OHCEPS - Respiratory System Flashcards
1
Q
Lower respiratory tract?
A
Larynx and below.
2
Q
Trachea divides to left and right main bronchi - where?
A
At the “carina” level with the sternal angle.
3
Q
Further divisions before reaching alveoli - number?
A
About 25.
4
Q
Bronchioles?
A
Last 16 orders are termed bronchioles:
- No cartilage
- Fewer goblet cells
- Progressively less muscular walls
5
Q
Anterior chest exam - which lobes?
A
Upper and middle (right) - lower lobes from behind.
6
Q
Horizontal fissure?
A
Separates upper from middle lobe (right).
Corresponds to 4th and 6th ribs anteriorly - EASILY MISSED.
7
Q
Inferior border of the lung - anteriorly/posteriorly?
A
Anteriorly –> 6th rib.
Posteriorly –> 12th rib.
8
Q
Mechanism of cough?
A
Cough receptors in the pharynx and lower airways initiate mechanisms resulting in deep inspiration followed by expiration against a closed glottis and a sudden glottal opening –> rapid, forceful expulsion of air which we know as a cough.
9
Q
Dyspnea - what is it?
A
Shortness of breath - the sensation that one has to use an abnormal amount of effort in breathing.
Patients say –> “breathlessness”, “inability to get their breath”, “shortwinded”, “tightness” (may actually mean asthma, or may be chest pain).
10
Q
Pleuritic pain and dyspnea?
A
Pleuritic pain is worse at the height of deep inspiration –> patients may say they are NOT ABLE TO GET MY BREATH.
11
Q
Dyspnea - Sudden onset?
A
- Pulmonary embolus
- Pneumothorax
- Asthmatic attacks
12
Q
Dyspnea - onset over days/weeks?
A
- Pneumonia
- HF
- Anemia
13
Q
Dyspnea - severity?
A
Quantify by asking “How many flight of stairs?” etc.
BE SURE that activities are restricted by shortness of breath (SOB) as opposed to arthritic hips, knees, chest pain, or some other ailment.
14
Q
Hyperventilation syndrome?
A
Decr. in blood CO2 will cause paresthesia in the lips and fingers along with light headedness and, in severe cases, tetany.
15
Q
Cough may be the ONLY symptom of what?
A
Childhood asthma.
16
Q
Chronic cough - def?
A
Lasting >3weeks.
17
Q
Chronic cough - etiology?
A
- Asthma
- Carcinoma
- Interstitial disease
- Bronchiectasis
- GERD
- Post-nasal drip
- Smokers - particularly in the morning.
18
Q
Character of cough - cough with a hoarse voice?
A
Laryngitis
19
Q
Character of cough - dry and painful?
A
Tracheitis
20
Q
Character of cough - sharp pain (chest wall)?
A
Pleurisy
21
Q
Character of cough - tickly?
A
Post-nasal drip.
22
Q
Character of cough - chronic, paroxysmal, worse after exercise and at night?
A
Asthma
23
Q
Character of cough - dry and nauseating. Often first thing in the morning.
A
GERD
24
Q
Character of cough - nauseating and worse after eating?
A
Tracheo-esophageal fistula (rare).
25
Character of cough - "barking"?
Epiglottitis
26
Character of cough - "bovine" hollow, brassy?
Laryngeal nerve palsy.
27
Character of cough - productive and worse on lying flat?
LHF.
28
Cough - NON pulmonary etiology?
1. Post-nasal drip
2. GERD
3. Pharyngeal pouch or tracheo-esophageal pouch
4. ACE inhibitors
29
Sputum - features to clarify?
1. How often?
2. How much?
3. How difficult is to cough up?
4. Colour?
5. Consistency?
6. Smell?
30
Green-colored sputum may ALSO be what?
Eosinophils in the sputum of asthmatics.
31
Miniature tree-like bronchial casts (sputum)?
Bronchopulmonary aspergillosis
32
Hemoptysis - must clarify?
1. Amount
2. Color
3. Frequency
4. Nature of any associated sputum
5. Easily CONFUSED with blood originating in the nose, mouth, and GI tract (hematemesis)
33
Massive hemoptysis?
>500mL in 24hr.
34
Hemoptysis - etiology?
1. Bronchitis
2. Carcinoma
3. Pulmonary embolus
4. Infarction
5. TB
6. CF
7. Lung abscesses
35
Infectious causes of hemoptysis?
Usually produce blood-stained SPUTUM as opposed to pure hemoptysis.
36
Hemoptysis - be alert for what?
```
Other potential sites of bleeding:
1. Skin
2. GI tract
3. Mouth
which could point to a coagulation disorder.
```
37
White/grey sputum?
Asthma - smoking.
38
Green/yellow sputum?
1. Bronchitis
| 2. Bronchiectasis
39
Green and offensive sputum?
1. Bronchiectasis
| 2. Abscesses
40
Sticky/rusty sputum?
Lobar pneumonia
41
Frothy/pink sputum?
CHF
42
Separates to 3 layers sputum?
SEVERE bronchiectasis --> mucoid, watery, rusty.
43
Very sticky, often green sputum?
Asthma
44
Sticky, with plugs?
Allergic aspergillosis (complication of asthma).
45
Wheeze - what is it?
High-pitched whistling "musical" sound produced by narrowing of airways, large or small.
46
Wheeze - when?
On inspiration + expiration - usually more prominent in EXpiration.
47
Wheeze due to small airway narrowing - as in asthma?
Will be accompanied by a prolonged expiratory phase.
48
Wheeze - etiology?
1. Asthma
2. Smoking related lung disease
3. Mucosal edema
4. Airway obstruction
5. Airway collapse
6. Pulmonary edema ('cardiac asthma')
49
Stridor?
A harsh "crowing" inspiratory + expiratory sound with a CONSTANT pitch.
50
Stridor - cause?
LARGE airway narrowing usually at the LARYNX/TRACHEA.
| Can precede complete airway obstruction so is treated as a medical emergency.
51
Pleuritic pain - features?
1. Arises from the pleura or mediastinum - LUNGS DO NOT HAVE PAIN FIBERS.
2. Severe, sharp pain at the height of inspiration OR on coughing.
3. Usually localized to a small area of chest
4. Patient will avoid DEEP BREATHING and may complain of breathlessness.
52
Pain from lung parenchymal lesions?
May be dull and constant - usually a sign of direct spread into the chest wall.
53
Pain of tracheitis - features?
1. Poorly localized
| 2. Central soreness
54
Diaphragmatic pain - radiation?
To the IPSIlateral shoulder tip - pain from the costal parts of the diaphragm --> may be referred to the abdomen.
55
Common cause of pleuritis pain?
Costochondritis - Tietze's syndrome is a specific cause --> pain+swelling of the superior costal cartilages.
56
Pain in a nerve-root distribution may be what?
1. Spinal lesions
| 2. Herpes zoster
57
Rest of history - fever at night?
1. Infection - TB
2. Malignancy
3. Connective tissue disorder
58
Rest of history - weight loss?
1. Carcinoma
2. Chronic lung disease
3. Chronic infection
59
Rest of history - PMH?
1. Vaccinations for resp. illnesses - BCG.
2. Previous infection - particularly TB before 1950.
3. X-ray abnormalities
4. Childhood - "chesty child" --> undiagnosed asthma.
5. Previous respiratory high dependency or ITU admissions and NIV.
60
Rest of history - DHx?
1. What inhalers and how often? Check inhaler technique.
2. Previous successful use of bronchodilators and steroids.
3. Oral steroid therapy predisposes to infection - especially TB.
4. β-blockers may exacerbate obstructive lung diseases.
5. ACE inhibitors cause a dry cough.
6. If O2 therapy - cylinders or concentrator? How many hours a day?
7. Illicit drug use - COCAINE is associated with respiratory disease.
61
Rest of history - FHx?
1. Asthma, eczema, allergies
2. Inherited conditions - CF, AAT def.
3. Family contacts with TB.
62
Rest of history - SHx?
1. Pets
2. Travel
3. Occupation - asbestos, coal, cotton, NO2, metals.
63
General appearance - Bedside clues?
1. Inhalers? Which ones?
2. Any additional inhaler devices? (aerochamber)
3. Nebulizer?
4. Is the patient receiving O2 therapy? What method? How much?
5. Sputum pot? Sputum-laden tissues?
6. Remember to inspect the sputum and record findings.
7. Any mobility aids nearby?
8. Look for cigarettes, lighter, or matches at the bedside or in a pocket.
64
Hands, face, and neck (HFN) - Temperature - cold fingers?
Indicate peripheral vasoconstriction or HF.
65
HFN - temperature - warm hands?
Dilated veins are seen in CO2 retention.
66
HFN - Staining of the fingers?
With tar --> appear yellow/brown where the cigarette is held --> NICOTINE IS COLORLESS and does NOT stain.
NOT an accurate indicator of the numbers of cigarettes smoked.
67
HFN - Cyanosis?
Bluish tinge to the skin, mucous membranes and nails evident when >2.5g/dL of reduced Hb is present (O2 sat about 85%).
68
Central cyanosis - etiology?
1. Severe lung disease
2. Pneumonia
3. COPD
4. PE
69
Peripheral cyanosis - etiology?
1. Peripheral vascular disease
| 2. Vasoconstriction
70
HFN - Clubbing - respiratory causes?
1. Carcinoma
2. Asbestosis
3. Fibrosing alveolitis
4. Chronic sepsis (bronchiectasis, abscess, empyema, CF)
71
HFN - pulse?
Rate, rhythm, character --> Tachycardic "bounding" pulse = CO2 retention.
72
HFN - Fine tremor - etiology?
Use of β-agonist drugs (e.g., salbutamol).
73
HFN - Flapping tremor (asterixis) - features?
1. Flapping when holding the hands dorsiflexed with the fingers abducted.
2. Identical to the flap of hepatic failure.
3. LATE SIGN OF CO2 RETENTION.
74
HFN - BP?
Pulsus paradoxus:
1. Pericardiac effusion
2. Severe asthma
75
HFN - JVP - Etiology?
1. Pulm. vasoconstriction - PHTN
2. RHF
3. SVC obstruction + distended upper chest wall veins, facial and conjunctival edema (chemosis).
76
HFN - Nose exam?
1. Examine inside and out.
2. Looking for polyp (asthma)
3. Deviated septum
4. Lupus pernio (red/purple nasal swelling of sarcoid granuloma)
77
HFN - Eyes exam - conjunctiva?
Evidence of anemia?
78
HFN - Eyes - Horner?
1. Tumor
2. Sarco
3. Fibrosis
79
HFN - Eyes - Iritis?
1. TB
| 2. Sarco
80
HFN - Eyes - conjunctivitis?
1. TB
| 2. Sarco
81
HFN - Eyes - Retina?
1. Papilloedema in CO2 retention or cerebral metastases.
2. Retinal tubercles in TB.
3. Choroiditis in TB or syphilis.
82
HFN - Lymph nodes?
Especially examine anterior/posterior triangles + supraclavicular areas.
Don't forget the axilla - receive lymph drainage from chest wall and breasts.
83
Inspection of the chest - surface markings - scars?
May indicate previous surgery - Look especially in the mid-axillary lines for evidence of past chest-drains.
84
Inspection of the chest - surface markings - radiotherapy?
Will often cause lasting local skin thickening and erythema.
85
Inspection of the chest - surface markings - veins?
Look for unusually prominent surface vasculature.
86
Inspection of the chest - shape - deformity?
1. Any asymmetry of shape?
| 2. Remember to check spin for scoliosis/kyphosis.
87
Inspection of the chest - shape - surgery?
TB patients from the 40-50s may have had operations resulting in lasting and gross deformity (thoracoplasty).
88
Inspection of the chest - Shape - "barrel chest"?
A rounded thorax with incr. AP diameter --> Hyperinflation, a marker of smoking related lung disease.
89
Inspection of the chest - shape - "pectus carinatum"?
1. Pigeon chest - Sternum and costal cartilages are prominent and protrude from the chest.
2. Caused by incr. respiratory effort when the bones are still malleable in childhood --> asthma, rickets.
90
Inspection of the chest - shape - pectus excavatum?
1. Funnel chest
2. Sternum and costal cartilages appear depressed into the chest.
3. Developmental defect - usually a normal variant with no significance.
91
Inspection of the chest - shape - surgical emphysema?
1. Air in the soft tissues will appear as a diffuse swelling.
2. Especially in the neck - may feel "crackly" to the touch.
92
Inspection of the chest - breathing pattern?
1. Examine rate and depth of breathing.
2. Fast, deep breaths are seen in anxiety states
3. Deep, sighing breaths "Kussmaul respiration" = systemic acidosis.
4. Cheyne-Stokes breathing
5. Prolonged expiratory phase
93
Cheyne-Stokes breathing?
Alternating pattern deep, regular breathing with very slow, shallow breaths. Due to failure of the normal respiratory regulation in response to blood CO2 levels.
94
Prolonged expiratory phase?
Marker of outflow limitation --> sign of smoking related lung disease if coupled with pursed-lip breathing.
95
Inspection of the chest - Movement?
1. Look for asymmetry - decreased movements indicate lung disease on that side.
2. Decr. movement globally is seen in COPD - along with a "pump handle" normal "bucket handle" (hinged at the front and back).
96
Inspection of the chest - Movement - Harrison's sulcus?
A depression of the lower ribs just above the costal margins and indicates severe childhood asthma.
97
Methods for checking trachea position?
1. Use a single finger to feel for the trachea - the distance between it and the sternocleidomastoids on each side should be the same.
2. Use 2 fingers and palpate the sulci either side of the trachea at the same time. They should feel of identical size.
98
Apex beat - where to palpate?
Normally at the 5th intercostal space in the mid-clavicular line.
It will shift with the mediastinum.
99
Apex beat - difficult to palpate?
In the presence of hyperexpanded lungs - may be shifted to the left if the heart is enlarged.
100
Tactile vocal fremitus - changes?
1. Incr. vibration in CONSOLIDATION.
2. Decr. vibration in:
a. Pneumothorax
b. Collapse
c. COPD
d. Pleural effusion
101
Percussion - Findings - Normal lungs sounds?
Resonant.
102
Percussion - findings - dullness?
Heard over areas of incr. density:
1. Consolidation
2. Collapse
3. Alveolar fluid
4. Pleural thickening
5. Peripheral abscess
6. Neoplasm
103
Percussion - findings - stony dullness?
The unique extreme dullness heard over a pleural effusion.
104
Percussion - findings - hyper-resonant?
Areas of decr. density:
1. Emphysematous bullae
2. Pneumothorax
COPD will create a GLOBALLY hyper-resonant chest.
105
Hyperextended lungs will "resonant" which sounds?
The dull sound of the heart and the liver.
106
Auscultation - findings - breath sounds - normal?
Vesicular.
1. Produced by airflow in the large airways and larynx and altered by passage through the small airways before reaching the stethoscope.
2. Often described as rustling.
3. Heard especially well in inspiration and early expiration.
107
Auscultation - findings - breath sounds - reduced sound?
1. If local --> effusion, tumor, pneumothorax, pneumonia or lung collapse.
2. If global --> COPD or asthma ("silent" chest is a sign of a life threatening asthma-attack).
108
Auscultation - bronchial breathing?
1. Caused by incr. density of matter in the peripheral lung allowing sound from the larynx to the stethoscope unchanged.
2. Hollow, blowing quality, heard equally in inspiration and expiration, often with a brief pause between.
3. Similar sound can be heard by listening over the trachea in the neck.
4. Heard over consolidation, lung abscess at the chest wall and dense fibrosis.
5. Also heard at the upper border of a pleural effusion.
109
Auscultation - wheezing (rhonchi)?
Musical whistling sounds caused by narrowed airways. Heard easier in expiration.
1. Different calibre airways = different pitch note --> asthma+COPD can cause a chorus of notes termed "polyphonic wheeze".
Monophonic wheeze indicates a single airway is narrowed - foreign body or carcinoma.
2. NOT a good marker of disease severity as decr. air entry --> decr. wheeze!
110
Auscultation - crackles (crepitations, rales)?
Caused by air entering collapsed airways and alveoli producing an opening snap. Heard in inspiration.
111
Auscultation - added sounds - "Coarse crackles"?
Made by larger airways opening and sound like the snap and pop of a certain breakfast cereal.
Causes:
1. Fluid
2. Infection.
112
Auscultation - "fine crackles"?
Sounds like the tear of the velcro and can also be reproduced by rolling the hair at your temples between the thumb and forefinger.
113
Fine crackles - etiology?
1. Fluid
2. Infection
3. Fibrosis (particularly at lung bases)
114
Important thing about crackles?
Often a normal finding at the lung bases. If so, they will clear after asking the patient to cough.
115
Important presenting patterns - Consolidation?
1. Decr. air entry locally - 2o to infection.
2. Decr. chest wall movement locally.
3. Dullness to percussion.
4. Bronchial breathing or incr. breath sounds.
5. Coarse or fine crackles, localized.
6. Incr. vocal resonance.
116
Important presenting patterns - Collapse?
1. Blockage of a major airway and collapse of the distal lung segment.
2. Mediastinal shift towards the abnormality.
3. Decr. chest wall movement locally.
4. Dullness to percussion restricted to affected lobe.
5. Decr. breath sounds
6. Decr. vocal resonance.
117
Important presenting patterns - Pleural effusion?
1. Collection of fluid between the 2 pleural layers creating a sound barrier between the examiner and the patient's lung.
2. Mediastinal shift away from the lesion (with a large effusion).
3. Decr. chest wall movement locally.
4. Stony dull to percussion.
5. Decr. breath sounds with bronchial breathing at the upper border.
6. Decr. vocal resonance
7. Sometimes a pleural rub just above.
118
Important presenting patterns - pneumothorax?
1. Air in the pleural space.
2. Mediastinal shift away from the lesion (with a tension pneumothorax)
3. Decr. chest wall movement locally.
4. Hyper-resonant to percussion
5. Decr. breath sounds
6. Decr. vocal resonance.
119
Important presenting patterns - Interstitial fibrosis?
1. No mediastinal shift. Trachea may move towards the fibrosis in upper lobe disease.
2. N or Incr. chest wall movement.
3. N percussion tone
4. N breath sounds
5. N vocal resonance
6. Fine crackles present.
120
Percentage of older people that suffer from respiratory symptoms?
Up to 60%.
121
The elderly patient - clarify diagnosis:
1. Not all disease in elders is COPD.
2. Many older people are life-long non-smokers.
3. Asthma + Pulm.fibrosis are often UNDERdiagnosed.
122
The elderly patient - fatigue?
Often associated with chronic respiratory illnesses and this may be more disabling to individuals than respiratory symptoms themselves.
123
The elderly patient - DHx?
1. Should be comprehensive and "dovetail" other medical problems.
2. Anticholinergic drugs (e.g. atrovent) may precipitate glaucoma or worsen bladder and bowel symptoms, so be thorough.
3. Ask about vaccinations - many miss their annual flu vaccine through hospitalization.
4. Consider vaccination in hospital.
124
The elderly patient - nutrition and mood?
1. Undernutrition is common with chronic diseases and those in long-term care --> Impact on illnesses with higher resting metabolic rates (e.g. COPD).
2. Low mood is similarly common and should be sought.
125
The elderly patient - SHx?
1. Functional history is paramount and may reveal key interventions.
2. A thorough occupational history is vital.
3. Many people do not know they have worked/lived with someone exposed to e.g. asbestos.
126
The elderly - exam - general?
Poorly fitting clothes/dentures may point to weight loss --> undernutrition, chronic disease, malignancy.
127
The elderly - Exam - hands?
1. Arthritis/other deformities may make inhaler use difficult and point to related diagnoses (eg rheumatoid lung disease).
2. Clubbing may NOT be present in later onset pulmonary fibrosis.
128
The elderly - exam - chest?
1. Beware of basal crepitations which are common in older age.
2. Pick out discriminating signs - tachypnea, position of crackles, added sounds etc.
129
The elderly - exam - inhaler technique?
KEY exam - may reveal why prior treatments were unsuccessful.
130
The elderly - diagnoses not to be missed:
Asthma --> up to 8% of over 60s, but UNDERrecognized and UNDERtreated. Spirometry is key.
TB --> Incr. in elderly - through reactivation, chronic illness, undernutrition. Presents non specifically - cough, lethargy, weight loss.
131
Upper respiratory tract?
Nose + pharynx.
