Respiratory Flashcards
How do you set up for a resp exam? (6)
WIPPPE:
- Wash hands
- Introduce yourself and identify patient
- Permission (gain from patient after explaining exam)
- Position (45 degrees for CVS/resp)
- Pain (check if patient has any pain)
- Exposure (adequately expose patient)
What are the two patient identifiers? (2)
- Name
- DOB
What are the end of bed observations that can be made in a resp exam? (7)
- Oxygen mass
- Walking aids
- Drip stand
- Nebuliser
- Urinary catheter
- Snacks
- Sputum pots
What features of a patient can be seen from their general appearance relevant to a resp exam? (9)
- In pain?
- Unwell?
- Breathless?
- Breathing observations?
- Cyanosis?
- Age?
- Scars?
- O2 sats?
- Cachexia?
What breathing observations can be made from a patient from their general appearance relevant to a resp exam? (8)
- Using accessory muscles of respiration?
- Leaning forward and using arms in breathing to brace chest? Tripod position?
- Pursed lips?
- Intercostal muscle recession?
- Nasal flaring?
- Cough? Dry/productive?
- Wheeze (expiratory)?
- Stridor (inspiratory?
What resp conditions do young patients tend to get? (2)
- Asthma
- Cystic fibrosis (CF)
What resp conditions do older patients tend to get? (3)
- COPD
- Interstitial lung disease (ILD)
- Malignancy
What does O2 around the bed indicate? (2)
- ILD
- COPD
What do inhalers/nebulisers around the bed indicate? (2)
- Asthma
- COPD
What do sputum pots around the bed indicate? (2)
- COPD
- Bronchiectasis
What does cachexia indicate in a resp exam? (3)
- Malignancy
- Cystic fibrosis
- COPD
What does a dry cough indicate? (2)
- Asthma: younger
- ILD: older
What does a productive cough indicate in older patients? (2)
- Bronchiectasis
- COPD
What does a productive cough indicate in younger patients?
Cystic fibrosis
What does an expiratory wheeze indicate? (3)
- Asthma
- COPD
- Bronchiectasis
What does an inspiratory stridor indicate?
Upper airway obstruction
What is the order of a resp exam? (23)
- General observation
- Hands
- Pulse
- Temp
- Resp rate
- Tremors
- Face
- Mouth
- Eyes
- JVP
- Trachea + cricosternal distance
- Thorax inspection
- Apex beat palpation
- Heave
- Expansion
- Percussion
- Auscultation
- Vocal resonance
- Repeat for posterior chest
- Lymph nodes
- Sacral oedema
- Legs and calves
- Investigations
What are looked for in hands in a resp exams? (5)
- Tar staining
- Clubbing
- Peripheral cyanosis
- Rhematological disease - joint swelling/tenderness
- Bruising/thinning of skin
What are the resp causes of clubbing? (5)
- Bronchial carcinoma
- Empyema/abscess (chronic lung suppination)
- Bronchiectasis (chronic lung suppination)
- Cystic fibrosis (chronic lung suppination)
- Fibrosing alveolitis
Why are signs of a rhematological disease checked for in a resp exam? (2)
- Pleural effusion association
- Pulmonary fibrosis association
What is bruising/thinning of skin associated with? Give 3 examples
Long term steroid use e.g in ILD/asthma/COPD
What does a reduced temperature suggest? (2)
- Peripheral vasoconstriction
- Poor perfusion
What is assessed in pulse palpation? (2)
- Rate
- Rhythm
When is a resp rate of up to 20 still normal?
Patients with anxiety
How is resp rate counted?
Breaths in 15 secs x 4
What two types of tremor are assessed for?
- Fine tremor
- Flapping tremor
How is fine tremor assessed?
Ask patients to hold out arms outstretched
What is a fine tremor associated with?
Beta agonist medications
How is flapping tremor assessed?
Cock wrists back
What is flapping tremor associated with?
- CO2 retention - type 2 resp failure e.g COPD
What signs are checked for in the face in a resp exam? (3)
- Central cyanosis on lips/under tongue
- Pursed lip on expiration
- Dusky appearance and swelling
What does a dusky appearance and swelling in the face indicate? And how (2)
SVP compression
- Mediastinal tumour
- Puenmothorax
What signs are checked for in the eyes in a resp exam? (2)
- Conjunctival pallor
- Horner’s syndrome
What does Horner’s syndrome look like in the eyes? (3)
- Unilateral miosis (pupil constriction)
- Ptosis (falling of upper eyelid)
- Enophthalmos (posterior eyeball placement in orbit)
What are the signs of Horner’s syndrome in the face?
Anhidrosis (inability to sweat) on affected side
What does a raised JVP indicate in resp? (4)
- Cor pulmonale
- SVC obstruction
- Acute: tension pneumothorax
- Acute: PE
How is the trachea palpated? (6)
- Warn
- Relaxed neck musculature: chin downwards
- Place 3 fingers gently
- Into sternal notch
- Central: trachea under middle finger
- Compare space between trachea and sternocleidomastoid on each side: difference = deviation
What does the trachea deviate away from? (2)
- Pnuemothorax
- Large pleural effusion
What does the trachea deviate towards? (2)
- Lobar collapse
- Pueumonectomy (surgical lung part removal)
What scars are inspected for on the chest? (2)
- Small mid axillary scars
- Horizontal postero-lateral scars (on back)
What do horizontal postero-lateral scars indicate?
Thoracotomy from e.g. lobectomy/pneumonectomy
What do small mid axillary scars indicate?
Chest drains
What surgeries does asymmetry of the chest wall indicate? And why? (2)
- Pneumonectomy: cancer
- Thoracoplasty : rib removed for TB
What is inspected for in the chest wall? (4)
- Scars
- Asymmetry
- Shape
- Intercostal recession due to rapid inspiration
What conditions cause intercostal recession due to rapid inspiration? (2)
- Acute infection
- Asthma
What does a displaced apex beat indicate in a resp exam?
Mediastinal mass
What does an absent apex beat indicate in a resp exam? (2)
- Large pleural effusion
- Pneumothorax
What are the two ways an apex beat can be changed in a resp exam? (2)
- Displaced?
- Absent?
- Difficult to feel/hear?
What might make the apex beat difficult to feel/hear in a resp exam?
Hyperinflation due to COPD
What is felt for on the chest? (2)
- Apex beat
- Right ventricular heave
What deformities can be seen in chest wall shape?
- Barrel chest
- Pectus excavatum
- Pectus carinatum
What does barrel chest indicate?
Hyperinflation due to COPD
What is pectus excavatum?
Genetic caved in chest, deformity of anterior thoracic wall
What are the dangers of pectus excavaum? (2)
- Can lead to difficulty of lung expansion
- Compression can squeeze heart
What is pectus carinatum?
“Pigeon chest”
Genetic chest jutting out due to unusual rib and sternum protrusion growth
What can pectus carinatum cause?
Shortness of breath esp on exertion
How is chest expansion assessed? (7)
- Cup hands
- Fingers spread
- Around upper anterior chest
- Press finger tips into mid axillary line
- Bring thumbs together in midline touching
- See how much thumbs move as patient breathes in: should move apart equally
- Look for asymmetry
Where should chest expansion be assessed? (3)
- Upper anterior chest
- Lower anterior chest
- On back
What is asymmetry of chest expansion?
One of thumbs moving less - reduced expansion on that side
What can reduced chest expansion on one side indicate? (2)
- Lung collapse
- Pneumonia
What are the resp causes right sided heart failure causing right ventricular heave be secondary to? (2)
Chronic hypoxic lung diseases:
- COPD
- ILD
Describe good percussion technique (4)
- Middle finger of non-dominant hand
- Along an intercostal space - Tap with flexed index/ middle finger of dominant hand
- On middle finger middle phalanx non dominant hand
What areas should be percussed side to side anteriorly? (4)
- Supraclavicular (lung apices)
- Infraclavicular
- Chest wall (3-4 locations bilaterally)
- Axilla
What is the normal percussion note?
Resonant
Posterior lung ausculation (3)
- 4 rows
- Around borders of scapula
- Then borders of back
Cricosternal distance? (2)
- Distance between suprasternal notch and cricid cartilage
- Healthy: 3-4 patient fingers
What does reduced cricosternal distance suggest?
Lung hyperinflation
What does a dull percussion note suggest? Give 4 examples
Increased tissue density
- Consolidation
- Fluid
- Tumour
- Collapse
What does a stony dull percussion note suggest?
Pleural effusion
What does a hyperresonant note suggest? Give an example
Decreased tissue density
Puenmothorax
What insructions should be given to a patient for auscultation?
Deep breaths in out through mouth
What position should the patient be in for auscultation of the back? (3)
- Lean forward
- Hunched over
- Cross arms
Describe vesicular breath sounds (4) Where should they be heard?
- Lower pitch
- Shorter expiration
- No pause between inspiration and expiration
THORAX
Describe bronchial breath sounds (4) Where should they be heard normally? (4)
- Higher pitch
- Louder/harsher
- Inspiration and expiration equal
- Pause between inspiration and expiration
TRACHEA
What are bronchial breath sounds over the thorax associated with?
Consolidation
What should be assessed in auscultation? (3)
- Quality: vesicular/bronchial?
- Volume: reduced?
- Added sounds: Stridor? wheeze? Coarse/fine crackles?
What do reduced breath sounds suggest? (3)
- Consolidation
- Collapse
- Pleural effusion
When is a wheeze heard? And what conditions is it associated with? (2)
Expiration
- Asthma
- COPD
What are coarse crackles associated with? (3) Inspiratory vs expiratory
- Puenmonia (inspiratory)
- Fluid overload (inspiratory) (e.g oedema/HF)
- Bronchiectasis (expiratory and inspiratory)
What are fine crackles associated with?
Pulmonary fibrosis
What are crackles that don’t clear after a cough associated with?
Bronchiectasis
What should you do if you hear crackles?
Ask patient to cough
How is vocal resonance assessed?
Ask patient to say 99
What does increased vocal resonance suggest? Give 3 examples
Increased tissue density
- Consolidation
- Tumour
- Lobal collapse
What does decreased vocal resonance suggest?
Fluid outside the lung - pleural effusion
What does lymphadenopathy indicate in resp exam? (3)
- Lung cancer
- TB
- Sarcoidosis
Why is sacral oedema relevant to a resp exam?
Fluid overload in cor pulmonale
What should be inspected for in the legs in a resp exam? (3)
- Pitting oedema
- Calves: DVT
- Erythema nodosum: Sacroidosis
Further investigations? (5)
- Peak flow
- O2 sats
- Chest x ray
- ABG
- Cardio exam
What should be assessed with crackles? (3)
- Fine/coarse?
- Change with breath?
- Change with cough?
Reduced chest expansion? (5)
- Fibrosis
- Consolidation
- Effusion
- Collapse
- Pneumothorax.
