Lower Respiratory Competency

Question 1

What are the special landmarks/anatomy that you should look at when inspecting the chest/back during a lower respiratory exam?

Answer 1

Sternal angle (where 2nd rib meets the manubrium)Suprasternal notchXiphoid processScapulaThoracic vertebrae

Question 2

Where would you insert a chest tube after performing a needle decompression of a pneumothorax?

Answer 2

4th intercostal space at mid or anterior axillary line in the 4th intercostal space just superior to the margin of the 5th rib

Question 3

What level of the T spine is the lower margin of the endotracheal tube on a chest X-ray?

Answer 3

T4

Question 4

What is the landmark for thoracentesis?

Answer 4

7th intercostal space

Question 5

What can pursed lips while breathing indicate?

Answer 5

Obstructive lung disease (COPD)

Question 6

When assessing a patients posture and postion, what is indicative of obstructive lung disorders?

Answer 6

Sit leaning forward with shoulders elevated (tripod position)

Question 7

When inspecting the neck during a lower respiratory exam, what are you looking for?

Answer 7

Contraction of accessory muscles (sternomastoid, scalenes or supraclavicular retraction) -> could indicate pathology Tracheal position -> should be midline

Question 8

What are signs of clubbing of the fingernails?

Answer 8

• 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

Question 9

How should you assess thoracic expansion when performing a lower respiratory exam?

Answer 9

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

Question 10

How do you perform a tactile fremitus test?

Answer 10

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

Question 11

What are the 4 normal breath sounds?

Answer 11

Vesicular Bronchovesicular BronchialTracheal

Question 12

Explain vesicular breath sounds

Answer 12

Soft and low pitchedHeard through inspiration and about 1/3 of expiration Heard over most of lungs (parenchyma)

Question 13

Explain bronchovesicular sounds

Answer 13

Intermediate in intensity and pitchHeard equally in inspiration and expiration Heard best n 1st and 2nd interspaces anteriorly and between the scapulae

Question 14

Explain bronchial sounds

Answer 14

Loud and high pitched Heard equally in inspiration and expiration Heard best over trachea in neck

Question 15

If bronchovesicular or bronchial breath sounds are heard more distal to expected locations, what should you suspect?

Answer 15

Air-filled lung has been replaced by fluid-filled or solid lung tissue

Question 16

What might decreased breath sounds be due to?

Answer 16

Decreased airflow due to COPD or muscular weaknessPoor transmission of sound due to COPD, pleural effusion or pneumothorax

Question 17

What are the 5 adventitious breath sounds?

Answer 17

Crackles (Rales)WheezesRhonchiStridorPleural friction rub

Question 18

What do crackle (rales) lung sounds sound like?

Answer 18

Discontinuous, intermittent, nonmusical and brief

Question 19

What is the difference between fine crackle and coarse crackle lung sounds?

Answer 19

Fine crackles: soft, high-pitched and very brief (sometimes sounds like velcro)Coarse crackles: louder, lower in pitch, brief

Question 20

What do wheezes sound like?

Answer 20

Continuous, musical quality and prolonged (not necessarily the entire respiratory cycle)- Relatively high pitched, musical hissing and shrill quality

Question 21

What pathology does wheezing suggest?

Answer 21

Narrowed airways (asthma, COPD, bronchitis)

Question 22

What do Rhonchi lung sounds sound like?

Answer 22

Relatively low pitched, snoring quality- Suggest secretions in large airways

Question 23

What do stridor lung sounds sound like?

Answer 23

Wheeze that is entirely or predominatly inspiratory in natureOften louder in neck vs. chest wall

Question 24

What do stridor lung sounds indicate?

Answer 24

Partial obstruction of larynx or trachea -> medical emergency

Question 25

What does pleural friction rub sound like?

Answer 25

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

Question 26

When performing a tactile fremitus test, where do you expect to feel more prominent vibrations?

Answer 26

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

Question 27

What regions of the back do you percuss when examining the chest?

Answer 27

5 points bilaterally in interscapular regions

2 points bilaterally near midclavicular space just lateral to points 4 and 5

Question 28

What 2 pathologies might hyperresonance heard over hyperinflated lungs be indicative of?

Answer 28

COPD/emphysema

Asthma

Question 29

What might unilateral hyperresonance over the lungs be indicative of?

Answer 29

Large pneumothorax

Large air-filled bulla in lung

Question 30

How do you perform diaphragmatic excursion?

Answer 30

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)

Question 31

What is the normal excursion range?

Answer 31

3 to 5.5cm

Question 32

What is dullness at a level higher than expected when performing diaphragmatic excursion suggestive of?

Answer 32

A pleural effusion or a high diaphragm (as in atelectasis or phrenic nerve paralysis)

Question 33

Define bronchophony

Answer 33

Spoken words become louder and clearer (indicates consolidation) when pt says 99 which lightening to the lungs

Question 34

When performing tests using transmitted voice sounds, what do you expect as normal when a pt says 99 while you listen to the lungs?

Answer 34

Normally sounds transmitted through healthy lungs are muffled and indistinct

Question 35

Define egophony

Answer 35

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

Question 36

When performing tests using transmitted voice sounds, what do you expect as normal when a pt says “ee” while you listen to the lungs?

Answer 36

normally you will hear a muffled long E sound

Question 37

Define whispered pectoriloquy

Answer 37

Whispers are heard louder and clearer during auscultation

Question 38

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?

Answer 38

normally a whispered voices is faint and indistinct or not heard at all