Bates Pulm PDF: Thorax & Lungs - Anatomy & Examination

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http://medsouls4you.blogspot.com 8 C H A P T E R The Thorax and Lungs The Bates’ suite offers these additional resources to enhance learning and facilitate understanding of this chapter: Bates’ Pocket Guide to Physical Examination and History Taking, 8th edition Bates’ Visual Guide to Physical Examination (Vol. 9: Thorax and Lungs) thePoint online resources, for students and instructors: http://thepoint.lww.com Anatomy and Physiology Study the anatomy of the chest wall, identifying the structures illustrated (Fig. 8-1). Note that the number of the intercostal space between two ribs is the same number as the rib above it. Suprasternal notch 2nd rib Manubrium of sternum 2nd rib interspace Sternal angle 2nd costal cartilage Body of sternum Xiphoid process Costochondral junctions Costal angle FIGURE 8-1. Chest wall anatomy. CHAPTER 8 | The Thorax and Lungs 303 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY EXAMPLES OF ABNORMALITIES Locating Findings on the Chest Describe chest findings in two dimensions: along the vertical axis and around the circumference of the chest. Vertical Axis. To locate findings in the thorax, learn to number the ribs and intercostal spaces (Fig. 8-2). Place your finger in the hollow curve of the supra- sternal notch, then move it down approximately 5 cm to the 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. From here, using two fingers, “walk down” the interspaces on an oblique line, illustrated by the red numbers below. (Note that the ribs at the lower edge of the sternum may be too close together to count correctly.) To count the intercostal spaces in a woman, displace the breast laterally or palpate more medially. Avoid pressing too hard on the tender breast tissue. Sternal angle Suprasternal notch (Angle of Louis) 2nd rib Note special landmarks: 2nd intercostal space for needle insertion for tension pneumothorax. 1 4th intercostal space for chest tube 1 2 insertion. T4 for the lower margin of an endo- 2 3 tracheal tube on a chest x-ray. 3 4 T4 4 5 5 Neurovascular structures run along 6 the inferior margin of each rib, so 6 needles and tubes should be placed 7 just at the superior rib margins. 7 8 11 12 9 10 8 9 FIGURE 8-2. Anterior ribs and intercostal spaces. Note that the costal cartilages of the first seven ribs articulate with the sternum; the cartilages of the 8th, 9th, and 10th ribs articulate with the costal cartilages just above them. The 11th and 12th ribs, the “floating ribs,” have no anterior attachments. The cartilaginous tip of the 11th rib usually can be felt laterally, and 304 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY EXAMPLES OF ABNORMALITIES the 12th rib may be felt posteriorly. When palpated, costal cartilages and ribs feel identical. Posteriorly, the 12th rib is a starting point for counting ribs and intercostal spaces and provides an alternative to the anterior approach (Fig. 8-3). With the fingers of one hand, press in and up against the lower border of the 12th rib; then “walk up” the intercostal spaces, numbered in red below, or follow a more oblique line up and around to the front of the chest. Spinous process of C7 Spinous process of T1 1 1 2 2 3 3 4 4 5 5 6 6 7 7 7th rib 8 8 9 9 Inferior angle of scapula 10 10 Note the T7–T8 intercostal space as a 11 11 landmark for thoracentesis with nee- 12 dle insertion immediately superior to the 8th rib. FIGURE 8-3. Posterior ribs and intercostal spaces. The inferior tip of the scapula is another useful bony landmark; it usually lies at the level of the 7th rib or interspace. The spinous processes of the vertebrae are also useful landmarks. When the neck is flexed forward, the most protruding process is usually the vertebra of C7. If two processes are equally prominent, they are C7 and T1. You can often palpate and count the processes below them, especially when the spine is flexed. CHAPTER 8 | The Thorax and Lungs 305 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY Circumference of the Chest. Visual- Midsternal line ize a series of vertical lines as shown in Figures 8-4 through 8-6. The midsternal and vertebral lines are easily demarcated Midclavicular and reproducible; the others are visual- line ized. The midclavicular line drops verti- cally from the midpoint of the clavicle. To find it, accurately identify both ends of Anterior axillary the clavicle (see p. 646). line F I G U R E 8 - 4. Midsternal, midclavicular, and anterior axillary lines. The anterior and posterior axillary lines drop vertically from the anterior and pos- terior axillary folds, the muscle masses that Anterior border the axilla. The midaxillary line axillary line drops from the apex of the axilla. Midaxillary line Posterior axillary line FIGURE 8-5. Anterior, midaxillary, and posterior lines. Posteriorly, the vertebral line overlies the spinous processes of the vertebrae. The scapular line drops from the inferior angle of the scapula. Scapular line Vertebral line FIGURE 8-6. Vertebral and scapular lines. 306 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY Lungs, Fissures, and Lobes. Picture the lungs and their fissures and lobes on the chest wall. Anteriorly, the apex of each lung rises approximately 2 to 4 cm above the inner third of the clavicle (Fig. 8-7). The 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 (Fig. 8-8). On inspiration, it descends in the chest cavity during contrac- tion and descent of the diaphragm. Apex of lung Spinous Horizontal LUL RUL RUL LUL process fissure of T3 Oblique RML fissure LLL RLL RLL LLL Inspiratory descent F I G U R E 8 - 7. The anterior lungs. FIGURE 8-8. The posterior lungs. 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 (Fig. 8-9). The right lung is further divided by the horizontal (minor) fissure. Anteriorly, this fis- sure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib. The right lung is thus divided into upper, middle, and lower lobes (RUL, RML, and RLL). The left lung has only two lobes, upper and lower (LUL, LLL) (Fig. 8-10). Each lung receives deoxygenated blood from its pulmonary artery. Oxygenated blood returns from each lung to the left atrium via the pulmonary veins. RUL LUL Left oblique fissure RML RLL LLL FIGURE 8-9. Right lung lobes FIGURE 8-10. Left lung lobes and fissures. and fissures. CHAPTER 8 | The Thorax and Lungs 307 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY EXAMPLES OF ABNORMALITIES Locations on the Chest. Learn the general anatomical terms used to locate chest findings. Anatomic Descriptors of the Chest Supraclavicular—above the clavicles Infraclavicular—below the clavicles Interscapular—between the scapulae Infrascapular—below the scapulae Bases of the lungs—the lowermost portions Upper, middle, and lower lung fields Usually, physical examination findings correlate with the underlying lobes. Signs in the right upper lung field, for example, almost certainly originate in the right upper lobe. However, signs found laterally in the right middle lung field could come from any of the three different lobes. The Trachea and Major Bronchi (the Tracheobronchial Tree). Breath sounds over the trachea and bronchi have a harsher quality than those over the denser lung parenchyma. Learn the locations of these structures. The trachea bifurcates into its mainstem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly (Figs. 8-11 and 8-12). The right main Aspiration pneumonia is more common bronchus is wider, shorter, and more vertical than the left main bronchus and in the right middle and lower lobe directly enters the hilum of the lung. The left main bronchus extends inferolater- because the right main bronchus is ally from below the aortic arch and anterior to the esophagus and thoracic aorta more vertical. and then enters the lung hilum. Each main bronchus then divides into lobar then into segmental bronchi and bronchioles, terminating in the sac-like pulmonary alve- oli, where gas exchange occurs. Trachea Trachea Left main Left main bronchus bronchus Right main Right main bronchus bronchus F I G U R E 8 - 1 1. Trachea and mainstem F I G U R E 8 - 1 2. Trachea and mainstem bronchi, anterior view. bronchi, posterior view. The Pleurae. Two continuous pleural surfaces, or serous membranes, sepa- Accumulations of pleural fluid, or pleu- rate the lungs from the chest wall. The visceral pleura covers the outer surface ral effusions, may be transudates, seen of the lungs. The parietal pleura lines the pleural cavity along the inner rib cage in heart failure, cirrhosis, and nephrotic and the upper surface of the diaphragm. Between the visceral and parietal syndrome, or exudates, seen in numer- pleura is the pleural space, containing serous pleural fluid. The surface tension ous conditions including pneumonia, of the pleural fluid keeps the lung in contact with the thoracic wall, allowing malignancy, pulmonary embolism, the lung to expand and contract during respiration. The visceral pleura lacks tuberculosis, and pancreatitis. 308 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com ANATOMY AND PHYSIOLOGY EXAMPLES OF ABNORMALITIES sensory nerves, but the parietal pleura is richly innervated by the intercostal Irritation of the parietal pleura pro- and phrenic nerves. duces pleuritic pain with deep inspira- tion in viral pleurisy, pneumonia, pulmonary embolism, pericarditis, and collagen vascular diseases. Breathing. Breathing is primarily automatic, controlled by respiratory cen- ters in the brainstem that generate the neuronal drive for the muscles of res- piration. The 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, which run from the cervical vertebrae to the first two ribs, and the parasternal intercostal muscles, or parasternals, which cross obliquely from the sternum to the ribs. As the thorax expands, intrathoracic pressure decreases, drawing air through the tracheobronchial tree into the alveoli, or distal air sacs, filling the expanding lungs. Oxygen diffuses into the adjacent pulmonary capillaries as carbon dioxide exchanges from the blood into the alveoli. 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. Normal breathing is quiet and easy—barely audible near the open mouth as a faint whish. When a healthy person lies supine, the breathing movements of the thorax are relatively slight. By contrast, the abdominal movements are usually easy to see. In the sitting position, movements of the thorax become more prominent. During exercise and in certain diseases, extra work is required to breathe, and accessory muscles are recruited; the sternocleidomastoids (SCM) and the sca- lenes may become visible (Fig. 8-13). Sternal head of the sternocleidomastoid Clavicular muscle head Scalene muscles F I G U R E 8 - 1 3. Accessory muscles in the neck. CHAPTER 8 | The Thorax and Lungs 309 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com THE HEALTH HISTORY EXAMPLES OF ABNORMALITIES The Health History Common or Concerning Symptoms Chest pain Shortness of breath (dyspnea) Wheezing Cough Blood-streaked sputum (hemoptysis) Daytime sleepiness or snoring and disordered sleep Chest Pain. Complaints of chest pain or chest discomfort raise concerns about See Table 8-1, Chest Pain, the heart but often arise from other structures in the thorax and lungs. To assess pp. 330–331. this symptom, you must pursue a dual investigation of both thoracic and car- diac causes. Sources of chest pain are listed below. For this important symptom, keep all of these possibilities in mind. Sources of Chest Pain and Related Causes The myocardium Angina pectoris, myocardial infarction, Chest pain is reported in one in four myocarditis patients with panic and anxiety The pericardium Pericarditis disorders.1–3 The aorta Aortic dissection The trachea and large bronchi Bronchitis The parietal pleura Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus The chest wall, including the muscu- Costochondritis, herpes zoster loskeletal and neurologic systems The esophagus Gastroesophageal reflux disease, esopha- geal spasm, esophageal tear Extrathoracic structures such as the Cervical arthritis, biliary colic, gastritis neck, gallbladder, and stomach This section focuses on pulmonary complaints, including chest wall symptoms, difficulty breathing (dyspnea), wheezing, cough, coughing up blood (hemoptysis), and daytime sleepiness or snoring and disordered sleep. For symptoms of exer- tional chest pain, palpitations, shortness of breath when supine (orthopnea) or at night relieved by sitting upright (paroxysmal nocturnal dyspnea), and edema, see Chapter 9, The Cardiovascular System (see pp. 355–358). Your initial questions should be as open-ended as possible. “Do you have any A clenched fist over the sternum sug- discomfort or unpleasant feelings in your chest?” Ask the patient to point to the gests angina pectoris; a finger point- location of the pain in the chest. Watch for any gestures as the patient describes ing to a tender spot on the chest wall the pain. Elicit all seven attributes of chest pain to distinguish among its various suggests musculoskeletal pain; a hand causes (see p. 79). moving from the neck to the epigas- trium suggests heartburn. 310 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com THE HEALTH HISTORY EXAMPLES OF ABNORMALITIES Lung tissue has no pain fibers. Pain in conditions such as pneumonia or pulmo- nary infarction usually arises from inflammation of the adjacent parietal pleura. Muscle strain from prolonged recurrent coughing or costochondral inflamma- tion may also be responsible. The pericardium also has few pain fibers. The pain of pericarditis stems from inflammation of the adjacent parietal pleura. Extrapul- monary sources of chest pain include gastroesophageal reflux disease and anxi- ety, but the mechanism remains obscure.1–4 Shortness of Breath (Dyspnea) and Wheezing. Shortness of breath, or dys- The degree of dyspnea, combined pnea, is a painless but uncomfortable awareness of breathing that is inappropri- with spirometry, is a key component ate to the level of exertion.5 Thoroughly assess this telltale symptom of cardiac of important chronic obstructive and pulmonary disease. pulmonary disease (COPD) classifica- tion systems that guide patient management.6–8 Ask, “Have you had any difficulty breathing?” Find out if the symptom occurs at See Table 8-2, Dyspnea, pp. 332–333. rest or with exertion, and how much exertion produces onset. Because of varia- tions in age, body weight, and physical fitness, there is no absolute scale for quantifying shortness of breath. Instead, 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? Has shortness of breath altered the patient’s lifestyle and daily activities? How? Carefully elicit the timing and set- ting, any associated symptoms, and relieving or aggravating factors. Most patients relate shortness of breath to their level of activity. Anxious patients Anxious patients may have episodic present a different picture. They may describe difficulty taking a deep enough dyspnea during both rest and exercise breath, a smothering sensation with inability to get enough air, and paresthesias, and also hyperventilation, or rapid which are sensations of tingling or “pins and needles” around the lips or in the shallow breathing. extremities. Wheezes are musical respiratory sounds that may be audible to the patient and Wheezing occurs in partial lower air- to others. way obstruction from secretions and tissue inflammation in asthma, or from a foreign body.9 Cough. Cough is a common symptom that ranges in significance from trivial See Table 8-3, Cough and Hemoptysis, to ominous. Typically, cough is a reflex response to stimuli that irritate receptors p. 334. in the larynx, trachea, or large bronchi. These stimuli include mucus, pus, blood, as well as external agents such as allergens, dust, foreign bodies, or even extremely hot or cold air. 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 car- Cough can signal left-sided heart diovascular in origin. failure. CHAPTER 8 | The Thorax and Lungs 311 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com THE HEALTH HISTORY EXAMPLES OF ABNORMALITIES For complaints of cough, pursue a thorough assessment. Establish the duration. The most common cause of acute Is the cough acute, lasting less than 3 weeks; subacute, lasting 3 to 8 weeks; or cough is viral upper respiratory infec- chronic, more than 8 weeks? tions. 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 sub- acute cough. Chronic cough is seen in postnasal drip, asthma, gastroesopha- geal reflux, chronic bronchitis, and bronchiectasis.10–17 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. Ask the patient to describe the volume of any sputum and its color, odor, and Foul-smelling sputum is present in consistency. anaerobic lung abscess, thick tena- cious sputum in cystic fibrosis. To help patients quantify volume, try a multiple-choice question. “How much do Large volumes of purulent sputum you think you cough up in 24 hours: a teaspoon, tablespoon, quarter cup, half are present in bronchiectasis and lung cup, cupful?” If possible, ask the patient to cough into a tissue; inspect the abscess. phlegm, and note its characteristics. The symptoms associated with a cough often lead to its cause. Diagnostically helpful symptoms include fever and productive cough in pneumonia; wheezing in asthma; and chest pain, dyspnea, and orthopnea in acute coronary syndromes. Hemoptysis. Hemoptysis refers to blood coughed up from the lower respira- See Table 8-3, Cough and Hemopty- tory tract; it may vary from blood-streaked sputum to frank blood. For patients sis, p. 334. Causes include bronchitis; reporting hemoptysis, quantify the volume of blood produced, the setting and malignancy; and cystic fibrosis and, activity, and any associated symptoms. Hemoptysis is rare in infants, children, less commonly, bronchiectasis, mitral and adolescents. stenosis, Goodpasture syndrome, and Wegener granulomatosis. Massive hemoptysis (>200 cm3) may be life-threatening.18 Before using the term “hemoptysis,” try to confirm the source of the bleeding. Blood originating in the stomach is Blood or blood-streaked material may originate in the nose, mouth, pharynx, or usually darker than blood from the gastrointestinal tract and is easily mislabeled. If vomited, it probably originates respiratory tract and may be mixed in the gastrointestinal tract. Occasionally, however, blood from the nasopharynx with food particles. or the gastrointestinal tract is aspirated and then coughed out. 312 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com HEALTH PROMOTION AND COUNSELING EXAMPLES OF ABNORMALITIES Daytime Sleepiness or Snoring and Disordered Sleep. Patients may These symptoms, especially daytime report excessive daytime sleepiness and fatigue. Ask about problems with snor- sleepiness and snoring, are hallmarks ing, witnessed apneas (defined as breathing cessation for ≥10 seconds), awaken- of obstructive sleep apnea, commonly ing with a choking sensation, or morning headache. 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 Health Promotion and upper airway muscles (genioglossus malfunction), and anatomic changes Counseling: Evidence and contributing to airway collapse such as obesity, among others.19,20 Recommendations Important Topics for Health Promotion and Counseling Tobacco cessation Lung cancer Immunizations—influenza and streptococcal pneumonia vaccines Tobacco Cessation. Despite declining smoking rates over the past several decades, 19% of U.S. adults continue to smoke, although the proportion of heavy smokers (>30 cigarettes per day) has dropped from about 13% to 8%.21 Nearly 90% of smokers first tried cigarettes by age 18 years.22 About 23% of high-school students and 7% of middle-school students use tobacco products, most often cigarettes or cigars, and use is higher among males than females. Smokers are more likely than nonsmokers to develop cardiovascular disease, emphysema, and lung cancer. Tobacco use is the leading preventable cause of premature death in the United States, accounting for one in five deaths each year.23 Half of all long- term smokers die of smoking-related diseases, losing an average of 10 years of life. Quitting smoking significantly reduces disease risk. The facts below can be motivating when counseling smokers. Quitting tobacco reduces the cardiovascular risk of heart attack and death from coronary heart disease by half after just 1 year. Stroke risk is reduced within 2 to 5 years to the same level as a nonsmoker. Lung cancer risk is cut in half after 10 years. The United States Preventive Services Task Force (USPSTF) has given a grade A recommendation to screening all adults, particularly pregnant women, for tobacco use and providing tobacco cessation interventions to all who are using tobacco.24 CHAPTER 8 | The Thorax and Lungs 313 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com HEALTH PROMOTION AND COUNSELING Adverse Effects of Smoking on Health and Disease Increased Risk Compared Condition with Nonsmokers Coronary artery disease 2–4 times higher Stroke 2–4 times higher Peripheral vascular disease 10 times higher COPD mortality 12–13 times higher Lung cancer 23 times higher mortality in men 13 times higher mortality in women Source: Centers for Disease Control and Prevention, DHHS. Smoking and tobacco use. Fact sheet. Health effects of cigarette smoking. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_ sheets/health_effects/effects_cig_smoking/index.htm. Accessed March 31, 2015. In addition to respiratory tract cancers, smoking contributes to cancers of the bladder, cervix, colon and rectum, kidney, oropharynx, larynx, esophagus, stom- ach, liver, and pancreas as well as acute myeloid leukemia.25 Smoking increases risk of infertility, preterm birth, low birth weight, and sudden infant death syn- drome. Smoking is associated with developing diabetes, cataracts, and rheuma- toid arthritis. Nonsmokers exposed to smoke also have increased risk of lung cancer, ear and respiratory infections, and asthma. Clinicians should focus on prevention and cessation, especially in teenagers and pregnant women.26 Because most smokers see a health care provider each year and nearly 70% of smokers express interest in quitting, clinicians have an impor- tant opportunity to identify and treat tobacco dependence.27,28 Behavioral sup- port and pharmacotherapy are both effective strategies. Combining these strategies is more effective than either strategy alone as it addresses withdrawal symptom and cravings as well as enhances motivation and skills for quitting. The benefits of even brief counseling interventions are considerable—advising smok- ers to quit during every visit raises quit rates by 30%.29 Use the “5 As” frame- work or the Stages of Change model to assess readiness to quit.24,30 Motivational interviewing techniques are also helpful for patients who are not yet ready to quit smoking.27,28 Assessing Readiness to Quit Smoking: Brief Interventions Models 5 As Model Stages of Change Model Ask about tobacco use Precontemplation—“I don’t want to quit.” Advise to quit Contemplation—“I am concerned but Assess willingness to make a not ready to quit now.” quit attempt Preparation—“I am ready to quit.” Assist in quit attempt Action—“I just quit.” Arrange follow-up Maintenance—“I quit 6 months ago.” 314 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com HEALTH PROMOTION AND COUNSELING Nicotine is highly addicting, comparable to heroin and cocaine, and quitting is difficult. More than 80% of smokers who try to quit on their own resume smoking within 30 days and only 3% of smokers quit successfully each year.31 Stimulation of the nicotinic cholinergic receptors in the brain increases release of dopamine, which enhances pleasure and modulates mood. Daily smokers inhale enough nico- tine to achieve almost complete receptor saturation. The inhaled nicotine reaches the brain in seconds, causing a powerful and reinforcing rush effect. Use cognitive ther- apy techniques to help smokers recognize and design strategies to combat the features of addiction: craving, triggers such as stress or environmental cues, and signs of withdrawal like irritability, poor concentration, anxiety, and depressed mood. Quit rates roughly double when counseling is combined with pharmaco- therapies such as nicotine replacement, bupropion, and varenicline.32 Lung Cancer Epidemiology. Lung cancer is the second most frequently diagnosed can- cer in the United States and the leading cause of cancer death for both men and women.33 Over 200,000 new cases and nearly 160,000 deaths (accounting for about 27% of all cancer deaths) were expected in 2014. Incidence rates and death rates have been decreasing since 2006. Risk Factors. Cigarette smoking is by far the leading risk factor for lung cancer, accounting for about 90% of lung cancer deaths.22 Longer smoking his- tories and higher numbers of cigarettes smoked are associated with higher risk. Radon, an invisible, odorless, radioactive gas released from soil and rocks in the ground, is the second leading cause of lung cancer in the United States. Other environmental and occupational exposures include second-hand smoke, asbes- tos, heavy metals, organic chemicals, ionizing radiation, and air pollution. Lung cancer also has a familial risk. Prevention. The most important strategies aim to prevent people from ever using tobacco products and getting tobacco users to quit. The previous sec- tion highlights smoking cessation strategies. Avoiding environmental and occu- pational exposures can also reduce lung cancer risk. Screening. Another strategy for addressing the burden of cancer is screening, also known as 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. Screening Tests and Evidence. Numerous studies conducted over many years have shown that lung cancer screening with chest x-ray or sputum cytology is not effective. Recently, however, the National Lung Screening Trial (NLST) showed that screening with low-dose computed tomography (LDCT) reduced the risk of dying from lung cancer compared to chest x-ray screening.35 The NLST was a randomized trial that enrolled more than 53,000 adults aged 55 to 74 years at risk for lung cancer due to at least a 30-pack-year smoking history or current smoking or having quit within the past 15 years. Subjects received three annual CHAPTER 8 | The Thorax and Lungs 315 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com HEALTH PROMOTION AND COUNSELING screenings with LDCT or chest x-rays. After nearly 7 years of follow-up, lung cancer deaths were reduced by 20% with LDCT compared to chest x-ray. How- ever, the absolute benefit was small; >320 subjects needed screening to prevent one lung cancer death. Although about 40% of study subjects had an abnormal LDCT, over 95% of these results were false positives. Screening can lead to harms, including anxiety over false-positive tests, complications from invasive diagnostic procedures, and cancer risks from radiation exposure. Screening Guidelines from Major Organizations. The USPSTF has given lung cancer screening with LDCT a B rating, meaning that there is a net benefit to offering screening.36 Annual LDCT screening is recommended for cur- rent smokers (or those who have quit within the last 15 years) aged 55 to 79 years. The American Cancer Society also recommends annual screening, although only until age 74 years.37 Both organizations agree that all current smok- ers should receive counseling about smoking cessation and should be offered ces- sation interventions. Before offering screening, clinicians should engage patients in discussions about the potential benefits, limitations, and harms of screening—and emphasize that screening is not a substitute for smoking cessation. Immunizations (Adults) Influenza. Influenza can cause substantial morbidity and mortality, espe- cially during the late fall and winter, peaking in February.38 The number of annual deaths related to influenza varies depending on the virus type and subtype, rang- ing from a few thousand to nearly 50,000 deaths. The Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) updates its rec- ommendations for vaccination annually. 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.39 Because influenza viruses mutate from year to year, each vaccine contains three to four vaccine strains and is modified yearly. Note that annual vaccination is recommended for everyone aged ≥6 months. Summary of 2015-2016 CDC Influenza Vaccine Recommendations—Adults Annual vaccination is recommended for all people aged 6 months and older, especially the groups listed below.40 Adults with chronic pulmonary and cardiovascular conditions (except hyperten- sion) and renal, hepatic, neurologic, hematologic, or metabolic disorders (includ- ing diabetes mellitus); adults who are immunosuppressed or morbidly obese Adults ≥50 years of age Pregnant women and women up to 2 weeks postpartum Residents of nursing homes and long-term care facilities American Indians and Alaska natives Health care personnel Household contacts and caregivers of children ≤5 years of age (especially infants ≤age 6 months) and of adults ≥50 years of age with clinical conditions placing them at higher risk for complications of influenza 316 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION Streptococcal Pneumonia. Streptococcal pneumonia causes pneumonia, bacteremia, and meningitis. In 2009, invasive pneumococcal disease accounted for 43,500 cases and 5,000 deaths.41 However, the introduction of the 7-valent pneumococcal vaccination for infants and children in 2000 has directly and indirectly (through herd immunity) reduced pneumococcal infections among children and adults.42 Since 2010, infants younger than age 2 years have rou- tinely been vaccinated with the 13-valent pneumococcal conjugate vaccine (PCV13). In 2014, the ACIP recommended vaccinating adults aged ≥65 years using the PCV13 along with the 23-valent inactivated pneumococcal polysac- charide vaccine (PPSV23). The vaccines should not be coadministered. Adults in this age range who never received the PPSV23 should first receive the PCV13 followed 6 to 12 months later by the PPSV23. Adults aged ≥65 years previously vaccinated with PPSV23 should receive a dose of PCV13 no earlier than 1 year following the most recent PPSV23 vaccination. The ACIP recommends using PCV13 and PPSV23 for the high-risk groups listed below. Summary of 2015 CDC Pneumococcal Vaccine 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 Techniques of Examination For best results, examine the posterior thorax and lungs while the patient is sit- ting, and the anterior thorax and lungs with the patient supine. Be considerate when draping the patient’s gown. For men, arrange the gown so that you can see the full chest. For women, cover the anterior chest when you examine the back; for the anterior examination, drape the gown over each half of the chest as you examine the other half. Begin with inspection, then palpate, percuss, and aus- cultate. Try to visualize the underlying lobes and compare the right lung field with the left, carefully noting any asymmetries. 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. CHAPTER 8 | The Thorax and Lungs 317 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES With the patient supine, examine the anterior thorax and lungs. For women, this position allows the breasts to be gently displaced. Some clinicians exam- ine both the posterior and anterior chest with the patient sitting, which is also satisfactory. For patients who cannot sit up, ask for assistance so that you can examine the posterior chest in the sitting position. If this is not possible, roll the patient to one side and then to the other. Percuss and auscultate both lungs in each position. Because ventilation is relatively greater in the dependent lung, you are more likely to hear abnormal wheezes or crackles on the dependent side (see p. 325). Initial Survey of Respiration and the Thorax Even though the respiratory rate might already be recorded, again carefully See Table 8-4, Abnormalities in Rate observe the rate, rhythm, depth, and effort of breathing. A healthy resting adult and Rhythm of Breathing, p. 335, breathes quietly and regularly about 20 times a minute. Note whether expiration including bradypnea, tachypnea, lasts longer than usual. hyperventilation, Cheyne–Stokes breathing, and ataxic breathing. Begin by observing the patient for signs of respiratory distress. Delayed expiration occurs in COPD. Signs of Respiratory Distress Assess the respiratory rate for tachypnea (>25 breaths/minute). Tachypnea increases the likelihood of pneumonia and cardiac disease. Inspect the patient’s color for cyanosis or pallor. Recall earlier relevant find- Cyanosis in the lips, tongue, and oral ings, such as the shape and color of the fingernails. mucosa signals hypoxia. Pallor and sweating (diaphoresis) are common in heart failure. Clubbing of the nails (see p. 211) occurs in bronchiectasis, congeni- tal heart disease, pulmonary fibrosis, cys- tic fibrosis, lung abscess, and malignancy. Listen for audible sounds of breathing. Is there audible whistling during inspi- Audible high-pitched inspiratory whis- ration over the neck or lungs? tling, 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 mus- Accessory muscle use signals difficulty cles, namely the SCM and scalene muscles, or supraclavicular retraction? breathing from COPD or respiratory During expiration, is there contraction of the intercostal or abdominal muscle fatigue. Lateral displacement oblique muscles? Is the trachea midline? of the trachea occurs in pneumotho- rax, pleural effusion, and atelectasis. Also observe the shape of the chest, which is normally wider than it is deep. The This ratio may exceed 0.9 in COPD, ratio of the anteroposterior (AP) diameter to the lateral chest diameter is usually producing a barrel-chest appearance, 0.7 to 0.75 up to 0.9 and increases with aging.43 although evidence of this correlation is conflicting. 318 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Examination of the Posterior Chest Inspection. Standing in a midline position behind the patient, note the shape See Table 8-5, Deformities of the of the chest and how the chest moves, including the following: Thorax, p. 336. Deformities or asymmetry in chest expansion Asymmetric expansion occurs in large pleural effusions. Abnormal muscle retraction of the intercostal spaces during inspiration, Retraction occurs in severe asthma, most visible in the lower intercostal spaces. COPD, or upper airway obstruction. Impaired respiratory movement on one or both sides or a unilateral lag (or Unilateral impairment or lagging sug- delay) in movement. gests pleural disease from asbestosis or silicosis; it is also seen in phrenic nerve damage or trauma. Palpation. As you palpate the chest, focus on areas of tenderness or bruising, Intercostal tenderness can develop respiratory expansion, and fremitus. over inflamed pleurae, costal cartilage tenderness in costochondritis. Identify tender areas. Carefully palpate any area where the patient reports pain Tenderness, bruising, and bony “step- or has visible lesions or bruises. Note any palpable crepitus, defined as a offs” are common over a fractured rib. crackling or grinding sound over bones, joints, or skin, with or without pain, Crepitus may be palpable in overt due to air in the subcutaneous tissue. fractures and arthritic joints; crepitus and chest wall edema are seen in mediastinitis. Assess any skin abnormalities such as masses or sinus tracts (blind, inflamma- Although rare, sinus tracts suggest tory, tube-like structures opening onto the skin). infection of the underlying pleura and lung (as in tuberculosis or actino- mycosis). Test chest expansion. Place your Unilateral decrease or delay in chest thumbs at about the level of the expansion occurs in chronic fibrosis of 10th ribs, with your fingers loosely the underlying lung or pleura, pleural grasping and parallel to the lateral effusion, lobar pneumonia, pleural rib cage (Fig. 8-14). As you position pain with associated splinting, unilat- your hands, slide them medially just eral bronchial obstruction, and paral- enough to raise a loose fold of skin ysis of the hemidiaphragm. between your thumbs over the spine. Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart F I G U R E 8 - 1 4. Assess lung during inspiration, and feel for the expansion. range and symmetry of the rib cage as it expands and contracts. This movement is sometimes called lung excursion. CHAPTER 8 | The Thorax and Lungs 319 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Palpate both lungs for symmetric tac- Fremitus is decreased or absent when tile fremitus (Fig. 8-15). Fremitus the voice is higher pitched or soft or refers to the palpable vibrations when the transmission of vibrations 1 1 that are transmitted through the from the larynx to the surface of the bronchopulmonary tree to the chest is impeded by a thick chest wall, 2 2 chest wall as the patient is speaking an obstructed bronchus, COPD, or and is normally symmetric. Fremi- pleural effusion, fibrosis, air (pneumo- tus is typically more prominent in 3 3 thorax), or an infiltrating tumor. the interscapular area than in the 4 4 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 the F I G U R E 8 - 1 5. Locations for ball (the bony part of the palm at palpating fremitus. the base of the fingers) or the ulnar surface 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.” Initially practice with one hand until you feel the transmitted vibra- tions. Use both hands to palpate and compare symmetric areas of the lungs in Asymmetric decreased fremitus raises the pattern shown in the photograph. Identify and locate any areas of the likelihood of unilateral pleural increased, decreased, or absent fremitus. If fremitus is faint, ask the patient effusion, pneumothorax, or neoplasm, to speak more loudly or in a deeper voice. which decreases transmission of low- frequency sounds; asymmetric Tactile fremitus is a somewhat imprecise assessment technique, but does increased fremitus occurs in unilateral direct your attention to possible asymmetries. Confirm any disparities by pneumonia which increases transmis- listening for underlying breath sounds, voice sounds, and whispered voice sion through consolidated tissue.44 sounds. All these attributes should increase or decrease together. Percussion. Percussion is one of the most important techniques of physical examination. Percussion sets the chest wall and underlying tissues in motion, producing audible sound and palpable vibrations. Percussion helps you estab- lish whether the underlying tissues are air-filled, fluid-filled, or consolidated. The percussion blow penetrates only 5 to 7 cm into the chest, however, and will not aid in detection of deep-seated lesions. The technique of percussion can be practiced on any surface. As you practice, listen for changes in percussion notes over different types of materials or different parts of the body. The key points for good technique, described for a right- handed person, are detailed below: Hyperextend the middle finger of your left hand, known as the plexim- eter finger. Press its distal interpha- langeal joint firmly on the lung surface to be percussed (Fig. 8-16). Avoid surface contact by any other part of the hand because this dampens out vibrations. Note that the thumb and second, fourth, and fifth fingers are F I G U R E 8 - 1 6. Press the pleximeter not touching the chest wall. finger firmly on the chest wall. 320 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION Position your right forearm quite close to the surface, with the hand cocked upward. The middle finger should be partially flexed, relaxed, and poised to strike. With a quick, sharp but relaxed wrist motion, strike the pleximeter finger with the right middle finger, called the plexor finger (Fig. 8-17). 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 F I G U R E 8 - 1 7. Strike the plexime- avoid changes in the percussion note ter finger with the right middle finger. due to your technique rather than underlying findings. Strike using the tip of the plexor fin- ger, not the finger pad. The striking finger should be almost at right angles to the pleximeter. A short fingernail is recommended to avoid injuring your knuckle. Withdraw your striking finger quickly to avoid damping the vibra- tions you have created (Fig. 8-18). F I G U R E 8 - 1 8. Withdraw the striking finger quickly. In summary, the movement is at the wrist. It is directed, brisk, yet relaxed and slightly bouncy. Percussion Notes. With your plexor or striking finger, 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. When percussing the lower posterior chest, stand somewhat to the side rather than directly behind the patient. In this position it is easier to place your plex- imeter finger more firmly on the chest, making your plexor strike more effective by creating a better percussion note. When comparing two areas, use the same percussion technique in both areas. Percuss or strike twice in each location and listen for differences in the per- cussion notes at the two locations. Learn to identify five percussion notes. You can practice four of them on your- self. These notes differ in their basic qualities of sound, intensity, pitch, and duration. Train your ear by concentrating on one quality at a time as you CHAPTER 8 | The Thorax and Lungs 321 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES percuss first in one location, then in another. Review the description of per- cussion notes on p. 323. Healthy lungs are resonant. While the patient keeps both arms crossed in front of the chest, percuss the Dullness replaces resonance when fluid thorax in symmetric locations on each side from the apex to the base. or solid tissue replaces air-containing lung or occupies the pleural space Percuss one side of the chest and then beneath your percussing fingers. the other at each level in a ladder-like Examples include: lobar pneumonia, in pattern, as shown in Figure 8-19. which the alveoli are filled with fluid 1 1 Omit the areas over the scapulae— and blood cells; and pleural accumula- the thickness of muscle and bone 2 2 tions of serous fluid (pleural effusion), alters the percussion notes over the blood (hemothorax), pus (empyema), 3 3 lungs. Identify and locate the area fibrous tissue, or tumor. Dullness and quality of any abnormal per- 6 4 4 6 makes pneumonic and pleural cussion note. effusion three to four times more 7 5 5 7 likely, respectively.45 Generalized hyperresonance is com- mon over the hyperinflated lungs of COPD or asthma. Unilateral hyperreso- F I G U R E 8 - 1 9. Percuss and nance suggests a large pneumothorax auscultate in a “ladder” pattern. or an air-filled bulla. Identify the descent of the diaphragm, or diaphragmatic excursion. First, deter- This technique tends to overestimate mine the level of diaphragmatic dullness during quiet respiration. Holding the actual movements of the diaphragm.45 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 (Fig. 8-20). Location Resonant and sequence of percussion Level of diaphragm Dull Dull F I G U R E 8 - 2 1. Absent descent of the diaphragm can indicate pleural FIGURE 8-20. Identify the extent of diaphragmatic excursion. effusion. An abnormally high level suggests a pleural effusion or an elevated hemidi- aphragm from atelectasis or phrenic nerve paralysis (Fig. 8-21). 322 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Percussion Notes and Their Characteristics Relative Relative Relative Example of Intensity Pitch Duration Location Pathologic Examples Flat Soft High Short Thigh Large pleural effusion Dull Medium Medium Medium Liver Lobar pneumonia Resonant Loud Low Long Healthy lung Simple chronic bronchitis Hyperresonant Very loud Lower Longer Usually none COPD, pneumothorax Tympanitic Loud Higha Longer Gastric air bubble Large pneumothorax or puffed-out cheek a Distinguished mainly by its musical timbre. 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 dia- phragm 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.46 Auscultation. Auscultation is the most important examination technique for Bedclothes, paper gowns, and even assessing air flow through the tracheobronchial tree. Auscultation involves chest hair can generate confusing (1) listening to the sounds generated by breathing, (2) listening for any adventitious crackling sounds that interfere with (added) sounds, and (3) if abnormalities are suspected, listening to the sounds of auscultation. For chest hair, press the patient’s spoken or whispered voice as they are transmitted through the chest harder or moisten the hair. 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. Listen to the breath sounds with the diaphragm of your stethoscope after Air movement through a partially instructing the patient to breathe deeply through an open mouth. Always obstructed nose or nasopharynx can place the stethoscope directly on the skin. Clothing alters the characteristics also introduce abnormal sounds. of the breath sounds and can introduce friction and added 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 Breath sounds may be decreased when mouth, and may vary from one area to another. Breath sounds are usually louder air flow is decreased (as in obstructive in the lower posterior lung fields. If the breath sounds seem faint, ask the patient lung disease or respiratory muscle to breathe more deeply. Shallow breathing or a thick chest wall can both alter weakness) or when the transmission of breath sound intensity. sound is poor (as in pleural effusion, pneumothorax, or COPD). CHAPTER 8 | The Thorax and Lungs 323 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES 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? Breath Sounds (Lung Sounds). Learn to identify breath sounds by their In cold or tense patients, watch for intensity, their pitch, and the relative duration of their inspiratory and expiratory muscle contraction sounds—muffled, phases. Normal breath sounds are: low-pitched rumbling, or roaring noises. Changing the patient’s posi- Vesicular, or soft and low pitched. They are heard throughout inspiration, tion may eliminate this noise. To continue without pause through expiration, and then fade away about one reproduce these sounds on yourself, third of the way through expiration. do a Valsalva maneuver (straining down) as you listen to your own chest. 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. Bronchial, or louder, harsher and higher in pitch, with a short silence be- tween inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds. Tracheal, or loud harsh sounds heard over the trachea in the neck. The characteristics of these four kinds of breath sounds are summarized below. Characteristics of Breath Sounds Intensity Locations of Pitch of Where Duration of Expiratory Expiratory Heard Sounds Sound Sound Normally Vesiculara Inspiratory sounds Soft Relatively low Over most of last longer than both lungs expiratory sounds. Broncho- Inspiratory and Intermediate Intermediate Often in the 1st If bronchovesicular or bronchial vesicular expiratory and 2nd breath sounds are heard in locations sounds are interspaces distant from those listed, suspect almost equal. anteriorly replacement of air-filled lung by fluid- and between filled or consolidated lung tissue. the scapulae Bronchial Expiratory Loud Relatively Over the See Table 8-6, Normal and Altered sounds last high manubrium, Breath and Voice Sounds, p. 337. longer than (larger proxi- inspiratory ones. mal airways) (continued ) 324 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Characteristics of Breath Sounds (continued ) Intensity Locations of Pitch of Where Duration of Expiratory Expiratory Heard Sounds Sound Sound Normally Tracheal Inspiratory and Very loud Relatively Over the tra- expiratory high chea in the sounds are neck almost equal. a The thickness of the bars indicates intensity; the steeper their incline, the higher the pitch. Sources: Loudon R and Murphy LH. Lungs sounds. Am Rev Respir Dis. 1994;130:663; Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014;370:744; Wilkins RL, Dexter JR, Murphy RLH, et al. Lung sound nomenclature survey, Chest. 1990;98:886; Schreur HJW, Sterk PJ, Vanderschoot JW, et al. Lung sound intensity in patients with emphysema and in normal subjects at standardised airflows. Thorax. 1992;47:674; Bettancourt PE, DelBono EA, Speigelman D, et al. Clinical utility of chest auscultation in common pulmonary disease. Am J Resp Crit Care Med. 1994;150:1921. Adventitious (Added) Sounds. Listen for any added, or adventitious, For further discussion and other sounds that are superimposed on the usual breath sounds. Detection of adventi- added sounds, see Table 8-7, Adventi- tious sounds—crackles (sometimes called rales), wheezes, and rhonchi—is an tious (Added) Lung Sounds: Causes important focus of your examination, often leading to diagnosis of cardiac and and Qualities, p. 338. pulmonary conditions. The most common adventitious sounds are described below. Note that the American Thoracic Society describes rhonchi as a low- pitched wheeze (unrelated to airway secretions), so some recommend not using the term “rhonchi.”47,48 Adventitious or Added Breath Sounds Crackles (or Rales) Wheezes and Rhonchi Crackles can arise from abnormalities of the lung parenchyma (pneumonia, Discontinuous Continuous interstitial lung disease, pulmonary Intermittent, nonmusical, and Sinusoidal, musical, prolonged (but not fibrosis, atelectasis, heart failure) or of brief necessarily persisting throughout the the airways (bronchitis, bronchiectasis). respiratory cycle) Like dots in time Like dashes in time Fine crackles: soft, high-pitched Wheezes: relatively high-pitched (≥400 Wheezes arise in the narrowed air- (∼650 Hz), very brief (5–10 ms) Hz) with hissing or shrill quality (>80 ms) ways of asthma, COPD, and bronchitis. Coarse crackles: somewhat Rhonchi: relatively low-pitched (150–200 Many clinicians use the term “rhonchi” louder, lower in pitch (∼350 Hz), Hz) with snoring quality (>80 ms) to describe sounds from secretions in brief (15–30 ms) large airways that may change with coughing. Source: Loudon R, Murphy LH. Lungs sounds. Am Rev Respir Dis. 1994;130:663; Bohadana A, Izbicki G, Kraman SS. Fundamentals of lung auscultation. N Engl J Med. 2014;370:744. CHAPTER 8 | The Thorax and Lungs 325 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES If you hear crackles, especially those that do not clear after coughing, listen care- fully for the following characteristics.47,49–52 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 Number, few to many abnormal lung tissue. Timing in the respiratory cycle Location on the chest wall The crackles of heart failure are usu- ally best heard in the posterior infe- Persistence of their pattern from breath to breath rior lung fields. 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. If you hear wheezes or rhonchi, note their timing and location. Do they change In the advanced airway obstruction of with deep breathing or coughing? Beware of the silent chest, in which air move- severe asthma, wheezes and breath ment is minimal. 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.6,53–58 Note that tracheal sounds originating in the neck such as stridor and vocal cord Stridor and laryngeal sounds are dysfunction can be transmitted to the chest and mistaken for wheezing, leading loudest over the neck, whereas true to inappropriate or delayed treatment. wheezes and rhonchi are faint or absent over the neck.47 Note any pleural rubs, which are coarse, grating biphasic sounds heard primarily Pleural rubs may be heard in pleurisy, during expiration. pneumonia, and pulmonary embolism. Transmitted Voice Sounds. If you hear abnormally located broncho- Increased transmission of voice sounds vesicular or bronchial breath sounds, assess transmitted voice sounds using three suggests that embedded airways are techniques below. With diaphragm of your stethoscope, listen in symmetric blocked by inflammation or secre- areas over the chest wall for abnormal vocal resonances suspicious for pneumo- tions.47 See Table 8-6, Normal and nia or pleural effusion. Altered Breath and Voice Sounds, p. 337. 326 BATES’ GUIDE TO PHYSICAL EXAMINATION AND HISTORY TAKING http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Egophony. Ask the patient to say “ee.” You will normally hear a muffled long If “ee” sounds like “A” and has a nasal E sound. bleating quality, an E-to-A change, or egophony, is present. Bronchophony. Ask the patient to say “ninety-nine.” Normally the sounds Localized bronchophony and egoph- transmitted through the chest wall are muffled and indistinct. Louder voice ony are seen in lobar consolidation sounds are called bronchophony. from pneumonia. In patients with fever and cough, the presence of bronchial breath sounds and egoph- ony more than triples the likelihood of pneumonia.59 Whispered pectoriloquy. Ask the patient to whisper “ninety-nine” or “one- Louder, clearer whispered sounds are two-three.” The whispered voice is normally heard faintly and indistinctly, called whispered pectoriloquy. if at all. Examination of the Anterior Chest When examined in the supine position, the patient should lie comfortably with Persons with severe COPD may prefer arms somewhat abducted. If the patient is having difficulty breathing, raise the to sit leaning forward, with lips head of the examining table or the bed to increase respiratory excursion and ease pursed during exhalation and arms of breathing. 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 See Table 8-5, Deformities of the Thorax, p. 336. Abnormal retraction of the lower intercostal spaces during inspiration, or Abnormal retraction occurs in severe any supraclavicular retraction 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 Assessment of bruising, sinus tracts, or other skin changes chest pain has a localized musculo- skeletal origin. Assessment of chest expansion. Place your thumbs along each costal margin, your hands along the lateral rib cage (Fig. 8-22). 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 sym- metry of respiratory movement. FIGURE 8-22. Assess chest expansion. CHAPTER 8 | The Thorax and Lungs 327 http://medsouls4you.blogspot.com  http://medsouls4you.blogspot.com TECHNIQUES OF EXAMINATION EXAMPLES OF ABNORMALITIES Assessment of tactile fremitus. If needed, compare both sides of the chest, using the ball or ulnar sur- 1 1 face of your hand. Fremitus is usu- ally decreased or absent over the precordium. When examining a 3 2 2 3 woman, gently displace the breasts as necessary (Fig. 8-23). F I G U R E 8 - 2 3. Locations for palpating fremitus. Percussion. As needed, percuss the Dullness represents airway obstruc- anterior and lateral chest, again com- 1 1 tion from inflammation or secretions. paring both sides (Fig. 8-24). The Because pleural fluid usually sinks to 2 2 heart normally produces an area of the lowest part of the pleural space dullness to the left of the sternum from 3 3 (posteriorly in a supine patient), only the 3rd to the 5th interspaces. 5 4 4 5 a very large effusion can be detected 6 6 anteriorly. The hyperresonance of COPD may obscure dullness over the heart. In a woman, to enhance percussion, The dullness of right middle lobe pneu- gently displace the breast with your monia typically occurs behind the left hand while percussing with the F I G U R E 8 - 2 4. Palate and percuss right breast. Unless you displace the in a “ladder” pattern. right, or ask the patient to move the breast, you may miss the abnormal breast for you. percussion note. Identify and locate any area with an abnormal percussion note. Percuss for liver dullness and gastric tym- The hyperinflated lung of COPD often pany. With your pleximeter finger above displaces the upper border of the liver and parallel to the expected upper bor- downward and lowers the level of dia- der of liver dullness, percuss in progres- phragmatic dullness posteriorly. sive steps downward in the right midclavicular line (Fig. 8-25). 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 nor- mal lung usually changes to the tym- pany of the gastric air bubble. F I G U R E 8 - 2 5. Percuss for liver dullness and gastric tympany. Auscultation. Listen to the chest anteriorly and laterally as the patient breathes with mouth open, and somewhat mor