Pulmonary exam

FF Week 3

Tidal volume (TV)

Air inspired (and therefore expired after) during normal, relaxed breathing

Reserve volumes

Reserve volumes are additionals/extras

Inspiratory reserve volume (IRV)

Additional air that can be forcibly inhaled after the inspiration of a normal tidal volume

Extra coming in

5-6x more than tidal volume

Expiratory reserve volume (ERV)

Additional air that can be forcibly exhaled after the expiration of a normal tidal volume

Extra going out

2-2.5x more than tidal volume

Residual volume (RV)

Volume of air remaining in the lungs after the expiratory reserve volume is exhaled

Always present in the lungs

Capacities

Capacities are totals

Total lung capacity (TLC)

Maximum amount of air that can fill the lungs

TLC = TV + IRV + ERV + RV

Inspiratory capacity (IC)

Maximum amount of air that can be inspired

IC = TV + IRV

Vital capacity (VC)

Total amount of air that can be expired after fully inhaling

VC = TV + IRV + ERV

~80% of TLC

Functional residual capacity (FRC)

Amount of air remaining in the lungs after a normal expiration

FRC = RV + ERV

Forced expiratory volume in 1 second (FEV1)

Volume of air exhaled in the first second under force after a maximal inhalation

Forced vital capacity (FVC)

Total volume of air that can be exhaled during a maximal forced expiration effort

What three values are all increased in patients with COPD?

Functional residual capacity, residual volume, & total lung capacity

FaRT

Obstructive lung conditions

Problem with airflow out of the lungs (comes in fine)

• CBABE:

  • Cystic fibrosis

  • Bronchitis (chronic)

  • Asthma

  • Bronchiectasis

  • Emphysema

  • & COPD

All values except for FaRT (functional residual capacity, residual volume, and total lung capacity) decrease with obstructive conditions

Restrictive lung conditions

Problem with lung expansion/air volume in, but also coming out too

• Sarcoidosis

• Lung fibrosis

• Ankylosing spondylitis

• Obesity

• Burns

• Pneumonia

• Pneumothorax

• Hemothorax

• Pulmonary effusion

All values decrease with restrictive conditions

GOLD Classification for COPD

30 is your gold #

• Mild COPD

  • FEV1/FVC: < 70%

  • FEV1: ≥ 80%

  • Sx: dyspnea due to exercise

• Moderate COPD

  • FEV1/FVC: < 70%

  • FEV1: 50% ≤ FEV1 < 80%

  • Sx: dyspnea with long walks

• Severe COPD

  • FEV1/FVC: < 70%

  • FEV1: 30% ≤ FEV1 < 50%

  • Sx: dyspnea with ambulation

• Very severe COPD

  • FEV1/FVC: < 70%

  • FEV1: < 30%

  • Sx: dyspnea at rest

COPD increases FaRT: functional residual capacity (FRC), residual volume (RV), and total lung capacity (TLC)

Vesicular breath sounds (normal sound)

• Duration: inspiratory are longer

• Intensity: soft

• Pitch of expiratory: low

• Location: over most of lungs

Broncho-vesicular breath sounds (normal sound)

• Duration: equal inspiratory/expiratory

• Intensity: intermediate

• Pitch of expiratory: intermediate

• Location: between 1st and 2nd IC space anteriorly and between the scapulae posteriorly

Bronchial breath sounds (normal sound)

• Duration: expiratory are longer

• Intensity: loud

• Pitch of expiratory: high

• Location: either side of manubrium

Tracheal breath sounds (normal sound)

• Duration: equal inspiratory/expiratory

• Intensity: very loud

• Pitch of expiratory: relatively high

• Location: over trachea in the neck

Rhonchi (abnormal sound)

Continuous, low-pitched, rattling, resembles snoring; heard when inhaling and exhaling

Causes: COPD, bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis

Wheeze/whistling (abnormal sound)

High-pitched whistling heard in expiration; can be heard in inspiration as well in cases of severe constriction

Causes: airway obstruction, asthma, COPD, aspiration of foreign body, bronchial spasms

Crackles (abnormal sound)

Brief, discontinuous, popping, high-pitched sounds heard in both phases of respiration

Associated with congestive heart failure (pulmonary edema)

Pleural rub (abnormal sound)

Auscultation in the lower lateral chest areas, occurring with each inspiration and expiration

Can be indicative of pleural inflammation

Bronchophony (abnormal sound)

Increased vocal resonance with greater clarity and loudness of spoken words

“99”

Egophony (abnormal sound)

A form of bronchophony in which the spoken long “E” sounds change to a long, nasal sounding “A”

Whispered pectoriloquy (abnormal sound)

An increased loudness of whispering; recognition of whispered words “1, 2, 3”

What causes louder sounds?

Secretions, also called consolidations

Arterial blood gas norms

pH: 7.35 - 7.45

PaCO2: 35 - 45 mm Hg

HCO3: 22 - 26 mEq/L

CO2 causes respiratory issues

HCO3 causes metabolic issues

Respiratory vs Metabolic & Acidosis vs Alkalosis

• CO2 changes = respiratory

• HCO3 changes = metabolic

• pH increased = alkalosis

• pH decreased = acidosis

• ROME: respiratory is opposite; metabolic is equal

  • Respiratory: pH and PaCO2 move in opposite directions

  • Metabolic: pH and HCO3 move in equal (same) directions

• Respiratory Acidosis

  • pH: decreased

  • PaCO2: increased

  • HCO3: normal

• Respiratory Alkalosis

  • pH: increased

  • PaCO2: decreased

  • HCO3: normal

• Metabolic Acidosis

  • pH: decreased

  • PaCO2: normal

  • HCO3: decreased

• Metabolic Alkalosis

  • pH: increased

  • PaCO2: normal

  • HCO3: increased

• Compensated = pH is normal

• Uncompensated = pH is outside of normal range

• Partially compensated = all three (pH, PaCO2, & HCO3) are outside of normal range

• Partial pressures of carbon dioxide (PaCO2) and oxygen (PaO2) have an inverse relationship