Respiratory Lab Flashcards
Needle Thoracentesis (decompression)
2nd intercostal space just superior to 3rd rib margin at the midclavicular line for emergent decompression of tension pneumothorax, followed by chest tube placement
Where does the neurovascular bundle run?
inferior to each rib, so needles should be placed superior to the rib margins
Chest tube insertion
4th intercostal space at mid or anterior axillary line just superior to the margin of the 5th rib
Where is the lower margin of the endotracheal tube after insertion seen on a chest x-ray?
T4
Healthy adult Respiration Rate
14-20x a minute
Pursed lips indicate
COPD
Asymmetrical movement indicates
pleural effusion
Intercostal retractions indicate
severe asthma, COPD, upper airway obstruction
Tripoding
obstructive lung disorders
Barrel chest
COPD
contraction of accessory muscles
scm, scalenes, supraclavicular retraction
lateral displacement of trachea
tension pneumothorax
Clubbing
- bulbous swelling of soft tissue at nail base
- loss of normal angle between nail and proximal nail fold leading to spongy or floating feeling
- mechanism involves vasodilation with increased blood flow to distal portion of digits and changes in hypoxia, changes in innervation, or a platelet derived growth factor
Conditions in which clubbing is seen
- congenital heart disease
- interstitial lung disease
- bronchiesctasis
- pulm fibrosis
- lung abscess
- IBD
- malignancies
- cystic fibrosis
Focus of palpation
- areas of tenderness
- abnormalities overlying skin
- respiratory expansion
- tactile fremitus
Tactile fremitus
- palpable vibrations transmitted through bronchopulm tree to the chest wall as the patient speaks
- perform on anterior and posterior chest
- use ball or ulnar surface of hands
- often more prominent in interscapular area than in the lower lung fields
- more prominent on the right side than the left
- disappears below the diaphragm
Decreased/absent fremitus
COPD, pleural effusions, fibrosis, pneumothorax, thick chest wall, infiltrating tumor
Increased fremitus
pneumonia (increased transmission through consolidated tissue)
Percussion technique
- hyperextend middle finger and firmly contact skin
- strike extended finger aiming for DIP with quick wrist motion
- start superiorly percussing both dies of chest, working toward base in a ladder like pattern
- done on posterior and anterior chest
- percussion penetrates 5-7cm into chest, so may miss deep seated lesions
- percuss 4 posts on the back and on the right middle post for the lower right lobe
- patient seated with arms crossed in front of chest
Flat sound
- soft, high pitch, short duration
- ex) thigh
Dull sound
- medium intensity, medium pitch, medium duration
- ex) liver
Resonant sound
- loud intensity, low pitch, long duration
- ex) healthy lung
Hyperresonant sound
- very loud, lower pitch, longer duration
- ex) usually none
Tympanic sound
- loud intensity, lower pitch, longer duration
- ex) gastric air bubble or puffed out cheek
When does dullness replace resonance?
when fluid or solid tissue replaces air containing lung or occupies space beneath percussing fingers
- lobar pneumonia
- pleural accumulations
Generalized hyperresonance
- hyper inflated lungs
- COPD/emphysema
- asthma
Unilateral hyperresonance
- large pneumothorax
- large air filled bulla in lung
Diaphragmatic Excursion
- determine distance between level of dullness on full expiration and level of dullness on full inspiration by progressive percussion down from resonance to dullness
- normal excursion = 3-5.5 cm
- dullness at a higher level than expected suggests a pleural effusion or a high diaphragm (atelectasis or phrenic nerve paralysis)
Vesicular Breath Sound
- soft and low pitched
- heard through inspiration and about 1/3 of expiration
- heard over most of lungs
Bronchovesicular sound
- intermediate in intensity and pitch
- heard equally in inspiration and expiration
- heard best in 1st and 2nd interspaces anteriorly and between the scapulae posteriorly
Bronchial
- loud and high pitched
- expiratory sounds heard longer than inspiratory
- heard over manubrium
Tracheal sound
- very loud and high pitched
- heard equally in inspiration and expiration
- heard best over trachea in neck
Crackles
- discontinuous, intermittenet, nonmusical
- fine: soft, high pitched, brief
- coarse: louder, lower pitch, brief
- timing in respiratory cycle
- seen in pneumonia, fibrosis, early heart failure, bronchitis, bronchiectasis
Wheezes
- continuous, musical quality, prolonged
- relatively high pitched
- suggest narrowed airways (asthma, COPD, bronchitis, heart failure)
Rhonchi
- relatively low pitched, snoring quality
- suggest secretions in large airways
Stridor
- high pitched wheeze that is entirely or predominantly inspiratory
- often louder in neck than over chest wall
- indicated partial obstruction of larynx or trachea (medical emergency)
Pleural friction rub
- inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction
- sounds like cracking, usually during expiration
- usually confined to small area of the chest wall
Bronchophony
spoken words become louder and clearer
indicates consolidation
Egophony
“ee” sounds like “A”
pneumonia
Whispered Pectoriloquy
whispers head louder and clearer during auscultation
