Term
| know the terminology to describe different respiratory patterns |
|
Definition
| Think in terms of rate, depth, and regularity; Normal: 14-20 breaths/min in adults, regular rate; tachypnea: rapid shallow breathing; hyperventilation: rapid deep breathing; Cheyne-Stokes breathing: cyclical periods of deep breathing alternate with periods of apnea; Ataxic breathing: unpredictable irregularity in depth, rate, and rhythm; sighing respiration: breathing punctuated by frequent deep breaths, alert when frequent sighing |
|
|
Term
| know the definitions of apnea, Kussmaul's respiration, Cheyne-Stokes respiration |
|
Definition
| *Apnea: no breathing. *Kussmaul's respiration: deep and labored breathing due to metabolic acidosis (often diabetic ketoacidosis), it is a form of hyperventilation and the rate of breathing may be normal, fast, or slow. *Cheyne-Stokes respiration: Periods of deep breathing alternate with periods of apnea (children and aging people normally may show this pattern in sleep, other causes include heart failure, uremia, drug-induced respiratory depression, and brain damage, typically on both sides of the cerebral hemispheres or diencephalon). |
|
|
Term
| know the physiology and significance of percussion tones heard during the lung exam |
|
Definition
| *Lung Percussion: Normal lungs are resonant. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers (examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor). Generalized hyperresonance may be heard over the hyperinflated lungs of emphysema or asthma, but it is not a reliable sign. Unilateral hyperresonance suggests a large pneumothorax or possibly a large air-filled bulla in the lung. *Diaphragm Percussion: An abnormally high level suggests pleural effusion, or a high diaphragm as in atelectasis or diaphragmatic paralysis. |
|
|
Term
| know and understand the physiology and significances of lung sounds (e.g. wheezing, crackes) |
|
Definition
| *Crackles have two leading explanations: (1) They result from a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration. This mechanism probably explains the late inspiratory crackles of interstitial lung disease and early congestive heart failure. (2) Crackles result from air bubbles flowing through secretions or lightly closed airways during respiration. This mechanism probably explains at least some coarse crackles. Late inspiratory crackles are usually fine, profuse, and persistent, and may begin in the first half of inspiration but must continue into late inspiration. Causes include interstitial lung disease (such as fibrosis) and early congestive heart failure. Early inspiratory crackles appear soon after the start of inspiration and do not continue into late inspiration. They are often but not always coarse and are relatively few in number. Causes include chronic bronchitis and asthma. Midinspiratory and expiratory crackles are heard in bronchiectasis but are not specific for this diagnosis. *Wheezes occur when air flows rapidly through bronchi that are narrowed nearly to the point of closure. They are often audible at the mouth as well as through the chest wall. Causes of wheezes that are generalized throughout the chest include asthma, chronic bronchitis, COPD, and congestive heart failure (cardiac asthma). In asthma, wheezes may be heard only in expiration or in both phases of the respiratory cycle. Rhonchi suggest secretions in the larger airways. In chronic bronchitis, wheezes and rhonchi often clear with coughing. Occasionally in severe obstructive pulmonary disease, the patient is no longer able to force enough air through the narrowed bronchi to produce wheezing. The resulting silent chest should raise immediate concern and not be mistaken for improvement. A persistent localized wheeze suggests a partial obstruction of a bronchus, as by a tumor or foreign body. It may be inspiratory, expiratory, or both. *A wheeze that is entirely or predominantly inspiratory is called stridor. It is often louder in the neck than over the chest wall. It indicates a partial obstruction of the larynx or trachea, and demands immediate attention. *Inflamed and roughened pleural surfaces grate against each other as they are momentarily and repeatedly delayed by increased friction. These movements produce creaking sounds known as a pleural rub (or pleural friction rub). Pleural rubs resemble crackles acoustically, although they are produced by different pathologic processes. The sounds may be discrete, but sometimes are so numerous that they merge into a seemingly continuous sound. A rub is usually confined to a relatively small area of the chest wall, and typically is heard in both phases of respiration. When inflamed pleural surfaces are separated by fluid, the rub often disappears. |
|
|
Term
| know the anatomic locations of the lobes of the lung |
|
Definition
| Each lung is divided roughly in half by an oblique (major) fissure. The right lung is further divided by the horizontal (minor) fissure. The right lung is thus divided into upper, middle, and lower lobes. The left lung has only two lobes, upper and lower. The upper (and right middle) lobes are mostly anterior, the lower lobes are mostly posterior. |
|
|
Term
| know the physical exam findings of respriatory failure |
|
Definition
| Two types of respiratory failure: hypoxemic and hypercapnic. *Hypoxemic respiratory failure (type I) is characterized by an arterial oxygen tension (Pa O2) lower than 60 mm Hg with a normal or low arterial carbon dioxide tension (Pa CO2). This is the most common form of respiratory failure, and it can be associated with virtually all acute diseases of the lung, which generally involve fluid filling or collapse of alveolar units (examples include cardiogenic or noncardiogenic pulmonary edema, pneumonia, and pulmonary hemorrhage). *Hypercapnic respiratory failure (type II) is characterized by a PaCO2 higher than 50 mm Hg. Hypoxemia is common in patients with hypercapnic respiratory failure who are breathing room air. The pH depends on the level of bicarbonate, which, in turn, is dependent on the duration of hypercapnia. Common etiologies include drug overdose, neuromuscular disease, chest wall abnormalities, and severe airway disorders (eg, asthma and chronic obstructive pulmonary disease [COPD]). *Respiratory failure may be further classified as either acute or chronic. *The physical exam findings of acute respiratory failure reflect the underlying disease process and the associated hypoxemia or hypercapnia. Signs and symptoms may include dyspnea, tachypnea, tachycardia and arrhythmias (may result from hypoxemia and acidosis), cyanosis (indicates hypoxemia), pulmonary hypertension (frequently is present in chronic respiratory failure), and ultimately cor pulmonale (if chronic). |
|
|
Term
| know the physical exam findings in patients with a pneumothorax |
|
Definition
| Sudden onset of dyspnea, hyperresonance, decreased breath sounds, trachea shifted toward opposite side, can possibly have a pleural rub, decreased tactile fremitus. (Bates pg 243) |
|
|
Term
| know the physical exam findings in patients with a pleural effusion |
|
Definition
"Decreased percussion over area, trachea shifted opposite side, decreased to absent breath sounds but bronichial breath sounds may be heard near top of large effusion, possible pleural rub, decreased tactile fremitus but may be increased at top of large effusion. (Bates 243)
" |
|
|
Term
| know the physical exam findings in patients with bronchiectasis |
|
Definition
| Chronic cough with purulent sputum- often foul smelling and may be bloody (Bates 238), midinspiratory and expiratory crackles (Bates 241), |
|
|
Term
| know the physical exam findings in patients with bronchitis |
|
Definition
"Acute Bronchitis: sputum production, dyspnea, wheezing, chest pain, fever,
hoarseness, malaise, rhonchi, and rales. Each of these may be present in varying degrees or
may be absent altogether. Sputum may be clear, white, yellow, green, or even tinged with blood.
On physical examination, the patient with acute bronchitis may or may not have fever and has
tachypnea, as well as pulmonary signs such as wheezing, rhonchi, and prolonged expiration. (Bates, A-13)"` |
|
|
Term
| know the physical exam findings in patients with CHRONIC bronchitis |
|
Definition
| Chronic cough- sputum mucoid to purulent, may be blood streaked or bloody (Bates 238). Resonant on percussion, trachea midline, vesicular (normal) breathsounds, variable adventitious sounds (none, or scattered coarse crackles or wheezes or rhonchi), normal tactile fremitus (Bates, 242) |
|
|
Term
| know the physical exam findings in patients with pneumonia |
|
Definition
On exam, a patient with pneumonia will have fever/chills, be tachycardic, tachypnic, and hypotensive, have bronchial breath sounds, dullness to percussion, and egophany and tactile fremitus will be positive because of the consolidation that is present. The patient will also most likely report cough, headache, fatigue, lethargy, SOB, sputum production (purulent, perhaps blood-tinged) pleuritic chest pain and nausea, diarrhea.
Pt may exhibit unilateral decrease or delay in chest expansion. |
|
|
Term
| know the physical exam findings in patients with pulmonary embolus |
|
Definition
Depending on the size and location of the embolus, there may or may not be significant symptoms and findings, but can range from mild shortness of breath to sudden death from loss of perfusion of a significant portion of lung. On exam of someone who has not already expired, exam will show tachypnea, diaphoresis, rales and wheezes, increased P2 heart sound, pleural friction rub, low-grade fever, hypotension, calf swelling/tenderness, and Homan's sign (calf pain with dorsiflexion of foot)
Homan's sign is only 50% sensitive in DVT. |
|
|
Term
| know the physical exam findings in patients with asthma exacerbations |
|
Definition
Asthma is a chronic inflammatory disease that causes obstruction of the airways leading to inspiratory and expiratory wheezing, prolonged expiration, coughing, shortness of breath, chest tightness, and sometimes phlegm production. You may also discover atopic dermatitis and rhinitis (hey check out that cross-sequence reference)
Symptoms, not exam findings: Cough, dyspnea, and wheezing are 3 most common symptoms. Can have hyperresonance from air-trapping, but breath sounds are often obscured by wheezing. Acute episodes are commonly nocturnal. |
|
|
Term
| kow the physical exam findings in patients with chronic obstructive pulmonary disease (COPD) |
|
Definition
COPD is an obstructive disease due to chronic bronchitis and/or emphysema, so the main finding early on will be prolonged expiration and wheezing. Later on into the course of the disease, exam findings will include increased AP diameter, decreased diaphragmatic excursion, decreased breath sounds, rhonchi, course rales, and prolonged expiration. In end-stage disease, patients will show accessory muscle use, pursed lips for breathing, bracing their body with their arms, and cyanosis.
Diffusely hyperresonant. Delayed expiration. Clubbing of fingernails. |
|
|
Term
| know the pulmonary physical findings associated with allergic reactions |
|
Definition
"*Allergic rhinitis (hay fever): sneezing, pruritis (of eyes, nose, palate, throat), conjunctivitis and watery discharge of eyes, rhinorrhea, and nasal obstruction. Edema can cause ""allergic shiners"" (discoloration of lower orbitopalpebral grooves). Can cause hoarseness, post-nasal drip, chronic cough, irritability, fatigue. Nasal mucosa (covers the septum and turbinates) may be pale, bluish, or red and boggy.
*Urticaria (hives): cutaneous form with erythematous rash that may be raised (wheals), and severe pruritis.
*Anaphylaxis- severe systemic reaction. Severe hypotension, bronchoconstriction, shock, death. |
|
|
Term
| know the pulmonary conditions associated with clubbing |
|
Definition
"Clubbing- Distal phalanx of each finger is rounded and bulbous. Nail plate is convex.
Causes: (many!) chronic hypoxia from chronic heart disease (eg CHF, congenital heart disease), chronic lung disease (eg. COPD, cancer), or chronic liver disease (eg hepatic cirrhosis)" |
|
|
Term
| know the physical exam findings in patietns with systemic lupus erythematosis (SLE) |
|
Definition
"**Serositis:
*Pleuritis- pleuritic pain (knife-like during inspiration) or pleural effusion
*Pericarditis- precordial chest pain (relieved by leaning forward, aggravated by leaning back), pericardial friction rub (heard best with patient leaning forward; persists while pt holds their breath), pericardial effusion (muffled heart sounds, low-V EKG, kussmaul's sign (neck vein distention during inspiration), pulsus paradoxus (decrease in systolic BP during inspiration), ST elevation in multiple leads)
**Oral or nasopharyngeal ulcers
**Arthritis of 2 or more peripheral joints (non-deforming), usually small joints (hands)
**Skin: photosensitivity rash, alopecia
*Malar rash- butterfly erythema, spares nasolabial folds
*Discoid rash- red raised patches with follicular plugging and keratotic scaling
**Generalized: fever, chills, anorexia, weight loss, weakness, fatigue |
|
|
Term
| know the physical exam findings in patietns with idiopathic pulmonary fibrosis |
|
Definition
"Ideopathic pulmonary fibrosis = abnormal and widespread infiltration of cells, fluid, and collagen into interstitial spaces btw alveoli. Many causes.
Signs/Sx: progressive dyspnea, late inspiratory crackles, decreased fremitus " |
|
|
