WEEK 4: RESPIRATORY Flashcards
Right main bronchus is more straight so when people choke, often it goes to the right lung before the left; true or false
true
Breathing controlled by ____ and ____
medulla oblongata and the pons
What is normal RR?
14-20
Hyperventilation is described as?
rapid, deep
Tachypnea is described as?
> 25/min (rapid, shallow)
Dyspnea:
difficulty breathing
Apnea:
not breathing
Ataxic (Biot):
irregular pattern- apnea, alternates w/regular deep breaths which stops suddenly for short intervals
Cheyne stokes:
deep breathing alternating w/periods of apnea
Respiratory Questions to Ask
SOB (difficulty breathing) with or w/out exertion- (table 15-1) (different question to determine upper and lower respiratory)
Upper respiratory vs lower respiratory
Chest Pain w/wout exertion or associated w/breathing? (table 15-3) (different area causes for chest pain)
Cough: productive or nonproductive (table 15-2)
Wheezing? (does it sound like a squeey high pitch noise)
Sputum (mucus): characteristics
Hemoptysis (table 15-2)
Orthopenea (does it get hard to breath when you lie down)
Daytime sleepiness, snoring, apnea during sleep (partner/roommate/friends may know more)
Unable to “catch a breath” or “take a deep breath”
RASH?
New Medications?
GERD? (chronic cough, hoarse voice or sore throat)
Travel, ill contacts?
Immunization Status
cough questions to ask?
Productive vs. nonproductive Sputum characteristics? Worse at certain time of day? Wake you up at night? Associated symptoms? Fever? Fits of coughs? Post-tussive vomiting? Exacerbated by physical activity or environmental surroundings? Smoking, PMH, ill contacts
chest pain questions to ask ?
Tightness, burning?
Associated with breathing or coughing?
Heaviness/thickness
Dull vs sharp
Point with a finger/pinpoint- musculoskeletal
Flat hand, fist- angina, pleuritic
Hand moving up and down from neck to stomach (reflux?)
Past medical history to ask?
Past Medical History Asthma, COPD, CHF, PNX, PNA TB, CA Hx of Intubation? Do you use O2? CAD, pulmonary HTN Medications, Allergies, Immunizations
Social history to ask?
Smoking/Second hand smoke exposure Marijuana/Hookah/E-Cigs/Vaping Occupational/Environmental Exposures Recent Travel Ill contacts Where have they lived?
what is the order of the lung exam?
Inspect, Palpate, Percuss, Auscultate
What should you note when inspecting the respiratory system?
Inspect
Symmetry
Sternum, ribs, scapula
Scoliosis, kyphosis, congenital chest conditions
Retractions, accessory muscle use, nasal flaring
Work of breathing; length of inspiratory vs expiratory phase
Clubbing, pursed lip breathing, color (cyanosis, pink/erythema)
Early hypoxia vs late hyposix
Early hypoxia Restlessness Agitation Fear Need to sit straight up Inability to concentrate Tachypnea ----- Late signs Decreased P.ox Change in BP Tachy/Brady Cyanosis Retractions Nasal Flaring Confusion
What should be included in the palpation exam?
Palpate structures that may be tender: sternum, ribs, costochondral areas (where cartilage & ribs meet) & sternal border
Palpate structures that appear abnormal
Palpate skin abnormalities- crepitus?-pneumothorax
Palpate chest expansion posteriorly @ 10th rib
Tactile Fremitus: “Ninety-Nine”(side of your hands and have them say 99)
Tactile Fremitus:
“Ninety-Nine”(side of your hands and have them say 99)
How to detect clubbing?
If distal phalangeal depth ratio is greater than interphalangeal depth ratio = clubbing
If putting two fingers together and it creates a diamond instead of straight, its clubbing (schamroth sign)
How to test chest expansion?
POSTERIOR CHEST: PALPATION: palm of hand or side of hand
Test chest expansion: thumbs at the level of the 10th rib with fingers parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration
Expect: symmetric expansion
How do you PERCUSS THE POSTERIOR CHEST
Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid
Perform from side to side to assess for asymmetry
Strike using the tip of your tapping finger, twice in each location
Use the lightest percussion that produces a clear note
PERCUSSION: HYPERRESONANCE
Hyperresonance: when lungs are hyperinflated
Loud, lower & longer than resonance
More common in children & very thin adults
COPD
ASTHMA (may be resonant to hyperresonant)
Unilateral: air-filled bulla
Air in lung
PERCUSSION: DULLNESS
Dullness: when fluid or solid tissue (mass) replaces air containing lung or pleural space
Pneumonia- alveoli filled with fluid, blood cells
Pleural effusion- pleura filled with serous solution
Hemothorax- pleura filled with blood
Empyema- pleura filled with pus
Tumor or fibrous tissue
Flatness
Flatness is high pitched & short, soft
Typically over solid structures such as bone (spine, scapulae, sternum)
Pleural effusion
Tympany
Tympany loud and high pitched- drum like, longer duration
Excessive air such as pneumothorax
Normal over abdomen; abnormal over chest
How do you auscultate the respiratory system
NEVER, EVER LISTEN over clothes (unless the patient refuses to allow you to listen directly on skin
The most important exam technique for assessing air flow
Use the diaphragm of a stethoscope
Superior to inferior, left to right to compare
Instruct to breathe deeply with mouth open
Slowly! Breathing in and out w/patient may help
You may need to demonstrate
Listen to at least one full breath in each location: don’t cut it short
Wheezes sometimes happen at last min, so might miss if dont listen fully
Remember: RIGHT MIDDLE LOBE
Vesicular
Soft
low pitched
Inspiration and through first 3rd of expiration
Over most of both lungs
Bronchovesicular
Inspiratory and expiratory sounds equal
Heard anteriorly in1st and 2nd intercostal spaces
Heard between scapulae posteriorly
Bronchial/Tracheal:
Louder Harsher Higher pitched Short silence between insp and exp phase Exp sounds last longer Inspiratory and exp are equal Heard over trachea in neck
CRACKLES/RALES
Air moving through fluid
Nonmusical
Intermittent or brief (not continuous)
Fine (higher pitched) vs coarse (low pitched)
Heard in following conditions
PNA (pneumonia)
Fluid (congestive heart failure)- heard posterior
Atelectasis- collapse of alveoli with period of prolonged shallow breaths
Pulmonary fibrosis
Bronchiectasis
WHEEZING
WHEEZING
High pitched whistling sound or low-pitched moaning
Musical
Intermittent (located any period during inspiration or expiration)
describe when late, vs. early.
Inspiratory vs expiratory
Caused by constriction of smallest airways due to inflammation and mucus
Asthma, Bronchitis, COPD, RSV
RHONCHI
Musical, prolonged Dashes in time Low pitched with a snoring/rattling quality Inflammation of lung tissue- bronchitis, area of larger airways containing mucus May change with cough Heard in the following conditions Bronchitis Pneumonia RSV
Stridor
high pitched continuous
Upper airway constriction/narrowing
Epiglottitis, anaphylaxis, foreign body, tracheal stenosis from intubation, airway edema
Pleural Rub
Low frequency, grating sound
Nonmusical, biphasic (inspiration, expiration)
Pleuritis, PNA, Pleural effusion
ABSENT OR DIMINISHED BREATH SOUNDS indiciates?
Think: lack of airflow Pneumothorax Consolidation Mass Lobectomy? Status Asthmaticus or severe broncho-constriction (tight airways prevent airflow sounds- after bronchodilator- may hear more)
Bronchophony:
have patient say “ninety-nine”
Indistinct, muffled: Normal
Loud, clear, understandable: Increased density
Egophony:
“eeee”
Normally muffled long E sound
Changes from “eee” to “aaa” over area of consolidation
ABCDEF:
Airways, bones, cardiomediastinal silhouette, diaphragm, expanded lungs/everything else foreign objects
PNEUMONIA (PNA)
Condition: bacterial infection, causing consolidations in lungs
Black area means clear lung, want to see more dark
Inspection: work of breathing, accessory muscle use, color, tachypnea
Palpation: tender structures, tactile fremitus, percussion
Auscultation: LS- crackles, diminished, rhonchi, egophany, bronchophany
COPD
Chronic obstructive pulmonary disease:
Emphysema- pink puffer
Chronic Bronchitis - blue bloater, coughing mucus up
ASTHMA
Condition: constriction of small airways & increased mucus production
Inspection: retractions, accessory muscles, color, dyspnea, tachypnea, anxiety, clubbing?
Auscultation: LS: wheezing, rhonchi, crackles?
Has it improved since given meds?
ACUTE BRONCHITIS
Condition: 98% cases caused by viral infections
Inspection: work of breathing, color, tachypnea, retractions, accessory muscle use
Palpation: excursion, fremitus
Auscultation: LS: wheezing, rhonchi, egophany
PLEURAL EFFUSION
Condition: fluid trapped in the pleural space- PNA, CHF, CA, Cirrhosis
Inspection: work of breathing, tachypnea, dyspnea, retractions, accessory muscle use
Palpation: lung expansion, tactile fremitus, percussion
Auscultation: LS: diminished? Crackles? Rhonchi?, egophany, bronchophony
HEART FAILURE (PULM EDEMA)
Condition: left sided heart failure- causing back up of fluid into lungs
Inspection: work of breathing- dyspnea @ rest w/exertion (how much- minimal-mod), tachypnea, (other cardiac signs- JVD), chest diameter?
Palpation: pain on palpation of structures, percussion
Auscultation: Crackles? Wheezing? Diminished?
OSA
Obstructive sleep apnea
Excessive daytime sleepiness Snoring Apnea T2DM CVD Cognitive Impairment Afib RF: male, obesity, older age, craniofacial and upper airway abnormalities, postmenopausal (for women)
FRACTURED RIB
Local pain and tenderness of one or more ribs
Compression of chest in AP plane:
One hand on sternum and one hand on thoracic spine- squeeze chest- is this painful? Where?
An increase in the local pain (away from hand) suggests rib fracture
LUNG CANCER
Lung CA:
Cigarette smoking 85% of Lung cancer cases
USPSTF Screening Recommendation Grade B UPDATE
LDCT in 50-80 yr old for 20 pack year hx
Annual LDCT x 3 years compared to CXR reduced risk of dying from Lung CA by 20% after 7 yrs of f/u
CONSIDERATIONS FOR INFANTS/CHILDREN
Order can be modified on state of wakefulness/cooperativeness
Infant: Examine on table with only diaper so respiratory effort can be viewed
May use bell for infants (over interspaces)
Use diaphragm for children (toddler age & up)
Bowel sounds heard easily in chest
Airway is shorter; upper airway sounds transmitted to lower airways
Respiratory rate varies with temperature, activity, feeding, sleep
Little structural support from ribs
Nose breathers until age 3 mos
Abdomen rise/fall
CONSIDERATIONS FOR OLDER ADULTS
Kyphosis - curvature of the spine measuring 50 degrees or greater
Chest wall appears bony»_space; loss of subcutaneous fat
Less mobile thorax- unable to compensate for long; tire easily; more reliance on diaphragm for breathing
Increased AP diameter of chest wall
May become dizzy when taking deep breaths during auscultations: take it slow
Dry mucous membranes in nares, throat, respiratory tract
Slight hyperresonance of lung fields with percussion
Pneumonia – present with atypical symptoms
