Thorax and Lungs Ch. 19 Flashcards
What is the sternal angle and what is its signifcants?
It is a useful place to start counting ribs as it is continuous with the 2nd rib. Palpate the sternal angle, and slide down to the 2nd intercostal. Each intercostal space is numbered by the rib above it.
This is also where the trachea bifurcates
What is the coastal angel
what is the costoverterberal (CVA)
- the angel under the anterior ribs, should be 90 degrees (>90 = barrel chest)
- where the ribs meet the spine, location of fist percussion
what is the supra aspect of teh lungs called
apices
describe the lobes of the right and left lung
right: 3 lobes, RML is at the 4th and 5th ICS
left: 2 lobes
apices are above the clavical, anterior LL end at the 6th ICS, posterior LL end at teh 9th ICS
Important health history questions for respiratory (12)
Coungh (productive, dry), SOB, allergies (asthma), past lung injury, URIs, current meds (PMH), O2 at home, last TB sink test/ X-ray, PNA vaccine (>65, or immuno comp), flu vaccine, family history (CF, asthma), smoking (present/ past, pacs/ yr), chindren exposure to 2nd/ 3rd hand smoke?
5 A’s to help smokers quit
1) Ask- about his or her tobacco use status at every visit
2) Advise- Give clear, nonjudgmental, and personalized suggestions for quitting
3) Assess- each person’s readiness for and interest in quitting
4) Assist- each person with a specific cessation plan that includes medications, behavioral modification, exercise programs, or referrals
5) Arrange- follow-up visits
Problem based question to ask regarding a cough (3)
OPQRSTU
Constant, or does it come and go? Associated with specific activities, positions, or other symptoms i.e. fever?Describe your cough (Dry, Congested, Wet, Barking, Hacking)
Are you coughing up sputum
What questions are asked about sputem and what it means
What is color of sputum: clear= vital white green= bacterial bloody= ulcer
Consistency of sputum:
thick, thin, frothy (PE, heart failure, ARDS)
Does it have an odor? yes= bacterial
what is bloody sputem called
hemoptysis
Problem based question to ask regarding SOB (4)
OPQRSTU
How many stairs or blocks can you walk before you become SOB?
Does it wake you up at night? (Paroxysmal nocturnal dyspnea), How many pillows do you use? (orthopnea)
Does anything seem to trigger episodes or make it worse?
What do you do to relieve symptoms?
Inability to breath when lying down:
orthopnea
An attack of severe shortness of breath and coughing that generally occurs at night
Paroxysmal nocturnal dyspnea
Pleuritis
what it is
s/s
(inflammation of pleura) = Pleural friction rub
can hear the rub with breathing. Can also occure in the heart; have the pt. hold theit breath while ascultating, sound will stop if it is the lungs and continue if it is the heart.
severe angina
Chostochondritis
what it is
s/s
Inflammation of the cartilage that connects a rib to the sternum. Pain might mimic that of a heart attack
physical exam: inspection of overall appearence (3)
1) General appearance (LOC may mean acute hypoxia), posture (tripoding, not wanting to lay down), breathing effort (symmetry in chest expansion, pursed liped breathing, nostral flaring)
2) Quality of respirations (rate, pattern, effort)
3) Nails, skin, lips (cyanosis, pallor)
Quality of respirations (3)
Rate (older adult breathes after, babies may breath irregular)
Breathing pattern
Effort (SOB, retractions, accessory muscles)
Breating patterns: Cheyne Stoke Tachypnea Kussmaul Hypoventilation Bradypnea
1) Cheyne Stoke: tachypnea followed by apnea
2) Tachypnea: fast and shallow breaths (anything that causes SOB)
3) Kussmaul respirations= Hyperventilation: anxiety, DKA (diabetic ketoacidosis)
4) Hypoventilation: shallow slow irregular breaths (sedative (opioid) overdose, abd pain)
5) Bradypnea: slow breathing (least common), late sign of increased ICP
Physical exam: Anterior chest and posterior thorax
IPPA for both
Physical exam: Anterior chest INSPECTION (7)
Symmetry, Retractions, Accessory muscle use, Muscle development, Lesions, Anteroposterior (AP) diameter, Costal angle
What is the Anteroposterior (AP) diameter
what is it compared to
how is it documented
what can it be a sign of
measurement from anterior to posterior. AP should be > transvers
(documented: AP>T, 1:2)
If AP=T could be a sign of barrel chest (which is a sign of COPD)
What can asymmetry of the chest mean?
PNA, pneumonthorax, plural effusion
Physical exam: Anterior chest PALPATION
Symmetric chest expansion Tenderness, lumps, masses? Skin temp, moisture Crepitus Tactile Fremitus
What can Crepitus signify?
= subcutaneous emphysema, feels like how rice crispy cereal sounds
Tactile Fremitus palpation
how to palpate
how to assess what you feel
where are vibrations the strongest
Use ball of fingers or ulnar edge of hand to feel for vibrations, while patient says “99” or “blue moon”. Using both hands start on top of shoulders, and then palpate at 3 locations down the midclavicular line, ending at the 6th ICS (where the lung ends)
Assess bilaterally; symmetry is most important (asymmetry could mean consolidation, PNA)
Vibrations stronger around sternum where major bronchi are closest to chest wall
How does consolidation effect breath sounds
Consolidation enhances the transmission of breath and voice sounds!!
what is Rhonchal Fremitus
palpable vibrations with inhalation (may be caused by mucous in brachioli)
Physical exam: Anterior chest PERCUSSION and ASCULTATION
how to percuss/ ascultate
start at the supraclavicular moving in a digital 2, and then palpate at 4 locations down the midclavicular line the 5th is closer to the axillary line, ending at the 6th ICS (where the lung ends).
how to assess what you hear during percussion
Resonance is the normal finding. Hyperresonance= decreased density and increased air (eg: emphasema). Dullness= organs or fluid.
how to assess what you hear during ascultation
Broncheal (tracheal)
Loud, hollow
Inspiration < Expiration
Bronchovesicular (midsternal line)
Moderate amplitude
Inspiration = Expiration
Vesicular (between ICS: supreclavicular to 6th ICS)
Soft, rustling
Inspiration > Expiration
Regardless of the type of normal breath sounds you hear, we report and document normal lung sounds as “CLEAR” (no adventitious sounds)
what can Broncheal in the LL mean (think about it!!)
PNA, b/c Consolidation enhances the transmission of breath and voice sounds!!
PNA
what it is
what causes it
Clinical findings:
pneumonia
an infection that inflames the air sacs in one or both lungs. The air sacs may fill with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty breathing.
A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia
clinical findings: tachypnea, asymmetric chest expansions, fever, elevated vitals, increased fremitus at LL, coarse crackles.
physical exam: posterior thorax (IPPA)
Inspect: symmetry, shape (kyphosis or scoliosis limiting thoracic excursion?), skin
Palpate: chest expansion, tactile fremitus (avoid scapula bones and spine… vibrations will be strongest between scapula)
Percuss: same areas you palpated for fremitus. Should hear resonance!
Auscultate: should hear vesicular, clear lung sounds
Lungs extend to the 9th ICS
what are the 6 adventitious breath sounds
1) Coarse crackles (rales)
2) Fine crackles (rales)
3) Pleural friction rub
4) Wheeze (high-pitched)
5) Wheeze (low-pitched)
6) Stridor
Coarse crackles (rales):
Low-pitched bubbling sounds; heard on inspiration and/or expiration; may decrease with cough/suctioning. Could mean mucous, PNA, pulm fibrosis, chronic bronchitis. upperairway.
Fine crackles (rales):
High-pitched crackling, popping sounds upon inspiration. Could mean Pulm edema (HF), PNA, chronic bronchitis. Fluid filled alvioli.
Pleural friction rub:
Grating, low-pitched (like walking on snow). Could mean pleuritis.
Wheeze (high-pitched):
High-pitched, musical, squeaking; usually expiratory. Could mean Airway obstruction from tumor, asthma, emphysema.
Wheeze (low-pitched):
AKA rhonchi; Snoring, moaning sounds. Could mean Bronchitis (upper airway).
Stridor:
EMERGENCY: High-pitched crowing sound; louder in neck. Could mean croup, obstructed airway.
physical exam: infants and children (4)
- Obligate nose breathers until 3 months
- Newborn RR 30-40 bpm and may be irregular; count for full minute
- AP diameter of 1:1 is a normal finding in individuals <6yo
- Thin chest walls may cause you to hear louder bronchovesicular breath sounds throughout the lung fields; Percussion may yield hyperresonance
Developmental Competence: Pregnancy (4)
- Enlarging uterus elevates diaphragm which decreases vertical diameter of the thorax; compensates by widening horizontally
- Increase in tidal volume (TV) to meet increased oxygen demand (deeper respirations)
- Wider costal angle
- Some report mild dyspnea
Developmental Competence: older adult (3)
- Costal cartilages become calcified, and lungs are more rigid causing lung bases become less ventilated and alveoli become closed off and thus less surface area is available for gas exchange and increased risk of postoperative pulmonary complications (atelectasis and infections)
- Kyphosismay make thoracic expansion more difficult.
- Older people fatigue more quickly during auscultation.
Atelectasis
what it is
Clinical findings
risk
collapsed alveoli (may be one section or entire lung); caused by external pressure from tumor, fluid, or foreign body. Most common post opp. complication.
Clinical findings: Affected lobe has diminished or absent breath sounds. Oxygen saturation may be low. Decreased fremitus. Dullness with percussion.
Can turn into PNA
Chronic Bronchitis
what it is
cause
Clinical findings
AKA smokers cough. Characterized by hypersecretion of mucus by goblet cells of trachea and bronchi resulting in productive cough.
Caused by irritants such as cigarette smoke and air pollution or by infection.
Clinical findings: Productive cough, increased mucus production (green mucous= bacterial infection on top of the bronchitis), and dyspnea. When mucus occludes alveoli, coars crackles or wheeze (low pitch) may also be heard.
Emphysema
what it is
cause
Clinical findings
destruction of pulmonary connective tissue that causes permanent abnormal enlargement of air spaces (hyper-inflated lung).
Cause: long-term exposure to irritants that damage your lungs and the airways (smoking)
Clinical findings: Classic appearance: underweight with barrel chest and SOB. Exam findings: diminished breath and voice sounds;possible wheezing on auscultation; decreased tactile fremitus; hyperresonant tones on percussion
Asthma/ RAD
what it is
Clinical findings
RAD= Reactive Airway Disease
Hyperreactive airway disease characterized bybronchoconstriction, airway obstruction, and inflammation.
Clinical findings: Tachypnea with prolonged expiration. Audible wheeze. Dyspnea; Anxiety; Cough. Use of accessory muscles. Auscultation: wheezy and diminished
COPD
Chronic Obstructive Pulmonary Disease.
chronic emphasema and bronchitis
Pleural Effusion
what it is
Clinical findings
accumulation of serous fluid in pleural space (outside of the lung)
Clinical findings: If large, there may be dyspnea or decreased chest wall movement. Decreased tactile fremitus. Percussion: dull (over fluid). Decreased breath sounds
PE
what it is
Clinical findings
Pulmonary Edema
fluid inside of the lung
caused by a heart condition (back flow from the left heart). Other causes include PNA.
Pneumothorax
what it is
Clinical findings
Partial or complete lung collapse resulting from air in pleural spaces.
Clinical findings vary, depending on amount of lung collapse. Pt may be slightly SOB, anxious or in severe distress. Decreased chest wall movement Hyper-resonance on percussion. Breath sounds decrease or absent on affected side. Tracheal displacement
TB
what it is
cause
Clinical findings
tuberculosis: contagious (airbourn), bacterial infection caused by Mycobacterium tuberculosis. Primarily in lungs, but kidney, bone, lymph node, and meninges can also be involved.
Clinical Findings: usually asymptomatic early on. May develop fatigue, anorexia, weight loss, fever, night sweats, crackles in apices, and cough (possible blood tinged/rust sputum)
Lung cancer
cause
Clinical findings
Most fatal of all cancers: 85% caused by tobacco smoking
Clinical findings: Most common initial symptom reported is a persistent cough. Weight loss, hemoptysis,SOB, Nail clubbing. If tumor is causing partial obstruction can cause atelectasis or wheezing. Percussion may be dull over a large tumor.
ARDS
what it is
cause
Clinical findings
Acute Respirtory Distress Syndrome
a type of respiratory failure characterized by rapid onset of widespread inflammation in the lungs. High mortality.
results from trauma or shock (but most often sepsis) leading to increased permeability of pulmonary capillaries. Leads to pulmonary edema.
Clinical findings: Restlessness, dyspnea, Ventilatory support often required; suctioning will reveal frothy sputum
What are the possible causes:
Upon inspection on the pt. you notice unequal chest expansion:
severe atelectasis, PNA, effusion, pneumothorax, trauma
What are the possible causes:
Upon inspection on the pt. you notice they have a barrel chest, pursed lip breathing and hypertrophied muscles
COPD, emphysema
What are the possible causes:
Upon palpation of the pt. you notice increased fremitus
consolidation due to PNA
What are the possible causes:
Upon palpation of the pt. you notice decreased fremitus
obstruction, effusion, pneumothorax, emphysema
What are the possible causes:
Upon palpation of the pt. you notice crepitus
subcutaneous emphysema
What are the possible causes:
Upon percussion of the pt. you notice dullness
increased density of the lungs- PNA, effusion, atelectasis, tumor
What are the possible causes:
Upon percussion of the pt. you notice hyperresonance
increased air- pneumothorax, emphysema
What are the possible causes:
Upon ascultation of the pt. you hear crackles
PNA, bronchitis, pulm fibrosis, pulm edema (ARDS)
What are the possible causes:
Upon ascultation of the pt. you hear wheezes
asthma, emphysema
What are the possible causes:
Upon ascultation of the pt. you hear stridor
epiglottitis, croup
What are the possible causes:
Upon ascultation of the pt. you hear plural effusion rub
pleuritis
Hypercapnia
increased CO2 in the blood
Egophony
how is the test done
normal
abnormal
(Greek: “the voice of a goat”)
Auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound
Normally you should hear “eeeeeeee” through your stethoscope
Over area of consolidation or compression the spoken “eeee” sound changes to a bleating long “aaaaa” sound
Bronchophony
how is the test done
normal
abnormal
Ask the person to repeat “ninety-nine” while you listen with the stethoscope over the chest wall; listen especially if you suspect pathology
Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said
Pathology that increases lung density enhances transmission of voice sounds; you auscultate a clear “ninety-nine”
The words are more distinct than normal and sound close to your ear
Whispered Pectoriloquy
how is the test done
normal
abnormal
Ask the person to whisper a phrase such as “one-two-three” as you auscultate
The normal response is faint, muffled, and almost inaudible
With only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still somewhat faint; it sounds as if the person is whispering right into your stethoscope, “one-two-three”
