What is Kussmaul breathing and when do you see this?
Rapid and deep breaths.
Seen in response to metabolic acidosis (trying to blow off CO2)
What is Cheyne-Stokes breathing and when is this seen?
Increasing and decreasing respiratory rate due to insensitivity in the respiratory centers of the brain to CO2.
Typically seen in heart failure patients.
In pulmonary physical exams, name 4 signs of distress/labored breathing.
1. Use of accessory muscles
3. Paradoxical abdominal movement
4. Pursed lip breathing
What is acrocyanosis?
What are 2 types of cyanosis?
2. Peripheral (acrocyanosis)
What is clubbing? What can this be a sign of?
Distorted angle of nail bed. It is a sign of hypoxemia, lung cancer, pulmonary fibrosis, cystic fibrosis, etc.
What are some skeletal shapes to watch out for during pulmonary physical exams? (name 5)
3. straight spine
4. pectus excavatum (chest dent inwards)
5. pectus carinatum (chest protruding outwards)
What is tactile fremitus? What increases (name 1) and decreases (name 3) tactile fremitus?
This is placing your hands on the posterior chest and having the patient say "99". You're feeling for the vibrations through the chest wall.
Things that increase tactile fremitus:
1. lung consolidation (water, blood, pus, etc). This is because the fluid will transmit the sound from the patients voice better than air which increases the vibration you palpate.
Things that decrease tactile fremitus are things that interfere with the connection between lung and the chest wall
2. pleural effusion
3. obstructed bronchus -- atelectasis
It is important to check the position of the trachea during the pulmonary physical exam. What can change the position of the trachea?
The trachea can be pushed away from a side that has a large pleural effusion or tension pneumothorax. Or, the trachea can be pulled towards a side that has atelectasis, fibrosis, or resection.
What can percussion during a pulmonary physical exam tell you about a patient?
Percussion that results in a dull sound can be from an effusion, consolidation (pneumonia, pulmonary edema, etc), or atelectasis.
Percussion that results in a resonant sound can be from a pneumothorax, bullae, or emphysema.
What is diaphragmatic excursion and how is it helpful?
This is when you percuss on a patient's back during full inspiration and full expiration to approximate the position of the diaphragm. This can help you detect unilateral diaphragmatic paralysis or other problems with the diaphragm.
Name and describe the pitch, duration, and location of 3 normal breath sounds
1. vesicular - soft and low pitched; heard through inspiration and continues through expiration stopping about 1/3 the way through expiration. This is heard throughout the chest and is always normal.
2. bronchovesicular - moderate in pitch and intensity; heard during inspiration, brief silent gap, then again during expiration. This is heard over the major bronchi
3. bronchial - high pitched and ordinarily heard over the trachea
Note: bronchovesicular and bronchial breath sounds heard over the periphery of the lungs is abnormal (can be atelectasis or pneumonia)
What do crackles/rales sound like? When are they heard? What are they associated with?
A "velcro" sound that is discontinuous and typically during inspiration. Rales/crackles are associated with pulmonary edema, pneumonia, or interstitial lung disease/fibrosis
What does wheezing sound like? When is it heard? What is it associated with?
Wheezing is a high-pitched, musical sound heard most commonly during expiration but sometimes during inspiration. It is sometimes audible without a stethoscope and is caused by high airflow through a narrowed airway. Diffuse wheezing is associated with asthma, bronchitis, COPD exacerbation, and local wheezing sounds suggest a focal obstruction and need to be evaluated further (e.g. aspirated peanut)
What are ronchi?
Rumbling sounds that are continuous, caused by passage of air through an airway that is partially obstructed by mucous or secretions.
What is egophany? How do you test for this?
Egophany is the change in timbre but not pitch or volume. Have the patient say "E" as you auscultate and if it sounds more like an "A" sound, that change is known as egophany. Egophany is present in areas of the lung that are over compressed or fluid filled (e.g. pneumonia).
What is stridor?
Stridor is a musical sound that is typically audible without a stethoscope. It can be either inspiratory or expiratory and is usually heard over the trachea. Stidor signals a pathology in the upper airway (trachea, larynx, or subglottis).
Inspiratory stridor can be a sign of laryngeal pathology such as laryngospasm, laryngeal edema, subglottic stenosis, or vocal chord disfunction.
Expiratory stridor can be a sign of central airway obstruction within the thorax such as a turmor obstructing the trachea
Note that stridor, especially expiratory stridor, almost always needs urgent evaluation.
True or False: Stridor almost always needs urgent evaluation.
True. Especially expiratory stridor
What does a friction rub sound like during a pulmonary physical exam and what does it indicate?
Friction rubs are harsh rubbing sounds that are during inspiration, similar to rubbing an inflated balloon. Due to pleural inflammation or pleuritis from a variety of causes: infection, malignancy, pulmonary infarct, lupus pleuritis, etc.
What is the purpose of Pulmonary Function Tests? (name 5 things)
1. Determine whether pulmonary disease is present
2. Determine the type or pattern of disease present
3. Determine the severity of disease
4. Determine if there is a change in disease severity over time with therapy
5. Pre-operative clearance
What are 6 variables measured using pulmonary function tests?
1. Lung volumes
3. Gas exchange
4. Airway responsiveness
5. Respiratory muscle strength
6. Compliance of the lung
(mainly the first three are regularly done)
What are the 3 patterns of disease seen using pulmonary function tests?
Name 3 obstructive pulmonary diseases
2. COPD (emphysema, chronic bronchitis)
Name 5 things that can cause restrictive patterns in pulmonary disease
1. Pulmonary edema
2. Interstitial lung disease
3. Neuromuscular weakness
4. Pleural disease
In PFT, what is the difference between a volume and a capacity?
Volume is a single unit while capacity is the sum of at least two volumes
What is tidal volume (TV or VT)?
This is the volume of normal, even respirations at rest.
(expiration is passive)
What is expiratory reserve volume (ERV)?
This is the volume of gas remaining in a lung after a normal tidal expiration that can be exhaled.
It requires effort to exhale this volume.
What is the inspiratory reserve volume (IRV)?
This is the volume of gas that you can inhale above the amount inhaled with normal tidal inspiration. This requires effort.
What is residual volume (RV)?
This is the remaining volume of gas in a the lungs after maximum expiration. You can't completely collapse the lung with expiration so this value is estimated and cannot be directly measured.
What is functional residual capacity (FRC)?
This is the volume of gas remaining in the lung at the end of a tidal expiration. This is the sum of the expiratory reserve volume (ERV) and residual volume (RV).
This is the volume at which the elastic recoil of the lung is balanced by the desire of the chest wall to spring outwards. The system is in equilibrium at FRC.
Which volume or capacity of the pulmonary function test represents when the system is in equilibrium?
Functional Residual Capacity (FRC).
This is the sum of expiratory reserve volume (ERV) and residual volume (RV).
FRC is after the tidal volume when the system is in equilibrium and doesn't require any effort.
What is the inspiratory capacity (IR)?
Inspiratory capacity is the volume of gas that can be maximally inspired from FRC.
Inspiratory capacity (IR) = Tidal Volume (VT) + Inspiratory reserve volume (IRV)
What is Vital Capacity (VC)?
Vital capacity is the volume of gas that can be maximally inspired from residual volume (RV). This is the sum of Expiratory Reserve Volume, Tidal Volume, and Inspiratory Reserve Volume.
This requires effort to breathe
What is total lung capacity (TLC)?
Total lung capacity is the total volume of gas in the lungs at maximal inspiration. This is the sum of Residual volume, expiratory reserve volume, tidal volume, and inspiratory reserve volume.
This value requires an estimation of residual volume and requires effort to obtain.
What is airflow in PFTs?
The measure of expiratory airflow (flow = volume/time)
What is an acceptable airflow test? (3 criteria)
1. 6 second expiratory time
2. curve plateaus for at least 1 second
3. test is reproducible (3 FEV1 measurements within 200 ml of each other)
Is forced vital capacity the same as vital capacity?
Yes, most of the time these are the same. However, there are some situations where if you exhale more slowly they may be different.
What is FEV1?
This is the amount of volume that you are able to exhale within the first second of expiration.
What is the FEV1/FVC ratio?
This ratio represents the amount of gas that is exhaled within the first second of expiration compared to the full vital capacity exhaled.
What is a typical value for FEV1/FVC ratio?
0.7-0.8 depending on age.
This means that you exhale between 70-80% of your functional vital capacity within the first second of expiration.