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304 Cards in this Set
- Front
- Back
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What part of the left lung is homologous to the middle lobe of the right lung?
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The lingula of the left lung is homologous to the middle lobe of the right lung
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What is the superior border of the lung?
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Superiorly the lungs extend 3-4cm above the clavicles.
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What are the inferior borders of the lungs anteriorly?
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The lungs extend to the sixth rib in the midclavicular line.
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What is the inferior border of the ribs in the midaxillary line?
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The lungs extend to the 8th rib in the midaxillary line.
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What is the inferior border of the lungs posteriorly?
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The lungs extend to between the 9th-12th thoracic vertebra posteriorly.
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Where does the trachea bifurcate anteriorly? posteriorly?
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At the level of the sternomanubrial angle anteriorly and the upper fourth thoracic vertebra posteriorly.
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How should the pt be seated during the chest exam?
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They should be sitting up while the physician moves from front to back to sides.
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What characterizes obstructive lung disease?
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Decreased expiratory flow that results from increased airway resistance.
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What causes hyperinflation seen in obstructive lung diseases?
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Air-trapping
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What are the two disease categories that make up chronic obstructive pulmonary diseases (COPD)?
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1. Emphysema
2. Chronic Bronchitis |
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What abnormalities are seen in a chest x-ray of a pt with an obstructive lung disease? why are these findings seen?
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1. The diaphragm loses its dome shape
2. The heart becomes much more midline as a result of over inflation of the lungs. |
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Where do inhaled foreign bodies tend to get stuck?
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In the lower part of the right lower lobe.
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What position should the patient be in when you are observing the posterior part of the lung?
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The patient needs to sit up with their arms crossed so that the scapula are pulled out of the way.
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What lobe of the lung makes up the majority of the posterior part of the lung?
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The inferior lobe makes up ~85% of the lung surface posteriorly. So you would never find middle lobe pneumonia on a patient if you only examined their back.
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What effect does obstructive lung disease have on the lung?
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The patient cannot exhale efficiently so the air is trapped inside and the lungs become hyperinflated.
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What is the problem that is caused by emphysema?
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There is destruction of the lungs peripheral tissues so it loses its elastic recoil.
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What is the problem with chronic bronchitis?
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The patient has an over production of mucus, so the mucus increases airway resistance.
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What is the problem with asthma?
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The patient has normal periods that are interrupted by intermittent "asthma attacks" where there is acute edema and inflammation and hyper activity of their airways.
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How can you tell asthma from COPD?
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COPD are chronic conditions where the lung never goes back to normal, asthma is normal lung functioning interrupted by acute periods of obstructive disease.
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How can you tell Emphysema from Chronic Bronchitis?
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Chronic Bronchitis has a chronic cough over a period of time, emphysema patients simply cannot exhale.
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What is the problem with Bronchiectasis?
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The patient has inflamed airways/obstruction with a cough, the only way to tell this problem from chronic bronchitis is patients w/ Bronchiectasis have dilation of the distal airways that occurs w/ concurrent lung infection.
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What is the problem with cystic fibrosis?
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The patient has a problem with their chloride channels, so their mucus is very THICK, so they have a problem clearing the mucus from their lungs, they have constipation and they have increased NaCl in their sweat which is how it is diagnosed.
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What is the problem w/ restrictive lung disease?
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Patients have decreased inspiratory flow that results from decreased lung compliance. So patients are unable to fill their lungs w/ air b/c the lungs are noncompliant.
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What are the two categories of restrictive lung disease?
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Is the disease occurring inside their lungs or in the muscles of the chest wall.
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What is the main restrictive lung disease that occurs inside the lung tissues?
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Pulmonary Fibrosis
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How could you diagnose Pulmonary Fibrosis on a chest x-ray?
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The diaphragm is still dome shaped but the lung volume appears small.
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What is consolidation?
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The replacement of alveolar air w/ solidified lungs that can better transmit higher frequency sounds.
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What produces consolidation?
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Filling alveoli w/ fluid or by collapsing alveoli.
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What is the effect of consolidation?
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To decrease the air/fluid ratio of lung tissue.
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What are the two common causes for consolidation?
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1. Alveolar pneumonia
2. Left ventricular failure |
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How does alveolar pneumonia cause consolidation?
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Inflammatory cells, cellular debris and microbial organisms replace the air in the alveoli. Basically it causes pus to fill the airway.
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How does left ventricular failure cause consolidation?
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The weak pumping action of the heart leads to increased LVEDP-> inc. LAP -> inc. transmembrane pressure which causes plasma to filter out of capillaries to replace the air in the alveoli.
*basically it causes blood to fill the airway. |
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Where would consolidation occur if it was caused by LV failure?
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The highest pressure region in the lung is the lower lobe, so the severity of the LV failure is shown by how high up the chest the consolidation occurs.
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What are the two types of pneumonia?
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1. Alveolar pneumonia = pus in the alveoli a type of consolidation.
2. Broncho pneumonia = pus in the bronchi/airways and not in the alveoli, which can also lead to a different kind of consolidation. |
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How can you tell the degree of severity of heart failure by looking at the lung?
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The higher up the consolidation of the lung the more severe the LV failure.
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What is atelectasis?
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A segment of lung collapses b/c air contained w/in is reabsorbed into the blood stream. Another type of consolidation.
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How does atelectasis cause consolidation?
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Instead of replacing nitrogen and oxygen w/ another fluid, like blood/pus, the nitrogen and oxygen are sucked out and not replaced, which increases water density.
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What is major atelactasis? what causes it?
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The obstruction occludes large airways which is caused by intrabronchial tumors.
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What is minor atelectasis? what causes it?
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Occlusion of the small airways typically caused by mucus.
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What would atelactasis look like in chest x-ray?
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Basically a vacuum is being created within the lung so it pulls the ribs close together, the trachea would get pulled toward the affected side.
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Where does lung atelectasis occur in the lung?
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Within in the tissues of the lung and not in the pleural space.
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What is a pneumothorax?
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Where atmospheric air pressure enters the pleural space, this causes the lung to collapse and the chest wall to expand outward and separation of the visceral and parietal pleura.
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How can you tell a pneumothorax on chest x-ray?
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There are no lung lines, the chest just looks SUPER dark on the affected side which smooshes the lung into a corner on the effected side and pushes the heart away from the affected side.
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What can cause a pneumothorax?
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1. Congenital blebs that rupture and allow air to leave the lung into the pleural space.
2. Knife/puncture wounds that allow atmospheric air into the pleural space. |
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What is a tension pneumothorax?
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The tension w/in the pleural space is higher than atmospheric pressure.
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What causes a tension pneumothorax?
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Air enters the pleural space but is not able to leave the space. So every time the patient breathes it increases the pressure in the pleural space.
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How can you tell a tension pneumothorax from a normal pneumothorax?
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The diaphragm become very flat, the heart and vasculature is pushed away from the affected side and the patients clinically become VERY hypotensive, the trachea deviates away from the pneumothorax, JVP would be elevated and low BP.
This is a type of obstructive shock. |
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If a patient presents w/ low BP, elevated JVP, the trachea deviates to the right and when you auscultate the heart you hear the heart sounds on the right, what's the dx?
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Tension pneumothorax.
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What are asthma patients on the ventilator prone to?
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Tension pneumothoraxes, b/c the lungs cannot exhale, the pressure builds and the lung pops creating a tension pneumothorax.
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What affect do tension pneumothoraxes have on cardiac output?
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They cause very decreased cardiac output.
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What is a pleural effusion?
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Where you have fluid in the pleural space that may be protein-rich or protein-poor.
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Where does pleural effusion tend to occur?
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In the gravity dependent regions of the lungs.
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What kind of pleural effusion is caused by necrotising pneumonia?
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Pus, protein-rich fluid, spreads into the pleural space
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What kind of pleural effusion is caused by CHF?
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Serous fluid that is protein-poor enters the pleural space.
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What kind of pleural effusion is caused by cancer that metastasized to the visceral pleura?
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Protein-rich fluid enters the pleural space from the cancer.
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How can you tell pleural effusion on chest x-ray?
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The fluid climbs the walls of the chest b/c it follows the pleural space.
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How can you tell pleural effusion from atelactasis on chest x ray?
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The fluid tracks up the wall, the trachea is pushed away from the affected side in pleural effusion.
In atelactasis the vacuum that is created pulls the trachea toward the affected side. |
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What causes dyspnea?
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Either cardiac or pulmonary and results from an imbalance b/e ventilatory demand and ventilatory capacity.
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What does the ventilatory capacity depend on?
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The mechanics of the respiratory system and neuromuscular performance.
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What chronic lung diseases cause dyspnea?
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Emphysema, obstructive bronchitis and pulmonary fibrosis.
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What diseases cause acute dyspnea?
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Pneumonia, pulmonary embolism, pneumothorax, aspiration and pulmonary edema.
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What does an acute dyspnea that developed w/in seconds-minutes make you think?
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Makes you think pulmonary embolism or pneumothorax.
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What does sub-acute dyspnea make you think? where the dyspnea developed over minutes-hours.
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pneumonia.
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What questions should you ask a patient who has dyspnea?
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"How much activity can you do, has that changed over the last months/years?"
"Can you climb a flight of stairs" |
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What is paroxysmal nocturnal dyspnea more indicative for?
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More indicative for cardiac diseases
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How can you judge the severity of orthopnea?
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By asking "how many pillows do you sleep on at night?"
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What is the function of coughing?
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Protects the lungs from injury and infection by clearing large airways of secretions and foreign material.
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What nerve mediates the cough reflex?
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Both the afferent and efferent nerves travel w/ the Vagus nerve.
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What are the most common cause of acute cough?
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1. Viral or bacterial upper respiratory infections
2. pneumonia 3. aspiration of gastric contents 4. pulmonary edema 5. rarely, pulmonary embolism |
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What is the difference b/e a chronic and acute cough?
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A chronic cough is a cough that has lasted for longer than 3 weeks.
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What are the most common pulmonary causes for chronic cough?
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1. Tobacco-related bronchitis
2. allergic postnasal drip 3. reactive airway disease (asthma) |
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What medications can cause a chronic cough as a side-effect?
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1. ACE inhibitors
2. beta-adrenergic agonists |
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What is cough frequently associated with?
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Sputum production
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What causes clear or mucoid sputum?
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Inhaled irritants
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What causes purulent (yellow or green) sputum?
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Infectious bronchitis or pneumonia
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What causes putrid (fowl-smelling) sputum?
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Suggests the presents of a lung abscess.
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What causes rusty (red) sputum?
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Indicates the presence of old blood.
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What is hemoptysis?
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Coughing up bright red blood from the lower respiratory tract.
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What is scant hemoptysis?
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Bright red blood streaking the sputum.
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What is Gross Hemoptysis?
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More bright red blood streaking but less than 600 mL.
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What is Massive Hemoptysis?
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More than 600 mL of blood in a 24 hour period.
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Why is massive hemoptysis an emergency?
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Not so much because the patient bleeds out, but more because the blood fills the alveoli which causes them to essentially drown.
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What is the most common cause of hemoptysis? How much hemoptysis does it produce?
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Acute bronchitis is the most common cause of hemoptysis in the USA and it typically produces scant amounts of blood.
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What is pleuritic chest pain?
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Chest pain that increases w/ deep breathing or coughing that is sharp in nature.
*cardiac pain is typically pressure-like pain. |
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What is the pattern of pain that is produced by pleuritic chest pain?
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sharp pain that increases in intensity w/ deep breathing or coughing and that may radiate to the ipsilateral shoulder/neck.
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How can you tell pleuritic chest pain from costochondritis?
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By pushing on the chest wall to see if the pain is reproduced, if it is then the patient has costochondritis.
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What is the most common cause of fingernail clubbing?
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Neoplastic or inflammatory lung disease (primary or metastatic lung cancer, chronic lung infection or mediastinal tumors)
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What is the second most common cause of digital clubbing?
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Non-pulmonary conditions like hepatic cirrhosis, congenital heart disease, infectious endocarditis, inflammatory bowel disease or non-thoracic malignancy.
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What is periosteal inflammation?
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(periostitis) that is located in the distal shaft of the long bones that causes limb pain and soft tissue swelling.
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What locations are most commonly affected by periosteal inflammation? second most commonly affected?
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Radius and ulna are most commonly affected
Distal Tibia and fibula are second most common affected sites. |
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What frequently accompanies periostitis?
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Swelling of the joints adjacent to the long bones.
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What is hypertrophic osteoarthropathy (HOA)?
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Periostitis and soft tissue swelling
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What causes HOA?
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Intrathoracic neoplasm.
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What neoplasms commonly cause HOA?
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1. Bronchogenic carcinoma
2. Lymphoma 3. Mesothelioma 4. metastatic cancer |
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What does the presence of clubbing and HOA signal?
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They precede the development of a neoplasm by several years.
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What is the normal respiratory rate? what is tachypnea? bradypnea?
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normal = 20 +/- 5
tachy = >25 breaths/min brady = <8 breaths/min |
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When is tachypnea a bad prognostic indicator?
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When it occurs in hospitalized patients b/c it frequently indicates the presence of underlying cardiopulmonary disease and may portend the development of cardiopulmonary arrest.
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What is the first physical exam manifestations of pneumonia or heart failure?
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Tachypnea
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What should you look for if a patient has bradypnea?
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hypothyroidism or hypothermia
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What happens to the thoracic ratio w/ age?
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The thoracic ratio increases w/ age causing older patients to be "barrel chested".
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What is the normal thoracic ratio?
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.70 to .75
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What causes the thoracic ratio to exceed .90?
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pulmonary emphysema and during severe bouts of asthma as a result of obstruction to expiratory flow.
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What is a non-pulmonary cause for restrictive lung disease? why?
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kyphoscoliosis b/c severe anatomic deformities restrict air movement as a result of impaired chest wall mechanics.
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What are common causes of kyphoscoliosis?
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1. muscular dystrophy
2. cerebral palsy 3. vitamin D deficient rickets 4. osteomalacia 5. connective tissue dz'es like Marfan's disease or ehlers-Danlos disease |
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What is Pectus Excavatum?
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A funnel-shaped depression of the lower portion of the sternum that shifts the heart to the patient's left.
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What do severe cases of pectus excavatum cause pulmonary and cardiac-wise?
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pulmonary: prevents complete inspiration and limits exercise capacity.
cardiac: shifts cardiac apical impulse and heart sounds. |
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What is pectus carinatum?
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"Pigeon Breast"
Where the sternum projects beyond the frontal plane of the abdomen. |
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What pulmonary conditions can be caused by pectus carinatum?
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May be painful and limit complete expiration of air and may limit exercise tolerance and increase the rate of pulmonary infections b/c of inability to ventilate properly.
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What is Flail Chest?
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Where one or both sides of the chest move paradoxically inward during inspiration and outward during expiration.
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What causes flail chest?
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Where multiple ribs fracture in sequence in one or both sides of the chest.
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What is the main muscle for inspiration?
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Diaphragm
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What muscles also contribute to inspiration besides the diaphragm? what do they do?
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External intercostals, they contract and help elevate the chest cage.
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When do the accessory muscles of respiration become important?
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In patients w/ injury to the phrenic nerve so the diaphragm doesn't function
Or in patients with terrible obstructive lung diseases that have completely flattened the diaphragm, so they cannot inspire using the diaphragm. |
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What are the accessory muscles of inspiration?
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sternocleidomastoid, external intercostals and the scalenes.
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What effect do emphysema and asthma have on the muscles of inspiration?
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Essentially they prevent the diaphragm cannot function due to overexpansion of the lung, so they have to use the scalenes, SCM and external intercostals. These muscles contracting w/ each breath tells you the pt is in respiratory distress.
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What causes normal passive expiration?
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passive expiration depends on the elastic recoil of pulmonary tissues to expel air.
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When are muscles needed in expiration?
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Normally no muscles are needed during expiration
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What does forced expiration require?
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Contraction of the internal intercostals, abdominal wall muscles and to a lesser extent accessory muscles in the neck.
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When does normal expiration become an active process?
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During emphysema and asthma where there is decreased elastic recoil of the lung, so the pt has to uses the internal intercostal muscles and the abdominal wall muscles.
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What affect on the expiratory phase does emphysema have?
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Causes respiration to be markedly prolonged.
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What happens to the intercostal spaces during inspiration and expiration?
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The spaces normally retract during inspiration and bulge outward during expiration.
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What diseases does exaggeration of the inspiratory retraction develop in?
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In patients w/ severe emphysema or pulmonary fibrosis.
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What does loss of inspiratory retraction over a given area of the chest suggest?
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A pt w/ underlying consolidation (pneumonia or atelactasis) or pleural effusion.
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What happens to the abdominal wall during inspiration and expiration?
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Normally the wall moves synchronously outward w/ the chest wall during inspiration and retracts synchronously w/ the chest wall during expiration.
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Why does the abdominal wall move inward/outward during inspiration/expiration?
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B/c downward movement of the diaphragm during inspiration compresses the intra-abdominal contents and pushes them outward, more pronounced in men than women.
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What is respiratory paradox or abdominal paradox?
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When the chest and abdomen move asynchronously, so the chest moves outward during inspiration and the abdomen moves inward.
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What does respiratory paradox indicate?
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The presence of bilateral diaphragmatic weakness or paralysis.
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What muscles are primarily responsible when the diaphragm is weak or paralyzed?
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The intercostal muscles.
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What dz is indicated by respiratory paradox?
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The presence of respiratory failure from diaphragmatic paralysis and the need for ventilator support.
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What blood-gas changes does respiratory paradox precede?
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The changes of hypoxema and CO2 retention that develop from diaphragmatic weakness.
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What is chest palpation utilized for?
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Utilized to ***** expansion of the thoracic cage during breathing.
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How should you perform a chest palpation?
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Your hands should be placed over each side of the lateral chest at about the eighth rib, w/ thumbs positioned posteriorly and opposed parallel to the ground. As the patient inspires watch the movement of your thumbs.
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How do the thumbs normally move during chest palpation?
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Normally the thumbs should move apart 4-6cm symmetrically w/ each side contributing an equal amount to the movement.
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What diseases cause decreased thoracic expansion?
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1. chronic obstructive lung dz (emphysema > chronic bronchitis)
2. restrictive lung dz (pulmonary fibrosis) 3. pneumothorax 4. major atelectasis 5. pts w/ chest wall or spinal deformities |
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How can thoracic expansion be quantified w/o using your thumbs?
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W/ a tape measure
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What does a chest wall expansion of less than one inch mean? what causes it?
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It is abnormal and is caused by emphysema or restrictive lung disease (pulmonary fibrosis).
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What is a normal chest wall measurement using a tape measure?
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3 inches
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What is a vocal tactile fremitus (VTF)?
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When a patient speaks and the buzzing thrill is felt on the surface of the chest wall.
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When is asymmetric VTF a normal finding? why?
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The VTF over the right upper lobe posteriorly is often greater in intensity than VTF over the left upper lobe posteriorly. B/c the trachea is closer to the apex of the right lung than to the apex of the left lung.
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When does decreased VTF develop?
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Whenever there is an obstruction in the pathway from the larynx to the chest wall surface.
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What happens to VTF when fluid or air accumulates b/e the lung and the chest wall?
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A decreased VTF
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What happens to VTF when fluid or air accumulates b/e the lung and the chest wall?
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It will decrease VTF
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What affect on VTF would an accumulation of adipose tissue (obsesity) have?
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It will decrease VTF
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What affect would a large airway obstruction have on VTF?
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It would lessen the intensity of VTF
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What dz'es can cause a decrease in VTF by obstructing a large airway?
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Tumor or an aspirated foreign body by lessening sound transmission.
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What affect does a small airway obstruction have on VTF?
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Decreases sound transmission and reduce the intensity of VTF
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What dz'es can cause small airway obstruction?
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1. mucus (acute bronchitis/asthma)
2. bacteria/inflammatory cells (bronchopneumonia) |
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What is the only consolidation that decreases VTF? why?
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Atelactasis; b/c there is obstruction of the airway, so even though there is increased water density in the alveoli b/c of the absorption of the air, the vocal vibrations cannot reach the water-filled alveoli so there is still decreased VTF.
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What effect does pulmonary hyperinflation (emphysema) have on VTF?
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Decreases VTF by increasing the air density and decreases the water density of lung tissue surrounding the tracheal bronchial tree.
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What causes increased intensity of VTF?
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Situations where the tracheobronchial tree is patent and the surrounding lung parenchyma is less air dense and more water dense than normal.
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What causes decreased intensity of VTF?
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Develops unilaterally when there is an obstruction in the pathway from the larynx to the chest wall surface.
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What affect does lung consolidation have on VTF?
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increases VTF intensity by replacing air-filled alveoli w/ alveoli that are filled w/ serum, pus or blood.
*basically causing the alveoli to be more water dense than normal which transmits sounds better. |
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What dz'es produce increased VTF by increasing consolidation?
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1. alveolar edema
2. alveolar pneumonia 3. alveolar hemorrhage 4. alveolar fibrosis |
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What does emphysema cause decreased VTF?
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B/c there is decreased water-density and increases the air density, so this causes the over-inflated lung to decreased VTF
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How do you palpate the trachea?
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W/ the pt sitting erect, the examiner places one index finger in the suprasternal notch to evaluate the position.
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Where is the trachea normally?
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lies either in the midline or w/in 4mm to the right of the midline.
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What affect does major atelectasis have on the trachea?
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Decreases volume a lot and pulls the mediastinum and trachea toward the side of atelectasis.
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What affect does a large pneumothorax have on the trachea?
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The lung collapses and the surrounding chest wall expands and pushes the trachea away from the side of the pneumothorax by the large volume of air in the pleural space.
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What affect does a large pleural effusion have on the trachea?
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Increases the volume of the thoracic cage on the side of the effusion and pushes the trachea away from the side of effusion.
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What affect does a lung tumor have on the trachea?
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Occasionally a tumor may surround and entangle a bronchus in such a way that it pulls the trachea toward the side from which it is being pulled.
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What kind of sound does water dense tissue produce during percussion?
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Produces a high-pitched note of low intensity.
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What kind of sound does air-dense tissue produce during percussion?
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Produces a low-pitched note of high intensity.
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What is tympany?
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The lowest pitched and loudest of the percussion notes. Represents the highest air/fluid ratio.
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Where is the tympany sound present?
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1. in patients who have not eaten for several hours.
2. Large pneumothorax. |
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What is hyperresonance?
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A low-pitched note of moderate intensity that represents a high air/fluid ratio.
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Where is hyperresonance present in a normal pt?
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Over both lungs at the end of a full, held inspiration.
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Where is hyperresonance present bilaterally in a dz'ed pt?
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Pts who have severe emphysema
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Where is hyperresonance present unilaterally in a dz'ed pt?
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In pts who have a pneumothorax involving a single lobe/segment
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What is resonance? what pts have resonance
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A low-pitched note of moderate intensity that is present over normal lungs during quiet breathing.
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If a pt has resonance during percussing can you rule out lung dz?
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Nope
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What is dullness? where is it present?
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A high-pitched note of low intensity that is normally produced over a solid organ (liver) that has a low air/fluid ratio.
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What does localized dullness of the chest indicate?
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Present over areas of consolidated lung and overlying mild-to-moderate sized pleural effusions where the underlying lung is aerated.
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In a pt w/ a fever and cough what does unilateral chest dullness indicate?
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Pneumonia
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What does generalized dullness over the chest indicate?
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Widespread pulmonary fibrosis.
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What is flatness? where is it localized normally?
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The highest-pitch and softest intensity percussion note. produced in tissues w/ lowest air/fluid ratio such as the muscles in the thigh.
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Where is unilateral flatness present?
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Overlying a large pleural effusion.
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Why does a large pleural effusion cause flatness to percussion?
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B/c it maximally decreases the air/fluid ratio by compressing the underlying lung parenchyma to cause loss of aeration and atelectasis.
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What is the diaphragmatic excursion?
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Evaluated w/ percussion and is the vertical distance of diaphragm movement b/e full inspiration and full expiration.
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What is the normal diaphragmatic excursion?
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3-6cm
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When does the diaphragmatic excursion decrease?
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In chronic lung dz caused by decreased expiratory airflow (emphysema) or caused by decreased inspiratory airflow (pulmonary fibrosis)
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What effect does emphysema have on diaphragmatic excursion? pulmonary fibrosis?
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Both decrease diaphragmatic excursion symmetrically to 2-3cm.
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How far into the chest wall does percussion penetrate?
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4-6cm
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What is the difference b/e the percussion of the diaphragm b/e right and left?
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The right hemi-diaphragm normally percusses 1-2 cm higher than the left hemi-diaphragm. But they should each move about the same distance.
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When does the left hemi-diaphragm percuss higher than the right hemi-diaphragm?
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When there is paralysis of the left hemi-diaphragm.
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What can give the impression that the left hemi-diaphragm is higher than the right?
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The presence of left lower lobe consolidation or a left-side pleural effusion.
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What will a massively enlarged spleen give the impression of on percussion? pleural effusion?
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It will give the impression that the left hemi-diaphragm is markedly elevated, same may be true of a large pericardial effusion.
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What is Ewart's sign?
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Percussion dullness at the lower tip of the left scapula caused by a large pericardial effusion.
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What causes Ewart's sign? why?
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Pericardial effusion. B/c the effusion compresses the adjacent lung tissue and causes dullness to percussion that may obscure the location of the left hemi-diaphragm by percussion.
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What affect would chronic aortic regurgitation have on percussion?
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Dullness to percussion at the tip of the scapula that obscures diaphragmatic dullness when there is marked elevation of the LV.
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When the right hemi-diaphragm percusses more than a few centimeters higher than the left hemi-diaphragm what's the dx?
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1. Right diaphragmatic paralysis
2. right-sided lower lung lobe consolidation 3. right-sided pleural effusion 4. massive hepatomegaly. |
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Where is percussion dullness common over?
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Common over areas of consolidation from pneumonia or atelectasis.
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When can percussion detect lung tumors?
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When they are larger than 3cm in diameter and are less than 5-6 cm deep.
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Where is Kronig's Isthmus?
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Passes over the shoulders b/e the neck and shoulder much like the straps of a tank top.
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What is the normal percussion of Kronig's isthmus?
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Normally hyperresonant to percussion
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What does dullness to percussion over Kronig's isthmus mean?
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Consolidation or pleural thickening which frequently is a result of tuberculosis.
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What part of the stethoscope is used for a auscultation of the lung sounds?
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The diaphragm b/c lung sounds tend to be of high and medium pitched frequencies.
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When is the bell of the stethoscope used when auscultating lung sounds?
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When listening over hollowed out areas such as the supraclavicular fossae.
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What is the proper technique for auscultating the lung sounds?
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Apply firm pressure w/ the diaphragm during auscultation and NEVER listen through/over clothing.
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What part of the lungs can you hear anteriorly?
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The upper lobes and the right middle lobes
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What lung sounds can you hear laterally?
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All lobes can be auscultated laterally, but ESPECIALLY the right middle lobe.
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What lung sounds can you hear posteriorly?
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The lower lobes dominate the posterior surface of the chest wall and the upper lobes are heard above the level of the mid scapula at about the third thoracic vertebra.
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Where is the right upper lobe region on the anterior chest wall?
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From the fourth rib inferiorly to the apex
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Where is the right middle lobe on the anterior surface of the chest wall?
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Inferior to the fourth rib in the midclavicular line to the sixth rib in the midclavicular line and forming a triangle to the fifth rib in the midaxillary line.
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Where are lobes of the lung posteriorly on the chest?
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Inferior lobe from T10 to T3
Superior lobe above T3 |
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Where is the oblique fissure on the chest wall? horizontal fissure?
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Oblique: From the spinous process of T3 down to the sixth rib in the midclavicular line
Horizontal: From the fifth rib in midaxillary line to the fourth rib. |
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Where are vesicular breath sounds heard normally?
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Over most of the chest except near the large airways.
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What is the description of vesicular breath sounds?
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They have an inspiratory component that is louder and longer than the expiratory component.
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Why does the inspiratory component of vesicular breath sounds seem louder and longer than the expiratory phase?
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B/c when auscultating over the periphery of the lung which is physically closer to the smaller airways the inspiratory component seems louder and longer than the expiratory component which is generated in the more central larger airways.
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When do vesicular breath sounds become most important?
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When they are absent over the periphery of the lung.
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What do breath sounds heard over a specific lobe indicate?
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Air entering that lobe.
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What is the difference b/e vesicular breath sounds in adults and children?
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The sounds have the same characteristics but the sounds are even higher pitched and louder in children. Pitch and intensity of vesicular sounds decreases w/ age until vesicular breath sounds become inaudible in the elderly.
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What are bronchovesicular breath sounds?
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Transitional sounds that have inspiratory and expiratory components of equal duration.
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Where are bronchovesicular breath sounds heard?
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Normally heard over the large airways on either side of the sternum and in between the scapula.
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Why are the duration and intensity of the expiratory phase enhanced compared to vesicular sounds?
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B/c the stethoscope is located nearer the source of the expiratory sounds which are produced in the central large airways.
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What are the bronchial breath sounds?
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Sounds that have a shorter and softer inspiratory component and a longer and louder expiratory component.
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Where are bronchial breath sounds heard?
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Directly over the intrathoracic trachea (only in the front)
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Why is the expiratory phase longer and louder in the bronchial region compared to the bronchovesicular region?
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B/c the stethoscope is located adjacent to the origin of the expiratory sounds and is far removed from the origin of the inspiratory sounds.
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What breath sound has a characteristic gap b/e the inspiratory and expiratory components?
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The bronchial breath sounds
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When are bronchial and bronchovesicular breath sounds abnormal?
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When they are heard over the periphery of the lung.
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What causes bronchovesicular and/or bronchial breath sounds to be audible distal to their origin?
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When there is increased transmission of expiratory sounds form their place of origin to the lung periphery
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When do bronchovesicular and bronchial breath sounds develop in the periphery?
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Whenever there is a decrease in the air/water ratio of the pulmonary parenchyma. So increased water density enhances transmission of the expiratory sounds from their place of origin in the central airways to the alveoli in the lung periphery.
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What dz'es cause bronchial and/or bronchiovesicular breath sounds to be heard over the lung periphery?
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1. alveolar pneumonia
2. microatelectasis 3. pulmonary edema 4. pulmonary fibrosis 5. parenchymal infiltration w/ tumor 6. extrinsic compression of the lung by lymph nodes 7. aortic aneurysm 8. enlarged heart |
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What breath sounds occur over a large pleural effusion? why?
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Bronchial breath sounds due to compression of the underlying alveoli by the effusion.
ALSO the very bottom of the effusion is characterized by silence, b/c the weight of the fluid above compresses the airways at the bottom and leads to lack of breath sounds. |
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What do the intensity/loudness of breath sounds correlate to?
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The amount of ventilation that occurs in the underlying lung segment.
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What is decreased breath sound intensity over the chest characteristic of?
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Dz'es that decrease air flow:
1. COPD 2. restrictive lung dz 3. pneumonia 4. atelectasis Dz'es that separate the stethoscope from the underlying parenchyma: 1. pleural effusion 2. pleural thickening 3. pneumothorax 4. hemothorax 5. obesity |
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Where can breath sounds in the large airways be heard w/o a stethscope?
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At the mouth!
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What does the intensity of the breath sounds heard at the mouth correlate directly to? why?
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The amount of spirometric airway obstruction that is present. b/c turbulent flow increases as obstruction increases.
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What do breath sounds in a normal person sound like at the mouth during quiet respiration?
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Normally too small to create audible mouth breathing w/ the unaided ear during quiet exhalation.
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What do breath sounds at the mouth sound like in pts w/ mild-moderate airflow obstruction? (asthma-chronic bronchitis)
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NOT EMPHYSEMA
the intensity of the breath sounds at the mouth during forced exhalation increase as the degree of airflow obstruction increases. |
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What do breath sounds at the mouth sound like in pts w/ severe airflow obstruction? (emphysema)
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The breath sounds heard at the mouth w/ the unaided ear will be extremely loud during forced exhalation and may be loud enough that they are audible during quiet breathing.
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What are adventitious lung sounds?
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Lung sounds that are normally absent in the respiratory cycle but become superimposed on the normal breath sounds when dz is present.
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What is the most important discontinuous adventitious breath sound?
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Crackles
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What is the most important continuous adventitious breath sound?
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Wheezes
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What are crackles/rales?
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Short discontinuous non-musical sounds that are the most common abnormal pulmonary breath sounds.
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What causes crackles/rales?
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1. The opening of small airways due to sudden equalization of pressures b/e the small airways and the alveoli.
2. The breaking of small bubbles or mucus films located in the medium to large conducting airways. |
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At what point of the breathing phase are crackles more likely to occur?
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During expiration the airways are smaller in caliber and are more likely to form an obstruction. During inspiration when the airway increases it pulls apart the obstruction and causes an explosive equalization of pressure or the crackle.
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What is the relationship b/e pitch of a crackle and the dz?
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The higher the pitch the more peripheral the dz process is located that produced the crackle.
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Where do fine crackles develop?
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When small airways or alveoli that close during expiration suddenly pop back open during inspiration.
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What dz'es produce fine crackles?
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1. alveolar pneumonia
2. alveolar hemorrhage 3. alveolar edema |
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Where do medium-sized crackles develop? what do they sound like? What dz causes them?
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"Velcro crackles" are characteristic of pulmonary fibrosis in and around small bronchioles and alveolar ducts.
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Where do coarse crackles develop?
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When air flows through large airways that are coated in secretions, turbulent airflow causes small bubbles in the secretions to break, generating coarse crackles.
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What dz'es cause coarse crackles?
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Acute and chronic bronchitis
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When do crackles typically occur?
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During inspiration
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When do expiratory crackles develop?
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When the dz is severe
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Where do early-mid inspiratory crackles occur?
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Early during inspiration and end by mid-inspiration.
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Where do early-mid inspiratory crackles originate? what produces them?
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In large-medium sized airways and are produced by the bubbling of air through thin secretions.
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What dz'es can you diagnose w/ early-mid inspiratory crackles?
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Chronic airway obstruction from asthma, chronic bronchitis, bronchiectasis or emphysema
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What are late inspiratory crackles?
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Crackles that are only heard during the latter half of inspiration.
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Where do late inspiratory crackles occur? what produces them?
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originate w/in small bronchioles and alveolar ducts and are produced when the airways, that are compressed by interstitial edema, pop open during late inspiration.
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What dz'es cause late inspiratory crackles?
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1. interstitial edema (heart failure or pneumonia)
2. interstitial scarring (pulmonary fibrosis) |
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What are posturally induced crackles?
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Crackles that develop only when the pt assumes a supine position.
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How do you check for posturally induced crackles?
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1. Pt sits up for 3 min.
2. You listen over the lowest posterior ribs during late inspiration for a total of 5 deep breaths 3. pt lies flat for 3 min. 4. you listen again using same technique 5. you passively elevate pts legs to 30 deg. for 3 min. 6. you listen again using same technique |
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How do you distinguish CHF crackles from alveolar pneumonia crackles?
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pulmonary edema crackles: neck vein elevation and cardiac exam abnormalities w/ leg edema. Fever w/ bilateral crackles.
CHF crackles: No fever but bilateral crackles |
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How do you score posturally induced crackles (PIC)?
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* if late inspiratory crackles are neg in all positions than the score = zero
*if late inspiratory crackles are audible only in the supine position or after leg elevation than the score = one *if late inspiratory crackles are present in all positions than the score = 2 |
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What is the PIC score used for?
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A valuable prognostic indicator for predicting recovery following myocardial infarction. (MI)
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What do PICs in a MI pt indicate?
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Indicate the presence of an elevated pulmonary capillary wedge pressure and a worse prognosis than in pts w/o PICs.
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What causes pulmonary edema crackles and CHF crackles?
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The high LVEDP backs up the system and causes increased hydrostatic pressure in the lung capillaries which causes fluid to accumulate
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How do you tell pneumonia crackles from CHF/pulmonary edema crackles?
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Usually pneumonia crackles are unilateral and have fever/cough/other symptoms along w/ it.
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What do crackles that clear after three-four coughs or after deep breathing mean?
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Means that the crackles are of little importance, but suggest minor degrees of atelectasis and small amounts of mucus.
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What do crackles that develop after coughing in the upper lobes indicate?
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The presence of apical tuberculosis.
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What are post-tussive crackles?
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Crackles that develop in the upper lobes after coughing. Indicate apical tuberculosis.
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What are wheezes?
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Continuous, musical, adventitious sounds that are caused by vibrations of the opposing walls of narrowed airways.
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What does wheezing indicate?
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Airway obstruction.
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IF a patient has clear signs of respiratory distress (accessory muscle use, cyanotic, etc) but you do not hear any wheezing, can you rule out airflow obstruction?
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nope, b/c the final stages of airway obstruction is the absence of all wheezing b/c the obstruction is blocking the airways.
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What do the pitch and duration of wheezing indicate?
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They are important clues to the degree of airflow obstruction. The more severe the obstruction, the higher in pitch and the longer in duration are the wheezes.
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What are polyphonic wheezes? what causes them?
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Contains several notes that start and stop at the same time (like a musical chord) they are caused by narrowing of multiple airways at the same time.
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What dz'ez cause polyphonic wheezing?
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1. asthma (mucous plugging)
2. bronchospasm 3. airway edema |
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What are monophonic wheezes?
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Consist of a single note or multiple notes that start and stop at different times.
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What dz'es cause monophonic wheezing?
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indicates airway obstruction by an intrabronchial tumor or foreign body.
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When does wheezing occur during breathing?
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B/c airway caliber is narrower during exhalation, wheezing occurs during exhalation or exhalation and inhalation.
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What does inspiratory wheezing indicate?
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Severe obstruction.
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Where is the wheezing caused by asthma located?
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Located diffusely and involves both lungs.
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What does wheezing of one lung or lung segment indicate?
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focal airway obstruction (foreign body aspiration)
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What does wheezing occuring during maximal forced exhalation indicate?
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does not indicate anything
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What is Stridor? what does it indicate?
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A loud, long high-pitched musical inspiratory sound that indicates the presence of upper airway obstruction.
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Where is stridor loudest?
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Louder over the neck than the chest.
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Where does inspiratory stridor occur?
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In tracheal, epiglottic or laryngeal obstruction.
*inspiratory stridor is considered a medical emergency. |
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What does isolated expiratory stridor indicate?
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Obstruction in a bronchus secondary to a aspirated foreign body.
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What is a pericardial friction rub?
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A continuous adventitious sound produced when the surfaces of the visceral and parietal pleura rub together during breathing.
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When does pericardial friction rub predominantly occur? what does it sound like?
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During expiration and sounds like a grating or leathery quality sound.
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What does a pericardial friction rub diagnose?
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Pleural inflammation (pleuritis)
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What does d'Espine's sign indicate?
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A mediastinal mass is present in the posterior mediastinum that lies b/e and adjacent to both the tracheobronchial tree and the vertebral body.
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How do you elicit d'Espine's sign?
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By comparing the intensity of breath sounds heard in the midline directly over the 4th thoracic vertebra w/ the intensity of breath sounds heard just to the left/right of the fourth vertebra
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What is a normal d'Espine's sign?
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Normally, vesicular breath sounds are heard on either side of the fourth vertebral body and vesicular sounds of decreased intensity are heard in the midline over the vertebral body.
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What is a abnormal d'Espine's sign?
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When breath sounds over T4 are bronchial in nature and louder than on either side of T4.
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What is the most common cause of d'Espine's sign?
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Lymph node enlargement caused by lymphomas, sarcoid, metastatic cancer and TB
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What is the normal transmission frequency of vocal sounds?
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Normally lowish frequency sounds (100-200Hz) are heard throughout the lung parenchyma while higher frequency sounds (>300Hz) are filtered out. SO normally the spoken voice is heard in an indistinct, low-pitched mumble.
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What affect does lung consolidation have on vocal sounds?
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Increases the transmission of high and low frequency sounds to the degree that they can be heard through the stethoscope.
Low frequency sounds are increased to the point that they are palpable as increased VTF |
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How do large pleural effusions (not small ones) affect vocal sounds?
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They reduce the transmission of frequencies below 200-300 Hz but increase transmission of frequencies higher than 400 Hz.
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Where are the vocal sounds caused by large pleural effusions heard?
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Voice sounds are audile over the middle of large pleural effusions. BUT b/c the transmission of low frequencies is reduced, the low frequency sounds are not palpable = decreased VTF
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What effect does pulmonary hyperinflation have on voice sounds?
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Diminishes voice sounds.
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What is bronchophony?
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An increase in the transmission and clarity of the spoken voice as heard through the stethoscope applied to the chest wall.
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What is whispered pectoriloquy?
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An increase in the transmission and clarity of high-pitched whispered sounds as heard through the stethoscope applied to the chest wall.
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What is egophony? (goat sound)
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When the spoken word heard through the stethoscope has an intensified nasal or bleating quality. ("e" is changed to "a")
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What do egophany, whispered pectoriloquy and bronchophony indicate?
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pulmonary consolidation.
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What does the presence of egophony in pts w/ cough and fever indicate?
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pneumonia
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When should you evaluate voice sounds?
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If pulmonary pathophysiology is suspected.
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What's the dx?
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Emphysema
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What's the dx?
|
Pulmonary Fibrosis
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What's the dx?
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Consolidation
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What's the dx?
|
Atelectasis
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What's the dx?
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Pleural Effusion
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What's the dx?
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Pleural Effusion
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What dz typically causes stridor?
|
*the barking seal cough*
Croop |
