week 6- resp Flashcards
• Which “system” could be source of respiratory symptoms?
o Respiratory; cardiovascular (e.g. CHF); gastrointestinal (GERD); CNS (eg. anxiety); renal (eg. CRF); endocrine (eg. DM); musculoskeletal (herpes zoster, costochrondritis)
• What questions should you ask on hx of resp sxs?
o What are the concomitant symptoms?
o environmental exposures: Occupation, household chemicals, recent travel, areas of pollution, smoking, pets, hobbies (eg. ceramics, carpentry)
o Sleep environment, type of pillows, bedding, use of humidifier
o Heating system- gas exacerbates allergies, wood exacerbates mold, electric cleanest
o Family history: hereditary conditions, shared exposures
• What are some common presenting sxs of resp problems?
o Cough; sputum; hemoptysis; dyspnea; chest pain
• What are cough receptors? Purpose of cough?
o in respiratory tracts, pericardium, diaphragm, esophagus, stomach;
o respond to chemical or mechanical stimuli.
o Afferent pathway via the vagus to “cough center” in medulla.
o Efferent signals via vagus, phrenic and spinal motor nerves to expiratory musculature
o functions to clear secretions and foreign bodies
• what are common causes of cough?
o Upper respiratory tract infections; Asthma; Lung infx (pneumonia, acute bronchitis); COPD (emphysema, chronic bronchitis); Rhinosinusitis leading to postnasal drip; Lung dz: bronchiectasis, interstitial, tumor; Gastroesophageal reflux disease (GERD); Cigarette smoking; Second-hand smoke exposure; Air pollution exposure; ACE inhibitors; Aspiration; Cystic fibrosis- young individual; CHF—unproductive cough at night; Anxiety—nervous cough; Chronic idiopathic cough
• What is some history taken to investigate cough?
o Duration, sudden or gradual, any recent change in cough?
o What factors affect it? (cold air, talking, eating, posture, drinking, exercise)
o Sputum production: amount, quality, color
o Any concomitant symptoms? Ie. chest pain, dyspnea, hoarseness, dizziness
o Patterns of the cough
• How do you asses duration of a cough? Likely causes?
o Acute cough: < 3 week duration—most likely from infection, exacerbation of underlying lung disease
o Subacute cough: 3-8 wks—often post-infectious
o Chronic cough: >8 wks—often from upper airway cough syndrome (i.e post-nasal drip from allergies, rhinitis, rhinosinusitis), asthma or GERD
• What are some patterns that may be seen with a cough?
o with posture change suggests chronic lung abscess, TB, bronchiectasis, tumor
o during eating suggests problem with swallowing mechanism
o with cold air or exercise suggests asthma
o in am, that persists until sputum is produced is characteristic of chronic bronchitis
o in am may suggest allergy to something in sleeping quarters
• when is sputum seen? What Q’s should be asked?
o Infection, allergic reaction, inhalation of irritants (e.g. smoke), COPD, CF, etc
o Color
o Quantity (scant, profuse) and quality (thin, stringy, thick, etc)
• What do colors of sputum mean?
o not always accurate!!!
o clear: allergy, COPD
o yellow: infection (acute bronchitis, acute pneumonia) (live neutrophils)
o green: chronic infection (chronic bronchitis, pneumonia, bronchiectasis, CF), (neutrophil breakdown)
o brown/black/rust: “old blood” eg. chronic bronchitis, chronic pneumonia, TB, lung cancer
• what is hemoptysis? Source?
o expectoration of blood
o Blood-streaked sputum to gross blood expectorated
o Massive hemoptysis: life threatening, loss of >600 ml in 24 hr
o Need to clarify source: upper or lower respiratory, upper GI??
• What are some causes of hemoptysis?
o Airway inflammation; Bronchogenic carcinoma (may be frothy); Foreign body; Airway trauma; Autoimmune disease; Coagulopathy; Lung parenchymal infection (TB {streaks of blood}, pneumonia, abscess); Cocaine-induced pulmonary hemorrhage; Pulmonary embolism (bright red; Esophageal varices
• What is dyspnea?
o sensation of difficulty in breathing
o shortness of breath (SOB) on exertion is a common type of dyspnea
• what are the 6 clinical types of dyspnea?
o Physiologic, pulmonary, cardiac, chemical, neuromuscular, psychological conditions
• What is physiologic dyspnea?
o most common, eg. exertion at high altitude
• what are the 4 types of pulmonary dyspnea? Examples?
o i) restrictive: low compliance of the lungs, usually OK at rest, worse with exertion; pulmonary fibrosis; chest deformities: eg pectus excavatum; scoliosis; broken ribs; obesity
o ii) obstructive: increased resistance to airflow, esp. with expiration; asthma; upper airway edema due to allergies, infection; cystic fibrosis; COPD (emphysema, chronic bronchitis)
o iii) infectious; pneumonia; severe acute respiratory syndrome (SARS)
o iv) non-infectious; lung cancer; sarcoidosis; pleural effusion; pneumothorax; pneumoconiosis; atelectasis
• what are causes of cardiac dyspnea?
o congestive heart failure; cardiogenic pulmonary edema; valvular heart disease; dissecting aortic aneurysm; ischemic heart disease; cardiomyopathy; pericardial effusion; malignant hypertension
o cardiac asthma: acute resp. insufficiency caused by L ventricular failure with bronchospasm, wheezing and hyperventilation
• what are the 3 signs that dyspnea is of cardiac origin?
o a. Cheyne-Stokes respiration: alternating periods of apnea and hyperpnea (gradually increasing depth and frequency of respiration)
o b. Orthopnea: respiratory problems while supine (Left ventricular failure)
o c. Paroxysmal Nocturnal Dyspnea (PND): pt awakens gasping for breath and must sit or stand up (eg mitral stenosis, aortic insufficiency, HTN)
• what is chemical dyspnea?
o acidosis may result in slow, very deep gasping respirations
o ie “Kussmaul breathing” (trying to blow off CO2 to compensate for acidosis)
o May be seen in diabetes (DKA), chronic anemia, pregnancy, renal failure
• What may cause neuromuscular dyspnea? Psychological?
o Nm: multiple sclerosis; ALS; myasthenia gravis; Guillain Barré Syndrome
o P: anxiety; panic attacks
• What are the 5 categories of causes of chest pain?
o Alert EMS
o a. Cardiac pain (angina, MI) is usually crushing, pressing or squeezing, generally aggravated by exertion, cold weather, stress, and after meals. May radiate to neck, jaw or arm. Nausea and diaphoresis are common classic concomitants to MI.
o b. Pulmonary pain- localized, sharp and knifelike; worse breathing or coughing (pleural pain); e.g. - pleurisy, pneumonia, TB, cancer, atelectasis, thromboembolism, pleural effusion, histoplasmosis, pneumothorax
o c. GI pain- may be sharp, burning, squeezing, or heavy; affected by swallowing (spasm), large meals, certain foods, body position, GERD
o d. Musculoskeletal/ skin- costochrondritis, fractured rib (history of fall)–(pain will be elicited by palpation exam), herpes zoster (prodromal sx, then vesicles erupt along dermatome)
o e. skin or CNS (anxiety, panic attack)- may create pain simulating MI or reflux.
• How do you report findings in a chest PE?
o Abnormal findings are reported in terms of location, referring to ribs and anatomic lines on chest (sternal, mid-clavicular, mid-axillary, mid-scapular lines
o All exams performed on anterior and posterior thorax
• What are the 4 general categories of chest PE?
o Inspection: resp rate, signs of respiratory distress, chest configuration, coloration, etc
o Palpation: assess area of pain, chest expansion, tactile fremitis
o Percussion
o Auscultation
How do you interpret percussion on chest PE?
o Percussion Notes- listen and feel for intensity, pitch and duration of note produced. 5 notes possible:
o A. Resonant: loud, low pitch, long duration - dominant note over normal lungs
o B. Flat: soft, high pitch, short duration – eg. sounds like percussion over thigh muscle
o C. Dull: medium intensity, pitch and duration – eg, sounds like percussion over liver suggests pleural thickening, atelectasis, consolidation, pleural effusion
o D. Hyperresonant: very loud, low pitch, long duration– suggests trapped air as in pneumothorax, severe emphysema
o E. Tympanic: musical quality, e.g., over stomach or puffed cheek
What is chest percussion also used to evaluate?
o Diaphragmatic Excursion (change in lung expansion w inhalation vs expiration)
• What are the 4 normal sounds found on chest auscultation?
o A. Vesicular - soft, low pitch, normal over most lungs fields; inspiration lasts longer than expiration I>E
o B. Bronchial – loud, moderately high pitched. Heard over central bronchus. I=E
o C. Bronchovesicular - medium intensity and pitch, normal over main-stem bronchi
o D. Tracheal - loud, high in pitch, normally heard over trachea, E>I (not performed)
• What are the 3 types of changes in breath sounds? Causes?
o i. Absent breath sounds: collapsed lung
o ii. Decreased breath sounds: when normal lung is displaced by air (emphysema or pneumothorax) or fluid (pleural effusion) Increased distance between lung and chest wall
o iii. Bronchial breathing: consolidation in lower lobes changes sounds from vesicular to bronchial (blockage of passage of air through area of consolidation, prevents vesicular sounds and makes bronchial sounds dominant).
• What are the adventitious (superimposed) lung sounds?
o Crackles; rhonchi; wheezes; pleural sounds
• What are crackles?
o (prev term “rales”) popping sounds, usually heard during inspiration, do not clear with cough
o produced by the passage of air through bronchi that 1) contain secretions (early inspiratory crackles) or that 2) are constricted by spasm or thickened walls (pan- or late insp)
• what are rhonchi?
o (low pitch wheezes) originating in upper airways
o often have a “snoring” or “gurgling”, rumbling quality
o caused by secretions and resulting obstruction in large bronchi
o prominent on expiration, tend to clear with coughing
• what are wheezes?
o high pitched, musical, or whistling sounds caused by narrowing or obstruction of small bronchi or bronchioles, the walls oscillate creating the sound
o may be of one pitch (monophonic) or several pitches (polyphonic) depending on size of airway(s) involved
o usually heard during expiration, particularly forced expiration
o diffuse over lung fields with asthma, bronchitis, COPD
o localized if obstruction in bronchus- eg tumor, secretions or foreign body
• what is stridor?
o an inspiratory wheeze associated with upper airway obstruction (eg Croup).
• What are pleural sounds?
o pleural friction rub
o pleural fluid decreased or absent; usually due to inflammation of pleura;
o loud creak or grating sound, like the cracking of leather
o Both inspiration and expiration
o Often with concurrent Pleurisy- sharp knife-like localized pain; patient may hold side (“splinting”) to minimize chest wall movement
• What are additional PE steps to pursue if abnormality found on initial exam?
o Voice Transmission Tests: All these tests become abnormal with lung consolidation
o Bronchophony
o Whispered pectoriloquy
o Egophony
• What is bronchophony?
o (vocal fremitus)
o a. patient repeats “ninety-nine” in a normal voice
o b. auscultate over area of concern as they repeat it, comparing to opposite side.
o c. “99” will normally be muffled and indistinct. Louder, clearer sounds (called bronchophony) over area of consolidation
• what is Whispered Pectoriloquy?
o a. patient repeats a whispered “1,2,3”
o b. auscultate over area of concern as they repeat it, comparing with opposite side.
o c. Normally faint sounds or nothing at all is heard. Clear “1,2,3” heard over area of consolidation
• what is egophony?
o a. patient repeats “ee” in a normal voice
o b. auscultate over area of concern as they repeat it, comparing with opposite side.
o c. Normal: muffled “ee” sound. Abnormal if “ee” turns to “Ay” (E to A change) over area of consolidation (Lower pitched frequencies transmitted)
• what labs might you do for chest complaints?
o CBC – for infection, allergies etc.
o Comprehensive Metabolic Panel (CMP) – electrolytes, glucose, lipids; liver enzymes (serum LDH and protein to compare with pleural fluid expressed from thoracentesis)
o Sputum cultures
o Arterial Blood Gases (pH, PaO2, PaCO2, HCO 3-)
o TB testing—Quantiferon Gold, Mantoux test (older technology)
• What are 3 special tests for respiratory complaints?
o Peak flow meter (in office)
o Pulse oximetry (in office)
o Pulmonary fxn tests (spirometry) PFT (referral to pulmonologist)
• What is a peak flow meter?
o Hand-held devices to monitor pulmonary function in patients with asthma., roughly correlates with the FEV1. Based on age and gender, compared to expected values.
o See “Predicted Peak Flow” (Search, medical apps)
o 1. Ask the patient to take a deep breath.
o 2. Then ask them to pinch nose and blow as hard as they can thru the peak flow meter.
o 3. Repeat the measurement 3 times and report the highest reading
• What is pulse oximetry, “pulse ox”?
o Non-invasive test of oxygen saturation in arterial blood.
o Portable, fingertip sensor uses photodiode.
o Normal saturation range is 95-99%
• What is spirometry (PFT)?
o Order to determine the presence of obstructive and restrictive diseases; (also done routinely pre-surgical/pre-anesthesia in elderly, smokers, etc)
o Assesses the functional status of the lung:
o 1. How much air volume can be moved in and out of the lungs
o 2. How fast the air in the lungs can be moved in and out
o 3. Lung and chest wall compliance
o 4. How the lungs respond to chest physical therapy procedures or bronchodilator tx
• What are PFT results for obstructed airflow?
o FEV1 (forced expiratory volume in one second) can be reduced if:
o i. narrowing of the airways due to bronchial smooth muscle contraction (asthma)
o ii. narrowing of the airways due to inflammation and swelling of bronchial mucosa and the hypertrophy and hyperplasia of bronchial glands (bronchitis)
o iii. material inside the bronchial passageways physically obstructing the flow of air (mucus plug, foreign body, tumor)
o iv. external compression of the airways by tumors and trauma
