Pulmonary Conditions

Chostocondritis

coughing→muscle pain

Normal Respiratory Rate

adults→14-20 bpm

infants→up to 44 bpm

Tachypnea

rapid+shallow breathing

Hyperpnea/Hyperventilation

rapid+deep breathing

Kussmaul Breathing

systemic acidosis→compensatory overbreathing

Bradypnea

slow breathing

with/wihout increase in tidal volume

Cheyne-Stokes Breathing

periods of hyperpnea alternating with apnea

Ataxic Breathing/Biot Breathing

unpredictable irregularity

Sighing Respiration

hyperventilation syndrome

Obstructive Breathing

airway narrowing→prolonged expiration

Fremitus

palpable vibrations transmitted through bronchopulmonary tree to chest wall

more prominent in interscapular areas than lower lung fields

Flat Percussion

relative intensity→soft

relative pitch→high

relative duration→short

example of location→thigh

pathologic example→large plerual effusion

Dull Percussion

relative intensity→medium

relative pitch→medium

relative duration→medium

example of location→liver

pathologic example→lobar pneumonia

Resonant Percussion

relative intensity→loud

relative pitch→low

relative duration→long

example of location→healthy lung

pathologic example→simple chronic bronchitis

Hyperresonant Percussion

relative intensity→very loud

relative pitch→lower

relative duration→longer

example of location→usually none

pathologic examples

• COPD

• pneumothorax

Tympanitic Percussion

relative intensity→loud

relative pitch→high

relative duration→longer

example of location

• gastric air bubble

• puffed-out cheek

pathologic example→large pneumothorax

Vesicular Breathing

duration→inspiratory sounds last longer than expiratory sounds (inspiratory>expiratory)

intensity→soft

pitch of expiratory sound→relatively low

locations where heard normally→over most of both lungs

Bronchovesicular Breathing

duration→inspiratory sounds equal length to expiratory sounds (inspiratory=expiratory)

intensity→intermediate

pitch of expiratory sound→intermediate

locations where heard normally

• anteriorly

• often in the 1st+2nd interspaces

• between the scapulae

Bronchial Breathing

duration→expiratory sounds last longer than inspiratory sounds (inspiratory<expiratory)

intensity→loud

pitch of expiratory sound→relatively high

locations where heard normally→over the manubrium (larger proximal airways)

Tracheal Breathing

duration→inspiratory sounds equal length to expiratory sounds (inspiratory=expiratory)

intensity→very loud

pitch of expiratory sound→relatively high

locations where heard normally→over the trachea in the neck

Clubbing Indications

congenital heart dx (CHD)

interstitial lung dx (fibrosis) (ILD)

bronchiectasis

cystic fibrosis (CF)

lung abscess

lung cancer

Signs of Respiratory Distress

tachypnea (25+ bpm)

cyanosis/pallor

audible sounds of breathing (stridor)

accessory muscle use during breathing

shape of chest

Barrel Chest

increased AP diameter (0.9+)

infancy+aging→normal

adults→I: COPD

Pectus Excavatum/Funnel Chest

depression in lower part of sternum

compression of heart+vessels→murmur

Pectus Carinatum/Pidgeon Chest

sternum displaced anteriorly→increases AP diameter

costal cartilage adjacent to the protruding sternum→depressed

Traumatic Flail Chest

multiple rib fractures→cause paradoxical movements of the thorax

inspiration→decreased intrathroacic pressure→depression of injured area

expiration→injured area bulges outward

Thoracic Kyphoscoliosis

abnormal spinal curvature+vertebral rotation→deforms the chest

Skin Findings

sinus tracts

zoster rash

Stridor

audible+high-pitched inspiratory whistling

I: upper airway obstruction→urgent evaluation needed
-larynx
-trachea

Fine Crackles

physiology

• small distal ariways deflated during expiration→pop open during inspiration→series of tiny explosions→thin secretions in the airways

characteristics

• soft

• high-pitched sounds

• very brief

• “velco being pulled apart”

• intermittent

• non-musical

• brief

• don’t clear with cough

location

• commonly heard at lung bases

clinical relevance

• interstitial pulmonary fibrosis

• PNA

• CHF

• atelectasis

Course Crackles/Rales

physiology

• movement of thicker fluid/air through fluid in small airways

characteristics

• loud

• discontinuous

• low-pitched

• explosive sounds

• “slurping at the end of fountain drink”

• inspiration or expiration

• could clear with cough

location

• commonly at lung bases

clinical relevance

• PNA

• bronchiectasis

• interstitial lung fibrosis

• CHF

Wheezing

physiology

• movement of air thorugh bronchial airway narrowing

characteristics

• continuous

• high-pitched (hissing/shrill) musical sounds

• inspiratory/expiratory/biphasic

location

• single location
  -or

• throughout the per

clinical relevance

• asthma

• COPD

• viral infxns/bronchiolitis

Rhonchi

physiology

• narrowing of larger ariways

• air through secretion in large airways

characteristics

• continuous

• low-pitched

• “snoring” sounds

• low+loud+harsher wheeze

location

• typically heard throughout the pericordium
  -inspiration
  -expiration
  -both

physiology

• narrowing of larger airways

• air through secretion in large airways

clinical relevance

• PNA

• bronchitis

Stridor

medical emergency→immediate intervention

physiology

• airflow through narrowed upper airway

characteristics

• continuous

• high-pitch

• harsh

• “musical” sound

• inspiration or biphasic

location

• neck+central airways

• loudest→over neck

• can hear heart without stethoscope

clinical relevance

airway obstruction

• tracheal stenosis 2/2 intubation

• edema post-ET removal

• epiglottitis

• foreign body

• anaphylaxis

Pleural Friction Rub

physiology

• inflamed/roughened visceral pleura→slides against parietal pleura

characteristics

• discontinuous

• low-frequency

• “grating” sound

• non-musical

location

• best heard→axilla+base of lungs

clinical relevance

• pleurisy

• PNA

• PE

Mediastinal Crunch (Hamman Sign)

physiology

• air enters into mediastinum→mediastinal emphysema (pneumomediastinum)

characteristics

• series of precordial crackles synchronous with heartbeat

• not with respiration

• usually produces severe chest pain

location

• left lateral position

clinical relevance

• tracheobronchial injury

• blunt trauma

• pulmonary dx

• recreational mxs

• childbirth

• rapid ascent from scuba diving

• spontaneous