Phys Di II - Exam 1 Chest + lungs (general info)

HPI - coughing

sputum production characteristics

postural influences (laying down)

HPI - Shortness of breath

position most comfortable (# of pillows used)

related to extent of exercise/certain activities/time of day

harder to inhale or exhale

HPI - Infants and Children

swallowing dysfunction (gastroesophageal reflex)

sudden-onset cough

difficulty breathing (ingestion of cleaners or choking)

Anatomical landmarks - nipples

4th intercostal space (males)

• more variable in females

Anatomical landmarks - manubriosternal junction

2nd intercostal space

Anatomical landmarks - clavicles

apex of lungs are slightly above

How to examine upper lobe posteriorly on a pt

protract the scpaula

Primary muscles of respiration - Diaphragam

contracts during inspiration

Primary muscles of respiration - External intercostal muscles

increase anteroposterior chest diameter during inspiration

Primary muscles of respiration - Interior intercostal muscles

decrease transverse chest diameter during expiration

Primary muscles of respiration - SCM and Traps (accessory muscles)

brought into play when there are pulmonary problems and compromise

Interior chest is divided into three spaces

mediastinum, R and L pleural cavities

Mediastinum

between lungs

contains thoracic viscera except lungs

R/L pleural cavities

lined w/parietal and visceral pleurae

lungs enclosed by serous membrane

You should inspect the ________ vs ___________ diameter of a patient’s chest to check for barrel chest

anteroposterior; transverse

You should inspect the sternum for

protrusion (pectus excavatum) /indentation (pectus carinatum)

Normal respiration rate

12-20 bpm

Bradypnea (marathon runner)

<12 bpm

Tachypnea (meds, stress)

>20 bpm

Hyperventilation/hyperna

>20 bpm and deep

Sighing (depression)

frequently interspersed deeper breaths

Air-trapping (COPD)

increased difficulty getting breath out

pursed lips

Cheyne-stokes (cerebral brain damage)

varying periods of increased depth interspersed w/apnea

Kussmaul (metabolic acidosis)

rapid, deep, labored

Biot (medulla oblongata brain damage)

irregular interspersed periods of apnea disorganized sequence of breaths

Ataxic (medulla oblongata brain damage)

significant disorganization w/irregular and varying depths

Retractions

chest wall caves in btw ribs, at suprasternal notch, above clavicles, at lowest costal margins

**Suggests - obstruction to inspiration at any point in resp. tract

Paradoxic breathing

lower thorax is drawn in during inspiration and out during expiration

Chest wall collapses as abdomen distends on inspiration

Peripheral clues that may suggest pulmonary or cardiac difficulties

clubbing, bad breath, skin/nail/lip cyanosis, pursing lips, flaring nostrils

Sweet/fruity breath

diabetic ketoacidosis (starvation ketosis)

Fishy/stale breath

uremia (trimethylamines)

Ammonia-like breath

uremia (ammonia)

Musty fish/clover

fetor hepaticus (hepatic failure, portal vein thrombosis, portacaval shunt)

Foul/feculent

intestinal obstruction

Foul/putrid

nasal/sinus pathology

Halitosis

tonsillitis, gingivitis, respiratory infection, Vincent angina, GERD

Cinnamon

pulmonary tuberculosis

Palpation - Crepitus

crackly/crinkly sensation (palpated and heard)

**Indicates: air in subcutaneous tissue - emphysema

Palpation - Friction rub (inflammation)

palpable, coarse, grating vibration on inspiration

pericardial or pleural

Palpation - Thoracic expansion at 10th rib

loss of symmetry in mvnt of thumbs = a problem on one or both sides

Palpation - Tactile fremitus (99 or micky mouse)

palpable vibration of chest wall that results from speech or other verbalizations

Vibration travels better through _____ objects

denser

Percussion/Auscultation - Over lungs

resonance

hyperresonance (COPD)

dullness (diminished air exchange - fluid/blood/tumor)

Percussion/Auscultation - Resonant

loud and low pitch

long duration

hallow (healthy lung)

Percussion/Auscultation - Flat

soft and high pitch

short duration

very dull (muscle/pneumonia)

Percussion/Auscultation - Dull

medium and medium/high pitch

medium duration

dull thud (liver/pneumonia)

Percussion/Auscultation - Tympanic

loud and high pitch

medium duration

drum-like (gastric bubble)

Percussion/Auscultation - Hyperresonant

very loud and very low pitch

long duration

booming (emphysema)

Diaphragm is usually high on the ____ side due to the liver

right

Normal diaphragmatic excursion

3-5cm

Lobes of the lungs

right lung - 3 lobes

left lung - 2 lobes + lingula

Tracheobronchial tree

tubular system that provides a pathway along which air is filtered, humidified, and warmed

Tracheobronchial tree divides into 3 right and 2 left main bronchi at

T4/5 and just below manubriosternal joint

Right bronchus

wider, shorter, more vertical

**more susceptible to aspiration of foreign bodies

Bronchi → Terminal branches →

respiratory bronchioles (gas exchange)

Bronchial arteries branch from

anterior thoracic aorta and intercostal arteries

*supply parenchyma (alveoli) and stroma

Bronchial vein is formed at the

hilum

*blood supplied by bronchi arteries is returned by pulmonary veins

Trachea lies anterior to _____ and posterior to ______

esophagus; isthmus of thyroid

Vesicular breath sounds

3:1 inhale/exhale ratio

low pitched and low-intensity

Vesicluar breath sounds are heard over

lesser bronchi, bronchioles, lobes (where alveoli are)

Bronchovesicular breath sounds

1:1 inhale/exhale ratio

Bronchovesicular breath sounds can be heard over

major bronchi

moderate pitch and intensity

Bronchial breath sounds

1:1 inhale/exhale ratio

highest pitch and intensity

Bronchial breath sounds can be heard over

trachea

Bronchovesicular and Bronchial breath sounds are abnormal if heard over

peripheral lung tissue

If vesicular sounds are absent and hear bronchial sounds instead, this is a positive finding on bronchophony and suggests

pneumonia

Amphoric breath sounds (blowing across mouth of bottle) are commonly heard with

large, relatively stiff-walled pulmonary cavity or

tension pneumothorax w/bronchopleural fistula

Cavernous (coming from cavern) breath sounds are commonly heard over

pulmonary cavity where the wall is rigid

Crackles (rales) - fluid in airways

discrete discontinuous (bubble) heard during INSPIRATION

Types:

• fine - high pitched w/short duration

• medium - medium pitched

• coarse - low pitched w/long duration

Rhonchi (sonorous wheezes) - passage of air through obstructed (thick secretions/muscular spasm) airway

deep, rumbling, prolonged and continuous during EXPIRATION

less discrete than crackles

Coughing can clear these sounds

Wheezes (low in resp. tree) - high velocity air flow through narrowed/obstructed airway

continuous, high pitched, musical sounds during INSPIRATION or EXPIRATION

bronchospasm of asthma or bronchitis (acute/chronic)

Friction rub (outside the respiratory tree) - inflamed, roughened surfaces rubbing together

Dry, crackly, grating, low pitched during INSPIRATION and EXPIRATION

Coughing does NOT clear these sounds

Mediastinal crunch (Hamman sign) - air around heart (mediastinal emphysema)

loud crackles, clicking, gurgling during HEARTBEATS

If a patient coughs and their abnormal breath sounds go away, what type of sound was it? What about if the cough did not clear the sound?

Cough cleared = rhonchi

Cough did not clear = friction rub

Vocal resonance diminishes and loses intensity where there is

a loss of tissue within respiratory tree (barrel chest of emphysema)

Bronchophony (99 or mickey mouse)

greater clarity and increased loudness of spoken sounds

Pectoriloquy (whisper 123)

extreme bronchophony where even a whisper can be heard clearly through the stethoscope

Egophony (E’s become A’s)

intensity of spoken voice is increased with a nasal quality

Within minutes after birth, a decrease in pulmonary pressure should lead to the closure of the

foramen ovale

Within minutes after birth, increased oxygen tension in arterial blood stimulates contraction and closure of the

ductus arteriosus

The chest of a newborn is generally round where the chest wall is ____ and bony structures are more

thinner; prominent

Adult chest proportions

lateral diameter > anteroposterior diameter

Chest circumference of infants

2-3cm smaller than head circumference

Infants - periodic breathing

sequence of relatively vigorous respiratory efforts followed by apnea (10sec)

Infants general breathing characteristics

paradoxic breathing is common during sleep

hiccups and sneezing are frequent

coughing is rare

Stridor (obstruction high in resp. tree)

high pitched, piercing sound during INSPIRATION

Respiratory grunting

infant tries to expel trapped air of fetal lung fluid while retaining air

Flaring of alae nasi in infants

indicator of respiratory distress or

patent ductus arteriosus (O2 blood flows back to lung)

Children’s breath sounds

more resonant (hyperresonance common)

easy to miss dullness

bronchovesicular sounds predominate

Pregnant women - mechanical and biochemical factors lead to changes in respiratory function

enlarging uterus and increased progesterone

dyspnea common

Pregnant women anatomic changes to chest

lower ribs flare

diaphragm rises and movement increases

minute ventilation increases (breathe deeper, NOT faster)

Older adults - Barrel chest

loss of muscle strength in thorax/diaphragm

loss of lung resiliency

Older adults - skeletal changes emphasizes

dorsal curve of thoracic spine

kyphosis w/flattening of lumbar curve

Older adults - alveoli less elastic

causing fatigue and dyspnea on exertion

Older adults - decrease in _____ or increase in ______

vital capacity; residual volume

Older adults - mucous membranes are ____ and hyperresonance is common

drier