Thorax & Lungs Flashcards
Signs of distress
- Retractions & paradoxical breathing
- Audible sounds (wheezes, stridor)
Stridor
- High pitched wheeze
- Largely inspiratory
- Louder in the neck
Stridor results from what?
Turbulent airflow in upper airway
What does stridor indicate?
Laryngeal/upper airway obstruction
- Can be associated w/ epiglottis, foreign body aspiration
Signs of COPD
- Clubbing
- Pursed lip breathing
Clubbing
- Fingertips become rounder
- Linked to heart/lung conditions
- “Schamroth’s Sign”
Pursed lip breathing
- Reduces RR (12-15)
- Increases tidal volume
- ↓PaCO2
- ↑PaO2
Checking chest expansion
- Place thumbs at level of 10th ribs, fingers parallel to lateral rib cage
- Ask pt to inhale deeply
- Make note of how far your thumbs diverge as the thorax expands, looking for symmetry
What does a unilateral decrease or delay in expansion suggest?
- Fibrosis
- Pleural effusion
- Lobar pneumonia
Indirect percussion
Finger of one hand strikes finger of other hand, but does not strike the pt directly
- Only 1 finger should be placed on pt
- Should be used to check for degree of resonance
Direct percussion
Fingers or fist strike pt’s body directly
- Should be used to check for areas of tenderness
Atelectasis
Loss of air from lung or collapse of lung tissue w/ reduced lung volume
What is atelectasis a result of?
Blockage of air passages w/ mucous or from pleural effusion
Tension pneumothorax
- Large amount of air entering chest
- When 1-way valve is formed by area of damaged tissue
Pneumonia
- Refers to inflammation of the lung
- Pulmonary infiltrates/ consolidation
- Usually due to infection (lower respiratory)
Consolidation
Lung tissue becomes firm & solid
- Due to accumulated fluids & tissue debris
- An infiltrate can cause consolidation
If CC = cough, what questions should you ask?
- Sputum?
- Amount, color, consistency? - Blood?
- SOB?
- At rest or w/ exertion?
*Note
Costal cartilage & ribs feel identical
1st bony prominence
Usually C7/T1
Thorax & lungs: circumferential landmarks
- Midsternal line
- Midclavicular line(MCL)
- Anterior axillary line
- Midaxillary line
- Posterior axillary line
Lung apex
2-4 cm above clavicle
Lower border of the lung
- 6th rib midclavicular line (MCL)
- 8th rib midaxillary line
- T10 posterior
Major (oblique) fissure
- Divides lung in 1/2
- From T3 spinous process to 6th rib at MCL
Minor (horizontal) fissure
- R lung only
- Runs close to 4th rib
Lung fields
- Subdivided into 6 regions
- Region 1-6 denote upper right, middle right, lower right, upper left, middle left, & lower left
- Auscultate to determine affected lobe (not definitive dx though!)
Signs in R upper lung field originate from where?
- Almost certainly from a process in R upper lobe
Signs in R middle lung field originate from where?
- Could come from any of the lobes
Trachea bifurcation
- Anteriorly: Level of sternal angle
- Posteriorly: T4
Pleurae
- Visceral: covers outer surface of lungs
- Parietal: lines inner rib cage & upper surface of diaphragm
- Pleural fluid: lubrication
- Pleural space: Btwn parietal & visceral pleura
Primary muscles of respiration
Diaphragm & intercostal muscles
Accessory muscles of respiration
- Sternocleidomastoid & trapezius
- “Recruited”
- May be visible when extra work to breathe is required
AP diameter
May increase w/ age & w/ COPD
Purpose of palpation
To check for tender areas & palpable masses
Purpose of percussion
- To determine if underlying tissues are air-filled, fluid, or solid
- Detect areas of tenderness
Hyper-resonant percussion tone
- Very loud intensity
- Low pitch
- Ex. Emphysematous lungs, pneumothorax
Resonant percussion tone
- Loud intensity
- Low pitch
- Ex. Healthy lungs
Tympanic percussion tone
- Loud intensity
- High pitch
- Ex. Gastric bubble
Dull percussion tone
- Soft to moderate intensity
- Moderate to high pitch
- Liver
Ex. Consolidation, pleural effusion
Flat percussion tone
- Soft intensity
- High pitch
- Muscle
Ex. Consolidation, pleural effusion
Purpose of ausculation
- To determine whether there is normal air-flow, airway obstruction, or abnormal air or fluid within the chest/lungs
Normal breath sounds
- Trachea: heard over trachea
- Bronchial: heard over manubrium
- Bronchovesicular: heard in 1st & 2nd interspace anteriorly & btwn scapula posteriorly
What should you suspect if bronchial &/or bronchovesicular sounds are heard at distant location?
Fluid-filled lung
Adventitious sounds
- Crackles
- Rhonchi
- Wheeze
Crackles (rales)
- Discontinuous
- Caused by “popping open”of small airways & alveoli that have collapsed.
- Fluid in lung (E.g. pneumonia, congestive heart failure).
Rhonchi
- Low-pitched, continous
- Snoring quality
- Caused by airway secretions & narrowing / partial obstruction (E.g. bronchitis, COPD)
Wheeze
- Continuous
- High-pitched, whistle
- Caused by airway obstruction (E.g. asthma)
Pleural effusion
Collection of fluid in the pleural space
Emphysema
- Pus in pleural space
- Results from infection that spreads from lungs (e.g. pneumonia, abscess)
Acute bronchitis
- Inflammation of bronchi (not involving the lungs)
- Bronchi are considered part of the upper airway
Asthma
- Bronchial tubes are hyper-responsive
- Airways become inflamed & produce excess mucus
- Muscles around airways tighten –> narrower airways –> obstruct breathing
- Reversible
COPD (e.g. emphysema)
- Assoc. w/ airway resistance & residual volume of air after full expiration
- Can result in hyperinflated lungs –> barrel chest
- Considered irreversible
Pleural friction rub
- Squeaking, grating sound of pleural linings rubbing together
- Assoc. w/ pleurisy
- Heard on inspiration & expiration
Crepitus
- Palpable grating, crunching
- Occurs w/ rib movement due to fracture
(bone crepitus)
Tactile fremitus
- Looking for consolidation
- Vibrations transmitted through bronchopulmonary tree
- Use ulnar surface of the hand to appreciate palpable vibrations
- Ask the pt to say “ninety-nine”
Increased tactile fremitus
- Consolidation increases transmission (E.g. pneumonia)
- “Solid” transmits sound better than air
Decreased tactile fremitus
- Air & effusions decrease transmission (Eg. Pleural effusion, pneumothorax, COPD, fibrosis)
Types of crackles
- Fine crackles: interstitial process, can be normal - Medium crackles - Coarse crackles: airway disease s/a damage to bronchi
Mediastinal hunch (Hamman sign)
- Loud crackles, clicks, & gurgling
- Due to pneumo-mediastinum (mediastinal emphysema)
- Synchronous w/ heart beat
What tests check for consolidation?
- Bronchophony
- Egophony
- Whispered pectoriloquy
Bronchophony
- “99” heard louder & clearer than normal
- Indicates presence of fluid or solid tissue in alveoli
- Ex. pneumonia, atelectasis, tumors
Egophony
- When voice sounds are louder, have a nasal quality, & “E” sounds like “A”
- aka. “E to A sounds”
- Indicates presence of fluid or solid tissue in alveoli
Ex. pneumonia, atelectasis, tumors
Whispered pectoriloquy
- Whisper heard more loudly through consolidated lung tissue
- Most noticeable when comparing a normal area of lung to an abnormal area
- Indicates presence of fluid or solid tissue in alveoli
Ex. pneumonia, atelectasis, tumors
Pneumonia characteristics
- Increased tactile fremitus
- Dull percussion
- Bronchial breath sounds
- Present voice sounds
- Crackles
Pleural effusion characteristics
- Decreased tactile fremitus
- Dull percussion
- Decreased breath sounds
- Absent voice sounds
Obstructive lung disease characteristics
- Decreased tactile fremitus
- Hyperresonant percussion
- Decreased breath sounds
- Absent voice sounds
- Wheezes, rhonchi
Acute bronchitis characterisitcs
- Normal tactile fremitus
- Resonant percussion
- Vesicular breath sounds
- Absent voice sounds
- Wheezes, rhonchi
Clinical pulmonary fxn tests (PFTs)
- Ask pt to walk down hall or climb 1 flight of stairs
- Observe rate & effort
Forced expiratory time
- Ask pt to “blow out the candles”
- >6 seconds = obstructive pulmonary disease
Auscultate during forced exhalation
May allow faint wheezes to be heard better
