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193 Cards in this Set
- Front
- Back
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Hi guys, these cards are for Dr. Scott's Lung Section.
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kcb
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Four major components of the lung exam
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Inspection
Palpation Percussion Auscultation |
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Inspection
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Watch Breaths-rate, rhythm, depth and effort
Accessory mm-SCM, platysma, scalenes Prolonged expiratory phase=COPD issues Finger clubbing=lung abscesses, malignancy, congential heart dz Color of pt-cyanosis anywhere(esp mouth)=late sign in hypoxia Postural position of pt-sitting upright, tri-pod position Pursed lips Ability to speak Noises w/breathing Abd wall movement on inspiration Chest or spine deformities |
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Paradoxical breathing
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With severe diaphragmatic flattening or paralysis, the abd wall may move inward during inspiration. Place your hand on the person's abd and you'll feel the flattening
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Rectus excavatum
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congenital posterior displacement of lower aspect of sternum. gives chest a "hollowed-out" appearance. x-ray shows a suble concave appearance of the lower sternum.
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Barrel Chest
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Increased (ant - post) AP diameter
Diaphragmatic flattening Associated with emphysema (COPD, aging and lung hyperinflation |
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T1 is about what level?
T12 is about what level? |
T1 = clavicles
T12 = umbilicus |
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Palpation
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Detecting Chest Excursion
Tactile Fremitus Investigating Painful Areas |
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Detecting Chest Excursion
Do in 3 places |
Place hands on back w/thumbs pointed toward spine.
Look for sym or asym expansion Asym = pleural dzes (has to be a lot of pleural effusion b4 asym can be seen) |
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Tactile Fremitus
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Place hands on back...use ulnar sides of hands and have pt say 99. Do this over entire lung fields. NL lung transmits a palpable vibratory sensation to the chest wall upon saying 99. Pathology alters fremitus.
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Pathological Tactile Fremitus
Lung consolidation |
Occurs when NLly air filled lung parenchyma becomes engorged with fluid or tissue-ie pneumonia. Alters transmission of air and sound.
Presence = fremitus becomes more pronounced. |
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Pathological Tactile Fremitus
Pleural Effusion (fluid) |
Fluid collects in the potential space that exists btwn the lung and the chest wall, displacing the lung upwards.
Presence = fremitus becomes decreased. |
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Investigating Painful Areas
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Palpate area of pain
Rib fracture SubQ air (rice crispies) |
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Percussion
5 percusses/lung=cover lung Usually will see the changes as you go down the lung field. (More resonant at top, more dull at bottom) Compare Lt to Rtof both and top to bottom of one. |
Resonant note = Over air-filled structure(NL lung)
Dull sound = Over fluid or tissue-filled cavity Deadened tone = If NL lung is displaced by fluid or infiltrate with WBCs and bacteria Hyperresonant(drum-like) = air-trapping in lung or pleural space |
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Auscultation
4 auscultates/lung=cover lung |
Have pt breath slowly and deeply through mouth. Go from top of left to top of right, then move done on right and go to left...comparing left to right as you go down
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Lungs cover the space of what ribs?
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1-9 ish
T1-9 |
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Atelectatic
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Areas at the lung bases
Collapsed Small stelectatic areas at the base of the lungs can sometimes be opened up by coughing. |
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Vescicular Breath sounds
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NL inspiration/expiration
Ins-soft sounds of air rushing in Exp-little sounds with exp |
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Wheezes
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Whistling/Musical noises w/exp, mostly when air is forced through airways narrowed by bronchoconstriction from tissue inflammation or tumors, secretions or asso mucosal edema
Frequently audible in all lung fields I:E = 1:2 NL 1:>2 ABNL Increased Exp = worse obstruction Focal Wheezes = occurs when airway narrowing restricted to single area (ie-tumor or pneumonia) |
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Wheezing heard only in inspiration = what?
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Stridor
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Stridor is associated with what?
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Mechanical Obstruction at the level of the trachea/upper airway
Heard best @ top of trachea |
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Rales (aka crackles)
Sounds like rubbing strands of hair together |
Scratchy sounds from fluid witin alveolar and interstitial spaces b/c of pulmonary edema(occurs first in lower lobes) and pneumonia (in specific regions of the lung).
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Dry rales(crackles) like velcro = what?
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Pumonary fibrosis
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Very little sound
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Severe, stable emphysema
Lung destruction and air trapping |
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Tubular or bronchial breath sounds
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Dense consolidation in lungs = large airway noises heard over trachea
Snorkel sounds Egophony |
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Egophony
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Say "eeee" = sounds like "aaaa" over involved lobe
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Rhonchi
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Secretions in larger airways
Bronchitis Gurgling noise like sucking last bits of a milkshake |
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Muffled Breath Sounds
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Over pleural effusion
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Breath Sounds Packet...
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...
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What affects breath sounds?
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Diameter of airway
Pressure changes in the airway Vibrations of solid tissue |
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Describe what happens during inspiration.
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Intrapleural pressure decreases b/c intrapleural space increases. Intrapulmonary pressure decreases b/c alveoli are expanding. Intrapulmonary pressure drops below atmospheric pressure = air goes in. Airways are widening which decreases resistance to incoming air.
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Describe what happens during expiration.
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Lungs contract passively. Both pressures rise and air is forced out of the lungs
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Airflow patterns
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Turbulent
Circular Laminar |
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Turbulent airflow occurs where?
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Trachea
Mainstream bronchi Other larger airways |
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Turbulent airflow occurs when?
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During rapid airflow movement
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What produces sound?
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Rapid pressure changes within the airway from colliding air molecules
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Circular airflow occurs how?
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Airflow abruptly changes direction in the branching airways, as it does it separates into layers, each moving at a different speed. Creates vortices.
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Vortices
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Shearing force of the high-speed airstream against the slower airstream triggers a circulating airflow
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How does this airflow pattern generate sound?
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As the flow of air carries the vortices "downstream"
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Laminar airflow occurs where?
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Small airways
Bronchioles |
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What does this sound like?
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no sound b/c no abrupt changes in pressure
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Mechanical Vibrations of Sound
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Frequency
Intensity Duration |
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Frequency
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Number of vibrations occurring over a period of time
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Frequency
Pitch |
Used to describe frequency in clinical setting
High-pitched = high frequency Love-pitched = low frequency |
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Intensity
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Loudness or softness of the vibrations that produce breath sounds
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What does this sound like?
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no sound b/c no abrupt changes in pressure
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What does this sound like?
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no sound b/c no abrupt changes in pressure
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Mechanical Vibrations of Sound
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Frequency
Intensity Duration |
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Mechanical Vibrations of Sound
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Frequency
Intensity Duration |
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Frequency
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Number of vibrations occurring over a period of time
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Frequency
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Number of vibrations occurring over a period of time
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Frequency
Pitch |
Used to describe frequency in clinical setting
High-pitched = high frequency Love-pitched = low frequency |
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Frequency
Pitch |
Used to describe frequency in clinical setting
High-pitched = high frequency Love-pitched = low frequency |
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Intensity
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Loudness or softness of the vibrations that produce breath sounds
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Intensity
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Loudness or softness of the vibrations that produce breath sounds
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What does this sound like?
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no sound b/c no abrupt changes in pressure
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Mechanical Vibrations of Sound
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Frequency
Intensity Duration |
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Frequency
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Number of vibrations occurring over a period of time
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Frequency
Pitch |
Used to describe frequency in clinical setting
High-pitched = high frequency Love-pitched = low frequency |
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Intensity
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Loudness or softness of the vibrations that produce breath sounds
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What is intensity affected by?
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Type of structure vibrating
Distance and type of substance through which the vibrations travel |
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Duration
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Length of time vibrations occur
Long or short Continuous or Discontinuous |
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Sound Damping
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High-pitched breath sounds are damped or absorbed as they travel through the lungs and thorax (air, fluid, tissue)
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Impedance
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How much a substance resists sound transmission. More resistance = more damping.
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What happens when 2 substances are next to each other?
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Sound is transmitted effectively
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What is an example of this?
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When consolidation enhances the transmission of breath sounds to the chest wall
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Why does this happen?
Impedance matching |
The fluid-filled airless lung tissue that is consolidated and the chest wall are acoustically well matched and breath sounds travel more easily
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Mismatch = what?
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Ineffectively transmitted sound
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Why?
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Flui
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What is an example of mismatch?
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Pleural effusion
Obesity |
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What is mismatch?
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When fluid or solid tissue collects btwn inflated lung segments
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What do you hear with Impedance mismatch?
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Filtered breath sounds (reduced sounds)
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How do you auscultate an obese pt's lungs?
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ask pt to breath through mouth while sitting upright or standing
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NL Breath Sounds
Over most of chest wall are soft |
Vesicular
Broncho-vesicular Bronchial Tracheal |
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Vesicular
Soft and Low pitched |
Through Inspiration w/out pause into Expiration
Fades 1/3rd through Exp Best Heard Over Lungs I:E ratio 3:1 to 4:1 |
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Broncho-vesicular
Intermediate Sound |
Through Inspiration and Exp w/a silent internal between them
Heard Best 1st and 2nd intercostal space anteriorly and between scapulae posteriorly I:E ratio = 1:1 |
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Bronchial
Louder or High pitched |
Exp lasts longer than inspiration w/a short silence btwn them
Best heard over manubrium I:E ratio = 1:3 |
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Tracheal
Harsh and High pitched |
Insp and Exp w/short silence btwn them
Best heard over Trachea I:E ratio = 1:1 |
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At the beg. of respiration where are breath sounds the loudest?
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Apices of lungs
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At the end of respiration wher the breath sounds the loudest?
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Bases of lungs
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5 Adventitious Sounds
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1. Crackles/Rales
2. Wheezes 3. Rhonchi 4. Stridor 5. Pleural Rub |
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Crackles/Rales-why?
rice crispies |
a. air bubbles from secretions
b. sudden, explosive opening of the small airways |
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Crackles/Rales sound like?
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Discontinuous
Short, explosive or popping On inspiration |
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Crackles/Rales
Characterized by: |
Loudness
Number Timing Location Persistance Changes after cough, movement |
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Three Types of crackles
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1. Late Inspiratory
2. Early Inspiratory 3. Midinspiratory and Expiratory |
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Late Inspiratory Causes
high-pitched |
Atelectasis
Lobar pneumonia Interstitial fibrosis Lt-sided heart failure |
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Early Inspiratory Causes
Course crackles |
Chronic bronchitis
Bronchiectasis Asthma |
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MidInspiratory and Exp Causes
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Bronchiectasis
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Wheezes
High-pitched |
Continuous
Musical and Prolonged |
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Wheezes
Characterized by: |
Timing
Location Pitch |
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Wheezes
Caused by: |
Airflow through bronchi that are narrowed nearly to the point of closure
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Wheezes
Types |
Exp polyphonic
Fixed monophonic Sequential Inspir Random monophonic |
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Wheezes
Causes |
Asthma
Chronic Bronchitis COPD CHF |
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Rhonchi
Snoring or gurgling |
Musical
Low-pitched Inp and Exp but more w/Exp |
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Rhonchi
Causes |
Secretions in large airways
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Stridor
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Emphysema
Inspiration Louder in neck Partial obstruction of the larynx or trachea=emergency |
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Pleural Rub
Creaking sound-like fingers rubbing together |
Inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction
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Sputum Colors
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...
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White sputum
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Lungs are clean
Asthma might be seen Mucus |
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Gray sputum
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Cold or Flu
Hay Fever Too |
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Yellow sputum
Purulent |
Bronchitis
Bronchiectasis |
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Black sputum
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Smoking crack
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Red sputum
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blood
CA or TB |
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Orange Sputum
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Pneumococcus
Klebsiella |
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Green sputum
Purulent |
Pseudomonas
Mycoplasma |
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Brown sputum
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Dehydration
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See the following sheets with the headings...
(I did not make cards for these sheets) |
Comparing Adventitious Breath Sounds
Characteristics of Breath sounds Locations of NL Breath sounds T27/T26 ABNL Rate and Rhythm of breathing |
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Know locations of Lungs...
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See sheet "Lung Anatomy & Landmarks"
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See sheet...
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..."Physical Findings in Selected Chest Disorders"
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Health History
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Handout
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What can chest pain mean?
DDx R/O |
Heart issues-angina pectoris, MI, pericarditis, dissecting AA
Lung issues-bronchitis, pneumonia Chest Wall-costochondritis(mm), herpes (skin) Esophagus-reflux dz, esophageal spasm Neck-Cervical arthritis GB-Radiating pain from biliary colic Stomach-gastritis |
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Ask lots of questions...
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Broad to specific
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Ask the 7 attributes of the Sx when you find the pts sx/sxes. What are the 7 attributes of a Sx?
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Location
Quality Quantity/Severity (use scale here) Timing Setting in which it occurs Remitting or exacerbating factors Asso manifestations |
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Does lung tissue have pain fibers?
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NO!!!!
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Why do you get pain in lung conditions?
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From inflammation of the adjacent parietal pleura (b/c of pulm infarction or pneumonia), a muscle strain, rib fractures and anxiety
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What is the most common cause of chest pain in children?
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ANXIETY!
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Define dyspnea...
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Nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of physical exertion-mostly from cardiac or pulmonary disease
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How do you assess the level of dyspnea?
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Ask lots of questions!!!!!
Grade it... |
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Grading dyspnea...
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Grade 0=not troubled by breathlessness except with strenuous exercise
Grade 1=troubled by SOB when hurrying on a level path or walking up a slight hill Grade 2=Breathlessness when walking on a level path Grade 3=stops to breath after walking about 100 yards on level path Grade 4=too breathless to leave the house/breathless when changing |
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Coughing...from irritated receptors where?
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Larynx
Trachea Large Bronchi |
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What irritates these receptors?
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mucus, pus, blood, dust, foreign bodies, hot or cold air, inflammation of mucosa, pressure or tension in the air passages, left-sided heart failure
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Ask lots of questions...
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dry or productive
describe phlegm or sputum time what helps it? what makes it worse? |
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Dry hacking cough...
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Mycoplasma pneumonia
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Productive cough...
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Bronchitis
Viral or bacterial pneumonia |
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Hemoptysis
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Coughing up of blood from lungs. Blood-streaked phlegm or frank blood
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In the young, Hemoptysis is seen most often with what?
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cystic fibrosis
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Ask lots of questions...
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7 symptoms attributes
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Is the bleeding actually coming from the lungs? If not, it's not hemoptysis
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can come from mouth, pharynx, gi tract
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If blood is coming from the stomach, how is it different than blood from the lungs?
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Much darker and may be mixed with food particles
Can have a coffee ground look |
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OK-so all that was from packets of notes he has given us...NOW,
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the following is from the packet, "Examination of Lung/Thorax"
This is more of what is needed for the practical...much of what he covered in this packet is on the previous cards!!! |
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Why would the trachea, upon inspection, be displaced laterally?
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Pleural effusion
Pneumothorax Atelectasis (collapsed) |
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What is the NL Chest depth to width ratio?
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depth is 1/2 the width
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Examination of...
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...Posterior Chest
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Inspection
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I
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I
Watch thorax from behind What are you noting? |
Shape of chest
How it moves with inspiration and expiration Masses Bruises Lesions Scars Sinus Tracts Retractions of Intercostals spaces-esp lower |
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When do you see retraction with inspiration?
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Severe asthsma
COPD Upper airway obstruction |
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Palpating
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Posterior Chest
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3 areas to focus on for Palpating the chest
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Areas of tenderness and abnormalities in the overlying skin
Respiratory Expansion Tactile Fremitus |
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Areas of tenderness and abnormalities in the overlying skin
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Intercostal tenderness over inflamed area
Bruises over fractured ribs Sinus Tracts |
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Excursion
Tests Chest Expansion |
See cards at the beginning...went over this
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What are the causes of unilateral decrease or delay in chest expansion?
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Chronic fibrotic dz of underlying lung or pleura
Pleural effusion Lobar pneumonia Pleural pain asso w/splinting Unilateral bronchial obstruction |
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Tactile Fremitus
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Palpable vibrations caused by the transmission of air through the bronchopulmonary tree to the chest wall when the pt speaks
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Tactile Fremitus is most helpful for detecting what?
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Consolidation
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Increased Tactile Fremitus is what?
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Increased ratio of lung tissue or solid matter to air, decreased distance between lung and chest wall
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Increased Tactile Fremitus is seen in what?
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Pneumonia w/consolidation
Atelectasis Lung tumors Pulmonary Infarct Pulmonary/Cystic Fibrosis Bronchiectasis Increase secretions in large airways |
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Decreased Tactile Fremitus is what?
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Decreased ratio of lung tissue or solid matter to air, increased distance btwn lung and chest wall
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Decreased Tactile Fremitus is seen in what?
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Pneumothorax w/Lung Collapse
Pleural Effusion Tumors in pleural space Pleural thickening Bronchial Obstruction Asthma Emphysema |
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Percussion
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Posterior chest
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Percussion
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Helps to identify whether the underlying tissue is air, fluid or solid-filled
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Resonant Sound
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NL Lung
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Flat Sound
(Like over thigh) |
Large Pleural Effusion
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Dull Sound
(Like over liver) When fluid or solid tissue replaces air-filled lung or occupies pleural space |
Lobar pneumonia
Pleural Effusion Hemothorax Pus Tumor Fibrous Tissue |
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Hyperresonance Sound
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Emphysema
Pneumothorax |
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Tympany Sound
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Large Pneumothorax
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Auscultation
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Posterior Chest
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What do you do if abnormalities are suspected upon auscultation?
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Listen to the sounds of the pt's spoken or whispered voice
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What part of stethoscope do you use for breath sounds?
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Diaphragm
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How long do you listen to at each location?
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Listen to at least 1 full breath
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Where are the breath sounds going to be loudest?
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In the lower posterior lung fields
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Is inspiration longer or expiration?
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Inspiration
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Are breath sounds increased or decreased when NL lung is displaced by air or fluid?
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Decreased
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What do vesicular breath sounds switch to when there is fluid in the lung itself?
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Bronchial Breath Sounds
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When do you test a pt for Transmitted Voice Sounds?
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When ABNL bronchovesicular or bronchial breath sounds are heard
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Vocal Resonance
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Male speech notes = 130 Hz
Female = 230 Hz Overtones = 400-3500 Hz |
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Vowel sounds are produced by pairs of high frequency overtones and can be heard upon auscultation as indistinct sounds b/c the NL lung acts as a filter
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If fluid or solid matter occupies the lung then the vowel sound becomes more distinct
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A NL lung also filters out the voice sounds of spoken words or whispered words. Spoken words are muffled and whispered words cannot be heard.
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In fluid or solid filled lungs, spoken words become more clear and whispered words are audible
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There are 3 types of voice resonance
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Bronchophony
Whispered Pectoriloquy Egophony |
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Bronchophony
"Bronchus Sound" as would be heard over pt's bronchus |
Negative Bronchophony = NL
Sounds will be muffled and indistinct |
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What would a positive Bronchophony (or ABNL) sound like?
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Louder, Clearer
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When would you find a positive finding?
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Pulmonary Consolidation
Pulmonary Edema Hemorrhage |
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Bronchophony is a sign of what?
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Unfiltered transmission of breath sounds through consolidated or compressed lung tissue
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When saying ninety-nine = clear and audible sounds then bronchophony is present.
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= problem
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Whispered Pectoriloquy
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Whisper ninety-nine or one, two, three
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Positive = ABNL
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Whispering becomes audible
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Negative = NL
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Cannot hear the whispering
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What does Whisper Pectoriloquy indicate?
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Early pneumonia
Infarction Pulmonary atlectasis |
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Egophony
Goat sound b/c has bleating quality |
Occurs when high frequency sounds (vowels) are not filtered out but instead are enhanced
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Positive Auscultation = ABNL
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EEEE sounds like Ay
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Negative Finding
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EEE sounds like EEE...muffled
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What does Egophony indicate?
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Pleural effusion
Pulmonary consolidation |
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With all 3 vocal resonance tests, what does he say you must do?
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Auscultate each bronchopulmonary segment
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Inspection
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Anterior Exam
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See beginning of cards
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Palpation
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Anterior Exam
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Same as posterior
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...
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Percussion
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Anterior Exam
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Same as Posterior
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...
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With percussion, where does the heart produce an area of dullness on the left side?
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From the 3rd to the 5th intercostal spaces
You can percuss the left lung lateral to this dullness |
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Down left side = what?
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Tympani of stomach
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Down right side = what?
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Dullness of liver
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Auscultation
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Anterior Exam
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Same as posterior
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...
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See pages 8 & 9
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for Misc Lung Exam Procedures
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