Thorax + lungs Flashcards
Locating findings on chest wall
Describe the chest findings in TWO DIMENSIONS:
- vertical axis: using ribs + interspaces
- circumference of the chest: midsternal, midclavicular, midaxillary (imagine a series of vertical lines)
What is the 4th rib a special landmark for?
For the lower margin of endotracheal tube on chest x ray
Where is chest tube insertion? + triangle of safety?
Intercostal space between 4th and 5th ribs Triangle of safety:
- Anatomical region in midaxillary line
-SAFE POSITION FOR CHEST TUBE INSERTION
Where should needles/ tubes be places?
Superior to rib margins
-Bc of neurovascular structures
What is the intercostal space between T7 and T8 serve as a landmark for?
Thoracentesis
Lung anatomy:
Right lung: 3 lobes (upper, middle, lower)
- oblique fissure
- horizontal fissure Left lung: 2 lobes (upper, lower)
- oblique fissure
Trachea and major bronchi anatomy
Trachea: bifurcates into mainstem bronchi at:
- Anteriorly: sternal angle
- Posteriorly: T4 spinous process R main bronchus: wider, shorter, and more vertical
- aspiration pneumonia MC in R middle and lower lobe (more vertical)
- ET advanced too far = lodged in R mainstem bronchus
Where is aspiration pneumonia more common?
right middle and lower lobe because the right main bronchus is more vertical
If an ET tube is advanced too far where will it enter?
Right mainstem bronchus
Pleurae anatomy
Visceral: covers outer surface of each lung
Parietal: covers inner rib cage and upper surface of diaphragm
- inflammation/irritation = PAIN Lubricated by pleural fluid; potential space
Transudates are seen in
HF, Cirrohosis, Nephrotic Syndrome
Exudates are seen in
Pneumonia, TB, Malignancy, PE, pancreatitis
What is a key component of COPD classification systems that guide patient management?
Degree of dyspnea combined with spirometry
When does wheezing occur? describe
Partial lower airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body
- MUSICAL respiratory sounds
- +/-audible to the pt and to others
Cough: description, what does it signal, acute vs subacute vs chronic
Cough = reflex action to stimuli irritating receptors in the airways
- internal stimuli: mucus, pus, and blood
- external: allergens, dust, cold air signals: Left sided HF acute: under 3 wks subacute: 3-8 wks chronic: 8+ wks
What is the most common cause of acute cough?
viral upper respiratory infections
Before using the term “hemoptysis,” try to confirm: _____
Before using the term “hemoptysis,” try to confirm the source of the bleeding
- hemoptysis: coughing up blood from the lungs
- coudl be GI bleed, nose, mouth
What are causes of subacute cough?
Post-infectious cough Bacterial sinusitis Asthma
What are causes of chronic cough?
Post-nasal drip Asthma Gastroesophageal reflux Chronic bronchitis Bronchiectasis
A finger pointing to a tender area on the chest wall suggests
Musculoskeletal Pain
A hand moving from neck to epigastrium suggests?
Heartburn
Most frequent cause of chest pain in children?
Anxiety
-Costochonditis is also common
What color is mucoid sputum? vs purulent
mucoid: Translucent, white or gray
purulent: Yellow or green
- Bronchiectasis
- Lung Abscess
When is Foul-smelling sputum present?
Anaerobic lung abscess
When is thick tenacious sputum present?
Cystic fibrosis
Who is Hemoptysis rare in?
infants, children, and adolescents
Blood originating in the stomach is ____ than blood from respiratory tract
Darker
-can be mixed w food particles
Causes of hemoptysis?
CF, Bronchitis, Malignancy
Massive hemoptysis is more than _______ml/24 hours.
> 500 ml
- may be life threatening
When is clubbing of the nails seen?
Bronchiectasis, CHD, PF, CF, Lung Abscess, Malignancy
What is stridor?
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.
Accessory muscle use can signal
Increased ventilatory requirements d/t airways/ parynchemal lung ds or respiratory muscle fatigue
When would the trachea be lateral displaced?
Pneumothorax, PE, Atelectasis
The AP ratio may exceed ____ in COPD
0.9 = Barrel Chest Appearance
Asymmetric expansion occurs in
large pleural effusion
Retraction occurs in
severe asthma, COPD, or upper airway obstruction
Unilateral impairment or lagging indicates
pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma
Tenderness, bruising, and bony “step-offs” are common over a
Fractured rib
Unilateral decrease or delay in chest expansion occurs in
Chronic fibrosis of underlying pleura, PE, or unilateral bronchial obstruction
Tactile Fremitus: definition; when is it more prominent vs decreased/absent
Assess the intensity of vibrations transmitted through the chest wall when a patient speaks (99)
- 4 areas posteriorly, 3 areas anterior
More prominent:
- interscapular area: closer to trachea
- right lung: R main bronchus is shorter = better vibration
- solid/fluid filled lungs: pneumonia, PE
Decreased/absent:
- Higher Pitched/Soft Voice
- thick chest wall: dampens transmission
- obstructed bronchus
- COPD , PE , fibrosis, tumor
Asymmetric decreased fremitus vs asymmetric increased fremitus
Decreased:
- unilateral pleural effusion
- pneumothorax
- neoplasm
Increased:
-unilateral pneumonia
What does percussion help you establish
whether the underlying tissues are air-filled, fluid-filled, or consolidated
What is the middle finger of your left hand hyperextended known as
Pleximeter finger
When percussing, dull can be heard in
Lobar pneumonia + Pleural effusion
- Dull = fluid or solid tissue
- dullness makes pneumonia and pleural effusion three to four times more likely, respectively.
When percussing, flat can be heard in
Large PE
When percussing, resonant can be heard in
Chronic bronchitis
When percussing, hyperressonant can be heard in
Pneumothorax, COPD
When percussing, tympanic can be heard in
Large pneumothorax
Generalized hyperresonance is common over the
Hyperinflated lungs of COPD or asthma
Unilateral hyperressonance suggests
Large pneumothorax or air filled bulla
Breath sounds may be decreased when
air flow is decreased (as in obstructive lung disease or respiratory muscle weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD).
An abnormally high level of diaphragmatic excursion suggests
PE or a high diaphrgarm as in atelectasis or phrenic nerve paralysis
Clearing of crackles, wheezes, or rhonchi after coughing or position change suggests
iNPISSATED SECRETIONS
If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect
that air filled lung has been REPLACED by fluid filled or solid lung tissue
Bronchovesicular breath sounds are best heard between the _____________of the anterior chest. Bronchial sounds are best heard over the body of the _______
first and second intercostal spaces manubrium
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 suggest
Asthma copd bronchitis
What are findings predictive of COPD?
Signs and symptoms Wheezing HX of smoking Age Decreased breath sounds DX W SPIROMETRY AND PFTs
The crackles of heart failure are usually best heard in the
posterior inferior lung fields.
Localized bronchophony and egophony are seen in
lobar consolidation from pneumonia.
The hyperinflated lung of COPD often displaces the
upper border of the liver downward and lowers the level of diaphragmatic dullness posteriorly.
What are the five “A”s of tobacco cessation counseling?
Ask about smoking at each visit
Advise patients regularly to stop smoking using a clear, personalized message.
Assess patient readiness to quit.
Assist patients to set stop dates and provide educational materials for self-help.
Arrange for follow-up visits to monitor and support patient progress.
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
