Respiratory Flashcards
Dyspnoea (SOB) is a common chief complaint. What are some of the causes?
Cardiovascular: acute coronary syndrome, pericarditis, myocarditis, shock, pulmonary oedema, cardiac tamponade and pulmonary embolism.
> Respiratory: COPD, asthma, pneumonia, bronchitis, bronchiolitis and pneumothorax.
> Musculoskeletal: fractures of the ribs and/ or sternum and muscle sprains involving the intercostal muscles.
> Metabolic: metabolic acidosis and sepsis.
> Other: anaemia, hyperventilation, airway
obstruction and anaphylaxis
What does a respiratory assessment involve
Respiratory assessment involves six steps: taking a history, inspection, palpation, percussion, auscultation and vital sign acquisition
Chest abnormalities
Chest wall expansion and movement:
– Look for asymmetry in chest wall expansion.
– Look for abnormal chest wall movement, for example flail chest or diaphragmatic breathing.
– Asymmetric expansion occurs with conditions that alter air movement into one lung compared with the other, for example pneumothorax, unilateral pneumonia or a large pleural effusion.
> Scars, bruising or wounds:
– Look for surgical scars, bruising or wounds which may help indicate a cause for the patient’s condition.
Respiratory assessment- palpating
> Feel the chest wall for abnormalities such as tenderness, crepitus or subcutaneous air.
Feel chest wall expansion by placing your hands on the patient’s anterior chest and feeling for chest wall expansion during inspiration, looking for a difference between the sides.
A decrease in chest wall expansion occurs with conditions that alter air movement into one lung compared with the other, for example pneumothorax, unilateral pneumonia or a large pleural effusion.
Respiratory assessment- Percussion
> Percussion is performed by tapping on a finger held flat on the chest and listening to the tone of the sound created.
Percussion is performed to determine whether the underlying tissues are air-filled or fluid-filled/solid.
Percussion is best performed in a quiet environment.
Percussion tones (or notes) can be broadly divided into three types:
– Resonant (normal). This occurs with normal lungs.
– Dull. This occurs when fluid replaces air. For example, pneumonia, pleural effusion and heamothorax.
– Hyper-resonant. This occurs when there is more air present than usual in the lung or air is in the pleural space. For example severe emphysema and pneumothorax.
It is possible to percuss the chest in multiple
sites and the number of sites chosen requires judgement that balances the time it takes with the amount of clinical information that is obtained. We recommend percussing in six anterior sites, two lateral sites and six posterior sites (see figure 2). You should only percuss the posterior chest if the patient is well enough to sit forward.
It is important to percuss regularly so that you learn what percussion tone is normal.
Document abnormalities according to the side and site. For example left/right, anterior (upper, mid or lower), lateral or posterior (upper, mid and lower
Respiratory Auscultation
> Auscultate (listen using a stethoscope) the breath sounds and note any abnormal sounds. Listen for equality of air entry and added sounds.
There are multiple different terms used to describe breath sounds and/or added sounds and it is common for different people to use the same term to describe different sounds. For this reason, use clear terminology that describes the nature of the sound, as this minimises confusion and creates consistency:
– Normal breath sounds: the normal sound of breathing in the setting of a patient with normal lungs.
– Fine crackles: fine crackling or popping sounds created when alveoli and small airways contain fluid. Causes include cardiogenic pulmonary oedema, pneumonia and drowning.
– Coarse crackles: coarse low pitched rattling sounds created when air flows through secretions and/or obstruction in large airways. Causes include COPD and pneumonia.
– Wheeze: a high pitched musical sound created when air flows through small and medium sized airways that are narrowed. Causes include COPD, asthma and cardiogenic pulmonary oedema.
– Stridor: a high pitched sound created when air flows through a partially obstructed
upper airway. Strictly speaking this is not a breath sound because it is not obtained by using a stethoscope. Causes include oedema secondary to allergy, infection or angioedema.
> It is possible to auscultate the chest in multiple sites and the number of sites chosen requires judgement that balances the time it takes with the amount of clinical information that is obtained. We recommend auscultating in six anterior sites, two lateral sites and six posterior sites (using the same sites as recommended for percussion). You should only auscultate the posterior chest if the patient is well enough to sit forward.
> Listen to 1–2 breath cycles in each site.
> It is important to auscultate regularly so that you
learn what breath sounds are normal.
> Document abnormalities according to the side and site. For example left/right, anterior (upper, mid or lower), lateral or posterior (upper, mid and lower).
> Beware of the silent chest. This could mean that there is very little air moving in and out of the lungs. It is a serious sign and usually means that the patient requires immediate intervention
Outline how you would question a patient with dyspnoea
A competent demonstration includes:
> Questions are systematic and
appropriate for patient condition.
> Questioning on recent illnesses, and/or complaints
Demonstrate how you would perform a physical assessment on a patient with dyspnoea
A competent demonstration includes:
> Inspection:
– Note the patient’s breathing/ work of breathing (i.e. intercostal retractions, tripod positioning, nasal flaring).
– Deformities/asymmetry in chest expansion.
– Presence of surgical scars, bruising, or wounds.
> Palpation:
– Identify painful/tender areas.
– Assess any abnormalities (i.e. crepitus, subcutaneous air).
– Assess chest expansion.
> Percussion:
– Determine if underlying tissues are air-filled, fluid-filled or solid.
> Auscultation:
– Auscultate lung sounds: air entry, tidal volume, equality of air entry, presence of adventitious sounds, hyper-resonance.
> Acquisition of vital signs
Inspection- Respiratory assessment
Work of breathing:
– Look for signs of increased work of breathing including indrawing, tripod positioning or nasal flaring.
– Increased work of breathing occurs with conditions that increase the resistance to airflow (for example asthma, COPD or airway obstruction) and conditions that decrease the compliance (elasticity) of the lungs (for example pneumonia or pulmonary haemorrhage).
Chest wall expansion and movement:
– Look for asymmetry in chest wall expansion.
– Look for abnormal chest wall movement, for example flail chest or diaphragmatic breathing.
– Asymmetric expansion occurs with conditions that alter air movement into one lung compared with the other, for example pneumothorax, unilateral pneumonia or a large pleural effusion.
> Scars, bruising or wounds:
– Look for surgical scars, bruising or wounds which may help indicate a cause for the patient’s condition.
