Lower Respiratory Exam Flashcards
Midsternal Line & Midclavicular Line
Midsternal - drops from suprasternal notch
Midclavicular - drops vertically from midpoint to clavicle
Landmarks
Sternal angle (angle of Louis) where 2nd rib meets with the the manubrium and the body of sternum Suprasternal notch Xiphoid process Scapula Thoracic vertebrae
Needle Decompression
2nd ICS just superior to the 3rd rib margin at midclavicular line
Emergent decompression tension pneumothorax, followed by chest tube placement
Chest Tube Insertion
4th ICS at mid or anterior axillary line
T4
Lower margin of endotrachial tube on a chest X-Ray
7th ICS
Landmark for thoracentesis
Evaluation of Respiration
Healthy resting adult breathes quietly and regularly 14-20 bpm
Assess for quality of movement: asymmetry, intercostal retractions
Assess patients for cyanosis (hypoxia)
Listen to breathing (audible wheezing)
Look for pursed lips while breathing (obstructive lung disease)
Patient’s posture and position (obstructive lung disease = sit leaning forward with shoulders elevated)
Inspections of neck
- contraction of accessory muscles (sternomastoid, scalenes, supraclavicular retraction)
- tracheal position - should be midline (lateral displacement can occur in tension pneumothorax)
Clubbing of Fingernails
Bulbous swelling of soft tissue at nail base
Loss of normal angle between nail and proximal nail fold (>180 degrees)
Spongy or floating feeling
Vasodilation, changes in connective tissue, inner action or platelet-derived growth factor from fragments of platelet clumps
Seen in:
- congenital heart disease
- interstitial lung disease
- lung cancer
- cystic fibrosis
Thoracic Expansion
Place thumbs at about level of 10th rib
Fingers loosely grasping and parallel to lateral rib cage
Patient inhales deeply
Watch distance between thumbs as they move apart during inspiration
Feel for range and symmetry of rib cage as it expands and contracts
Tactile Fremitus
Palpable vibrations transmitted through bronchopulmonary tree to chest wall
Patient speaks “ninety-nine” or “one-one-one”
More prominent in inter scapular area than lower lung fields
More prominent on right than left
Disappears below diaphragm
Decreased/Absent = COPD, pleural effusions, fibrosis, pneumothorax, infiltrating tumor Increased = pneumonia (increased transmission through consolidated tissue)
Percussion Notes
Flat
- soft intensity
- high pitch
- short duration
- ex: thigh
Dull
- medium intensity
- medium pitch
- medium duration
- ex: liver
Resonant
- loud intensity
- low pitch
- long duration
- ex: healthy lung
Hyperresonant
- very loud intensity
- lower pitch
- longer duration
- ex: usually none (COPD)
Tympanitic
- loud intensity
- high pitch
- longer duration
- ex: gastric air bubble or puffed-out cheeck
Dullness
Replaces resonance when fluid or solid tissue replaces air-containing lung or occupies space beneath per cussing fingers
Lobar pneumonia (alveoli filled with fluid and blood cells)
Pleural accumulations
- effusion (serous fluid)
- hemothorax (blood) - treatment with chest tube
- empyema (pus)
- fibrous tissue or tumor
Hyperresonance
Generalized: Hyperinflated lungs
- COPD
- Asthma
Unilateral
- large pneumothorax
- large air-filled bulla in lung
Diaphragmatic Excursion
Determine distance between level of dullness on full inspiration and level of dullness on full expiration by progressive percussion down from resonance (lung parenchyma) to dullness (structures below diaphragm)
Normal = 3-5.5 cm
Vesicular Breath Sounds
Soft and low pitched
Heard through inspiration and about 1/3 of expiration
Heard over most of lungs (parenchyma)
Bronchovesicular Breath Sounds
Intermediate in intensity and pitch
Heard equally in inspiration and expiration
Head best in 1st and 2nd ICS anteriorly and between scapulae
At bifurcation
Bronchial Breath Sounds
Load and high pitch
Expiration sounds heard longer than inspiratory
Head best over manubrium (larger proximal airways)
Tracheal Breath Sounds
Very loud and high pitched
Heard equally in inspiration and expiration
Heard best over trachea in neck
Crackles (Rales)
Discontinuous
Intermittent
Nonmusical
Brief
Fine crackles = soft, high-pitched, very brief (5-10 msec)
Coarse crackles = louder, lower in pitch, brief (20-30 msec)
Wheezes and Rhonchi
Continuous
Musical quality
Prolonged
Wheezes = relatively high pitched, musical, hissing or shrill quality
- narrowed airway (asthma, COPD, bronchitis)
Rhonchi = relatively low-pitched, snoring quality
- secretions in large airways
Stridor
Wheeze that is entirely or predominantly inspiratory in nature
Often louder in neck vs. chest wall
Indicates partial obstruction of larynx or trachea (immediate attention)
Pleural Friction Rub
Inflamed and roughened pleural surfaces grate against each other
Sounds like creaking, usually during expiration but can occur during both phases
Usually confined to a relatively small area of the chest wall
Bronchophony
Spoken words become louder and clearer
Normal = muffled and indistinct
Egophony
“ee” sounds like “A” - nasal bleating quality, localized
Normal = muffled long E sound
Whispered Pectoriloquy
Whispers heard louder and clearly during auscultation
Normal = fain and indistinct or not heart at all
Acute Cough
3 weeks
Upper respiratory, viral
Subacute Cough
3-8 weeks
Post infection
Chronic Cough
> 8 weeks
Low grade infection
Post nasal drainage
Cough more in morning
Traumatic Flail Chest
Broken several ribs
Paradoxical motion: inhale - goes out, exhale - goes in
Potential collapsed lung
Pectus Excavatum
Funnel Chest
Most common bony structure abnormality of chest wall
Prone to progressive dypsnea
Exercise intolerance
Pectus Carinatum
Pigeon Chest
Dyspnea
Exercise intolerance
Anterior/Posterior/Midaxillary Line
Drops vertically from anterior and posterior axillary folds
Midaxillary line drops from the apex of the axilla
