2 session 2 lungs

8/10/2019 2 Session 2 Lungs

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Session 2: Lung

Sounds:

http://meded.ucsd.edu/clinicalmed/lung.htm

https://www.mededportal.org/publication/129

Information

Type

Lungs

Normal PE

Findings

Inspection

Little use of accessory muscles

Abdomen should move outward during inspiration

Palpation

Symmetrical accentuated chest excursion

Percussion:

Resonant percussion

Auscultation:

Soft inspiratory sound with little noise on expiration (Vessicular

breath sounds)

1:2 "I to E" ratio; expiration twice as long as inspiration

Abnormal PE

Findings

Inspection at rest

Diaphoresis

Labored breathing

Use of accessory muscles (scalenes, SCM) to breath at rest

Blue lips, nail beds (cyanosis)

Tri-pod position required to breathe: leaning forward with hands

resting on knees

Breathing through pursed lips (emphysema)

Unable to speak in complete sentences (judge by words/ breath)

Noises w/ breathing that are audible to naked ear (wheezing,

gurgling caused by secretions)

Diaphragmatic flattening w/ emphysema:abdominal wall moves

inward during inspiration (aka paradoxical breathing)

Chest & spine deformities that arise due to lung issues or are

congenitalo

Pectus excavatum: chest caves in; posterior displacement of

lower aspect of sternumo

Barrell Chest:increased Anterior-Posterior diameter and

diaphragmatic flattening

Associated with emphysema and lung hyperinflationo

Kyphosis: hump backed; extreme posterior displacement of

spine curvatureo

Scoliosis: curved spine, more pronounced on x-ray

Palpation

Asymmetric chest excursion (fluid or air in pleural space); side with

fluid/ air in pleural space will move less; usually requires a lot of

pleural disease to manifest in this part of the exam

Tactile fremitus: subtle finding, used as supporting evidenceo

More pronounced: due tolung consolidation; lung
http://meded.ucsd.edu/clinicalmed/lung.htmhttp://meded.ucsd.edu/clinicalmed/lung.htmhttp://meded.ucsd.edu/clinicalmed/lung.htm


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parenchyma engorged with fluid or tissue, usually in setting

of pneumoniao

Less fremitus in a certain area: due to pleural effusion;

displaces lung upward

Pain: investigate fro trauma, rib fracture, subcutaneous air, etc.

Percussion: Dull percussion: fluid filled lung due to pneumonia or pleural

effusion

Hyperesonant: due to chronic (emphysema) or acute

(pneumothorax) air trapping in lungs or pleural space, respectively

Auscultation:

Wheezes: whistling type noise during expiration, sometimes

inspiration due to narrowed airway by bronchoconstriction,

secretions, mucosal edemao

Most commonly occurs diffusely, in all lobeso

With significant bronchoconstriction, expiration becomes

prolonged (increased I to E ratio, E>>>I, normal I:E = 1:2)o

Greater difference = greater obstruction

Focal wheezing: pneumonia in specific area

Stridor: wheezing on inspiration, associated with mechanical

obstruction at level of trachea/ upper airway

Rales/ crackles: scratchy sound associated with processes that

cause fluid to accumulate in alveolar and interstitial spaceso

Sounds like rubbing hair together close to earo

Usually due to pulmonary edemain older adults w/

symmetric raleso

Pneumonia--> focal rales

Crackles that sound like separating pieces of velcro: pulmonary

fibrosis (relatively uncommon) Dense consolidation of lung parenchyma (pneumonia, etc.) results

in transmission of large airway noises to peripheryo

If you direct patient to say "EEE," it will sound like a nasal-

sounding "AAAA" over the involved lobe (egophony)

Ronchi: Gurgling noises that can be caused by collection of

secretions in larger airways; sound like slurping of last bit of

milkshake

Auscultation over effusion may sound muffled; auscultation on top

of effusion will suggest consolidation due to compression of lung

by fluid pushing up from belowo

Asymmetric effusion easier to detect Auscultation of severe emphysema patients will produce very little

sound due to significant lung destruction and air trappingo

Wheezing will occur with acute inflammatory process

Basic

Physiologic

Principles

Khan Academy Lungs:

Air through nose/mout to back of throat, down to thyroid

cartilage, down to trachea, down to lungs, to bronchiole tree that


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serves each lobe of lungs, alveoli, location of molecular exchange

in capillaries

Right lung: Upper, middle, lower lbe

Left lung: Upper, lower lobeo

Cardiac notch

Diaphragm: floor Ribs: walls

Khan Academy Breathing Basics:

Trachea: size restricted by cartilage

Bronchi: size restricted by cartilage

Bronchioles: designed to change sizeo

Have smooth muscle in walls = contractile capacity; can

modulate air intake and releaseo

Mucus

Lungs:

Pleural sac: surrounds lung; potential space with little fluid;

reduced friction between rib cage, diaphragm and lung

Inhalation at rest:o

Diaphragm contracts, moves down, increase volume of

thoracic cavity, decreases pressure

Inhalation at exercise: recruit more muscleso

External intercostals; pull ribcage upward and outward,

increase volume of thoracic cavityo

Neck muscles; contract, pull clavicle upward, increase

volume of thoracic cavity

Exhalation at rest:o

No muscles contracto

Diaphragm relaxes, decreases volume of thoracic cavity

o

Elastic recoil of lung tissue Exhalation at exercise: accessory muscles recruited

o Internal intercostal muscles; pull ribcage downward and

inward--> reduce volume of thoracic cavityo

Abdominal muscles: contract, push contents of abdominal

cavity upward, reduce volume of thoracic cavity

Correct

Technique and

Appropriate

Landmarks

Patient should take slow, deep breaths through mouth during

examination

Perhaps have patient cough beforehand to clear airways

If patient cannot sit up, perform auscultation while patient lays

sideways; if not possible, listen laterally/ posteriorly as patient is supine

May request patient to forcibly exhale

Inspection/ Observation

Watch patient breatheo

Judge comfort, depth of breaths, perspiration, use of

accessory muscles (especially in neck) to assess respiratory


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difficulty, observe color of patient (especially around lips and

nail beds), patient position, ability to speak, noises

accompanying breathing, direction of abdominal wall

movement, chest or spine deformities

Palpation: minor role

Accentuate normal chest excursion by placing hands on patientsback with thumbs pointed towards spine; hands should lift

symmetrically when patient takes a deep breath

Tactile fremitus: detect palpable vibratory sensation of chest wall

by placing bony, ulnar aspect of each hand on either side of chest

while patient says "Ninety-Nine;" repeat until entire posterior

thorax is covered

Percussion: generally limited to posterior lung fields except in further

exploring anterior auscultation abnormality; swing hands freely at wrist

(not stiff), hammering finger onto target at bottom of down stroke; go

down "percussion alley" (see photo) between scapulae and vertebral

column to avoid bone

Strike air filled structure to produce resonant note

Strike fluid filled structure to produce relatively dull sound

Have patient cross hands in front of their chest asn grasp opposite

shoulder with each hand to pull scapulae laterally

Percussion technique: strike DIP of left middle finger with tip of

right middle finger while last two digits rest firmly on patient's

back; keep rest of fingers from touching to prevent dulling of

resonance

2-3 taps should sufficeo

5 locations should cover a hemithoraxo

Any abnormalities in one side of thorax should be compared

to the other side "Speed Percussion:" constantly percuss down back to accentuate

difference between resonant and dull sounds and identify location

ofl ungs

Auscultation:

Generally, patient is sitting upright; asking females to lie down will

alow breasts to fall laterally and make anterior auscultation easier

Examine posterior field upper lobes first (top 1/4 of posterior

field)--> posterior field --> axillas --> anterior fields

Listen to lower lobes in bottom 3/4 of posterior field

Listen to upper lobes in anterior chest, top 1/4 of posterior fieldo

Listen in one spot, then compare to same spot on other lung Listen to right middle lobe in right axilla (while behind patient)

Linsten to lingula in left axilla (while behind patient)

Gown management:

Area to be examined must be exposed, keep other areas relatively

unexposed

Explain what you're doing before doing it

Expose minimum amount of skin as necessary


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o Ask patient to remove bra prior to examinationo

Expose only to extent neededo

Enlist patient assistance

Do not rush

DO NOT EXAMINE THRU GOWN or BRA

Ambulation w/ use of pulse oxymeter: helpful in providing objectiveinformation when symptoms seem out of proportion to findings;

generate a measurement that you can refer back to during subsequent

evaluations in order to determine if there has been any real change in

functional status; determine disease and symptom severity over time to

assist diagnosis and rational use of other tests

Keep track of:o

Exercise toleranceo

Rate of exerciseo

Duration of exerciseo

Distance coveredo

Development of dyspneao

Changes in heart rate, O2 saturation

Age-related

Changes and

Features

Differences in

PE Findings in

Children

Infants:

Assess respiration and pattern of breathing

Use more observationo

Respiratory rateo

Coloro

Nasal component of breathingo

Audible breath sounds

Nasal flaring

Stridor, Gruntingo

Retractions (chest indrawing)

Inward movement of ribs during inspiration

Indicates respiratory pathology

Percussion not helpful; infant chest is hyper-resonant throughout

Auscultation will be louder as stethoscope is closer to origin of

sounds

Difficult to distinguish transmitted upper airway sounds from

sounds originating in the chest

Hold stethoscope in front of infant nose to compare quality ofsound

Note symmetry from right to left

Expiratory sounds usually from intrathoracic; inspiratory either

from chest or upper airway or nose

Characteristic breath sounds same as for adults (wheezes, crackles,

ronchi, etc. more likely from infection than cardiac disease)

Children


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Observation is significant

Tactile fremitus indicates pathology

Auscultate like adult; have them breath normally

Sounds transmit better

Wheezes, ronchi, wet crackles are commonly heard and can be

caused by infection or asthma

Photos

Inspection/ Observation

Cyanosis:

o

Tri-Pod Position in Emphysema Patient

o

Pectus excavatum

o


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Barrel Chest

o

o

Kyphosis:

o

o

Scoliosis: (notice shoulders)


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o

o

Lung anatomy


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Percussion Alley


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o

Class Notes

Respiratory/Chest Exam

Muscles used in the respiratory cycle:

Phase of the

Respiratory Cycle

Activity State

At rest During exercise/exertion

Inspiration (inhalation)

Involves contraction of the

diaphragm

Involves diaphragm plus the external

intercostal musclesand neck muscles

(sternocleidomastoid)

Expiration (exhalation)

Passive movementinvolves no

active muscle use, only elasticrecoilof diaphragm

Involves the internal intercostal

musclesand the abdominal wallmuscles

Important landmarks:

Trachea (anterior and lateral)

Chest wall:

o

Mid-clavicular line

o

Mid-axillary line

o Supraclavicular area, clavicles

o Sternum, sternal angle, suprasternal notch, substernal area (xiphoid process)

o

Costal margins

Normal vs. abnormal sounds in the respiratory tract:

Normal:

o Bronchial: lower pitched; upper lung fields, trachea

o Bronchovesicular: between bronchial and vesicular in pitch; middle fields


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o Vesicular: higher pitched; lower lung fields

Adventitious breath sounds:

o

Upper airway sounds: e.g., stridor

o

Lower airway sounds

Discontinuous (cracklesincl. fine and coarse)

Continuous (wheezesmusical; rhonchi)

Transmitted voice sounds(listen for these if you hear bronchial breath sounds where they

should not be); all of these sounds suggest that the air-filled lung has become airless:

o Bronchophony: 99 (auscultate)if breath sounds louder/clearer than normal,

bronchophony is present.

o

Egophony: eee (auscultate)if it sounds like aaay, then egophony is present.

o

Whispered pectoriloquy: whisper 1, 2, 3 (auscultate)when these sounds are

louder/clearer than normal), whispered pectoriloquy is present.


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Differences in the respiratory exam in infants and children compared to adults:

Infants/young children:

o Tongue is larger relative to oropharynx in young children

o Larynx in young children (


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2 session 2 lungs

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