Pulmonary Exam and Ultrasound

Question 1

What is the normal adult respiratory rate?

Answer 1

10-14 breaths

Question 2

What is the normal neonate respiratory rate?

Answer 2

30 to 60 breaths

Question 3

What is the normal young child respiratory rate?

Answer 3

20 to 40

Question 4

What is the normal older child respiratory rate?

Answer 4

15-25

Question 5

Define tracheal tugging. What is it a sign of?

Answer 5

sucking in of skin and tissue just above the suprasternal notch.
Indicates respiratory distress

Question 6

What is the cause of tracheal tugging towards the diseased side of the body?

Answer 6

volume loss of the lung

Question 7

What is the cause of tracheal tugging away from the diseased lung?

Answer 7

Increase in lung pressure or volume, potential emergency if tension pneumothorax

Question 8

What disease processes can caused decreased fremitus?

Answer 8

disease processes that decrease the transmission of sound from the lung to the chest wall (“increased air” in the lungs - emphysema, asthma; air or fluid in the pleural space – pneumothorax, pleural effusion).

Question 9

What disease processes cause increased fremitus?

Answer 9

present with increased fluid in the lung tissue, facilitating sound transmission (consolidation of the lung as with pneumonia or pulmonary hemorrhage).

Question 10

Where is resonance normally heard during percussion?

Answer 10

over the lung fields

Question 11

What is normal lung percussion described as?

Answer 11

resonant

Question 12

What is suggested by hyperresonance?

Answer 12

less dense lung tissue or more air

Question 13

What is suggested by percussive dullness?

Answer 13

more dense tissue

Question 14

How must a patient breathe during auscultation?

Answer 14

through their mouth, to minimize nasal passage noise

Question 15

How are normal breath sounds described? what does this mean?

Answer 15

vesicular

(where the inspiratory sound lasts longer than the expiratory component) and are heard over most of the lung fields

Question 16

What are bronchovesicular breath sounds?

Answer 16

normal
In bronchovesicular breath sounds, the inspiratory and expiratory components are equal. These can be heard in the normal lung in the 1st and 2nd interspaces anteriorly and between the scapulae.

Question 17

What are bronchial breath sounds?

Answer 17

normal
Bronchial breath sounds are louder and more high-pitched and are only hard over the manubrium, if at all, in the normal lung.

Question 18

What are tracheal breath sounds like?

Answer 18

Tracheal breath sounds are very loud and high-pitched and can be heard over the trachea in the neck.

Question 19

What bronchial breath sound findings are indicative of pulmonary consolidation?

Answer 19

If bronchial or bronchovesicular breath sounds are heard in an area of lung where vesicular breath sounds should be,

Question 20

Define adventitious breath sounds

Answer 20

Adventitious breath sounds refer to extra sounds heard in addition to the normal lung sounds. They suggest the presence of a disease process.

Question 21

What do crackles sound like?

Answer 21

brief, intermittent, discontinuous sounds that can be on a continuum from fine and dry to coarse and wet-sounding.

Question 22

What causes crackles?

Answer 22

The sounds are believed to be caused by small airways popping open during inspiration and sometimes may be related to secretions in closed small airways

Question 23

What do persistent mid to late inspiratory crackles suggest?

Answer 23

abnormal lung parenchyma or abnormal small airways

Question 24

“continuous sounds with a musical quality” describes what adventitious breath sound?

Answer 24

rhonchi

Question 25

What causes rhonchi?

Answer 25

Rhonchi are caused by narrowing of larger airways from secretions in the airways (as in COPD, bronchitis, bronchiolitis). These noises often change breath-to-breath, or clear after coughing.

Question 26

What does wheezing suggest? What part of the breath are they heard on?

Answer 26

Wheezing suggests a narrowing of the intra-thoracic airways (as in asthma, COPD, bronchiolitis). Wheezing should contain an expiratory component, though can be biphasic (inspiratory and expiratory).

Question 27

What causes stridor? What part of the breath are they heard on?

Answer 27

Stridor is caused by narrowing of the extra-thoracic upper airway (croup, laryngeal edema, mass) and should contain an inspiratory component, though can be biphasic (inspiratory and expiratory).

Question 28

Define bronchophony

Answer 28

Increased transmission of spoken words heard in the presence of consolidation of the lungs. Words will be transmitted louder than normal if bronchophony is present.

Question 29

Define whispered pectorlioquy

Answer 29

Intensification of whispered words (“one-two-three”) heard in the presence of consolidation of the lung.

Question 30

Define egophony

Answer 30

The spoken word heard through the lungs takes on a nasal or bleating sound. When consolidation is present, the “ee” sound will be heard as a long “a”.

Question 31

What findings would I expect to hear in consolidated lung tissue? What special tests would support this?

Answer 31

findings on auscultation in the focal area of consolidation may include: decreased breath sounds, bronchial breath sounds, and/or persistent late inspiratory crackles in the affected area of the lung. You may not hear these all at once depending on the degree of consolidation.

Findings of bronchophony, egophony and whispered pectoriloquy in the area of consolidation would support this diagnosis.

Question 32

What findings would I expect on percussion and auscultation in a patient with asthma?

Answer 32

Asthma – resonant or hyperresonant to percussion throughout both lungs, diffuse wheezes; with severe bronchoconstriction there may be markedly decreased breath sounds bilaterally such that very little wheezing is heard, or wheezing may just be at end expiration.

Question 33

What findings would I expect on percussion and auscultation of a pneumothorax?

Answer 33

Pneumothorax – hyperresonant to percussion on the affected side only, absent breath sounds over the area of pneumothorax

Question 34

Describe differences between crackles and rhonchi and in what disease process they are heard

Answer 34

Crackles are brief, intermittent, nonmusical adventitious (extra) breath sounds caused by abnormalities of the lung parenchyma or small airways, such as with interstitial lung disease, pulmonary fibrosis, pulmonary edema, pneumonia and bronchiolitis. Rhonchi are lower-pitched musical sounds created by mucous in the larger airways, which often change when the patient coughs, and are found in diseases such as bronchitis and bronchiolitis.

Question 35

Describe the difference between wheezes and stridor. In what disease processes are these sounds heard?

Answer 35

Wheezes are higher-pitched musical sounds, often more continuous, though not heard throughout the entire respiratory cycle, and are caused by narrow airways of asthma, COPD, bronchitis and bronchiolitis. Wheezing is usually heard in expiration due to collapse of the airways with obstructive lung disease, but can be biphasic (in inspiration and expiration).

Stridor is a high-pitched musical sound caused by narrowing of the upper airway, as with airway edema from intubation or anaphylaxis, epiglottitis, croup, or a foreign body in the airway. Stridor should be heard in inspiration, but can also be biphasic (in inspiration and expiration).

Question 36

Absent sliding of the pleural line indicates what state?

Answer 36

pneumothorax

Question 37

What are A lines? are they normal or abnormal?

Answer 37

A lines are horizontal lines deep to the pleura which are artifacts caused by the ultrasound waves bouncing between the skin surface and the pleura (these are normal)

Question 38

Describe the normal luing in an evaluation of a pleural effusion or hemothorax

Answer 38

In a normal lung the ultrasound waves are scattered and an artifact is created which makes the lung appear just like the liver or spleen

Question 39

Describe the abnormal or positive findings in a lung ultrasound for pleural effusion or hemothorax

Answer 39

· In a lung with a pleural effusion or hemothorax, the ultrasound sound waves can travel through the fluid and a black triangle is seen cranial (on the left of the screen) to the liver or spleen

spine sign

Question 40

How do you evaluate for interstitial fluid with ultrasound?

Answer 40

B lines

Question 41

What 2 things do B lines indicate?

Answer 41

interstitial fluid (e.g. pulmonary edema) or thickening of the interstitial tissue (e.g. pulmonary fibrosis, diffuse lung infections)