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Flashcards in Clinical Assessment Module 3 Pulm Deck (232)
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Health History

what 7 things would you want to ask a patient about if they are presenting with pulm complaint

Chest pain-Wheezing in chest pain ….. No pain fibers in lungs themselves… what hurts is the chest space (parietal space) want to rule out chest pain…. Could be a pleurtis (between ribs and lungs)

Dyspnea- SOB, how does it affect your ADL’s (activity of daily living)


Cough-Cough, productive (wet), sputum (color), how often is the cough

Hemoptysis- coughing up blood (maybe TB or cancer)

Smoking history

Immunization history- flu pneumonia vaccinations




Techniques for exam

Inspection- Rate Rhythm Depth and Effort



Auscultation- And listen to lungs (normal or adventitious breath sounds)


What is Stridor

  • Audible high-pitched wheeze
  • Sign of upper airway obstruction in the larynx or trachea
  • Something you notice when you walk in the room. Don’t need a stethoscope.
  • Common with croup
  • More on inspiration than expiration…. Obstruction in upper airways


What does Nasal Flaring represent?

  • Represents an increased effort of breathing
  • Trying to increase a way that air can get in from having low O2


what does intercostal retractions represent?

  • Represents an increased effort of breathing

  • Increased lung volume
  • When fluid in lungs and body experiences hypoxemia
  • Inspect patient without clothes and gown to really see the chest



what three conditions do you commonly see it with?

  • Helps to open airway….
  • Common in emphysema
  • Epiglottitis common
  • Haemophilus influenzae


Normal Breathing sound words to use (3)

Vesicular- Usually they are quiet and vesicular  (heard more on inspiration)

Bronchial- louder and higher pitches (bronchial) more tracheal mostly on expiration



Adventitious Sounds

Adventitious souds: abnormal sounds

  • Crackles
  • Wheezes
  • Rhonchi


So, do you just listen to the back of the chest for lung sounds?

what are you missing?

NO NO NO NO! If you don’t listen to the front you ARE NOT even listening to the right middle lung….


where do you listen? 




  • Intermittent, Brief
  • Nonmusical
  • Suggestive of pneumonia or heart failure
  • Mostly inspiration
  • stepping on dry leaves (crackling tissue paper)
  • Loud crackles everywhere --- inspect chest (may be hairy or clothes)



  • Relatively high-pitched sound with hissing or shrill quality
  • Suggestive of narrowed airways, as in asthma, COPD asthma or bronchitis
  • Constricted airway- airway smaller as air goes through=wheezing
  • You sometimes can here it without auscultation
  • Inspiration and expiration



  • Relatively low-pitched sound with snoring quality
  • Suggestive of secretions in large airways
  • Can ask them to cough and it can maybe clear it
  • Usually heard more on expiration


Speical tests: list them (4)





Quick info Hoffman listed off :

  • See Bates Table 8-5 (p 328)
  • Fremitus- transmission of vibration through chest
  • If weird stuff going on then you have increased fremitus
  • If you hear more profound on one side then that can be where the consolidation is
  • Listen anterior and posterior!
  • Bronchophony/ egophony/ whispered pectoriloquy = do only one to better help understand consolidattion in lungs of the pt
  • Fluid transmits vibration more then air







Tactile Fremitus

when is it increased? when is it decreased?

presence of fluid transmits better through liquid than air


Technique: Use the ulnar surface of the hand and ask the patient to repeat the words “ninety-nine” as the entire posterior thorax is covered


Normal lung transmits a palpable vibratory sensation to the chest wall; this is called fremitus

Fremitus becomes more pronounced over areas of consolidation, as in pneumonia (when the normally air-filled parenchyma becomes fluid-filled)

Fremitus is decreased or absent when the transmission of vibrations is impeded by a thick chest wall, an obstructed bronchus, COPD or pleural changes (eg, effusion or air)




Techniques: Ask the patient to repeat the word “ninety-nine” each time the lung fields are auscultated


Normally the lung sounds transmitted through the chest wall are muffled and indistinct

Bronchophony is when the spoken words are louder or more clear as would be the case over consolidation, as in pneumonia




Techniques: Ask the patient to repeat the vowel “E” each time the lung fields are auscultated

Findings: Normally the spoken “E” is heard as “E”  
If “E” sounds like “A,” egophony is present, seen in lobar consolidation from pneumonia  



Whispered Pectoriloquy


Techniques: Ask the patient to whisper “one-two-three” while the lung fields are auscultated  


Findings: Normally the whispered words are heard faintly and indistinctly, if at all

Louder, clearer whispered words are called whispered pectoriloquy and represent consolidation, as in pneumonia


CASE 1: 

•14 Y.O. Female w/ no medical Hx presents c/o SOB.

•HPI: Onset 2 weeks prior with SOB and cough when going outside in the cold. Lasts 1-2 hours. Seems to be getting worse. Can’t play outside. Now doesn’t want to go to school.

•Meds – None

•Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-94, RR-32, BP-117/72, T-37, SaO2-97% RA


what do we think?



•Further exam:

  • Heart - reg, no murmur
  • Lungs – diffuse expiratory wheezes, prolonged expiratory time
    • Percussion, egophany, fremitus normal, no whispered pectoriloquy
  • Peak flow = 100 L/min (want to see at least 200, so this is bad)
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

•DDX – COPD, Bronchitis, Asthma, Anxiety/Panic

•Other diagnostics:

  • CXR
  • PFTs (reversibility)

What we discussed:

(Wheezes start in expiratory and if bad enough go to inspiration

No consolidation because of no whispered pertorlioquy

Bad peak flow—cant breathe out

Such thing as a cardiac wheeze

If someone is faking a wheeze then you hear it more up top vs. where it should come from lower.)


WHAT IS IT: Asthma



what are the four categorizations?

what do you treat with?

what airway size does this effect?

why is it harder to exhale and not inhale (as much)?

  • Categorization (tells us the treatment)
    • Intermittent- comes at certain time with certain stressor
    • Mild persistent
    • Moderate persistent
    • Severe persistent
  • Tx:
    • Beta agonists- use 10-20 min before going outside
      • Short vs. long acting
    • Steroids (reduce inflammation—make lumen wider)- then move onto steroids once under control
      • Inhaled vs. systemic
      • Leukotriene receptor antagonists


Airway becomes inflamed but smaller in the middle (becomes thicker) so muscles are are squishing in on airway ---- resistance of flow goes up exponentially while inflamed (constricted) airway

Harder to exhale–

Radial traction=

Inhale-diaphragm drops chest wall out and enlarge chest= when that happens the lumen get a tiny bit bigger this is radial traction (pulling from center out)

Exhale-diaphragm rises chest wall closes and diameter closes in pushed towards center (when we exhale you have more constriction) that’s why you hear wheezes on exhale and when its really bad it is on inhale because they can barely exhale


•62 Y.O. male w/ Hx heart Dz, Diabetes, HTN, presents c/o malaise.

•HPI: Onset 2 days prior with fatigue and non-productive cough. Yesterday developed increasing malaise and fever of 100.4. Admits to chills.

•Meds – metformin, metoprolol, lisinopril, aspirin, atorvastatin

•Exam – WD/WN/WM. Sitting on exam table. Appears ill.

–V.S. – P-94, RR-28, BP-133/85, T-38.2, SaO2-93% RA

  -- What do you think? --

  • Pulse- high- metoprolol
  • RR-high– increase o2 with infection
  • Temp- fever
  • O2- low- low o2 stat suggest pulmonary
  • Maybe infection

Further exam:

  • Heart - reg, no murmur
  • Lungs – Diminshed over LLL
    • Percussion dull at L base, no egophany or whispered pectoriloquy, fremitus decreased over LLL
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

DDX – COPD, Bronchitis, pneumonia, pleural effusion, heart failure

Other diagnostics:

  • CXR- yes with this case you should get it … required for pleural effusion diagnosis
  • CBC (white count elevated with neutrophils will tell us infection) , sputum Cx, EKG, Troponin-I


COPD- basically asthma on steroids

Bronchitis- no because this is viral so don’t expect fever and malaise

Pneumonia- no because he doesn’t have signs of consolidation

Pleural effusion- possibly

Heart failure- fluid can back up into the lungs but then you would expect crackles and no fever

What is it?

Pleural Effusion - ? empyema


Pleural Effusion  vs empyema

what test shoul you do?

what are the two treatment plans depending on the fluid type?



  • Thoracentesis with analysis
    • Cell count, cytology, culture, chemistries
  • ? Antibiotics – yes due to infection
  • ? Diuretics– if infection NO – if from heart failure (yes!)


Have to always sample it

Empyema is an exudate

Transudate- fluid has been transmitted through a barrier

Exudates- dumped by something (dead cells dump blood, cancer cells dump, bacterial infections dump puss)


•62 Y.O. male w/ Hx heart Dz, Diabetes, HTN, presents c/o malaise.

•HPI: Onset 2 days prior with fatigue and cough productive of green sputum. Yesterday developed increasing malaise and fever of 100.4. Admits to chills.

•Meds – metformin, metoprolol, lisinopril, aspirin, atorvastatin

•Exam – WD/WN/WM. Sitting on exam table. Appears ill.

–V.S. – P-94, RR-28, BP-133/85, T-38.2, SaO2-93% RA


  -- What do you think? --

Green sputum- has productive cough compared to last guy

Pulse- HIGH

RR- high



O2- low

Productive cough usually tells you RESPIRATORY

  • Further exam:
    • Heart - reg, no murmur
    • Lungs – Inspiratory crackles over LLL
      • Percussion normal, has some egophany and whispered pectoriloquy, fremitus increased over LLL
    • Abdomen – benign
    • Extremities – pulses 2+, No edema
  • DDX – COPD, Bronchitis, pneumonia, heart failure
  • Other diagnostics:
    • CBC (elevated white count), sputum Cx (if you can YES), EKG, Troponin-I


WHAT IS IT: Pneumonia – Likely acute bacterial


Pneumonia – Likely acute bacterial



  • Antibiotics – Consider appropriate choice- CAP vs. HCAP
  • Fluids
  • Bronchodilators (if wheezing) /mucolytics (if something needs to be broken up)
  • Chest physiotherapy (tap on the chest)
  • Flutter valve  (helpful to also break things up)
  • Oxygen (no O2 with stats in 90’s)


Has acute infection should have fluids


•41 Y.O. female smoker presents c/o SOB.

•HPI: Onset this morning at 0830 with sudden onset SOB. Pain in R chest, sharp. Worse with inspiration. No cough.

•Meds – OCPs.

•Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-108, RR-28, BP-101/68, T-38.0, SaO2-90% RA


  -- What do you think? --


Chest pain- heart, aorta, pulmonary embolism

Left sided chest pain is more concerning then right side pain

Sharp pain- less concerned about heart because usually dull pain

inspiration worse- less concerned with heart issues… doesn’t usually change with inspiration with heart issues

HR- high

RR- high

BP- low (soft)

T- elevated

O2- low

Smoker, birth control, certain spot of chest, sharp, no cough, tachy, high RR, BP soft from no blood to left side of heart), saturation drops, and fever a bit can occur

Further exam:

  • Heart - reg, no murmur
  • Lungs – vesicular (normal)
    • Percussion normal, no egophany or whispered pectoriloquy, fremitus normal.
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

DDX – ACS, Anxiety, Pneumonia, Heart failure, Pulmonary embolism, pneumothorax (maybe, sharp pain, specific area but tympani with percussion)

Other diagnostics:

  • CXR (to see if there is a pneumothorax)
  • ABG (arterial blood gas) how well lungs are exchanging oxygen
  • EKG (inexpensive and easy… not sensitive but it is SPECIFIC)
  • CBC (INFECTION- THEN WBC-no role in this case), D-Dimer (fibrin degradation process– people form clots they break down and release this D-Dimer) (but it can be elevated for a lot of reasons) (makes it sensitive but not specific) , sputum Cx (fever so she could get this?) , Troponin-I
  • Chest CTA (CT angiogram) gold Standard.. Have to put dye but puts strain on kidneys… cant use this on people with renal disease
  • VQ scan (people with chronic lung disease already have VQ abnormalities)
  • Lower extremity venous Doppler (look at deep veins) if positive the suspicion for PE goes WAY UP!

Normal lung exam except for pain with inspiration- hallmark of pulmonary embolism

WHAT IS IT? Pulmonary Embolism 


Pulmonary Embolism



  • Anticoagulation (use 1 of these 4 things)
    • Heparin (IV at hospital)
    • Low molecular weight heparin (sub Q injection… can go home)
    • Warfarin (provoked DVT- 6 months)
    • Factor X-A inhibitor (Riv. Doesn’t need to be monitored like warfarin and effectively immediately) BUT doesn’t have an antidote
  • Oxygen (maybe dependent)
  • Pain control (pain with inspiration)
  • Vena cava filter (uncommon)--- clot gets trapped from filter



Wells Criteria

criteria of whether they have PE or not

Pretest probability

Can give some ideas of what to do it you cant use a diagnostic test listed previously


•19 Y.O. female smoker presents c/o SOB.

•HPI: Onset this morning at 0830 with sudden onset SOB. Pain in R chest, sharp. Worse with inspiration. No cough.

•Meds – OCPs.

•Exam – WD/WN/WF. Sitting on exam table. Anxious.

–V.S. – P-108, RR-28, BP-101/68, T-37.0, SaO2-90% RA


  -- What do you think? --

  • Hr- high
  • Rr- high
  • Bp- soft
  • Temp- no fever
  • O2- stat
  • Saturation really made him feel not anxiety but before thought maybe that

Further exam:

  • Heart - reg, no murmur
  • Lungs – vesicular
    • Percussion tympanic RUL, no egophany or whispered pectoriloquy, fremitus normal.
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

DDX – ACS, Anxiety (yes, until o2 and exam), Pneumonia (no consolidation), Heart failure, Pulmonary embolism (less likely with tympani) , pneumothorax

Other diagnostics:

  • CXR– tool of choice for diagnosising this… but rarely obvious on a chest x-ray
  • Ask for end exhalation views (want it to be as dense as possible – more squished)
  • ABG
  • EKG
  • CBC, D-Dimer, sputum Cx, Troponin-I (no Acute coronary syndrome don’t need this)
  • Chest CTA– maybe … chest x-ray may give answer
  • VQ scan
  • Lower extremity venous Doppler


Exam= tympani leans towards maybe spontaneous pneumothorax

Right upper lobe… think about gravity… air escaping lung and going into space.. The air will go up in the water like a bubble… so you will here tympani upwards because of this

If you have fluid trapped it will go down!

WhaT is it? Pneumothorax






  • Observation vs. chest decompression (needle aspiration)
    • <2-3 cm
    • >3 cm
  • Needle aspiration
  • Chest tube
  • Oxygen
  • Pain control
  • pleurodesis


•41 Y.O. female smoker presents c/o cough.

•HPI: Onset this morning at 0830 upon awakening with hacking non-productive cough. Pain throughout chest with cough. Admits to URI Sx up until yesterday.

•Meds – OCPs.

•Exam – WD/WN/WF. Sitting on exam table, NAD (no apparent distressed).

–V.S. – P-90, RR-18, BP-101/68, T-37.0, SaO2-96% RA


  -- What do you think? --


  • Hr- little high
  • Rr- good
  • Bp- fine
  • T-fine
  • SaO2-fine
  • What are we worried about in these vital signs- not worried about vital signs

Further exam:

  • Heart - reg, no murmur
  • Lungs – vesicular except she wheezes when she coughs
  • Percussion normal, no egophany or whispered pectoriloquy, fremitus normal.
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

DDX – ACS, Pneumonia (not likely but not uncommon for someone with obstructive disease to then get a bacterial infection), Heart failure, Pulmonary embolism (no pain), bronchitis, pneumothorax

Other diagnostics:

  • CXR– get the chest x-ray if available …but this can be a clinical diagnosis
  • EKG-- +/-
  • CBC, D-Dimer, sputum Cx, Troponin-I (for ruling out ACS don’t need that here)
  • Chest CTA
  • VQ scan
  • Lower extremity venous Doppler

WHAT IS IT? Acute Bronchitis


Acute Bronchitis


what is it aimed at?


–Possibly bronchodilators, cough suppressants

–Tincture of time (reassurance)

–Consider antibiotics (not necessarily needed)


  • Frequently follows colds
  • And cough can last for weeks
  • Want to treat the symptoms


•41 Y.O. female smoker presents c/o SOB.

•HPI: Not sure when it began. Maybe months to years ago. Hates medical providers and avoided coming in. Admits hacking cough, worse in a.m. Swallows sputum. No fever or chills. No hemoptysis.

•Meds – OCPs.

•Exam – WD/WN/WF. Sitting on exam table. Irritable. Thin. Barrel chested. + digital clubbing. + pursed lip breathing when she moves about.

–V.S. – P-100, RR-20, BP-144/95, T-37.3, SaO2-90% RA


  -- What do you think? --

  • P- high
  • RR-normal
  • BP- high
  • T- normal
  • O2- low
  • Lung cancer would have more hemoptysis

Further exam:

  • Heart - reg, no murmur
  • Lungs – Almost inaudible. (ALMOST CAN’T HEAR THEM)
  • Abdomen – benign
  • Extremities – pulses 2+, No edema

DDX – ACS, Pneumonia (no signs of consolidation), Heart failure, Pulmonary embolism, pneumothorax (only inaudible over a certain side, and would have hypotension and pulse), COPD

Other diagnostics:

  • CXR– yes!
  • EKG
  • CBC, ABG, D-Dimer, sputum Cx, Troponin-I
  • Chest CTA (for PE)
  • VQ scan (for PE)
  • Lower extremity venous Doppler
  • Bronchoscopy (if chest x-ray does not help… these do)




what is the difference in acute and maitenance treatment?

  • Acute Tx:
  • Short acting  Beta adrenergic, anticholinergic, or combination
  • Steroids  (in combination only)
  • Maintenance Tx
  • Possibly LABA
  • Long acting Anticholinergics
  • Theophylline
  • PDE-4 inhibitors
  • Other approaches
    • Oxygen
    • Smoking cessation
    • Vaccinations
    • Rehab
    • Education
    • Nutrition
    • Lung volume reduction surgery

Emphysema vs. chronic bronchitis

NOTES: Regulate breathing on pH of blood– medullary= breathing control.– CO2 level regulates all of our breathing…. Breathe out to remove carbon dioxide from blood

In COPD cant remove carbon dioxide effectively and receptors get messed up in midbrain … so o2 sensors stimulate COPD people to breathe… by giving COPD patients oxygen it removes their want to breathe … but don’t try to get it to 98% spO2 get it to 80-90%

On ambulance ride- not going to kill them if you give too much O2– but if you admit them in the hospital and put them on 4% O2 and then now it's at 98% they slowly decrease their respiration and carbon dioxide levels slowly increase they have hypoxic drive so they can become comatose and die. :(


Blue Bloater Vs. Pink Puffer


COPD lung Vs. Healthy lung

  • Barrel chest and air trapping so when they try to take a deep breathe very little air comes in or out.
  • So COPD usually hardly any breath
  • COPD= blue bloaters


•71 Y.O. female smoker with Hx DM-2 presents c/o SOB.

•HPI: Onset last week with nausea followed by Dyspenia On Exertion (DOE progressing to SOB. Sleeping in a recliner. No chest pain. No cough.

•Meds – Metformin, glargine insulin

•Exam – WD/WN/WF. Sitting on exam table. Anxious. Can’t lay flat for exam.

–V.S. – P-108, RR-28, BP-101/68, T-37.0, SaO2-90% RA


  -- What do you think? --

  • P-high
  • Rr-high
  • Bp-soft
  • T-ok
  • O2-low

Further exam:

  • Heart - reg, no murmur
  • Lungs – crackles from bases to 2/3 up to the apex bilateral
  • Percussion dull in bases, no egophany or whispered pectoriloquy, fremitus normal.
  • Abdomen – benign
  • Extremities – pulses 2+, 3+ bilateral LE edema

DDX – ACS (no chest pain), Anxiety, Pneumonia (crackles), Heart failure (fluid drains out in the lungs– crackles), Pulmonary embolism, pleural effusion

Other diagnostics:

  • CXR- YES
  • EKG- YES
  • CBC (hemoglobin!), BNP (marker for heart failure… increases with atrial stretch), D-Dimer (don’t get D-dimer if no worry about PE), sputum Cx, Troponin-I (YES!)
  • Chest CTA
  • 2D Echo– (YES!... Picture of heart)
  • VQ scan
  • Lower extremity venous Doppler
  • Pulmonary Ultra sound (US)– chest filled with air and US doesn’t do well with air but there is a new technique to use US for heart failure it is sensitive and specific


Diabetes ACS- nausea! (suspicion of MI--- Do work up for MI)





what is the treatment?

  • Tx:
  • Diuresis (gets them out of acute heart failure)
  • Oxygen
  • Possibly
  • ACE-I  
  • Beta blocker (cardio protective for people who have had an MI)
  • Aldosterone antagonist (reduce fluid retention and people in heart failure)


CHF because they now have wall motion abnormality because they had an MI last week (remmeber from the case)

Cant lay flat because of fluid and gravity

Had the big one (MI) (last week) not having it now


CXR Challenges


  • 2 dimensional image
  • Focus without a lens
  • Magnification
  • Alignment (must be straight on)
  • Crowding
  • Fluid and tissue density
  • Anatomical variation or abnormality (breasts)


Standard Views

  • The standard chest examination
    • PA (Posterior-Anterior) and lateral chest x-ray
    • Films are read together
    • AP (Anterior- Posterior) portable or supine
    • AP/Lateral


Why does the x-ray have a lot of distance from the patient?

Need distance to focus rays because there is no lens

Only the straight rays make it


What side is lateral view always on?

Always LEFT SIDE of patient against receptor

Because of heart

So put heart as close to receptor as we can get so that it is in focus as best as can


Positioning for xrays?

why are PA preferred to AP?

and why is lateral always have the plate against the pts left side?

•Why PA and not AP?
•Why left side against the film on the lateral view?
o It diminishes the effect of blurring and magnification on the heart.
•On the AP film, the heart shadow is magnified and blurred because it is an anterior structure.
You want the heart to be as close to the receptor (plate) as possible, so must be facing backwards


What About Supine vs. Upright?

•On the AP supine film there is more equalization (cephalization) of the pulmonary vasculature when the size of the lower lobe vessels are compared to the upper.

•X Ray tube is closer to the receptor



AP- heart will be bigger

Supine- equalize vasculature (cephalization)

See vasculature more prominent in bases of lungs when standing (gravity)…. If we cephalization when standing--- heart failure


when patient laying supine it minics the cephalization and can look like pathology, but in fact its how the patient was positioned so need to know this when interpreting the xray


AP is a tougher xray to read and harder to interpret since farther away from the receptor


First, HOW to evaluate the Image

•Turn off stray lights, optimize room lighting

•Patient Data (name, date, old films)

•Routine Technique:


oSupine, erect, portable

•Quality issues

o Inspiration

o Exposure/penetration

o Rotation


How should the patient be examined

(inspiration or expiration? )

what levels should the diaphram be at compared with anterior and posterior ribs?

•The patient should be examined in full inspiration.

o Diaphragm at about the level of the 8th - 10th posterior rib or 5th - 6th anterior rib.



what is a good tactic to measure the penetration on a xray?

what do you want to see to tell that it is appropriate penetration?

•A good PA film

oThe thoracic spine disc spaces should be barely visible through the heart but bony details of the spine are not usually seen

Look at spine disc spaces… want to make sure they are a little visible through heart


left- over penetration (removes details, makes it so you miss something)


right- under penetrated (everything looks brighter, can't interpret this)



Lateral View Penetration

what are two landmarks or patterns you want to recognize from the lateral view to confirm there is appropriate penetration?

•Observe that the spine appears to darken as you look caudally.

o This is due to more air in lung in the lower lobes and less chest wall.

•The sternum should be seen edge on.

Want to see spinal canal and more seen as you go down caudally


Assessing Rotation

•The patient must be imaged flat against the cassette

•If there is rotation of the patient, the structures may look very unusual

•Observe the clavicular head alignment with spinous process

NOTES on Picture:

  • Clavicle front
  • Spinous process back
  • So to see if they are turned can see that it wont be middle


check it out


know your anatomy


In front LUL goes all the way to bottom!!!! no way! that's crayzeee


Reading the Image

what shouldn't you do for technique?

what should you do for technique?

•Conduct a directed search

o Avoid simply gazing at the film

o Have a planned search in mind


What to Examine on a CXR

6 categories

•Lungs: Trachea, L & R mainstem bronchi, abnormal shadowing, or lucency

•Pleura: effusion, thickening, calcification

•Heart: thorax: heart width > 2:1 ? Heart Borders. Cardiac configuration?

•Mediastinum: contour, width, mass?

•Hila: masses, lymphadenopathy

•Pulmonary vessels: artery or vein enlargement

•Soft tissues: subcutaneous emphysema, mastectomy

•Bones: lesions or fractures


What is it?



Chronic obstructive pulmonary disease

Barrel chest

Lower hemi diagrams (flattened)

Looks over exposed



What is it

Pleural Effusions


Air goes up fluid goes down

Cant see the costaphrenic angle and meniscus from fluid

(this would be seen in the corner between the diaphram and the ribs, in Pleural effusion this is obliterated)


What's this?

Large Pleural Effusion


Now a bucket of fluid and an air fluid line on the left side


the line at the top is the key to differentiate between conslidation like pneumonia, it has pushed everything to the right side


what is this?



Lines markings inside and no markings outside, look for visceral line


**make sure expiratory view!**


what is this?

Right Sided Pneumo-thorax


Right side… all open space


what's this?

Resolved Pneumo-thorax with Sub Q air

A lot of sub Q emphysema

Don’t want air under left diaphragm….


Great explanation from Ruth: :)

"I'm pretty sure the air under the left diaphragm is gastric air - the sub Q air is the grainy texture throughout the right and mid torso, very diffuse. He described it as "rice crispies" under the skin that popped and crackled."


what is this?

Right sided tension pneumothorax

o Right sided lucency

o Leftward mediastinal shift

o This is a medical emergency



Silhouette Sign

  • One of the most useful signs in chest radiology
    • Elimination of the silhouette or loss of lung/soft tissue interface caused by a mass or fluid in the normally air filled lung
    • Most commonly associated with infiltrates
    • If an intrathoracic opacity is in anatomic contact with, for example, the heart border, then the opacity will obscure that border
  • Commonly applied to:
    • Heart
    • Aorta
    • Chest wall
    • Diaphragm  



Border of something is obscured in chest



what is this?

Silhouette Sign

•The right heart border is silhouetted out

•Which lobe does the infiltrate affect?


infiltrative process, but you can't tell which lobe since all the lobes (think about bates picture) overlap here, you can't tell


not sure about this guys? sorry 

Right middle lobe touches that portion of the hear

Silhouette of left lower lobe means left hemi diagram is obscured?




you can tell where the consolidation is here because you think about the structure of the lung. the fluid/pus or whatever is stays here because its is contained within one lobe, thats why its not all the way at the bottom near the diaphram


Burring of right hemi diaphragm so right lower lobe ….



Where is the Pneumonia?

what was said in class:R oblique fissure

BUT confusing card

but pneumonia looks like RUL


again said this in class R oblique fissure


but looks like RUL


R oblique fissure

Because of aorta being obscured


what's going on?


•60 year-old male with shortness of breath and orthopnea

o Cardiomegaly

o Marked prominence of the pulmonary vascularity

o Increased density in the small vasculature and alveolar spaces

o Kerley B lines


HEART FAILURE– heart dilates and gets bigger (hypertrophy or dilation--floppy bag)

Bronchial cupping--can see thickness of it because full of fluid


what is it?

Post Operative Acute Pulmonary Edema


What is this?

Severe HF: Before and after treatment

Heart failure from heart



other tests.....

•Imaging/procedural testing
•PFTs  (peak flows)
•VQ scan
•Chest CTA (CT scan with pulmonary angiography)
•Thoracic US
•MRI (rarely for chest unless looking for masses)
•Thoracentesis (pulling fluid out)


what's this?

Pulmonary function test


Used for obstructive disease


**pay attention to the first image on the left, the exhale loop above the x axis, thats normal, but when see the second line, it is characteristic of obstructive lung disease**


what's this?

VQ Scan Showing PE


Nuclear imaging …. Vs…. Perfusion

Whole lung is ventilated but not perfused

So embolism blocking that


what's this?

Chest CTA showing PE


Dark area where not perfusing LOT


what's this?

bullus emphasema CT




Labs to think about in PULM?






•Fluid studies

o Cytology

o Culture

o Other


consolidation is most commonlu associated with?





She said this like 93840928 times during class so think you might want to know it....


when someone has asthma, what are two things that happen?

1. the lumen gets narrower

2. the muscles around the tube contract


if you suspect a pneumothorax what do you want them to do on the chest xray?

you want them to exhale completely because it hightlights where there is more air



usually for lung xray, you have the patient inhale all the way, but that will hide the pneumothorax, so you need t ohave the patient exhale compeltely and then it wil highlight it


for a pneumothorax, when do you want to observe vs chest compression

2-3 observe

>3 decompress


can do this by needle aspiration or chest tube


if diabetes presents with NAUSEA....THINK....

coronary syndrome....Heart failure!!! which leads to pulmonary edema!!!


when looking at the xray of a woman what does it look like and why is it important?

it will be more opaque because of breast tissue


this is important to keep in mind because you don't want to confuse this opacity with pathologic disease


lateral view on chest xrays allows you to see what?



this is important



What are 4 types of Pulmonary Function Tests (PFTs)

1) Spirometry  : Measure Volume of Air Movement

2) Body Plethysmography: Total Lung Capacity + Residual Volume

3) Inhalation Challenge Tests: Nebulized Meds Followed by Spirometry

4) Exercise Stress Tests: Followed by Spirometry



Gas Diffusion Tests  (2)

1) Arterial Blood Gas

2) Carbon Monoxide Diffusion Capacity (DLCO)



what does it measure?

do it often?

  • Measures Amount of O2 + CO2 in Blood  
  • Measure Acidity + Alkalinity
  • Avoid Unless Necessary (Invasive)


Carbon Monoxide Diffusion Capacity (DLCO)

Measures How Well Lungs Transfer CO into Blood


What is a D-Dimer?

What are causes for elvated D-Dimer?

3 things to remember with D-Dimer?


Degradation Product of Fibrin – Indicates Ongoing Activation of Hemostatic System

Reference [Concen] < 0.5 ug/mL FEU

Causes of Elevated D-Dimer:

  • Pregnancy
  • Rheumatoid Arthritis
  • Trauma
  • Elevated Triglycerides
  • Heart + Liver Disease


  1. Clinical Setting Where There is a Need to R/o Thrombotic Cause of Symptom
  2. Never Rely SOLELY on a D-Dimer to R/i or R/o a Pulmonary Embolus (Helps to Exclude Dx – Not Make One)
  3. A D-Dimer(-) is Most Valid and Useful When Test is Completed on People Who are Low Risk for Thrombosis




what can you detect?


Can Detect Pulmonary Embolism


spiral CT scan

what can you detect?

Can Detect Abnormalities Well


picture: pulmonary embolism


Ventilation/perfusion scan (V/Q scan)

what type of material is used for this test? how is it administered to the patient?

  • Small Amount of Radioactive Material to Study Ventilation + Perfusion

  • Radioactive Material is Inhaled – Allowing the Capture of Images of Air Movement within Lungs


Pulmonary Angiogram

what is it the gold standard for?

Gold Standard dx PE

  • Provides Very Clear Image of Blood Flow within the Lungs
  • Usually Performed AFTER Other Tests FAIL to Provide Answers
  • Potentially Serious Risks – Heart Arrhythmia, Renal Damage from Dye


What's this?

Right Saddle Embolus



Bridges Across the Pulmonary Artery From Heart as it Divides into Right + Left Pulmonary Arteries – Causes Sudden Death


What kind of picture is this?

CT angiogram




what is it used to Rule Out

who is it reserved for 

what has greatly increased the value of MRI



R/o Pulmonary Embolism in Pregnancy/Allergy

  • Traditionally Reserved for Pregnant Women or Patients with Renal Disease (Pulmonary Angiogram Too Risky)
  • Use of Helium-3 + Other Gases Have Greatly Increased the Value of MRI



Direct Visual Exam of Larynx + Upper Airway

  • Investigate Suspected Bleeding
  • Sample Tissue if Cancer Suspected
  • Sample Fluid to ID Pathogens
  • Assess Burns + Smoke Inhalation


Bronchoalveolar Lavage

Collect Specimens from Smaller Airways + Alveoli that Cannot be Visualized (Fluid Exam)

  • Saline Infused, Suctioned, Examined
  • May Reveal Neoplastic Cells
  • Fluid Cultured to Determine Pathogen




Visual Examination of Lung + Pleural Spaces

  • Video Assisted Thoracoscopic Surgery VATS
  • Obtain Tumor Samples



what is it?

2 main reasons it is done?

complications (3)?

Removal of Fluid in Pleural Space (Effusion)

  • Main 2 Reasons Done – Relieve SOB + Obtain a Sample for Diagnostic Testing

Complications (Low Risk) –

  • May Puncture Lung
  • Cause Pneumothorax
  • Puncture Spleen or Liver


3 main things you ask before ordering a test?

(when do you order?)

  1. Ask yourself what you will gain
  2. Never go “searching” without a reason – use your clinical skills to determine differential diagnosis
  3. Select the test based on your differential diagnosis


Pulmonary Edema

what do you hear? what are the findings? where does it start?

  • Rales/crackles
  • Symmetric Findings
  • Occurs first in most dependent portion of lower lobes
  • As disease progresses, sounds heard throughout



what do you hear?


  • Rales/crackles
  • Heard over distinct area, restricted to a specific lung region
  • The consolidation associated w/ pna causes central lung sounds to be heard in periphery (use “eee” and “aaah” tests to determine if this is occurring)
  • Tactile Fremitus Increased


Pulmonary Fibrosis 

(intersitial lung disease)

what do you hear? whats it look like?

Distinct, harsh, diffuse crackles (think of Velcro)—Looks like cob webs



what do you hear? whats it caused from? whats the main symptom?

  • Rhonchi
  • Cough >5 days
  • Airway passages are inflamed
  • Tip: Don’t always need abx (viral)



what do you hear if its severe?

what does wheezing tell you?


  • Breathing will produce very little sound
  • Wheezing in severe emphysema indicates a superimposed acute inflammatory process


Pleural effusion

what are results for tactile fremitus? percussion? ascultation?

  • Decreased tactile fremitus
  • Dullness to percussion
  • Absence of breath sounds



Chronic Obstructive Pulmonary Disease

what are the two things that make it?

what is NIH def?

Chronic Bronchitis + Emphysema

Chronic Bronchitis: Cough & Sputum most days of 3mo of two successive years

Emphysema: Loss of elastic recoil of lung & histologic changes of small airways & destruction of walls of alveoli

Nat’l Inst for Hlthcre Excell Dx Crit:

  • Age >35
  • Hx of Smoking
  • Long standing production of sputum, cough, SOB w/o clear variations throughout the day


COPD conintued:




(explain their ventilation, O2 levels, CO2 levels)

Pink Puffers:

  • have good ventilation of alveoli
  • Near normal O2
  • Low/normal CO2 in blood
  • No cyanosis

Blue Bloaters:

  • Poor ventilation of alveoli
  • Low oxygen
  • Heart failure common




what do you hear? what is this from? what might you see on kids? what are 6 red flags? what is the gold standard?

Inflammation of airways

Constriction of flow

Often present w/ increased RR & HR (working hard to breath)

Intercostal Retractions (Pediatrics)


Critical Hx in Acute Asthma Pts:

  • “Have you ever been intubated?”
  • Prior need for intubation should increase your suspicion of severe dz
  • Any hx of IC admission for asthma?
  • 3 or more ED visits, 2 or more admissions in the last year
  • The hx should put you on alert that this pt could decompensate rapidly


  • Carefully assess tactile fremitus, breath sounds, & perussion
  • It is the combination of these findings which will help you differentiate between diagnosis
  • You may have to do the exam components more than once to work out what is going on


Red Flags:

  • Cyanosis
  • Decreased level of activity awareness
  • Rapid Pulse
  • Severe anxiety
  • Sweating
  • Increased time for expiration (doubles that on inspiration)

Further Testing:

  • PulseOX-measures oxygen sat (at rest&ambulation)
  • Measurement of distanced walked in certain time
  • Have the pt attempt stair climbing (watch for SOB)
  • This indicates the pt’s functional status

Chest XRAY “Gold Standard”

CT Scan- used to evaluate finding on CXR or in trauma setting w/ obv injury or if pt obviously very ill, but no findings on CXR

MRI-used less frequently-typically to take a closer look at a tumor, adjunct structures


what is this?

Pulmonary Edema


**there is fluid on the inside of the lungs, so you on't see the fluid where the lungs are, not in the costoverteral angles like pleural effusion...starts at the bottom of the lungs because the fluid falls to gravity :)**


what is this?



what is this?

Pulmonary Fibrosis


what is this?



what is this?



what is this?

pleural effusion


what is this?

Pink puffer


what is this?

blue bloater


Overview of






Inspection/ Observation: 

  • Breathing Pattern (fast, slow, shallow, struggling, etc)
  • Use of Accessary Muscles
  • Color of nail beds, skin
  • Cyanosis of Nail Beds
  • Perioral Cyanosis
  • Deformity? (Pectus excavatum)
  • Tripod position


  • Anterior View: RUL, LUL, RML, RLL, LLL
  • Right Lateral View: RUL, RLL, RML
  • Left Later View: LUL LLL


  • Assess for tenderness
  • Equal Expansion
  • Tactile Fremitus
    • Consolidation: When normally air filled lung becomes engorged w/ fluid or tissue (i.e pna). Fremitus becomes more PRONOUNCED.
    • Pleural Effusion: Fluid collection in the potential space that exists between the lung and chest wall. Displaces lung upwards. Fremitus over effusion is DECREASED.


  • Generally: 
    • Resonant over air
    • Dull over fluid or tissue
  • Pleural effusions/ pneumonia:
    • Deadened tone
  • Chronic (emphysema) or acute (pneumothorax
    • Hyper-resonant (drum-like)
  • Tip: Try doing percussion quickly-it will sometimes assist you in hearing the different tones


Right lower lobe: Heard best in right axilla

Lower lobes: Bottom ¾ of the posterior fields

Upper lobes: Anterior chest and top ¼ of posterior fields

Vesicular(Normal): Soft sound of rushing air on inspiration, no, or minimal sound, on expiration.

Wheezing (lower airway): Whistling sound secondary to air being forced through narrowed airways

Strider: Wheezing heard only on inspiration and typically caused by mechanical obstruction at level of trachea/upper airway (epiglottis)

Rales/Crackles: Scratchy sounds-occur in assoc w/ processes that lead to fluid accumulation in alveolar & interstitial spaces (Pulm edema)

Rhonchi: Gurgling type sounds (slurping thru a straw)


  • Increased resonance of voice sounds transmitted through consolidation or other abnormal areas
  • High nasal quality
  • Patient says “eee”; you hear “eee” over healthy lungs
  • over consolidation it sounds like “aaay”


Normal Respiratory Rate

RR is about 14-20 per min in normal adults and upto 44 per min in infants



slow breathing

slow breathing may be secnodary to diabetic coma, durg induced repiratory depression, and increased intracranial pressure


Sighting respiration

breathing punctured by frequent sighs should alert you to the possibility of hyperventilation syndrome- a common cause of dyspnea and dizziness. ocassional sighs are normal 



what is it, what are three causes?

rapid shallow breathing

Rapid shallowing breathing has a number of causes:

  • restircitve lung disease 
  • pleuritic chest pain 
  • elevated diaphragm


Cheyne- Strokes Breathing

what two groups of pts is this common in?

  • Periods of deep breathing alternate with periods of apnea (no breathing). 
  • children and aging people normally may show this pattern in sleep
  • Other causes
    • heart failure
    • uremia
    • drug induces repiratory depression
    • brain damage (typically on both sides of the cerebral hemispheres or diencephalon) 



Obstructive Breathing

what is elongated? what are three causes?


  • In obstructive lung disease, expiration is prolonged because narrowed airways increase the resistance to air flow. 
  • Casues:
    • asthma
    • chronic bronchitis
    • COPD



Rapid Deep Breathing

  • Casues
    • exercise
    • anxiety
    • meatbolic acidosis
  • in comatose patient consider
    • infarction
    • hypoxia
    • hypoglycemia affecting midbrain or pons


kussmaul respiration

what is this breathing caused by?

deep breathing due to metabolic acidosis

may be fast, normal in rate or slow


Ataxic Breathing

Biot's breathing

  • unpredictable irregularity
  • breaths may be shallow or deep, and stop for short periods
  • casues
    • repiratory depression
    • brain damage medullary level


most frequent cause of chest pain in children



Why does wheezing occur

from partial airway obstruction from secretions and tissue inflammation in asthma, or from a foreign body


what can be a symptom of left sided heart failure



Mucoid Sputum vs Purulent sputum

Mucoid: white or gray

Purulent: yellow or green


when is foul smeeling sputum present

anaerobic lung abscess

tenacious sputum in cystic fibrosis


when do you see large volumes of purulent sputum



lung abscess


What is Hemopysis rare and common in

Rare: infants, children, adolescents

common: cystic fibrosis


blood of stomach vs repiratory tract

Stomach blood is draker and mixed with food particles compared to that or Resp. tract



Increased risk of these diseased compared with nonsmokers

  • coronary artery disease
  • Stroke
  • Peripheral vascular disease
  • COPD Mortality
  • Lung Cancer mortality

  • coronary artery disease: 2-4 X higher
  • Stroke: 2-4 X higher
  • Peripheral vascular disease: 10 time higher
  • COPD Mortality: 12-13 time higher
  • Lung Cancer mortality: 23 times higher in men, 13 times higher in women 


5 A's model for quitting smoking

Ask about tobacco use

Adivse to quit

Assess willingness to make a quit attempt

Assist in quit attempt

Arrange follow up


Stages of CHnage model



Precontemplation- I dont want to quit

Contemplation- i am concerned but not ready to quit now

Preparation- I am ready to qut

Action- I just quit

Maintenance- i quit 6 months ago



what does clubbing occur in

  • bronchiectasis
  • congenital heart disese
  • pulmonary fibrosis
  • cystic fibrosis
  • lung abscess
  • malignancy 


Audible Stridor

high pitched wheeze

ominoous sign of upper airway obstruction in larynx or trachea


what do you see lateral displacement of the trachea in 


pleural effusion




Increased AP diameter



what does unilateral decrease or delay in chest expansion occur in

chronic fibrosis of the underlying lung or pleura



WHAT do you see asymmetric decreased fremitus in?

  • unilateral pleural effusion
  • pneumothorax
  • neoplasm

due to decreased transmission of low frequency sounds


what do you see asymmetric INCREASED fremitus in

  • unilateral pneumonia

increased transmission through conolidated tissue


why would dullness replace resonance and give me some examples.... please:)

dullness replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussing fingers

  • lobar pneumonia (the alveloi are filled with fluid and bloof cells
  • pleural accumulations of serous fluid (pleural effusion)
  • blood (hemothorax)
  • Pus (empyema)
  • fibrous tusse
  • tumor


when would you hear hyperresonance 

heard over the hyperinflated lungs of COPD and asthma


unilateral hyperressonace siggests a large pneumothorax or a large air filled bulla in the lunh


if you have a high measured diaphragmatic exercusion what does this mean

abnormally high level suggests pleural effusion or a high diaphragm as in atelectasis or phernic nerve paralysis



alight it is probably due to the excessive amount of chest hair.....get out the wax... you have to wax this patient


just kidding!  either press harder or wet the hair!


never listen over clothes!


if patient is cold or tense what may happen

you may hear muscle contraction sounds- muffled low pitched rumbling or roraring noises


change the patients position



inspriatory and expiratory sounds are about equal

often heard in 1st and 2nd interspaces anteriorly and between the scap



expir. sounds last longer than inspiratory ones


insitiry of expir sound: loud

Pitch of expir sound: relativ. high


heard over manubrium



inspir and expiratory sounds are about equal


intensity of expir: very loud

pitch or expir: relativ. high


heard over the trachea in the neck


what 2 conditions can you clear crackles, wheezing, or rhonichi after coughing or position change





abnormal. in lungs: pneumonia, fibrosis, early HF

Abnorm. in airways: bronchitis, bronchiectasis


wheezes sugegst

narrowed airways





Rhonchi suggest

secretions in large airways


Sign/ Sym/ diagnosis of COPD


hx of smoking, age and decreased breath sounds

diagnosis: spirometry and other pulm testing



louder voice sounds


how do patients with COPD like to sit

sit leaning forward

lips pursed during exhalation

arms supported o their knees or a table


only a very large effusion can be deteced anteriorly why is this?

pleural fluid usuall sinks to the lowest part of pleural space (posteriorly in a supine patient)


where can you hear the dullness of middle right lobe pneumonia as to not miss it

behind right breast! 



  • process
  • Location
  • quality
  • severity
  • timing
  • aggrevating factors
  • relieving factors
  • associated symptoms

  • process: inflammation of trachea and large bronchi
  • Location: upper sternal or on either sife of the sternum
  • quality: burning
  • severity: mild to mod
  • timing: variable
  • aggrevating factors: coughing
  • relieving factors: lying on the involved side
  • associated symptoms: cough


Plueritc Pain

  • process
  • Location
  • quality
  • severity
  • timing
  • aggrevating factors
  • relieving factors
  • associated symptoms

  • process: inflamm. of the pariteal pleura like in pleurisy, pneumonia, pulm infarction, neoplasm
  • Location: chest wall overlying the process
  • quality: sharp, knife like
  • severity: severe
  • timing: presistent
  • aggrevating factors: deep inspiration, coughing, movements of the trunk
  • relieving factors: n/a
  • associated symptoms: underlying illness


Chronic Bronchitis

  • process
  • timing
  • aggrevating factors
  • relieving factors
  • associated symptoms
  • setting

  • process: excessie mucus prodiction in bronchi, followed by chronic obstuction of airways
  • timing: chornic productive cough followed by slowly progressive dyspnea
  • aggrevating factors: exertion, inhaled irritants, repir. infections
  • relieving factors: expectoration; rest, though dyspnea may become persistent
  • associated symptoms: chronic productive cough, recurrent resp. infeciton, wheezing
  • setting: Hx smoking, air polluntants, recurrent resp infections



  • Process
  • timing
  • aggrevating factors
  • relieving factors
  • associated symptoms
  • setting

  • Process:
    • overdistention of air spaces distal to terminal bronchioles,
    • destuction of alceolar septa,
    • alveloar enlargement and
    • limitaiton of expiratory air flow
  • timing: 
    • slowly progressive dyspnea
    • mild cough later
  • aggrevating factors: exertion
  • relieving factors: rest
  • associated symptoms: cough, scant mucoid sputum
  • setting: smoking, air pullutants, familial deficency in alpha1-antitrypsin



  • Process
  • timing
  • aggrevating factors
  • relieving factors
  • associated symptoms
  • setting

  • Process: 
    • reversible bronchial hyperresponsiveness involving release of inflamm. mediators
    • increased airway secretions 
    • bronchoconstrition
  • Timing: 
    • acute episodes seperated by symp free periods
    • nocturanl episodes common
  • Aggrevating Factors:
    • variable, allergens, irritants, resp infec, exercise, emotion
  • Relieve: seperation form aggravating factors
  • Assoicated symp: wheezing, cough, tightness
  • setting: envir and emotion conditions



  • Process
  • timing
  • associated symptoms
  • setting

  • Process: inflamm of lung parenchyma from the respiratory bronchioled to the alveoli
  • Timing: acute illness
  • associated symptoms: 
    • pleurtic chest pain
    • cough
    • sputum
    • fever
  • setting: varied


Spontaneous Pnemothorax

  • Process
  • timing
  • associated symptoms
  • setting

  • Process: leakage of air into pleural space through blebs on visceral pleura, resulting partial or complete collapse of lung
  • timing: suden onset of dyspnea
  • associated symptoms: pleurtic pain, cough
  • setting: often previously healthy young adult


Acute Pulmonry Embolism

  • Process
  • timing
  • associated symptoms
  • setting

  • Process: sudden occlusion of all or part of pulmonary arterial tree by a blood clot that usually orginates in deep veins of legs or pelvis
  • timing: sudden onset of dyspnea
  • associated symptoms: often none. 
    • pleurtic pain
    • cough
    • hemoptysis may follow embolism is pulmonary infarction ensues
    • symptom of anxiety
  • setting:
    • postpartum or postopertive 
    • bed rest
    • HF
    • chronic lung disease
    • fractures of hip/leg
    • DVT


Anxiety with Hyperventilation 

  • Process
  • timing
  • Aggrevating
  • Relieving
  • associated symptoms
  • setting

  • Process: overbreathing, resultant respiratory alkalosis
    • fall in arterial partial pressure of Carbon Dioxide
  • timing: episodic, recurrent
  • Aggrevating: at rest, upsetting event may not be evident
  • Relieving: breathing in and out of a paper of plastic bag may help
  • associated symptoms:  
    • sighing 
    • lightheadedness
    • numbness/tingeling of hands and feet
    • palpitations
    • chest pain
  • setting: often manifestations of anxiety may be present, such as chest pain daiphoresis, palpations


Acute Inflammations (4)

talk about their cough and sputum and associated symptoms and setting

  • Laryngitis:
    • Dry cough (no sputum)
    • may become productive 
    • acute
    • minor illness with hoarseness
    • associated with viral nasopharyngitis
  • Tracheobronchitis:
    • dry cough
    • may become productive
    • acut
    • viral illness
    • burning retrosternal discomfort
  • Mycoplasma and Viral Pnemonias
    • dry hacking cough
    • productive with mucoid sputum
    • acute febrile illness
    • malaise
    • headache
    • possibe dyspnea
  • Bacterial Pnemonia
    • Pneumococcal: sputum mucoid or purulent
    • blood streaked
    • diffusely pinkish
    • rusty
    • KLEBSIELLA: stick red and jelly-like (typically occurs in older alcoholic men)
    • acut illness with chills
    • high fever
    • dyspnea
    • chest pain
    • ususally proceded by acute upper resp. infection


Chonic inflammation (7)

cough sputum

assoc. symp. setting

  • Postnasal Drip: 
    • chronic cough, mucoid or mucopurulent
    • repeated attempts to clear throat
    • seen in post. pharynx
    • associated with allergic rhinitis
  • CHronic Bronchitis
    • chronic cough, mucoid or purulent
    • blood streaked or even bloody
    • hisroty of smoking 
    • recurrent superimposed infections
    • wheezing/dyspnea may develop
  • Bronchiectasis:
    • chronic chough
    • purulent
    • copious 
    • foul smelling
    • blood streaked or bloody
    • recurrent bronchopulmonary infection
    • sinusitis may coexist
  • Pulmonary Tuberculosis
    • cough dry
    • mucoid or purulent
    • blood dtreaked or bloody
    • early no symp.
    • later: anorexia, weight loss, ftigue, fever, night sweats
  • LUng abscess:
    • purulent
    • foul smelling
    • bloody
    • febrile
    • poor dental hygiene
    • prior episoe of impaired consciousness
  • Asthma
    • cough
    • thick mucoid (near end of an attack)
    • wheezing
    • dyspnea
    • cough may occur alone
    • hx of allergy
  • gatroesophageal refux
    • chronic cough
    • nigh or early monring
    • wheezing (night)
    • early morning horseness
    • repested attempts to clear throat
    • history of heart burn and regurgitation



Cancer of Lungs


cough sputum

symp/ setting


  • cough dry to productive
  • blood streaked or bloody
  • hx of smoking 
  • dyspnea
  • weight loss


What is important to know about the sputum for left ventricular failure or mitral stenosis 

often dry cough (specially on exertion of at night) 




Pulmoary Emboli



  • dry to productive
  • may be dark
  • bright red
  • mixed with blood
  • dyspnea
  • anxiety
  • chest pain
  • fever
  • factors that predispose to DVT


how should the thorax look in normal adult (AP diameter)

  • thorax should be wider than deep
  • lateral is larger than it AP diameter


Funnel Chest

(pectus Excavatum)

  • depression in lower portion of the sternum 
  • compression of the heart and great vessels may cause murmurs


Barrel Chest


  • increased AP diam.
  • shape is normal during infancy
  • accompanies aging and COPD


Pigeon Chest

(pectus carinatum)

  • sternum siplaced anteriorly
  • increased AP diameter
  • costal cartilages adjacent to protruding sternum are drepressed


Traumati  Flail Chest

  • multiple rib fractures= results in paradoxical movements of the thorax
  • on inspiration injured area curved inward
  • expiration area moved outward


Thoracic Kyphoscoliosis

  • abnormal spinal curvature and vertebral rotation defrom chest
  • sitortion of underlying lungs -interpretations of lung findings may be difficult


Crackles (2 leading explanations)


3 time frames

  1. result of series of tiny explosions when small airways, deflated during expiration, pop open during inspiration 
    • explains the late inspirartoy crackels of intersitial lung disease and early HF
  2. crackles result from air bubles flowing through secresions or lightly closed airways during respiration
    • explains at least some coarse crackles


Late Inspiratory crackles: appear first at base of lungs spread upwar as the condition worsens

ie. intersitual lung diease (pulm fibrosis) and HF

Early inspirartory crackles: coarse 

ie. chronic bronchitis, asthma

Midinspiratory and expiratory crackles:  heard in bronchiectasis (not specific for this diagnosis however) 


Wheezes and Rhonchi 

when does it occur and why

  • when air flows rapidly thorugh bronchi that are narrowed nearly to the point of closure
  • sometimes can hear at the mouth as well as chest wall
  • asthma : heard only in expiration or in both phases of the respiratory cycle
  • COPD
  • HF
  • Rhonchi: suggest secretion in larger airways
  • chronic bronchitis: you can clear wheezes and rhonchi with coughing


silent chest

sometime in severe obstructive pulmonary disease patietn is unable to force enough air through the narrowed bronchi to produce wheezing.


resulting in silent chest


this is ominous and warratns immediate attention


perisistent localized wheezing suggests?

patrial obstuction of a bronchus 

seen with tumor or foreign body

may be inspir. or expir. or both



  • wheeze that is entirely or predominantly inspiratory
  • louder in the neck than over the chest wall
  • indicated partial obstruction of the larynx or trachea
  • immediate attention


pleural rub

  • inflamed or roughened pleural surface grate against each other as they are momentarily and repeatedly delayed by increase friction
  • creaking sounds
  • usually during expiration
  • resemble crackles but produced by diff athologic processes. 
  • dicrete... sometimes can merge into continuous sound
  • confined to small area of chest wall
  • heard on both phases of respiration
  • when inflammed pleural surfaces are seperated by fluid and sound disappears 


Mediastinal Crunch

(Hamman's sign)

  • series of precordial crackles synchronous with heart beat not with respiration
  • best heard on left lateral position (due to mediastinal emphysema) 


Chronic Bronchitis

  • brief what is it
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

bronchi chronically inflammed and productive cough is present. airway obstruction may develop

  • Percussion: resonant
  • Breath Souds: vesicular
  • Advenitious sounds: none (or scattered coarse crackles in early inspriation and perhaps expiration, or wheezes or rhonic)
  • Tactile frem/voice sounds: normal


Left sided HF (early)

  • brief what is it
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

increased pressure in the pulm viens casues congestion and intersitial edema

  • percussion sound: reson.
  • breath sounds: vesicular
  • adventitious sounds: late inspir. crackles in deendent portions of lung, possible wheeze
  • tactile fremitus/voice sounds: normal



  • brief what is it
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

Alveoli dill with fluid aor blood cells, as in pneumonia, pulmonart edema, or pulmoary hemorrhage

  • percussion sound: dull over the airless area
  • breath sounds: bronchial over involved area
  • adventitious sounds: Late inspiratory crackles over involv. area
  • tactile fremitus/voice sounds: increased over involv. area with bronchophony, egophony, and whipered pectoriloquy


Atelectasis (Lobar obstruction)

  • Brief explaination
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

when a plug in a mainstem bronchus obstructs air flow, affected lung tissue collapses into an airless state

trachea may be shifted toward involved side

  • percussion sound: dull over airless area
  • breath sounds: usually absent when bornchial plug persists. expetion is upper right lobe atelectasis where adjacent tracheal sounds may be transmitted
  • adventitious sounds: none
  • tactile fremitus/voice sounds: usually absent when the bronchial plug persists. exception (R. upper love atelectasis) may be increased


Pleural Effusion

  • Brief explaination
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

fluid accumlates in the peural space, speerated air filled lung from the chest wall, blocking the transmission of sound

trachea may be shifted away from large effusion

  • percussion sound: dull to flat over fluid
  • breath sounds: decreased to absent, bornchial breath sounds may be heard near top of large effusion
  • adventitious sounds: none
  • tactile fremitus/voice sounds: decreased to absent, may be increased toward top of a large effusion 



  • Brief explaination
  • percussion sound
  • breath sounds
  • adventitious sounds
  • tactile fremitus/voice sounds

when air leaks into the pleural space, usually unilaterally, lung recoils from the chest wall. pleural air blcks transmission of sound

trachea shifted toward opposite side if much air

  • percussion sound: hyperresonant or tympanic over the pleural air
  • breath sounds: decreased to absent over pleural air
  • adventitious sounds:none
  • tactile fremitus/voice sounds: decreased to absent over pleural air



Brief explanation

percussion sound

breath sounds

adventitious sounds

tactile fremitus/voice sounds

slowly pogressive disrder in which the distal air spaces enlarge and lungs become hyperinflated. chronci bronchitis is often assoiated

  • percussion sound: hyperresonant
  • breath sounds: decreased to absent
  • adventitious sounds: none, or the crackles, wheezes, and rohonchi or assoiated chronic bronchitis
  • tactile fremitus/voice sounds: decreased



Brief explanation

percussion sound

breath sounds

adventitious sounds

tactile fremitus/voice sounds

widespread narrowing of the trachobronchial tree diminshs air flow to a fluctuating degree. during attacks air flow decreases further and lungs hyperinflate.

  • percussion sound: resonant to diffusely hyperresonant
  • breath sounds: often obscured by wheezes
  • adventitious sounds: wheezes, possibly crackles
  • tactile fremitus/voice sounds: decreased


Metered Dose Inhaler (MDI)

  • Age
  • advantages
  • diadvantages

  • Age: 5 or older
  • advantages:
    • newer inhaler have a dose counter
    • delivery of medication in less than 2 min
    • portable durable
    • lower medication dose needed vs neb
  • diadvantages
    • older inhalers do not have dose counter
    • techinique and coordination may be difficult
    • propellant may taste bad or irritate airways


MDI plus valved holding chamber (VHC)




  • Age
    • if less then 4 use VHC with mask
    • 4 or older use VHC
  • advantages: 
    • VHC enhances MDI tech
    • VHC decreased topical side effects of inhaled corticosteriods (ICS)
    • albuterol MDI with VHC is as effective as neb for asthma exacerbation
  • diadvantages:
    • bulky
    • lack of coverage by some insurance
    • limited testing
    • potential for increased systemic side effecxts with inhaled corticosteriod (ICS)


Jet Neb





  • Age: any age, usually infants or elderly
  • advantages: 
    • no coordination
    • O2 may be dellivered simutaneously with medications
  • diadvantages
    • requires 5-15 min to deliver med
    • limited number of medications available for neb
    • not portable 


Ultrasonic Nebulizer




  • Age: any age, usually infant or elderly
  • advantages: 
    • more portable than jet neb
    • faster delivery of meds than jet neb
  • diadvantages
    • heat generated from neb breaks down suspension for nebulization
    • do not use with budesonide suspension for nebulization


Dry powder inhaler (DPI)




  • Age:
    • Aeroizer: 5 and older
    • diskus: 4 years of age and older
    • flexhaler: 6 years and older
    • twisthaler: 12 years and older
  • advantages:
    • easy to use
    • has dose counter
    • sweet taste
    • quick delivery of med
  • diadvantages
    • limited porfict stability 30-45 days after opening
    • optimal delivery of medication in children less than 4 years old is not feasible because high inspiratory volume needed
    • amount of lactose filler is insuficent to cause concern in lactose intolerance


explain steps of proper use of MDI (9 steps)

  1. remove cap and shake
  2. exhale all air away from the inhaler
  3. place mouthpiece in mouth with lips tightly around inhaler
  4. to deliver: push down on the canister one time while inhaling a slow steady breath. a puff or mist of medication id sprayed out of the inhaler into the mouth
  5. hold breath for 10 seconds 
  6. exhale
  7. wait 1 min. if the dose is to be repeated
  8. recap the inhaler when done
  9. rinse your mouth with water if the medication is an inhaled corticosteroid. 


  • prime the MDI the first time it is used or its beeen more then 10 days. Prime the inhaler by spraying 4 sprays into the air
  • for patients who cannoy hold their breath for 10 seconds, instruct them to hold their breath as long as possible
  • do not immerse the canister of medication in water at any time
  • if a counter is not availble on the inhaler, the patient should tally the numbers of puffs used to determine when the inhaler is empty



What do Peak flow meters measure?


  • Peak flow meters measure your peak expiratory flow rate (PEFR), a number that correlates with how open the lung's airways are
  • as asthma worsens and the airways narrow, the PEFR decreases.
  • Monitoring can help you (the patient) and your healthcare provider determine the most appropriate asthma treatment plan.

The patient needs to be aware of this to help with management: The management of asthma relies on a patient's ability to monitor their asthma regularly. Self-monitoring includes assessing the frequency and severity of symptoms (such as wheezing and shortness of breath) and measurement of lung function with a peak flow meter.


Asthma monitoring recommendations in relation to peak flow meters

  • Experts recommend that people with moderate to severe persistent asthma have a peak flow meter at home and know how to use it  
  • A peak flow meter is small, inexpensive, and easy for most patients to use.
  • patients should use a peak flow meter to:
    • Regularly monitor lung function and response to treatment over the short- and long-term
    • Determine the severity of an asthma attack
    • Assess response to treatment during an attack
  • asthma diary to record (This can help to show a cause-and-effect relationship between exposure to triggers and decreases in peak flow)
    • your daily peak flow meter readings 
    • exposure to potential asthma triggers 
    • asthma medication use
    • asthma symptoms  


when do i use my Peak Flow Meter?

  • Peak flow monitoring should be performed on a regular basis (even when asthma symptoms are not present) 
  • Peak flow should also be checked if symptoms of coughing, wheezing, or shortness of breath develop.


how do i ensure that i am getting the best reading with my peak flow meter that i can get?

  • The peak flow meter should read zero or its lowest reading when not in use.
  • Use the peak flow meter while standing up straight.
  • Take in as deep a breath as possible.
  • Place the peak flow meter in the mouth, with the tongue under the mouthpiece.
  • Close the lips tightly around the mouthpiece.
  • Blow out as hard and fast as possible; do not throw the head forward while blowing out.
  • Breathe a few normal breaths and then repeat the process two more times.
  • Write down the highest number obtained.
  • Do not average the numbers.
  • IMPORTANT: Repeat the test if your tongue partially blocks the mouthpiece or if you cough or spit during the test.


establishing a baseline for peak flow meter

  • no "normal" peak flow measurement for everyone.
  • determine what peak flow value is normal for you.
  • Ideally, the baseline values should be obtained when the patient is feeling well after a period of maximal asthma therapy

  • To determine your normal peak flow measurement: 
    • measure peak flow when you have no asthma symptoms.
    • Perform three measurements with the same peak flow meter two to four times daily for two to three weeks.
    • note the highest peak flow measurement achieved; this is the “personal best.”
    • This number is used to determine if future peak flow measurements are normal or low, and is also used to create a normal range (between 80 and 100 percent of the personal best peak flow measurement).
  • Readings below the normal range are a sign of airway narrowing in the lungs.
    • A low peak flow measurement can occur before asthma symptoms such as wheezing or shortness of breath develop.
  • Remeasure your personal best peak flow value once per year to account for growth or changes in the disease .
  • verify home peak flow measurements with readings taken with equipment in a healthcare provider's office since this equipment is more sensitive.
    • PEFR measurements should be periodically correlated with office spirometry, since the PEFR in some cases has been less accurate than measurement of FEV1 in detecting airflow obstruction.

  • long term management= peak flow testing once per day, usually in the morning.


is Peak expiratory flow rate (PEFR) monitoring and FEV1 helpful in asthma?

  • the PEFR percent predicted correlates reasonably well with the percent predicted value for the forced expiratory volume in one second (FEV ).
  • Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control
  • significant testing variability makes it important to confirm or exclude airflow limitation with a more reliable test, such as spirometry
  • Self-monitoring can be performed by subjectively evaluating the frequency and severity of symptoms

  • Patients can gain further information by monitoring peak expiratory flow rates (PEFRs), which provide an objective measurement of airflow obstruction

  • can be performed accurately by most adults and children older than five years of age.

  • PEFR monitoring can provide the patient and clinician with objective data upon which to base therapeutic decisions


Efficacy of PEFR monitoring

conflicting information and results

A number of studies failed to demonstrate an advantage of using PEFR monitoring over symptom monitoring to guide self management actions


whats the best way to monitor asthma

  • The most conservative approach is to have patients monitor their condition using both objective and subjective measures
  • use a patient diary to record daily PFM readings and the presence of any asthma symptoms.
  • This dual approach may help patients observe a cause-and-effect relationship between exposure to triggers and decrements in peak flow and/or exacerbations of asthma.
  • The patient should understand that such monitoring is undertaken to check on the effectiveness of therapy and to give early warning of potential deterioration.


determining PEFR values

  • PEFR values can be compared to age-, gender- and height -matched normal subjects
  • When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometric values
  • Spirometric values tend to be lower than peak flow meter predicted values


If PEFR begins to decline what guideline do you follow

Asthma action plan


Zone scheme

self-management decisions

  • It is suggested that a zone scheme similar to a traffic light system be used to illustrate a plan upon which patients can base self-management decisions:
    • GREEN (80 to 100 percent of personal best) signals "all clear". When readings are within this range and symptoms are not present, the patient is advised to adhere to his or her regular maintenance regimen.
    • YELLOW (50 to 80 percent of personal best) signals "caution", since the airways are somewhat obstructed.
      • The patient should implement the treatment plan decided upon with the clinician to reverse airway narrowing and regain control.
      • The wide range represented by the yellow zone can be subdivided above and below the 65 percent level if desired.
    • RED (below 50 percent of personal best) signals "medical alert". Bronchodilator therapy should be started immediately
      • clinician should be contacted if PEFR measures do not return immediately to the yellow or green zones.


asthma action plan

(If the picture is too small I wrote it all out....the pictures never upload big enough)

Top of form:

  • long term meds and dose and instructions
  • quick relief meds and instructions 

Bottom of form: Traffic light system


  • i feel good! Personal best peak flow
  • PREVENT asthma symp. everyday
  • take long term control meds
  • before exercise that ___ puffs of ____
  • avoid things that make asthma worse


  • symptoms may be: wheeze, tight chest, cough, SOB, waking up at night, decreased ability to do usual activities
  • take _____
  • still dont feel well and peak flow is not back up to green zone after one hour i should:
    • increase____
    • add_____
    • call_______


  • i feel AWFUL
  • warning signs: its getting harder to breathe
  • unable to sleep or do usual acitivities because of breathing problem
  • MEDICAL ALERT... get help
  • take _____ until i get help immed.
  • take____ 
  • call_____
  • DANGER! GET HELP IMMED. call 911 if you have trouble walking or talking due to SOB or lips and fingernails are gray or blue



important summary points from "PEeak Expiratory Flow Rate Monitoring in Asthma"

  • The peak expiratory flow rate (PEFR, also known as peak flow) is the maximal rate that a person can exhale during a short maximal expiratory effort after a full inspiration. 
  • Monitoring the PEFR is useful for detecting changes or trends in a patient’s asthma control.
  • significant testing variability makes it important to use a more reliable test, such as spirometry, to confirm or exclude airflow limitation suggested by the PEFR.
  • When determining predicted PEFR values, the reference values should be derived from a peak flow meter, rather than spirometry.
  • The prolonged expiratory effort of spirometry tends to give a lower peak flow value than that obtained from the brief and rapid exhalation used with a peak flow meter. 
  • PEFR values can be compared to age-, gender- and height-matched normal subjects
  • The predicted values for black and Hispanic minorities are approximately 10 percent lower than those shown in the tables on UP TO DATE
  • When instructing a patient on use of a peak flow meter at home, the first step is for the patient to demonstrate adequate peak flow technique.
  • patient is then asked to monitor and record their PEFR two to four times daily for two weeks, ideally during a time that their asthma is well-controlled.
  • At the next visit, the two-week baseline results are reviewed to determine that patient’s "personal best" PEFR value.
  • The personal best is generally the highest PEFR measurement achieved during this post-treatment monitoring period.
  • An individual patient's normal PEFR range is defined as 80 and 100 percent of their personal best.
  • This value is used to develop an "asthma action plan” 
  • The frequency of peak flow monitoring depends on the needs of the individual patient.


so ...

what is the difference between spirometry and Peak flow meter?

  • Spirometry:

    • most common of the lung function tests used for asthma.

    • It's a simple, quick, and painless way to check your lungs and airways.

    • You just take a deep breath and exhale into a hose attached to a device called a spirometer.

    • records how much air you blow out (FVC, or forced vital capacity) and how quickly you do it (FEV, or forced expiratory volume).

    • Your score is lower if your airways are swollen or constricted because of asthma or other lung diseases.

    • Your doctor may want you to have several spirometry lung function tests to monitor your asthma over time.

    • You might have spirometry before and after you take medication to see if the medication helps.

    • Your doctor may also want readings taken during exercise to see how your airways react to exercise.

  • Peak Flow meter

    • measure how well your lungs push out air.  

    • less accurate than spirometry 

    • good way to regularly test your lung function at home -- even before you feel any symptoms.

    • A peak flow meter can help you know what makes your asthma worse, whether treatment is working, and when you need to seek emergency care.

    • A peak flow meter is a handheld plastic tube with a mouthpiece on one end, which you breathe into.



FEV1 and FVC and ratio....

what is low in which disorder: Obstructive vs. Restritive vs. Mixed

  • An obstructive defect is indicated by a low forced expiratory volume in one second/forced vital capacity (FEV1/FVC) ratio,

    • If obstructive defect is present, the physician should determine if the disease is reversible based on the increase in FEV1 or FVC after bronchodilator treatment

    • asthma is reversible after bronchidilator treatment whereas COPD is not
  • A restrictive pattern is indicated by a low FVC {below the fifth percentile (adults) or less than 80% (in patients five to 18 years of age). }

    • If a restrictive pattern is present, full pulmonary function tests with diffusing capacity of the lung for carbon monoxide testing should be ordered to confirm restrictive lung disease and form a differential diagnosis.

  • If both the FEV1/FVC ratio and the FVC are low, the patient has a mixed defect.
    • The severity of the abnormality is determined by the FEV1.
    • If pulmonary function test results are normal, but the physician still suspects exercise- or allergen-induced asthma, bronchoprovocation (e.g., methacholine challenge, mannitol inhalation challenge, exercise testing) should be considered.


what is another term instead of Pulmonary funtion testing





Before PFT results can be reliably interpreted, three fac-
tors must be confirmed:

(1) the volume-time curve reaches a plateau, and expiration lasts at least six seconds 

 (2) results of the two best efforts on the PFT are within 0.2 L of each other  

(3) the flow-volume loops are free of artifacts and abnormalities.

******IF the patient’s efforts yield flattened flow-volume loops,  submaximal effort is most likely; however, central or upper airway obstruction should be considered.*********



Step 1: Determine If the FEV1/FVC Ratio Is Low

  • GOLD STANDARD: cutoff is less than 70%
  • but some people say w/ symptoms if people between 5-18 can be ratio less than 85%
  • ATS Criteria: can also us LLN (lower limit of normal) in adults - less than fifth percentile
  • if low= indicative of obstructive 

Step 2: Determine If the FVC Is Low

  • indicating a restrictive pattern, a mixed pattern (ratio and FVC low)

Step 3: Confirm the Restrictive Pattern

  • If the patient’s initial PFT results indicate a restrictive pattern or a mixed pattern that is not corrected with bronchodilators, the patient should be referred for full PFTs with DLCO testing.

  • DLCO is a quantitative measurement of gas transfer in the lungs. Diseases that decrease blood flow to the lungs or  damage alveoli will cause less efficient gas exchange, resulting in a lower DLCO measurement.

Step 4: Grade the Severity of the Abnormality

  • should grade the severity of the abnormality based on the FEV1 percentage of predicted.

Severity                                      FEV1 percentage of predicted

Mild                                                > 70

Moderate                                     60 to 69

Moderately severe                      50 to 59

Severe                                          35 to 49

Very severe                                   < 35

Step 5: Determine Reversibility of the Obstructive Defect


  • determine if it is reversible based on the increase in FEV1 or FVC after bronchodilator treatment
  • asthma=reversible
  • COPD= not
  • if pt has mixed pattern and after bronchodilator treatment the FVC corrects itself (leaving you with only a low FEV1/FVC) then it is likely a pure obstructive lung disease with air trapping

Step 6: Bronchoprovocation

  • ​If PFT results are normal but the physician still suspects exercise- or allergen-induced asthma, the next step is  bronchoprovocation (methacholine challenge, a mannitol inhalation challenge, exercise testing, or sometimes eucapnic voluntary hyperpnea testing.)
  • When the FEV1 is 70% or more of predicted on standard spirometry, bronchoprovocation should be used to make the diagnosis.

  • If the FEV1 is less than 70% of predicted, a therapeutic trial of a bronchodilator may be considered

Step 7: Establish the Differential Diagnosis

Step 8: Compare Current and Prior PFT Results


DLCO testing

  • During the DLCO test, patients inhale a mixture of helium (10%), carbon monoxide (0.3%), oxygen (21%),  and nitrogen (68.7%) then hold their breath for 10 seconds before exhaling.
  • The amounts of exhaled helium and carbon monoxide are used to calculate the DLCO. 
  • Carbon monoxide is used to estimate gas transfer instead of oxygen due to its much higher affinity for hemoglobin.
  • A baseline hemoglobin level should be obtained before DLCO testing because results are adjusted for the hemoglobin level.
  • HIGH DLCO: asthma
  • NORMAL DLCO WITH RESTRICTIVE PATTERN: kyphoscolliosis, pleural effusion
  • NORMAL DLCO WITH OBSTRUCTIVE PATTERN: asthma, bronchiectasis, chronic bronchitis
  • LOW DLCO WITH RESTRICTION: asbestosis, isiopathic pulm. fibrosis, lymphangitic spread of tumor, tuberculosis, sarcoidosis
  • LOW DLCO WITH OBSTRUCTION: cystic fibrosis, emphysema 
  • LOW DLCO WITH NORMAL PULMONARY FUNCTION TEST RESULTS: chronic pulm emboli, CHD, intersitial lung disease (early), pimary pulmonary hypertension



The methacholine challenge is highly sensitive for diagnosing asthma; however, its low specificity results in false-positive results.


high sensitivity

low specificity



The mannitol inhalation challenge has a lower sensitivity for the diagnosis of asthma or exercise-induced bronchoconstriction than the methacholine challenge, but has a higher specificity for the diagnosis of asthma.


low sensitivity

high specificty 



A treadmill exercise test has excellent sensitivity and specificity for the diagnosis of exercise-induced bronchoconstriction, but has only modest sensitivity and specificity for the diagnosis of asthma.

In this test, baseline spirometry is measured, followed by exercise on a treadmill. The goal is to achieve 80% to 90% of the maximum heart rate within two minutes, and maintain that heart rate for eight minutes. Inhaled medical-grade dry air or an air conditioned room. The patient must wear a nose clip.




some definitions! 

  1. FEV1
  2. FVC
  3. FEV1/FVC ratio
  4. DLCO
  5. EIB
  6. LLN
  7. TLC
  8. VC

  1. FEV1: forced expiratory volume in one second; total volume of air a patient is able to exhale in the first second during maximal effort
  2. FVC: forced vital capacity; total volume of air a patient is able to exhale for the total duration of the test during maximal effort
  3. FEV1/FVC ratio: the percentage of the FVC expired in one second
  4. DLCO: diffusing capacity of the lung for carbon monoxide
  5. EIB: exercise-induced bronchoconstriction
  6. LLN: lower limit of normal, defined as below the fifth percentile of spirometry data obtained
  7. TLC: total lung capacity; the volume of air in the lungs at maximal inflation
  8. VC: vital capacity; the largest volume measured on complete exhalation after full inspiration


Differential dx for OBSTRUCTIVE and RESTRICTIVE lung disease


  • α1-antitrypsin deficiency (seen in COPD)
  • Asthma
  • Bronchiectasis
  • Bronchiolitis obliterans
  • Chronic obstructive pulmonary disease
  • Cystic fibrosis
  • Silicosis (early)


  • Chest wall
    • Ankylosing spondylitis
    • Kyphosis
    • Morbid obesity
    • Scoliosis
  • Drugs (adverse reaction)
    • Amiodarone
    • Methotrexate
    • Nitrofurantoin (Furadantin)
  • Interstitial lung disease
    • Asbestosis
    • Eosinophilic pneumonia
    • Idiopathic pulmonary fibrosis
    • Sarcoidosis
    • Silicosis (late)
  • Neuromuscular disorders
    • Amyotrophic lateral sclerosis
    • Guillain-Barré syndrome
    • Muscular dystrophy
    • Myasthenia gravis

***** I know we dont have to know all these... it was one of the charts in the reading... just read it over once and you should be good! just nice to know some differential diagnoses!*****


Pulse oximetry 

Pulse oximetry is a procedure used to measure the oxygen level (or oxygen saturation) [HYPOXEMIA] in the blood. It is considered to be a noninvasive, painless, general indicator of oxygen delivery to the peripheral tissues (such as the finger, earlobe, or nose).


do this in people with possible Pnemonia

and obstructive lung diseases

well can do with anyone but these are some emphasized ones