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203 Cards in this Set

  • Front
  • Back
True Ribs
1-7
Primary muscles of inspiration
Diaphragm and internal intercostals
Increase the AP diameter during inspiration
External intercostals
Decreases the transverse diameter during expiration
Internal intercostals
Contains all the thoracic viscera except the lungs
Mediastinum
Location of the lingula
Inferior portion of Left Upper Lobe
Location of Horizontal fissure
Divides the upper and middle right lobes at the 5th rib in the axilla and the 4th rib anteriorly
Apex extends how far above the 1st rib
4cm
Posteriorly, apex extends how far
T1
Lower borders extend how far
T12 on inspiration
T9 on expiration
Location of trachea
Anterior to esophagus and posterior to isthmus of thyroid
Location of tracheobronchi junction
T4-T5
Bronchus that is more susceptible to foreign objects
Right bronchus
Shorter, wider, and more vertical
Transports air and traps noxious foreign particles
Bronchi
Acini consists of
respiratory bronchioles, alveolar ducts, alveolar sacs, and alveoli
Bronchial arteries derived from
thoracic aorta and intercostal arteries
Bronchial vein formed where
Hilum of the lung
Movement of air back and forth from the alveoli to the outside
Ventilation
Gas exchange across the alveolar-pulmonary capillary membrane
Diffusion and perfusion
Respond to changes in the H ion concentration of the blood
Medulla
Nerve impulses from the medulla travel here to control the respiratory muscles
Pons
What may cause the Right lung to be slightly higher
Liver
Anterior view of the R Lung is mostly
Upper and middle lobe
Is the middle lobe viewed posteriorly
NO!
Borders of middle lobe
4th rib at sternum to the 5th rib mid axillary and then extending inferomedially to the 6th rib at the midclavicular line
Posteriorly, the Lower lobe extends from?
T3-T10 or T12
The Posterior lung is mostly what lobe?
At T3, the oblique fissure separates the upper and lower lobes. So the lower lobe is dominant posteriorly.
Path of the oblique fissure
Spinous process of T3 to the 6th rib at the midclavicular line anteriorly
Stabilizes the alveoli by lessening surface tension at the air-liquid interface
Surfactant
Shape of a newborns chest? ratio of AP-Transverse Diameter.
Round
1:1
Circumference is equal to that of an adults head.
Alveoli increase rapidly up to what age?
2 yrs
How much does the transverse diameter increase in a pregnant woman? Circumference?
2cm
5-7 cm
How much does the diaphragm rise in the pregnant woman? How much does the subcostal angle increase?
4cm
From 68.5 degrees to 103.5
Results from loss of muscle strength in the thorax and diaphragm of older adults
barrel chest
this is couple with loss of lung resiliency
What results from underventilation of the alveoli from decreased alveolar surface, decreased inspiratory muscle strength, and decreased lung resiliency?
Decrease in vital capacity and increase in residual volume
Predisposes the older adult to respiratory infections
Aging mucous membranes become dry and encourages bacterial growth
The Cardia should have what type of percussive sound?
Flat
Hyperresonance may be associated with what diseases
Emphysema, pneumothorax, or asthma
Dullness or flatness to percussion suggests
Atelectasis, pleural effusion, pneumothorax, or asthma
The diaphramatic excursion may be limited by what?
Emphysema
abdominal tumors or ascites
Fractured rib
Excursion diameter
3-5 or 6 cm
Cinnamon breath
Pulmonary tuberculosis
Fishy, stale Breath
Ammonia Breath
Uremiea (trimethylamines)
Uremia (ammonia)
Musty fish, clover smell
Fetor Hepaticus
liver failure, portal vein thrombosis
Foul, feculent breath
Int obstruction
Hallitosis
Tonsillitis, gingivitis, respiratory infections
Foul, putrid breath
Nasal sinus pathology or respiratory infections
A slight deviation of the trachea to the right may indicate
Nothing, its normal
What may cause the trachea to be pushed to the contralateral side
Tension pneumothorax, tumor, nodal enlargements
What may cause deviation of the trachea
Atelectasis
thyroid enlargement
significant parenchymal or pleural fibrosis
pleural effusion
Thoracic respiration is primarily the use of
Intercostal muscles
It is not unusual to see what accessory muscles used in inspiration in young infants
Abdominal muscles
Pregnant women are more likely to use what type of respiration?
Thoracic
Prolonged expiration and bulging on expiration
Outflow obstructions or valvelike compression by a tumor, aneurysm, or enlarged heart
Suggests an obstruction to inspiration at any pt in the respiratory tract
Retractions
Chest asymmetry is associated with
Collapsed lung, tumor, extrapleural fluid/air
Usually symmetric and painless, and may be associated disease or be hereditary
Clubbing
Occurs when a negative intrathoracic pressure is transmitted to the abdomen by a poorly functioning diaphragm
Paradoxic breathing
Unilateral retraction without suprasternal notch involvement
Foreign body in the bronchi
Retraction of the lower chest
Bronchiolitis and asthma
Characteristics of upper airway obstruction.
Severe?
Inspiratory stridor
A hoarse cough
Flaring of Nasal Ali
Retraction at suprasternal notch

Stridor on inspiration and expiration
Barking cough
Cyanosis
Upper airway obstruction above the glottis
Below the glottis?
Muffled voice
Stridor is quiet
Difficulty swallowing
There is no cough
Awkward position of head and neck

Lound, rasping Strider
Hoarse Voice
Swallowing not affected
Harsh Cough
Head Position not a factor
Common sign of air hunger, especially when the alveoli are involved
Flaring of Nasal Ali
Accompaniment of increased expiratory effort
Pursing of lips
It may be a good idea to auscultate what part of the lung first in older pts
The Base
The sounds of the middle lobe and lingula are best heard where on auscultation
Over the axillae
Bronchial sounds
Heard over trachea
High pitch
Loud and long expirations
Bronchovesicular sounds
heard over main bronchi anteriorly and upper right posterior lung field.
Medium pitch
Expirations=Inspirations
Vesicular
Heard over lung fields
Low pitch
soft and short expirations
When examining a pt with CHF, it is best to start auscultation where? Why?
In the base
To detect crackles that may disappear upon repeated exaggerated respirations
What is the Lords of the Congregation?
Scottish nobility coming together stating that they are for reformation
What condition may give an inconclusive anterior thoracic expansion
Barrel chested pt with COPD. The chest is so inflated that it cannot expand further and your hands may come together.
Palpable coarse, grating vibration on inspiration
Pleural friction rub
Tactile Fremitus is best felt where
Parasternally over the 2nd intercostal space at the level of the bifurcating bronchi
How do you tell the difference between lobar pneumonia and pleural effusion
Breath sounds are absent in pleural effusion but may be bronchial in pneumonia
On palpation, the tactile fremitus is absent when an effusion is present, but present with pneumonia.
Both conditions have dullness to percussion
Increase in the AP diameter
Barrel chest: COPD, asthma, emphysema
Ratio of respirations to heart beats
1:4
Thoracic ratio
.7-.75
Acute unknown chest pain in a young adult
Possible cocaine abuse
When does chest pn not originate in the heart?
1. There is a constant achiness
2. It stays in one position
3. It is made worse by pressure on the precordium
4. It is situated in the shoulders or between the shoulder blades.
Difficult and labored breathing with shortness of breath
Dyspnea
Shortness of breath that begins or worsens upon laying down
Orthopnea
Protective splinting from pain of a broken rib, pleurisy, or liver enlargement/abdominal ascites may cause what type of respiration
Shallow hyperventilation
Neurologic or electrolyte imbalances
Bradypnea
Rapid deep breathing
Kassmaul: Metabolic acidosis
Regular periodic pattern of breathing with intervals of of apnea followed by a crescendo/descendo sequence of respiration
Cheyne-Stokes: cerebral brain damage, and drug-induced compromise.
May also be normal in children or older adults.
An occasional deep, audible sigh that punctuates an otherwise regular respiratory pattern
Emotional distress
Prolonged but inefficient expiratory effort, in which the rate of respiration increases in order to compensate
air trapping:
obstruction of pulmonary tree
Irregularly interspersed periods of apnea in a disorganized sequence of breaths
Biot respiration:
Severe and persistent intracranial pressure, drug overdose, or lesions of the medulla
Significant disorganization with irregular and varying depths of respiration
Ataxia
Long inspiration with strained expirations
Apneustic respirations:
lesion of the pons
Primary apnea
Self-limited and common with blow to the head
Secondary apnea
Breathing does not restart unless resuscitative measures are taken
Will aspirin poisoning increase or decrease RR
increase due to metabolic acidosis
Are fat babies more prone to asthma?
Yes
What type of air irritates asthmatics
Cold air
Warm, humid air is better
Incomplete expansion of the lung at birth, or the collapse of the lung at any age
Atelectasis
COPD characterized by airway inflammation and generally resulting from airway hyperactivity triggered by allergens, anxiety, URI, cigarette smoke, etc
Asthma
Inflammation of the mucus membranes of the bronchial tubes
Bronchitis
Can bronchitis present with fever and chest pn?
What is the usual cause?
Yes
Irritation by a noxious stimulus
Inflammatory process involving the visceral and parietal pleura.
What is it often associated with?
Pleurisy
Result of pulmonary infections, bacterial or viral, and sometimes with neoplasms or asbestosis
How does pleurisy typically present?
Sudden onset with acute chest pn. Pleura becomes dry and the rubbing can be felt and heard. respiration are rapid and shallow with diminished breath sounds. Pain close to the diaphragm can be referred to the shoulder.
Right angled area of dullness over the posterior chest, which can sometimes be percussed opposite a large pleural effusion. What percussive sound is heard superior to the dullness?
Grocco's triangle:
Seen in pleural effusion
Hyper-resonance is heard above the lesion and is called Skodiac resonance.
Flaring of the nasal alae, tachypnea, and a productive cough in the absence of crackles should alert you of
Acute bacterial pneumonia:
Crackles are commonly heard but not necessary for a diagnosis of pneumonia, especially in children.
In pneumonia, infective agents lead to exudates that cause what?
consolidation of the lung resulting in tachypnea, dyspnea, and crackles, with diminished breath sounds and dullness to percussion over the area of consolidation.
Involvement of the right lower lobe can cause pain where?
Irritation of the 10th and 11th thoracic nerves can cause right lower quadrant pn and an abdominal process
Pt presents with tachypnea, fever, and foul breath. Percussion is dull with distant breath sounds. The pt recently was seen for a tooth abscess
Lung abscess:
May also be caused by aspiration of food or infected material from the upper respiratory tract.
Purulent exudate that collects in the pleural spaces. How does this present?
Empyma
Pt presents with diminished breath sounds, dull to precussion, absent vocal fremitus, tachypneic and febrile
50 y/o pt presents with sputum producing cough, and fever. Hx of smoking. What may this result in?
Chronic bronchitis:
may result in Right ventricular failure and cor pulmonale
Chronic dilation of the bronchioles from repeated pulmonary infections and bronchial obstructions. The extent of exam findings is based on? What are the major clues?
Bronchiectasis:
Degree of wetness
Cough and expectoration
Autosomal recessive condition characterized by bronchiectasis
Kartegener's
Major risk factor for COPD
smoking
Dilation of the air space distal to the terminal bronchioles, with destruction of alveoli and hyperinflation of the lung. What is a common precursor? Common presentation?
Emphysema
chronic bronchitis
Dyspnea, hyper-resonant percussion, prolonged expiration, barrel chest and thin.
How is TB transmitted. What population is especially susceptible?
Through the airborne moisture of coughs and sneezes of infected persons.
HIV infected persons
Pt presents with an unexplained but persistent tachycardia.
Minimal pneumothorax
Presence of air or gas in the pleural cavity. When this occurs spontaneously, how does it present?
Pneumothorax:
A rupture of a congenital bleb may cause it to occur spontaneously in which it presents most often when the pt is at rest, and has boom-like sounds.
What can a "coin click" help to diagnose?
Pneumothorax
Pleuritic chest pn without dyspnea and low grade fever
Pulmonary embolism
Lung cancer generally refers to?
Bronchogenic carcinoma:
Malignant tumor arising from bronchial epithelium.
Blood on the pleural cavity. May be the result of? How can this be differentiated from pneumothorax?
Hemothorax
Trauma or invasive medial proedure
Breath sounds are distant like in pneumothorax, but the percussion is dull not booming and "coin click" is absent.
Acute cor pulmonale is often caused by?
Pulmonary embolism
Breath sounds are easier to hear in what abnormality?
Consolidation
Low-pitch, low-intensity breath sounds heard over healthy lung tissue
vesicular
Moderately ptiched and intense breath sounds heard over major bronchi
bronchovesicular
High pitched and intense sounds heard only over the trachea
bronchial/tracheal
When is amphoric breathing most often heard
1. Stiff walled pulmonary cavity
2. Tension pneumothorax with with bronchopleural fistula
Cavernous breathing heard when
pulmonary cavity with a stiff wall
Abnormal respiratory sound heard more often upon inspiration and characterized by discrete discontinuous sounds
Crackles
How can you seperate Crackles from wheezes/rhonchi
Crackles are discontinuous and wheezes/ronchi are continuous
High pitched crackles
Low pitched crackles
Sibilant
Sonorous
Dry crackles, more crisp than gurgling are more apt to occur where in the respiratory tree?
Higher than lower
A radio static like sound lacking a musical pitch. When is this heard?
White Noise
Expiratory and inspiratory wheezing. Caused by a narrowed central airway in people with asthma or chronic bronchitis.
Pleural friction rubs are loudest where
Lower lateral anterior surface
Course, low pitched continuous sound, more pronounced on expiration. What conditions are they heard?
Rhonchi (sonorous wheeze):
Airway obstructed by thick secretions, muscular spasms, growths, or external pressure.
Sibilant high-pitched ronchi are found where? Lower-pitched ronchi?
Smaller bronchi as in asthma
Larger bronchi, tracheobronchitis
Coughing may clear what adventitious sound
ronchi
Loud, bubbly noises heard during inspiration
coarse crackles:
Low pitched, high amplitude, long duration
High pitched, low amplitude with short duration, heard more at the end of inspiration.
Fine crackles
Pt is observed sitting up and leaning forward...
Anterior mediastinal mass
Vocal fremitus greater in men or women?
Men: due to lower pitched voice
Pulmonary infarction and a pulmonary crisis called "chest syndrome" is often seen in pts with?
SCC
How can you differentiate between pericarditis and pleurisy
The respiratory rub disappears when the breath is held and the pericardial does not
Pleurisy occurs where along the respiratory tree
outside the tree
A continuous, high-pitched, musical sound heard during inspiration or expiration. is it louder on inspiration or expiration?
Wheeze:
Usually louder on expiration
The longer the wheeze, and the louder the pitch...
the worse the obstruction
bilateral wheeze is associated with?
bronchospasm associated with asthma
or bronchitis
Unilateral wheezing may be associated with?
Foreign object
If infection is the source of wheezing...
...it is a virus
Air and fluid simultaneously present within the pleural cavity or in large cavities
Succussion splash
Mediastinal crunch is found with?
the characteristics of ?
Synchronous with?
emphysema:
also called hammans sign
loud cracking and gurgling sounds
The heartbeat
What CNS lesion will increase RR? lower?
Pons
Medulla
When is a mediastinal crunch easiest to hear?
When a pt is leaning to the left or lying on their left side.
Extreme bronchophony, with a clear voice on whisper is seen in what condition?
Lung consolidation as in pneumonia.
Vocal resonance diminishes when there is?
Blockage of the respiratory tree for any reason
In the past, what disease was known as wool-sorters?
Anthrax, after the people who sorted wool that was contaminated with bacillus anthracis
Pt presents with flu-like fever, chills, achiness and sniffles. Pleural effusion then develops a few hours later. What must you suspect?
Anthrax
Anthrax txmt must be given...
Before lab confirmation is known. It is curable if treated early, but is not later on.
Common complication to smallpox virus
Pneumonia occurs
Smallpox agent
variola virus
Cough of acute onset generally occurs with..
infection
A regular, paroxysmal cough is heard when?
Pertussis
Hoarse dry cough associated with?
Croup
Dry brassy cough
Compression of the respiratory tree as with a tumor
Maximal inspiration followed by maximal expiration
Vital capacity
The blow out test is performed about how far away from the pt?
10-15 cm
Maximum flow of air that can be expelled
Peak expiratory flow rate
How do you measure forced vital capacity?
Have pt exhale fully and then hold the breath. count the number of sec until the pt has to take the next breath and multiply by 50
Yellow, green, rust colored with possible blood, or purulence in the sputum
Bacterial inf
Viscous, mucoid, with possible blood streaked sputum
Viral inf
Slight, persistent blood streaking
Carcinoma
Large amounts of clotted Blood in sputum
Pulmonary infarction
Large amounts of non-clotted blood
Tuberculous cavity
What might be responsible for a 250% increase in bronchiolitis hospitalization rates over the past 20 years?
Pulse ox:
The 5th vital sign
Supernumerary nipples are more common in?
Blacks
Epiglottitis is an acute life threatening illness caused by?
What age group is most often affected?
Haemophilus influenzae B
children 3-7
Child presents sitting up with neck extended and head held forward. The child is drooling and unable to swallow. Cough is not present, but there is a high fever. What is characteristic finding? What should you not attempt?
Epiglottitis:
Epiglottis is beefy and red
Should not attempt to visualize the epiglottis w/o artificial airway.
Child awakens suddenly, with labored, retractive breathing and a harsh bark like cough? What age group is the most prevalent? Agent? Inflammation?
Croup:
1.5-3 yrs
Parainfluenza virus
Inflammation is subglottic with swollen tracheal tissue and may involve areas beyond larynx.
Respiratory distress syndrome is associated with?
Surfactant deficiency
High-pitched piercing sound heard on inspiration. It is the result of? What is the I:E ratio? Signifies a serious problem where?
Stridor
Obstruction high in the respiratory tree
3 or 4:1
Trachea or Larynx
What side is a diaphragmatic hernia usually on? Clinical findings?
Left
Bowel sounds heard in the chest and a flat or scaphoid shaped abdomen. Also, heart lays to the right.
Newborns rely primarily on what for respiration?
Diaphragm, but also commonly use the abdominal muscles
What rarely occurs in the newborn and should be considered a problem?
coughing
Asymmetric chest expansion
Atelectasis
Pleural effusion
Pneumothorax
Asymmetry in the newborn could be from?
Pneumothorax
Diaphragmatic hernia
Asymmetric auscultatory findings
aspiration of meconium
Persistance of a round barrel chest in a young child should alert you of?
COPD such as CF
In children, obvious intercostal exertion (retractions) is usually?
Asthma
RR:
Newborn
1
3
6
10
17
30-80
20-40
20-30
16-22
16-20
12-20
What lung sound is common in children
Hyper-resonance. The child is usually skinnier than the adult and resonance is louder.
Mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air
Respiratory grunting
the most apparent change in pregnant women's lung volume
A decrease in the functional residual capacity, which is the volume of air left after quiet expiration. However, vital capacity increases 100-200 mL
The tidal volume in a pregnant woman increases how much?
The amount of air inhaled and exhaled during normal breathing increases 40%
The pregnant woman increases her ventilation by?
breathing more rapidly and deeply
What lung sound is common in children
Hyper-resonance. The child is usually skinnier than the adult and resonance is louder.
Mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air
Respiratory grunting
the most apparent change in pregnant women's lung volume
A decrease in the functional residual capacity, which is the volume of air left after quiet expiration. However, vital capacity increases 100-200 mL
The tidal volume in a pregnant woman increases how much?
The amount of air inhaled and exhaled during normal breathing increases 40%
The pregnant woman increases her ventilation by?
breathing more deeply
The chest circumference of a full-term infant. What can be used to measure the chest ratio?
30-36 cm
The distance between the nipple is 1/4th the circumference
What is common in the newborn and can persist for several days without cause for concern?
Cyanosis in the hands and feet
What type of delivery is associated with a greater RR at birth
C-Section
What type of breathing is common in the newborn. When does it become a concern?
Periodic: A sequence of vigorous respiratory efforts followed by apnea of as long as 15 seconds.
When the episodes are prolonged and the baby is centrally cyanotic.
A hot or cold room temperature can cause what in the newborn?
tachypnea