Breathing Patterns, Lung Antomy And In Depth Observation

Question 1

Signs and symptoms of cardiorespiratory dysfunction -

Answer 1

Shortness of breath
Sputum
Cough
Wheeze
Pain
Changes in exercise tolerance
Functional ability
Psychological hangers - eg reduced self efficacy can lead to reduced motivation

Question 2

Why is observation from the start so important in cardio physio?

Answer 2

You want to observe without the patient realising to try and make it as natural as possible
This is to attempt to see their natural breathing
Especially important with counting breaths for respiratory rate

Question 3

What are the components of cardio objective assessment?

Answer 3

Observation
Palpation
Auscultation (listening with stethoscope)
Chest x-rays (CXR) and imaging (CT scans)
Pulse oximetry (O2 saturation)/BP/HR.
Arterial blood gases (ABG’s)
Pulmonary function tests (PFT’s)

Question 4

Assessment tools
Exercise tolerance tests -

Answer 4

6 minute walk test (self-paced) - allowed to stop and rest if they wish within the time
Distance covered is measured in metres

Incremental shuttle walk test (externally paced) - bleep test but walking

Step test

Question 5

Assessment tools
Functional ability tests -

Answer 5

Elderly mobility scale (EMS)
Functional independence measure (FIM)
Acute care index of function CPAx

*also use all the info on nursing charts - will find BP, rep rate etc here…

Question 6

Observation
What are we looking for in their general appearance?

Answer 6

Is patient alert, responding to voice,pain or unresponsive (AVPU)
Are they agitated/restless
Appear breathless/distressed/confused
Face, eyes, hands, mouth, oedema
Do they look comfortable? Appear in pain?

Question 7

Observation
Position -

Answer 7

Are there any lines, drains, evidence of surgical intervention etc.. to be aware of
If on oxygen, how much?

Question 8

Observation
Chest -

What is WOB? (Definition)

Answer 8

Respiratory rate per min
Chest shape
Chest wall movement
Breathing pattern
WOB - the pressure required to move a volume of gas and the amount of O2 required by respiratory muscles to perform this task

Question 9

Observations
Abdomen -

Answer 9

Distended/incisions/post op drains/feeding tube
Abdomen is in close relationship with the best, therefore important to pay attention to.

Question 10

Observations
Skin colours and what they mean -

Answer 10

Pale or blue
Pallor (pale) - anaemia/low BP
Ruddy/plethoric - appear flushed, red skin due to increased heamoglobin in attempt to increase O2 carrying capacity. Common in COPD patients
Central cyanosed/peripheral cyanosis - central= tongue/lips peripheral = fingers and hands
Blue discolouration

Question 11

Observation
What is pursed lip breathing?

Answer 11

Seen in patients with severe airway disease (COPD)
Opposing lips during exhalation causes airway pressure inside the chest to be maintained, preventing floppy airways from collapsing

Can be adopted naturally/physios can teach it to their patients

Question 12

Observation - general appearance
What are we looking for in their eyes?

Answer 12

Pallor (pale) - anaemia
Redness (high BP)
Jaundice - yellow discolouration, liver diseases?biliary obstruction
Drooping of one eyelid and a constricted pupil _ aka horns syndrome
Seen in patients with lung cancer
Oedema - excess fluid in interstitial spaces

Question 13

Observation
General appearance - what are we looking for in their hands?

Answer 13

Course flapping tremor - fingers/hands uncontrollably move up and down due to increased CO2
Fine tremor - more of a slight shake - medication related ie. Beta agonists
Wastage
Nicotine stains - sign of smoking
Cyanosis - circulation issue
Clubbing - reduced angle between nail and nail bed
Temperature feel during palpation - hot and cold or clammy

Question 14

Observation
Causes of clubbing
Cardiac -
Lung disease -
Bowel disease -

Answer 14

Congenital heart diseases
Endocarditis

Cystic fibrosis
Infective (eg bronchiectasis)
Fibrotic lung disease
Malignant lung disease

Crohn’s disease
Ulcerative colitis

Question 15

Obersvation, general appearance
What are we looking for at their mouth?

Answer 15

Moist or dry - if dry, secretions will stick to roof of mouth
Dehydrated? - can use wet sponges to help
Drooling? - suggests neural problem
Any swelling/abnormality?
Colour ? - ie. Central cyanosis
Hydrated
Purse lip breathing

Question 16

Observation - general appearance
What are we looking for in oedema?

Answer 16

Peripheral - ( ankles and sacral areas)
Pitting oedema - leaves a mark once pressed - suggests it been there for a while as skin does not spring back

Question 17

Observation
What are we looking for in a patients position?

Answer 17

In bed? - slumped, sat up or supine
In a chair?
Using a position of ease - sometimes adopted in respiratory stress. Helps reduce respiratory fixing
Fixing with upper limbs to allow accessory muscles to aid breathing

Question 18

Why is it important to note how much oxygen a patient may be on?

Answer 18

Nasally - normally smaller amounts
Important because we need to keep track if the oxygen being given is going up or down
Going up - patient is getting worse
Going down - patient is getting better

Question 19

What is the first thing to be affected when a patients breathing is deteriorating/comprimised?

Answer 19

Respiratory rate (RR)

Question 20

Observation
Examples of different chest shapes -

Answer 20

Scoliosis
Kyphosis
Kyphoscoliosis
Pectus exacavatum - funnel chest
Pectus carinatum - pigeon chest
Hyperinflated/barrel chest - gas trapping in lungs , increased residual volume

Question 21

How to examine a fine tremor -

Answer 21

Due to meds ie. Beta agonist overdose
Ask patient to extend their arms and hands out in front of them. (+) test if their is a slight controllable shaking movement of hands/fingers

Question 22

How to examine a flapping tremor -

Answer 22

Due to increase CO2
Ask patient to put hands out in front of them, as if they are gesturing a car to stop (fingers will be pointed upwards)
Position allows u to note any flapping of hands around the wrist joint - up and down movement or fingers/hand

Question 24

Relationship between volume and pressure when it comes to breathing -

Answer 24

Increase in volume means decreased pressure (inspiration allowing air to flood in)
Decrease in volume means increase in pressure (expiration forcing air out)

Question 25

Consequences of a distended abdomen on breathing -

Answer 25

It inhibits diaphragmatic movement and will restrict the lungs from expanding Therefore reduces the volume of air that can be held by the lungs at full inspiration And also increases the WOB as diaphragm has to work harder against a greater resistance

Question 26

What is seen in a normal breathing pattern?

Answer 26

Ratio 1:2 inspiration to expiration Small, symmetrical coordinated increase in AP, transverse and vertical diameter of thorax Chest movement elements moving in harmony Abdomen - anterior abdominal wall motion

Question 27

Abnormal breathing signs What does excess negative pressure cause? What is hoovers sign? Flail segment -

Answer 27

Tracheal tube, asymmetry and paradoxical Hoovers sign - lower ribs move in on inspiration In drawing/recession of intercostal space A flail segment is paradoxical movement of chest wall - inward inspiration and outward expiration Segment of chest wall is ‘flail’ - cannot contribute to lung expansion ie flail rib fractures

Question 28

What are the accessory muscles of inspiration?

Answer 28

Scalenes (elevate rib cage) Sternocleidomastoid (elevate sternum) Trapezii Pectoralis major and minor Serratus anterior Latissimus Doris

Question 29

What are the accessory muscles of exhalation?

Answer 29

Rectus abdominis External and internal oblique Trans versus abdominis Internal intercostals - contraction of abdominal muscles causes abdominal contents to push up against diaphragm

Question 30

Quality of voice - what are we listening for?

Answer 30

Loudness Wet sounding Are they able to talk in full sentences Audible sounds

Question 31

Alerted breathing patterns: Eupnoea - Apnoea -

Answer 31

Eupnoea - normal breathing 12-20bpm Apnoea - absent breathing

Question 32

Altered breathing patterns Cheyne-stokes breathing - Biots respiration - How are these similar?

Answer 32

Cheyne - due to cardiac insult (heart failure, myocardial infarction etc) Period of apnoea followed by gradual increase and decrease of rapid breathing, and then apnoea again Biots - due to brain insult (strokes, brain infections) Period of apnoea followed by rapid breathing. Brain injury may cause breathing centre to be inhibited, therefore only responds to really strong stimulus eg. Increased CO2 in blood *similar, by cheyne is a gradual increase followed by gradual decrease in breathing before apnoea, whereas biot is sudden breathing to no breathing.

Question 33

Altered breathing patterns Kussmausl respiration - Tachypnoea - Bradypnoea -

Answer 33

Kussmauls - due to asodotic states - ketones of DKA. (Anaesthesia) Long tidal loops Tacypnoea - rapid breathing more than 20bpm Panic, pulmonary embolisms, myocardial infarctions Bradypnoea - abnormally slow, less than 10bpm Obesity, alcoholism

Question 34

What is auscultation? What is good to do prior to auscultation?

Answer 34

Process of listening to and interpreting the sounds produced within the thorax Used to verify observed and palpated findings before, during and after treatment Prior - listen at mouth Crackles heard at the mouth should be cleared by coughing in order to prevent them from masking other sounds during auscultation

Question 35

Where do the lung sit in the body?

Answer 35

Either side of the heart Bases sit on the diaphragm Apexes extend up and above the clavicle and into the root of the neck Right lung is larger and heavier

Question 36

Anatomy of lungs Trachea and bronchi - how many and what do they do?

Answer 36

Trachea - divides into R and L primary bronchi These divide into secondary bronchi - one for each lobe of lung Right primary bronchus branches 3 times to supply 3 lobes Left primary bronchus branches twice to supply two lobes Secondary divide again into tertiary/segmental bronchi Segmental bronchi lead to the different bronchopulmonary segments of each lobe **these conducting airways do not participate in gaseous exchange, simply allow air passage

Question 37

Anatomy of lungs How are they separated into lobes? How many lobes do R and L have? What are the lobes separated by?

Answer 37

Separated into lobes by the pleura which surrounds them R - 3 lobes, upper, middle and lower L - 2 lobes, upper and lower, but has something similar to middle called the lingula (always listening on auscultation) Lobes separated by fissures

Question 38

Anatomy of the lungs What are fissures?

Answer 38

Double fold of visceral pleura that fold back on one an another to either completely or incompletely separate lung parenchyma to help form lung lobes

Question 39

Anatomy of the lungs Fissures in the L lung - Fissures in R lung -

Answer 39

L - has one fissure, the oblique fissure which separates upper and lower lobe R - has two fissures Oblique fissure - physically separates lower lobe from upper and middle lobe Horizontal fissure - separates upper lobe from the middle lobe

Question 40

Auscultation What are we listening for?

Answer 40

The quality of the breath sounds Intensity of the breath sounds Presence of any added sounds

Question 41

Name bony points that help identify lung placement -

Answer 41

2.cm above medial 1/3 clavicle on both right and left lung 4th costal cartilage/costo-sternal joint on both right and left On the right - 6th costal cartilage/costo-sternal joint On left - rib 6 at mid-clavicular line to avoid the heart Rib 8 at mid axillary line on both the right and the left T10 posteriorly on either side 2cm away from spinous process

Question 42

Paradoxical breathing - Examples of this:

Answer 42

Chest wall moves inward on inspiration and outward on expiration Eg. Hoovers sign, flail chest and abdominal paradox

Question 43

How are breath sounds generated?

Answer 43

Turbulent air in airways Only generated in small proportion of the airways Transmitted through lung to chest wall Lung tissue is a good sound conductor Air = poor sound conductor

Question 44

Breath sounds - what does normal sound like? (Vesicular)

Answer 44

Sounds heard over entire lung fields Muffled in quality Normal to get quieter the further from the trachea Inspiration, louder than expiration Inspiration is longer than expiration No pause between inspiration and expiration

Question 45

Breath sounds -what does increased/bronchial sound like? Due to:

Answer 45

Louder, coarse on expiration and inspiration, with a pause between Normally heard over the trachea (which is not done clinically) Due to: consolidation (pneumonia) Collapse Large mass Fluid line of a pleural effusion

Question 46

Breath sounds - decreased/absent, what does it sound like? Caused by:

Answer 46

Either a decrease from normal or completely absent Cause: shallow breathing/drowsiness/pain Poor positioning Collapse Collapse with complete obstruction if airway Hyperinflation eg. Emphysema Obesity/very muscular patients Pleural effusion Pneumothorax/heamothrax

Question 47

Added sounds Crackles/crepitations -

Answer 47

Due to secretions in airways being audible as air passes through them Two groups - coarse and fine Can happen anywhere in respiratory cycle (inspiration/expiration/both) Mostly indicative of sputum, however absence of crackles does not always indicate sputum absence Can also be due to explosive sound from equalisation of pressure in an obstructed airway

Question 48

Added sounds Crackles and their timing -

Answer 48

Timing of when they are heard can indicate potential position in bronchial tree: Early inspiratory crackles - proximal airways Late inspiratory crackles - peripheral airways Early expiratory crackles - proximal airways Late expiratory crackles - peripheral airways

Question 49

Added sounds Wheeze -

Answer 49

Whistling sound causes by air passing through narrowed airway 2 types: Monophonic - generated by one airway, single note, same position in respiratory cycle Polyphonic - generated by several airways giving different notes Pitch varies depending on narrowing - greater narrowing=higher pitch Can occur in inspiration/expiration/both Eg. Brochospasm, tumour, airway oedema, forgiven body

Question 50

Added sounds Pleural rub -

Answer 50

Creaky leathery sound Pleural surfaces rubbing together Usually heard in late inspiration and early expiration, and often identical Eg. Inflammation of pleura

Question 51

Good auscultation technique entails:

Answer 51

Systematic manner, comparing one side to the other whilst visualising underlying structures Good surface anatomy to ensure correct placement Stethoscope never placed over clothing and/or sheets Cleaned in between patient use Patients sit upright where they can breath through mouth to reduce nose turbulence

Question 52

Auscultation, how do we assess: Upper lobes - Middle lobes - Lower lobes -

Answer 52

Upper - anteriorly Middle - anteriorly (males and lingula) or laterally Lower - posteriorly

Question 53

What can interfere with auscultation?

Answer 53

Movement of stethoscope on skin Oral cavity sounds Clothing/sheets Talking Hairy skin Water in tubing Shivering External sounds

Question 54

How can we find out what bronchial (increased) breath sounds sound like?

Answer 54

It is normal to hear this if your auscultate over the trachea This is not done clinically, but if you are hearing the same sound in the lung fields as you hear over the trachea, this could indicate bronchial breath sounds

Question 55

What does normal breathing appear quieter/louder in certain areas?

Answer 55

More intense closer to the trachea Quieter the further away you get from main airways, air flow is lamina here.

Question 56

Normal breath sounds: inspiration and expiration timings -

Answer 56

Inspiration is louder than expiration Inspiration is longer than expiration No pause between inspiration and expiration

Question 57

What can cause abnormal quiet breath sounds?

Answer 57

Reduced air entry, effects ability to generate sound - atelectasis - alveoli deflates causing partial or complete collapsed lung Reduced chest wall movement Reduced transmission of sound - pleural effusion pleural thickening Hyperinflation - breath at small volumes

Question 58

Bronchial breath sounds - inspiration and expiration timings:

Answer 58

Inspiration and expiration will be more equal in timing, more harsh and more intense Due to… Consolidation Large collapse Large mass in lung etc

Question 59

Added sounds What is stridor?

Answer 59

Caused by turbulent airflow through narrowing/obstruction in the upper airway This is an emergency and can often be heard normally, no stethoscope needed Eg. What happens to my throat during anaphalaxsis

Question 60

Added sounds Types of wheeze-

Answer 60

Monophonic - one airway, one sound eg. Tumour Polyphonic - multiple airways, multiple sounds eg. Asthma

Question 61

Added sounds Types of crackles -

Answer 61

Fine - due to liquid. Can sound like twisting hair by ear Course - sputum

Question 62

What comes under the bracket of breath sounds? What comes under the bracket of added sounds?

Answer 62

Breath - normal, reduced/quiet and bronchial Added - crackles (fine/course), wheeze (mono/pol), pleural rub, stridor

Question 63

management strategies to help reduced interference during auscultation:

Answer 63

Firm skin contract Cough/blow nose beforehand Place stethoscope directly on skin Ensure patient has a way of getting your attention eg. Tapping you on the arm