Chest & Lung Exam Flashcards
Inspection: Signs of Respiratory Distress
Breathing Pattern
Breathing Rate
Use of Accessory Neck muscles
Shape of chest
Cyanosis
Breathing Patterns
Bradypnea: Less than 12 breaths/min
Tachypnea: Greater than 20 breaths/min
Hyperventilation (hyperpnea): Greater than 20 breaths/min + deep breathing (larger dilations of chest with inspiration & expiration
Cheyne-Stokes: Varying periods of increasing depth interspersed with apnea. Class in brainstem disorders in adults. Also seen in premature babies with underdeveloped respiratory systems.
Kussmaul: Rapid, Deep, Labored. Seen in Severe metabolic acidosis. Trying to blow off CO2.
Biot: Irregularly interspersed periods of apnea in a disorganized sequence of breaths (no pattern). “Agonal” breathing. Seen in severe respiratory failure, sign of near death.
Cyanosis Characteristics
Bluish color of Skin or Mucous membranes due to Deoxyhemoglobin.
Traditional: > 4 gm/dL deoxyhemoglobin
Unreliable, subjective sign
Central cyanosis more reliable than peripheral cyanosis. (These can occur separately or together.)
—Central cyanosis: Lips
—Peripheral cyanosis: Fingertips
Anemia: Hypoxemia, but does not have cyanosis because the hemoglobin is saturated.
Causes of Cyanosis
Causes of Cyanosis
Central Cyanosis: Decreased Arterial Oxygen Saturation Hemoglobin Abnormalities: —Methemoglobinemia —Sulfhemoglobinemia
Peripheral Cyanosis (acrocyanosis): Reduced Cardiac Output Cold exposure Shock: Redistribution of blood flow Arterial Obstruction Venous Obstruction
Note: Cardiac tends to do Peripheral cyanosis & Respiratory tends to do Central cyanosis.
Note: Carbon Monoxide poisoning causes “cherry red lips,” not central cyanosis. It also gives a normal pulse ox reading.
Methemoglobinemia
Normal MetHb: 1%
Abnormal Levels: >3%
Gray, Blue skin
Chocolate brown lips in early methemoglobinemia
Pulse Oximetry for Hb Oxygen Saturation: Unreliable, may be near-normal.
Approach to Patient with Cyanosis
Timing of Onset:
—Since Infancy = Congenital Heart Disease
Central vs. Peripheral
—If only peripheral: test by warming the extremities
Evidence of Heart or Lung disease
Presence of Clubbing: Congenital heart disease or Lung disease
Measure Oxygen Saturation or PaO2
Finger Clubbing
An extrapulmonary sign of lung disease.
Typically due to chronic low oxygen states that result in hypertrophy of the base of the nail.
Seen in
—Carcinoma of the Lung
—Bronchiectasis (deep infection of lung)
—Pulmonary Fibrosis (fibrotic tissue, poor ventilation & poor perfusion of lungs)
Test: put tops fingernails together and see if there is a diamond-shaped air space in between.
Shift of Trachea due to Intrathoracic Abnormality
Shift to Contralateral side = Away:
—Massive Pleural Effusion
—Tension Pneumothorax
Shift to Ipsilateral side = Toward:
—Collapse or Atelectasis of a lung on the same side
Palpation: Fremitus
Increased Fremitus:
—Consolidated Pneumonia with a Patent Bronchus
—Lobar Pneumonia with a Patent Bronchus
Decreased Fremitus: —Pleural Effusion —Pneumothorax —Severe Emphysema —Consolidated Pneumonia with an Obstructed Bronchus —Atelectasis
Percussion
Normal: Resonant
Dull:
–Pleural Effusion
—Consolidated Pneumonia
—Lung Atelectasis or Collapse
Hyperresonance:
—Severe Emphysema
—Pneumothorax
Auscultation: Adventitious Lung Sounds
Discontinuous Sounds: Crackles —Usually with CHF or overload —Loudness, Pitch, Duration —Fine crackles —Coarse Crackles
Continuous Sounds:
—Wheezing: High-pitched, shill quality. Usually with Asthma
—Rhonchi: Low-pitched. Usually with Pneumonia.
Timing of Common Inspiratory Crackles
Congestive Heart Failure: Early crackle very common, Late crackle common
Obstructive Lung Disease: Early crackles (no late crackles)
Interstitial Fibrosis: Late crackles (no early crackles)
Pneumonia: Late crackles (no early crackles)
Pleural Friction Rub
Inflamed & Roughened Pleural surfaces.
Resembles crackles, but crackles tend to be only inspiratory & more diffuse.
Usually confined to small area of chest wall.
Typically both phases of respiration (inspiration & expiration)
Mediastinal Crunch (Hammon’s Sign)
Precordial crackles synchronous with heart beat (not with respiration)
Best heard in Left Lateral Decubitus Position
Due to mediastinal air (pneumomediastinum).
Pneumothorax
Inspection: —Tachycardia —Respiratory Distress —Shock —Tracheal Deviation —Respiratory Lag on Affected side
Palpation:
—Decreased or Absent Fremitus
Percussion:
—Hyperresonance
Auscultation:
—Diminished or Absent Breath Sounds
Tension Pneumothorax: the shifting of the mediastinum causes kinking of the great vessels, causing cardiac failure and thus death; that is what kills these patients; the death is not due to the collapsed lungs.
