PD Thorax and Lungs Flashcards
What are the imaginary lines on the anterior thorax?
Midsternal
Midclavicular
What are the imaginary lines on the lateral thorax?
Anterior and posterior axillary
Midaxillary
What are the imaginary lines on the posterior thorax?
Scapular
Vertebral
At what levels anteriorly and posteriorly does the carina sit?
Sternal angle and T4
What fissure do both lungs have?
Oblique major fissure
Where is the oblique fissure located?
T3 to 6th rib anteriorly
Which lung has a second fissure, and what is it called?
Right lung has a horizontal fissure
Where is the horizontal fissure located?
Anteriorly from 4th rib and meets oblique fissure in midaxillary line near 5th rib
Where is the lower border of the lung, anteriorly and posteriorly?
Anteriorly 6th rib midclavicular and 8th rib midaxillary
Posteriorly T10
What are the stimuli for breathing?
Chemoreceptors in medulla sensitive to changes in H concentration
Chemoreceptors in carotid body respond to changes in arterial oxygen and CO2 concentrations
Which organ regulates respiratory muscles?
Pons
What is the primary muscle of respiration?
Diaphragm
What other muscles are involved in respiration during stress or exercise?
Parasternal
Scalenes
SCM
Abdominal muscles
What are the chief pulmonary complaints?
Chest symptoms Dyspnea Wheezing Cough Hemoptysis
How should the patient be positioned to inspect them?
Sitting and supine, properly draped or exposed
What do we observe about respirations?
Rate Rhythm Depth Effort Pattern
Color
Cyanosis
Listen
Wheezing
Stridor
Where in respiratory cycle?
Inspection
Accessory muscle use Retraction Nasal flaring Pursed lips Trachea midline Shape of chest - deformity, asymmetry Movement of chest - unilateral lag
Supernumerary nipples
Associated with congenital heart disease
Polythelia
How do we palpate to see if the trachea is midline?
Place finger in sternal notch and slip to each side
Barrel chest
Examples
Increased AP diameter, kyphosis, ribs more horizontal
Normal during infancy
Aging, COPD
Kyphosis
Anterior chest wall collapse
May make interpretation of lung findings difficult
Kyphoscoliosis
Abnormal spinal curvatures and vertebral rotation deform the chest
Distortion of underlying lungs, interpretation is difficult
Pectus excavatum
Depression in lower portion of sternum
Compression of heart and great vessels may cause murmurs
Pectus Carinatum
Sternum is displaced anteriorly, increasing AP diameter
Costal cartilages next to protruding sternum are depressed
Palpation
Tenderness Pulsations Bulges Masses Depressions Crepitus Pleural friction rub
Crepitus
Examples
Crackly, crinkly sensation can be felt or heard
Indicates air in soft tissues
Pneumothorax, infection
Is crepitus a normal finding?
No, always abnormal
Pleural friction rub
Example
Often heard before felt
Palpable, coarse, grating vibration
Usually on inspiration
Inflammation of pleurae
Tactile fremitus
Palpable vibration of chest from speech
Decreased or absent tactile fremitus
Emphysema
Pleural thickening
Effusion
Bronchial obstruction
Increased tactile fremitus
Lung consolidation
Large effusion
Tumor
Non obstructing bronchial secretions
Where do you check chest expansion posteriorly?
T10
Where is fremitus normally more prominent?
Interscapular area than lower lung fields
Right than left
Where do you check chest expansion anteriorly?
Thumbs along costal margin and xiphoid process
Examples of deviated trachea
Tension pneumothorax Tumor Nodal enlargement Large effusion Thyroid enlargement Severe parenchymal or pleural fibrosis
Percussion
Compare all areas bilaterally, from superior to inferior and medial to lateral, systematically
How do you position a patent for percussion?
Posterior - flex head with arms folded in front
Anterior lateral - raise arms
What area on the chest do we percuss, over ribs or intercostals?
Intercostal spaces
Normal lungs should sound… on percussion
Resonant
Hyperresonant lungs examples
COPD
Pneumothorax
Asthma
Dull lungs examples
Atelectasis pleural effusion Consolidated lung Tumor Organ
Which diaphragm is usually higher?
Right side
What conditions limit diaphragmatic excursion?
Emphysema Ascites Rib fracture Piaphragmatic paralysis (phrenic nerve injury) Large effusion Tumor
What is the normal diaphragmatic excursion?
About 5 cm
How should a patient breath for auscultation?
Slow, deep breaths through the mouth
What do we caution the patient of with auscultation?
Go slow, don’t hyperventilate
Which side of the stethoscope do we auscultate the lungs with?
Diaphragm - can hear higher pitched sounds better, and is wider than the bell
Auscultation
Listen systematically from side to side for comparison, starting at apex
What are we evaluating during auscultation?
Intensity
Pitch
Quality
Duration
How do inspiration and expiration duration usually compare?
Equal
Vesicular
Heard over most lung fields
Low pitched, soft
Fade away 1/3 through expiration
Bronchovesicular
Medium pitch
Inspiration and expiration are equal in length
Heard over main bronchus and R posterior lung field
Bronchial (tubular)
Louder, harsher, higher in pitch
Expiration lasts longer, short silence between
Heard over trachea, consolidation, large effusion
Where is it abnormal to hear bronchovesicular and bronchial lung sounds?
Periphery of lungs
Amphoric breath sounds
Resembles blowing mouth across open bottle
Heard with large pulmonary cavity (blebs with emphysema) or tension PTX with bornchopleural fistula
Decreased breath sounds
Fluid in pleural space
Secretions in airways
Severe emphysema
Increased breath sounds
Consolidated lung
Large effusion
Empyema
Large tumor
Adventitious breath sounds
Crackles, rales Rhonchi Wheeze Pleural/friction rub Stridor
When are crackles usually heard?
Inspiration
Are crackles continuous or discontinuous?
Discontinuous, lasting only few miliseconds
What can we do to demonstrate what crackles sound like?
Rubbing hair between thumb and forefinger
What causes crackles?
Result from noise of previously closed airways opening in the distal radicals of bronchial tree
Heard with opening and closing of alveoli
Fine crackles
Example
High pitched, short in duration, wet
CHF
Coarse crackles
Example
Low pitched, longer in duration, dry
Pneumonia
Examples of crackles
Interstitial lung disease Pulmonary fibrosis Pneumonia Atelectasis Bronchiectasis ARDS Pulmonary edema
Are rhonchi continuous or discontinuous?
COntinuous
What do rhonchi sound like?
Low pitched rumbling or gurgling sounds
What causes rhonchi?
Passage of air through larger airways that are obstructed by fluid or mucous
What can clear rhonchi?
Cough
What is the death rattle?
When rhonchi is heard in agonal states
What are some examples of when patients develop rhocnhi?
Patient can't control secretions Tracheobronchitis Pneumonia Bronchial obstruction Foreign body
What do wheezes sound like?
High pitched, whistle like
What causes wheezes?
Turbulent air and vibration of the airway walls in which there is partial obstruction to airflow
Are wheezes continuous or discontinuous?
Continuous
When do you usually hear wheezes, inspiration or expiration?
Expiration
Examples of wheezes
Bronchospasm Asthma Neoplasm Edema (CHF) Foreign body
Where does a pleural friction rub occur?
Outside of the respiratory tree
What causes a pleural friction rub?
Inflamed pleurae rubbing against each other with respiration
Is a pleural friction rub continuous or discontinous?
Discontinuous
What does a pleural friction rub sound like?
Dry, crackly, grating, low pitched
New leather rubbing together
Crunching of snow underfoot
How do you differentiate between a pleural and pericardial rub?
Have patient hold breath - pericardial rub persists
What does stridor sound like?
High pitched
Is stridor heard during inspiration or expiration?
Inspiration
Is stridor continuous or discontinous?
Continuous
Stridor examples
Malignancy Laryngeal obstruction Eplglottitis Foreign body Tracheal stenosis Laryngomalacia Croup
Vocal resonance
Vocalizations are transmitted through the respiratory tree
Where are whispered words heard in a normal lung?
Faint and syllables are not distinct except over main bronchi
When do you evaluate vocal resonance?
If abnormalities are detected on percussion, palpation, or auscultation
What are the vocal resonance tests?
Bronchophony
Egophony
Whispered pectoriloquy
Bronchophony example
Loudness of vocalization increased due to pulmonary consolidation or large effusion
Egophony example
EEE turns to AAA with nasally quality
Heard with pleural effusion or consolidation
Whispered pectoriloquy example
Whispered words are clearly audible
Consolidation, pulmonary infarction, atelectasis
