Recorded Lecture: Pulmonary Examination

Describe all the lung volumes.

• Inspiratory reserve volume - ~5-6x TV, deep inhale fill lungs w/ air, inspired OVER AND ABOVE TV

• Tidal volume - normal, relaxed breathing

• Expiratory reserve volume - ~2-3x TV, deep exhale let air out, expired OVER TV

• Residual volume - air reserve so lungs stay inflated, always present

• Functional reserve capacity = ERV + RV, air remaining in lungs after normal expiration

• Inspiratory capacity = TV + IRV, max you can inspire

• Vital capacity = IRV + TV + ERV, total amount that can be expired after fully inhaling, varies w/ age and body size, decreases w/ aquatic therapy

• Total lung capacity = IRV + TV + ERV + RV, max amount of air that can fill the lungs

Describe how obstructive and restrictive conditions affect lung volumes.

• Obstructive

  • Increased: TV*, FRC, RV, TLC

  • Decreased: IC, IRV, ERV, VC, FEV1, FVC

• Restrictive

  • Decreased: TV, IC, IRV, ERV, VC, FRC, RV, TLC, FVC

  • Normal: FEV1

What are examples of obstructive vs restrictive lung conditions?

• Obstructive - hyperinflated, chronic hypoventilation, hard to get air out “CBABE”, slower exhalation, holding onto more CO2

  • Cystic fibrosis (sometimes)

  • Bronchitis, chronic

  • Asthma

  • Bronchiectasis

  • Emphysema

• Restrictive - hard to get air in

  • Sarcoidosis, lung fibrosis, ankylosing spondylitis, obesity, burns, pneumonia, pneumothorax, hemothorax, pulmonary effusion, pregnancy

Describe the gold classification FEV1/FVC, FEV1, and symptoms at each stage of COPD.

• Mild COPD

  • FEV1/FVC: <70%

  • FEV1: >80%

  • Sx: w/ or w/o production of cough and sputum

• Moderate COPD

  • FEV1/FVC: <70%

  • FEV1: 50-80%

  • Sx: SOB w/ exertion, w/ or w/o production of cough and sputum

• Severe COPD

  • FEV1/FVC: <70%

  • FEV1: 30-50%

  • Sx: greater SOB w/ exercise, decreased exercise capacity, fatigue and repeated exacerbation of disease

• Very severe COPD

  • FEV1/FVC: <70%

  • FEV1: <30% OR <50% w/ chronic resp failure

  • Sx: respiratory failure, signs of R HF/cor pulmonale

What FEV1/FVC is required to diagnose COPD?

<70%

If a patient has a weak, wet cough, what is the best way to clear secretions?

Huffing

Describe the 4 normal breath sounds, the duration, intensity, pitch of expiratory, and location.

• Vesicular

  • Insp longer

  • Soft intensity

  • Low pitch

  • Over most of lungs

• Broncho-vesicular

  • Insp & exp equal

  • Intermediate intensity

  • Intermediate pitch

  • Between 1st & 2nd IC anteriorly & between the scapulae

• Bronchial

  • Exp longer

  • Loud intensity

  • High pitch

  • Over manubrium

• Tracheal

  • Insp & exp equal

  • Very loud intensity

  • Relatively high pitch

  • Over trachea in the neck

Describe the 4 abnormal respiratory sounds.

• Rhonchi - continuous, low pitched, rattling lung sounds that often resemble snoring. They can be heard in pts w/ COPD, bronchiectasis, pneumonia, CB, or CF (obstructive)

• Wheeze - high-pitched sound heard in expiration, caused by airway obstruction (asthma, COPD, aspiration of foreign body); if severe → inspiration too

• Crackles - brief, discontinuous, popping lung sounds that are high-pitched. Previously termed rales, heard in insp & exp

• Pleural rub - auscultation in the lower lateral chest areas, occurs w/ insp & exp, indication of pleural inflammation, sounds like sandpaper

What breath sound is associated with CHF? Heart sound?

• Crackles - high pitched, discontinuous, heard in insp, indicate pulmonary edema associated w/ L side HF, fluid overload

• S3

Describe the 3 voice sounds.

• Bronchophony - increased vocal resonance w/ greater clarity and loudness i.e. 99

  • Muffled/quiet = normal

  • Loud = abnormal

• Egophony - form of bronchophony where long “E” sounds change to a long “A” sound

  • E sounds like E = normal

  • E sounds like A = abnormal

• Whispered pectoriloquy - increased loudness of whispering i.e. 1,2,3

  • Muffled/quiet = normal

  • Loud/clear = abnormal

If a patient’s E sounds like an A, what condition does this indicate?

Pneumonia - fluid, secretions, more sound transmission

Describe the acidic, normal, and alkaline ABGs.

Describe the changes in pH, PaCO2, and HCO3 during uncompensated respiratory/metabolic acidosis/alkalosis. Mneumonic?

If pH, PaCO2, and HCO3 are all abnormal what does this mean?

Partially compensated

If HCO3 is normal what does this mean?

Respiratory condition, uncompensated if pH abnormal

If PaCO2 is normal what does this mean?

Metabolic condition, uncompensated if pH abnormal

If pH is normal what does this mean?

Fully compensated

Describe the sxs of respiratory/metabolic acidosis/alkalosis. Mneumonics?

• Respiratory acidosis: CARBS confused

  • Confused

  • Agitation

  • Restlessness

  • Blurred vision

  • Seizures

• Respiratory alkalosis: NO CARDS bp, anxious

  • Numbness

  • OTH

  • Confusion

  • Anxiety

  • Rapid breathing

  • Dizziness

  • Seizures

• Metabolic acidosis: SHAMED heart

  • Stupor (decreased consciousness)

  • Hyperkalemia

  • Arrhythmia

  • Muscle twitching

  • Emesis

  • Decreased CO

• Metabolic alkalosis: QUAD T nerves & heart

  • Tingling

  • Tremor

  • Tetany

  • Tachy