Pulmonary Flashcards
HPI
SOB, cough/choking, sputum/characteristics, wheezing, hemoptysis, pleurodynia, chest/bacl pain, fever/night sweats, wt loss
Related Pulm Hx
PMH, PSH, Family Hx, Social Hx, Tobacco use/drugs/ETOH, environment, exposure
New Onset Dyspnea
PNA, PTHX, Pl Ef, Peanut/FB, P HTN, Peak seekers, PE, Pump porbs, Psychogenic, poisons
Health Promotion
smoking cessation- Inc CAm infertility, preterm birth, SID, low birth wt.
5 A’s: Ask, Advise, Assess, Assist, Arrange
2 drugs to quit:
Nicotine replacement
Buprioprion- norepi/dopa reuptake inh/nicotine rec antagonist
Vareniche- nicotine receptor, partagonist
Plueral Effusion
Fluid displaces lung tissue away from costophrenic angle
Plueral Effusion
Fluid displaces lung tissue away from costophrenic angle
Thorax Anatomy
12 prs ribs
12 thoracic spine
suprasternal notch
manubrioangle
costal angle A/P
clavicular reference points
axillary reference points
Tip of scapula T7, if bent over most prominent cspine 7
Where to listen to which lobe
RUL- A/P
RML- A
RLL- P
LUL- A
LLL-P
Fissures
Minor: between right lobes
Major: between left lobes
Inspect Thorax
Rate, Rhythm, Depth, Effort
Listen to breathing
Shape/Symmetry
Neck/Trachea
AP diameter
Skin- clubbing, cyanosis(lips, nails)
Bony deformities
Retractions
Pectus Carinatum
Pigeon Chest
Pectus Excavatum
Funnel chest
Accessory Muscle Use
Muscles: Scalene, Trapezius, Sternomastoid
Retractions- caused by high work of breathing or airway blockage.
Check top of ribcage and ICS
Bulging between ribs may indicate PTX
Inward mvmt of soft tissue reflects -pressure during forced inspiration
Tracheal Position
Deviates to side of less pressure
Deviates toward atelectasis, fibrosis, simple PTX
Deviates away from Pl Eff, Tension PTX
Abnormal Breathing Patterns
Obstructive breathing
Ataxic breathing (Biots)
Cheyne-stokes breathing
Kussmaul breathing (deep fast or slow- blow off CO2 from acidosis)
Sighing Respirations
Inspection: Chest Symmetry
Equal movement bilaterally
One sided movement only?
Consider: hemidiaphragm paralysis, PTX, Old lung resection, fibrosis
Auscultation Technique
Sit up
Deep breathe through mouth
stethescope on skin
TV, Radio, Visitors OFF
Systematic comparision L/R and all lobes
Normal Breath Sounds
Bronchial
Pitch: high
Amplitude: loud
Duration: I<e></e>
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Quality: harsh or hollow</p>
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Normal location: trachea</p>
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found over high lung fields over fast moving air, mainstem bronchi, trachea</p>
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Normal Breath Sounds
Bronchovesicular
Pitch: medium
Amplitude: moderate
Duration: I=E
Quality: mixed
Normal location: over major bronchi
Normal Breath Sounds
Vesicular
Pitch: low
Amplitude: sofr
Duration I>E
Quality: soft blowing
Normal location: peripheral lung fields, posterior and lower areas
Adventitious Sounds Discontinuous
Fine Crackles/ Rales
fine crackles/rales
Mechansm: inspired air collides with deflated terminal airways
Early: COPD, Chronic Bronchitis
Late: PNA, CHF, Fibrosis, RLD
Deflated airways- fluid pressure(serum, mucus or inf materials) or mech restiction/comp; fine crackles are high pitched and heard on exp.
Adventitious Sounds Discontinuous
Course Crackles/ Rales
Mechanism: inspired air collides with fluid or secretions in bronchi
examples: P Edema, PNA, Bronchiectasis and Moribund patients
Adventitious Sounds Discontinuous
Atelectasis crackles/rales
Mechanism: when secretions of alveoli are not aerated (deflated)
Examples: bedridden, postop, depressed respirations
location: axillae, bases
clear/reversible on exam
Fine crackles from opening collapsed alveolar sacs- can resolve temporarily with CDB
Adventitious Sounds Discontinuous
Pleural Friction Rub
Mechanism: inflammed pleura cause friction during respiration
Example: Pleuritis, TB, malignancy, PE, PNA, viral syndromes( Influenza),
during inspiration
Adventitious Sounds Continuous
Wheeze (high pitched/rhonchi)
Mechanism: air flow through compressed/swollen airways
predominately in expiration
Examples; COPD, Asthma, tumors, CHF
Adventitous Sounds Continuous
Wheeze (low pitched/rhonchi)
Mechanism: airflow obstruction by secretions or bronchospasm
clears somewhat with cough/suctioning
Bronchitis- major cause in outpts.
Sonorous, may be coarse as well as low cracles present
Adventitious Sounds
Mediastinal Crunch
Precordial crackles synchronous with heart beat
Mechanism: mediastinal emphysema (pneumomediastinum)
Examples: postop CV surgery, mech vent, PTX
procedure or pathology that introduces air to MS space
Tactile Fremitus
refers to palpable vibration when patient speask
used to check symmetry
“99” or “ 1 1 1”
Increased or absent with lobar consolidation, pl eff and obstruction
reflects increased transference of voice through partially filled fluid lung. If + check bronchophony, egophony, and whispered petriloquy
Percussion
determines if underlying structure is air, fluid or solid
vibrates tissue and chest wall
symmetrical or generalized
best used to ID pl eff, empyema, PTX
normal: resonant
dull: consolidation (acculmulation pus, cellular debris with PNA)
flat: fluid filled (Pl Eff, some PTX, HTX)
Percussion Sounds
Flat
Dull
Resonant
Hyperresonant
Typmanic
Uses: Diaphragm excursion, Pl Eff, PTX
Alteration of Breath/Voice Sounds
Bronchial BS: loud/high pitched- lobar PNA
Egophony: EE to AY changes- with consolidation (PNA)
Bronchophony: louder/clear with consolidation (PNA)
Whispered Pectoriloquy: 1-2-3 whispered- sounds clear/loud with consolidation (PNA)
Lobar PNA
Percussion: dull
TF: increased
Bronchophony, Egophony, WP- present
Abn bronchial sounds
consolidation of infection (mucus, bacterial material, cellular debris)
Pleural Effusion
Percussion: dull to flat
TF: decr or absent
B, E, WP: may be present near top
BS- decreased
Fluid from inc Pl pressure from CHF transudative or inf/CA- exudative
Fill pl space between visceral(lung tissue) and parietal(chest wall), compressing lung parenchyma, lose BS at base often unilat.
Pneumothroax (PTX)
Percussion: hyperresonant
TF: dec or absent
B, E, WP: decr or absent
BS: absent
Lung collapse(spont/iatrogenic); pleural space is partly air filled->compresses lung tissue- fluid filled space dull(effusion), air filled space hyperresonant
COPD
Percussion: hyperresonant
TF: decrea
B, E, WP- decreased
BS: decreased with prolonged expiration
Alveolar walls broken down, small air spaces become large with less surface area for gas exchange but more air trapping and decr exp flow= obstr disease
Atelectasis
Percussion: dull
TF: decr
B, E, WP: decr/absent
BS: decr/vesicular
Collapsed alveoli at bases- not air/fluid filled, but dull to percussion, no voice transfer
Clubbing of digits
Osteoarthopathy
Early: nail base spongy, angle close to 180 degrees
Late: nail base elevated or swollen, nail angle greater than 180 degrees
Pneumonia
Air space disease and consolidation. Space filled with bacteria or other microorganisms/pus
Other causes of air space filling not distinguishable radiographically would be fluid: inflammatory, cancer cells, protein (alveolar proteinosis), and blood (pulm hemmorghage).
PNA not associated with volume loss
CXR: air space opacity, lobar consolidation or interstitial opacities.
Masses are well defined
PNA may have associated parapneumonic effusion
PNA- CXR findings
Lobar: pneummococcal, entire lobe consolidation/ air bronchograms common
Lobular: Staphlococcus, multifocal, patchy, sometimes wo bronchograms
Intersititial: Viral/mycoplasma, latter starts perihilar and can become confluent and/or patchy as disease progresses, no air bronchograms
Aspiration PNA: follow gravity flow, imp consciousness, post anestesia, common with alcoholics, debilitated, demented, anerobic: bacterorides, fusobacrerium
Diffuse pulm inf: community acquired(mycoplasma), nosocomial(pseudomonas, debilitated, mech vents, high mortaltiy rate, patchy opacity, caviation, ill-defined nodular), immunocompromised host(bacterial, fungal, PCP)
Atelectasis vs PNA
Atelectasis: volume loss, assoc ipsilateral shift, linear wedge shaped, apex at hilum.
PNA: Normal/inc volume, no shift, or if present contralateral, consolidation, air space process, not centered at hilum
Air bronchograms can occur in both
Cough
acute < 3 weeks
subacute 3-8 weeks
chronic > 8 weeks
