WEEK 4: RESPIRATORY

Question 1

Right main bronchus is more straight so when people choke, often it goes to the right lung before the left; true or false

Answer 1

true

Question 2

Breathing controlled by ____ and ____

Answer 2

medulla oblongata and the pons

Question 3

What is normal RR?

Answer 3

14-20

Question 4

Hyperventilation is described as?

Answer 4

rapid, deep

Question 5

Tachypnea is described as?

Answer 5

> 25/min (rapid, shallow)

Question 6

Dyspnea:

Answer 6

difficulty breathing

Question 7

Apnea:

Answer 7

not breathing

Question 8

Ataxic (Biot):

Answer 8

irregular pattern- apnea, alternates w/regular deep breaths which stops suddenly for short intervals

Question 9

Cheyne stokes:

Answer 9

deep breathing alternating w/periods of apnea

Question 10

Respiratory Questions to Ask

Answer 10

SOB (difficulty breathing) with or w/out exertion- (table 15-1) (different question to determine upper and lower respiratory)
Upper respiratory vs lower respiratory
Chest Pain w/wout exertion or associated w/breathing? (table 15-3) (different area causes for chest pain)
Cough: productive or nonproductive (table 15-2)
Wheezing? (does it sound like a squeey high pitch noise)
Sputum (mucus): characteristics
Hemoptysis (table 15-2)
Orthopenea (does it get hard to breath when you lie down)
Daytime sleepiness, snoring, apnea during sleep (partner/roommate/friends may know more)
Unable to “catch a breath” or “take a deep breath”
RASH?
New Medications?
GERD? (chronic cough, hoarse voice or sore throat)
Travel, ill contacts?
Immunization Status

Question 11

cough questions to ask?

Answer 11

Productive vs. nonproductive
Sputum characteristics?
Worse at certain time of day?
Wake you up at night? 
Associated symptoms?
Fever?
Fits of coughs?
Post-tussive vomiting?
Exacerbated by physical activity or environmental surroundings?
Smoking, PMH, ill contacts

Question 12

chest pain questions to ask ?

Answer 12

Tightness, burning?
Associated with breathing or coughing?
Heaviness/thickness
Dull vs sharp
Point with a finger/pinpoint- musculoskeletal
Flat hand, fist- angina, pleuritic
Hand moving up and down from neck to stomach (reflux?)

Question 13

Past medical history to ask?

Answer 13

Past Medical History
Asthma, COPD, CHF, PNX, PNA TB, CA
Hx of Intubation?
Do you use O2?
CAD, pulmonary HTN
Medications, Allergies, Immunizations

Question 14

Social history to ask?

Answer 14

Smoking/Second hand smoke exposure
Marijuana/Hookah/E-Cigs/Vaping
Occupational/Environmental Exposures
Recent Travel
Ill contacts
Where have they lived?

Question 15

what is the order of the lung exam?

Answer 15

Inspect, Palpate, Percuss, Auscultate

Question 16

What should you note when inspecting the respiratory system?

Answer 16

Inspect
Symmetry
Sternum, ribs, scapula
Scoliosis, kyphosis, congenital chest conditions
Retractions, accessory muscle use, nasal flaring
Work of breathing; length of inspiratory vs expiratory phase
Clubbing, pursed lip breathing, color (cyanosis, pink/erythema)

Question 17

Early hypoxia vs late hyposix

Answer 17

Early hypoxia
Restlessness
Agitation
Fear
Need to sit straight up
Inability to concentrate
Tachypnea
-----
Late signs
Decreased P.ox
Change in BP
Tachy/Brady
Cyanosis
Retractions
Nasal Flaring
Confusion

Question 18

What should be included in the palpation exam?

Answer 18

Palpate structures that may be tender: sternum, ribs, costochondral areas (where cartilage & ribs meet) & sternal border
Palpate structures that appear abnormal
Palpate skin abnormalities- crepitus?-pneumothorax
Palpate chest expansion posteriorly @ 10th rib
Tactile Fremitus: “Ninety-Nine”(side of your hands and have them say 99)

Question 19

Tactile Fremitus:

Answer 19

“Ninety-Nine”(side of your hands and have them say 99)

Question 20

How to detect clubbing?

Answer 20

If distal phalangeal depth ratio is greater than interphalangeal depth ratio = clubbing
If putting two fingers together and it creates a diamond instead of straight, its clubbing (schamroth sign)

Question 21

How to test chest expansion?

Answer 21

POSTERIOR CHEST: PALPATION: palm of hand or side of hand
Test chest expansion: thumbs at the level of the 10th rib with fingers parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration
Expect: symmetric expansion

Question 22

How do you PERCUSS THE POSTERIOR CHEST

Answer 22

Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid
Perform from side to side to assess for asymmetry
Strike using the tip of your tapping finger, twice in each location
Use the lightest percussion that produces a clear note

Question 23

PERCUSSION: HYPERRESONANCE

Answer 23

Hyperresonance: when lungs are hyperinflated
Loud, lower & longer than resonance
More common in children & very thin adults
COPD
ASTHMA (may be resonant to hyperresonant)
Unilateral: air-filled bulla
Air in lung

Question 24

PERCUSSION: DULLNESS

Answer 24

Dullness: when fluid or solid tissue (mass) replaces air containing lung or pleural space
Pneumonia- alveoli filled with fluid, blood cells
Pleural effusion- pleura filled with serous solution
Hemothorax- pleura filled with blood
Empyema- pleura filled with pus
Tumor or fibrous tissue

Question 25

Flatness

Answer 25

Flatness is high pitched & short, soft Typically over solid structures such as bone (spine, scapulae, sternum) Pleural effusion

Question 26

Tympany

Answer 26

Tympany loud and high pitched- drum like, longer duration Excessive air such as pneumothorax Normal over abdomen; abnormal over chest

Question 27

How do you auscultate the respiratory system

Answer 27

NEVER, EVER LISTEN over clothes (unless the patient refuses to allow you to listen directly on skin The most important exam technique for assessing air flow Use the diaphragm of a stethoscope Superior to inferior, left to right to compare Instruct to breathe deeply with mouth open Slowly! Breathing in and out w/patient may help You may need to demonstrate Listen to at least one full breath in each location: don’t cut it short Wheezes sometimes happen at last min, so might miss if dont listen fully Remember: RIGHT MIDDLE LOBE

Question 28

Vesicular

Answer 28

Soft low pitched Inspiration and through first 3rd of expiration Over most of both lungs

Question 29

Bronchovesicular

Answer 29

Inspiratory and expiratory sounds equal Heard anteriorly in1st and 2nd intercostal spaces Heard between scapulae posteriorly

Question 30

Bronchial/Tracheal:

Answer 30

``` Louder Harsher Higher pitched Short silence between insp and exp phase Exp sounds last longer Inspiratory and exp are equal Heard over trachea in neck ```

Question 31

CRACKLES/RALES

Answer 31

Air moving through fluid Nonmusical Intermittent or brief (not continuous) Fine (higher pitched) vs coarse (low pitched) Heard in following conditions PNA (pneumonia) Fluid (congestive heart failure)- heard posterior Atelectasis- collapse of alveoli with period of prolonged shallow breaths Pulmonary fibrosis Bronchiectasis

Question 32

WHEEZING

Answer 32

WHEEZING High pitched whistling sound or low-pitched moaning Musical Intermittent (located any period during inspiration or expiration) describe when late, vs. early. Inspiratory vs expiratory Caused by constriction of smallest airways due to inflammation and mucus Asthma, Bronchitis, COPD, RSV

Question 33

RHONCHI

Answer 33

``` Musical, prolonged Dashes in time Low pitched with a snoring/rattling quality Inflammation of lung tissue- bronchitis, area of larger airways containing mucus May change with cough Heard in the following conditions Bronchitis Pneumonia RSV ```

Question 34

Stridor

Answer 34

high pitched continuous Upper airway constriction/narrowing Epiglottitis, anaphylaxis, foreign body, tracheal stenosis from intubation, airway edema

Question 35

Pleural Rub

Answer 35

Low frequency, grating sound Nonmusical, biphasic (inspiration, expiration) Pleuritis, PNA, Pleural effusion

Question 36

ABSENT OR DIMINISHED BREATH SOUNDS indiciates?

Answer 36

``` Think: lack of airflow Pneumothorax Consolidation Mass Lobectomy? Status Asthmaticus or severe broncho-constriction (tight airways prevent airflow sounds- after bronchodilator- may hear more) ```

Question 37

Bronchophony:

Answer 37

have patient say “ninety-nine” Indistinct, muffled: Normal Loud, clear, understandable: Increased density

Question 38

Egophony:

Answer 38

“eeee” Normally muffled long E sound Changes from “eee” to “aaa” over area of consolidation

Question 39

ABCDEF:

Answer 39

``` Airways, bones, cardiomediastinal silhouette, diaphragm, expanded lungs/everything else foreign objects ```

Question 40

PNEUMONIA (PNA)

Answer 40

Condition: bacterial infection, causing consolidations in lungs Black area means clear lung, want to see more dark Inspection: work of breathing, accessory muscle use, color, tachypnea Palpation: tender structures, tactile fremitus, percussion Auscultation: LS- crackles, diminished, rhonchi, egophany, bronchophany

Question 41

COPD | Chronic obstructive pulmonary disease:

Answer 41

Emphysema- pink puffer | Chronic Bronchitis - blue bloater, coughing mucus up

Question 42

ASTHMA

Answer 42

Condition: constriction of small airways & increased mucus production Inspection: retractions, accessory muscles, color, dyspnea, tachypnea, anxiety, clubbing? Auscultation: LS: wheezing, rhonchi, crackles? Has it improved since given meds?

Question 43

ACUTE BRONCHITIS

Answer 43

Condition: 98% cases caused by viral infections Inspection: work of breathing, color, tachypnea, retractions, accessory muscle use Palpation: excursion, fremitus Auscultation: LS: wheezing, rhonchi, egophany

Question 44

PLEURAL EFFUSION

Answer 44

Condition: fluid trapped in the pleural space- PNA, CHF, CA, Cirrhosis Inspection: work of breathing, tachypnea, dyspnea, retractions, accessory muscle use Palpation: lung expansion, tactile fremitus, percussion Auscultation: LS: diminished? Crackles? Rhonchi?, egophany, bronchophony

Question 45

HEART FAILURE (PULM EDEMA)

Answer 45

Condition: left sided heart failure- causing back up of fluid into lungs Inspection: work of breathing- dyspnea @ rest w/exertion (how much- minimal-mod), tachypnea, (other cardiac signs- JVD), chest diameter? Palpation: pain on palpation of structures, percussion Auscultation: Crackles? Wheezing? Diminished?

Question 46

OSA | Obstructive sleep apnea

Answer 46

``` Excessive daytime sleepiness Snoring Apnea T2DM CVD Cognitive Impairment Afib RF: male, obesity, older age, craniofacial and upper airway abnormalities, postmenopausal (for women) ```

Question 47

FRACTURED RIB

Answer 47

Local pain and tenderness of one or more ribs Compression of chest in AP plane: One hand on sternum and one hand on thoracic spine- squeeze chest- is this painful? Where? An increase in the local pain (away from hand) suggests rib fracture

Question 48

LUNG CANCER

Answer 48

Lung CA: Cigarette smoking 85% of Lung cancer cases USPSTF Screening Recommendation Grade B UPDATE LDCT in 50-80 yr old for 20 pack year hx Annual LDCT x 3 years compared to CXR reduced risk of dying from Lung CA by 20% after 7 yrs of f/u

Question 49

CONSIDERATIONS FOR INFANTS/CHILDREN

Answer 49

Order can be modified on state of wakefulness/cooperativeness Infant: Examine on table with only diaper so respiratory effort can be viewed May use bell for infants (over interspaces) Use diaphragm for children (toddler age & up) Bowel sounds heard easily in chest Airway is shorter; upper airway sounds transmitted to lower airways Respiratory rate varies with temperature, activity, feeding, sleep Little structural support from ribs Nose breathers until age 3 mos Abdomen rise/fall

Question 50

CONSIDERATIONS FOR OLDER ADULTS

Answer 50

Kyphosis - curvature of the spine measuring 50 degrees or greater Chest wall appears bony >> loss of subcutaneous fat Less mobile thorax- unable to compensate for long; tire easily; more reliance on diaphragm for breathing Increased AP diameter of chest wall May become dizzy when taking deep breaths during auscultations: take it slow Dry mucous membranes in nares, throat, respiratory tract Slight hyperresonance of lung fields with percussion Pneumonia – present with atypical symptoms