Chapter 19

Thorax and Lungs

What brain regions control breathing?

Medulla and pons (involuntary control)

Neuro pop quiz - brain damage to medulla and pons caused what type of posturing?

Decerebrate posturing!! Very bad

If a COPD has an O2 sat of 88%, why can’t you just give them enough oxygen to get up to 95% + ?

COPD pts have high CO2 already, so their bodies stop using CO2 as a trigger and rely on low O2 levels to tell them to breathe (aka hypoxic drive)

So if u give them O2, it makes the brain think they don’t need to breathe → causing resp failure

When a pt uses ____ muscles for breathing, this is indicative of COPD. Why?

accessory

Diaphragm becomes flattened and less effective, so COPD pts use accessory muscles to increases expansion and lets more air in

What accessory muscles are used in COPD pts?

Sternocleidomastoid

Scalene

Trapezius

Intercostal

Abdominal muscles

Injury to ___ results in loss of diaphragm function

spinal cord above C3

C3 → phrenic nerve, which controls diaphragm

Inspiration/increase in chest cavity → ____ pressure
Expiration/decrease in chest cavity → ____ pressure

inspiration: less pressure in lungs
expiration: greater pressure lungs

What are some subjective questions to ask for lung/thorax issues?

• coldspa for dyspnea

• cough sx

• medications

• chest pain

• smoking hx

• family hx

• lifestyle (exercise, smoking)

  • pack years

How would you differentiate dyspnea that is caused by cardiac vs lung/thorax issues?

• when do you experience orthopnea/SOB

  • while laying down: cardiac

  • all the time: lung/thorax

• do you experience SOB that wakes you up at night?

  • indicative of HF, COPD, asthma

Why do you ask about medications when assessing cough?

Some meds, like ACE-inhibitors and beta-blockers, cause a dry nonproductive cough

A continuous cough is often linked to… ?

Acute infection

An early morning cough is linked to…?

Chronic bronchial inflammation or smoking

An evening cough may be caused by…?

Daytime irritant exposure

A nighttime cough may associated with…?

Post nasal drip or sinusitis

How can you differentiate heart/lung/GI related chest pain?

Cardiac: chest pain upon exertion

GI: heartburn, tummy issues, relieved by antacids

Lung: green sputum + fever (resp infection)

Describe what some sputum colors could indicate

White - viral/cold

Yellow/green - bacterial

Rust - pneumonia/TB

Pink/frothy - pulmonary edema

Brown/black - blood maybe

Odee sputum - irritation, chronic bronchitis, infection

Thique sputum - dehydration

What’s a pack year? How do you calculate it?

A value that helps determine a pt’s risk of cancer
(# of packs per day) * (# of years smoked)

What pack year value warrants screening?

20 pack year history b/w ages of 50-80; they need yearly screening

COLDSPA for dyspnea

C - describe difficulty breathing

O - when did it begin?

L - N/A

D - how long do episodes last?

S - impact on ADLs

P - what aggravates/relieves it?

A - cough, edema, chest pain, sputum

What can tripod positioning in adults indicate?

COPD

What is an abnormal finding in the AP diameter assessment

1:1 ratio, which would indicate a barrel chest due to chronic lung hyperinflation (emphysema)

How does pectus excavatum (funnel chest) look like?

A sunken sternum

How does pectus carinatum (pigeon chest) look like?

Protruding sternum

Is kyphosis normal in older adults?

Yea, but not great since it decreases lung expansion capacity

How do you assess ease of respirations?

Check for:

• pursed lip breathing

• nasal flaring

• accessory muscle use

What is fremitus?

Transmission of sound (air) through lung tissue

How do you assess for fremitus?

Have pt say 99 repeatedly and feel the vibration each time in diff parts of the pt’s back

It should be rlly clear near clavicles and decrease in intensity as you go down to lung bases

Increased fremitus means…?

Decreased fremintus means…?

Increased - consolidation (from fluid, blood, pus, pneumonia)

Decreased - excess air (copd, emphysema)

Think - sound travels faster in water than air

What’s creptius?

Rice-krispie/crackly noise that happens when you palpate b/c of air escaping into fatty tissue

What would unequal chest expansion mean?

Pneumonia, pneumothorax, atelactasis

What does diaphragmatic excursion measure?

The expansion of lungs during respiration

Explain the difference b/w atelectasis and pneumothorax

atelactasis: collapse of alveoli due to blockage or external pressure

pneumothorax: collapsed lung b/c of air leaking into the space b/w the lung and chest wall

What are the 5 different sounds you’re listening to when percussing?

1 - resonance: normal lung sound; medium loud, low pitch, hollow

2 - tympanic: drum-like, normal over tummy

3 - dullness: over solid organs OR consolidated lung, tumor, pleural effusion

4 - flatness: over bone

5 - hyperresonance: mad loud, low pitch, seen in emphysema or pneumothorax

Why would a tympanic sound over the thorax indicate large pneumothorax?

Pneumothorax happens when air enters pleural space. That air displaces the lung tissue and fills the pleural space, causing the drum-like tympanic sound that is heard over air-filled spaces

Think of it this way - odee air in lungs = giant resonant drum = tympanic drum-like

If an abnormal sound is heard, what should you do?

Have the pt cough, then reassess

What are the 3 normal breath sounds? Where are they located and how long are their inspiration/expiration?

1 - bronchial: hurd near trachea and thorax; short inspiration and long expiration

2 - bronchovesicular: near sternum and b/w shoulder blades; equal inspiration/expiration

3 - vesicular: near peripheral lung fields; long inspiration and short expiration

How would the trachea move in obstructive atelectasis?

trachea shifts towards the affected side, causing less breath sounds

loss of air volume creates pulling affect, so it pulls the trachea

How would the trachea move in pneumothorax?

trachea shifts away from affected side, causing absent breath sounds

buildup of air pushes trachea away

How would the trachea move in pleural effusion/hemothorax?

trachea shifts away, so there’s absent sounds over affected area

buildup of fluid pushes trachea away

What auscultation sound would be present in emphysema?

prolonged breath sounds/air-trapping—> so hyperresonance

How do you assess for bronchophony? What would an abnormal finding mean?

Ask pt to say “99” and see if it sounds muffled (normal) or clear (abnormal)

Abnormal finding indicates lung consolidation

How do you assess for egophony? What would an abnormal finding mean?

Ask pt to say “E” and see if it sounds like eee (normal) or aaa (abnormal)

Abnormal finding means lung consolidation or compression

How do you assess for whisphered pectoriloquy? What would an abnormal finding mean?

Ask pt to whisper “1-2-3” and see if it sounds faint/inaudible (normal) or clear (abnormal)

Abnormal findins means lung consolidation or compression

List some adventitious sounds you may hear and what it can indicate

Crackles - fluid in alveoli → HF, pulmonary edema OR COPD, asthma, emphysema

Wheezes - asthma, emphysema

Friction rub - pleuritis

Stridor - harsh honking, airway obstruction (PRIORITY PATIENT!!!)

What’s the difference b/w sibilant and sonorous wheezes?

They differ in pitch and underlying cause

Sibilant - musical pitch; cause by asthma/emphysema

Sonorous - low pitch snoring; seen in bronchitis

What is normal lung/thorax stuff in older adults?

• kyphosis (curved thoracic spine)

• reduced lung expansion

• weak cough reflex

• higher risk of pneumonia, atelectasis

• few functioning alveoli

• sternum/ribs are more prominent b/c of less fat

What are two major lung cancer risk factors

Smoking and radon

Bronchophony, egophony, and whispered pectoriloquy are all positive in pneumonia - why?

B/c there’s excess fluid in the lungs, and sound travels better in liquid/solid than in air