thorax and lungs hape Flashcards
horizontal bony ridge where the manubrium joins the body of the sternum
sternal angle or the angle of Louis.
2nd intercostal space
needle insertion for decompression of a tension pneumothorax.
intercostal space
between the 4th and 5th ribs for chest tube insertion.
level of the 4th rib
for the lower margin of a well-placed endotracheal tube on a chest x-ray.
why should needles and tubes be placed only at superior rib margins?
Neurovascular structures run along the inferior margin of each rib
intercostal space between 7th / 8th rib
landmark for thoracentesis with needle insertion immediately superior to the 8th rib.
triangle of safety
an anatomical region in the midaxillary line formed by the lateral border of the pectoralis major muscle anteriorly, lateral border of the latissimus dorsi posteriorly, and the nipple line (4th or 5th intercostal space) inferiorly. This triangle represents a “safe position” for chest tube insertion.
why is aspiration pneumonia more common in the right middle and lower lobes?
because the right main bronchus is more vertical. For this same reason, if an endotracheal tube is advanced too far during intubation, it will more likely enter the right mainstem bronchus.
difference between transudate and exudate pleural effusions
may be transudates, seen in heart failure, cirrhosis, and nephrotic syndrome, or exudates, seen in numerous conditions including pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis.
when does Irritation of the parietal pleura produce pleuritic pain?
with deep inspiration in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular diseases.
what are common or concerning symptoms during the thorax/lung exam
-Shortness of breath (dyspnea) and wheezing Cough
-Blood-streaked sputum (hemoptysis)
-Chest pain
-Daytime sleepiness, snoring and disordered sleep
what is a key component of important chronic obstructive pulmonary disease (COPD) classification systems that guide patient management.2–4
degree of dyspnea combine with spirometry
what patients may have episodic dyspnea during both rest and exercise and also hyperventilation, or rapid shallow breathing?
anxious patients
what occurs in partial lower airway obstruction from secretions and tissue inflammation in asthma, or
from a foreign body
wheezing
can signal left-sided heart failure.
cough
most common cause of cough
upper respiratory infections
when is chronic cough seen?
postnasal drip, asthma, gastroesophageal reflux, chronic bronchitis, and bronchiectasis
mucoid sputum
translucent, white, or gray and seen in viral infections and cystic fibrosis
purulent sputum
yellow or green—often accompanies bacterial pneumonia.
when is foul smelling sputum present?
anaerobic lung abscess, thick tenacious sputum in cystic fibrosis
Before using the term “hemoptysis,” try to confirm the source of the bleeding
Blood or blood-streaked material may originate in the nose, mouth, pharynx, or gastrointestinal (GI) tract and is easily mislabeled. If vomited, it probably originates in the GI tract. Occasionally, however, blood from the nasopharynx or the GI tract is aspirated and then coughed out.
Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles.
what is reported in one in four patients with panic and anxiety disorders
chest pain
a clenched fist over the sternum (levine sign)
suggests angina pectoris
a finger pointing to a tender spot on the chest wall suggests
musculoskeletal pain
a hand moving from the neck to the epigastrium may suggest
heartburn
daytime sleepiness and snoring are hallmarks of…
obstructive sleep apnea (OSA), commonly seen in patients with obesity, posterior malocclusion of the jaw (retrognathia), treatment- resistant hypertension, heart failure, atrial fibrillation, stroke, and type 2 diabetes
key components of thorax and lung examination
-Survey respiration (rate, rhythm, depth, effort of breathing, signs of respiratory distress).
-Examine the anterior and posterior chest:
-Inspect the chest (deformities, muscle retraction, lag). -Palpate the chest (tenderness, bruising, sinus tracts, respiratory expansion, fremitus).
-Percuss the chest (flat, dull, resonant, hyperresonant or tympanitic).
-Auscultate the chest (breath sounds, adventitious, transmitted voice sounds).
cyanosis
in the lips, tongue, and oral mucosa signals hypoxia
Pallor and sweating (diaphoresis) are common in
acute coronary syndromes and heart failure
Clubbing of the nails occurs in
occurs in bronchiectasis, congenital heart disease, pulmonary fibrosis, cystic fibrosis, lung abscess, and malignancy.
Audible high-pitched inspiratory whistling, or stridor, is
an ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation.
Asymmetric expansion occurs in
large pleural effusions
retractions occurs in
severe asthma, COPD, or upper airway obstruction.
Unilateral impairment or lagging suggests
pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma.
Tactile fremitus
is decreased or absent when the voice is higher pitched or soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor.
Asymmetric decreased fremitus raises the likelihood of
unilateral pleural effusion, pneumothorax, or neoplasm, which decreases transmission of low-frequency sounds; asymmetric increased fremitus occurs in unilateral pneumonia which increases transmission through consolidated tissue
percussion helps establish
whether the underlying tissues are air-filled, fluid- filled, or consolidated
what kind of lungs are resonant?
healthy lungs
dullness replaces resonance when
fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells, and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonia and pleural effusion three to four times more likely, respectively
before beginning auscultation…
ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant added sounds.
Is there a silent gap between the inspiratory and expiratory sounds?
A gap suggests bronchial breath sounds.
crackles can arise from…
abnormalities of the lung parenchyma (pneumonia, interstitial lung disease, pulmonary fibrosis, atelectasis, heart failure) or of the airways (bronchitis, bronchiectasis).
wheezes arise in
the narrowed airways of asthma, COPD, and bronchitis.
sounds from secretions in large airways that may change with coughing.
sounds from secretions in large airways that may change with coughing.
Fine late inspiratory crackles that persist from breath to breath suggest
abnormal lung tissue.
The crackles of heart failure are usually best heard where?
posterior inferior lung fields.
Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests
inspissated secretions, seen in bronchitis or atelectasis.
wheezes and breath sounds may be absent due to low respiratory airflow (“silent chest”), a clinical emergency may be present in?
severe ashtma or advanced airway obstruction
pleural friction rubs
may be heard in pleurisy, pneumonia, and pulmonary embolism.
what do increased transmitted voice sounds suggest?
embedded airways are blocked by inflammation or secretions
If “ee” sounds like “A” and has a nasal bleating quality, an E-to-A change, what is present?
egophony
whispered pectoriloquy.
louder, clearer whisper sounds
Persons with severe COPD may prefer to sit
leaning forward, with lips pursed during exhalation and arms supported on their knees or a table.
Patients ≥age 60 years with a forced expiratory time of ≥9 seconds are…
4x more likely to have copd
Important Topics for Health Promotion and Counseling in thoracic and lung exam
Lung cancer screening
Latent tuberculosis
Screening for obstructive sleep apnea (OSA)
Tobacco cessation
Immunizations—influenza and streptococcal pneumonia
Epworth Sleepiness Scale
Consider how you have felt over the past week or two. How likely are you to doze off or fall asleep in the following situations?
0 = Never
1 = Slight chance
2 = Moderate chance 3 = High chance
stop-bang
STOP
S: Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
T: Do you often feel tired, fatigued, or sleepy during the day?
O: Has anyone observed you stop breathing during the day?
P: Do you have or are you being treated for high blood pressure?
Bang
B: Body mass index >35 kg/m2
A: Age >50 years?
N: Neck circumference >40 cm (16 in)?
G: Gender male?
