CH 19: Thorax and Lungs pt 2

Difficulty breathing when supine. State number of pillows needed to achieve comfort (e.g., “two-pillow orthopnea”).

Orthopnea

Awakening from sleep with SOB and needing to be upright to achieve comfort.

Paroxysmal nocturnal dyspnea

Coughing up blood

Hemoptysis

White or clear mucoid/sputum =

Colds, bronchitis, viral infections

Rust-colored mucoid/sputum

TB, pneumococcal pneumonia

Pink, frothy mucoid/sputum =

Pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus.

Chest pain of thoracic origin

Occurs with muscle soreness

The anteroposterior (AP) diameter should be less than the transverse diameter. True or false?

True

Increased anteroposterior diameter in COPD patients due to chronic hyperinflation

Barrel chest

What does normal, healthy lung tissue sound like when percussed?

Resonant; low-pitched, clear hollow sound

You percuss over the scapula when assessing lung sounds and hear a dull noise instead of resonance. Does this person have a lung issue?

No; percussing over the scapula gives a dull note.

Bronchial (tracheal) breath sounds

High pitch, loud amplitude, harsh-hollow tubular quality. Duration is longer in expiration than inspiration. Sounds hear over trachea and manubrium

Bronchovesicular breath sounds

Medium-moderate pitch, moderate amplitude, duration during inspiration and expiration is equal; quality is mixed. Heard over main bronchi

Vesicular breath sounds

Low pitch, soft sound. Inspiration has longer duration than expiration. Has rustling, like wind in the trees quality. Heard over peripheral lung fields

Assessing symmetric expansion

Place hands on posterior chest, thumbs at T9-T10. Assess equal movement during deep inspiration.

Assessing tactile fremitus

Use palmar surface or ulnar edge of hand. Patient repeats "99" or "blue moon." Compare bilateral vibrations.

Low-pitched, loud voices generate stronger vibrations. True or false?

True

Adventitious sounds

Added sounds that are not normally heard in the lungs. If present, they are heard as being superimposed on the breath sounds. They are caused by moving air colliding with secretions in the tracheobronchial passageways or by the popping open of previously deflated airways.

• Crackles (rales)

• Wheeze (rhonchi)

• Atelectatic

• Pleural friction rub

Adventitious sound that is not pathologic. Fine crackling sounds that last only a few breaths. Occurs when sections of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths.

Atelectatic crackles

What equipment do you need in a lung assessment?

Stethoscope and alcohol wipe

Percussing female breast

Do not percuss directly over female breast tissue because this would produce a dull note. Shift the breast tissue over slightly, using the edge of your stationary hand. In females with large breasts, percussion may yield little useful data.

What controls breathing rhythm and depth

Medulla and pons

Most powerful drive to breath

Hypercapnia

In chronic CO2 retention (COPD), hypercapnia or hypoxemia is the primary respiratory drive?

Hypoxemia

COPD patients lean forward with arms supported to maximize breathing efficiency

Tripod position

Lateral curvature of spine 

Skoliosis

Exaggerated thoracic curvature affecting lung capacity

Spinal deformities

What does decreased fremitus indicate?

Obstructed bronchus, pleural effusion, pneumothorax, or emphysema blocking transmission

Right lung has how many lobes?

3 lobes

There is no gas exchange in = dead space

Main bronchi and trachea

Gas exchange takes place in

Acinus; bronchioles, alveoli, alveolar sacs,

Exaggerated thoracic curve affecting lung capacity

Kyphosis

Blue discoloration indicates significant hypoxemia

Cyanosis

Enlarged neck and accessory muscles from muscle hypertrophy  indicates

Chronic respiratory distress

Thin serous membrane adhering to lung surface

Visceral plerua

Few mL of lubricating fluid, enables lung movement

Pleural fluid

Lines chest wall & diaphragm surface, creates barrier

Parietal pleura

Vacuum effect maintains lung expansion

Negative Pressure

Protective function of trachea and bronchiole tree

Goblet cells secrete mucus trapping particles; cilia sweep debris upward

Right bronchus of bronchial tree is shorter and wider, meaning that

It’s more susceptible to aspiration

Individual air sacs where oxygen and CO2 exchange occurs

Alveoli

Functions of respiratory system

• Oxygen supply

• CO2 removal

• Acid balance

• Heat exchange → regulates body temp through warming & humidifying air

Pain with deep breathing indicates

Pleural inflammation (pleuritis) or chest wall injury

What does increased fremitus indicate?

Lung compression (e.g. lobar pneumonia) or consolidation where solid material enhances vibration transmission

Unequal chest expansion indicates

Atelectasis, pleural effusion, pneumothorax, lobar pneumonia, or fractured ribs

Asymmetric findings are more significant than bilateral change. True or false?

True

Limitations of pulse oximeter

Limitations in dark skin pigmentation, nail polish, or poor perfusion

Normal O2 sat values

97%-99%

6-minute walk test

Safe, simple, inexpensive functional assessment. Patients walking >300 meters typically maintain independence in activities of daily living

Collapsed alveoli or entire lung segments. Results from airway obstruction, external lung compression, or inadequate surfactant production. 

Atelectasis

Inspection findings for atelectasis

Increased respiratory rate and pulse as compensation mechanism.

Palpation results for atelectasis

Markedly decreased chest expansion on affected side due to reduced lung volume

Percussion & auscultation of atelectasis

Percussion: Dull sound over collapsed area

Auscultation: Decreased or absent breath sounds

Early recognition and treatment of atelectasis prevent progression to complete lung collapse and respiratory failure.

Make patients take deep breaths and ambulate

Damage to alveolar-capillary membrane increases permeability, causing non-cardiogenic pulmonary edema

ARDS

Subjective data for thorax & lungs assessment

1. Cough

2. Shortness of breath

3. Chest pain with breathing

4. History of respiratory infections

5. Smoking history

6. Environmental exposure

7. Patient-centered care

When do decreased or absent breath sounds occur?

1. Bronchial obstruction

2. Emphysema/COPD; lungs are hyperinflated and lungs have lost elasticity

3. Obstruct transmission of sound between lung & stethoscope; pleurisy, pleural thickening, air (pneumothorax) or fluid (pleural effusion) in pleural space

4. Silent chest = no air is moving (OMINOUS)

Increased breath sounds (sounds are louder, high-pitched with tubular quality) occur when

1. Consolidation (pneumonia)

2. Compression (fluid in intrapleural space)

Where do you start percussion?

Begin at lung apices, percussing across shoulder tops bilaterally; avoid ribs and scapulae

Asymmetric dullness or hyperresonance when percussing indicate

Underlying disease process

What part of stethoscope do you use when auscultating lungs?

Diaphragm 

Silent chest when auscultating is a medical emergency. True or false?

True

Decreased/absent breath sounds indicate

Bronchial obstruction, hyperinflated lungs (COPD), pneumothorax, or pleural effusion blocking transmission

Adventitious sound characterized by continuous musical sounds

Wheeze (rhonchi)

Adventitious sound characterized by discontinuous. high-pitched, short crackling wet or dry sounds heard during inspiration but not cleared by coughing.

• Late inspiratory crackles: occur with restrictive disease: pneumonia, heart failure, and interstitial fibrosis

• Early inspiratory crackles occur with obstructive disease: chronic bronchitis, asthma, and emphysema

• Posturally induced crackles (PICs) are fine crackles that appear with a change from sitting to the supine position or with a change from supine to supine with legs elevate

Crackles (rales)

Sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths; heard in axillae and bases (usually dependent) of lungs.

Atelectatic crackles

Mechanism of atelectatic crackles

When sections of alveoli are not fully aerated, they deflate and accumulate secretions; crackles are heard when these sections reexpand with a few deep breaths

Where are atelectatic crackles typically found?

In aging adults, bedridden persons, or persons just aroused from sleep

Coarse, palpable vibrations caused by thick bronchial secretions creating turbulent airflow; vibration (fremitus) felt when inhaled air passes through thick secretions in the larger bronchi. This may decrease somewhat by coughing.

Ronchal fremitius

Grating sensation produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing. Can be palpable. It is synchronous with respiratory excursion. Also called a palpable friction rub.

Pleural friction fremitus

Normal breathing

Eupnea

Rapid, shallow breathing. Increased rate, >24 per minute. Normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons.

Tachypnea

A cycle in which respirations gradually wax and wane in a regular pattern, increasing in depth and then decreasing until apnea occurs. Breathing period lasts 30-45 sec. Apnea lasts 20 sec.

Cheyne-Stokes

A form of deep, labored hyperventilation due to severe metabolic acidosis (increase in rate & depth)

Kussmaul’s breathing

Most common cause of cheyne-stokes breathing

Severe HF

Causes of cheyne-stokes breathing

• Severe HF

• renal failure

• meningitis

• drug OD

• increased intracranial pressure

Cheyne-stokes breathing occurs normally in infants and older adults during sleep. True or false?

True

Bacterial infection causing alveolar consolidation. Air spaces fill with inflammatory exudate, bacteria, fluid, and blood cells.

Lobar pneumonia

Clinical presentation of lobar pneumonia

• Tachypnea (>24/min)

• Splitting behavior on affected side

• Possible cyanosis with severe infection

Physical findings of lobar pneunonia

• Palpation: Reduced expansion

•  Percussion: Dullness over consolidation

• Auscultation: Loud bronchial sounds, crackle

Coarse, crackling sensation when air escapes lungs into subcutaneous tissue—medical emergency

Crepitus (occurs in subcutaneous Emphysema)

Crepitus may indicate tension pneumothorax. What should the nurse do?

Critical alert. Assess immediately for tracheal deviation and hemodynamic instability.

What is palpated in subcutaneous emphysema?

Crepitus → medical emergency

Life-threatening condition requiring immediate needle decompression and chest tube insertion

Tension pneumothorax

What is assessed when palpating thorax and lungs?

• Symmetric expansion (T9-T10)

• Tactile fremitus

• Voice transmission

• Surface assessment (palpate for masses, tenderness subQ emphysema, skin abnormalities )

How to maintain consistency in spacing when percussing?

5cm intervals; avoid bony landmarks (ribs & scapulae)

How long do you auscultate for at each site?

Full respiration cycle per site

Posterior auscultation

• Upper zones

• Interscapular area

• Lower zones

• Lateral bases (posterior axillary line)

Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but reappear shortly—sounds like opening a Velcro fastener.

Crackles (coarse)

Where do coarse crackles occur in?

Occurs when inhaled air collides with secretions in the trachea and large bronchi as in pulmonary edema, pneumonia, pulmonary fibrosis, and terminally ill who have a depressed cough reflex

A very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto the chest wall; sound is inspiratory and expiratory

Pleural friction rub (adventitious sound)

What causes pleural friction rub?

Caused when pleurae become inflamed and lose their normal lubricating fluid; their opposing roughened pleural surfaces rub together during respiration; heard best in anterolateral wall where greatest lung mobility exists.

• occurs in pleuritis, accompanied by pain with rubbing

High-pitched, musical squeaking sounds that sound polyphonic. Caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; the passageway walls oscillate in apposition between the closed and barely open positions

Wheeze (high-pitched)

Low-pitched; monophonic, single-note, musical snoring, moaning sounds; may clear somewhat by coughing. Caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; the passageway walls oscillate in apposition between the closed and barely open positions (same as high-pitched wheezing). However, the pitch of the wheeze cannot be correlated to the size of the passageway that generates it

Wheeze (low-pitched)

What can cause high-pitched wheezing?

Diffuse airway obstruction from acute asthma or chronic emphysema

What can cause low-pitched wheezing?

Bronchitis, single bronchus obstruction from airway tumor

What can cause stridor?

Croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-threatening

High-pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall. Caused by obstruction originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body

Stridor