pulmonary examination

what should an xray of the lungs look like

radiolucency

radio-opaque

there is more density (looks white on the imaging)

radiolucency

appears black on the imaging (less dense)

xray of lungs with COPD

• widened intercostal spaces

• flattened hemidiaphragms

• squared off costophrenic angles and rib angles that approach 90 degree angles

xray of lungs with atelectasis

• diaphragm elevation on the collapsed side

• deviation of the mediiastinum, trachea (deviated towards collapsed side

• increased density of the lobe

normal FEV1 value

above 80% of the predicted value for age, gender, height and ethnicity

normal FEV1/FVC ratio in adults

above 0.7% (70%)

normal FEV1/FVC ratio in younger individuals

above 0.75-0.8%

normal FEV1/FVC ratio in people with COPD

less than 70%

forced vital capacity

the maximal volume of gas a patient can forcefully and quickly exhale

forced vital capacity technique

maximal inspiration followed by rapid and forceful expiration

forced vital capacity interpretation

generally reduced in both obstructive and resistive diseases

regulation of acids

• the lungs violate acids by CO2 excretion

• the kidney regulate nonvolatile acids through exctetion

the pationets ABG findings are

• PH: 7.51, pCO2: 27, pO2: 146, HCO3: 24

a. respiratory acidosis

b. respiratory alkalosis

c. metabolic acidosis

d. metabolic alkalosis

B. Respiratory alkalosis

the patients ABG findings are

• PH: 7.2, pCO2: 40, PaO2: 60, HCO3: 1

a. respiratory acidosis

b. respiratory alkalosis

c. metabolic acidosis

d. metabolic alkalosis

C metabolic acidosis

what regulates major blood base (bicarbonate)

kidneys

normal blood pH

7.4

pH value that indicates acidosis

less than 7.4

2 mechanisms of acidosis

• metabolic acidosis (decreased HCO3)

• respiratory acidosis (increased PcCO2)

pH value that indicates alkalosis

pH above 7.4

2 mechanisms of alkalosis

• metabolic alkalosis: increased HCO3

• respiratory alkalosis: decreased PaCO2

normal PaCO2 value

40 mmHg

PaCO2 value that is considered acidic

above 40 (respiratory acidosis)

PaCO2 value that is considered alkaline

less than 40 (respiratory alkalosis)

normal HCO3 value

24 mEq/L

HCO3 value that is considered acidic

less than 24 (metabolic acidosis)

HCO3 value that is considered alkaline

above 24 (metabolic alkalosis)

causes of respiratory alkalosis

hyperventilation

causes of respiratory acidosis

respiratory depression (medications, CNS trauma), pulmonary disease (pneumonia, COPD, cystic fibrosis, asthma)

presentation of respiratory alkalosis

• lightheadedness

• dyspnea

• parestheia

• chest tightness

• seziure

clinical implications of respiratory alkalosis

• monitor vital signs

• breathing pattern

• respiratory status

presentation of respiratory acidosis

• anxiety

• confusion

• fatigue/lethargy

• tachypnea

• coma

• seizure

clinical implications of respiratory acidosis

• monitor vital signs

• breathing pattern

• respiratory status

causes of metabolic alkalosis

• sodium bicarbonate overdose

• prolonged vomiting

• nasogastric drainage

• cystic fibrosis

causes of metabolic acidosis

• diabetes

• shock

• renal failure

• interstitial fistula

presentation of metabolic acidosis

• dyspnea

• fatigue

• nausea/vomiting

• tachyarrhythmias

• hypotension

presentation of metabolic alkalosis

• confusion

• delirium

• dysrhythmias

• hypotension

• muscle cramping

clinical implications of metabolic alkalosis

• monitor vital signs and cardiac rhythm throughout the physical therapy interventioin

• assess + monitor for cognitive impairment due to increased risk for altered mental status

clinical implications of metabolic acidosis

• monitor breathing pattern, respiratory status, vital signs, and cardiac rhythm during PT intervention

• consider treating using the BORG RPE scale

normal PaO2

80-100

severity of hypoxemia

60-80 mmHg = mild hypoxemia

40-60 mmHg = moderate hypoxemia

<40 mmHg = severe hypoxemia

factors that influence hypoxemia

• hemoglobin concentration

• capillary blood flow

clinical implications of oxygen status assessment

• hypoxemia is a key indicator of impaired oxygen delivery

• requires further investigation

• may necessitate intiiation or adjustment of supplemental oxygen

assessment equation for someone with supplemental oxygen

expected PaO2 = FiO2 × 500

vesicular breath sounds

• soft

• low pitched

• except near trachea and mainstream bronchi

• heard during inspiration and early expiration

bronchial breath sounds

• loud

• hollow/tubular sounds

• high pitched

• heard near trachea and mainstream bronchi (sternal notch)

bronchovesicular breath sounds

• softer than bronchial breath sounds

• heard near parasternal and supraclavicular and suprascapular region

• at the junction of mainstream bronchi with the segmental bronchi

crackle breath sounds

• discontinous popping sound

• heard over the infiltrate or cough

• fine crackles (atelectasis)

wheezes breath sounds

• continous, low or high pitched

• airway obstruction bronchospasm

stridor breath sounds

• very high pitched

• indicates upper airway obstruction

pleural rub breath sounds

grating sound indicates pleural information

normal respiratory rate for an adult

12-20

brown sputum color

indicates possible bleeding from awhile ago, bright red means new blood

black mucus sputum color

may indicate the presence of a fungal infection

white mucoid sputum color

signals nasal congestion

respiratory distress signs

• nasal flaring

• sweating

• paleness

• focused or enlarged pupils

mediate percussion characterized sounds

• resonant

• hyper resonant

• dull

hyper resonant mediate percussion sound

over emphysematous lungs or pneumothorax

dull mediate percussion sound

increased tissue density or lungs with decreased air

fremitus definition

vibreation produced by voice or secretions in the airway

fremitus palpation technique

• palpation with palms placed lightly on the chest wall

• patient repeats a word (ex: 99) to distinguish normal and abnormal fremitus

normal fremitus findings

palpation reveals uniform vibrations throughout the entire chest wall

increased fremitus signs

increase in secretions in a specific area

decreased fremitus signs

increase in air in a particular area