Patient Assessment (Iacona)- Thorax/Lungs

Barrel Chest

There is an increased AP diameter. This shape is normal during infancy, and often accompanies aging and chronic obstructive pulmonary disease.

Diffuse Interstitial Lung Diseases Dyspnea

(e.g., Sarcoidosis, Widespread Neoplasms, Idiopathic Pulmonary Fibrosis, and Asbestosis) -Process: Abnormal and widespread infiltration of cells, fluid, and collagen into interstitial spaces between alveoli; many causes -Timing: Progressive dyspnea, which varies in its rate of development with the cause -Aggravating: exertion -Relieving: Rest, though dyspnea may become persistent -Symptoms: Often weakness, fatigue; cough less common than in other lung diseases -Setting: Varied; exposure to trigger substances

Clinical lung considerations

- Accumulations of pleural fluid, or pleural effusions, may be transudates, seen in heart failure, cirrhosis, and nephrotic syndrome, or exudates, seen in numerous conditions including pneumonia, malignancy, pulmonary embolism, tuberculosis, and pancreatitis. - Irritation of the parietal pleura produces pleuritic pain with deep inspiration in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular diseases. -Anything below T4 when putting tube in is in the right bronch, must pull back -Right mid lobe is common for infection -Interscapular=btw scapula -Dyspnea/breathing: base activity tolerance on daily activity -Every positive for a symptom then gets 7 questions (7 attributes)

Aortic Dissection

-A splitting within the layers of the aortic wall, allowing passage of blood to dissect a channel -Local: Anterior or posterior chest, radiating to the neck, back, or abdomen -Quality of pain: Ripping, tearing, Very severe. Abrupt onset, early peak, persistent for hours or more. -Aggravating: Hypertension -If thoracic, hoarseness, dysphagia; also syncope, hemiplegia, paraplegia

Mycoplasma and Viral Pneumonias

-Acute Inflammation -Dry hacking cough, may become productive of mucoid sputum -Acute febrile illness, often with malaise, headache, and possibly dyspnea.

Bacterial Pneumonias

-Acute Inflammation -Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty -Acute illness with chills, often high fever, dyspnea, and chest pain. Commonly from Streptococcus pneumonia, Haemophilus influenza, Moraxella catarrhalis; Klebsiella in alcoholism, especially if underlying smoking, chronic bronchitis and COPD, cardiovascular disease, diabetes.

Acute Bronchitis

-Acute Inflammation -Cough, may be dry or productive -Acute, often viral, illness generally without fever or dyspnea; at times with burning retrosternal discomfort.

Chest pain

-Angina pectoris, - myocardial infarction, -myocarditis -Pericarditis -Aortic dissection -Bronchitis -Pericarditis, -pneumonia, -pneumothorax, -pleural effusion, -pulmonary embolus -Costochondritis, -herpes zoster -Gastroesophageal reflux disease, -esophageal spasm, -esophageal tear -Cervical arthritis, -biliary colic, -gastritis -Your initial questions should be as open-ended as possible. "Do you have any discomfort or unpleasant feelings in your chest?" -Ask the patient to point to the location of the pain in the chest. Watch for any gestures as the patient describes the pain. Elicit all seven attributes of chest pain to distinguish among its various causes A clenched fist over the sternum 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 suggests heartburn. -Visceral Pleura not many pain fibers, pain in pneumonia etc is from parietal, pain in pericarditis is also likely from parietal pleura -Chest wall pain, costochondritis/herpes zoster (finger pointing to tender area). If diabetic w/zoster may have neuropathy and not necessarily realize Extrathoracic structures (neck, gallbladder, stomach)

Posterior chest palpation

-As you palpate the chest, focus on areas of tenderness or bruising, respiratory expansion, and fremitus. Intercostal tenderness can develop over inflamed pleurae, costal cartilage tenderness in costochondritis. -Identify tender areas. Carefully palpate any area where the patient reports pain or has visible lesions or bruises. Note any palpable crepitus, defined as a crackling or grinding sound over bones, joints, or skin, with or without pain, due to air in the subcutaneous tissue. Tenderness, bruising, and bony "step- offs" are common over a fractured rib. Crepitus may be palpable in overt fractures and arthritic joints; crepitus and chest wall edema are seen in mediastinitis. -Assess any skin abnormalities such as masses or sinus tracts (blind, inflammatory, tube-like structures opening onto the skin). Although rare, sinus tracts suggest infection of the underlying pleura and lung (as in tuberculosis or actino- mycosis). -Do lung excursion. Unilateral decrease or delay in chest expansion occurs in chronic fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, pleural pain with associated splinting, unilateral bronchial obstruction, and paralysis of the hemidiaphragm.

Daytime sleepiness/snoring/disordered sleep

-Ask about problems with snoring, witnessed apneas (defined as breathing cessation for ≥10 seconds), awakening with a choking sensation, or morning headache. -hallmarks of obstructive sleep apnea, commonly seen in patients with obesity, posterior malocclusion of the jaw (retrognathia), treatment-resistant hypertension, heart failure, atrial fibrillation, stroke, and type 2 diabetes. -Mechanisms include instability of the brainstem respiratory center, disordered sleep arousal, disordered contraction of upper airway muscles (genioglossus malfunction), and anatomic changes contributing to airway collapse such as obesity, among others

Egophony

-Ask the patient to say "ee." You will normally hear a muffled long E sound. -If "ee" sounds like "A" and has a nasal bleating quality, an E-to-A change, or egophony, is present.

Bronchophony

-Ask the patient to say "ninety-nine." Normally the sounds transmitted through the chest wall are muffled and indistinct. -Louder voice sounds are called bronchophony. -Localized bronchophony and egophony are seen in lobar consolidation from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egoph- ony more than triples the likelihood of pneumonia.

Whispered pectoriloquy

-Ask the patient to whisper "ninety-nine" or "one- two-three." The whispered voice is normally heard faintly and indistinctly, if at all. -Louder, clearer whispered sounds are called whispered pectoriloquy.

Breath sounds

-Learn to identify breath sounds by their intensity, their pitch, and the relative duration of their inspiratory and expiratory phases. Normal breath sounds are: *Vesicular, or soft and low pitched. They are heard throughout inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration.Throughout most lung. *Bronchovesicular, with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration. Often in the 1st and 2nd interspaces anteriorly and between the scapulae *Bronchial, or louder, harsher and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds. Over the manubrium, (larger proximal airways) *Tracheal, or loud harsh sounds heard over the trachea in the neck. Over the trachea in the neck -If bronchovesicular or bronchial breath sounds are heard in locations distant from those listed, suspect replacement of air-filled lung by fluid- filled or consolidated lung tissue.

Auscultation

-Auscultation is the most important examination technique for assessing air flow through the tracheobronchial tree. -Auscultation involves (1) listening to the sounds generated by breathing, (2) listening for any adventitious (added) sounds, and (3) if abnormalities are suspected, listening to the sounds of the patient's spoken or whispered voice as they are transmitted through the chest wall. -Before beginning auscultation, ask the patient to cough once or twice to clear mild atelectasis or airway mucus that can produce unimportant extra sounds. -Bedclothes, paper gowns, and even chest hair can generate confusing crackling sounds that interfere with auscultation. For chest hair, press harder or moisten the hair. -Listen to the breath sounds with the diaphragm of your stethoscope after instructing the patient to breathe deeply through an open mouth. Air movement through a partially obstructed nose or nasopharynx can also introduce abnormal sounds. -Use the ladder pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs. Listen to at least one full breath in each location. If you hear or suspect abnormal sounds, auscultate adja- cent areas to assess the extent of any abnormality. If the patient becomes light- headed from hyperventilation, allow the patient to take a few normal breaths. -Note the intensity of the breath sounds, which reflects the air flow rate at the mouth, and may vary from one area to another. Breath sounds are usually louder in the lower posterior lung fields. Breath sounds may be decreased when air flow is decreased (as in obstructive lung disease or respiratory muscle weakness) or when the transmission of sound is poor (as in pleural effusion, pneumothorax, or COPD). -Is there a silent gap between the inspiratory and expiratory sounds? A gap suggests bronchial breath sounds. -Listen for the pitch, intensity, and duration of the inspiratory and expiratory sounds. Are vesicular breath sounds distributed normally over the chest wall? Are breath sounds diminished, or are there bronchovesicular or bronchial breath sounds in unexpected places? If so, in what distribution?

Anatomy of breathing

-Breathing is primarily automatic, controlled by respiratory centers in the brainstem that generate the neuronal drive for the muscles of respiration. -principal muscle of inspiration is the diaphragm. During inspiration, the diaphragm contracts, descends in the chest, and expands the thoracic cavity, compressing the abdominal contents and pushing out the abdominal wall. -The muscles in the rib cage also expand the thorax, especially the scalenes During expiration, the chest wall and lungs recoil and the diaphragm relaxes and rises passively. Abdominal muscles assist in expiration. As air flows out- ward, the chest and abdomen return to their resting positions. accessory muscles are recruited; the sternocleidomastoids (SCM) and the sca- lenes may become visible

Left Ventricular Failure or Mitral Stenosis

-Cardio disorder -Often dry, especially on exertion or at night; may progress to the pink frothy sputum of pulmonary edema or to frank hemoptysis -Dyspnea, orthopnea, paroxysmal nocturnal dyspnea.

Anxiety, panic disorder

-Cause Unclear -Local: precordial, below the left breast or across the anterior chest -Stabbing, sticking, dull, aching. Pain is variable -Timing: Fleeting to hours or days -Aggravating: May follow effort, emotional stress -Assoc symptoms: Breathlessness, palpitations, weakness, anxiety

Common/concerning symptoms of chest/lungs

-Chest pain ● Shortness of breath (dyspnea) ● Wheezing ● Cough ● Blood-streaked sputum (hemoptysis) ● Daytime sleepiness or snoring and disordered sleep

Gastroesophageal Reflux

-Chronic inflamm -Chronic cough, especially at night or early in the morning -Wheezing, especially at night (often mistaken for asthma), early morning hoarseness, and repeated attempts to clear the throat. Often with heartburn and regurgitation.

Asthma

-Chronic inflamm -Cough, at times with thick mucoid sputum, especially near end of an attack -Episodic wheezing and dyspnea, but cough may occur alone. Often with a history of allergies.

Pulmonary Tuberculosis

-Chronic inflamm -Cough, dry or with mucoid or purulent sputum; may be blood-streaked or bloody -Early, no symptoms. Later, anorexia, weight loss, fatigue, fever, and night sweats.

Lung Abscess

-Chronic inflamm -Sputum purulent and foul-smelling; may be bloody -Usually from aspiration pneumonia with fever and infection from oral anaerobes and poor dental hygiene; often with dysphagia or episode of impaired consciousness.

Postnasal Drip

-Chronic inflammation -Chronic cough; sputum mucoid or mucopurulent -Postnasal discharge may be seen in posterior pharynx. Associated with allergic rhinitis, with or without sinusitis.

Chronic Bronchitis

-Chronic inflammation -Chronic cough; sputum mucoid to purulent, may be blood-streaked or even bloody -Often with recurrent wheezing and dyspnea, and prolonged history of tobacco abuse.

Bronchiectasis

-Chronic inflammation -Chronic cough; sputum purulent, often copious and foul-smelling; may be blood- streaked or bloody -Recurrent bronchopulmonary infections common; sinusitis may coexist.

Lung cancer

-Cough, dry to productive; sputum may be blood-streaked or bloody -Commonly with dyspnea, weight loss, and history of tobacco abuse.

Laryngitis

-Dry cough, may become productive of variable amounts of sputum -Acute fairly minor illness with hoarseness. Often associated with viral rhinosinusitis.

Fine crackles

-Fine crackles are softer, higher pitched, and more frequent per breath than coarse crackles. -They are heard from mid to late inspiration, especially in the dependent areas of the lung, and change according to body position. They have a shorter duration and higher frequency than coarse crackles. -Fine crackles appear to be generated by the "sudden inspiratory opening of small airways held closed by surface forces during the previous expiration. -Examples include pulmonary fibrosis (known for "Velcro rales") and interstitial lung diseases such as interstitial fibrosis and interstitial pneumonitis.

Diaphragmatic excursion

-Identify the descent of the diaphragm, or diaphragmatic excursion. First, determine the level of diaphragmatic dullness during quiet respiration. Holding the pleximeter finger above and parallel to the expected level of dullness, percuss downward in progressive steps until dullness clearly replaces resonance. Confirm this level of change by percussing downward from adjacent areas both medially and laterally -An abnormally high level suggests a pleural effusion or an elevated hemidi- aphragm from atelectasis or phrenic nerve paralysis -Note that with this technique, you are identifying the boundary between the resonant lung tissue and the duller structures below the diaphragm. You are not percussing the diaphragm itself. You can infer the probable location of the diaphragm from the level of dullness. Now, estimate the extent of diaphragmatic excursion by determining the distance between the level of dullness on full expiration and the level of dullness on full inspiration, normally about 3 to 5.5 cm.

Transmitted voice sounds

-If you hear abnormally located broncho- vesicular or bronchial breath sounds, assess transmitted voice sounds using three techniques below. With diaphragm of your stethoscope, listen in symmetric areas over the chest wall for abnormal vocal resonances suspicious for pneumonia or pleural effusion. -Egophony. Ask the patient to say "ee." You will normally hear a muffled long E sound. -Bronchophony. Ask the patient to say "ninety-nine." Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony. Localized bronchophony and egoph- ony are seen in lobar consolidation fAsk the patient to say "ninety-nine." Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony. Localized bronchophony and egoph- ony are seen in lobar consolidation from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egoph- ony more than triples the likelihood of pneumonia.rom pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egoph- ony more than triples the likelihood of pneumonia. -Whispered pectoriloquy. Ask the patient to whisper "ninety-nine" or "one- two-three." The whispered voice is normally heard faintly and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy.

Transmitted Voice Sounds

-If you hear abnormally located bronchovesicular or bronchial breath sounds, assess transmitted voice sounds using three techniques below. With diaphragm of your stethoscope, listen in symmetric areas over the chest wall for abnormal vocal resonances suspicious for pneumonia or pleural effusion. -Increased transmission of voice sounds suggests that embedded airways are blocked by inflammation or secretions *Tests include: -Egophony. Ask the patient to say "ee." You will normally hear a muffled long E sound. -Bronchophony. Ask the patient to say "ninety-nine." Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony. -Whispered pectoriloquy. Ask the patient to whisper "ninety-nine" or "one- two-three." The whispered voice is normally heard faintly and indistinctly, if at all.

Crackles

-If you hear crackles, especially those that do not clear after coughing, listen care- fully for the following characteristics. These are clues to the underlying condition: *Loudness, pitch, and duration, summarized as fine or coarse crackles. Fine late inspiratory crackles that per- sist from breath to breath suggest abnormal lung tissue. *Number, few to many *Timing in the respiratory cycle *Location on the chest wall. The crackles of heart failure are usually best heard in the posterior infe- rior lung fields. *Persistence of their pattern from breath to breath *Any change after a cough or change in the patient's position. Clearing of crackles, wheezes, or rhon- chi after coughing or position change suggests inspissated secretions, seen in bronchitis or atelectasis. -In some normal people, crackles may be heard at the anterior lung bases after maximal expiration. Crackles in dependent portions of the lungs may also occur after prolonged recumbency.

Wheezes/Ronchi

-If you hear wheezes or rhonchi, note their timing and location. Do they change with deep breathing or coughing? Beware of the silent chest, in which air move- ment is minimal. -In the advanced airway obstruction of severe asthma, wheezes and breath sounds may be absent due to low respiratory airflow (the "silent chest"), a clinical emergency. -Findings predictive of COPD include combinations of symptoms and signs, especially dyspnea and wheezing by self-report or examination, plus >70 pack-years of smoking, history of bronchitis or emphysema, and decreased breath sounds. Diagnosis requires spirometry and, often, further pulmonary testing -Note that tracheal sounds originating in the neck such as stridor and vocal cord dysfunction can be transmitted to the chest and mistaken for wheezing, leading to inappropriate or delayed treatment. Stridor and laryngeal sounds are loudest over the neck, whereas true wheezes and rhonchi are faint or absent over the neck. -Note any pleural rubs, which are coarse, grating biphasic sounds heard primarily during expiration. leural rubs may be heard in pleurisy, pneumonia, and pulmonary embolism.

Pleuritic Pain

-Inflammation of the parietal pleura, as in pleurisy, pneumonia, pulmonary infarction, or neoplasm; rarely, subdiaphragmatic abscess -Local: Chest wall overlying the process -Pain quality: Sharp, knifelike. Often severe. Persistent. -Aggravating: Deep inspiration, coughing, movements of the trunk -Assoc symptoms: Of the underlying illness

Adult immunizations

-Influenza: can cause substantial morbidity and mortality, espe- cially during the late fall and winter, peaking in February. Two types of vaccine are available: the "flu shot," an inactivated vaccine containing killed virus, and a nasal-spray vac- cine containing attenuated live viruses, approved only for healthy people between the ages of 2 and 49 years. -Strep Pneumonia: causes pneumonia, bacteremia, and meningitis. Recommendations: Adults ≥65 years ● Children and adults from ages 2 to 64 years with chronic illnesses specifically associated with increased risk of pneumococcal infection (sickle cell disease, cardiovascular and pulmonary disease, diabetes, alcoholism, cirrhosis, cochlear implants, and leaks of cerebrospinal fluid) ● Any adult aged 19 to 64 years who is a smoker or has asthma ● Adults and children older than age 2 years who are immunocompromised (including from HIV infection, AIDS, long-term steroids, Hodgkin disease, lymphoma or leukemia, kidney failure, multiple myeloma, nephrotic syndrome, organ transplant, damaged spleen or no spleen, radiation, or chemotherapy) ● Residents of nursing homes or long-term care facilities

Pericarditis

-Irritation of parietal pleura adjacent to the pericardium -Local: Retrosternal or left precordial, may radiate to the tip of left shoulder -Pain quality: Sharp, knifelike. Often severe. -Persistent pain -Aggravating: Breathing, changing position, coughing, lying down, sometimes swallowing -Relieving: Sitting forward may relieve it -Assoc symptoms: Seen in autoimmune disorders, postmyocardial infarction, viral infection, chest irradiation

Gastrointestinal Reflux Disease

-Irritation or inflammation of the esophageal mucosa due to reflux of gastric acid from lowered esophageal sphincter tone -Local: Retrosternal, may radiate to the back -Pain: Burning, may be squeezing. Mild to severe. Timing Variable. -Aggravating: Large meal; bending over, lying down -Relieving: Antacids, sometimes belching -Assoc.: Sometimes regurgitation, dysphagia; also cough, laryngitis, asthma

Adventitious sounds

-Listen for any added, or adventitious, sounds that are superimposed on the usual breath sounds. Detection of adventi- tious sounds—crackles (sometimes called rales), wheezes, and rhonchi—is an important focus of your examination, often leading to diagnosis of cardiac and pulmonary conditions. -Crackles: Discontinuous, Intermittent, nonmusical, and brief, Like dots in time, Fine crackles: soft, high-pitched (∼650 Hz), very brief (5-10 ms), Coarse crackles: somewhat louder, lower in pitch (∼350 Hz), brief (15-30 ms) -Wheezes/Ronchi: Continuous, Sinusoidal, musical, prolonged (but not necessarily persisting throughout the respiratory cycle), Like dashes in time, Wheezes: relatively high-pitched (≥400 Hz) with hissing or shrill quality (>80 ms), Rhonchi: relatively low-pitched (150-200 Hz) with snoring quality (>80 ms) -Crackles can arise from abnormalities of the lung parenchyma (pneumonia, interstitial lung disease, pulmonary fibrosis, atelectasis, heart failure) or of the airways (bronchitis, bronchiectasis). -Wheezes arise in the narrowed air- ways of asthma, COPD, and bronchitis. -Many clinicians use the term "rhonchi" to describe sounds from secretions in large airways that may change with coughing

Lung Anatomy

-Lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line. -Posteriorly, the lower border of the lung lies at about the level of the T10 spinous process -Each lung is divided roughly in half by an oblique (major) fissure. This fissure may be approximated by a string that runs from the T3 spinous process obliquely down and around the chest to the 6th rib at the midclavicular line - The right lung is further divided by the horizontal (minor) fissure. Anteriorly, this fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. -signs found laterally in the right middle lung field could come from any of the three different lobes. -Breath sounds over the trachea and bronchi have a harsher quality than those over the denser lung parenchyma. -trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly -Right main bronchus is wider, shorter, and more vertical than the left main bronchus and directly enters the hilum of the lung. The left main bronchus extends inferolaterally from below the aortic arch and anterior to the esophagus and thoracic aorta and then enters the lung hilum. (This why aspiration is more common into right) -surface tension of the pleural fluid keeps the lung in contact with the thoracic wall, allowing the lung to expand and contract during respiration. The visceral pleura lacks - sensory nerves, but the parietal pleura is richly innervated by the intercostal and phrenic nerves.

Diffuse Esophageal Spasm

-Motor dysfunction of the esophageal muscle -Local: Retrosternal, may radiate to the back, arms, and jaw -Pain quality: Usually squeezing. Mild to severe. Timing variable. -Aggravating: Swallowing of food or cold liquid; emotional stress -Relieving: Sometimes nitroglycerin -Assoc: Dysphagia

Tactile Fremitus

-Palpate both lungs for symmetric tac- tile fremitus -Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetric. Fremitus is typically more prominent in the interscapular area than in the lower lung fields and easier to de- tect over the right lung than the left. It disappears below the diaphragm. -To detect fremitus, use either theball (the bony part of the palm atthe base of the fingers) or the ulnarsurface of your hand to optimize the vibratory sensitivity of the bones in your hand. Ask the patient to repeat the words "ninety-nine" or "one-one- one." -Use both hands to palpate and compare symmetric areas. Identify and locate any areas of increased, decreased, or absent fremitus. If fremitus is faint, ask the patient to speak more loudly or in a deeper voice. -Asymmetric decreased fremitus raises the likelihood of unilateral pleural effusion, pneumothorax, or neoplasm, which decreases transmission of low- frequency sounds; asymmetric increased fremitus occurs in unilateral pneumonia which increases transmis- sion through consolidated tissue.

Percussion (posterior chest)

-Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or consolidated. -will not aid in detection of deep-seated lesions. -Hyperextend the middle finger ofyour left hand, known as the plexim-eter finger. Press its distal interpha-langeal joint firmly on the lungsurface to be percussed. Avoid surface contact by any other partof the hand because this dampens outvibrations. -Withaquick,sharpbutrelaxedwrist motion, strike the pleximeter finger with the right middle finger, called the plexor finger. Aim at your distal interphalangeal joint. Your goal is to transmit vibrations through the bones of this joint to the underlying chest wall. Use the same force for each percussion strike and the same pleximeter pressure to avoid changes in the percussion note due to your technique rather than underlying findings. -Percuss one side of the chest and then the other at each level in a ladder-like pattern. Omit the areas over the scapulae—the thickness of muscle and bone alters the percussion notes over the lungs. Identify and locate the area and quality of any abnormal percussion note. -Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumula- tions of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. -Dullness makes pneumonic and pleural effusion three to four times more likely, respectively.45 -Generalized hyperresonance is com- mon over the hyperinflated lungs of COPD or asthma. Unilateral hyperreso- nance suggests a large pneumothorax or an air-filled bulla.

Chronic Bronchitis dyspnea

-Process: Excessive mucus production in bronchi, followed by chronic obstruction of airways -Timing: Chronic productive cough followed by slowly progressive dyspnea -Aggravating: Exertion, inhaled irritants, respiratory infections -Relieving: Expectoration; rest, though dyspnea may become persistent -Assoc symp: Chronic productive cough, recurrent respiratory infec- tions; wheezing may develop -Setting: History of smoking, air pollutants, recurrent respiratory infections; often present with COPD

Pneumonia Dyspnea

-Process: Infection of lung parenchyma from the respiratory bronchioles to the alveoli -Timing: An acute illness, timing varies with the causative agent -Aggravating: Exertion, smoking -Relieving: Rest, though dyspnea may become persistent -Symptoms: Pleuritic pain, cough, sputum, fever, though not necessarily present -Setting: varied

Spontaneous Pneumothorax dyspnea

-Process: Leakage of air into pleural space through blebs on visceral pleura, with resulting partial or complete collapse of the lung -Timing: Sudden onset of dyspnea -No aggravating or relieving -Symptoms: Pleuritic pain, cough -Setting: Often a previously healthy young adult or adult with emphysema

Chronic Obstructive Pulmonary Disease (COPD) Dyspnea

-Process: Overdistention of air spaces distal to terminal bronchioles, with destruction of alveolar septa, alveolar enlargement, and limitation of expiratory air flow -Timing: Slowly progressive dyspnea; relatively mild cough later -Aggravating: exertion -Relieving: Rest, though dyspnea may become persistent -Assoc symp: Cough, with scant mucoid sputum -Setting: History of smoking, air pollutants, sometimes a familial deficiency in α1- antitrypsin

Asthma dyspnea

-Process: Reversible bronchial hyperresponsiveness involving release of inflammatory mediators, increased airway secretions, and bronchoconstriction -Timing: Acute episodes, separated by symptom-free periods. Nocturnal episodes common -Aggravating: Variable, including allergens, irritants, respiratory infections, exercise, cold, and emotion -Relieving: Separation from aggravating factors -Symptoms: Wheezing, cough, tightness in chest -Setting: Environmental conditions

Myocardial Infarction

-Prolonged myocardial ischemia, resulting in irreversible muscle damage or necrosis -Local: Retrosternal or across the anterior chest, often radiates to the shoulders, arms, neck, lower jaw, or upper abdomen -Quality: Pressing, squeezing, tight, heavy, occasionally burning -Severity: Often, but not always, a severe pain -20 min to several hours -Aggravating: Not always triggered by exertion -Relieving: Not relieved by rest -Assoc. Symptoms: Dyspnea, nausea, vomiting, sweating, weakness

Angina Pectoris

-Temporary myocardial ischemia, usually secondary to coronary atherosclerosis -Local: Retrosternal or across the anterior chest, often radiates to the shoulders, arms, neck, lower jaw, or upper abdomen -Quality: Pressing, squeezing, tight, heavy, occasionally burning -Severity: Mild to moderate, sometimes perceived as discomfort rather than pain -Usually 1-3 min but up to 10 min. Prolonged episodes up to 20 min -Aggravating: Often exertion, especially in the cold; meals; emotional stress. May occur at rest -Relieving: Often, but not always, rest, nitroglycerin -Assoc. symptoms: Sometimes dyspnea, nausea, sweating

Lung Excursion

-Test chest expansion. -Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. As you position your hands, slide them medially just enough to raise a loose fold of skin between your thumbs over the spine. Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during inspiration, and feel for the range and symmetry of the rib cage as it expands and contracts. This movement is sometimes called lung excursion. -Palpate both lungs for symmetric tactile fremitus. Fremitus is decreased or absent when the voice is higher pitched or soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, or pleural effusion, fibrosis, air (pneumo- thorax), or an infiltrating tumor.

Chest Wall Pain, Costochondritis

-Variable, including trauma, inflammation of costal cartilage -Often below the left breast or along the costal cartilages -Pain: Stabbing, sticking, or dull, aching. Intensity variable -Timing: Fleeting to hours or days -Aggravating: Coughing; movement of chest, trunk, arms -Assoc symptoms: Often local tenderness

Irritating Particles, Chemicals, or Gases

-Variable. There may be a latent period between exposure and symptoms. -Exposure to irritants. Eyes, nose, and throat may be affected.

Special Techniques chest/thorax

-Walk tests are practical, simple ways to assess cardiopulmonary function commonly used in rehabilita- tion and pre- and postoperative settings. The 2002 American Thoracic Society guidelines that standardize the 6-minute walk test continue to predict clinical outcomes in most patients with COPD. The test is easy to administer and requires only a 100-foot hallway. It measures "the distance that a patient can quickly walk on a flat, hard surface in a period of 6 minutes" and provides a global evaluation of the pulmonary and cardiovascular systems, neuromuscular units, and muscle metabolism. -Forced Expiratory Time: This test assesses the expiratory phase of breath- ing, which is typically slowed in obstructive pulmonary disease. Ask the patient to take a deep breath in and then breathe out as quickly and completely as possible with mouth open. Listen over the trachea with the diaphragm of a stethoscope and time the audible expiration. Try to get three consistent readings, allowing a short rest between efforts, if necessary. *Patients ≥age 60 years with a forced expiratory time of ≥9 seconds are four times more likely to have COPD -Identification of a Fractured Rib. Local pain and tenderness of one or more ribs raise the question of fracture. By AP compression of the chest, you can help to distinguish a fracture from soft-tissue injury. With one hand on the sternum and the other on the thoracic spine, squeeze the chest. Is this painful, and where? *An increase in the local pain (distant from your hands) suggests rib fracture rather than just soft-tissue injury.

Wheezing

-Wheezing occurs in partial lower airway obstruction from secretions and tissue inflammation in asthma, or from a foreign bod

Exam of anterior chest

-When examined in the supine position, the patient should lie comfortably with arms somewhat abducted. If the patient is having difficulty breathing, raise the head of the examining table or the bed to increase respiratory excursion and ease of breathing. *Persons with severe COPD may prefer to sit leaning forward, with lips pursed during exhalation and arms supported on their knees or a table -Inspection. Observe the shape of the patient's chest and the movement of the chest wall. Note: *Deformities or asymmetry of the thorax *Abnormal retraction of the lower intercostal spaces during inspiration, or any supraclavicular retraction. Abnormal retraction occurs in severe asthma, COPD, or upper airway obstruction. *Local lag or impairment in respiratory movement. Lag occurs in underlying diseases of the lung or pleura. -Palpation: Palpate the anterior chest wall for the following purposes: *Identification of tender areas. Tender pectoral muscles or costal car- tilages suggest, but do not prove, that chest pain has a localized musculo- skeletal origin. *Assessment of bruising, sinus tracts, or other skin changes *Assessment of chest expansion. Place your thumbs along each costal margin, your hands along the lateral rib cage. As you position your hands, slide them medially a bit to raise loose skin folds between your thumbs. Ask the patient to inhale deeply. Observe how far your thumbs diverge as the thorax expands, and feel for the extent and symmetry of respiratory movement. *Assessment of tactile fremitus. If needed, compare both sides of the chest, using the ball or ulnar sur- face of your hand. Fremitus is usually decreased or absent over the precordium. When examining a woman, gently displace the breasts as necessary -Percussion. The heart normally produces an area of dullness to the left of the sternum from the 3rd to the 5th interspaces. The hyperresonance of COPD may obscure dullness over the heart. *Dullness represents airway obstruction from inflammation or secretions. Because pleural fluid usually sinks to the lowest part of the pleural space (posteriorly in a supine patient), only a very large effusion can be detected anteriorly. In a woman, to enhance percussion, gently displace the breast with your left hand while percussing with the right, or ask the patient to move the breast for you. *The dullness of right middle lobe pneumonia typically occurs behind the right breast. Unless you displace the breast, you may miss the abnormal percussion note. Percuss for liver dullness and gastric tympany. With your pleximeter finger above and parallel to the expected upper bor- der of liver dullness, percuss in progres- sive steps downward in the right midclavicular line. Identify the upper border of liver dullness. Later, during the abdominal examination, you will use this method to estimate the size of the liver. As you percuss down the chest on the left, the resonance of normal lung usually changes to the tym- pany of the gastric air bubble. *The hyperinflated lung of COPD often displaces the upper border of the liver downward and lowers the level of dia- phragmatic dullness posteriorly. -Auscultation: Listen to the chestbreathes with mouth open, and somewhat more deeply than normal. Compare symmetric areas of the lungs, using the pattern suggested for percussion and extending it to adjacent areas, if indicated. ■ Listen to the breath sounds, noting their intensity and identifying any variations from normal vesicular breathing. Breath sounds are usually louder in the upper anterior lung fields. Bronchovesicular breath sounds may be heard over the large airways, especially on the right. ■ Identify any adventitious sounds, time them in the respiratory cycle, and locate them on the chest wall. Do they clear with deep breathing? ■ If indicated, listen for transmitted voice sounds.

Course crackles

-appear in early inspiration and last throughout expiration (biphasic), have a popping sound, are heard over any lung region, and do not vary with body position. They have a longer duration and lower frequency than fine crackles, change or disappear with coughing, and are transmitted to the mouth. -Coarse crackles appear to result from "boluses of gas passing through airways as they open and close intermittently." -Examples include COPD, asthma, bronchiectasis, pneumonia (crackles may become finer and change from mid to late inspiratory during recovery), and heart failure.

Techniques of exam

-examine the posterior thorax and lungs while the patient is sitting, and the anterior thorax and lungs with the patient supine -With the patient sitting, examine the posterior thorax and lungs. The patient's arms should be folded across the chest with hands resting, if possible, on the opposite shoulders. This position swings the scapulae laterally and increases access to the lung fields. Then ask the patient to lie down. -With the patient supine, examine the anterior thorax and lungs. For women, this position allows the breasts to be gently displaced. Some clinicians examine both the posterior and anterior chest with the patient sitting, which is also satisfactory.

Important locals on chest

-horizontal bony ridge where the manubrium joins the body of the sternum, called the sternal angle or the angle of Louis. Directly adjacent to the sternal angle is the 2nd rib and its costal cartilage. -2nd intercostal space for needle insertion for tension pneumothorax. -4th intercostal space for chest tube insertion. -T4 for the lower margin of an endo- tracheal tube on a chest x-ray. -Neurovascular structures run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margins. -1-7 true, 8-10 false 11/12 floating -T7-T8 intercostal space as a landmark for thoracentesis with nee- dle insertion immediately superior to the 8th rib.

Initial survey of respiration/thorax

-observe the rate, rhythm, depth, and effort of breathing. A healthy resting adult breathes quietly and regularly about 20 times a minute. -Assess the respiratory rate for tachypnea (>25 breaths/minute). increases the likelihood of pneumonia and cardiac disease. -Inspect the patient's color for cyanosis or pallor. Recall earlier relevant findings, such as the shape and color of the fingernails. Cyanosis in the lips, tongue, and oral mucosa signals hypoxia. Pallor and sweating (diaphoresis) are common in heart failure. Clubbing of the nails occurs in bronchiectasis, congenital heart disease, pulmonary fibrosis, cystic fibrosis, lung abscess, and malignancy. -Listen for audible sounds of breathing. Is the audible whistling during inspiration over the neck or lungs? Audible high-pitched inspiratory whistling, or stridor, is an ominous sign of upper airway obstruction in the larynx or trachea that requires urgent airway evaluation. Wheezing is either expira- tory or continuous. -Inspect the neck. During inspiration, is there contraction of the accessory muscles, namely the SCM and scalene muscles, or supraclavicular retraction? During expiration, is there contraction of the intercostal or abdominal oblique muscles? Is the trachea midline? Accessory muscle use signals difficulty breathing from COPD or respiratory muscle fatigue. Lateral displacement of the trachea occurs in pneumothorax, pleural effusion, and atelectasis. -observe the shape of the chest, which is normally wider than it is deep. ratio may exceed 0.9 in COPD, producing a barrel-chest appearance, although evidence of this correlation is conflicting.

Cough

-reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. -Other causes include inflammation of the respiratory mucosa, pneumonia, pulmonary edema, and compression of the bronchi or bronchioles from a tumor or enlarged peribronchial lymph nodes. -Cough may also be cardiovascular in origin. SIGNALS LEFT SIDE HF -pursue a thorough assessment. Establish the duration. Is the cough acute, lasting less than 3 weeks; subacute, lasting 3 to 8 weeks; or chronic, more than 8 weeks? -most common cause of acute cough is viral upper respiratory infections. Also consider acute bronchitis, pneumonia, left-sided heart failure, asthma, foreign body, smoking, and ace-inhibitor therapy. -Postinfectious cough, pertussis, acid reflux, bacterial sinusitis, and asthma can cause subacute cough. -Chronic cough is seen in postnasal drip, asthma, gastroesopha- geal reflux, chronic bronchitis, and bronchiectasis. -Ask whether the cough is dry or produces sputum, or phlegm. Mucoid sputum is translucent, white, or gray and seen in viral infections and cystic fibrosis; purulent sputum— yellow or green—often accompanies bacterial pneumonia. -Foul-smelling sputum is present in anaerobic lung abscess, thick tenacious sputum in cystic fibrosis. -Large volumes of purulent sputum are present in bronchiectasis and lung abscess. - Diagnostically helpful symptoms include fever and productive cough in pneumonia; wheezing in asthma; and chest pain, dyspnea, and orthopnea in acute coronary syndromes -Cough causes: left sided heart failure! Asthma is usually subacute, when dont know cause of cough, ask GI questions, usually GERD, bronchiectasis is a chronic cough

Lung cancer

-second most frequently diagnosed cancer in the United States and the leading cause of cancer death for both men and women. -Cigarette smoking is by far the leading risk factor for lung cancer, accounting for about 90% of lung cancer deaths. -Screening: secondary prevention, which targets finding and treating early-stage cancers. This is particularly important for lung cancer; cancers diagnosed at an early stage (before metastasis) have a 54% 5-year relative survival.34 Meanwhile, the 5-year relative survival is a dismal 4% for cancers diagnosed at later stages (metastatic). Unfortunately, only 15% of lung cancers are diagnosed at an early stage.

Mediastinal crunch (Hamman's sign)

-series of precordial crackles synchronous with the heartbeat, not with respiration. Best heard in the left lateral position, it arises from air entry into the mediastinum causing mediastinal emphysema (pneumomediastinum). It usually produces severe central chest pain and may be spontaneous. It has been reported in cases of tracheobronchial injury, blunt trauma, pulmonary disease, use of recreational drugs, childbirth, and rapid ascent from scuba diving.

SOB

-telltale symptom of cardiac and pulmonary disease. -degree of dyspnea, combined with spirometry, is a key component of important chronic obstructive pulmonary disease (COPD) classification systems that guide patient management. -make every effort to determine its severity based on the patient's daily activities. How many steps or flights of stairs can the patient climb before pausing for breath? What about carrying bags of groceries, vacuuming, or making the bed? -Most patients relate shortness of breath to their level of activity. -Anxious patients present a different picture. They may describe difficulty taking a deep enough breath, a smothering sensation with inability to get enough air, and paresthesias, which are sensations of tingling or "pins and needles" around the lips or in the extremities. Anxious people will present more with hyperventilation

Percussion notes

-use the lightest percussion that produces a clear note. A thick chest wall requires a more forceful percussion blow than a thin one. However, if a louder note is needed, apply more pressure with the pleximeter finger. -While the patient keeps both arms crossed in front of the chest, percuss the thorax in symmetric locations on each side from the apex to the base. -5 different sounds: *Flat: thigh, happens with large pleural effusion * Dull: Liver, Can happen with lobar pneumonia *Resonant: healthy lung, Simple chronic bronchitis *Hyperresonant: usually none, COPD, pneumothorax *Tympanitic: gastric air bubbles, puffed out cheek, large pneumothorax

blood-streaked sputum

-vary from blood-streaked sputum to frank blood. -For patients reporting hemoptysis, quantify the volume of blood produced, the setting and activity, and any associated symptoms. -Hemoptysis is rare in infants, children, and adolescents. -Blood originating in the stomach is usually darker than blood from the respiratory tract and may be mixed with food particles. -Should include ab palpation is coughing up blood

Pulmonary Embolism

Cardio disorder -Dry cough, at times with hemoptysis -Tachypnea, chest or pleuritic pain, dyspnea, fever, syncope, anxiety; factors that predispose to deep venous thrombosis.

Thoracic Kyphoscoliosis

Abnormal spinal curvatures and vertebral rotation deform the chest. Distortion of the underlying lungs may make interpretation of lung findings very difficult.

Ataxic Breathing (Biot Breathing)

Breathing is irregular—periods of apnea alternate with regular deep breaths which stop suddenly for short intervals. Causes include meningitis, respiratory depression, and brain injury, typically at the medullary level.

Sighing Respiration

Breathing punctuated by frequent sighs suggests hyperventilation syndrome—a common cause of dyspnea and dizziness. Occasional sighs are normal.

Hyperpnea, Hyperventilation

In hyperpnea, rapid deep breathing occurs in response to metabolic demand from causes such as exercise, high altitude, sepsis, and anemia. In hyperventilation, this pattern is independent of metabolic demand, except in respiratory acidosis. Light-headedness and tingling may arise from decreased CO2 concentration. In the comatose patient, consider hypoxia, or hypoglycemia affecting the midbrain or pons. Kussmaul breathing is compensatory overbreathing due to systemic acidosis. The breathing rate may be fast, normal, or slow.

Obstructive Breathing

In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.

Inspection of posterior chest

Look for: -Deformities or asymmetry in chest expansion. Asymmetric expansion occurs in large pleural effusions. -Abnormal muscle retraction of the intercostal spaces during inspiration, most visible in the lower intercostal spaces. Retraction occurs in severe asthma, COPD, or upper airway obstruction. -Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement. Unilateral impairment or lagging suggests pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma.

Traumatic Flail Chest

Multiple rib fractures may result in paradoxical movements of the thorax. As descent of the diaphragm decreases intrathoracic pressure, on inspiration, the injured area caves inward; on expiration, it moves outward.

Funnel Chest (Pectus Excavatum)

Note depression in the lower portion of the sternum. Compression of the heart and great vessels may cause murmurs.

Cheyne-Stokes Breathing

Periods of deep breathing alternate with periods of apnea (no breathing). This pattern is normal in children and older adults during sleep. Causes include heart failure, uremia, drug-induced respiratory depression, and brain injury (typically bihemispheric).

Left-Sided Heart Failure dyspnea

Process: Elevated pressure in pulmonary capillary bed with transudation of fluid into interstitial spaces and alveoli, decreased compliance (increased stiffness) of the lungs, increased work of breathing -Timing: Dyspnea may progress slowly, or suddenly as in acute pulmonary edema -Aggravating: Exertion, lying down -Relieving: Rest, sitting up, though dyspnea may become persistent -Assoc symptoms: Often cough, orthopnea, paroxysmal nocturnal dyspnea; sometimes wheezing -Setting: History of heart disease or its predisposing factors

Acute Pulmonary Embolism dyspnea

Process: Sudden occlusion of part of pulmonary arterial tree by a blood clot that usually originates in deep veins of legs or pelvis -Timing: Sudden onset of tachypnea, dyspnea -Aggravating: exertion -Relieving: Rest, though dyspnea may become persistent -Symptoms: Often none; retrosternal oppressive pain if massive occlusion; pleuritic pain, cough, syncope, hemoptysis, and/or unilateral leg swelling and pain from instigating deep vein thrombosis; anxiety -Setting: Postpartum or postoperative periods; prolonged bed rest; heart failure, chronic lung disease, and fractures of hip or leg; deep venous thrombosis (often not clini- cally apparent); also hypercoagulability, hereditary (i.e., protein C, S, factor V Leiden deficiency) or acquired (e.g., cancer, hormonal therapy)

Anxiety with Hyperventilation dyspnea

Processing: Overbreathing, with resultant respiratory alkalosis and fall in arterial partial pressure of carbon dioxide (pCO2) -Timing: Episodic, often recurrent Aggravating: Often occurs at rest; an upsetting event may not be evident -Relieving: Breathing in and out of a paper or plastic bag may help -Symptoms: Sighing, lightheadedness, numbness or tingling of the hands and feet, palpitations, chest pain -Setting: Other manifestations of anxiety may be present, such as chest pain diaphoresis, palpitations

Tachypnea

Rapid shallow breathing has numerous causes, including salicylate intoxication, restrictive lung disease, pleuritic chest pain, and an elevated diaphragm.

Bradypnea

Slow breathing with or without an increase in tidal volume that maintains alveolar ventilation. Abnormal alveolar hypoventilation without increased tidal volume can arise from uremia, drug- induced respiratory depression, and increased intracranial pressure.

Normal Resp rate

The respiratory rate is about 14-20 per min in normal adults and up to 44 per min in infants.

Pigeon Chest (Pectus Carinatum)

The sternum is displaced anteriorly, increasing the AP diameter. The costal cartilages adjacent to the protruding sternum are depressed.

Angina

a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium