Thorax/Lungs Flashcards
List potential causes of nail clubbing and explain their significance.
Clubbing is associated with a variety of respiratory and cardiovascular diseases, cirrhosis, colitis, and thyroid disease.
Describe inspection findings suggestive of respiratory distress.
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Barrel chest: AP diameter approaches or equals the lateral diameter – compromised respiration as in, for example, chronic asthma, emphysema, or cystic fibrosis
Tachypnea/Shallow breathing
Pursing of the lips: increased expiratory effort
Flaring of the alae nasi: during inspiration is a sign of air hunger
Tachypnea
Persistent respiratory rate > 20 breaths per minute (in adult) – could be d/t examiner watching if not persistent; symptom of protective splinting from the pain of a broken rib or pleurisy; Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern
Bradypnea:
a rate slower than 12 respirations per minute – neurologic or electrolyte disturbance, infection, or a conscious response to protect against the pain of pleurisy or other irritative phenomena OR excellent level of cardiorespiratory fitness.
Dyspnea
difficult and labored breathing with shortness of breath – pulmonary or cardiac compromise, sedentary lifestyle/obesity
Orthopnea
shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps.
Paroxysmal nocturnal dyspnea
a sudden onset of shortness of breath after a period of sleep; sitting upright is helpful.
irregular respirations
Hyperpnea
exercise, anxiety, CNS dz, metabolic dz, acidosis, aspirin poisoning, hypoxemia, pain
Hyperventilation
irregular respirations
Hypopnea
Abnormally shallow respirations – pleuritic pain
irregular respirations
Air trapping
If the pulmonary tree is seriously obstructed for any reason, inspired air has difficulty overcoming the resistance and getting out.
Result of a prolonged but inefficient expiratory effort – also increased resistance (i.e. chronic bronchitis), decreased elastic recoil of the lung (i.e., emphysema) or a drop in the critical closing pressure of the airway (i.e., asthma); resp rate increases to compensate (more shallow and air trapping increases - lung hyperinflation = barrel chest)
irregular respirations
Periodic breathing:
regular periodic pattern of breathing with intervals of apnea followed by a crescendo/decrescendo sequence of respiration – during sleep, seriously ill, particularly those with brain damage at the cerebral level, with drug-associated respiratory compromise or severe congestive heart failure
irregular respirations
Kussmaul respirations
always deep and most often rapid – respiratory effort associated with metabolic acidosis.
irregular respirations
Biot/Ataxic
irregular respirations varying in depth and interrupted by intervals of apnea, but lacking the repetitive pattern of periodic respiration – severe and persistent increased intracranial pressure, respiratory compromise resulting from drug poisoning, or brain damage at the level of the medulla and generally indicates a poor prognosis
AP:transverse thorax diameter
HEALTHY ADULTS:
The AP diameter of the chest is ordinarily less than the lateral diameter – thoracic ratio and is expected to be about 0.70 to 0.75
AP:transverse thorax diameter
INFANTS
chest of the newborn is generally round, the AP diameter approximating the lateral diameter, and the circumference is roughly equal to that of the head until the child is about 2 years old
AP:transverse thorax diameter
OLDER ADULTS:
The barrel chest that is seen in many older adults results from loss of muscle strength in the thorax and diaphragm, coupled with the loss of lung resiliency. In addition, skeletal changes of aging tend to emphasize the dorsal curve of the thoracic spine, resulting in an increased AP chest diameter. There may also be stiffening and decreased expansion of the chest wall.
anatomical changes of chest/thorax
PREGNANT:
Anatomic changes that occur in the chest as the lower ribs flare include an increase in the lateral diameter of about 2 cm and an increase in the circumference of 5 to 7 cm. The costal angle progressively increases from about 68.5 degrees to approximately 103.5 degrees in later pregnancy.
AP:transverse thorax diameter
ABNORMALITIES:
compromised respiration as in chronic asthma, emphysema, or cystic fibrosis
TECHNIQUE: To evaluate thoracic expansion during respiration
To evaluate thoracic expansion during respiration, stand behind the patient and place your thumbs along the spinal processes at the level of the tenth rib, with your palms lightly in contact with the posterolateral surfaces. Watch your thumbs diverge during quiet and deep breathing. A loss of symmetry in the movement of the thumbs suggests a problem on one or both sides.
SIGNIFICANCE of assessing thoracic chest expansion
A patient who is barrel-chested with chronic obstructive pulmonary disease may not demonstrate this. The chest is so inflated that it cannot expand further and your hands may even come together a bit
subcutaneous crepitus (subcutaneous emphysema).
CREPITUS: a crackly or crinkly sensation, can be both palpated and heard—a gentle, bubbly feeling.
→ indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism (always pathologic)
technique to assess tactile fremitus
Fremitus is best felt posteriorly and laterally at the level of the bifurcation of the bronchi. Ask the patient to recite a few numbers or say a few words (“99” is a favorite, as is “Mickey Mouse,” depending perhaps on the age) while you systematically palpate the chest with the palmar surfaces of the fingers or with the ulnar aspects of the hand. Use a firm, light touch, establishing even contact. For comparison, palpate both sides simultaneously and symmetrically; or use one hand, alternating between the two sides. Move about the patient, palpating each area carefully, right side to left side.
Decreased or absent fremitus:
excess air in the lungs, emphysema, pleural thickening or effusion, or bronchial obstruction.
Increased fremitus:
often coarser or rougher in feel – presence of fluids or a solid mass within the lungs and may be caused by lung consolidation, heavy but non-obstructive bronchial secretions or compressed lung.
Gentle more tremulous fremitus:
lung consolidations, inflammatory and infectious processes
Hyperresonance of thorax
abnormal sound, the result of air trapping; emphysema, pneumothorax, or asthma
Dullness or flatness of thorax
pneumonia, atelectasis, pleural effusion, or asthma.
thoracic excursion distance
The excursion distance is usually 3 to 5 cm
The diaphragm is usually higher on the right than on the left because it sits over the bulk of the liver.
Bronchial breath sounds
Heard only over trachea; high pitch; loud and long expirations, sometimes a bit longer than inspiration
Bronchovesicular breath sounds
Heard over main bronchus area and over upper right posterior lung field; medium pitch; expiration equals inspiration
Vesicular breath sounds
Heard over most of lung fields; low pitch; soft and short expirations; more prominent in a thin person or a child, diminished in the overweight or very muscular patient
Crackles (rales):
Discontinuous; fine crackling, high pitched
Rhonchi:
loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)
Wheezes:
musical noise most often heard continuously during inspiration or expiration; usually louder during expiration
Pleural friction rub:
dry, rubbing, or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface
Mediastinal crunch (Hamman sign):
found with mediastinal emphysema – great variety of sounds (loud crackles, clicking, and gurgling sounds) are heard over the precordium. They are synchronous with the heartbeat and not particularly so with respiration.
These sounds can be more pronounced toward the end of expiration and are easiest to hear when the patient leans to the left or lies down on the left side.
disorders that result in diminution of breath sound and explain clinical significance
Fluid or pus has accumulated in the pleural space, secretions or a foreign body obstructs the bronchi, breathing is shallow from splinting due to pain, or the lungs are hyperinflated such as occurs in severe obstruction from asthma or chronic obstructive pulmonary disease (COPD)
Emphysema, Pleurisy (often result of PE), Pneumonia, Bronchiolitis, Hemothorax, lung abscess, pleural effusion, pneumothorax, COPD
Describe three tests for identifying abnormal vocal resonance and list disorders associated with increased vs. decreased vocal resonance.
Broncophony- 123 with increasing clarity
Egophony- e sounds like a
Whispered pectoriloque - if you can hear the whisper
Identify conditions which may alter the inspiratory:expiratory (I:E) ratio and explain clinical significance.
Airway obstruction: I/E > 2/1
Stridor heard with I/E > 3:1
→ floppy epiglottis, congenital defects, croup, edematous response, aspirated foreign body, abscess, tumor, double aortic arch
