Lungs Flashcards
Which ribs articulate with the sternum?
1-7
Which ribs articulate with the costal cartilage above belonging to the ribs?
8-10
Which ribs are considered false ribs?
11-12
What is the typical starting point for counting ribs?
12th rib
Which rib is located at the inferior tip of the scapula?
7th
Where is the spinous process most prominent in?
C7/T1
What is the pleura
Continuous or Serous Membranes which separate the lobes from the chest wall
What is the difference between the parietal and visceral pleura?
The visceral pleura covers the lung and does not have nerve fibers. The parietal pleura has nerve fibers this is why some pathologies have pain and others may not.
Pleural effusion transudative
CHF, Cirrhosis, Nephrotic Syndrome
Pleural effusion exudative
PNA, Malignancy, PE, TB, Pancreatitis
What is the primary muscle of breathing?
diaphragm
What are the accessory muscles involved with breathing?
scalenes
cervical to ribs 1-2
Parasternals – Sternum to Ribs
What are the red flag symptoms of the lungs?
Shortness of Breath/Wheezing
Cough– Productive vs Nonproductive
Hemoptysis
Chest Pain
Daytime sleepiness, Snoring, Disordered sleep
What are DDX of dyspnea?
Left HF
Chronic bronchitis
COPD
Asthma
diffuse interstitial lung disease
PNA
Spontaneous PTX
Acute PF
Anxiety with hyperventilation
What is a cough
Reflex to irritating stimulant in larynx, trachea, or large bronchi
Mucous, pus, blood vs allergens, dust, FB, extreme hot/cold air
Inflammatory changes respiratory mucosa, PNA, pulmonary edema, compression of bronchi from tumor or enlarged nodes
Cardiogenic –Left HF
Duration of cough is key, what are the classifications
- acute < 3 weeks
- subacute 3-8 weeks
- chronic > 8 weeks
Mucoid vs Purulent cough
mucoid- transparent, white, grey
purulent- bacterial pneumonia
What is hemoptyisis?
-Blood coughed up in lower respiratory tract
-Quantify amount, timing, associated activity
-Rare in infants-teens
-Must confirm its cause- Pulmonary, GI, Trauma
GI- usually darker
What is the etiology of Hemoptysis
- bronchitis
- malignancy
- cystic fibrosis
- PE
Quantity of massive hemoptysis
500cc/24 or > 100/hr
Lung has NO ___________
pain fibers
Anxiety in _____ of 4 pts
1
Red Flags for potential cardiac etiology
Exertional CP
Palpitations
Orthopnea
Paroxysmal Nocturnal Dyspnea
Edema
What are differential DX of CP?
Extrapulmonary Etiology:
GERD
Anxiety
MSK
Isolating one spot with a finger- MSK etiology
Radiating pain from epigastrium to throat- GI
What is the source of CP?
Myocardium –
Pericardium
Aorta
Trachea / Large Bronchi
Parietal Pleura
Chest Wall
Esophagus
Extrapleural
Angina, MI, Myocarditis
Pericarditis
Aortic Dissection
Bronchitis
Pericarditis, PNA, PTX, Pleural Effusion, PE, Connective Tissue
Costochrondritis, Herpes Zoster, CW contusion, Rib Fx
GERD, Esophageal spasm, Esophageal tear
Cervical arthritis, Biliary Colic, Gastritis
What is apnea
Breathing cessation > 10 seconds
Awakening with choking sensation
Morning HA
What are questions you want to ask pts if you suspect obstructive sleep apnea?
- daytime sleepiness/fatigue
- snoring problems
- apnea
What are risk factors of obstructive sleep apnea?
Obesity
Posterior malocclusion of jaw
HTN
HF
Afib
CVA
T2DM
Mechanisms of instability of brain stem
Disordered contraction of neck musculature
Disordered sleep arousal
What is the tripod positon?
Physical stance often assumed by people experiencing respiratory distress or who are simply out of breath. In this position, a person sits or stands leaning forward and supports the upper body with hands on knees or other surface.
What are you generally assessing with a pt that could have respiratory issues?
Cyanosis (Hypoxia)
Pale Skin (Anemia)
Extrapulmonary – Clubbing
What are the basics of the PE?
Sitting and Supine
Chest wall symmetry with inspiration
Percussion of Lung Fields
Palpating for tenderness
Auscultation of Adventitious Breath Sounds
Be on the lookout for symptoms right heart failure:
JVD, Peripheral Edema, Accentuated pulmonic component of 2nd heart sound, S3-4 gallops, Valvular disorders
Observe abdominal wall for inward movement during inspiration- diaphragm weakness
What are the steps to the PE?
- Survey Respiration
Rate, Rhythm, Depth, Effort including signs of distress - Examine and Inspect A/P Chest:
Inspect chest – deformities, muscle retraction, Ecchymosis, Rash/lesion - Palpate Chest- Tenderness, Respiratory Expansion, Fremitus
5.Percuss the Chest
Flat, dull, resonant, hyperresonance, tympanic
- Auscultate the chest
Breath sounds, presence, Adventitious sounds, transmitted voice sounds
What is tachypnea and what are the causes?
Rapid Shallow Breathing
Causes
Salicylate Intoxication
Restrictive Lung Disease
Pleuritic Chest pain
Pain
Elevated Hemidiaphragm
What is hyperpnea and what are the causes?
– rapid deep breathing
Causes: Metabolic demands
Increase exercise, high altitude, sepsis, anemia
What is hyperventilation?
Independent of metabolic demands except Resp Acidosis
C/o lightheadedness, dizziness
Decreased CO2
When does Kussmaul breathing occur with and what is the rate?
SYSTEMIC ACIDOSIS— Rate- fast or slow
What is bradypnea?
Slow breathing with or without tidal volume
Respiratory Depression
Increased ICP
What is cheyne?
strokes of breathing
Periods of deep breathing alternated with periods of apnea
Normal in children and older adults during sleep
What are the causes of cheyne?
Heart Failure
Uremia
Drug – Resp Depression
TBI
What is ataxic breathing (biot) and what are the causes of it?
Irregular Breathing- periods of apnea alternate with deep breaths which stop suddenly for short intervals
Causes
-Meningitis
-Resp Desppression
-TBI
What is sighing respiration?
Breathing punctuated by frequent sighs
Hyperventilation Syndrome
Common cause of dizziness, dyspnea
What is obstructive respiration and what are its cuases?
Obstructive Lung Disease
Expiration is prolonged due to narrowed airways and resistance to air flow
Cause
Asthma
Chronic Bronchitis
COPD
Delayed expiratory effort=
COPD
What are audible signs of breathing?
Stridor
Wheeze
What are signs of distress
Tachypnea (>25 bpm)
Cyanosis vs Pallor +/- Diaphoresis
Nail shape/color
What are we looking for when observing chest shape
Normal: Width > Depth
AP : Lateral diameter -> 0.7-0.9
Increase with age
Barrel Chest
Increased AP Diameter
Normal during infancy
Seen in aging and COPD
Funnel chest
Pectus Excavatum
Depression in lower portion of sternum
If Heart or GV compressed may cause murmur
Pigeon Chest
Pectus Carinatum
Sternum displaced anterior > Increased AP Diameter
Costocartilage adjacent to sternum are depressed
Flail chest
Traumatic
Multiple Successive Rib Fractures
Paradoxical movements of the thorax
Injured area caves inward during inspiration
-Expiration – Outward
Thoracic Kyphoscoliosis
Abnormal Spinal Curvatures and Vertebral Rotation deform the chest
Lung exam may be difficult to interpret
When palpating the chest wall, what are areas that you want to focus on?
tenderness and ecchymosis
What is crepitus?
-Chest wall
PTX, Mediastinitis
-Bones/Joints
Arthritis
+/- Pain
What are masses or sinus tracts suggestive of?
(rare)
suggestive of infection of underlying pleura
Where do you want to place your thumbs when doing chest wall expansion?
10th rib- fingers loosely grabbing anf parallel to ribacage
What is tactile fremitus?
Palpable vibrations that are transmitted through bronchial tree to chest wall as pt is speaking (NORMAL- Symmetric)
Where is tactile fremitus more prominent over?
Interscapular areas > lower lung
right > left
What is Asymmetric DECREASED fremitus (air or fluid in pleural space or decreased lung density)
indicative of?
Effusion, PTX, COPD, Asthma
What is asymmetric INCREASED fremitus (Density in pleural space or lung tissue) indicative of?
unilateral PNA
What are causes of decreased fremitus?
excess air in lungs and increased thickness of chest wall
What are causes of increased fremitus?
lung consolidation
air in healthy lung replaced with something else (inflammatory exudate, blood, pus, cells)
Percussion only penetrates _______ to _____ cm into the tissue
5-7
What are the 5 percussion notes?
flat, dull, resonant, hyperesonant, tympanic
Pathology of a flat percussion
large pleural effusion
Pathology of a dull percussion
lobar PNA
Pathology of a resonant percussion
simple chronic bronchitis
Pathology of a hyperresonant percussion
COPD, PTX
Pathology of a tympanic percussion
Large PTX
When is a diaphragmatic excursion abnormal?
if the pt has Pleural Effusion, Elevated Hemidiaphragm from ATX or phrenic nerve paralysis
What is the goal of diaphragmatic excursion?
to ID boundary between lung and duller structures below diaphragm- NOT percussing diaphragm itself
If when doing auscultation there is abnormal sounds even when doing the whispered voice test, what do you instruct the pt to do?
cough
Vesicular breath sounds
heard over both lungs
Soft and low pitched; Inspiration-> Exp; I > E
Bronchovesicular breath sounds
First and Second Interspace Ant/Interscapula
I=E length +/- silent interval; Differences in pitch heard during expiration
Bronchial breath sound
Manubirum
Loud, Harsh, High Pitched; short silence between I/E ; E>I
Tracheal –Neck/Trachea breath sounds
Stridor heard over neck vs wheeze which radiates from lung fields
What are adventitious lung sounds?
Added sounds – Superimposed on normal breath sounds
What are some examples of adventitious lung sounds?
- Crackles (Rales)
Abnormalities of the parenchyma- PNA, Interstitial disease, ATX, Heart Failure
Airways- Bronchitis, Bronchiectasis - Wheeze
Narrowed airway– Asthma, COPD, bronchitis - Rhonchi
Often described sounds from secretions in large airways– change with cough - Pleural Friction Rubs
Course, heard during expiration
Pleurisy, PNA, PE
Crackles/Rales vs wheeze/Rhinchi
Crackles/rales
Discontinuous
Intermittent, brief, NON-musical
DOTS in time
Small distal airway- “POP” open during inspiration
Fine vs Coarse Crackles
Wheeze/Ronchi
Continuous
Musical, prolonged
DASHES in time
Wheeze- high-pitched with hissing/shrill
Rhonchi- Low-pitched with snoring quality
During wheezing/rhonchi a patient may have a silent chest. What does this mean?
pt not moving air, you cant hear anything.Need to do intervention to open it up.
Dull sound left parasternal, 3-5th ICS =
heart
Assessment of pulmonary function
6 min walk test- predict outcomes in COPD
100ft hallway
global eval of pts pulm, cardiac neuromuscular status
PFTs- Forced Expiratory Time
Expiratory Phase: slowed in obstructive disease
Take deep breath in and breath out as quickly and completely with OPEN mouth
Listen over trachea and document expiratory phase time
Record 3 readings
What is the 2nd most dx cancer in the US, leading cause of CA death?
Lung CA, for men and women
Incidence and death rates for lung CA decrease with ________
smoking cessation
What are the risks for Lung CA
Smoking, radon, environmental exposures such as asbestos, diesel exhaust, heavy metals, organic chemicals, radiation, air pollution + Family hx esp if dx at young age
Screening for Lung CA
Early stage (confined to lung) 56% 5 year survival
16% of dx
Screen with CT Chest for those with risks
Current smoker or quit within 15 years
Smoked 1ppd 30 years (age 55-80)
Family hx of lung CA
Counsel on risks of screening
Smoking Cessation
T/F latent TB has no symptoms and is not contagious
TRUE
T/B without treatment, TB can convert to active TB
TRUE
What are risks for TB?
Countries with high TB prevalence, homeless shelters, prisons
What is the screening for TB
Tuberculin Skin Test and IGRA blood test
+ Indurated areas measured vs blood sample
What is OSA
Repeated episodes of upper airway collapse during REM sleep leading to hypoxia and disrupted sleep
Symptoms of OSA
Daytime sleepiness Significant Risk
Loud snoring
Choking, gasping during sleep
What is the common age range for people to be diagnosed with OSA
30-70, 15% men and 5% women
What are the risk factors for OSA
Obesity, Male, Age, Craniofacial/upper airway abnormalities, post menopausal
What tests are performed to diagnose OSA
sleep studies
What is the severity of OSA based on?
episodes and time spent with breathing flow reduction + desaturation or sleep arousal)
How does one manage OSA?
CPAP/BiPAP
Wt loss- Bariatric Surgery
Airway surgery
Stop BANG: OSA
S: Snore Loudly
T: Do you feel tired, fatigued, during day
O: Observed you stop breathing during day
P: Treated for high blood PRESSURE
BMI> 35kg/m2
Age .> 50
Neck Circumference > 40cm
Gender- Male
