Lower Respiratory Exam Flashcards
What can tracheal deviation indicate?
pneumothorax
pleural effusion
atelactasis
mass
What is a tracheal sound?
very loud and high pitched
heard equally over inspiration and expiration
heard best over trachea in neck
What is a bronchovesicular sound?
intermediate, equally in inspiration and expiration
heard best in 1st and 2nd interspaces anteriorly and btw scapulae
What does decreased/absent fremitus suggest?
COPD
pleural changes = effusions, fibrosis, air (pneumothorax), tumor
What is the pneumonic to remember for Adequacy of chest x ray?
PIER position - AP/lateral? Inspiration - should see 10-11 ribs Exposure Rotation
What can cause falsely normal or elevated oximetry reading? (4)
carboxyhemoglobin (CO poisoning)
high A1c
methemoglobin, sulfhemoglobin
ambient light
What do you palpate for on a lower thoracic exam?
areas of tenderness abnormalities in overlying skin rib motion (inhalation vs exhalation dysfunctions) thoracic expansion tactile fremitus
Where do you do needle thoracentesis?
2nd intercostal space midclavicular line (removing air) superior margin of rib
Where does the neurovascular bundle run?
along inferior margins of each rib
How do you use an incentive spirometer?
move slider to level that you want to reach
breathe out normally then put mouth on mouthpiece
take a slow deep breath in –> piston will move up as you breath in
when you can’t breath in anymore, hold your breath for 2-5 sec
How do you evaluate thoracic expansion?
place thumbs at about 10th ribs and wrap hands around
ask pt to inhale deeply –> watch distance btw thumbs as they move apart and feel for range and symmetry of rib cage
Where do you do chest tube insertion?
4th and 5th intercostal space
just anterior to the mid-axillary line (mid clavicular?)
superior margin of rib
What do pursed lips while breathing indicate?
an obstructive dx (COPD)
What does a tympanic percussion suggest?
thick abdominal percussion
What is dyspnea?
feeling short of breath
What is a vesicular sound?
soft and low pitched
heard thru inspiration and abt 1/3 of expiration
heard over most of lungs (parenchyma)
What are the pleximeter and plexor fingers?
pleximeter = hyperextended middle finger of non-dominant hand in percussion plexor = tapping finger
How should the patient be posed during chest percussion?
seated with hands crossed in front of chest, holding opposite shoulders w hands
What is traumatic flail chest?
multiple rib fractures may result in paradoxical mvnt of the thorax
on inspiration, injured area caves inward and moves out on expiration
What is a pink puffer?
seen in emphysema/COPD older and thin severe dyspnea quiet chest hyperinflation with flattened diaphragms
What is whispered pectoriloquy?
Pt whispers 99 or 123
normal = faint and indistinct or not heard at all
pectoriloquy = whispers are heard louder and clearer during auscultation
What type of percussion note does a healthy lung have?
resonant
What does stridor indicate?
partial obstruction of larynx or trachea
What can cause a bad pulse oximetry waveform?
improper placement
hypoperfusion
hypothermia
motion artifact
What accessory muscles for breathing are located in the neck?
scalenes
trapezius
sternomastoid
How many spots do you auscultate the chest?
2 spots anterior
4 spots posterior
What do wheezes indicate?
narrowed airways (asthma, COPD, bronchitis, heart failure)
What do crackles/rales indicate?
in dependent portions = after prolonged recumbency
also seen in pneumonia, fibrosis, early heart failure, bronchitis, bronchiectasis
What does increased fremitus suggest?
pneumonia - increased transmission thru consolidated tissue
What are the adventitious breath sounds to know?
crackles/rales wheezes rhonchi stridor pleural friction rub
What are rhonchi?
relatively low-pitched, snoring quality
What is bronchophony?
spoken words become louder and clearer = indicates consolidation
when patient says 99
How does pulse oximetry work?
oxygenated hemoglobin absorbs infrared light and allows red light to pass
deoxygenated Hgb is the opposite = absorbs red light and allows infrared to pass
% sat = red / red + blue
What is a normal diaphragmatic excursion?
What does asymmetry mean?
normal = 3-5.5 cm asymmetry = pleural effusion or high diaphragm from atelactasis or phrenic nerve paralysis
What is pectus excavatum?
funnel chest
What are the 4 major vital signs?
what is the 5th you should always get for respiratory cases?
RR, HR, BP, temp
5th = oxygen saturation
What is end tidal CO2?
concentration of CO2 in exhaled air at the end of respiration
expressed as partial pressure in mm Hg (PETCO2)
normal PETCO2 = 35-40 mmHg
normal PaCO2 = 35-45 mmHg
What is the difference btw hypoxia and hypoxemia?
hypoxia = deficiency in the amt of O2 reaching the tissues hypoxemia = low O2 in arterial blood
What is a normal cardiac size on chest x ray?
<50% of chest diameter of PA films and <60% of AP films
What are the ABCs for chest x ray interpretation? (A thru I)
Adequate/assessment Airway Bones and soft tissue Cardiac size, valves Diaphragm Effusions/endotracheal tube Fields and fissures Foreign body Great vessels Gastric bubble Hilar masses Impression
What has occurred if dullness replaces resonance upon percussion?
fluid or solid tissue replaces air-containing lung
pleural accumulations
empyema (pus)
fibrous tissue or tumor
What is hypopnea?
decreased depth and rate of respiration
What is atelactasis?
collapse of lung tissue that affects alveoli from normal O2 absorption
What is pectus carinatum?
pigeon chest
How do you perform diaphragmatic excursion?
- Pt exhales and holds it
- Percuss for spot where resonant lung tissue and dullness of structures below meet = diaphragm
- mark w/ a pen
- Pt breathes a few normal breaths
- Pt inhales completely and holds it
- Percuss for level of diaphragm
distance btw 2 = diaphragmatic excursion
What is cyanosis a sign of?
hypoxia
see in nails and lips (perioral)
What is hyperpnea?
increased depth of breathing and rate of respiration (normal in exercise)
Where is the lower margin of an endotracheal tube on xray?
T4
How do you perform tactile fremitus?
perform on anterior and posterior chest
use ball or ulnar surface of hands
pt says ninety-nine or one-one-one
often more prominent in interscapular area than in lower lung fields, more prominent on right than left
What is bradypnea?
regular rhythm but slow rate <14/min
What does accessory muscle use in breathing indicate?
sign of respiratory distress
can see in asthma, COPD, airway obstruction, viral illness (RSV)
What is a bronchial sound?
loud and high pitched
expiratory sounds heard longer than inspiratory
heard best over manubrium
What physical findings will you see with atelectasis?
decreased breath sounds
diaphragmatic excursion
tracheal deviation
What is a normal breathing rate?
14-20/min
What is a thoracentesis and where do you perform it?
insertion of a needle to remove fluid from pleural space
insert at 7th intercostal space
What can cause decreased breath sounds?
decreased air flow (COPD, muscular weakness)
poor transmission of sound (COPD, pleural effusion, pneumothorax)
What is tachypnea?
rapid breathing
>20-25/min
What is egophony?
when pt says ee –> hear A, sounds nasal and bleating, should be localized
triples likelihood of pneumonia if pt has fever and cough
What is considered chronic bronchitis?
daily productive cough for 3 months or more, in at least 2 consecutive years
What are the causes of fingernail clubbing? (8)
congenital heart disease interstitial lung disease bronchiectasis pulmonary fibrosis cystic fibrosis lung abscess/mass malignancy inflammatory bowel disease
What do rhonchi suggest?
secretions in large airways
What do you suspect if bronchovesicular or bronchial sounds are hear more distal than expected?
suspect fluid or solid lung tissue (abnormal)
What is a blue bloater?
chronic bronchitis from smoking overweight and cyanotic elevated hemoglobin peripheral edema rhonchi and wheezing
What are normal breath sounds?
bronchial
Bronchovesicular
vesicular
tracheal
What has occurred if there is hyperressonance upon chest percussion?
bilateral: heard over hyperinflated lungs (COPD, asthma)
unilateral: large pneumothorax, large air-filled bulla in lung (COPD)
