What is the chest/thorax a cage of? Consist of anteriorly, laterally & posteriorly?
Cage of bone, cartilage, & muscle capable of movement as the lungs expand; Anteriorly of Sternum, Manubrium, Xiphoid process & costal cartilages; Laterally of 12 pairs of ribs; Posteriorly of 12 thoracic vertebrae
Primary muscles of respiration? Which one is dominant?
Diaphragm (dominant) & Intercostal Muscles
Fxn of Diaphragm
Contracts & moves downwards during inspiration, lowering abdominal contents to increase intrathoracic space
Fxn of External Intercostal Muscles
INCREASE AP chest diameter during INSPIRATION
Fxn of Internal Intercostal Muscles
DECREASE AP chest diameter during EXPIRATION
Accessory muscles of respiration?
SCM & Trapezius; only brought into play when there are pulmonary problems & compromise
3 major spaces of Interior of chest?
Right & Left Pleural Cavities & Mediastinum
Contents of Mediastinum
All the thoracic viscera except for the lungs (since its located b/t lungs)
What are pleural cavities lined with?
Parietal & Visceral Pleura, serous membranes that enclose the lungs
Lobes of Left Lung
Upper & Lower Left Lobes
Lobes of Right Lung
Upper, Middle & Lower Right Lobes
Which lobe has a Lingula? What is it a counterpart of?
Left Upper Lobe; counterpart of Right Middle Lobe
Fxn of Oblique Fissure
Separates Upper & Lower Lobes of both Lungs
Fxn of Horizontal Fissure; Location
Separates Upper & Middle Lobes of RIGHT lung; 4th Rib Anteriorly & 5th rib of Axilla
Contents of each lobe
Blood Vessels, Lymphatics, Nerves, An Alveolar Duct connecting w/ the Alveoli (as many as 300 million in an adult)
Elastic tissue that shapes entire lung parenchyma & limits its expansion
Apex extends anteriorly where?
4 cm above the 1st rib into the base of the neck in adults
Apex extends posteriorly where?
rise up to T1
Lower borders of Lungs descend to what level during Deep inspiration? Forced Expiration?
Fxn of Tracheobronchial Tree
Tubular system that provides a pathway which AIR is FILTERED, HUMIDIFIED & WARMED as it moves from upper airway to the farthest alveoli
What is Anterior to the Tracheobronchial Tree? Posterior?
Anterior to Esophagus; Posterior to Isthmus of Thyroid Gland
Where does the trachea divide/bifurcate into Right & Left Main Bronchi
T4-T5 & just below the Manubriosternal Joint
Which bronchus is more susceptible to aspiration of foreign bodies and why?
RIGHT Main Bronchus because it is WIDER, SHORTER, & more VERTICALLY placed than the left bronchus
How many branches do each bronchi divide into?
1 for each lobe: 3 on the right & 2 on the left
Pathway of air flow from Bronchi onwards
Bronchus -> Branches of Bronchus -> Terminal Bronchioles -> Respiratory Bronchioles composed of 1 Acinus -> Respiratory Bronchioles, Alveolar Ducts, Alveolar Sacs, & Alveoli
Fxn of Bronchi
Transport air & to some extent, trap noxious foreign particles in the mucus of their cavities & sweep them toward the pharynx
What is Ventilation?
Movement of air back and forth from the deepest reaches of the alveoli to the outside
What is Diffusion & Perfusion?
Gas exchange cross the Alveolar-Pulmonary Capillary Membranes
What do chemoreceptors in the Medulla Oblongata do?
Very sensitive & respond quickly to changes in HYDROGEN ION concentrion in the blood and spinal fluid
Where are chemoreceptors responsible for peripheral circulation located? Respond to what changes?
CAROTID BODY at the bifurcation of the Common Carotid Arteries; respond to changes in arterial OXYGEN & CO2 levels
What do both types of chemoreceptors do?
Respond by sending signals to the respiratory center in the medulla oblongata. Nerve impulses from here are transmitted to 2 subcenters in the pons, which regulate the respiratory muscles
What do excess levels of carbon dioxide stimulate?
Rate & Depth of Respiration
What are Topographic Markers on the Chest?
Nipples, Manubriosternal Junction (angle of Louis), Suprasternal Notch, Costal Angle, Vertebra Prominens & the Clavicles
What is fetal gas exchange mediated by?
Placenta via Umbilical Cord; Alveoli are collapsed and lungs contain no air
Why are many infants pneumonically challenged?
The lung is not fully grown at birth; # of alveoli increase at a very rapid rate the 1st 2 years of life; This slows down by the age of 8 yrs
Describe the chest of the newborn? AP : Transverse diameter? Circumference of Chest
Chest of newborn is round with a circumference roughly equal to that of the head until the child is about 2 yrs old; AP diameter is about the same as Transverse diameter
What Anatomical changes occur with the chest & lungs of pregnant women?
Lower ribs flare out & Transverse Diameter INCREASES by 2cm -> Subcostal angle progressively increases from 68.5 degrees to 103.5 degrees; Circumference INCREASES by 5-7cm; Diaphragm rises as much as 4cm; Diaphragmatic movement increases so that most work is done by diaphragm; Minute ventilation increases 30-50% w/ a corresponding 50-70% increase in Alveolar Ventilation; Increased tidal volume due to minute ventilation; Respiratory Rate remains the same
Describe the Chest & lungs of Older Adults
BARREL CHEST (due to loss of muscle strength in thorax & diaphragm and loss of lung resiliency); INCREASED AP DIAMETER due to kyphosis; STIFFENING/DECREASED EXPANSION of chest wall; LESS ELASTIC & MORE FIBROUS ALVEOLI; UNDERVENTILATION of ALVEOLI in LOWER LUNGS; DECREASED TIDAL VOLUME; INCREASED Residual Volume; DYSPNEA usually; DRIER MUCOUS MEMBRANES encouraging bacterial growth & respiratory infxns
When does chest pain NOT originate from the heart generally?
When there is a CONSTANT ACHINESS that lasts ALL DAY; it STAYS in ONE POSITION; it is made WORSE by PRESSING on the PRECORDIUM; it is a FLEETING, NEEDLE-LIKE JAB that lasts ONLY A SECOND or TWO; it is SITUATED in the SHOULDERS or b/t the SHOULDER BLADES in the back
How do you calculate pack years?
Pack Years = # of yrs smoking x # of packs smoked per day
What chest symptoms are caused by Cocaine use?
ACUTE CHEST PAIN; PNEUMOTHORAX; TACHYCARDIA; HTN; CORONARY ARTERIAL SPASM (W/ INFARCTION)
What are the Risk Factors for Respiratory Disability?
Men; Age; Family history of Asthma, Cystic Fibrosis, TB, Neurofibromatosis, Smoking, Sedentary Lifestyle, Occupational exposure to Asbestos, Dust, or other Irritants/Toxic Inhalants, Extreme Obesity, Difficulty Swallowing for any reason, Weakened Chest Muscles, History of Frequent Respiratory Infections
What is the sequence of steps in examining the chest & lungs?
Inspection, Palpation, Percussion, & Auscultation
What are the 7 Various Thoracic Landmark Lines?
1) Midsternal Line; 2) Right/Left (R/L) Midclavicular Lines; 3) R/L Anterior Axillary Lines; 4) R/L Midaxillary Lines; 5) R/L Posterior Axillary Lines; 6) Vertebral Line; 7) R/L Scapular Lines
Features of Barrel Chest
Results from Compromised Respiration (Chronic Asthma, Emphysema, Cystic Fibrosis); HORIZONTAL Ribs, KYPHOTIC Spine, PROMINENT Sternal Angle, POSTERIORLY Displaced Trachea; THORACIC RATIO approaches 1.0 or more (AP equals transverse diameter)
What are 2 common STRUCTURAL problems of the Chest?
1) Pigeon Chest (Pectus Carinatum) - prominent sternal protrusion; 2) Funnel Chest (Pectus Excavatum) - indentation of Lower Sternum Above Xiphoid process
What is a normal Thoracic Ratio?
AP Diameter is 0.70-0.75 that of Transverse Diameter
Intrathoracic Infxn may make the breath smell like?
Normal Respiration Rate? Ratio of RR to HR?
12-20rpm; 1:4 RR to HR ratio
What is Dyspnea?
Difficult & Labored Breathing w/ SOB
Dyspnea of Rapid Onset: 10 Ps
Pneumonia, Pneumothorax, Pulmonary Constriction/Asthma, Peanut (Foreign Body), Pulmonary Embolus, Pericardial Tamponade, Pump/Heart Failure, Peak Seekers (High Altitudes), Psychogenic, Poisons
Orthopnea? What helps?
SOB that begins or Increases when Px lies Down (sleeping on more than 1 pillow is helpful)
Paroxysmal Nocturnal Dyspnea? What helps?
Sudden Onset of SOB after a period of sleep (sitting upright is helpful)
Dyspnea increases in the Upright Posture
Bradypnea? May indicate what?
Slower than 12 breaths per minute; neurologic/electrolyte disturbance, infxn, or a sensible response to protect against pain of pleurisy/irritation or someone that is cardiovascularly fit
Faster than 20 breaths per minute; Persistent RR approaching 25 rpms
Faster than 20 breaths per minute with DEEP breathing; aka HYPERVENTILATION; symptom of protective splinting from pain of a broken rib or pleurisy, or massive liver enlargement/abdominal ascites preventing diaphragm from descending
Frequently interspersed deeper breath; significant only if they exceed the infrequent sighs of daily life
Increasing Difficulty in getting breath out; result of a prolonged but inefficient expiratory effort; rate of respiration increases in order to compensate causing the effort to be more shallow, amt of trapped air increases & lungs inflate; usually due to OBSTRUCTION of pulmonary tree for any reason
Varying periods of Increasing Depth interspersed w/ Apnea; aka PERIODIC BREATHING; Regular periodic pattern of breathing, w/ intervals of apnea followed by a CRESCENDO/DECRESCENDO sequence of respiration; usually due to SERIOUSLY ILL Px, those w/ CEREBRAL BRAIN DAMAGE or w/ DRUG-CAUSED Respiratory Compromise
Rapid, Deep, Labored; due to METABOLIC ACIDOSIS
Irregularly interspersed periods of apnea in a disorganized sequence of breaths; lacks the repetitive pattern of periodic respiration; due to severe/persistent INTRACRANIAL PRESSURE, DRUG POISONING, MEDULLA BRAIN DAMAGE
more severe form of Biot respiration; Significant disorganization w/ irregular & varying depths of respiration
6 Influences that will INCREASE Rate & Depth of Breathing
1) Metabolic Acidosis 2) Pons CNS Lesions 3) Anxiety 4) Aspirin Poisoning 5) Oxygen Need (Hypoxemia) 6) Pain
5 Influences that will DECREASE Rate & Depth of Breathing
1) Metabolic Alkalosis 2) Cerebrum CNS Lesions 3) Myasthenia Gravis 4) Narcotic Overdoses 5) Extreme Obesity
5 Common contributors to Apnea
Seizures, CNS Trauma/Hypoperfusion, Resp Infxns, Drug Ingestions, Obstructive Sleep Disorders
Universal expectation of the Absence of Breathing when one is Swallowing
Self-limited apnea, common after blow to the head or immediately after birth (spontaneously breathe when enough CO2 accumulates in circulation)
Involuntary, Temporary halt to breathing when Irritating & Nausea-provoking vapors/gases are inhaled
Grave condition where breathing stops and it will not begin spontaneously until resuscitative measures are used; due to any event that severely limits the absorption of oxygen into the bloodstream
Periods of an absence of breathing effort during sleep; very disturbing; resp muscles dont fxn & airflow is not maintained thru nose & mouth
Apnea that affects only part of the breathing cycle
Type of breathing that involves Long Inspiration & what amounts to Expiration Apnea; due to DAMAGE to PONS (control center for breathing)
Apnea of Prematurity
more intense version of Periodic Apnea of the Newborn where irregular pattern of rapid breathing is interspersed w/ brief periods of apnea that is usually associated with REM sleep
Thoracic (Costal) Respiration
done by Intercostal Muscles; most common type of respiration for most ages unless intercostal muscles are compromise; Women are more likely to use this, esp PREGNANT Women
done by movement of Diaphragm responding to Intrathoracic pressure; MEN are more likely to use this
done by contraction of Diaphragm & interplay of abdominal muscles, resulting in the expansion/recoil of abdominal walls; NEWBORN Infants are more likely to use this
Unilateral or Bilateral bulging of the chest can be caused by what?
Reaction of the Ribs & Interspaces to Respiratory Obstruction
Prolonged expiration & bulging on expiration are caused by? What happens to Costal Angle?
Outflow Obstruction or the Valvelike Action of Compression by a Tumor, Aneurysm, or Enlarged Heart; Costal Angle widens beyond 90 degrees
What do retractions suggest?
Obstruction to INSPIRATION at any point in respiratory tract; intrapleural pressure becomes increasingly negative, the musculature "pulls back" in an effort to overcome blockage.
When the obstruction is high in the resp tree, what retracts? characterized by what?
Chest wall caves in at Sternum, b/t Ribs, at Suprasternal Notch, above Clavicles, and at Lowest Costal Margins; Characterized by STRIDOR
When does Paradoxic Breathing occur?
When a NEGATIVE Intrathoracic pressure is transmitted to the Abdomen by a weakened, poorly functioning diaphragm; obstructive air-way disease; or during sleep; on INSPIRATION, LOWER Thorax caves in; on EXPIRATION, UPPER Thorax caves in
Retraction of the Lower Chest occurs with what 2 resp problems?
Asthma & Bronchiolitis
What causes Unilateral Retraction?
Foreign Body (most likely in right bronchus)
What is Lip Pursing associated with?
Increased Expiratory Effort
What is Clubbing associated with?
Chronic Fibrotic Changes w/in the Lung, Chronic Cyanosis of Congenital Heart Disease, or Cystic Fibrosis; (Asthma & Emphysema are NOT related to clubbing)
What is Flaring of the Alae Nasi during INSPIRATION associated with?
What features present when the upper airway is obstructed but not severely?
INSPIRATORY Stridor (w/ a ratio of more than 2 : 1 w/ Expiration); A HOARSE Cough/Cry; Flaring of Alae Nasi, Retraction at Suprasternal Notch
What features present when the upper airway is SEVERELY obstructed?
INSPIRATORY & EXPIRATORY Stridor, BARKING Cough, Retractions also involve Subcostal/Intercostal spaces; CYANOSIS is obvious even w/ blow-by oxygen
What features present when the obstruction is ABOVE the Glottis?
QUIETER Stridor, MUFFLED VOICE ("hot potato" in mouth feeling), DIFFICULT Swallowing, Head & Neck positioned awkwardly; NO Coughing
What features present when the obstruction BELOW the Glottis?
LOUDER RASPING Stridor, HOARSE VOICE, HARSH/BARKING Cough; (Swallowing & position of head/neck NOT affected)
CRACKLY or CRINKLY Sensation, can be both PALPATED & HEARD, a GENTLE, BUBBLY FEELING; indicates AIR IN SUBCUTANEOUS TISSUE or by INFXN by GAS-PRODUCING ORGANISM; localized or cover a wide area of the THORAX, anteriorly and toward the Axilla; always requires Attention!
PALPABLE, COARSE, GRATING VIBRATION, usually on INSPIRATION; Inflammation of the PLEURAL SURFACES; feels like LEATHER rubbing on LEATHER, heard LOUDEST over Lower Lateral Anterior Surface
Pleural Friction Rub
A Barrel-Chested patient with Chronic Obstructive Pulmonary Disease (COPD) can NOT demonstrate what?
Doctor's thumbs on T10 spinous processes do not diverge normally as they should when Px breathes in and out; thumbs might actually get closer together
PALPABLE VIBRATION of the CHEST WALL that results from SPEECH or other VERBALIZATIONS; best felt Parasternally at the 2nd ICS at the level of the BIFURCATION of the BRONCHI; Great Variability depending on the INTENSITY & PITCH of the VOICE & the STRUCTURE & THICKNESS of the CHEST WALL; SCAPULA OBSCURES FREMITUS
Indications of Decreased or Absent Fremitus
caused by EXCESS AIR in LUNGS or may indicate EMPHYSEMA, PLEURAL THICKENING/EFFUSION, Massive PE, or Bronchial Obstruction
Features of Increased Fremitus
COARSER or ROUGHER in FEEL, occurs in the PRESENCE of FLUIDS or a SOLID MASS w/in the LUNGS & may be caused by LUNG CONSOLIDATION, HEAVY but NONOBSTRUCTIVE BRONCHIAL SECRETIONS, COMPRESSED LUNG, or TUMOR
Features of Gentle, More Tremulous Fremitus
occurs w/ some LUNG CONSOLIDATIONS & some INFLAMMATORY & INFECTIOUS PROCESSES
Causes of Trachea being DISPLACED
Atelectasis, Thyroid Enlargement, Significant Parenchymal &/or PLEURAL Fibrosis, or Pleural Effusion
Causes of Trachea being Pushed to One Side
Tension Pneumothorax, Tumor, Nodal Enlargements on Contralateral Side
Cause of Trachea being Pulled to One Side
pulled by a TUMOR on the SIDE to which it DEVIATES
Cause of Trachea being pushed Posteriorly
Anterior Mediastinal Tumors
Cause of Trachea being pushed Forward/Anteriorly
A palpable pull out of midline with respiration is what?
What are the necessary steps when percussing a woman's breast?
Shift breast slightly w/ Pleximeter hand, and keeping it in place, strike the finger of that hand w/ the plexor of your free hand
Type of Tone: Loud Intensity, Low Pitch, Long Duration, Hollow Quality
Type of Tone: Soft Intensity, High Pitch, Short Duration, Very Dull Quality
Type of Tone: Medium Intensity, Medium to High Pitch, Medium Duration, Dull Thud Quality
Type of Tone: Loud Intensity, High Pitch, Medium Duration, Drumlike Quality
Type of Tone: Very Loud Intensity, Very Low Pitch, Longer Duration, Booming Quality
What length intervals should one percuss at over the ICSs?
What is the expected sound of the lungs and where can you hear it?
Resonance and it can be heard over all areas of the lungs
What does Hyperresonance with Hyperinflation indicate?
Emphysema, Pneumothorax, or Asthma
What does Dullness or Flatness suggest?
Atelectasis, Pleural Effusion, Pneumothorax, or Asthma
What is the sound usually associated with Percussion over the Abdomen?
What various lesions limit the Diaphragm's Descent?
Pulmonary (ex: Emphysema), Abdominal (ex: Massive Ascites, Tumor), or Superficial Pain (Fractured Rib)
When performing Diaphragmatic Excursion, what sound noise transition do you hear to make marks; what distance should this be?
From scapular Line to lower border, should be a change in note FROM Resonance TO Dullness, then from this point mark again going upwards when you hear Dullness change to Resonance; 3-5/6 cm
Smell of Breath: Sweet, Fruity
Diabetic Ketoacidosis; Starvation Ketosis
Smell of Breath: FIshy, Stale
Smell of Breath: Ammonia-Like
Smell of Breath: Musty Fish, Clover
Fetor Hepaticus: Hepatic Failure, Portal Vein Thrombosis, Portacaval Shunts
Smell of Breath: Foul, Feculent
Smell of Breath: Foul, Putrid
Nasal/Sinus Pathology: Infxn, Foreign Body, Cancer; Respiratory Infxns: Empyema, Lung Abscess, Bronchiectasis
Smell of Breath: Halitosis
Tonsillitis, Gingivitus, Respiratory Infxns, Vincent Angina, GERD
Smell of Breath: Cinnamon
Features of Normal Vesicular Sounds
Heard over MOST of LUNG FIELDS; LOW Pitch, SOFT & SHORT Expirations; more prominent in a THIN person or CHILD, diminished in the OVERWEIGHT or very Muscular Px
Features of Normal Bronchovesicular Sounds
Heard over MAIN BRONCHUS AREA & Over UPPER RIGHT POSTERIOR LUNG FIELD; MEDIUM Pitch; Expiration EQUALS Inspiration
Features of Normal Bronchial/Tracheal (Tubular) Sounds
Heard ONLY over TRACHEA; HIGH Pitch, LOUD & LONG Expirations, sometimes a bit longer than inspiration
Why is the diaphragm of the stethoscope preferred over the bell when listening to lungs?
transmits the HIGH-PITCHED Sounds BETTER & provides a BROADER AREA of SOUND
Where are the sounds of the Middle Lobe of the Right Lung & the Lingula of the Left best heard?
In their respective Axillae
Where should you begin Auscultation on a Px w/ CHF and why?
Begin auscultating at the Base of the Lungs to detect Crackles that may disappear w/ Continued Exaggerated Respiration
When are AMPHORIC Breath sounds heard?
Breathing that resembles the noise made by BLOWING across the mouth of a BOTTLE; most often heard w/ a LARGE, Relatively STIFF-WALLED PULMONARY CAVITY or a TENSION PNEUMOTHORAX w/ BRONCHOPLEURAL FISTULA
What type of breath sounds is commonly heard over a Pulmonary Cavity in which the wall is RIGID?
Breath sounds are generally hard to hear under what circumstances? Easy to hear?
If Fluid or Pus in Pleural Space, Secretions or Foreign Body Obstructing Bronchi, Hyperinflated Lungs, or if Breathing is Shallow from Splinting b/c of Pain; When lungs are consolidated
What promotes sound transmission better: Mass surrounding Tube of Respiratory Tree or Air-Filled Alveoli?
Mass surrounding Tube of Respiratory Tree
Type of Adventitious Breath Sound: Discontinuous High Pitched, Low Amplitude, Short Duration, END of INSPIRATION, aka SIBILANT; cause?
Fine Crackles; caused by Disruptive Passage of Air thru the Small airways in respiratory tree
Type of Adventitious Breath Sound: Discontinuous Low Pitched, High Amplitude, Long Duration, LOUD BUBBLY NOISE during INSPIRATION, aka SONOROUS; cause?
Coarse Crackles; caused by Disruptive Passage of Air thru the Small airways in respiratory tree
Type of Adventitious Breath Sound: Continuous Low Pitched, Deeper, more Rumbling, SNORE like, Inspiration but more pronounced during Expiration, more likely to be Prolonged & Continuous & less discrete than Crackles, CAN be cleared from COUGHING usually
Ronchus/Ronchi (Sonorous Wheezes); caused by passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure; arise from LARGER BRONCHI as in TRACHEOBRONCHITIS
Type of Adventitious Breath Sound: Continuous High Pitched, Musical Sound (whistle/squeak-like) heard during Inspiration or Expiration, louder during Expiration, the Longer the sound the Higher the Pitch, the Worse the Obstruction, can vary in pitches, w/ area & w/ time; caused by?
Wheeze (Sibilant Wheeze); caused by relatively high-velocity air flow thru a narrowed or obstructed airway
If a wheeze is heard bilaterally, it may be caused by what?
Bronchospasm of Asthma (Reactive Airway Disease) or Acute or Chronic Bronchitis
Unilateral or Sharply Localized Wheezing or Stridor may occur w/ what?
A Tumor compressing a part of the Bronchial Tree can create what?
A Consistent Wheeze or Whistle of Single Pitch at the Site of Compression
If infxn is the source of Wheezing, the organism is usually what?
VIRUS; Not bacterium
What kind of sound is heard outside the Respiratory Tree, has a Dry, Crackly, Grating, Low-Pitched Sound & is heard in both Expiration/Inspiration, may have a Machine-Like Quality, may have No significance if heard over the liver or spleen; caused by what?
Friction Rub; caused by Inflamed, Roughened Surfaces rubbing together
A Friction Rub sound heard over the Pericardium suggests what? over the Lungs? Which rub disappears when one holds their breath?
Pericarditis; Pleurisy; Respiratory Rub (pleurisy) disappears when breath is held, NOT Cardiac Rub (pericarditis)
What kind of sound is found w/ Mediastinal Emphysema? Involves Loud Crackles, Clicking & Gurgling Sounds that are Synchronous w/ Heartbeat w/ sounds more pronounced at the end of Expiration; easiest to hear when the patient leans to the LEFT or Lies done on the LEFT side
Mediastinal Crunch (Hamman Sign)
What kind of sound is heard when Air & Fluid are present at the same time in the pleural cavity or large cavities w/in the lungs and when SHAKING the Px from side to side w/ a little Vigor causing the Fluid to Splash?
What kind of Pulmonary Problems do Px w/ Sickle Cell Disease have?
Pulmonary Infarction, Pulmonary Crisis, "Chest Syndrome", Arching of the Back as the Px attempts to breathe more comfortably
What is the Clue to an Anterior Mediastinal Mass in a Px?
mass compresses the trachea & compromises breathing, making it Noisier & more Difficult; Instinctively, the Px may sit up and lean forward to relieve the Compression
Where are Vocal Sounds generally best heard in the Lungs?
Greater Clarity & Increased Loudness of Spoken Sounds are known as?
If Bronchophony is extreme, this test proves even a Whisper can be heard Clearly & Intelligibly thru the Stethoscope. Usually caused by what?
Whispered Pectoriloquy; Lung Consolidation
What is the auditory quality called when the Intensity of the Spoken Voice is Increased & there is a Nasal Quality (ex: E's become stuffy broad A's)? Cause?
Egophony; Lung Consolidation
When does Vocal Resonance Diminish & Lose Intensity? Example?
When there is a Blockage of Respiratory Tree for any Reason (ex: Emphysema)
Name of organism that causes Anthrax? Early to Late Pathogenesis findings? Common Occupations at risk?
Bacillus Anthracis; Once inhaled, bacilli take hold & progression is RAPID & IRREVERSIBLE; Early finding: Pleural Effusion, then Progressive Respiratory Distress, and Ultimately: Cyanosis, Shock & Coma; In the past affected Ppl who handled wool contaminated w/ Bacillus (Woolsorter's Disease); Nowadays, it affects Postal Workers
Caused by the Variola Virus, transmitted from Px to Px, presents w/ a prodrome lasting 3-4 days w/ Headache, Chills, Fever & Aches/Pains; Temp Drops & then Skin Lesions begin to appear, initially on the Face & Extremities; Common Complication of Pneumonia
Cuased by Yersinia Pestis, harbored in Rats/other Rodents & Spread by Droplet Infxn from Px to Px; begins w/ fever, malaise, Mental Confusion, & possible Staggering Gait; appearance of Nodal Enlargement; may occur w/o Buboes; may occur w/ Septicemia
Physiology of a Cough; 3 Causes
DEEP INSPIRATION -> CLOSURE OF GLOTTIS & CONTRACTION OF CHEST/ABDOMINAL/PELVIC MUSCLES -> SUDDEN, SPASMODIC EXPIRATION -> OPENING OF THE GLOTTIS -> AIR & SECRETIONS EXHALED; Foreign Body Irritant, Infectious Agent, or Mass compressing Respiratory Tree
What causes a Moist Cough?
Infxn accompanied by Sputum Production
What are causes of Dry Cough?
Variety of Causes (Cardiac Problems, Allergies, HIV Infxn)
An Acute onset of a Cough w/ Fever suggests what primarily? w/o Fever?
Infxn; Foreign Body or Inhaled Irritants
Infrequent cough may result from?
Allergens or Environmental Insults
A regular Paroxysmal Cough is heard when?
Pertussis (Whooping Cough)
An irregularly occuring Cough is caused by what?
Variety of Causes: Smoking, Early CHF, Inspired Foreign Body/Irritant, Tumor compressing Bronchial Tree
What are 2 Postures that can cause someone to cough?
Soon after a person RECLINES or assumes an ERECT position (ex: w/ a Nasal drip or pooling of secretions in the Upper Airway)
When does a Dry Cough sound Brassy? sound Hoarse?
Compression of Respiratory Tree (by a Tumor); Croup
What produces an Inspiratory Whoop at the end of a Paroxysm of Coughing?
What is a good test to do at Home to assess if you have Compromised Pulmonary Fxn such as COPD?
Light a match and hold it 10-15cm in front of sitting Px, ask the Px to blow the flame out w/ mouth open but w/ NO lip pursing and there is a problem if he/she can't blow it out
Pulmonary Measure: Amt of Air that is Expelled After the Px takes a Maximal Inspiration & follows that w/ a Maximal Expiration
Vital Capacity (VC)
What can impair Vital Capacity (VC)?
Loss of Lung Tissue, Airway Obstruction, Loss of Muscle Strength, Chest Deformity, Pneumothorax
Pulmonary Measure: Maximum Flow of Air that can be achieved during Forced Expiration; useful surrogate for VC in children/adults; useful for LARGE AIRWAY FXN; suggests the EXTENT of IMPAIRMENT; can be used to measure SUCCESS/LACK of TREATMENT
Peak Expiratory Flow Rate (PEFR)
Pulmonary Measure: used when there is No measuring tool available; Px Exhales to the limit & then holds their breath; Count seconds until breath must be taken & multiply by 50 to get # of cc's of this measure
Forced Vital Capacity (FVC)
Cause of Sputum: Yellow, Green, Rust (Blood mixed w/ yellow sputum), Clear, or Transparent; Purulent; Blood Streaked; Mucoid, Viscid
Cause of Sputum: Mucoid, Viscid; Blood Streaked (Not common)
Cause of Sputum: All of the Above; particularly abundant in the EARLY MORNING; slight, INTERMITTENT blood streaking; occassionally, large amts of blood
Chronic Infectious Disease
Cause of Sputum: Slight, PERSISTENT blood streaking
Cause of Sputum: Blood Clotted; Large amts of blood
Cause of Sputum: Large amts of blood
What has been termed the Fifth Vital Sign by many Pediatric Emergency Physicians and is in controversial use for being unnecessary when evaluating baby lung fxn?
APGAR: Infant Evaluation @ Birth for Score of 0 = HR, RR, Muscle Tone, Response to Catheter in Nostril, Color
HR = Absent, RR = Absent, Muscle Tone = Limp, Response to Catheter = No Response, Color = Blue or Pale
APGAR: Infant Evaluation @ Birth for Score of 1 = HR, RR, Muscle Tone, Response to Catheter in Nostril, Color
HR = Slow (<100bpm), RR = Slow/Irregular, Muscle Tone = Some Flexion of Extremities, Response to Catheter = Grimace, Color = Body Pink, Extremities Blue
APGAR: Infant Evaluation @ Birth for Score of 2 = HR, RR, Muscle Tone, Response to Catheter in Nostril, Color
HR = Over 100bpm, RR = Good Crying, Muscle Tone = Active Motion, Response to Catheter = Cough or Sneeze, Color = Completely Pink
What is the usual Chest Circumference in a healthy full-term infant? compared to Head Circumference?
30-36cm; 2-3 cm smaller than head circumference
An infant w/ what condition has a relatively smaller chest circumference compared to the head?
Intrauterine Growth Retardation
An infant of what type of mother will have a relatively Larger Chest Circumference?
Poorly Controlled Diabetic Mother
What is the distance b/t the nipples and the circumference of the chest in infants as a rough measure?
Nipples are 1/4th the Circumference of the Chest
What is the Incidence of Supernumerary Nipples in Blacks out of 1000? Whites?
What is the expected respiratory rate in 1 minute for infants?
40-60; although 80 is common
Which babies tend to have more rapid respiratory rate: Cesarean Section or Vaginal Delivery
Where do babies normally breathe from? What type of breathing is common with babies?
Nose, they are Obligate nose breathers and would prefer respiratory distress over opening their mouths to breathe, therefore Nasal Flaring is common; Periodic Breathing (sequence of vigorous effort followed bye apnea for as long as 10-15 seconds)
What type of Cyanosis is common with babies? Not common?
Acrocyanosis (cyanosis of hands & feet); Central Cyanosis (Mouth, Face, Torso)
Which of these are expected in the newborn? Not expected?
Expected: Sneezing (clears the nose) & Occassional hiccups (silently after meals); Not Expected: Coughing & Frequent Hiccuping (may suggest seizures, drug withdrawal, or encephalopathy)
What type of breathing is common in infants?
Paradoxic Breathing (Chest wall collapses as the Abdomen distends on Inspiration), particularly during sleep
What is compromised if a baby's chest expansion is asymmetric? 2 causes?
Baby's ability to fill one of the lungs; Pneumothorax or Diaphragmatic Hernia
Crepitus around a fractured clavicles (w/ no evidence of pain) is common when?
After a difficult Forceps delivery
A high-pitched, piercing sound most often heard during Inspiration; result of an Obstruction high in the respiratory tree; a 3:1 or 4:1 inspiration : expiration ratio
Stridor w/ cough, hoarseness & retraction (at supraclavicular notch & of SCM), where are there serious problems?
In the TRACHEA &/or LARYNX (ex: Floppy Epiglottis, Congenital Defects, Croup, or an Edematous Response to an Infxn, Allergen, Smoke, Chemicals, or Aspirated Foreign Body)
A mechanism of breathing by which the Infant tries to Expel trapped air or Fetal Lung Fluid while trying to Retain Air & Increase Oxygen levels; when persistent, it is a cause for a concern
At what age do children 1st begin to use Thoracic (Intercostal) Muscles for Breathing?
6 or 7 yrs
Respirations per Minute for Newborn?
Respirations per Minute for 1 year old?
Respirations per Minute for 3 year old?
Respirations per Minute for 6 year old?
Respirations per Minute for 10 year old?
Respirations per Minute for 17 year old?
If the roundness of the young child's chest persists past the 2nd yr of age, what respiratory problems may be present?
COP problem such as Cystic Fibrosis
The persistence of a barrel chest at which age can be ominous?
5-6 yrs old
What 2 things does an infant's Sob allow one to evaluate?
Vocal Resonance & Tactile Fremitus
What promises more favorable results than Nicotine Replacement Therapy (NRT) for teens to stop or never try smoking?
Programs in high schools that formally engage students in community-advocacy activities that deal w/ the adverse environmental influences of cigarette smoking
What is the most apparent change in lung volume in pregnant women? Other changes?
DECREASE in Functional Residual Capacity (FRC) - volume of air left in lungs after quiet respiration; INCREASE in VITAL CAPACITY & Tidal Volume (amt of air inhaled & exhaled during normal breathing) by 40%; Overall pregnant women increase ventilation by breathing more DEEPLY not frequently; In late pregnancy, supine position can further decrease pO2
What is Gibbus?
Extreme Kyphosis, found in older adults
Disorder: a COPD characterized by Airway Inflammation resulting from Airway HYPERREACTIVITY by ALLERGENS, ANXIETY, Upper Resp Infxns, Cigarette Smoke, or Exercise; results in MUCOSAL EDEMA, INCREASED SECRETIONS, & BRONCHOCONSTRICTION; Airway Resistance increases & resp flow is impeded; characterized by Paroxysmal Dyspnea, Tachypnea, Cough, Wheezing on both expiration/inspiration, prolonged expiration; Chest Pain (tightness); Obstruction is REVERSIBLE!!; Always ACUTELY ANXIETY PROVOKING
Asthma (Reactive Airway Disease)
Disorder: INCOMPLETE EXPANSION of the Lung at Birth or COLLAPSE of lung at ANY age; collapse can be caused by outside compression (tumor, exudates) or Resorption of gas from Alveoli in the presence of Complete Internal Obstruction (loss of elastic recoil); AFFECTED AREA of lung is AIRLESS; overall effect is to DAMPEN/MUTE SOUNDS involved in the area
When a young patient 1st presents with Wheezing, what should one think the problem is?
Which birthweight predisposes to increased incidence of Asthma in Childhood?
A high birthweight (>4.5kg or 9.92 lbs)
Disorder: INFLAMMATION of the MUCOUS Membranes of the BRONCHIAL TUBES; Acute may have Fever & Chest Pain; Chronic has EXCESSIVE SECRETION of Mucus in BRONCHIAL TREE; initial stimulus is IRRITATION by INTERNAL/EXTERNAL NOXIOUS INFLUENCE; most often quite MILD
Disorder: INFLAMMATION of the VISCERAL/PARIETAL PLEURA (fluid b/t the 2 layers usually) due to Pulmonary Infxns (Bacterial/Viral); SUDDEN ONSET & ACUTE PAIN; Pleura becomes "DRY", EDEMATOUS & FIBRINOUS, making breathing DIFFICULT allowing RUBBING to be FELT & HEARD; Respirations are RAPID & SHALLOW; If it is close to Diaphragm, pain is referred to IPSILATERAL SHOULDER
Disorder: Excessive NONPURULENT Fluid in the PLEURAL SPACE resulting in permanent FIBROTIC THICKENING; Infxn, Neoplasm & Trauma can all cause fluid build up; Fluid is Mobile & will gravitate towards most DEPENDENT position; BREATH SOUNDS are MUTED in Affected Areas; GROCCO'S TRIANGLE (right-angled area of dullness over posterior chest) can sometimes be percussed OPPOSITE a large pleural effusion, the diaphragm on horizontal of triangle, the spinous processes, the vertical; percussion note is often HYPERRESONANT in area above perfusion
Disorder: When Fluid collected in the pleural space is a PURULENT EXUDATE arising from adjacent infected traumatized tissues; complicated by Pneumonia, Penetrating Injury, Simultaneous Pneumothorax, or Bronchopleural Fistula; Breath sounds are distant/absent in Affected area, percussion note is dull, vocal fremitus is absent, Px is FEBRILE, TACHYPNEIC & ILL
Disorder: A WELL-DEFINED CIRCUMSCRIBED MASS defined by Inflammation, SUPPURATION, & Subsequent CENTRAL NECROSIS; usually due to ASPIRATION of FOOD or Infected Material from Upper Respiratory or DENTAL Sources of Infxn; Px usually Ill, Febrile & w/ FOUL ODOR of breath
Disorder: Inflammatory response of the BRONCHIOLES & ALVEOLAR SPACES to an INFECTIVE AGENT (Bacterial/Fungal/Viral); Exudates lead to Lung Consolidation leading to Dyspnea, Tachypnea, & Crackles; diminished breath sounds & dullness to percussion over consolidation area; Involvement of the RIGHT Lower Lobe can stimulate the 10th/11th Thoracic nerves to cause right lower quadrant pain & simulate an abdominal process
Disorder: A host of viruses cause ACUTE, GENERALIZED FEBRILE ILLNESS; Cough, Fever, Malaise, Headache & Coryza; Entire resp tract may be overwhelemed by interstitial inflammation & necrosis extending thru out the bronchiolar & alveolar tissue; Crackles, Rhonchi, Tachypnea, Cough & Substernal Pain
Disorder: Chronic Infectious disease that begins in the lung & may spread to many organs & systems; TUBERCLE BACILLUS (usually mycobacterium tuberculosis, sometimes mycobacterium bovis or atypical mycobacterium) is INHALED from airborne moisture of COUGHS & SNEEZES of infected persons; settles in FURTHEST reaches of Lung; LATENT Period where organism entrenches itself; Px may not be ill, only a bit of lung/some regional lymph nodes may be involved; increased incidence of HIV infxn w/ this
Disorder: Presence of AIR or GAS in PLEURAL CAVITY due to either Trauma or spontaneous rupturing of a Congenital Bleb; Air may not communicate w/ that in the lung but in the tension form of this disease, air LEAKS continuously into pleural space, becoming TRAPPED on expiration & resulting in increasing pressure in the Pleural Space; Spontaneous form has onset most often when Px is AT REST; DISTANT Breath Sounds & BOOMING Percussion Note; Positive "COIN CLICK" (striking a coin placed over suspect area results in CLEAR CLICK sound heard from opposite side of chest (ex: ant vs post); Collapsed Lung w/ Air Accumulation & Depressed Diaphragm Ipsilaterally resulting from Trauma is an example
Disorder: An unexplained but persistent tachycardia may be a clue to what disease not otherwise detected on physical exam?
Disorder: Presence of BLOOD in Pleural Cavity; usually due to result of TRAUMA or INVASIVE MEDICAL PROCEDURES (Thoracentesis, Pleural Biopsy); Breath Sounds Distant or Absent; Dull Percussion; Absent/Negative "Coin Click" Test
Disorder: Presence of BLOOD & AIR in Pleural Cavity due to TRAUMA or INVASIVE MEDICAL PROCEDURES; may have positive coin click test
Disorder: generally refers to BRONCHOGENIC CARCINOMA, a MALIGNANT tumor that evolves from Bronchial Epithelial Structures; Etiologic Agents include: Tobacco Smoke, Asbestos, Ionizing Radiation, Inhaled Chemicals/Noxious Agents; Cough, Wheezing, Emphysema, Atelectasis, Pneumonitis & Hemoptysis
Lung Cancer (Squamous Epidermoid Cell Carcinoma, Small Oat Cell Carcinoma, Adenocarcinoma, Large Cell Carcinoma)
Disorder: Acute or Chronic condition involving RIGHT-SIDED HEART FAILURE; Acute = DILATION of Right side of heart leading to Failure usually due to PE; Chronic = massive disease of lungs causes gradual obstruction producing HYPERTROPHY of RV, Increasing STRESS & Ultimate Heart Failure; also due to Pulmonary EMPHYSEMA & Pulmonary ARTERIOSCLEROSIS
Cor Pulmonale (Acute or Chronic)
Disorder: 1-2 out of every 6 Pxs die of this; no specific finding on physical exam or noninvasive test for correct Diagnosis; Risk factors: Age >40, History of Venous Thromboembolism, Surgery w/ Anesthesia >30 mins, Heart Disease, Cancer, Fracture of Pelvis/Leg bones, Obesity, & Acquired/Genetic Thrombophilia; PLEURITIC CHEST PAIN in ABSENCE of Dyspnea is major clue; possible LOW-GRADE Fever
Pulmonary Embolism (PE)
Children/Adolescent Disorder: AUTOSOMAL RECESSIVE disorder of EXOCRINE GLANDS involving Lungs, Pancreas & Sweat Glands; COUGH w/ SPUTUM in children <5 yrs old; SALT LOSS IN SWEAT (Child's skin tastes unusually salty); Abnormally THICK MUCUS may progressively clog Bronchi & Bronchioles -> Pulmonary Infxns; Initially: HYPERINFLATION & ATELECTASIS; Later: EXERCISE TOLERANCE DIMINISHES, PULMONARY HTN, & COR PULMONALE; In Adults: NASAL POLYPS, COUGH & MALE STERILITY
Children/Adolescent Disorder: Acute Life-threatening disease almost always caused by HAEMOPHILUS INFLUENZA Type B; begins SUDDENLY & progresses RAPIDLY, often to full obstruction of airway resulting in death; usually children b/t ages 3-7; child SITS STRAIGHT UP, Neck EXTENDED, Head held FORWARD, Very ANXIOUS & ILL, UNABLE to SWALLOW, DROOLING from OPEN MOUTH, Cough, High Fever, BEEFY RED EPIGLOTTIS
Children/Adolescent Disorder: Syndrome generally resulting from INFXN w/ variety of VIRAL Agents, usually Parainfluenza Viruses; in children from 1.5-3 yrs age; BOYS moreso; often happens after child sleeps, awakening SUDDENLY very FRIGHTENED, w/ a HARSH BARK-LIKE COUGH; Labored Breathing, Retraction, Hoarseness & Inspiratory Stridor; Inflammation is SUBGLOTTIC & involves areas beyond Larynx (such as LARYNGOTRACHEOBRONCHITIS)
Children/Adolescent Disorder: Trouble Breathing in PRE-TERM INFANTS due to SURFACTANT DEFICIENCY; Risk Factors; Decreasing Gestational Age, Maternal DM, Acute Asphyxia, Family History, WHITE Males, 2nd of TWINS; Tachypnea, Retractions, Grunting, Cyanosis; Full-term infants may have Adult form of this
Respiratory Distress Syndrome (RDS)
Children/Adolescent Disorder: "NOISY BREATHING" in INFANCY is Inspiratory Stridor often attributed to FLOPPINESS of TRACHEA/AIRWAY owing to Lack of Rigidity; Trachea changes in response to varying pressures of inspiration/expiration; tends to be BENIGN & SELF-LIMITED w/ Increasing Age
Children/Adolescent Disorder: INFANTS <6 mos old; HYPERINFLATION of LUNGS; RESPIRATORY SYNCYTIAL VIRUS cause; Difficult Expiration, Anxious & Tachypneic, Hyperresonant Percussion, Increased AP Diameter, DISTENDED Abdomen from Swallowed Air
Older Adults Disorder: Nonspecific group of respiratory problems involving COUGHS, Chronic & Excessive SPUTUM PRODUCTION, & DYSPNEA leading to IRREVERSIBLE EXPIRATORY AIRFLOW OBSTRUCTION; Examples: Chronic Bronchitis, Emphysema, Asthmatic Bronchitis, Bronchiectasis & Cystic Fibrosis; usually SMOKERS; LIP PURSING when Breathing; FORCED EXPIRATION TIME >4-5 secs; 4th Leading cause of Death in US
Chronic Obstructive Pulmonary Disease (COPD)
Older Adults Disorder: Most severe COPD, Air takes over & dominates a space disrupting fxn; Air spaces beyond terminal Bronchioles dilate, Rupturing Alveolar Walls, permanently destroying them, reducing their #, & permanently hyperinflating the lung; Alveolar Gas is TRAPPED in EXPIRATION & Gas Exchange is seriously compromised; Precursor: Chronic Bronchitis; Lungs lose elasticity due to Age, Smoking, Impairment of ALPHA-ANTITRYPSIN Defenses; Px is THIN & BARREL-CHESTED, even CACHECTIC
Older Adults Disorder: Chronic DILATION of BRONCHI or BRONCHIOLES caused by repeated Pulmonary Infxns & Bronchial Obstruction; Dilations may involve Tube Uniformly (CYLINDRIC) or Irregularly (SACCULARLY); may lead to MALFUNCTION of Bronchial Muscle Tone & Loss of Elasticity; extent governed by degree of "WETNESS"; partly characterizes Kartagener Syndrome
Older Adults Disorder: usually Px >40 yrs old; MUCUS of BRONCHI Chronically INFLAMED, RECURRENT BACTERIAL INFXNS, Dyspnea, Cough, Sputum; SMOKING History w/ EMPHYSEMA; may result in RV FAILURE w/ DEPENDENT EDEMA if severe