pulmonary Flashcards
kyphoscloliosis
can lead to cor pulmonale and portal HTN
horizontal sloped ribs in…
obstructive lung diseases (emphysema, COPD, chronic bronchitis, status asthmaticus)
beading of costochondral joints in…
rickets! (rachitic rosary)
Hoover’s sign
COPD, flattened diaphragm on inspiration, more acute subcostal angle
pectus excavatum
sunken, funnel chest
due to Marfan’s, Rickets, Noonans
accessory muscles of breathing
inspiration: SCM, scalenes
expiration: abdominal muscles
- if clavicle moves up >5mm=severe obstructive lung disease
- inspiratory retraction of suprasternal and supraclavicular fossa
Cheyne-stokes breathing
- progressively deeper and faster breathing until temporary stop (apnea)
- due to damage to respiratory centers in brain or heart failure, high altitude
- poor prognosis
- swings in cerebral blood flow (swing between alert/agitated and sleepy/slow)
Biot’s breathing
groups of quick shallow inspiration followed by period of apnea
- brainstem damage
- opiod use
kussmaul breathing
deep labored breathing assoc. w/ severe metabolic acidosis (eg. DKA)
DDX: MAKEUPL (Methanol, Aspirin, Ketones, Ethylene glycol, Uremia, Paraldehyde, Lactic Acidosis)
paradoxical respiration
- all or part of lung is deflated during inhalation and inflated during exhalation
- due to flail chest (rib fractures)
- diaphragm paralysis
expiratory bulging of intercostal spaces
if focal–>pneumothorax
if diffuse–>obstructive disease
tirage breathing
inspiratory retraction of intercostal spaces seen w/ focal obstruction
cyanosis
ineffective ventilation
pallor, diaphoresis, agitation
ineffective oxygenation
symptoms of SVC syndrome
shortness of breath, arm or face swelling
Dahl’s sign
COPD patients lean forward and rest on knees to breath, calluses above knees
ipsilateral deviation of trachea
atelectasis
contralateral deviation of trachea
pneumothorax, large pleural effusion
axial fixation of trachea
tumor or mediastinal fibrosis
oliver’s sign
systolic “tug” seen w/ aortic aneurysm, synchronous with each heart beat
campbell’s sign
tracheal descent with inspiration, due to chronic airflow obstruction, seen w. COPD
costochondritis
tietze’s syndrome
inflammation of costal cartilage
sternal pain
CML or arthritis
What is tactile fremitus? What happens in pneumonia?
- compare sides when patient says “eee” or “99”
- alveolar pneumonia: inc. fremitus
- bronchopneumonia: dec. fremitus
percussion in patients with emphysema, status asthmaticus, or COPD
hyperresonant
- lower pitch
- louder intensity
percussion in patients with pleural effusion
- flat
- very high pitch
- soft intensity
late inspiratory crackles seen with…
- pulmonary fibrosis–will have vesicular breathing
- consolidation (pneumonia, hemorrhage)–will have bronchial breathing
- asbestosis, sarcoidosis, granulomatous d/o
mid-inspiratory crackles seen with…
bronchiectasis
early inspiratory crackles seen with
bronchitis
What breath sounds will I have if I have a solid consolidation (pleural effusion)?
top: vesicular b/c no fluid
middle: bronchial sound
bottom: no sound b/t alveoli totally collapsed
stridor
inspiratory wheeze
vocal cord dysfunction
expiratory wheeze; louder over the neck than the lungs
asthma
wheeze (expiratory alone or insp+exp)
length of wheeze determines severity of asthma (if both inspiratory and expiratory this is bad)
-asthmatics in impending respiratory failure don’t wheeze b/c too weak to generate airflow
cardiac asthma
wheezing in the presence of LV failure (due to interstitial edema)
rhonchi
- early expiratory, over vesicular breathin
- air flow through narrow airway, due to inspissated secretions (obstructive lung disease)
- if localized and persistent, worry about endobronchial neoplasm
pleural friction rub
- imposed on underlying vesicular breath sound
1. bacterial pneumonias
2. collagen vascular diseases
3. pulmonary infarcts
4 reasons why rubs are not crackles
- rubs are both insp and exp (crackles just insp)
- rubs dont’ clear with coughing (crackles do!)
- rubs are localized over chest (crackles are bilateral)
- rubs are palpable (crackles are not)
tachypnea
RR>25
- bad prognosis in hospitalized pts
- more valuable if absent–>if absent not PE (90% patients with PE have tachy)
bradypnea
RR<8
- tiring/hypothyroidism
- stroke/CNS depression
- narcotics/sedatives
grunting respiration
- Rale de la mort: preterminal grunting/gurgling by patients too ill to clear respiratory secretions
- kids: forced expiration against a closed glottis
pursed lip breathing
emphysema
- improves tidal volume
- slows RR
- dec. dyspnea
- overall dec. work of breathing
orthopnea
- dyspnea that is relieved by sitting upright and aggravated by lying flat
1. CHF
2. massive ascites
3. COPD/asthma (improves vital capacity and lung compliance)
4. bullous bi-apical lung disease (keeps perfusion in lower lobes)
5. pleural effusion, pneumonia, diaphragmatic paralysis (fluid in lungs)
pickwickian syndrome
obesity hypoventilation
paroxysmal nocturnal dyspnea
dyspnea relieved by lying down and aggravated in erect position
- assoc. w/ orthodeoxia: Hb desaturation from upright posture
- R–>L shunt (intracardiac=ASD or intrapulmonary=bi-basilar disease, PE, pneumonia, effusion)
- cirrhotics (AV shunting at lung bases)
trepopnea
- preference for lateral decubitus position
- down with the good lung–>unilateral lung collapse
- down with the bad lung–>lung filled with fluid or if you’re a kid with unilateral lung disease
abdominal paradox breathing
rocking motion of chest and abdomen due to paralysis or weakening of diaphragm
-predicts respiratory failure
respiratory alternans
alternate use if diaphragm or intercostal mm
- rock in one direction then switch to antoher
- predicts respiratory failure
still abdomen
diffuse: generalized peritonitis
localize to LLQ: focal diverticulitis
localized to RLQ: appendicitis
clubbing
- focal enlargement of CT in ends of fingers and toes
- never painful
- diagnostic features: loss of lovibond’s angle, floating nails (inc. sponginess of nailbed), abnormal phalangeal depth ratio
Causes:
- underlying respiratory d/o (chronic bronchitis but NOT emphysema)
- GI (cirrhosis, IBD, cancer)
- Cardiac (endocarditis, congential heart disease)
- pregnancy
hypertrophic osteoarthropathy
- painful and tender periosteal new bone proliferation, often assoc w/ clubbing
- intrathoracic neoplasm (lymphoma, mesothelioma, metastatic cancer)
- non-neoplastic pulmonary d/o (CF, bronchiectasis, empyema, abscess)
pink puffer
thin, uses accessory mm, no clubbing
emphysema
blue bloater
stocky, pulmonary HTN, coughs up stuff, clubbing
chronic bronchitis
-inc. breath sounds at mouth but dec over chest
-chest can be noisy (early crackles, rhonchi, wheezes) but most clears with coughing
bibasilar fine late crackles with no clinical signs of pulmonary disease are considered a sign of…
heart failure
posturally induced crackles: PIS have prognostic significance
patient presents with cough, fever, sputum and dyspnea
Pneumonia
- paplation: inc. tactile fremitus
- percussion: dull
- ausculatation: bronchial breath sounds, late insp. crackles adn egophony
- diminished breath sounds indicate concomitant pleural effusion
- poor prognosis: hypothermia, and hypotension
- good prognosis: improved BP and fever, dec. HR, dec RR
wheeze
length of wheeze correlates wtih severity (not intensity)
-can be expiratory or insp+exp (not just insp=stridor)
-
pulmonary embolism
- tachycardia
- tachypnea
- peripheral crackles
- pleural friction rub
- distended neck veins (if massive PE!)
transmitted voice sounds
- bronchophony (voice sounds heard over chest in areas remote from bronchi or layrnx)
- pectorlioquy (clear words heard over chest)
- egophony (bleating and goatlike sounds heard over areas of consolidation)
- E-to-A changes
* indicate that lung parenchyma has become airless and consolidated (bronchi must be open)
