Course Physical Assessment 1 Date 8/7/08 Class 4

Transcription

1 Course Physical Assessment 1 Date 8/7/08 Class 4 Re-wrap from last week. Pulse, resp, bp are 3 critical vital signs. Pulse: (below or above are bad news) Fast pulse: tachycardia, thyroid problems (younger), pacemaker problems, heart attack. Slow: post heart attack. Resp: 6-20 (below 4 per minute, above 20 are critical) Extreme rapid breathing can = asthma, pneumonia, pulmonary embolism, pulmonary edema, pneumothorax Very slow breath can = drug overdose (opiates, codeine, depressors, street depressors ), alcohol overload, reticular activating system (see pharmacology class xanax or valium switches off the reticulating system which keeps you awake), liver or heart failure + drugs. Page 1 of 28

2 Pulmonary Lecture Thoracic Anatomy Know the anatomy and landmarks of the thoracic area. One landmark omitted below is the Angle of Louis or Manubriosternal Angle where the 2 nd rib meets the sternum. This is also called the Sternal angle in the illustration below. Don t confuse this with the sternal costal angle, which is also called the costal angle in the illustration. The sternal costal angle is wider and flatter in children than in adults as their thoracic cages are not fully formed. You can feel liver and spleen easily in children, while in adults the liver and spleen should be covered by the ribcage. If one or both of them are palpable below the ribcage the organs (or organ) are enlarged. The xyphoid process hardens over time as one grows older. Children have a very soft xyphoid process while elderly people have a very hard process. This can easily be mistaken for a lump in older patients. Page 2 of 28

3 It is also critical to be able to count rib spaces accurately. This should be familiar from Point Locations. Remember that the intercostal space number is the same as the rib above it. Example: the 2 nd intercostal space is below the 2 nd rib. One important reason to know how to count the intercostal spaces, aside from the obvious acupuncture applications, is because the apical pulse of the heart is felt in the 4 th, 5 th, even the 6 th intercostal space on the left. I remember Dr. Luo mentioning this in his lecture on the Heart in Diagnostics 2 and how it is important to feel this pulse a bounding pulse here indicates the Heart Qi is leaking out. In biomedicine this is where you can hear the mitral valve of the heart shut. Cardiologists listen for, among other things, mitral valve stenosis here. More on that later. Remember too that the 11 th and 12 th ribs float, only attached to the 11 th and 12 th thoracic vertebra respectively, not attached to the sternum. You cannot feel the intercostal space between the 1 st rib and collarbone because the collarbone/clavicle obscures it. The first one you can feel is the intercostal space between the 1 st and 2 nd rib. You should be able to feel the 1 st through 5 th intercostal spaces right next to the sternum easily in most people. Around the 6 th space however, the configuration of the costal cartilage makes this impossible. See the illustration above. You will need to move outward to about the mamillary line to feel this. And of course, with women you need to use your most diplomatic skills to avoid a sexual harrassment suit! Anatomical Lines of the Thoracic Region Anatomical lines should be a familiar concept to an acupuncture student. (Think mamillary line, axillary line, etc.) The vertical anatomical lines on the anterior side of the body you need to know are: Midsternal This line divides the left and right sides of the body. This is also called the anterior midline among other things you might remember from anatomy and physiology, but which escape me at the moment. Page 3 of 28

4 Midclavicular line Starts at mid-clavicle and extends downward through the nipple (in a perfect world!) and chest/abdominal area. Anterior axillary line This line begins at the lateral extremity of the clavicle and extends downward close the the tip of the axillary fold. The lateral anatomical lines you need to know are: Anterior axillary line See the bullet point above. Midaxillary line This isn t such a great illustrative photograph. The midaxillary line should extend down the side of the body from the anatomical center of the armpit. Posterior axillary line This mirrors the anterior axillary line. Posterior anatomical lines you need to know: Vertebral or Posterior Midline Runs right down the middle of the spine. Midscapular or Scapular line Not really midscapular looking in the photograph. It s the posterior equivalent of the mid-clavicular line. Lung Anatomy The liver is obscured by the thoracic/rib cage. Upon deep inspiration the diaphragm pushes the liver down 2-3 cm, but is still within the ribcage if it isn t enlarged. When you exhale the diaphragm goes up and the liver does too. At full exhale the top of the liver is approximately level with the top of the nipple. Page 4 of 28

5 The lung is located like this in the thoracic cavity. Note this important stuff: 1. The apex (top point) of the lungs extend above the clavicle. This is why deep peripheral needling above the clavicle can cause pneumothorax. Zoiks! It s also why Dr. Shen needles GB 21 from front to back or back to front by pinching the muscle up then inserting. 2. The right lung has 3 lobes a. Right upper lobe or RUL with the apex protruding above the clavicle. b. RML or right middle lobe between the sternum and the nipple area. There is an oblique fissure separating the RML and the right lower lobe. c. Right lower lobe or RLL. 3. The left lung has 2 lobes a. Left upper lobe (LUL), which occupies most of the real estate. b. LLL or left lower lobe which is a small portion on the lateral inferior edge of the lung area. 4. The lungs expand upon inspiration to about the positions noted by the dashed lines in the illustrative photograph above. From the posterior side the lungs look like this. The trachea splits in two (bifurcates) at about T3. If you listen at this location you will hear loud breathing noises which is normal. (Acu-geek side note: this is the Back Shu of the Lung) While you can listen from the front of the chest and hear lung sounds, you can t do it from the back because the scapula blocks most of the sound. The dashed lines on the illustration are the levels to which the lungs descend when they fill with air upon inspiration. Page 5 of 28

6 Regarding the anatomy of the back in the thoracic area, be able to locate vertebrae on the back. This too was covered extensively in Point Location classes. Specific thing to know: 1. Be able to locate C7. This quite often the most prominent protruding vertebra at the top of the base of the neck, hence the name, vertebra prominens. 2. Know what a spinous process is. Learned that in point locations too. 3. Be able to find the inferior border of the scapula (bottom tip) 4. Be able to find the 12 th rib. Sometimes that s a chore! All of these landmarks are harder to locate on obese people, on patients who are very very muscular, on people with connective tissue disorders, etc. The Pleural Cavity The pleura is a sac surrounding the lungs, serving also as an envelope between the lungs and the chest wall. The outer layer of the pleura is called the parietal pleura and the inner layer is called the visceral pleura which is attached to the lungs. The pleura should have a thin layer of lubricating fluid allowing the lungs to slide across the pleura when you breathe. If the pleural cavity becomes filled (with water, blood or air) this is abnormal and is called pleural effusion. If there is a pneumothorax this space becomes filled with air. If there is bleeding into this space the term for blood here is hemapneumothorax. Pleural mesothelioma is a cancer starting in the pleural layer which moves inward from the chest wall. Shipyard workers and occupations such as asbestos miners are at risk for this. Page 6 of 28

7 The Trachea and Bronchial Tree Since it is critical to keep the acinus and alveoli sacs clean and clear, the bronchial tree is lined with cilia and goblet cells which produce mucous which trap inhaled particles before they reach the alveoli. Diseases affecting the cilia will result in pus and excess mucous production. Ask a smoker... they ll tell you! The trachea is about 10 cm long and bifurcates (forks) at about the vertebral level of T3 or T4. The bronchial tree is described by generations meaning that as the bronchial tubes branch they become smaller and smaller. Each smaller branching is a generation. The smallest are described by the term bronchioles. The right bronchus is shorter and much more vertical than the left. If a foreign object is aspirated (inhaled) it goes directly down the right bronchus and generally lodges in the right middle lobe. Bronchioles lead to the alveoli or alveoli sacs which are the site of gas exchange. The functional respiratory unit in which gas is exchanged is the acinus. Other tissues in the lungs which are filled with air, but not available for gaseous exchange are considered anatomical dead space (which I think is a pretty ungrateful thing to say about one s lungs!). The trachea and bronchii fall into the anatomical dead space category. Emphysema patients have a lot of non-working alveoli and thus are said to have an awful lot of anatomical dead space. In emphysema the functional tissues expand and lose their ability to contract again, leaving a lot of emptiness in the lung tissues. This why they sound so tympanic when you percuss they are more hollow than they should be. So even when they can inhale easily, they feel short of breath which technically they are. The function of breathing/respiration is to: 1. Supply oxygen 2. Remove carbon dioxide 3. Maintain homeostasis through maintenance of the ph (acid-base) balance of the body. This is a very important function of the lungs, actually, as is the next numeric 4. Maintain heat exchange. Page 7 of 28

8 Chest size and breathing Inspiration increases chest size. The diaphragm drops down during inspiration, which is the active phases of respiration. This creates a negative pressure in the thoracic cavity causing air to rush in as the diaphragm contracts. Intercostal muscles then lift the sternum and ribs increasing the diameter of the chest. Expiration is the passive phase of respiration. The diaphragm relaxes, reverting to it s relaxed dome shape. This pushes upward into the thoracic cavity, creating positive pressure in the alveoli and air rushes out. For this reason, proper breathing requires belly expansion! Many people do not use the belly during breathing. While breath retraining is important for everyone, it is really important for people with lung disease to retraining their breathing in order to get the best possible air intake. Respiratory Control There are stretch response nerve endings in the chest. The brain regulates the amount of time that they can be stretched out before recoiling. The pons and medulla in the brainstem are the breathing centers of the brain, though higher emotional responses can override the autopilot breathing functions. These structures receive stimulus from the levels of O 2 and CO 2 in the body. An increase in CO 2 is called hypercapnia and triggers the breathing response to get rid of CO 2. That s what can cause you to yawn that and watching someone else yawn. Heck, I bet you want to yawn right now! Hypoxemia is a decrease in the O 2 levels in the blood. This too triggers your brain to grab more oxygen. Page 8 of 28

9 Changes in Respiration that come with Age Even without smoking (pipes, cigarrettes, pot, whatever) or occupational aspiration of crud, lungs undergo the following changes as they age. Aging people have special circumstances created simply by living a good while. Here are some things to know. Costal cartilage calcifies resulting in a more rigid thorax. This makes it harder for the thoracic cage to expand and can result in posture changes all of which make it harder to breathe. Elastic properties in the lung decrease in function, so capacity of the lung is reduced as well. Vital capacity decreases resulting in the closure of small airways. There is an increase in residual (crud build up) volume. Loss of alveoli results in less surface area available for gas exchange. The bases of the lungs become less ventilated. Pneumonia risk increases when this happens. Retraining for deeper breath through yogic breathing and qigong greatly improves this situation. Focused Subjective Pulmonary Assessment A focused subjective pulmonary assessment takes the following factors into consideration: cough, shortness of breath, chest pain upon breathing, medical history of upper respiratory infection, history of or current smoking, environmental exposure, self-care behaviors. You should also be familiar with the main symptoms of pulmonary disease: Cough Dyspnea painful or difficult breathing Hemoptysis spitting up blood Chest pain which is pleuritic feels like a stitch Wheezing also wheezing with phlegm production Cyanosis Sputum (phlegm) production Cough Ask if your patient has a cough. If no, skip this section. If yes, determine the following: 1. Do you also have difficulty breathing? If so, what came first: the difficulty breathing or the cough? 2. Is the cough barking or hacking? 3. When do you cough? What activities make you cough? Page 9 of 28

10 4. How long have you had it? (duration) Acute cough would be days or less. Chronic would be longer than Why 14-21? Depends upon whom you ask as to the definition of acute. Some say less than 14 days, some say less than How frequently do you cough? 6. What time of day do you cough? What is diagnosed as night-time asthma can be acid reflux disease irritating and inflaming the esophagus. 7. Is your cough productive? Productive: patient coughs up sputum (phlegm). If there is excessive phlegm a doc will often ask the patient to collect the sputum over a 24 hour period and then evaluate it. In the picture to the right three layers are shown: froth at the top, a thick and non-solid layer in the middle and a more solid bottom layer of pus. Dry or non-productive: no sputum/phlegm upon coughing. Sometimes asthma presents as only a dry cough. 8. Is there blood when you cough? If the answer is yes, you have to distinguish whether they are coughing blood (coming from the lung) or spitting up blood (coming from the stomach). a. Hemaptysis coughing up blood from the lung. Blood coming from the lung usually denotes a serious illness such as tuberculosis, tumors, pulmonary embolism (PE), bronchiectasis, or cardiac disease. The patient should be questioned carefully regarding how much is expelled, how frequently, if they have any weight loss they cannot explain, etc. Hemaptysis possible symptoms. Compare these to hematemesis symptoms below. i. Accompanied by a cough ii. Frothy iii. Bright red in color iv. Presence of pus v. Dyspnea vi. Individual may be a cardiac patient b. Hematemesis: Blood coming from the stomach. Here are some possible symptoms i. Nausea and vomiting ii. Blood is not frothy iii. Vomit looks like coffee grounds iv. Food is always mixed in with the blood v. Patient may have GI disease Page 10 of 28

11 9. Do you cough more in one position than in another? 10. What medications are you taking? Many ACE inhibitors and all of the pril medications (lisinopril, etc.) can cause a dry cough. 11. What makes it better (alleviates) or worse (aggravates)? 12. Does the cough have an associated manifestation? What is the location of this manifestation? Sputum If your patient has sputum/phlegm, you need to determine what it s characteristics are. Yellow-green: indicates bacterial infection White: often a viral infection, but can also be bronchitis. Rusty: indicates pneumococcal infection (strep pneumonia) Currant jelly: in other words, gelatinous and bloody, indicating blood + sputum Pink-blood tinged: acute pulmonary edema, leaking of fluids into the bronchii, left ventricular heart failure Frothy: heart failure Bloody (not as gooey as the currant jelly kind): can indicate pulmonary embolism, cancer, TB Foul smelling: abscess of the lung, pus in the alveoli or bronchial tubes. CSF patients will have this. Shortness of breath (SOB) 1. Position Is there a position that makes it better or worse? More on this in the pathology section too. Different pathologies have shortness of breath that is alleviated or aggravated in certain positions. This called autopnia. 2. Aggravating or alleviating factors. 3. Time of day when patient is short of breath or more short of breath. 4. Self care Here are some breathing patterns to be aware of when evaluating shortness of breath and rate of breathing Dyspnea difficulty or pain upon breathing Tachypnea respiratory rate greater than 25 breaths per minute Bradypnea respiratory rate less than 8 breaths per minute Paroxysmal Nocturnal Dyspnea or PND sudden onset of SOB during sleep Orthopnea SOB while lying flat Platypnea SOB while sitting up (better when lying flat) Trepopnea SOB while lying in one lateral decubitus position which is improved by turning on the opposite side Page 11 of 28

12 Chest pain upon breathing Always rule out a cardiac reason for pain upon breathing. Heavy pain in the center of the chest upon breathing is almost always cardiac in nature. Cardiac is always central. Can t emphasize this enough. 1. When does it happen? 2. How would you describe the pain? Lung pain will usually be described as a stitch in the chest, a stabbing pain, worse when they breathe in. Ask them to rate the pain on a scale of 1-10 with 10 being unbearable. Ask the patient to point to where the pain is. 3. What brings it or brought it on? 4. What are the aggravating or alleviating factors? What interventions? (did you use an inhaler, etc.) 5. What medications are you taking? 6. What self-care or prescribed care have you tried or do you do regularly? There are numerous etiologies for chest pain. Here are some organs in which there can be dysfunction generating a pain in the chest. Some examples of disease are given, but these are by no means the only dysfunctions that can cause chest pain: Pleura Pleuritic dysfunction in the parietal pleura is one example. Manifests as a sharp stabbing pain upon inspiration. Esophagus Esophageal reflux disease for instance Heart Myocardial infarction Gallbladder Cholecystitis Chest Wall Costochondritis Large blood vessels Dissection of the vessel for instance. Lung Pneumothorax. Past medical history (PMH) It is always relevant to know about histories of asthma, TB, or other lung diseases and URI s (upper respiratory infections). TB is often found in low income settings, in international travelers, people migrating from high density countries, long-term care facility workers, hospital workers, people who have been in prisons, residents of dorms, HIV patients, people who have been taking immunosuppressants for a long time (think steroids), and diabetic patients. Also, people who move to an urban setting from a rural one are more susceptible to urban diseases such as TB. Page 12 of 28

13 Take into consideration the following: 1. Recent infection 2. History of allergy (self or family) 3. History of TB or asthma. Smoking Whether patient has quit smoking or still does, this is relevant information as well in a pulmonary assessment. 1. What do or did you smoke? Cigarettes, pipe, cigars 2. How frequently did or do you smoke? How long have you or did you smoke? How many packs per day or pack years? Pack years is a way to quantify the collective damage of cigarette smoking. It s not so much a measure of how many packs one has smoked cumulatively per year, but the average number of packs one daily and for how many years. The higher the number, the worse the damage. To calculate pack years: a. Multiply number of cigarettes smoked per day by number of years smoked. b. Divide by Do you or have you lived with a smoker? Environmental exposure 1. Where do you work and play? If you work in a bar (exposure to cigarette smoke), in a dusty environment (silica, concrete dust, asbestos, coal, even wood dust), hazardous environment, etc. you are more at risk for lung damage/pneumoconiosis. 2. Do you do any self care (cardio workout) for your lungs? 3. Education? 4. Health promotion 5. Have you had a PPD or chest x-ray 6. What immunizations have you had? Lung exam After the patient interview and data gathering, you need to gather some objective data. Inspection 1. First verify that the sternocleidomastoid muscles are the same side. If so, see if trachea protrudes to one side or another. If the lung is scarred and collapsed it will pull the trachea to one side. Page 13 of 28

14 2. Look for symmetry of both the clavicular region and the thoracic cage. Unevenness could indicate breakage. Uncorrected or poorly healed bone breakage of the clavicle or ribs can affect the ability of the lung to expand properly. Longstanding lung disease are indicated by a hollowing under the clavicle. This could include long term asthma, cancer, tuberculosis, etc. 3. Look at breathing and see how chest wall moves. Ask them to deepen breath if needed. Use a measuring tape around the circumference of the chest at the level of the nipples/4 th intercostal space. Ask the patient to exhale fully and hold while you measure. Hold the tape in place, but loosely enough that it will expand along with their chest. Ask them to breathe in fully and measure again. Compare the difference between the two measures. There should be a difference of between 2 ½ and 3 inches in the diameter (super atheletes: 4-5 inches) for healthy lung expansion. Obstructive or restrictive diseases of the lung will have smaller measurement differences. 4. Measure the respiratory rate if you have not already (you have!) breaths per minute is considered within normal ranges. Also observe the regularity of breathing as well as whether it seems to be an effort to breathe. Note whether the patient breathes from the chest or from the diaphragm. 5. Look at lips and tongue (central) and nails (peripheral at fingers/toes) for bluing indicating compromised lung function. 6. Look at the distal interphalangeal and base of nailbed from the side. You are looking for clubbing of the fingers. This is enlargement of the connective tissues in this area. It is painless and the fingertips and nails are curved and warm. A patient with clubbing will also have Schamroth s sign, the loss of the subungual angle. While clubbing can be hereditary, it is often symptomatic of chronically low blood oxygen levels and indicative of disease such as interstitial fibrosis, tumor, bronchiectasis, heart disease and endocarditis. It can also be caused by a lung abscess or lung cancer. Be aware that diseases which cause mal-absorption like cystic fibrosis or celiac disease can also cause clubbing. Page 14 of 28

15 Know these main symptoms of pulmonary disease: Palpation When palpating for a lung assessment, there are 4 things you are doing: 1. Identifying any areas of tenderness if the patient has reported pain or injury 2. Assessing observed abnormalities. 3. Assessing respiratory excursion or the range of respiratory movement like you did above with the tape measure. 4. Evaluating tactile fremitus. This is the term for vibrations (some people call it thrills ) felt from lungs when the patient is speaking. To evaluate tactile fremitus use only one hand and find the area of your hand that is most sensitive to vibration. For many people this is the back or ulnar side of the hand. You probably won t find that your fingertips are sensitive enough to vibration for that to work for you. Finger pads are more tactile than vibration sensitive. a. Solid tissues such as scars will transfer vibration well. b. Fluids (pleural effusion, fluid in the lung) and air space (pneumothorax or emphysema does not transmit well. Here are some ways to feel for tactile fremitus. Once you have picked a method that works best for you, procede to the steps below. c. Have your patient repeat the same phrase which makes full rich vibration sounds such as ninety-nine or one-one-one. d. Place the part of your hand where you best feel vibration on the right shoulder just above the clavicle and feel. Move to the left at the same level and feel again. Work your way down zigzagging like this to about the 3 rd or 4 th intercostal space on women and slightly lower for men. The vibration should be the same for both sides, though it decreases at the lower levels. e. Note any increases between left and right. Remember that there will be a decrease where there is fluid or excessive air space and an increase where there is solidity such as scarring, tumors or pneumonia. f. Repeat on the back of the body, noting your findings. The illustration indicates the sequence on the back to use for this procedure. Page 15 of 28

16 Tactile fremitus: Increases with pneumonia. Decreases with pneumothorax, emphysema, pleural effusion, COPD, and fat. Percussion When you percuss you are feeling mostly for resonance. Hyperresonance is found in cases such as emphysema while dullness is found in pneumonia or tumors. Some other things you might feel: Flatness. This is soft in intensity but high in pitch and short in duration. Percuss on your thigh to feel this. Mandyam s notes don t cover flatness at all Got it from this groovy website: Free-ed.net. Flatness indicates about the same as dullness: solidity of some sort. You will hear flatness or dullness on tumors, pneumonia, etc. Dullness is medium in intensity, pitch and duration of feedback sound when you percuss. Percuss on your liver to feel this. Mandyam s notes also say you can hear dullness on the thigh. You might hear this in pleural effusion, tumors, pneumonia, anything solid in the lungs. Resonance is loud in intensity, low in pitch and long in duration of sound made. Percuss a normal lung to hear resonance. Tympany is the term used to describe a percussion sound which is loud and sounds musical. You can percuss your puffed out cheek to hear what this sounds like. You can also hear it over the abdomen. Tympany or hyperresonance indicates empty space it s like tapping on a drum head. This indicates lots of empty air space pneumothorax, emphysema. To percuss, identify you dominant and non-dominant hands. You tap with the middle finger of your dominant hand on the middle finger of the non-dominant hand at the middle phalanx. (For this reason, you should keep your nails short or you ll be cleaning up your own blood!) Stretch your non-dominant middle finger out on the spot where you wish to percuss. Don t let your other fingers touch the patient. With your dominant hand you tap using the motion of the wrist. Withdraw the striking finger immediately to avoid dampening the sound. Strike once, wait long enough to hear the whole duration of the sound and if you need to hear it again, strike once more. Move symmetrically to the other side of the chest to compare the sounds coming from the same level on both sides. Page 16 of 28

17 Shown here is a one-handed method of percussion in which the practitioner is tapping in the intercostal spaces This is also called direct percussion. Here is the two handed method of percussion, described above (all but the middle fingers are indeed lifted off the skin, but it doesn t show clearly in the photo). This method is referred to as indirect percussion. Here is the anterior percussion pattern to follow when palpating the chest. Obviously, be sensitive to women s breast tissues. Position 5 is on the lateral of the body. Bear in mind that lung cancer often starts on the periphery and moves inward. Here is the pattern to follow on the posterior side Always move from one side to the other symmetrically. No need to percuss over the shoulder blades since all that will tell you is that there is bone there and you pretty much know that already! Auscultation Auscultation refers to listening to lung sounds with your stethoscope to estimate airflow through the tracheobronchial tree, detecting any obstructions and assessing the condition of the surrounding lung and pleural space. General Guidelines: You can position your patient either sitting or lying supine for this, though sitting gives easier access to both sides of the body and is often more comfortable for patients with breathing difficulty. Page 17 of 28

18 Show your patient how you want them to breathe, through the mouth and more deeply/forcefully than usual. Use the diaphragm side of your stethoscope to listen. Start at the top of the back and work downward moving symmetrically from left to right as you zigzag your way down. Next, start at the top of the chest moving symmetrically downward. Compare each side as you listen, noting differences from one side to another. Listen to one full breath (inhale + exhale) before moving locations. Watch for patient discomfort lightheadedness and fainting which indicate hyperventilation. Normal breathing sounds Inhalation or inspiration normally takes 2ce the time that an exhale takes. Noises are generally softer in the vesicular/lobe areas and louder and harsher over the trachea and bronchovesicular areas. 1. Bronchial/Tracheal Listening over the trachea and larynx on the centerline of the body, you will hear higher pitched, louder than sounds heard over the lung and harsh in nature. Like wind blowing through a hollow tube. The sounds are: Short = inhale Long = exhale You will not hear these noises elsewhere in a normal lung. If you hear them over the posterior or lateral chest wall, this is pathological. 2. Broncho-vesicular These sounds are heard near the center over the larger branchings of the bronchial tree. They are moderate in pitch and in volume. 3. Vesicular These are normal breath sounds made at the sites over the alveoli (but not over the manubrium, sternum or interscapular regions). They sound long on inhale and short on exhale. They are low in pitch, soft in volume and rustling. The timing of normal breathing sounds is like this: Tracheal: inspiration = expiration Bronchial: inspiration is about 1/3 the length of expiration. Bronchovesicular: inspiration = expiration Vesicular: inspiration is 3 times longer than expiration. Page 18 of 28

19 Adventitious or extra sounds Abnormal sounds include, but are not limited to: Ronchi Ronchi are coarse rattling sounds produced on the exhale that tend to be continuous. The sounds are usually clear, but may change if there is coughing. The sounds are low pitched and usually occur when there is mucous in the bronchii. Wheezes Wheezes are musical and high pitched continuous sounds. I think they sound like a very soft high note on a clarinet. These are caused by partially constricted or obstructed airways. In asthma you ll hear them on the exhale most of the time, but can also be on the inhale. Asthma and bronchitis can produce this noise. This said, not all that wheezes is asthma! Here are some other possible causes for wheezing: o Bronchitis (often heard on the inhale) o Vocal chord dysfunction o Aspiration of a foreign body o Infections such as laryngitis o Croup o Congestive heart failure o COPD o Hard forced expiration in normal/undiseased people o Cystic fibrosis Crackles or rales Fine or coarse rattling sounds, usually non-continuous. High pitched fine crackles sound like carbonated beverages when you first pour them out of a can. The coarse rales can sound like velcro when you pull it apart. You usually hear this when the patient breathes in and sometimes when they start to exhale. The cause is usually fluid in the alveoli and bronchioles. Coughing makes it sound louder. Page 19 of 28

20 Pneumonia and emphysema can produce crackles/rales. Friction rub or pleural rub Pleuritis (inflamed pleura) can cause this scratchy sound, which sounds somewhat like Saran wrap when you crinkle it. Can also sound like squeaking leather. This is the sound of two dry surfaces rubbing against each other. Pulmonary embolism can also cause this noise. Doesn t follow inspiration or expiration. If you press deeply on it the sound will disappear. A pulmonary embolism is a blood clot in the pulmonary artery which can result in infarction of tissue, can cause a gangrenous place, or can heal and leave a scar. Stridor This is a high pitched noisy respiration sound, sometimes rattley, sounding like wind blowing. This is usually heard on inspiration and is caused by obstruction of the upper airway. Croup produces these noises along with a barking cough. Can also be caused by an inflamed epiglottis or larynx. Vocal sounds or auscultation of the spoken voice. You can also learn a lot about the internal condition of the lung by listening with your stethoscope to the sounds made in the lung when the patient vocalizes. This is also called vocal fremitus. Bronchophony have the patient say 99 while you listen on the chest. It should sound muffled. If you clearly hear 99 then there is something dense in the lung. Egophony have the patient say eeeeee. If there is consolidation in the lung you will hear aaaaaaaa (ay like the Fonz not ah ). Whispered pectoriloquy have the patient whisper If the sound is muffled, that s good. If you hear it clearly, there is some sort of consolidation in the lung. Note: TB is often in the apical area of the lung and can produce a cavity called an apical lesion which is a caseous necrosis filled with gooey greenish pus. Produces a cold abscess, not a hot one with inflammation and a whispering dome which transmits sound clearly in places. In summary: You should know anatomical landmarks both surface and interior, pertinent vocabulary and how to express what you have found from the assessment, symptoms and signs, how to perform the exam, how to present the information, how to formulate a differential diagnosis. Indications of Lung Pathologies Pathologies sometimes are very obvious. In your interaction with the patient you might notice obvious signs of respiratory distress: Anxiousness Labored breathing Clutching of the chest Engaging accessory muscles Page 20 of 28

21 Cyanosis o Cyanosis may be peripheral, affecting hands and feet. Warming can decrease it. Indicative of decreased cardiac output. o Central cyanosis is of the lips, tongue, and sublingual area. Right to left shunts. o Pseudocyanosis is a blue pigmentation of the skin resulting from something other than a lack of oxygen, usually drug related. This is not true cyanosis. Gasping Stridor Clubbing of the nails Also, make it a habit to observe the body habitus or the basic shape of the body which may have been modified by disease or dysfunction. Many of the postures below which fall out of the range of the norm can cause respiratory problems. Barrel Chest The 2 nd posture above shows a barrel chest, as does the picture to the left. This is determined by calculating a ratio of the anterior-posterior to the lateral. Normal is 0.70 to Anything greater than 0.9 is considered abnormal in an adult. In English, look from the side of the patient the anterior to posterior depth in a normal patient is smaller than the full on frontal or posterior view. A barrel chest is the same or wider when viewed from the side. On a chest Xray the lung will show very little white area. All of this can indicate COPD, emphysema + bronchitis. If the Xray shows a big dark empty sac where the lung should show, this is an indication of emphysema. Page 21 of 28

22 Pursed Lips while Breathing COPD patients will often purse their lips while breathing. This decreases dyspnea, decreases respiratory rate, increases tidal volume and decreases the work of breathing. This increases resistance to airflow, forcibly dilating small bronchi. White Noise or Noisy Breathing You can hear this without a stethoscope in chronic bronchitis patients. The sound occurs with air turbulence caused by narrowed airways. It lacks a musical pitch. Abnormal Breathing Patterns Apnea lack of breath indicating cardiac arrest BIOT s comes from increased intercranial pressure, drugs, and medullary suppression. Cheyne Stokes can be caused by CHF, drugs, cerebral ischemia Kussmaul s metabolic acidosis Specific Lung Pathologies COPD Chronic Obstructitive Pulmonary Disease patients have both chronic bronchitis and emphysema. However, a patient will typically be classified as either suffering primarily from one or the other. They are classified with the terms pink puffers and blue bloaters. Pink Puffers Patients suffering primarily from emphysema are referred to as "pink puffers." The term is derived from the reddish complexion and the "puffing" (hyperventilation) seen in patients suffering from Type A Chronic Obstructive Pulmonary Disease (COPD). A pink puffer is typically thin and breathes with pursed lips, has tachypnoeic (increased respiratory rate) and experiences breathing difficulty. An arterial blood gas test shows evidence of less hypoxemia than blue bloaters and no carbon dioxide retention. The prognosis for pink puffers is thus better than for blue bloaters. In addition to the signs above, look for Dahl s Sign, two patches of hyperpigmentation on the elbows and above the knees. This comes from long term sitting forward with elbows on knees to improve breathing. Also look for nicotine stains and a smoker s face very ruddy, possibly purplish or bluish. Blue Bloaters Patients with COPD and suffering primarily from chronic bronchitis are referred to as blue bloaters. This term is derived from the bluish coloration of the lips and skin commonly seen in patients with Type B COPD. Page 22 of 28

23 Pneumonia A blue bloater has a history of cough with sputum for 3 months to one year or more. Blue bloaters experience cyanosis due to decreased amounts of oxygen reaching the blood. Ankles and legs may be swollen and there may be distention in the neck veins. Blue bloaters develop signs of right-sided heart failure. An arterial blood gas test will show evidence of hypoxemia, carbon dioxide retention and compensated respiratory acidosis. Prognosis for blue bloaters is poor, most dying within 2-4 years. Long-term oxygen therapy is about the only way to improve prognosis. Decreased chest expansion. Tactile fremitus increases. Dull sound upon percussion over the infiltrate or infected areas. Increased breath sounds You may hear crackles This is chest X-ray of a patient with pneumonia in the right upper lung. The consolidation noted will be dull when you percuss on it. This shows infiltrates in the right upper lung. The triangular looking wedge you see is the fissure between the upper and middle lobes. Pneumothorax Uneven expansion of the chest Decreased tactile fremitus. Hyper resonance Page 23 of 28

24 Decreased diaphragmatic excursion Absent or decreased breathing sounds. This is a chest Xray of pneumothorax on the left side. The top label points to the collapsed lung tissue. The black part on the patient s left side is just empty space at this point. The middle label on the left of the x-ray indicates a mediastinal shift to the patient s right. The bottom label points to the empty space. Emphysema or Pleural Effusion Barrel chest: increased antero-posterior diameter Sits in tripod position, may have Dahl s sign Hyper resonance Decreased breathing sounds upon auscultation Occasional wheezing Pleural Effusion results in a chest X-ray that looks like this: This patient has a pleural effusion on the left side (our right as we are viewing it). Note the difference between the left and right. Look at the end of this document and compare this with the normal chest x-ray given there. Asthma Low tactile fremitus due to increased alveolar sacs Uses accessory muscles to breathe, looks uncomfortable Hyper resonance upon percussion Prolonged inspiration, wheezing upon expiration Page 24 of 28

25 Gibbus This is angulation of the spine. Note the bluish bump on the spine about 2/3 of the way down. This is tuberculosis of the spine. Page 25 of 28

26 Chest X-Rays (CXR) This is a normal CXR. It has been included for comparison with the X-ray examples given above as well as for those that follow. The X-ray below shows a mass in the right upper lung. Page 26 of 28

27 This X-ray shows an aneurism in the aortic arch Below is pericardial effusion and massive cardiomegaly Page 27 of 28

28 Cardiomyopathy. Enlargement is greater than ½ of thoracic width Page 28 of 28