thorax juju Flashcards
Lobe anatomy
R: oblique and horizontal fissure
- upper, middle, lower
- R main bronchus more VERTICAL so abscesses tend to be in the R middle or lower lobes
- inserting a ET tube too far will go into here
L: oblique fissure
- upper, lower
Trachea anatomy bifurcation
Bifurcation
- anteriorly: sternal angle
- posteriorly: T4
chest pain
PARIETAL PLEURA:
- lines the pleural cavity and inner rib cage and upper surface of diaphragm
- innervated by: intercostal and phrenic nerve
- pain: pleuritic pain with deep inspiration
- visceral pleura and lungs = NO pain fibers
DDx:
Viral pleurisy, pneumonia, PE, pericarditis and collagen vascular diseases
pectus carinatum and pectus excavatum
carinatum - pigeon chest: the sternum is displaced anteriorly -> INCREASED AP
- costal cartilages adjacent to protruding sternum = depressed
excavatum - funnel chest; sunken chest
- sternum depresses into the chest
= compression of heart/great vessels + MURMURs
cough
reflex response to stimuli that irritates the receptors in:
- larynx
- trachea
- large bronchi
- can be cardiovascular in origin: SX OF LEFT SIDED HF
Ask about: sputum
- mucoid: white, translucent
- purulent: green, yellow -> bronchiectasis
- foul smelling: abscess
hemoptysis
make sure bleeding is from lungs
- stomach: darker blood that can be mixed with food
rare in infants children
common in:
- CF
- malignancy
- bronchitis
- less common: MS, bronchiectasis
asymmetric chest expansion + Unilateral decrease or delay in chest expansion
asymmetric: pleural effusion
Unilateral decrease or delay in chest expansion:
- Chronic fibrosis of the underlying lung of pleura
- Pleural effusion
- Lobar pneumonia
-Pleural pain with associated splinting
-Unilateral bronchial obstruction
retraction of interspaces
Severe asthma
COPD
Upper airway obstruction
unilateral impairment or lagging
▪ Asbestosis or silicosis
▪ Phrenic nerve damage/trauma
tactile fremitus: when is it decreased
3 anterior, 4 posterior
transmission of vibrations from the larynx to the chest wall is impeded or there is an increase in AIR (More air = worse conduction of
- Thick chest wall: obesity
- Obstructed bronchus: asthma
- Pneumothorax: more air
- Pleural effusion*: fluid blocks the transmission of the vibration; asymmetric
increased tactile fremitus
Air is replaced with more dense fluid/solids that increase transmission
Consolidation
Pneumonia
Pulmonary edema: fluid within the alveoli and interstitium
Atelectasis: more dense over the collapsed lung
Basics of percussion:
Use lightest percussion that produces a clear note!!
Percussion blow: penetrates 5-7 cm into the chest
Helps establish whether the underlying tissues are: air filled vs fluid filled vs consolidated
Hyperextend the pleximeter hand and press distal interphalangeal joint on skin (avoid any other contact with the hand or other fingers: dampens the vibration)
Strike: same force and pressure each time using fingerTIP
intensity/loudness, pitch, duration
Flat: LEAST RESONANT - think large fluids or bone; tapping a solid wall; least resonant (sad meow): soft intensity high pitch short duration
Dull: Dull: less resonant - think less air than normal with more fluid/tissue; tapping a thick book (normal = wall); THREE Ms ( dull = meh): Medium loud Medium pitch Medium duration
Resonant: 3 Ls
hyperresonant: even louder, even longer, even lower
tympanic: louder, higher pitch, longer duration (think hitting drum)
dull
organs, areas with less air but not solid organs or large fluid accumulations- liver, heart, spleen, lobar pneumonia, pleural effusion (usually cannot percuss anteriorly)
hyperresonant
COPD
asthma
pneumothorax
air filled bulla
Flat
LEAST resonant - BONE, muscle; large pleural effusion
tympanic
higher pitch and more musical quality because tympanic sites indicate a larger, enclosed pocket of air:
- LARGE PNEUMOTHORAX,
- bowel obstruction,
- gastric air bubble
- Diaphragmatic excursion: procedrure
Step 1: estimate location of diaphragm with quiet respiration (tends to overestimate actual movement of diaphragm)
Step 2: EXHALE completely and hold breath
Step 3: inhale completely and hold breath
Normal diaphragmatic excursion: 3-5.5 cm
Overestimates actual movements of diaphragm
- you are identifying the boundary between the resonant lung tissue and the duller structures below the diaphragm. You are not percussing the diaphragm itself.
- normal: 3-5.5 cm
high diaphragmatic excursion
▪ Pleural effusion
▪ High diaphragm: Atelectasis; Phrenic nerve paralysis
Auscultation key points
- Pt should breath deeply through an open mouth
- Listen to at least one full breath in each location using the DIAPHRAGM
- Place diaphragm directly onto SKIN
- Clothes, chest hair, paper gowns: generate confusing crackling sounds that interfere… chest hair = press down harder or moisten the hair (?)
anterior: 6; posterior - 7
Bronchovesicular or bronchial breath sounds heard in abnormal locations
Air-filled lung replaced by fluid filled or solid lung tissue
breath sounds what does it reflect and when is it decreased
reflects the air flow rate at the mouth, and may vary from one area to another
- louder: lower posterior lung fields
- need pt to breath deeply
shallow breathing and thick chest wall decrease breath sounds
Decreased:
- air flow decreased -> OBSTRUCTIVE lung ds; respiratory muscle weakness
- transmission of sound is decreased: pleural effusion, pneumothorax, COPD
vesicular breath sounds
low pitch
soft intensity
over all lung fields
bronchovesicular
inspiration = expiration
medium
medim
bronchial
over manubrium
exhalation > inhalation
- loud
- high pitch
GAP between inspiration and exhalation
tracheal
over trachea
- loud
- harsh
inspiration = expiration
bronchovesicular
inspiration = expiration
- medium loudness
- medium pitch
1st, 2nd interspaces
between the scapulae
coarse vs fine crackles
fine: soft, high pitched, very brief (fine women)
- suggest abnormal lung tissue
coarse: louder, lower pitched, brief (tomboy = coarse)
crackles:
- airways: bronchitis, bronchiectasis
- lung parenchyma: pneumonia, ILD, PF, HF (posterior inferior lung fields), atelectasis
Pleural friction rub
heard in expiration
pleurisy, pneumonia, and pulmonary embolism.
Wheezing
NARROWED airways
Exhalation: High pitched whistling sound from the turbulent airway
musical~~
Asthma
COPD
Bronchitis
airway obstructions
Rhonchi
associated with constricted/partially obstructed LARGE airway with mucus or secretions that are rattling
Low pitched snoring
Changes with coughing: inspissated secretions*
area of dullness to left of sternum from 3-5 rib interspaces
heart
percuss liver
percuss down the right midclavicular line
The hyperinflated lung of COPD often displaces the upper border of the liver downward and lowers the level of diaphragmatic dullness posteriorly.
latent tb screen
only screen populations with increased RISK
Screening Test: tuberculin skin test (TST) and interferon-gamma release assay (IGRA) blood Test
TST: 48-72 hr turnover ; measured in mm of induration
IGRA: 8-30 hr turnover; single venous blood sample
Sleep Apnea Screening:
Sleep Apnea Screening: NOT RECOMMENDED
- OSA: repeated episodes of upper airway collapse -> hypoxemia + disrupted sleep
estimated prevalence of OSA in adults ages 30 to 70 is about 15% for men and 5% for women, though OSA is often undiagnosed
Risks:
- Male
- Older
- Craniofacial and upper airway abnormalities
- Postmenopause
- Obese
Definitive dx: polysomnography
lung cancer screening
3 years of ANNUAL LOW DOSE CT
- screen Adults 50-80 with a 20 year pack hx who currently smoke or quit within 15 years
- Pack-Years= (Number of Packs per Day) × (Number of Years Smoked)
- 20 cigarettes = 1 pack
- Ex: you smoke 0.5 packs for 5 years - 0.5 x 5 = 2.5 pack years
Lung Cancer: Leading COD of cancer in men + women: often not caught till late stage
GERIATRICS ADL
BDTTCF
bathing
dressing
toileting
transferring
continence
feeding
GERIATRICS: ETHNICS
- Explanation
- Treatment
- Healers
- Negotiate
- Intervention
- Collaborate
- Spirituality
Frailty
suggests frailty:
- Undernutrition
- slowed motor performance
- loss of muscle mass
- weakness
Frailty:
- decreased muscle mass
- decreased energy and exercise intolerance, and decreased physiologic reserve, with increasing vulnerability to physiologic stressors.
