Pulmonary

Question 1

Where is the insertion site for decompression of a tension pneumothorax?

Answer 1

2nd intercostal space

Question 2

Where is the insertion site for chest tube insertion?

Answer 2

Between the 4th and 5th ribs.

Question 3

Where is the lower margin for a well-placed endotracheal tube on a chest x-ray?

Answer 3

Level of the 4th rib.

Question 4

Where should needles and tubes be placed to avoid neuro vascular structures?

Answer 4

Neurovascular structures run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margins.

Question 5

Where is the landmark for thoracentesis with needle insertion?

Answer 5

The intercostal space between the 7th and 8th ribs, immediately superior to the 8th rib.

Question 6

What is the “triangle of safety”?

Answer 6

An anatomical region in the midaxillary line formed by the lateral border of the pectoralis major muscle anteriorly, lateral border of the latissimus dorsi posteriorly, and the nipple line (4th or 5th intercostal space) inferiorly. This triangle represents a “safe position” for chest tube insertion.

Question 7

In which lung lobes is aspiration pneumonia more common & why?

Answer 7

The right middle and lower lobes because the right main bronchus is more vertical. For this same reason, if an ET tube is advanced too far during intubation, it will more likely enter the right mainstem bronchus.

Question 8

Define transudates.

Answer 8

Accumulations of pleural fluid, or pleural effusions, seen in heart failure, cirrhosis, and nephrotic syndrome.

Question 9

Define exudates.

Answer 9

Accumulations of pleural fluid, or pleural effusions, seen in numerous conditions including pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis.

Question 10

Pleuritic pain.

Answer 10

Irritation of the parietal pleura produces pleuritic pain with deep inspiration in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular diseases.

Question 11

Principle muscle of inspiration.

Answer 11

The diaphragm. The muscles of the rib cage also expand the thorax during inspiration, especially the scalenes and the parasternals.

Question 12

What respiratory symptoms are present in patients with anxiety?

Answer 12

Episodic dyspnea during rest and exercise and also hyperventilation, or rapid shallow breathing.

Question 14

When does wheezing occur?

Answer 14

In partial lower airway obstruction from secretions and tissue inflammation in asthma, or from foreign body.

Question 15

Cough

Answer 15

A reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. Cough can also signal left sided heart failure.

Question 17

Causes of acute cough (less than 3 weeks:

Answer 17

Most common- viral upper respiratory infections
Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ACE-inhibitor therapy.

Question 18

Subacute cough (3-8 weeks) is caused by:

Answer 18

Post infectious, pertussis, acid reflux, bacterial sinusitis, and asthma.

Question 19

Chronic cough (more than 8 weeks) is seen in:

Answer 19

Postnasal drip, asthma, GERD, chronic bronchitis, and bronchiectasis.

Question 20

Mucoid sputum

Answer 20

Translucent, white, or gray and seen in viral infections and cystic fibrosis.

Question 21

Purulent sputum

Answer 21

Yellow or green; often accompanies bacterial pneumonia.

Question 22

What is a sign that sputum is related to anaerobic lung abscess?

Answer 22

Foul smelling

Question 23

What type of sputum is present in cystic fibrosis?

Answer 23

Thick and tenacious

Question 24

What information should you assess about a cough?

Answer 24

Duration
Dry or productive
Volume
Color
Odor
Consistency

Question 25

For patients reporting hemoptysis, what other information should you gather?

Answer 25

Volume of blood Setting Activity Associated symptoms

Question 26

Causes of hemoptysis

Answer 26

Bronchitis Malignancy Cystic fibrosis Bronchiectasis Mitral stenosis Goodpasture syndrome Granulomatosis with polyangitis

Question 27

Massive hemoptysis

Answer 27

> 500 mL over a 24-hour period or >/= 100 mL per hour

Question 28

How do you distinguish blood originating in the stomach from blood originating in the respiratory tract?

Answer 28

Blood originating in the stomach is usually darker and may be mixed with food particles.

Question 29

Common gestures used to describe chest pain

Answer 29

A clenched fist over the sternum (Levine sign) suggests angina pectoris. A finger pointing to a tender spot on the chest wall suggests musculoskeletal pain. A hand moving from the neck to the epigastrium may suggest heartburn.

Question 30

Lung tissue has no pain fibers. So, where does pain in conditions such as pneumonia and pulmonary infarction arise from?

Answer 30

Inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing or costochondral inflammation may also be responsible. The pain of pericarditis stems from inflammation of the adjacent parietal pleura.

Question 31

What are hallmarks of OSA?

Answer 31

Daytime sleepiness and snoring. Commonly seen in patients with obesity, posterior malocclusion of the jaw (retrognathia), treatment-resistant hypertension, heart failure, atrial fibrillation, stroke, type 2 diabetes.

Question 32

Mechanisms that lead to disordered sleeping include:

Answer 32

Instability of the brainstem respiratory center, disordered sleep arousal, disordered contraction of upper airway muscles, and anatomical changes contributing to airway collapse such as obesity.

Question 33

What does the tripod position combined with increased work of breathing (supraclavicular retractions, use of accessory muscles) indicate?

Answer 33

Increased airway resistance or stiff lungs and/or chest wall.

Question 34

Percussion- dullness

Answer 34

Pleural effusion Atelectasis

Question 35

Percussion- hyperresonance

Answer 35

Emphysema

Question 36

Auscultation

Answer 36

Wheezes, crackles, rhonchi, prolonged expiratory phase, and/or diminished breath are clues to disorders of breathing or lung parenchyma.

Question 37

Right sided heart pressures signs

Answer 37

Jugular venous distention Peripheral edema Accentuated pulmonic component of the second heart sound

Question 38

Left ventricular dysfunction signs

Answer 38

S3 & S4 gallops

Question 39

Stridor

Answer 39

Audible high-pitched inspiration whistling. An ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation

Question 40

Lateral displacement of the trachea occurs with:

Answer 40

Pneumothorax Pleural effusion Atelectasis

Question 41

When does asymmetry in chest expansion occur?

Answer 41

Large pleural effusions

Question 42

When does retraction occur?

Answer 42

Severe asthma COPD Upper airway obstruction

Question 43

When does unilateral impairment or lagging occur?

Answer 43

Pleural disease from asbestosis or silicosis Phrenic nerve damage or trauma

Question 44

When can intercostal tenderness develop?

Answer 44

Over inflamed pleurae

Question 46

When does costal cartilage tenderness occur?

Answer 46

Costochondritis

Question 47

Crepitus

Answer 47

Crackling or grinding sound over bones, or skin, with or without pain, due to air trapping in the subcutaneous tissue. May be palpable in overt fractures and arthritic joints.

Question 48

Signs of a fractured rib

Answer 48

Tenderness Bruising Bony “step-offs”

Question 50

Signs of mediastinitis

Answer 50

Crepitus Chest wall edema

Question 51

Sinus tracts

Answer 51

Blind, inflammatory, tube-like structures opening onto the skin. Rare. Suggest infection of the underlying pleura and lung (as in tuberculosis or actinomycosis).

Question 52

In what conditions can unilateral decrease or delay in chest expansion occur?

Answer 52

Chronic fibrosis of the underlying lung or pleura Pleural effusion Lobar pneumonia Pleural pain with associated splinting Unilateral bronchial obstruction Paralysis of hemidiaphragm

Question 53

Tactile fremitus

Answer 53

The palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetrical.

Question 54

When is tactile fremitus decreased or absent?

Answer 54

High pitched voice Soft voice Thick chest wall Obstructed bronchus COPD Pleural effusion Fibrosis Pneumothorax Infiltrating tumor

Question 55

Percussion Notes and Pathologic examples

Answer 55

Flat (soft, high pitch, short)- large pleural effusion Dull (medium, medium pitch, medium duration)- lobar pneumonia Resonant (loud, low, long)- simple chronic bronchitis or healthy lung Hyperresonant (very loud, lower, longer)- COPD, pneumothorax Tympanic (loud, high, longer)- large pneumothorax

Question 56

Dullness in percussion indicates

Answer 56

When fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your percussion fingers. Lobar pneumonia Pleural effusion Hemothorax Empyema Fibrous tissue Tumor

Question 57

Hyperresonance with percussion indicates

Answer 57

Hyper inflated lungs of COPD or asthma. Unilateral hyperresonance suggests a large pneumothorax or an air filled bulla.

Question 58

What does absent descent of the diaphragm indicate?

Answer 58

Pleural effusion Atelectasis Phrenic nerve paralysis

Question 59

What does a silent gap between inspiratory and expiratory breath sounds suggest?

Answer 59

Bronchial breath sounds