulae
Explain bronchial sounds
Loud and high pitched Heard equally in inspiration and expiration Heard best over trachea in neck
If bronchovesicular or bronchial breath sounds are heard more distal to expected locations, what should you suspect?
Air-filled lung has been replaced by fluid-filled or solid lung tissue
What might decreased breath sounds be due to?
Decreased airflow due to COPD or muscular weaknessPoor transmission of sound due to COPD, pleural effusion or pneumothorax
What are the 5 adventitious breath sounds?
Crackles (Rales)WheezesRhonchiStridorPleural friction rub
What do crackle (rales) lung sounds sound like?
Discontinuous, intermittent, nonmusical and brief
What is the difference between fine crackle and coarse crackle lung sounds?
Fine crackles: soft, high-pitched and very brief (sometimes sounds like velcro)Coarse crackles: louder, lower in pitch, brief
What do wheezes sound like?
Continuous, musical quality and prolonged (not necessarily the entire respiratory cycle)- Relatively high pitched, musical hissing and shrill quality
What pathology does wheezing suggest?
Narrowed airways (asthma, COPD, bronchitis)
What do Rhonchi lung sounds sound like?
Relatively low pitched, snoring quality- Suggest secretions in large airways
What do stridor lung sounds sound like?
Wheeze that is entirely or predominatly inspiratory in natureOften louder in neck vs. chest wall
What do stridor lung sounds indicate?
Partial obstruction of larynx or trachea -> medical emergency
What does pleural friction rub sound like?
Inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction Sounds like creaking, usually during exxpiration but can occur in both phases of respiration - Usually confined to a relatively small area of the chest wall
When performing a tactile fremitus test, where do you expect to feel more prominent vibrations?
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
What regions of the back do you percuss when examining the chest?
5 points bilaterally in interscapular regions
2 points bilaterally near midclavicular space just lateral to points 4 and 5
What 2 pathologies might hyperresonance heard over hyperinflated lungs be indicative of?
COPD/emphysema
Asthma
What might unilateral hyperresonance over the lungs be indicative of?
Large pneumothorax
Large air-filled bulla in lung
How do you perform diaphragmatic excursion?
Determine the distance between the level of dullness on full expansion and level of dullness on full inspiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm)
What is the normal excursion range?
3 to 5.5cm
What is dullness at a level higher than expected when performing diaphragmatic excursion suggestive of?
A pleural effusion or a high diaphragm (as in atelectasis or phrenic nerve paralysis)
Define bronchophony
Spoken words become louder and clearer (indicates consolidation) when pt says 99 which lightening to the lungs
When performing tests using transmitted voice sounds, what do you expect as normal when a pt says 99 while you listen to the lungs?
Normally sounds transmitted through healthy lungs are muffled and indistinct
Define egophony
The “ee” sounds like “A”. The “A” has a nasal bleating quality and should be localized
**In its with fever and cough, the presence of bronchial breath sounds and ego phony more than triples the likelihood of pneumonia
When performing tests using transmitted voice sounds, what do you expect as normal when a pt says “ee” while you listen to the lungs?
normally you will hear a muffled long E sound
Define whispered pectoriloquy
Whispers are heard louder and clearer during auscultation
When performing tests using transmitted voice sounds, what do you expect as normal when a whispers 99 or 123 while you listen to the lungs?
normally a whispered voices is faint and indistinct or not heard at all
