Respiratory Module Flashcards
In recording the amount of cigarette smoking that a patient does and has done
measure the quantity of cigarette exposure in terms of packs-years
To calculate packs-years
it is the number of packs of cigarettes (20 per pack) a person smokes per day multiplied by the number if years he has smoked that many
The thorax has 4 surfaces, each of which deserves attention during the course of the physical exam:
- ) Anterior surface- between the 2 axillary lines
- ) Posterior surface - b/t2 posterior axillary lines
- ) Lateral surface - b/t the anterior and posterior lines bilaterally
- ) Supraclavicular surface - above the clavicles bilaterally
The thorax is divided horizontally by the
ribs and the interspaces
Each interspace is named (numbered) by the
number of the rib right above it. It is further referred to as either right or left.
It should be noted that on physical exam, the highest rib that can be palpated on the anterior surface of the chest is
the second rib
The 1st interspace that can be identified on the anterior surface of the chest is the
second interspace
The first rib and the first interspace are
“hidden” beneath the clavicle and cannot be detected on physical examination
Ribs and interspaces are easily detected on the anterior and lateral surfaces of the thorax but
are more difficult to detect on the posterior surface of the thorax
Using the ribs as real horizontal lines, the thorax can be divided into a
grid of sorts by using a system of imaginary vertical lines that intersect the ribs at specified points
The imaginary lines are:
Mid-sternal line
A line extending from the suprasternal notch in the anterior midline of the neck to the tip of the xyphoid process. It bisects the sternum.
Parasternal lines (right and left)
Lines that run vertically down each side of the sternum, joining the points at which the ribs (costal cartilages) meet the sternum
Mid-Clavicular lines (right and left)
Lines which extend from the mid-point of each clavicle to the mid-point of each anterior costal margin bilaterally. These lines generally intersect the nipples on each side and are occasionally referred to as the nipple lines
Anterior axillary lines (right and left)
Lines which extend down along each anterior axillary fold bilaterally and which parallel the mid-sternal and mid-clavicular lines
Mid-Axillary lines (right and left)
lines which extend vertically down from the apex of each axilla bilaterally and which parallel the anterior and posterior axillary lines
Posterior axillary lines (right and left)
lines which extend downward along the posterior axillary folds
Mid-scapular lines (right and left)
lines that extend through the inferior tip of the scapulae bilaterally. These lines are parallel to the thoracic spine and the mid-spinal line
Mid-spinal line (or vertebral line)
A line extending from the spinous process of the seventh cervical vertebrae to the spinous process of the 1st lumbar vertebrae. It intersects the spinous processes of each of the thoracic vertebrae. This line is straight in patients with a normal spine but may be curvilinear in patients with scoliosis.
The muscles utilized in the act of ventilation are divided into groups:
- ) the main muscles of respiration
2. ) the accessory muscles of respirations
The diaphragm and occasionally the external intercostal muscles are the
main muscles of respiration and are only needed during the act of inspiration to inflate the lungs. During expiration, all these muscles do is relax.
The accessory muscles of respirations are not needed to any extent during
non-labored breathing but become very necessary for both inspiration and expiration in patients with labored breathing.
In patients with labored inspiration, the accessory muscles utilized are the
sternocleidomastoid, scalenus, the pectoralis minor, and greater effort from the external intercostal muscles.
In patients with labored expiration, accessory muscles required for forced expiration include
the abdominal muscles (rectus abdominus) and the internal intercostals.
Angle of Louis (or sternomanubrial junction)
a bony prominence projecting forward on the anterior surface of the sternum about 2 inches (5cm) below the suprasternal notch
Angle of Louis is the fixed joint b/t the manubrium and the sternum and marks the site at which the
second rib (second costal cartilage) joins the sternum. it is a convenient landmark with which to locate the 2nd intercostal space
Costal Angle
the angle formed at the site of the xiphoid process by the intersecting costal margins.
The costal angle is measured in
degrees (normally the costal angle is 90 degrees or less)
Anterior-Posterior (A-P) Diameter
The distance b/t the sternum and the spine; it is usually “measured” as to how it relates to the lateral diameter of the chest at its widest point
4 techniques of physical assessment are used for chest examination:
- ) inspection
- ) palpation
- ) percussion
- ) auscultation
Structures outside of the thoracic region that relate to respiratory function and should be examined are:
the nose for nasal flaring, the position of the trachea in the neck, the color of the skin of the fingertips and around the mouth, the structure of the fingernails, etc.
The thorax and lungs can be examined with the patient sitting
up (preferable) or lying down
The thorax can be visualized in layers, consisting of a
skin layer, a muscle layer, a bone layer, and lung layer.
In examining the surface of the thorax, the examiner should attempt to relate surface findings to
underlying lung structure
For a complete evaluation of the thorax, the patient should be
completely disrobed to the waist
All significant chest findings should be described as to how they relate to the
“grid” on the patient’s chest defined by the horizontal ribs and interspaces and the “imaginary” vertical lines. Ex: “expiratory wheezing is audible in the right third interspace, 2 cm medial to the mid-clavicular line”
Anterior Chest
Inspection
Examiner should stand
directly in front of patient but should have the ability to move from side to side to inspect the lateral and supraclavicular surfaces of the chest as well
Observe chest for size, shape, and symmetry
Note the approx. A-P diameter as it relates to the lateral diameter (A-P diameter: Lateral diameter should be 1:2)
Increased AP to lateral diameter is associated with
air-trapping conditions, esp. chronic bronchitis, emphysema, cystic fibrosis
Ask the patient to take a deep breath.
Note the degree and the symmetry of respiratory expansion. Note the ease with which a patient can expand the chest.
Observe whether there is any splinting of the chest wall from apparent pain
Note the posture required by the patient to facilitate a full inhalation. Note the use of accessory muscles when breathing
In thin patients note the costal angle and estimate the number of degrees (this may not be possible to observe in obese patients but can be estimated by palpation later)
Increased costal angle (Greater than 90 degrees) is associated with the air-trapping conditions.
Observe the position of the patient’s sternum relative to the anterior ribs
1.) If more anterior than the anterior ribs = pectus carinatum
2.) If more posterior than the anterior ribs = pectus excavatum
These are congenital conditions that may be associated with other congenital conditions
Pectus excavatum can be the cause of
decreased lung volume and a heart that is pushed more to the left with compromised ability to deliver adequate cardiac output. It is frequently seen in Marfan’s syndrome (aortic arch dissection and aortic valvular incompetence) and is associated with mitral valve prolapse
Pectus carinatum is also noted in
Marfan’s syndrome
Palpation should be done in
Layers
Palpation of the skin:
Begin by very lightly touching the patient’s skin and observing for the temperature, texture, turgor, sensitivity, and skin masses
This palpation of the skin should include
the anterior, lateral, and supraclavicular surfaces; the posterior chest will be examined later. The patient should be asked to breathe normally at this time.
Palpation of the muscles:
touch and palpate with greater pressure to examine the second layer of the chest wall, the muscles. Note the bulk, tone, symmetry, and sensitivity of each muscle. Inspect for any involuntary contractions or masses.
Palpation of the bones:
the third layer, the bones, requires knowledge of the normal bony structure of the chest wall.
When palpating bones, note
size, position, masses, sensitivity and stability. Observe for instability or bony crepitus.
Bones to include in palpation of the thoracic skeleton are the
clavicles, sternum, manubrium, anterior and lateral ribs and the costal cartilages
A quick assessment of the general rib stability and/or rib tenderness is accomplished by
compressing the chest in an anterior-posterior direction. This is performed by placing one hand on the patient’s sternum and the other hand on the patient’s spine and, by pushing the hands toward one another, any rib tenderness will be easily demonstrated as pain
Lastly, palpate the
lungs.
It is possible to feel, on the surface of the chest wall, evidence of the function of the lungs. This is done in 2 ways:
- ) Thoracic Expansion
2. ) Tactile Fremitus
Thoracic Expansion
This maneuver is done to roughly measure the degree to which a patient can
expand the chest with a deep inspiration
Thoracic Expansion
The examiner places the fingertips of both hands firmly on the lateral chest walls, as far to the patient’s sides as possible, while
still being able to bring the thumbs of both hands together just below the patient’s xiphoid bone
Thoracic Expansion
With the thumbs only lightly touching the patient, ask the patient to
take as deep a breath as possible. Keeping the fingertips firmly in place, allow the thumbs to glide apart over the surface of the patient’s skin and note (measure in cm) how far apart the pt. can move the examiner’s thumbs with just the expansion of his lower chest
Tactile Fremitus
This maneuver is done to assess the degree of
aeration of the lungs and the presence of any substance in the pleural spaces
Tactile Fremitus
With the examiner firmly but lightly touching the skin of the chest, the pt. is asked to
recite words that have a strong vocal quality, such as “ninety-nine”
Tactile Fremitus
By palpating while the patient repeats the words “99”, vibrations can be felt on
the surface of the chest wall.
Tactile Fremitus
These vibrations are created by the pt.’s
vocal cords and transmitted bi-directionally; outward, which the examiner hears as speech and backward into the alveoli; which the examiner can feel as vibrations. Note the intensity and symmetry of the vibrations.
Tactile Fremitus
The most sensitive parts of the hands with which to feel tactile fremitus are the
bases of the fingers or the ulnar surfaces
Palpate for tactile fremitus by placing both hands simultaneously in
several symmetrical locations on the anterior, lateral, and supraclavicular surfaces of the chest; the posterior surface will be examined later.
Decreased fremitus will be noted in any conditions in which
vocal cord vibrations are prevented from reaching the chest wall.
Decreased fremitus will be noted in the following conditions:
asthma during an acute attack b/c of the bronchospasm of the upper airway occluding the air passages
Decreased fremitus will be noted in the following conditions:
atelectasis b/c of the deflated alveoli and (usually) the occluding lesion in the bronchus causing the atelectasis
Decreased fremitus will be noted in the following conditions:
Emphysema b/c of the deminished number of alveoli capable of vibrating
Decreased fremitus will be noted in the following conditions:
Chronic obstructive bronchitis b/c of the occluding mucus plug in the major bronchi common in this condition
Decreased fremitus will be noted in the following conditions:
Pleural effusion b/c of the interposition of free fluid b/t the vibrating alveoli and the chest wall
Decreased fremitus will be noted in the following conditions:
Pneumothorax b/c of the interposition of free air b/t the vibrating alveoli and the chest wall
NOTE: Fremitus may be ___ in a large pneumothorax
totally absent
Increased fremitus is noted in those conditions in which the lung tissue is more
solid than usual (air in the alveoli somewhat dampen the intensity of vocal cord vibrations)
Solid lung tissue (as seen in pneumonia and a large solid mass (lung tumor) that is still in contact with patent air passages will
vibrate with greater intensity than usual. This increased fremitus is most often noted in consolidated lobar pneumonia in which the bronchi are still patent
Note: there is normal asymmetry to those vibrations over the
precordium because of the imposition of the heart between the lung tissue and the chest wall
Note: Palpation for tactile fremitus on a female patient’s chest requires that the
breasts be “pushed aside” as far as possible. It is not possible to evaluate tactile fremitus through breast tissue
Percussion is a technique employed by the examiner to create sounds with the hands that will
penetrate the chest cavity (and the lung) and then reverberate back to the examiner’s ears. It is used to evaluate the degree of aeration of underlying lung tissue
Percussion: Ask the patient to sit
upright as straight as possible
Percussion
Place on the long finger of the non-dominate hand firmly against the chest wall
not allowing any other part of the hand to come in contact. This finger is called the pleximeter
Percussion
Flex the long finger of the dominant hands 90 degree at the PIP joint but keep the
DIP joint fully extended. This long finger is called the plexor.
Percussion
By striking the DIP joint of the pleximeter with the tip of the plexor like a hammer, a
sound will be created that can penetrate several centimeter’s into the patients chest
Percussion
Correct striking motion is with the
wrist only, (do not use forearm) and with a sharp, brief contact b/t the plexor and the pleximeter
Percussion
Perform percussion in several symmetrical areas on the
anterior, lateral, and supraclavicular surfaces of the chest wall.
Percussion
The reflected sound coming back to the examiner’s ears from normal, well-aerated lung has a tonal quality referred to as
resonance
Percussion
The percussion notes heard in symmetrical areas should be equal in
loudness (intensity) and tonal quality but there is a normal dull percussion note heard over the precordium, again bc of the fluid filled heart
A dull percussion note can be heard over lung tissue that is comparatively deflated when compared to normal lung
These conditions include atelectasis, lobar pneumonia (because the alveoli are filled with fluid), or over a large lung tumor or abscess located close to the surface of the lung.
A dull (or flat) percussion note will also be noted over an area of pleural effusion because of
the large area of fluid (and the absence of air) between the lung tissue and the chest wall.
A hyperresonant percussion note will be noted over lung tissue in which the alveoli are
comparatively overfilled with air compared to normal lung tissue. These include emphysema, asthma (during the acute attack), and chronic obstructive lung disease.
A hyperresonant note will also be noted over an area of pneumothorax because
of the large pocket of air between the lung and the chest wall
Auscultation is typically performed with the diaphragm of the stethoscope because
the diaphragm is designed to hear high-pitched sounds and most respiratory sounds are high- pitched.
Auscultation
The examiner should stand at the side of the patient to place an arm across the patient’s upper back
This is to allow the examiner to be able to prevent a patient from falling if they become dizzy from deep breathing
Begin auscultating the chest in the supraclavicular areas
moving the stethoscope from side to side to symmetrical areas
The examiner should ask the patient to take slow, deep breaths in and out through the mouth (examiner may have to demonstrate this) and listen for
a minimum of two full breaths at each area.
Continue these steps, moving in a stair-step fashion, auscultating several areas in the
anterior and lateral surfaces and comparing breath sounds in symmetrical areas
In evaluating breath sounds, characteristics to note include their
intensity, their pitch, and the durations of their inspiratory and expiratory phases
Discontinuous adventitious sounds
These are sounds called crackles or rales and are further classified as fine crackles and coarse crackles
Discontinuous adventitious sounds
They are intermittent, can range from high (fine crackles) to low pitch (coarse crackles), and are heard during inspiration only. They do not clear with coughing.
Continuous adventitious sounds
These are sounds called wheezes or rhonchi. They are continuous, can be heard during either inspiration or expiration or both, can be high-pitched (wheezes) or low-pitched (rhonchi), and may clear with coughing.
If any abnormal lung finding is detected on inspection, palpation, percussion, or especially auscultation
one further auscultatory maneuver should be done.
The examiner should evaluate the type of transmitted voice sounds that
can be heard through the abnormal areas.
While the patient is saying “ninety-nine,” the examiner auscultates over the suspect area.
These words are not well transmitted through normal well-aerated lung tissue and are muffled and indistinct
If these words are heard well and distinctly as “ninety-nine”
the patient is said to have bronchophony in this area. This usually means that the lung underlying this area is probably consolidated as occurs in lobar pneumonia
An additional test done to confirm this finding is to ask the patient to say the letter “E” repeatedly
Normally, this sounds to the examiner as the letter “E” but through consolidated lungs tissues it is heard distinctly as “A”. This finding is referred to as egophony
A variation to the bronchophony test is to ask the patient to whisper the words “ninety-nine”;
if they are heard loudly and distinctly, this is the abnormal sign referred to as whispered pectoriloquy.
POSTERIOR CHEST INSPECTION
The examiner should stand directly
behind the patient and the patient should be sitting up straight. Observe the size, shape and symmetry of the thorax from this direction.
Posterior Chest
Palpation
Palpate the skin:
Lightly touch the skin, applying only enough pressure to note skin temperature, texture,
turgor, and the presence of any subcutaneous masses.
Posterior Chest
Palpation
Palpate the muscles
Palpate a little deeper with enough finger pressure to note muscular tone, bulk, tenderness, or masses. Understand the anatomy of the named muscles of the back.
Posterior Chest
Palpation
Palpate the bones
Specifically palpate the posterior ribs, the scapulae, and the thoracic spine noting tenderness, deformity, masses, or bony crepitus.
Posterior Chest
Palpation
Palpation of the “lungs” on the posterior chest is done to detect the degree of
tactile fremitus. This is best accomplished by asking the patient to hunch forward, folding his arms across the front of the chest. This allows the scapulae to move laterally, exposing more of the lung to be “exposed” for examination
Posterior Chest
Palpation
Palpate the lungs: Using the same techniques that were used on the anterior and lateral chest, ask the patient to again repeat the words
“ninety-nine”, moving both hands simultaneously to several symmetric locations and comparing the degree of tactile fremitus. There are no normal asymmetries of tactile fremitus on the posterior chest.
Posterior Chest
Percussion
Percussion of the lung fields for the intensity and quality of the reflected sound is done
in the same way as is described for the anterior-lateral chest.
Posterior Chest
Percussion
The patient should again be in the hunched over position with
the arms folded in front to expose as much of the lung to the percussion technique as possible
Posterior Chest
Percussion
A second use of percussion is employed on the back;
it can be used to measure the amount of diaphragmatic excursion
Posterior Chest
Percussion
Diaphragmatic excursion is the number of centimeters that a patient can
lower the diaphragm with a full inspiration
Posterior Chest
Percussion
The position of the diaphragm at rest can be detected by
percussion on the posterior chest wall
Posterior Chest
Percussion
By beginning the percussion in an area of normally resonant lung above the diaphragm and
percussing slowly downward in 1cm increments until the area of dullness is detected, the examiner will observe that the sound of the percussion note will change to a dull percussion note over the non-aerated tissues below the diaphragm
The place on the posterior chest wall where the percussion note changes from resonance to dullness is the position of the diaphragm at rest.
This spot can be marked with a skin marking pencil
Posterior Chest
Percussion
Now ask the patient to take a deep breath and hold it.
Percussing again at the location of the diaphragm at rest will reveal that the area that was dull is now resonant
Posterior Chest
Percussion
This is because by taking a deep breath, the patient has depressed his diaphragm,
more lung has inflated with air and now occupies more of the chest cavity.
Posterior Chest
Percussion
Beginning at the pencil mark, resume percussion in 1 cm increments downward until a new point is detected between resonance above and dullness below
This is the new position of the diaphragm and its location can be marked with a skin marking pencil
Posterior Chest
Percussion
By measuring the distance between these two pencil marks, the number of centimeters of diaphragmatic excursion can be noted.
[Note: A normal healthy adult with good lungs and lung function should be able to lower the position of the diaphragm at least 4 centimeters with a deep inspiratory effort.]
Posterior Chest
Percussion
Common conditions resulting in decreased diaphragmatic excursions are
asthma (during the acute attack), chronic obstruction lung disease, emphysema, phrenic nerve paralysis, obesity, chest wall stiffness, ascites, abdominal pain, subphrenic abscess.
Posterior Chest
Auscultation
Auscultation of the posterior lung fields is done in the same way that is described for the anterior chest
After about 10-12 deep breaths, allow the patient to rest by breathing normally for 1-2 minutes
Posterior Chest
Auscultation
The examiner should stand at
the side of the patient with an arm placed across the patient’s upper anterior chest. This will prevent the patient from falling forward while the examiner is auscultating
Locations on the Chest
Supraclavicular
Above the clavicles
Locations on the chest
Infraclavicular
Below the clavicles
Locations on the chest
Interscapular
Between the scapulae
Locations on the chest
Infrascapular
Below the scapula
Locations on the chest
Bases of the Lungs
The lowermost portion
