872: Pulmonary Evaluation

Apnea

Episodes of no breathing

Hyperpnea

Increased depth and sometimes increased RR compared to normal breathing

Bradypnea

Shallow breathing with slower RR

Crackles/rales

Breath sound that can be heard with a stethoscope that is due to fluid in the lungs or collapsed alveoli

Sounds like rustling plastic wrapper

Eupnea

Normal breathing rate and depth

Stridor

Higher pitched sound caused by an obstruction or inflammation in the larynx or trachea

Can be heard during inspiration or expiration

Wheezing

Whistling sound that can be heard with or without a stethoscope typically during expiration and can represent obstruction or inflammation in the airways

Hemoptysis

Blood present during coughing

Consolidation

The smaller airways are filled with fluid or solid material instead of air

This can occur due to various reasons

Chest x-ray

• typically posteroanterior view and or lateral view

• Heart size is assessed and appears white

• Lungs are visualized and if they appear clear that is healthy/normal

• Diaphragm position is assessed

CT chest

Can be used to see more specifics with tumors, infections, bleeding, blockages, and inflammation

Bronchoscopy

Endoscopic procedure that visualizes the proximal airways and remove secretions if needed

V/Q scan

Assesses the lungs ability to perfuse throughout the structure

Perfumed areas appear gray/black in color

Commonly used to diagnose pulmonary emboli

Paradoxical breathing

If the abdominal wall moves inward during inspiration

May be due to diaphragmatic flattening or paralysis

Normal breathing

Upward and outward chest and abdominal movement during breathing that occurs at the same time

Excessive accessory muscle use

Increased upper chest movement with SCM, scalene, and other upper chest/neck muscles movements

Hypoventilation

Shallow irregular breathing

Hyperventilation

Increased rate and depth of breathing

Called kussmaul’s respiration if caused by diabetic ketoacidosis

Apnea

Period of cessation of breathing. Time duration varies; apnea may occur briefly during other breathing disorders such as with sleep apnea

Life threatening if sustained

Cheyne-stokes

Regular cycle where the rate and depth of breathing increase then decrease until apnea (usually about 20 seconds) occurs

Biot’s respiration

Periods of normal breathing (3-4 breaths) followed by a varying period of apnea (usually 10 seconds to one minute)

Accessory muscle use

Includes SCM, scalene muscles, levator costarum and serratus

Pursed lip breathing

Breathing in through the nose and pursing lips together to breathe out more slowly

Barrel chest

Increase in anterior to posterior diameter, appearing to be more of this shape with superior and inferior aspect with also similar diameter

Flail chest

Increased rib mobility due to fractures with outward movement during exhalation

Pes excavatum

Aka concave chest where the sternum is sunken in and gets worse over as the patient grows up

Pectus carinatum

Pigeon chest where the sternum is more prominent and sticks out more than it should

Ratio for tracheal/bronchial sounds

1:2 ratio, inspiration to expiration

Tracheal/bronchial sounds

Heard over the trachea and heard more loud/harsh sounds

Expiration will sound longer than inhalation with same volume

Ratio for bronchovesicular sounds

1:1 ratio

Bronchovesicular (primary/secondary branches of the bronchi)

Heard over the 1st and 2nd intercostal space and between the scapulae with a sound that is more medium pitched

Expiration and inspiration are equal in both length and volume

Ratio for vesicular sounds

2:1 ratio, inspiration: expiration

Vesicular sounds

Heard over the lungs and are a softer and lower pitched sound

Inspiration is longer with more volume than expiration

There is no pause between inspiration and expiration

Adventitious (extra sounds)

Crackles (rales or rhonchi)/ wheezing

If you hear adventitious sounds early in inspiration

Bronchitis, emphysema, asthma

If you hear adventitious sounds later in inspiration

Interstitial lung disease

Pulmonary edema

Right and left apical segments of the upper lobes

Anterior and above clavicle on the left and right side

Anterior segments of the right and left upper lobes

Midclavicular and in the 2nd intercostal space on the left and the right

Right middle lobe and left lingula

Midclavicular and in the 4th intercostal space on the left and right

Anterior basal segment of the right and left lower lobes

Midaxillary and in the 6th intercostal space

At the level of the xiphoid process

Posterior apical segments of the right and left upper lobe

Between C7 and T3 on the right and left of the spine

Above the spine of the scapulae

Posterior segments of the right and left upper lobe

3rd intercostal space (spine of the scapula) and slightly medial

Have the pt give themselves a hug to move the scapula

Superior segment of the right and left lower lobe

Between the 3rd and 7th intercostal space and slightly lateral

Posterior basal segment of the right and left lower lobe

7th to 10th intercostal space and to the left and right of the spine

Lateral basal segment of the right and left lower lobe

7th to 10th intercostal space and slightly lateral

Move more lateral towards the midaxillary line

Tracheal position

Assessed to determine if there has been a mediastinal shift

Tracheal will shift away from the pathology side

If there is an increase in lung volume (Atelectasis or fibrosis) or intrathoracic pressure (Pneumothroax or pleural effusion)

Chest wall excursion

Assess the movements of the chest wall while breathing using either palpation or tape measure

Procedure for tape measure

• Wrap the tape measure at the angle of Louis, xiphoid process or midpoint between xiphoid and umbilicus

• Keep the tape measure at zero and the width of the patient

• Have the patient take a breathe in and allow the tape measure to move with the patient to measure the difference between the chest wall at rest and inhalation

Procedure for chest wall excursion palpation

• place hands on either side of the chest wall and have thumbs meet in midline of the chest wall

• Have the pt breathe in and assess the movement of your thumbs relative to each other

• Thumbs should move laterally and equal in distances with similar timing

Tactile fremitus

Refers to the vibrations caused by air moving through the airways in the lungs that an examiner can feel when a patient phonates

Procedure for tactile fremitus

• place the ulnar aspect of both hands on each side of the chest. The examiners hands should be placed so that each side can be compared to the other

• Have the patient say “ninety nine” with each segment assessed

• Compared the vibrations felt at each segment right vs left

Increased fremitus (vibrations)

Consolidation of the underlying tissue

Decreased fremitus (vibrations)

Decreased density or presence of fluid/air

Mediate percussion

Technique used to assess the density of the lungs

Increased density (consolidation)

Dull sound

Decreased density (increased air)

Hyper resonant

Compression test for rib fracture

Examiner places one hand on the patients back and the other on the sternum while providing compression on the sternum

Stages of a cough

• voluntary closure of the glottis

• Buildup of intrathoracic and intraabdominal pressure

• Sudden quick release of pressure with opening of the glottis

• Forceful air helps to clean airways