Pulmonary Eval Flashcards
what is the purpose of Pulmonary Function Tests? (3)
- tests of lung volumes and capacity
- tests of gas flow rates
- tests of diffusion
list tests of lung volumes and capacity
- tidal volume: normal breathing
- inspiratory reserve volume: the amount of air a person can inhale forcefully after normal tidal volume inspiration
- expiratory reserve volume: the amount of extra air — above a normal breath — exhaled during a forceful breath out.
- vital capacity (4000-5000 ml): the total volume of air that can be displaced from the lungs by maximal expiratory effort
- residual volume: what’s left in the lungs
list tests of gas flow rates
- FVC
- FEV1
- FEV1/FVC
- Forced midexpiratory flow (FEF)
- Maximum voluntary ventilation (MVV)
describe MVV
maximum voluntary ventilation
“breath as deeply and as rapidly as possible for 10, 12, 15 seconds”
measures the max amount of air that can be inhaled and exhaled in a determined time
list tests for diffusion
- what does it measure?
- what is it?
DL or DLCO
diffusing capacity of the lung or the amount of gas entering the pulmonary blood flow per unit time
measures the integrity of the functional unit of the lung
what is included in the evaluation/physical examination of a pulmonary exam?
- general appearance
- use of supplemental oxygen
- evaluation of neck
- resting chest eval
- breathing patterns
- speech
- lung sounds
- cough/sputum
- palpation
- percussion
general appearance examination during a physical exam
- posture → kyphosis and scoliosis are 2 postures that functionally limit VC
- positioning → can they tolerate supine?
- skin color → cyanosis
- presence of external monitoring and equipment
- effort of breathing
- clubbing → distal enlargement of fingers w/down slopping nails
Physical exam: supplemental oxygen
- check to ensure that it is being used properly
- check the flow rate
- breath in a manner that makes use of the supplemental O2
- check facial signs of pulmonary distress including nasal flaring, sweating, paleness, and focused, or enlarged pupils
- pursed-lip breathing → clinical sign of COPD
Physical exam → evaluation of the neck
- check of hypertrophy of SCM
- chronic forward-bent posture → shortening of SCM
- adaptive changes of the SCM may indicate chronic pulmonary condition
- JVD
- position of clavicle → often very prominent in pulmonary pathologies
the resting chest is evaluated for what?
- symmetry
- rib angles
- muscles
describe chest symmetry
what is the normal ratio of the AP diameter to the transverse diameter? What would it be in a COPD patient?
normal AP diameter (measurement from xiphoid to the vertebrae) is ½ of the transverse diameter (lateral side to lateral side)
hyperinflated chest → ratio approaches 1
1: 2 in a normal patient
1: 1 in a barrel chested patient (COPD, etc.)
a normal chest will have what shape?
jelly bean
with obstructive disorders and air trapping you see the AP direction grow resulting in a barrel chest
chest eval → rib angles
- rib angles should be observed for abnormalities that might suggest the presence of chronic disease
- normally, rib angles measure less than 900 and they attach to the vertebrae at approximately 450 angles
how does chronic hyperinflation impact rib angles?
what does this do to the diaphragm?
causes rib angles to increase placing an increased stretch on the diaphragm causing it to become flatter and less effective
chest-evaluation → muscles
check for hypertrophy and/or adaptive shortening of the SCM → may indicate a chronic pulmonary condition
list normal RR ranges across age groups
- infants → 30-60 bpm
- 3-6 years → 22-34 bpm
- 6-12 years → 18-30 bpm
- 12-18 years → 12-20 bpm
list and describe different breathing patterns
- eupnea
- bradypnea
- tachypnea
- hyperpnea
- hyperventalation
- Eupnea → normal rate, depth and regular rhythm
- Bradypnea → slow rate, shallow or normal depth, regular rhythm
- Tachypnea → fast rate, shallow depth
- Hyperpnea → normal rate, increased depth, regular rhythm
- Hyperventilation → fast rate, increased depth, regular rhythm
- results in decreased arterial CO2
describe things to look for relating to pt speech
- dyspnea of phonation → when speech is interrupted for a breath
- ID how many words can be expressed before the next breath
- one-word dyspnea would mean that speech is interrupted for a breath between every word
- great to write goals off of
things to consider relating to lung sounds
- produced from the turbulence of airflow in the airways
- heard through a stethoscope
- an increase in lung tissue density causes increased sound transmission
- a decrease in lung tissue density, as in the empysematous lung, would cause decreased sound transmission
- normal breath sounds → normal noises of breathing
list and describe several different lung sounds
- adventitious
- wheezes
- rhonci
- crackles
- pleural rub
- adventitious breath sounds → abnormal noises heard only with stethoscope
- wheezes → continuous but high pitched
- rhonchi → subtype of wheeze; low pitched like a snore; implies obstruction f larger airway
- crackles → are discontinuous adventitious lung sounds that sound like brief bursts of popping bubbles
- pleural rub → sounds like 2 pieces of leather or sandpaper rubbing together
- occurs with both inspiration and expiration
what are you looking at with a cough during the physical exam?
- strength
- duration
- effectiveness
- intrathoracic pressures of up to 300 mmHg and expiratory velocities approaching 500 mph
- qualities of the cough-strength, depth and length
describe mucous
a material from the lungs that is produced (brought up) by coughing
is sticky and this helps to trap dust particles, bacteria and other inhaled debris
what to consider/look at with sputum during the physical exam
- is there mucous?
- amount
- consistency
- color → white, opaque, grey, orange, green, brown
- yellow, orange = bacterial infection
- change over time
- mucoid, purulent, mucopurulent, frothy, viscous
- bloodstained?
describe the 2 types of cough
what is one thing they are each associated with?
- productive cough
- produces mucus or sputum
- generally should not be suppressed
- associated with lung infections
- non-productive cough
- dry and does not produce sputum
- lung neoplasms
assessing breathing during the physical exam
- rate
- use of diaphragm
- effort
- accessory muscle use
- paradoxical breathing?
describe paradoxical breathing
- chest moves inward instead of outward during inhalation
- can be caused by a strong contraction of the diaphragm with no support from the intercostals or abdominal muscles. Excessive and rapid abdominal rise and upper chest collapses. Inefficient but sufficient
- weak diaphragm but strong accessory muscles
- the abdomen is drawn inward during inspiration
- chest rises and abdomen falls
what could cause paradoxical breathing? (5)
- presence of airway obstruction
- mechanical disruption of the chest wall (trauma)
- phrenic nerve injury
- flail chest → broken ribs
- diaphragmatic dysfunction
what is included with palpation during the pulmonary physical exam?
- assess muscle tone esp. accessory muscles in neck
- tracheal position (mediastinum)
- assess use of diaphragm
- symmetry of costal expansion
- presence of crepitus
- assess for tactile fremitus
describe how to assess tracheal position
place an index finger n the medial aspect of the suprasternal notch. Repeat on opposite side. An equal distance between the clavicle and the trachea should exist bilaterally
list conditions that cause tracheal deviation
- Atelectasis → complete or partial collapse of a lung or lobe of a lung. trachea moves toward the collapsed side
- Pneumothorax → an abnormal collection of air or gas in the pleural space that causes an uncoupling of the lung from the chest wall. Air leaks into the space between one’s lungs and chest wall and creates a restrictive lung situation. Traches deviates away
list some repercussions of a pneumothorax (5)
- tachypnea
- asymmetric lung expansion
- distant or absent breath sounds
- decreased tactile fremitus
- adventitious lung sounds → ipsilateral crackles, wheezes
how would the presence of a tumor impact tracheal position?
ipsilateral pull towards the atelectasis
describe how to assess tracheal position
place an index finger n the medial aspect of the suprasternal notch. Repeat on opposite side. An equal distance between the clavicle and the trachea should exist bilaterally
describe chest expansion measurement
can be measured with tape meter around the chest at about the level of the nipples or 4th intercostal space in males, or just below the breasts in females on deep max inspiration and on max forced expiration.
take the difference between these 2 measurements
list norms for chest expansion measurements
- in children → 2 cm
- in a fit young man may expand 5 cm (ranges from 5-8 cm)
- in severe emphysema → may expand less than 1 cm
describe crepitus
hallmark sign is increasing edema chest > scapula > neck to face with rice crispy feeling and crackling when skin palpated (or like popping those plastic air bubbles)
what causes crepitus?
- due to presence of air in the subcutaneous tissue
- air leaks out of the lungs follows fascial planes and enters the subcutaneous layer of the skin
- called subcutaneous emphysema
describe tactile fremitus
- spoken words produce vibration over the chest wall
- when the PT’s hands are placed over the chest wall, the vibrations of a spoken word can be felt
- the presence of absence of these vibrations of tactile fremitus provides info about the density of the underlying lungs and thoracic cavity
- sound waves are transmitted with less decay in a solid medium (the consolidation) than in a gas medium (aerated lungs)
when is tactile fremitus decreased?
decreased or absent over areas of pleural effusion or pneumothorax
when there is air outside of the lung in the chest cavity, preventing lung expansion and creating more space in the lung and limiting or preventing sound transmission
describe percussion technique
when will percussion sound dull versus resonant?
makes use of the fact that striking a surface which covers an air-filled structure (normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound
what would create a deadened tone during percussion?
list the two conditions associated with either of these circumstances.
if the normal, air-filled tissue has been displaced by fluid (pleural effusion)
or infiltrated with white cells and bacteria (pneumonia)
what would create a hyper-resonant/drum-like sound during percussion?
air-trapping
describe the process of performing percussion
- try to focus on striking the distal inter-phalangeal joint of your L middle finger with the tip of the R middle finger
- the last 2 phalanges of your L middle finger should rest firmly on the pt’s back. Try to keep the remainder of your fingers from touching the pt, or rest only the tips on them
- when percussing any one spot, 2-3 sharp taps should suffice
with percussion, as you move down towards the base of the lungs ________
the quality of the sound changes
list 3 different sounds that could be heard with auscultation
- Egophony
- Bronchophony
- Whispered pectoriloquy
describe egophony
increased resonance of voice sounds
- say “Eeeeee”
- healthy = Eeeee heard on auscultation
- unhealthy = nasal “A” or “goat call” sound auscultated
describe bronchophony
abnormal transmission from lungs or bronchi
- say “99” repeatedly
- healthy = not understandable
- unhealthy/consolidation = “99” understood
describe whispered pectoriloquy
increased loudness heard upon whispering
- whisper “1, 2, 3’
- healthy = not understood
- unhealthy = understood “1, 2, 3” or a clear separation in sound