Pulmonary Flashcards
Where is the insertion site for decompression of a tension pneumothorax?
2nd intercostal space
Where is the insertion site for chest tube insertion?
Between the 4th and 5th ribs.
Where is the lower margin for a well-placed endotracheal tube on a chest x-ray?
Level of the 4th rib.
Where should needles and tubes be placed to avoid neuro vascular structures?
Neurovascular structures run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margins.
Where is the landmark for thoracentesis with needle insertion?
The intercostal space between the 7th and 8th ribs, immediately superior to the 8th rib.
What is the “triangle of safety”?
An anatomical region in the midaxillary line formed by the lateral border of the pectoralis major muscle anteriorly, lateral border of the latissimus dorsi posteriorly, and the nipple line (4th or 5th intercostal space) inferiorly. This triangle represents a “safe position” for chest tube insertion.
In which lung lobes is aspiration pneumonia more common & why?
The right middle and lower lobes because the right main bronchus is more vertical. For this same reason, if an ET tube is advanced too far during intubation, it will more likely enter the right mainstem bronchus.
Define transudates.
Accumulations of pleural fluid, or pleural effusions, seen in heart failure, cirrhosis, and nephrotic syndrome.
Define exudates.
Accumulations of pleural fluid, or pleural effusions, seen in numerous conditions including pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis.
Pleuritic pain.
Irritation of the parietal pleura produces pleuritic pain with deep inspiration in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular diseases.
Principle muscle of inspiration.
The diaphragm. The muscles of the rib cage also expand the thorax during inspiration, especially the scalenes and the parasternals.
What respiratory symptoms are present in patients with anxiety?
Episodic dyspnea during rest and exercise and also hyperventilation, or rapid shallow breathing.
When does wheezing occur?
In partial lower airway obstruction from secretions and tissue inflammation in asthma, or from foreign body.
Cough
A reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. Cough can also signal left sided heart failure.
Causes of acute cough (less than 3 weeks:
Most common- viral upper respiratory infections
Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ACE-inhibitor therapy.
Subacute cough (3-8 weeks) is caused by:
Post infectious, pertussis, acid reflux, bacterial sinusitis, and asthma.
Chronic cough (more than 8 weeks) is seen in:
Postnasal drip, asthma, GERD, chronic bronchitis, and bronchiectasis.
Mucoid sputum
Translucent, white, or gray and seen in viral infections and cystic fibrosis.
Purulent sputum
Yellow or green; often accompanies bacterial pneumonia.
What is a sign that sputum is related to anaerobic lung abscess?
Foul smelling
What type of sputum is present in cystic fibrosis?
Thick and tenacious
What information should you assess about a cough?
Duration
Dry or productive
Volume
Color
Odor
Consistency
For patients reporting hemoptysis, what other information should you gather?
Volume of blood
Setting
Activity
Associated symptoms
Causes of hemoptysis
Bronchitis
Malignancy
Cystic fibrosis
Bronchiectasis
Mitral stenosis
Goodpasture syndrome
Granulomatosis with polyangitis
Massive hemoptysis
> 500 mL over a 24-hour period or >/= 100 mL per hour
How do you distinguish blood originating in the stomach from blood originating in the respiratory tract?
Blood originating in the stomach is usually darker and may be mixed with food particles.
Common gestures used to describe chest pain
A clenched fist over the sternum (Levine sign) suggests angina pectoris.
A finger pointing to a tender spot on the chest wall suggests musculoskeletal pain.
A hand moving from the neck to the epigastrium may suggest heartburn.
Lung tissue has no pain fibers. So, where does pain in conditions such as pneumonia and pulmonary infarction arise from?
Inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing or costochondral inflammation may also be responsible. The pain of pericarditis stems from inflammation of the adjacent parietal pleura.
What are hallmarks of OSA?
Daytime sleepiness and snoring. Commonly seen in patients with obesity, posterior malocclusion of the jaw (retrognathia), treatment-resistant hypertension, heart failure, atrial fibrillation, stroke, type 2 diabetes.
Mechanisms that lead to disordered sleeping include:
Instability of the brainstem respiratory center, disordered sleep arousal, disordered contraction of upper airway muscles, and anatomical changes contributing to airway collapse such as obesity.
What does the tripod position combined with increased work of breathing (supraclavicular retractions, use of accessory muscles) indicate?
Increased airway resistance or stiff lungs and/or chest wall.
Percussion- dullness
Pleural effusion
Atelectasis
Percussion- hyperresonance
Emphysema
Auscultation
Wheezes, crackles, rhonchi, prolonged expiratory phase, and/or diminished breath are clues to disorders of breathing or lung parenchyma.
Right sided heart pressures signs
Jugular venous distention
Peripheral edema
Accentuated pulmonic component of the second heart sound
Left ventricular dysfunction signs
S3 & S4 gallops
Stridor
Audible high-pitched inspiration whistling. An ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation
Lateral displacement of the trachea occurs with:
Pneumothorax
Pleural effusion
Atelectasis
When does asymmetry in chest expansion occur?
Large pleural effusions
When does retraction occur?
Severe asthma
COPD
Upper airway obstruction
When does unilateral impairment or lagging occur?
Pleural disease from asbestosis or silicosis
Phrenic nerve damage or trauma
When can intercostal tenderness develop?
Over inflamed pleurae
When does costal cartilage tenderness occur?
Costochondritis
Crepitus
Crackling or grinding sound over bones, or skin, with or without pain, due to air trapping in the subcutaneous tissue. May be palpable in overt fractures and arthritic joints.
Signs of a fractured rib
Tenderness
Bruising
Bony “step-offs”
Signs of mediastinitis
Crepitus
Chest wall edema
Sinus tracts
Blind, inflammatory, tube-like structures opening onto the skin.
Rare.
Suggest infection of the underlying pleura and lung (as in tuberculosis or actinomycosis).
In what conditions can unilateral decrease or delay in chest expansion occur?
Chronic fibrosis of the underlying lung or pleura
Pleural effusion
Lobar pneumonia
Pleural pain with associated splinting
Unilateral bronchial obstruction
Paralysis of hemidiaphragm
Tactile fremitus
The palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetrical.
When is tactile fremitus decreased or absent?
High pitched voice
Soft voice
Thick chest wall
Obstructed bronchus
COPD
Pleural effusion
Fibrosis
Pneumothorax
Infiltrating tumor
Percussion Notes and Pathologic examples
Flat (soft, high pitch, short)- large pleural effusion
Dull (medium, medium pitch, medium duration)- lobar pneumonia
Resonant (loud, low, long)- simple chronic bronchitis or healthy lung
Hyperresonant (very loud, lower, longer)- COPD, pneumothorax
Tympanic (loud, high, longer)- large pneumothorax
Dullness in percussion indicates
When fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussion fingers.
Lobar pneumonia
Pleural effusion
Hemothorax
Empyema
Fibrous tissue
Tumor
Hyperresonance with percussion indicates
Hyper inflated lungs of COPD or asthma.
Unilateral hyperresonance suggests a large pneumothorax or an air filled bulla.
What does absent descent of the diaphragm indicate?
Pleural effusion
Atelectasis
Phrenic nerve paralysis
What does a silent gap between inspiratory and expiratory breath sounds suggest?
Bronchial breath sounds
