Robert Erickson, RRT-NPS, RPFT

Transcription

1 Robert Erickson, RRT-NPS, RPFT Clinical Systems Manager Respiratory Care Community Hospital, Munster Indiana Community Healthcare System This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 United States License.

2 Bob s Disclaimer My Apologies To elementary for some To advanced for others Not comprehensive (not intended to be, don t have the time) And will include personal opinion. But hopefully have a few pulmonary pearls that all can use. And - unapologetically, a clinical talk. 2

3 Assumption #1 Physical assessment of the lungs and thorax is at the very spirit of what we do. Auscultation for the respiratory therapist is a distinct focus of assessment. (As imperfect & as limited as it may be) 3

4 Assumption #1 (cont d) As non-ordering care providers, physical assessment (focused on auscultation today) continues to be the jumping off point for much of what we do at the bedside. Graphic analysis & automation of lung sounds is part of our future but is outside of the primary scope of the clinical talk I was asked to present today. RCPs (if they choose) have the potential of developing an extraordinary level of expertise due to the vast number of chests we auscultate. 4

5 Assumption #2 We would like to believe that our students & colleagues can recall & understand a majority of the physical assessment information we report. But as bedside practitioners, we must be honest with ourselves and appreciate the opposite is actually true. Our students and overwhelmed colleagues take into account very little of what we provide. It is within this reality that I would like to discuss and introduce relatively simplified methods that can assist in applying physical assessment findings. 5

6 Assumption #2 (cont d) The Problem To Much & Inconsistent Information & The Solution - K.I.S.S. (Not comprehensive, it s about tools you can use) (& Leaving with a few pearls) 6

7 Decision Making & Strawberry Jam 1 This room full of people. Each given 3 small unmarked containers of strawberry jam. Everyone asked to individually determine which was the Best. There would be amazing agreement between individuals and food tasting professionals. Which is the best? 7

8 Decision Making & Strawberry Jam 2 This same room full of people 4 hours later. Introduced to the idea of professional food tasters. Each given 3 small unmarked containers of strawberry jam. Each given a 2 page form to complete outlining all of the potential taste characteristics of strawberry jam. Everyone asked to individually determine which was the Best. There would be amazing disagreement between individuals and food tasting professionals. 8

9 Strawberry Jam & Adventitious Lung Sounds Why the (new) disagreement- Added complexity. How does this relate to the bedside clinician? Consider our commonly used descriptions. 9

10 Commonly Used Terms for Adventitious Lung Sounds Rales Whistles Coarse rale Fine rale Squawks Sibilant rhonchus Crepitation Coarse crackle Coarse rales Râle gargouillement Râle crepitation Râle sonore Sonorous rhonchus Râle sibilant Coarse Crackles Wheeze Rhonchus Harsh Mild PRN terminology Overwhelming and confusing! 10

11 3 containers of strawberry jam. Solution? - The 3 primary adventitious lung sounds recommended by the American Thoracic Society (ATS). 1. Crackle 2. Wheeze 3. Rhonchus Manageable, consistent & straightforward to communicate. (& before I start a riot, there are other important sounds. These are the principal.) 11

12 The 3 Primary Adventitious Sounds, Have 3 Primary Descriptions Crackle Wheeze Rhonchus Discontinuous Continuous Continuous Variable pitch * Higher-pitched Lower-pitched Crackling Hissing, whistling Snoring Manageable, consistent & straightforward to communicate. * Fine crackle, higher pitched. Coarse Crackle, lower pitch. R. Erickson, RRT-NPS, RPFT 12

13 What is that 3 thing, you may have noticed? Human beings have great success in remembering and applying in sets of 3. Bunching / Chunking Triads / Triplets 13

14 Stories you have read to the children in your life. How many little pigs? How many blind mice? How many billy goats gruff? How many bears did Goldilocks bother? 14

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16 Step 2 -Simpler Localization of Adventitious Lung Sounds You can localize auscultation finding into sections by just answering 3 questions. 1.Right or Left lung? 2.Upper, middle or lower lung field? 3.Anterior, posterior or lateral lung field. Manageable, consistent & straightforward to communicate. (& accurate) 16

17 3 rd Step in Classifying Adventitious Lung Sounds The phase of the ventilatory cycle. 1. Inspiratory 2.Expiratory 3.Inspiratory & Expiratory 17

18 Implications of when in the Ventilatory Cycle, Adventitious Sounds Occur 1. Crackles are primarily created during the active cycle of ventilation. Most likely to be appreciated during inspiration. A worse finding if appreciated during both inspiration & expiration. 2. Rhonchi are also primarily created during the active cycle of ventilation. Most likely to be appreciated during inspiration. A worse finding if appreciated during both inspiration & expiration. 3. Wheezes are primarily created when the airway is of smaller diameter. Most likely to be appreciated during expiration. A worse finding if appreciated during both expiration & inspiration. R. Erickson, RRT-NPS, RPFT 18

19 Some brains like a different way - of learning and organizing adventitious lung sounds. Algorithms 19

20 3 Primary Algorithm Conventions 1. Oval = Beginning or end point 2. Diamond = A decision point. Always a Yes or No answer. 3. Rectangle = An action point 20

21 If they look familiar- Think high school biology. 21

22 Start Start Decision Is the sound discontinuous, variable pitch & crackling? Description 22

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25 Start Identify the sound as a crackle. Yes Is the sound discontinuous, variable pitch & crackling? Then No Identify the sound as a wheeze. Yes Is the sound continuous, high-pitch & hissing whistling? Then No Identify the sound as a rhonchus. Yes Is the sound continuous, lowerpitch & snoring? 25

26 Start Identify the sound as a crackle. Yes Is the sound discontinuous, variable pitch & crackling? No Document & re-assess Then Start Identify the sound as a wheeze. Yes Is the sound continuous, high-pitch & hissing whistling? Decision Description Then No Identify the sound as a rhonchus. Yes Is the sound continuous, lowerpitch & snoring? R. Erickson, RRT-NPS, RPFT 26

27 1. More Data Points 2. More complex 3. Encourages rule following 1. Less Data Points 2. Less Complex 3. Encourages insight 27

28 Where do adventitious sound come from? A simplification to see in your minds eye. 1. Crackle opening of collapsed lung tissue. fibrotic lung moving Air thru fluid 2. Wheeze constricted/tightened airways 3. Rhonchus adhered mucous moving with an airstream 28

29 3 adventitious sounds we did not focus on today. Stridor Pleural Friction Rub Squawks High-pitched, musical Leather-on-leather Short inspiratory, musical Upper airway/glottis acute obstruction Rubbing acutely inflamed serous surfaces / pleurisy. hypersensitivity pneunionitis, fibrosis, pneumonia Extraparenchymal Extraparenchymal Parenchymal & Present, Absent & Varied volume as compared to expected. 29

30 And still: The worse lungs sounds are NO lung sounds. 30

31 Pneuma, Spiritus, Breath Auscultation of the lungs also give you the opportunity to: 1. Calm and reassure the patient. 2. Help them regain some control of their breathing. 3. Establish a human connection. 31

32 3 big auscultation mistakes 1. All that crackles is not wet. Fibrotic lung changes 2. All that wheezes is not asthma. CHF, other airway obstruction 3. Diminished breath sounds are not always COPD Any thing that removes the lung from the chest wall. 32

33 Breath Sounds & Tissue Density Vesicular Bronchial Broncho-Vesicular Peripheral, more inspiratory. Trachea/central, more expiratory. Upper Chest, inspiratory & expiratory. Low in pitch High in pitch Moderate in pitch Soft in volume with a rustling leave quality. High in volume with a tubular quality. Moderate in volume with a tubular quality. Non-vesicular sounds heard in the peripheral lung fields - suspect increased density of underlying lung tissue. 33

34 & the classic question What is the most important part of the stethoscope? The answer is, the part between the ear-pieces. 34

35 To request a copy of this presentation. me a request at boberrtrpft@gmail.com My Blog Go to Google and search Respiratory KISS. 35

36 A look at a future of auscultation. Diagnostics & teaching. 36

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40 Links for listening - Google videos and search lung sounds ann/stethoscope/education/heart-lung-sounds/ e/pulmonar/pd/b-sounds.htm 40