Respiratory Palpation, Purcussion, Auscultation Flashcards
1
Q
Palpation heart during exam sequence
A
- Locate the apex beat,the most inferior and lateral place where the finger is lifted by the twisting systolic movement of the cardiac apex.
- This is normally in the fifth intercostal spacein the mid-clavicular line.Count down the intercostal spaces;the second is below the second rib, which attaches at the manubriostenal junction.
- Palpate for a right ventricular heave using a straight arm,with the palm over the lower sternum
2
Q
Palpation heart meaning
A
- The apex beat is displaced laterally by dilatation of the ventricles or leftward displacement of the mediastinum.
- In patients with significant hyperinflation, the apex beat may be impalpable because the lingula expands between the heart and the chest wall.
- In this situation, the heart sounds are often barely audible and may be heard better by auscultating in the epigastrium.
- In pulmonary hypertension, the lower sternum is lifted by the cardiac cycle (right ventricular heave) and a finger gently placed over the pulmonary area may detect closure of the pulmonary valve: a so-called palpable P2.
- Next, assess thoracic expansion in both the upper and loweranterior chest wall.
3
Q
Palpate- chest wall
A
- First, place the palms of your hands over the pectoral region overlying both upper lobes and oppose the elevated thumbs over the midline.
- Ask the patient to take a deep breath using the thumbs as pointers to judge how much each hand moves outwards.
- Then, cup your hands,with fingers spread, around the patient’s lower anterior chest wall overlying the lingula and right middle lobe, pressing the fingertips firmly in the mid axillary line.
- Pull your hands medially towards each other to tighten any loose skin,and once again use your thumbs (off the skin) aspointers to judge how much each hand moves outwards whenthe patient is instructed to take a full breath in.
- In a healthy thorax, the ribs move out and up with inspiration.
Check for any asymmetry. This is more important than the ab-solute degree of expansion,which will vary between individuals. - In COPD with hyperinflation, the normal outward movement of the lower ribs on inspiration is replaced by paradoxical inward movement (‘Hoover’s sign’), caused by contraction of the abnormally low, flat diaphragm.
- This important signmay be missed if expansion is assessed only in the upper chest or from behind.
4
Q
Percussion- what it sounds like
A
- Correctly performed, percussion should generate a hollow, ringing sound accompanied by a palpable resonance over air-filled lungs, but a dull thud lacking resonance over consolidation or fluid.
- Percussion is most valuable when detecting asymmetry of resonance between mirror image positions on the right and left sides.
- The absolute quality and volume of the percussed sound vary widely between individuals with differing chest wall thickness, muscularity and subcutaneous fat, and is of little value.
5
Q
Percussion examination
A
- To percuss the chest, apply the middle finger of your non-dominant hand firmly to an intercostal space, parallel to the ribs, and drum the middle phalanx with the flexed tip of your dominant index or middle finger.
- The movement should come from the wrist and not the elbow.
- Starting in the supraclavicular fossae, compare percussion at mirror image sites on right and left before moving to the next level
- Posteriorly, the scapular and spinal muscles obstruct percussion, so position the patient sitting forwards with their arms folded in front to move the scapulae laterally.
- Percuss a few centimetres lateral to the spinal muscles, taking care to compare positions the same distance from the midline on right and left
- Remember to percuss the lateral chest wall in the mid-axillary line, comparing both sides.
- In healthy people, anterior chest percussion is symmetrical except for the area immediately lateral to the lower left sternal edge, where the right ventricle causes dullness
6
Q
Percussion- meaning
A
Dullness can mean pneumothorax, consolidation, effusion
7
Q
Ausculation- physiology
A
- The tracheobronchial tree branches 23 times between the trachea and the alveoli.
- This results in an exponential rise in the number of airways and their combined cross-sectional area moving towards the alveoli.
-During a maximal breath in and out, the same vital capacity (about 5 L of air in-healthy adults) passes through each generation of airway - In the larynx and trachea, this volume must all pass through a cross-sectional area of only a few square centimetres and therefore flow rate is fast, causing turbulence with vibration of the airway wall, generating sound.
- In the distal airway, the large combined cross-sectional area of the multitude of bronchioles means that 5 L can easily pass at slow flow rates, so flow is normally virtually silent
- The harsh bronchial’ sound generated by the major airways can be appreciated by listening with the diaphragm of the stethoscope applied to the.
- Most of the sound heard when auscultating the chest wall originates in the large central airways but is muffled and deadened by passage through overlying air-filled alveolar tissue; this, together with a small contribution from medium-sized airways, results in ‘normal’ breath sounds at the chest wall, sometimes termed ‘vesicular’.
- When healthy, air-filled lungs become consolidated by pneumonia or thickened and stiffened by fibrotic scaring (e.g. post-tuberculous scaring), sound conduction is improved, and the centrally generated “bronchial’ breath sounds may be auscultated clearly and loudly on the overlying chest wall.
In the same way, with soft speech (‘say one, one, one’), the laryngeal sounds are muffled by healthy lung but heard clearly and loudly at the chest wall overlying consolidation and fibrotic scarring, due to improved conduction of major airway sounds through diseased lung. - When there is lobar collapse caused by a proximal bronchial obstruction, the signs are different from those in simple consolidation.
- The usual findings are diminished expansion, sometimes with chest asymmetry due to loss of volume, dullness to percussion over the collapsed lobe, and reduced breath sounds and vocal resonance.
- When the lung tissue is physically separated from the chest wall by intervening air (pneumothorax) or fluid (pleural effusion), sound conduction is greatly impaired and the breath sounds are usually very quiet or absent.
- These two causes are readily distinguished by percussion, which will be resonant with pneumothorax and dull over pleural fluid.
8
Q
Auscultation- breath sounds examination
A
- Auscultate the apices, comparing right with left, and changing to the bell if you cannot achieve flat skin contact with the diaphragm.
- Ask the patient to take repeated slow, deep breaths in and out through their open mouth.
- Auscultate the anterior chest wall from top to bottom, always comparing mirror image positions on right and left before moving down.
- Use the same sequence of sites as for percussion
- Note whether the breath sounds are soft and muffled, absent or loud and harsh (bronchial, like those heard over the laryrox).
- Seek and note any asymmetry and added sounds deciding which side is abnormal.
- Auscultate the lateral chest wall in the mid axillary line, again comparing right with left before changing level.
9
Q
Auscultation- added sounds wheeze
A
The three common added sounds are wheezes, crackles and rubs.
- Wheeze is a musical whistling sound accompanying airflow and usually onginates in narrowed small airways. It is most commonly expiratory, due to dynamic airway narrowing on expiration,but can also occur on inspiration.
- Usually, multiple wheezing sounds are heard together this sign is common in asthma, bronchitis and exacerbation of COPD.
- A single (monophonic) wheeze that is present consistently with each breath and does not clear with coughing is consistent with a fixed bronchial obstruction and may indicate an underlying cancer partially obstructing a bronchus.
10
Q
Auscultation- added sounds crackles
A
- Crackles are brief non-musical sounds that are most often heard on inspiration but may occur in any phase of breathing
- They are thought to represent the sudden opening of small airways but sometimes indicate secretions in the airways or underlying interstitial fibrosis.
- In healthy people, gravitational compression of the dependent lung bases may cause a few crackles on the first few deep breaths; these should clear with a deliberate cough and are of no pathological significance.
- Crackles that persist after several breaths and a cough are pathological.
- They are graded as ‘fine’, meaning soft, multiple crackles, to coarse, indicating loud, scanty crackles that tend to change with each breath.
- Showers of fine crackles during inspiration, resembling the sound made by peeling a Velcro fastener are characteristic of interstitial pulmonary fibrosis, and are commonly heard at the lung bases posteriorly and laterally.
- Fine crackles also occur in pulmonary oedema and some viral pneumonias.
- Coarse crackles are generally heard in patients with significant purulent airway secretions such as those with pneumonia or bronchiectasis.
- Inspiratory crackles may also be heard over incompletely inflated lung immediately above a pleural effusion.
11
Q
Auscultation- added sounds pleural rub
A
- A pleural rub is a rasping, grating sound occurring with each breath and sounding superficial, just under the stethoscope, like two sheets of sandpaper rubbing together.
It indicates pleural inflammation, usually due to infection or infarction of the lung, and is often accompanied by pleuritic chest pain. - In pneumonia, a pleural rub and the associated pain may disappear if a para- pneumonic effusion or empyema develops.
12
Q
Auscultation- vocal resonance
A
- Breath sounds normally reveal the presence of consolidation or fibrotic scarring (bronchial breath sounds) or pleural air or fluid (diminished or absent breath sounds).
- These signs can be confirmed by asking the patient to generate laryngeal sounds deliberately (‘Please say “one,one,one” each time I move mystethoscope’) and listening on the chest wall in the samesequence of sites used for breath sounds.
- Through the stethoscope, the spoken sound is muffled and deadened over healthy lung but is heard loudly and clearly over consolidated or fibrotic scarred lung.
- As with breath sounds, vocal resonance is absent or greatly diminished over pneumothorax and pleural effusion.
- Whispering pectoriloquy’ may be used to confirm the same changes in sound conduction.
- Whispered speech is muffled to silence by normal lung but may be heard over consolidated or scarred lungs
