Thorax and Lung review Flashcards
2nd intercostal space is used for
needle insertion for tension penumothorax
angle of louis
sternal angle
-5 cm lower than suprasternal notch
4th intercostal space is used for
chest tube insertion
level of the 4th rib
endotracheal tube on chest xray
7th intercostal space is for
thoracentesis needle
What vertebra is the most protruding process when neck is flexed?
c7 vertebra
What spinous process does the lower border of the lung lie around?
T10
Where should the RML be assessed along?
right anterior axillary line
Traits of the right main bronchus
wider, shorter and more vertical
common or concerning symptoms of thorax and lung analysis
dyspnea
wheezing
cough
hemoptysis
angina pectoralis
daytime fatigue
snoring
History to obtain for Dyspnea
-occurs at rest or exertion?
-pt’s daily exercise as a basis
-Timing, setting, any associated symptom and A/A factors
-
in dyspnea secondary to anxiety
-rest and exercise
-hyperventilation
-difficulty breathing/smothering sensation
-paresthesia around lips or extremities
Left sided heart failure
slow progression of dyspnea or sudden onset if pulmonary edema
associated symptoms: orthopnea, paroxysmal nocturnal dyspnea, sometimes wheezing
Chronic bronchitis
chronic productive cough
slowly progressive dyspnea
-recurrent respiratory infections, wheezing
-HX of smoking, exposure to air pollutants, COPD
COPD
-slowly progressive dsypnea
-cough with scant mucoid sputum
-hx of smoking, air pollutants, familial alpha1-antitrypsin deficiency
Asthma
reversible bronchoconstriction
-symptom free periods
-nocturnal episodes common
-wheezing, cough, tightness in the chest
-Aggravated by allergens, irritants, respiratory infection, exercise, cold and emotional
Diffuse Interstitial Lung Disease
progressive dyspnea with rate variable due to cause
-exertion aggravates
-weakness and fatigue
-cough is less common
Pneumonia
acute illness
-aggravated by exertions, smoking
-symptoms: pleuritic pain, sputum, fever (not present in much)
Spontaneous Pneumothorax
air pleural space w partial or full lung collapse
-sudden dyspnea
-pleuritic pain, non productive cough
COMMON: tall & young males, hx of emphysema
Acute Pulmonary Embolism
sudden dyspnea and tachypnea
-no associated symptoms
(sometimes: unilateral leg swelling, retrosternal oppressive pain, pleuritic pain, cough, syncope, hemoptysis, DVT)
-RISK FACTORS: Post-partum, Post-op, bed-rest, heart failure, COPD, fractures of the hips or legs, DVT, hypercoagubility
Anxiety with Hyperventilation
over breathing resulting in alkalosis
-@ rest
-symptoms: sighing, lightheadedness, numbness or tingling, palpitations, angina pectoralis
Duration of Coughs
Acute: < 3 weeks
subactute: 3-8 weeks
Chronic: >8 weeks
Color of Sputum
Yellow/green=bacterial
Clear/white= viral
Foul odor of sputum
indicates lung absess
Symptoms to help determine cause of a cough
fever, wheezing, chest pain, dyspnea, orthopnea
Hemopytsis
-determine the volume, setting and activity, and associated symptoms
Cough and Hemoptysis
Pink frothy sputum seen with
left heart failure
What to ask with chest pain
location of pain
-attributes of chest pain
Tearing from the front of the chest to the back
aortic dissection
Initial Survey signs of Respiratory Distress
tachypnea
Cyanosis or pallor
clubbing of fingernails
Audible breath sounds
accessory muscle use
tracheal displacement
shape of chest
Tracheal displacement is seen in
tension pneumothorax, pleural effusion, atelectasis
Inspection checks for
deformities or asymmetry in chest expansion
intercostal retractions
impaired respiratory movements
Palpation Identifies
Areas of tenderness
palpable crepitus (grating sound)
Masses
Test fo chest expansion
Vocal fremitus
Palpation Process
-Chest expansion (front and back- check how far your thumbs expand)
-Tactile Fremitus (say 99 and use ulna down the chest. 4 on the back and 3 down the front)
-assess for masses
Causes of Unilateral Decrease in chest expansion
chronic fibrosis
pleural effusion
lobar pneumonia
pleural pain with splinting
unilateral bronchial obstruction
paralysis of hemi-diaphragm
Causes of asymmetric decreased tactile fremitus
chest impeded by thick chest wall
obstructed bronchus
COPD
pleural effusion
fibrosis
pneumothorax
malignancy
asthma
cause of asymmetric increased tactile fremitus
unilateral pneumonia
Percussion process
Percuss the back (14 total, 5 down the middle, 2 on the sides)
Diaphragmatic excursion
Flat percussion sound examples
pleural effusion
Dull percussion sound
lobar pneumonia
atelectasis
pleural effusion
hemothorax
tumor
Resonant
Healthy lung sound!
Chronic bronchitis
asthma (between attacks)
Hyperresonant
Unilateral with pneumothorax
COPD
Asthma attack
Tympanitic
Large pnuemothorax
Diaphragmatic excursion
Identify the diaphragm and then find the dullness
mark the dullness at full inspiration and full expiration
Normal diaphragmatic excursion
3-5.5cm
Auscultation
Ask for the pt to breath through their mouth
-ladder position, 14 on the back, 12 on the front
Go through Egophony, bronchophony and whispered pectoriloquy
Vesicular Breath Sounds
Inspiratory > Expiratory
soft
low pitch
heard over both lungs
Broncho-Vesicular breath sounds
inspiratory = expiratory
intermediate sound
intermediate pitch
-in the 1st and second interspaces and between the scapula
Bronchial Breath sounds
Expiratory > inspiratory
Loud
high Pitch
over the large proximal airways
Tracheal breath sounds
inspiratory=expiratory
very loud
high pitch
over the trachea
Crackles (Rales)
popping
-dots in time, non musical, brief
-Fine=high pitched
-Coarse= louder and lower pitched
Wheezing Breath Sounds
Asthma, COPD, airway obstruction
-dashes in time
-high pitched
Rhonchi
“snoring”
secretions in the large airways
-dashes in time
-low pitched
Crackles is caused by
abnormalities of the lungs
pneumonia
lung disease
pulmonary fibrosis
heart failure
bronchitis and bronchiectasis
Wheezing is caused by
narrowed airways of asthma
COPD
bronchitis
Egophony
ask pt to say “eee”
negative (“eee”)
positive (“aye”)
positive= lung consolidation
Whispered Pectoriloquy
ask pt whisper “99”
normal (heard faintly)
abnormal (words heard clerarly)
Indicates= tissue has lost air (pneumonia)
Bronchophony
ask pt to say “99”
normal (sounds are muffled and indistinct)
abnormal (sounds are clear)
High pitched sounds indicates lung tissue has lost air
Egophony, bronchophony and whispered pectoriloquy are seen in
lobar consolidation and pneumonia
Normal adult chest inspection
Lateral Diameter > AP diameter
0.7-0.9 ratio
Increases with age
Funnel Chest
Pectus excavtum
-depression in lower portion of the sternum
-cause murmurs and heart compression
Pectus Carinatum
Pigeon chest
Sternum displaced anteriorly, increases the diameter of AP
-costal cartilages near sternum are depressed
Barrel Chest
increased AP diameter
-normal during infancy and old age
-COPD
Traumatic Flail Chest
Multiple rib fractures cause paradoxical movement of the thorax
-Inspiration: injured area caves inward
-expiration: it moves outward
Thoracic Kyphoscoliosis
Abnormal spinal curvatures
vertebral rotation deform the chest
Special Techniques
6-minute walk test
Forced Expiratory Time (FET)
Fractured rib test
6 minute walk test
measures the distance a patient can walk on hard, flat, for 6 minutes
-100 ft minimum
-predictor of clinical outcome of COPD
FET
PT: deep breath in and out as quickly as possible with mouth open
Listen over the trachea
slow expiratory time >5 seconds
Pts >60 yo and FET of >9 seconds are
4x more likely to have COPD
Identification of a Fractured Rib
Compress the chest in the AP plane
-one hand on sternum and one on the thoracic spine and squeeze
-pain distal to your hands=rib fracture
Normal Physical Findings
Resonant
Trachea Midline
Vesicular Breath sounds
No adventitious sounds
Normal tactile fremitus and voice sounds
Left sided heart failure physical findings
Resonant
midline trachea
vesicular breath sounds
Late inspiratory crackles
possible wheezing
normal tactile fremitus and voice sounds
Chronic Bronchitis Physical Findings
Resonant
Midline trachea
Vesicular breath sounds
no adventitious sounds (sometimes scattered wheezing, crackles or rhonchi)
normal tactile fremitus
Lobar Pneumonia Physical Findings
Dull
Midline Trachea
Bronchial sounds (Over affected lobe)
Late inspiratory crackles
Increased tactile fremitus
Abnormal egophony, bronchophony and whispered pectorlioquy
Partial Lobar Obstruction (atelectasis) Physical findings
Dull
Tracheal shift (toward injured side)
Absent breath sounds
No adventitious sounds
absent tactile fremitus and transmitted voice sounds
Pleural Effusion Physical findings
Dull to flat
shifted trachea toward the unaffected side
Decreased breath sounds
No adventitious sounds (sometimes wheezes, crackles, rhonchi)
Decreased tactile fremitus or voice sounds
Pneumothorax Physical Findings
Hyperresonant/tympanitic
Shifted toward opposite side (in tension)
Decreased breath sounds over the pleural air
No adventitious sounds
Decreased tactile fremitus and voice sounds
COPD physical findings
Diffusely hyperresonant
Midline trachea
Decreased breath sounds (w delayed expiration)
No adventitious sounds (unless assoc. w chronic bronchitis)
normal tactile fremitus and voice sounds
Asthma physical findings
Resonant to diffusely hyperresonant
Midline trachea
Breath sounds obscured by wheezing
Wheezing, rales
Decreased tactile fremitus and voice sounds
Example of normal Inspection documentation
Breathing is easy without signs of distress. Chest wall is symmetric without deformity. No retractions.
Palpation example of normal documentation
No areas of tenderness to palpation. No palpable masses. Symmetric lung expansion A and P. Tactile fremitus is symmetric A and P.
Percussion normal documentation example
Percussion is resonant to all areas of the lung anteriorly and posteriorly. Diaphragmatic excursion is 5cm L and R.
Auscultation normal documentation example
Vesicular breath sounds are heard throughout the lung fields anteriorly and posteriorly with good aeration. There are no adventitious sounds noted. No abnormalities of egophony, bronchophony, or whispered pectoriloquy detected.
Example of a normal lung exam
Breathing is easy without signs of distress. Chest wall is symmetric without deformity. No retractions. No areas of tenderness to palpation. No palpable masses. Symmetric lung expansion A and P. Tactile fremitus is symmetric A and P. Percussion is resonant to all areas of th elung A and P. Diaphragmatric excursion is 5 cm L and R. Vesicular breath sounds are hear throughout the lungs fields A and P with good aeration. There are no adventitious sounds noted. No abnormalities of egophony, bronchophony, or whispered pectoriloquy.
Emphysema
pathologic DX, permanent enlargment of respiratory zone.
-older and thin
-severe dyspnea
-quiet chest
-Xray- hyperventilation with flattened diaphragm
Chronic bronchitis
clinical dx of daily productive cough for 3 or more months for 2 years.
-overweight and cyanotic
-elevated hemoglobin
-rhonchi and wheezing
-edema
Typical Community Acquired Pneumonia
Acute infection of lung parenchyma
-from hospital
-Fever, cough, sputum, rigors, pleuritics, dyspnea, tachycardia
Bronchiol breath sounds
Rales
Egophony positive
whispered pectoriloquy
increased tactile fremitus
Streptococcus pneumonae is most common
Exudative Pleural Effusion
occurs due to inflammation and icnreased capillary permeability
-pneumonia, cancer, TB, automimmune
high protein and LDH
Yellow
Transudative Pleural Effusion
increased hydrostatic pressure or low plasma oncotic pressure
(CHF, cirrhosis, nephrotic syndrome, PE, Hypoalbuminemia)
Low in protein and LDH
Clear color
