Chapter 19 Thorax and Lungs - Anatomy and Physiology PDF

Chapter 19 Thorax and Lungs Term Definition Alveoli Functional units of the lung; the thin-walled chambers Hypercapnia (also termed Increased levels of carbon dioxide in the blood surrounded by networks of capillari...

Chapter 19 Thorax and Lungs Term Definition Alveoli Functional units of the lung; the thin-walled chambers Hypercapnia (also termed Increased levels of carbon dioxide in the blood surrounded by networks of capillaries that are the site of hypercarbia) respiratory exchange of carbon dioxide and oxygen Hyperventilation Increased rate and depth of breathing Angle of Louis Manubriosternal angle, the articulation of the manubrium and Hypoxemia Decreased level of oxygen in the blood body of the sternum, continuous with the second rib Intercostal space Space between the ribs Apnea Cessation of breathing Kussmaul respiration Type of hyperventilation that occurs with diabetic ketoacidosis Asthma An abnormal respiratory condition associated with allergic Orthopnea Difficulty breathing when supine hypersensitivity to certain inhaled allergens, characterized by Paroxysmal nocturnal Sudden awakening from sleeping, with shortness of breath inflammation, bronchospasm, wheezing, and dyspnea dyspnea Atelectasis An abnormal respiratory condition characterized by collapsed, Percussion Striking over the chest wall with short, sharp blows of the shrunken, deflated sections of alveoli fingers to determine the size and density of the underlying Bradypnea Slow breathing, fewer than 10 breaths per minute, regular rate organ Bronchiole One of the smaller respiratory passageways into which the Pleural effusion Abnormal fluid collection between the layers of the pleura segmental bronchi divide Stridor High-pitched inspiratory crowing sound caused by upper airway Bronchitis Inflammation of the bronchi with partial obstruction of bronchi obstruction, louder over the neck than the chest wall due to excessive mucus secretion Tachypnea Rapid, shallow breathing; more than 24 breaths per minute Bronchophony The spoken voice sound heard through the stethoscope, which Vesicular Refers to soft, low-pitched, normal breath sounds heard over sounds soft, muffled, and indistinct over normal lung tissue peripheral lung fields Bronchovesicular The normal breath sound heard over major bronchi, Wheeze High-pitched, musical, squeaking adventitious lung sound; also characterized by a moderate pitch and an equal duration of used with low-pitched (sonorous) adventitious sounds inspiration and expiration Xiphoid process Sword-shaped lower tip of the sternum Carina Ridge of cartilage located inside the trachea where it bifurcates into the right and left mainstem bronchi Chronic obstructive A functional category of abnormal respiratory conditions pulmonary disease (COPD) characterized by airflow obstruction (e.g., emphysema, chronic bronchitis) Cilia Millions of hairlike cells lining the tracheobronchial tree Consolidation The solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia Crackles Abnormal, discontinuous, adventitious lung sounds heard on inspiration Crepitus Coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue Dead space Passageways that transport air but are not available for gaseous exchange (e.g., trachea, bronchi) Dyspnea Difficult, labored breathing Emphysema Type of chronic obstructive pulmonary disease characterized by enlargement of the alveoli distal to terminal bronchioles Fissure The narrow crack dividing the lobes of the lungs Fremitus A palpable vibration from the spoken voice felt over the chest wall Friction rub A coarse, grating, adventitious lung sound heard when the pleurae are inflamed  Structure and Function  Position and surface landmarks Thoracic cage is a bony structure with a conical shape, which is narrower at top Defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae First seven ribs attach to sternum by costal cartilages Ribs 8, 9, and 10 attach to costal cartilage above Ribs 11 and 12 are “floating,” with free palpable tips Costochondral junctions are points at which ribs join their cartilages; they are not palpable  Anterior Thoracic Landmarks  Suprasternal notch: U shaped depression just above sternum between clavicles  Sternum: “breastbone” Manubrium, body, and xiphoid process  Sternal angle: “Angle of Louis,” at articulation of manubrium and sternum, and continuous with second rib Identify Angle of Louis, palpate lightly to second rib, and slide down to second intercostal space Angle of Louis also marks site of tracheal bifurcation into right and left main bronchi Corresponds with upper border of atria of the heart, and it lies above fourth thoracic vertebra on back  Costal angle: the right and left costal margins form an angle where they meet at xiphoid process  Posterior Thoracic Landmarks  Vertebra prominens: Flex your head and feel for most prominent bony spur protruding at base of neck  Spinous processes: Count down these knobs on vertebrae, which stack together to form spinal column  Inferior border of scapula: Scapulae are located symmetrically in each hemithorax  Twelfth rib: Palpate midway between spine and a person’s side to identify its free tip  Reference Lines  Use reference lines to pinpoint finding vertically on chest Anterior chest: note midsternal and midclavicular line Posterior chest: note vertebral (midspinal) line and scapular line  Lift up the person’s arm 90 degrees, and divide lateral chest by three lines: Anterior axillary line Posterior axillary line Midaxillary line Anterior Reference Lines Posterior Reference Lines Lateral Reference Lines  Thoracic Cavity  Mediastinum: middle section of thoracic cavity containing  esophagus,  trachea,  Heart  great vessels  Lung borders Right and left pleural cavities contain lungs  Lobes of the lungs Lungs are paired but not precisely symmetric structures Right lung shorter than left because of underlying liver Left lung narrower than right because heart bulges to left Right lung has three lobes, and left lung has two lobes  Lobes of the Lung  Anterior chest On anterior chest, oblique (major or diagonal) fissure crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line Also contains the horizontal (minor) fissure that divides the right upper & middle lobes  Posterior chest Most remarkable point about posterior chest is that it is almost all lower lobes  Lateral chest Lung tissue extends from apex of axilla down to seventh or eighth rib  Examination landmarks Left lung has no middle lobe Anterior chest contains mostly upper and middle lobe with very little lower lobe Posterior chest contains almost all lower lobes  Posterior Lobes 2 lobes on the left because of the heart. 3 lobes on the right. Posterior lobes has both lower lobes accessible  Pleurae The pleurae provide a slippery lining between lungs and chest wall. Visceral pleura covers the lung surface and fissures, merging with the chest wall's parietal pleura. The pleural cavity typically has negative pressure, securing lungs to the chest wall. Only a few milliliters of lubricating fluid fill the pleural cavity. The pleural cavity extends 3 cm below the lungs, forming the costodiaphragmatic recess. Filling of the recess is unusual and can hinder lung expansion.  Trachea and Bronchial Tree The trachea, 10-11 cm long, is located in front of the esophagus. The right main bronchus is shorter, wider, and more vertical compared to the left. The carina, a cartilage ridge, marks the trachea's base. The trachea and bronchi move gases between the environment and lung tissue. They represent dead space of 150 ml, air- filled but not used for gas exchange. The bronchial tree protects alveoli from inhaled particles. It has goblet cells for mucus and cilia to sweep away debris. The acinus, the gas exchange unit, includes bronchioles, alveolar ducts, sacs, and alveoli. Structures of Respiratory System Mechanics of Respiration: Function Four major functions of respiratory system: 1. Supplies oxygen for energy. 2. Eliminates metabolic carbon dioxide. 3. Maintains arterial pH balance. 4. Aids in thermal regulation (secondary in humans).  Mechanics of Respiration  Control of respirations Major feedback loop is humoral regulation or change in carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion level Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapnia. Excessive carbon dioxide prompts increased breathing. Decrease of oxygen in blood (hypoxemia) also increases respirations but is less effective than hypercapnia. Low blood oxygen also elevates breathing rate but less effectively than high carbon dioxide.  Changing chest size  Ventilation: physical act of breathing  Actual “respiration” occurs at the cellular level Air rushes into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration) Mechanical expansion and contraction of chest cavity alters size of thoracic container in two dimensions Vertical diameter and anteroposterior diameter Inspiration and Expiration  Developmental Competence: Across the Life cycle Infants and children Pregnant woman Aging adult Development in utero → Impact of enlarging Decreased vital capacity at 32 weeks surfactant uterus and increased residual production→ functions Impact of physiologic volume based on after birth dyspnea structural changes Increased vulnerability of Histologic changes lead respiratory system: to decreased gas Associated with exchange environmental tobacco smoke (ETS) exposure include sudden infant death syndrome, negative behavioral and cognitive functioning, and increased rates of adolescent smoking  Genetics and Environment Lung cancer 2nd most diagnosed cancer in both genders & leading cause of cancer death in the U.S. → smoking leading to mutational burden Tuberculosis (TB) Affected more than 1/3 of the world’s population →”social and migratory” disease Need to identify and actively treat Asthma Most common chronic disease in childhood Highest burden seen in those living at or below the federal poverty level Ethnic and environmental factors play significant role Extrinsic/allergic (or pediatric –onset) asthma Long-term exposure to traffic-related air pollution (TRAP) Subjective Data Cough Shortness of breath History of Chest pain respiratory with breathing infections Smoking Environmental history exposure Patient- centered care  Subjective Data  Do you have a cough? When Cough Shortness of did it start? Gradual or breath sudden? Ask about duration, frequency, timing, and presence of cough as an History of irritating factor Chest pain whether the cough is productive respiratory with breathing infections or non-productive and identify related characteristics quality of cough in terms of description Smoking Environmental precipitating and/or alleviating history exposure factors treatments tried as well as both Rx and over the counter any associated symptoms Patient- impact of cough on ADLs and centered care quality of life Sputum Color Possible Indication White or clear mucoid Colds, bronchitis, viral infections Yellow or Green Bacterial infections Tuberculosis, pneumococcal Rust colored pneumonia Pulmonary edema; Some sympathomimetic medications Pink, frothy have a side effect of pink-tinged mucus.  Subjective Data  Ever had any shortness of Cough Shortness of breath or hard-breathing breath spells? Ask about precipitating factor, severity, and duration History of impact of change of position and Chest pain specific timing pattern respiratory with breathing infections association with any other clinical symptoms any triggering mechanisms r/t: food, environment, or emotion Smoking Environmental the measures taken when SOB history exposure occurs in terms of treatment or medication both Rx and over the counter impact of SOB on ADLs Patient- Progression of SOB centered care  Subjective Data Shortness of  Any chest pain with Cough breath breathing? Please point to exact location. Ask History of about Chest pain respiratory onset, timing—constant with breathing infections versus intermittent pain characteristics in terms Smoking Environmental of quality and intensity history exposure associated clinical symptoms Patient- treatment interventions centered care used to decrease pain  Subjective Data  Any past history of breathing Cough Shortness of trouble or lung diseases, such breath as bronchitis, emphysema, asthma, or pneumonia? Ask about History of any unusually frequent or Chest pain unusually severe colds respiratory with breathing infections any family history of allergies, tuberculosis, or asthma  Smoking history Smoking Environmental Onset, duration. and pattern of history exposure smoking Secondhand exposure to smoke Smoking cessation Counseling using the five A’s: Patient- Ask, Advise, Assess, Assist, and centered care Arrange  Subjective Data Shortness of  Are there any Cough breath environmental conditions that may affect your History of breathing? Ask about Chest pain respiratory occupational factors and with breathing infections exposure protection from exposure Smoking Environmental monitoring and follow-up to history exposure exposure awareness of symptoms Patient- that might signal breathing centered care problems  Subjective Data Cough Shortness of Screening and follow- breath up testing When was the last History of Chest pain respiratory time you had the with breathing infections following? TB skin test Smoking Environmental Chest x-ray study history exposure Pneumonia or influenza immunization COVID status and/or Patient- centered care vaccination  Additional History for Infants and Children  Has the child had any frequent or very severe colds?  Is there any history of allergy in family?  Does child have a cough or seem congested? Does child have noisy breathing or wheezing?  What measures have you taken to child-proof your home and yard? Is there any possibility of child inhaling or swallowing toxic substances?  Has anyone taught you emergency care measures in case of accidental choking or a hard-breathing spell?  Are any smokers in home or in car with child?  Additional History for Aging Adult  Have you noticed any shortness of breath or fatigue with your daily activities? Ask about Tell me about your usual amount of physical activity (For those with a history of chronic obstructive pulmonary disease (COPD), lung cancer, or tuberculosis): Use Lung Function Questionnaire How is your energy level? Do you tire more easily? How does your illness affect you at home and at work? Do you have any chest pain with breathing? Do you have any chest pain after a bout of coughing or after a fall?  Objective Data: Preparation and Equipment  Provide respect and comfort while allowing for access of examination techniques Perform inspection, palpation, percussion, and auscultation on posterior and lateral thorax  Equipment Stethoscope Alcohol wipe IPPA  Inspect palpation of vibration Percussion Auscultation tactile fremitus breath sounds I listen with stethoscope the breath sound coming from patient adventitious sounds voice sounds I listen with the stethoscope and make my patient say stuff or I whisper stuff my patient says 99 and I I initiate the sound, by I look at the patient Bronchophony (tell feel the vibration percussing/tapping patient to say 99 while I listen with stethoscope) Egophony (eee vs aaa w/ stethoscope) Whispered Pectoriloquy (muffled whisper vs clear whisper w/stethoscope)  Anterior Chest Exam IPPA  Inspect: shape, configuration, facial expression, skin color, respiratory effort, accessory muscles  Palpate: Palpate for symmetric expansion or lag expansion. Palpate for tenderness, lumps, turgor, temperature, moisture, crepitus. Tactile fremitus or palpable vibration - ask patient to say 99 or blue moon to feel vibrations.  Percuss: Bilateral comparison from percussion to elicit sound Dull Resonance, Hyperresonance  Ausculate: bilateral comparison when you listen Breath sounds Adventitious sounds Voice sounds Bronchophony Egophony Whispered pectoriloquy  Inspect the Anterior Chest  Note shape and configuration of chest wall  Note patient’s facial expression  Assess level of consciousness  Note skin color and condition  Assess quality of respirations Note respiratory effort Observe for symmetry Determine if accessory muscles are being used  Palpate the Anterior Chest  Palpate symmetric chest expansion Lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding. Atelectasis: Partial lung collapse prevents full expansion. Pneumonia: Lung infection limits expansion due to inflammation and fluid. Postoperative Guarding: Pain after surgery leads to shallower breaths, reducing lung expansion.  Palpate anterior chest wall Note any tenderness or lumps Note skin mobility, turgor, temperature, and moisture  Assess tactile (vocal) fremitus Compare vibrations from one side to other as the person repeats “ninety-nine”. Avoid palpating over female breast tissue because breast tissue normally damps the sound.  Percuss the Anterior Chest  Begin percussing apices in supraclavicular areas Perform bilateral comparison Do not percuss directly over female breast tissue because this would produce a dull note; shift breast tissue over slightly using edge of your stationary hand  Note borders of cardiac dullness normally found on anterior chest Do not confuse these with suspected lung pathology In right hemithorax, upper border of liver dullness is located in 5th intercostal space in right midclavicular line On left, tympany is evident over gastric space  Percuss the Anterior Chest  Begin percussing apices in supraclavicular areas Perform bilateral comparison Do not percuss directly over female breast tissue because this would produce a dull note; shift breast tissue over slightly using edge of your stationary hand  Note borders of cardiac dullness normally found on anterior chest Do not confuse these with suspected lung pathology In right hemithorax, upper border of liver dullness is located in 5th intercostal space in right midclavicular line On left, tympany is evident over gastric space Auscultate Anterior Chest  Breath sounds 1. Auscultate lung fields from anterior chest from the apices in supraclavicular areas to 6th rib 2. Listen to one full respiration in each location 3. Use sequence indicated for percussion 4. Evaluate normal from abnormal 5. Displace breast tissue as needed  Posterior Chest Exam IPPA  Inspect: shape, configuration, facial expression, skin color, respiratory effort, accessory muscles  Palpate: Palpate for symmetric expansion or lag expansion. Palpate for tenderness, lumps, turgor, temperature, moisture, crepitus. Tactile fremitus or palpable vibration - ask patient to say 99 or blue moon to feel vibrations.  Percuss: Bilateral comparison from percussion to elicit sound Dull Resonance, Hyperresonance  Ausculate: bilateral comparison when you listen Breath sounds Adventitious sounds Voice sounds Bronchophony Egophony Whispered pectoriloquy  Inspect  Inspect: shape, configuration, facial expression, skin color, respiratory effort, accessory muscles  Palpation of Vibration Tactile Fremitus Fremitus refers to the palpable vibration that can be felt through the chest wall when a person speaks or makes certain sounds Palpation of Vibration Tactile Fremitus  Palpation of Vibration Tactile Fremitus = Tactile Vibration Increased Tactile Fremitus Decreased Tactile Fremitus Pneumonia (lung infection) Pneumothorax (collapsed lung) Lung tumors Emphysema Pulmonary edema (fluid in lungs) Asthma Lung abscess Pleural effusion (fluid between lung and chest wall) Consolidation (lung becomes firm from inflammation Obesity or thick chest wall or other causes) Increased Tactile Fremitus: Decreased Tactile Fremitus: This happens when the lung tissue This occurs when something prevents the becomes denser or there's a substance vibrations from moving through the chest. like fluid or a mass in the lungs. These This can be due to air trapping in the conditions make it easier for vibrations lungs, a gap between the lung and chest from the voice to travel through the chest. wall, or anything that creates a barrier to the transmission of sound vibrations. THIS CONCEPT IS normal tactile IMPORTANT!! fremitus is a little bit  Molecules solid, liquid, gas Tactile Fremitus Increased tactile fremitus normal tactile fremitus Decreased tactile fremitus Increased Tactile Fremitus Decreased Tactile Fremitus Pneumonia (lung infection) Pneumothorax (collapsed lung) Lung tumors Emphysema Pulmonary edema (fluid in lungs) Asthma Lung abscess Pleural effusion (fluid between lung and chest wall) Consolidation (lung becomes firm from inflammation or other Obesity or thick chest wall causes) Emphysema normal tactile Pleural fremitus effusion (fluid is a little bit solid, between lung liquid, gas and chest wall) Don’t confuse palpation of vibration with percussion Percussion  Dull  Resonant Percussion  Hyperresonant I initiate the sound, by percussing Dull Resonant Hyperresonant THIS CONCEPT IS IMPORTANT!!  Molecules  Percussion and Auscultation  Percussion: Lung fields Determine predominant note over lung fields starting at apices and percuss band of normally resonant tissue across tops of both shoulders Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult Relative term with no defined standards Variation in differing body types  Auscultation Passage of air through tracheobronchial tree creates a characteristic set of noises that are audible through chest wall *Diaphragmatic excursion is no longer recommended as a physical technique  Percuss the Posterior Chest Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax. A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.  Auscultation  Auscultation Points  Breath sounds  Adventitious sounds  Voice sounds  Lung Assessment Auscultation Auscultation Lung Points  Breath Sounds  Evaluate presence and quality of normal breath sounds both anterior and posterior Use flat diaphragm of stethoscope and listen to at least one full respiration in each location Perform bilateral comparison  Three types of breath sounds heard normally in adults and older child: Bronchial, sometimes called tracheal or tubular Bronchovesicular Vesicular  Note description of characteristics and location of breath sounds  Do not confuse background noise with lung sounds NORMAL BREATH SOUNDS Decreased or absent breath sounds 1. Blockage in the airways from secretions, mucus, or an inhaled object. 2. Loss of elastic lung tissue and weaker airflow in emphysema, along with already expanded lungs that reduce sound. 3. Sound transmission barriers like inflammation of the pleura, thickened pleura, or air (pneumothorax) or fluid (pleural effusion) in the pleural space. Complete absence of breath sounds, indicating no air movement, is a grave sign.  Adventitious Sounds  Added sounds that are not normally heard in lungs  Sources differ as to the classification and nomenclature of these sounds: Crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners.  Atelectatic crackles: a type of adventitious sound that is not pathologic Short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths this is better learned with abnormalities section of presentation Adventitious Sounds Shorts  Decreased Breath Sounds Decreased or absent breath sounds occur: 1. When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body 2. In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; the lungs also are already hyperinflated, so the inhaled air does not make as much noise 3. When anything obstructs transmission of sound between the lung and your stethoscope such as pleurisy or pleural thickening or air (pneumothorax) or fluid (pleural effusion) in the pleural space 4. A silent chest means that no air is moving in or out; an ominous sign.  Voice Sounds  Determine quality of voice sounds or vocal resonance as noted in tactile fremitus Normal voice transmission is soft, muffled, and indistinct; you can hear sound through stethoscope but cannot distinguish exactly what is being said  Pathology that increases lung density enhances transmission of voice sounds  Perform supplemental maneuvers if you suspect lung pathology on basis of earlier data Testing for possible presence of bronchophony, egophony, and whispered pectoriloquy special tests/equipment  NotebookLM Output Normal Test/Tool Description Abnormal Finding/Result Nursing Considerations Finding/Result Number of seconds it takes to This test is not routinely performed Forced exhale from total lung capacity 6 seconds or more2 This indicates during a respiratory assessment.1 to residual volume. It is a simple obstructive lung disease and the Instruct the patient to inhale deeply Expiratory screening measure of airflow 4 seconds or less2 patient should be referred for more and then exhale forcefully and as obstruction.1 precise pulmonary function studies. quickly as possible with their mouth Time Peak flow meter open.2 FEV1/FVC ratio of less than 70%2 This A handheld device used in indicates obstructive lung disease. The ambulatory care settings to FEV1/FVC ratio of severity of the obstruction can be Instruct the patient to inhale deeply measure lung health in chronic 75% or greater2 This classified by FEV1: Mild obstruction = and then to exhale into the Spirometer conditions such as asthma.2 It means that no FEV1 >80% predicted; Moderate spirometer as fast as possible until measures forced vital capacity significant obstruction obstruction = FEV1 of 50%-79% they have exhaled as much air as (FVC) and forced expiratory of airflow is present. predicted; Severe obstruction = FEV1 possible.2 volume in 1 second (FEV1). 30%-49% predicted; Very severe = FEV1 45°) may impair lung function and affect self-image. Kyphosis (Humpback) An exaggerated posterior curve of the thoracic spine, causing back pain and limited mobility. Severe cases can impair lung function. Common in postmenopausal women due to osteoporosis but can occur earlier. Regular exercise may prevent kyphosis. Barrel Chest ELI5 Breathing Problems Over a Long Time: People with lung diseases like emphysema, which is often caused by long-term smoking, can get barrel chest. In emphysema, air gets trapped in the lungs and they can't empty properly. Imagine a balloon that stays a bit inflated all the time and never goes back to its original size. That's what happens to the lungs. Because the lungs are always a bit inflated, the ribcage stays exp Scoliosis Kyphosis Pectus Excavatum Pectus Carinatum  Configurations of the Thorax Normal Pectus Pectus Barrel Chest Excavatum Carinatum AP-to-transverse concave/hollow pigeon diameter is equal Scoliosis Kyphosis  Abnormal Findings: Respiration Patterns  Sigh  Tachypnea  Hyperventilation  Bradypnea  Hypoventilation  Cheyne-Stokes respiration  Biot respiration  Chronic Obstructive Breathing  Abnormal Findings: Respiration Patterns Respiratory Pattern Description Normal Adult 10–20 breaths/min, even pattern, 500–800 mL depth. Pulse to respiration ratio is 4:1. Rate increases with exercise, fear, or fever. Sigh Occasional deep breath to expand alveoli. Frequent sighs may indicate emotional distress or lead to hyperventilation and dizziness. Tachypnea Rapid, shallow breathing (>24 breaths/min). Seen in fever, fear, exercise, respiratory insufficiency, pneumonia, and alkalosis. Hyperventilation Increased rate and depth. Causes include extreme exertion, anxiety, diabetic ketoacidosis (Kussmaul respirations), salicylate overdose, and midbrain lesions. Lowers CO2 levels (alkalosis). Bradypnea Slow, regular breathing (24/min), conducts consolidation; instead of “eee”) cyanosis vibrations egophony Whispered Pectoriloquy: Distinct better) (whispered words are clearly heard) Reason: (Consolidated lung tissue conducts sound more effectively)  Heart Failure Heart pump failure increases pressure in the lung's blood vessels, causing congestion and swelling, which squashes air sacs and inflames airway linings. In acute heart failure, may have pulmonary edema with pink, frothy sputum. Crackles at lung base. A chronic condition where the heart doesn't pump blood as well as it should, sometimes causing fluid in lungs. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Heart Failure Increased Normal or Resonant or Normal vesicular, Characteristic Bronchophony: Often normal or respirations, slightly ↑ in slightly dull at S3 gallop fine crackles mildly decreased (words may remain Pulmonary Edema SOB, edema, areas of bases (fluid (“rales”) at somewhat indistinct) pink frothy fluid (mild accumulation) bases (fluid in Egophony: Absent (“eee” does not Elevated pulmonary sputum consolidatio alveolar become “aaa”) venous pressure → fluid n effect) spaces) Whispered Pectoriloquy: Usually in alveoli (pulmonary faint or normal (whispers not edema) distinctly heard) Reason: (Diffuse “wet” lungs, but not typically solid consolidation)  Excess fluid between the layers of the pleura outside the lungs, often causing chest pain and breathlessness. Pleural Effusion (Fluid) Excess fluid accumulates in the space around the lungs, compressing lung tissue. This fluid can be watery, protein-rich, infected, bloody, or lymphatic, and settles at the lower part of the chest, dampening all lung sounds. Decreased tactile fremitus because of pleura fluid decreased tactile fremitus/vibration Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Pleural Effusion Dyspnea, ↓ Dull (fluid is Decreased or Possibly a Bronchophony: Muffled (words not Fluid or thickening in asymmetric (fluid/pleura relatively absent breath pleural rub if distinctly heard) pleural space separates expansion l changes dense) sounds (lung is inflamed; Egophony: Absent or slightly lung from chest wall block “pushed away”) often none increased near fluid level (usually no vibration) clear “eee” → “aaa”) Whispered Pectoriloquy: Faint (whispers not distinctly heard) Reason: (Fluid or thickened pleura dampens conduction)  Air in the pleural space causing the lung to collapse, which can lead to sudden chest pain and shortness of breath. Pneumothorax Pneumothorax occurs when air enters the pleural space, either spontaneously, through injury, or due to trapped air, causing partial or complete lung collapse by disrupting the normal pressure. This usually affects one lung and can compress the lung and shift chest structures, leading to increased breathing and heart rates, and potentially lower blood pressure. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Pneumothorax Unequal ↓ (vibrations Hyperresonant Absent or None Bronchophony: Muffled or absent Air in pleural space → expansion, blocked by (excess air) markedly (words not transmitted) lung collapses away tachypnea, pleural air) decreased Egophony: Absent (no “eee” → “aaa” from chest wall cyanosis breath sounds change) Whispered Pectoriloquy: Faint or absent (no distinct whispers heard) Reason: (Air in the pleural space disrupts sound transmission)  Asthma (Reactive Airway Disease) Asthma is an allergic reaction to allergens, irritants, microbes, stress, or exercise, causing airway narrowing, inflammation, and mucus buildup. This increases breathing resistance, especially when exhaling, leading to wheezing, shortness of breath, and chest tightness. A respiratory condition marked by spasms in the bronchi, causing difficulty in breathing. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Asthma SOB, Often Normal to Prolonged Bilateral Bronchophony: Muffled (words not Bronchoconstriction + wheezing, use normal or hyperresonant expiratory phase, wheezing clearly heard) hyperinflation → of accessory slightly ↓ (air trapping) wheezing (expiratory) Egophony: Absent (you hear “eee” as narrowed airways with muscles (turbulent flow “eee”) trapped air through narrowed Whispered Pectoriloquy: Faint bronchi) (whispered words not distinctly heard) Reason: (Hyperinflated lungs reduce sound conduction)  Emphysema Emphysema, a COPD variant, results from the breakdown of lung connective tissue, causing enlarged air sacs and damaged walls between them. This leads to increased airway resistance, particularly when breathing out, and results in overinflated lungs. Smoking is the primary cause in 80-90% of cases. Chronic conditions where airway flow is impeded, leading to shortness of breath and wheezing. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Emphysema Barrel chest, ↓ (less Hyperresonant Diminished breath Wheezing Bronchophony: Muffled (words not Overdistention/ SOB, tripod dense lung (excess sounds (poor may occur clearly heard) destruction of alveoli → position transmits trapped air) airflow through (narrowed Egophony: Absent (you hear “eee” as hyperinflated lung with vibrations damaged alveoli) airways) “eee”) less tissue density poorly) Whispered Pectoriloquy: Faint (whispered words not distinctly heard) Reason: (Hyperinflated lungs reduce sound conduction)  Pneumocystis jiroveci (P. carinii) Pneumonia Pneumocystis pneumonia, a severe protozoal infection, often occurs in AIDS patients. While the P. jiroveci parasite is typically harmless, it causes widespread lung inflammation in those with weakened immune systems. This leads to cyst formation in the lungs, thickened walls, and widespread fluid buildup. A form of pneumonia caused by the yeast-like fungus Pneumocystis jiroveci, common in immunocompromised individuals. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Pneumocystis jiroveci Anxiety, SOB, Decreased Dull over May be relatively Crackles (may Bronchophony: Often normal or Pneumonia dry cough chest infiltrates, but normal initially or be absent) slightly decreased (words not sharply Diffuse, often expansion usually have diffuse fine amplified) interstitial/alveolar resonant crackles Egophony: Rarely present (usually infection in “eee” remains “eee”) immunocompromised Whispered Pectoriloquy: Faint patients (whispers not distinctly heard) Reason: (Diffuse, interstitial infection rather than dense lobar consolidation)  Bacterial disease that mostly affects the lungs Tuberculosis Inhaling tubercle bacilli triggers a multi-stage tuberculosis infection: initially, the immune response encases but doesn't kill the bacteria. The infection may then become dormant, showing as a calcified spot on X- rays. If reactivated, the bacteria multiply, causing tissue death and cavities in the lungs, often most severe at the top. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Tuberculosis Cough, night ↑ over areas of Dull over Normal or Crackles over Bronchophony: Variable (may be Granulomatous sweats, consolidation consolidati decreased upper lobes normal unless there is significant infection → can cause weight loss or ↓ over on, possibly vesicular sounds consolidation or cavity) consolidation, cavitation hyperreson Egophony: Possible (may have “eee” cavitation ant over → “aaa” if localized consolidation) cavities Whispered Pectoriloquy: Distinct if consolidated, faint if cavitation dominates Reason: (Patchy/cavitary lesions produce variable conduction changes)  Acute Respiratory Distress Syndrome (ARDS) Acute Respiratory Distress Syndrome (ARDS) A severe condition occurs from widespread damage to lung characterized by sudden respiratory membranes, increasing their permeability and failure due to fluid causing fluid buildup. It can result from direct accumulation in the lung injuries like severe pneumonia or alveoli. aspiration, or indirect causes like sepsis or trauma. Autopsies typically reveal dark, firm, fluid-filled lungs with collapsed alveoli and lined membranes. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Acute Respiratory Restless, Can be ↑ if Dull if alveolar Diffuse crackles Fine to Bronchophony: Often decreased Distress Syndrome rapid consolidati fluid (fluid in alveoli), coarse (words not clearly heard) (ARDS) breathing, on is accumulation often severe crackles Egophony: Absent (you hear “eee” Widespread alveolar frothy extensive is substantial throughout as “eee”) injury → sputum, Whispered Pectoriloquy: Faint noncardiogenic hypotension, (whispered words not distinctly pulmonary edema, tachycardia heard) “stiff” lungs Reason: (Diffuse alveolar damage/collapse impairs sound transmission)  COVID-19 Viral Pneumonia Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds COVID-19 Viral Fever, cough, Often Dull over Diminished breath Crackles, Bronchophony: Often normal or Pneumonia dyspnea, normal or infiltrates sounds rhonchi (in slightly decreased (words remain Primarily interstitial and fatigue slightly ↓ severe cases) fairly muffled) alveolar inflammation Egophony: Absent (no “eee” → “aaa”) typical of viral Whispered Pectoriloquy: Faint pneumonias (whispers not distinctly heard) Reason: (Diffuse/interstitial changes rather than dense, lobar consolidation)  Acute Bronchitis Chronic Bronchitis Chronic bronchitis, Acute bronchitis is a short- a form of COPD, term inflammation of the involves increased trachea and major bronchi, mucus production typically causing a cough and inflammation lasting up to three weeks. in the bronchi, Often viral, it doesn't leading to airway usually require antibiotics. blockage and It involves bronchial potential lung inflammation and damage, deflation. Often leading to narrowed caused by airways, excess mucus, smoking, it's and swelling. Smokers, marked by a older adults, children, and recurring cough people during winter are with mucus. more susceptible. Inflammation of the bronchial tubes, leading to coughing and mucus production. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Acute Bronchitis Cough, sore Typically Resonant (no Clear bilaterally None Bronchophony: Usually normal or Bronchial throat, fatigue normal consolidation slightly muffled (words somewhat inflammation, but or effusion) indistinct) alveoli and pleura not Egophony: Absent (you hear “eee” as significantly involved “eee”) Chronic Bronchitis Cough with Typically Resonant (no Normal vesicular, Crackles over Whispered Pectoriloquy: Bronchial thick sputum, normal consolidation prolonged deflated Faint/normal (no distinct whisper inflammation, but cyanosis, or effusion) expiration areas, amplification) alveoli and pleura not fatigue wheezes Reason: (Bronchial inflammation without significantly involved alveolar consolidation)  A blockage in one of the pulmonary arteries in Pulmonary Embolism the lungs, often caused by blood clots that travel from the legs. Pulmonary embolism occurs when materials like blood clots, air bubbles, or fat block the pulmonary arteries, often originating from leg vein clots. This blockage can reduce blood flow to the lungs, increase artery pressure, lower heart output, and cause low oxygen levels. While rare cases can be fatal, most smaller blockages cause shortness of breath and may dissolve naturally. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Pulmonary Embolism Anxiety, Usually Typically Tachycardia, Crackles, Bronchophony: Usually normal Clot obstructs dyspnea, normal. normal (no accentuated S2 wheezes (muffled as per normal lungs) pulmonary artery cyanosis Diaphoresis fluid or Egophony: Absent (“eee” does not branch; alveoli often , consolidation) become “aaa”) spared initially hypotension Whispered Pectoriloquy: Normal/faint (no distinct whispers) Reason: (Primarily vascular problem; no alveolar consolidation or effusion)  Lung Cancer Lung cancer, the deadliest cancer type, causes as many deaths as breast, colorectal, and prostate cancers combined. Mostly caused by smoking (85%), secondhand smoke, and asbestos exposure. It has four types: squamous cell in central bronchi, often near the hilus; adenocarcinoma in the lung periphery, hard to detect early; large cell, also peripheral, forming clustered tumors; and small cell, narrowing central bronchi. A malignant lung tumor characterized by uncontrolled cell growth in tissues of the lung. Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Lung Cancer Weight loss, Variable— Dull over May have — Bronchophony: Variable (can be Tumor mass +/- hoarseness, may tumors decreased clear if post-obstructive post‐obstructive hemoptysis decrease if sounds, or pneumonia/consolidation, or pneumonia/atelectasis obstructing, bronchial muffled if atelectasis) or increase breathing if Egophony: Possible (if there is if there’s post‐obstructive localized consolidation) consolidatio pneumonia Whispered Pectoriloquy: Also n behind the variable (distinct with consolidation, block faint with collapse) Reason: (Depends on whether tumor causes obstruction/collapse or infiltration/consolidation) now chunk/cluster by similarities  Conditions Involving Airway Obstruction or Hyperreactivity Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Asthma SOB, wheezing, Often normal Normal to Prolonged expiratory Bilateral Bronchophony: Muffled (words not clearly Bronchoconstriction + use of accessory or slightly ↓ hyperresonant phase, wheezing wheezing heard) hyperinflation → narrowed muscles (air trapping) (turbulent flow (expiratory) Egophony: Absent (you hear “eee” as “eee”) airways with trapped air through narrowed Whispered Pectoriloquy: Faint (whispered bronchi) words not distinctly heard) Reason: (Hyperinflated lungs reduce sound conduction) Acute Bronchitis Cough, sore Typically Resonant (no Clear bilaterally None Bronchophony: Usually normal or slightly Bronchial inflammation, but throat, fatigue normal consolidation or muffled (words somewhat indistinct) alveoli and pleura not effusion) Egophony: Absent (you hear “eee” as “eee”) significantly involved Whispered Pectoriloquy: Faint/normal (no distinct whisper amplification) Chronic Bronchitis Cough with thick Typically Resonant (no Normal vesicular, Crackles over Bronchial inflammation, but sputum, normal consolidation or prolonged expiration deflated areas, Reason: (Bronchial inflammation without alveoli and pleura not cyanosis, fatigue effusion) wheezes alveolar consolidation) significantly involved Emphysema Barrel chest, ↓ (less dense Hyperresonant Diminished breath Wheezing may Bronchophony: Muffled (words not clearly Overdistention/ destruction SOB, tripod lung transmits (excess trapped sounds (poor airflow occur (narrowed heard) of alveoli → hyperinflated position vibrations air) through damaged airways) Egophony: Absent (you hear “eee” as “eee”) lung with less tissue density poorly) alveoli) Whispered Pectoriloquy: Faint (whispered words not distinctly heard) Reason: (Hyperinflated lungs reduce sound conduction) Conditions Involving Fluid Accumulation Percussion – Dull Auscultation - crackles Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Lobar Pneumonia Fever, increased ↑ Dull (tissue is Bronchial (tubular) Crackles (air Bronchophony: Clear (words become distinctly Consolidation/infection fills respirations (solid/fluid‐fill more dense) breath sounds over bubbling through heard) alveoli → denser lung (>24/min), ed lung consolidation; fluid) Egophony: Present (you hear “aaa” instead of cyanosis conducts egophony “eee”) vibrations Whispered Pectoriloquy: Distinct (whispered better) words are clearly heard) Reason: (Consolidated lung tissue conducts sound more effectively) Heart Failure Increased Normal or Resonant or Normal vesicular, S3 Characteristic Bronchophony: Often normal or mildly respirations, slightly ↑ in slightly dull at gallop fine crackles decreased (words may remain somewhat Pulmonary Edema SOB, edema, areas of fluid bases (fluid (“rales”) at indistinct) pink frothy (mild accumulation) bases (fluid in Egophony: Absent (“eee” does not become Elevated pulmonary venous sputum consolidation alveolar spaces) “aaa”) pressure → fluid in alveoli effect) Whispered Pectoriloquy: Usually faint or (pulmonary edema) normal (whispers not distinctly heard) Reason: (Diffuse “wet” lungs, but not typically solid consolidation) Pleural Effusion Dyspnea, ↓ (fluid/pleural Dull (fluid is Decreased or absent Possibly a Bronchophony: Muffled (words not distinctly Fluid or thickening in pleural asymmetric changes block relatively dense) breath sounds (lung is pleural rub if heard) space separates lung from expansion vibration) “pushed away”) inflamed; often Egophony: Absent or slightly increased near chest wall none fluid level (usually no clear “eee” → “aaa”) Whispered Pectoriloquy: Faint (whispers not distinctly heard) Reason: (Fluid or thickened pleura dampens conduction)  Conditions Involving Lung Collapse or Loss of Lung Volume Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Atelectasis (Collapse) Cough, ↓ (collapsed Dull (less air, Diminished/absent Often none; Bronchophony: Muffled (words not Alveolar collapse → less cyanosis, lag area doesn’t relatively more breath sounds (no maybe a few clearly heard) air in affected segment on affected transmit solid tissue) air movement in crackles if Egophony: Absent (no “eee” → “aaa” side vibrations collapsed region) partial change) well) reopening Whispered Pectoriloquy: Faint (whispered words not distinctly heard) Reason: (Collapsed alveoli impede sound transmission) Pneumothorax Unequal ↓ (vibrations Hyperresonant Absent or markedly None Bronchophony: Muffled or absent Air in pleural space → expansion, blocked by (excess air) decreased breath (words not transmitted) lung collapses away from tachypnea, pleural air) sounds Egophony: Absent (no “eee” → “aaa” chest wall cyanosis change) Whispered Pectoriloquy: Faint or absent (no distinct whispers heard) Reason: (Air in the pleural space disrupts sound transmission)  Infectious Conditions Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Lobar Pneumonia Fever, increased ↑ Dull (tissue is Bronchial (tubular) Crackles (air Bronchophony: Clear (words become Consolidation/infection fills respirations (solid/fluid‐fill more dense) breath sounds over bubbling through distinctly heard) alveoli → denser lung (>24/min), ed lung consolidation; fluid) Egophony: Present (you hear “aaa” instead cyanosis conducts egophony of “eee”) vibrations Whispered Pectoriloquy: Distinct better) (whispered words are clearly heard) Reason: (Consolidated lung tissue conducts sound more effectively) Pneumocystis jiroveci Anxiety, SOB, dry Decreased Dull over May be relatively Crackles (may Bronchophony: Often normal or slightly Pneumonia cough chest infiltrates, but normal initially or have be absent) decreased (words not sharply amplified) Diffuse, often expansion usually resonant diffuse fine crackles Egophony: Rarely present (usually “eee” interstitial/alveolar infection remains “eee”) in immunocompromised Whispered Pectoriloquy: Faint (whispers patients not distinctly heard) Reason: (Diffuse, interstitial infection rather than dense lobar consolidation) Tuberculosis Cough, night ↑ over areas of Dull over Normal or decreased Crackles over Bronchophony: Variable (may be normal Granulomatous infection → sweats, weight consolidation consolidation, vesicular sounds upper lobes unless there is significant consolidation or can cause consolidation, loss or ↓ over possibly cavity) cavitation cavitation hyperresonant Egophony: Possible (may have “eee” → over cavities “aaa” if localized consolidation) Whispered Pectoriloquy: Distinct if consolidated, faint if cavitation dominates Reason: (Patchy/cavitary lesions produce variable conduction changes) COVID-19 Viral Pneumonia Fever, cough, Often normal Dull over Diminished breath Crackles, Bronchophony: Often normal or slightly Primarily interstitial and dyspnea, fatigue or slightly ↓ infiltrates sounds rhonchi (in decreased (words remain fairly muffled) alveolar inflammation severe cases) Egophony: Absent (no “eee” → “aaa”) typical of viral pneumonias Whispered Pectoriloquy: Faint (whispers not distinctly heard) Reason: (Diffuse/interstitial changes rather than dense, lobar consolidation)  Breath Sounds Adventitious Voice Sounds Lobar Pneumonia Fever, increased ↑ Dull (tissue is Bronchial (tubular) Crackles (air Bronchophony: Clear (words become Consolidation/infection fills respirations (solid/fluid‐fill more dense) breath sounds over bubbling through distinctly heard) alveoli → denser lung (>24/min), ed lung consolidation; fluid) Egophony: Present (you hear “aaa” instead cyanosis conducts egophony of “eee”) vibrations Whispered Pectoriloquy: Distinct better) (whispered words are clearly heard) Reason: (Consolidated lung tissue conducts sound more effectively) Pneumocystis jiroveci Anxiety, SOB, dry Decreased Dull over May be relatively Crackles (may Bronchophony: Often normal or slightly Pneumonia cough chest infiltrates, but normal initially or have be absent) decreased (words not sharply amplified) Diffuse, often expansion usually resonant diffuse fine crackles Egophony: Rarely present (usually “eee” interstitial/alveolar infection remains “eee”) in immunocompromised Whispered Pectoriloquy: Faint (whispers patients not distinctly heard) Reason: (Diffuse, interstitial infection rather than dense lobar consolidation) Tuberculosis Cough, night ↑ over areas of Dull over Normal or decreased Crackles over Bronchophony: Variable (may be normal Granulomatous infection → sweats, weight consolidation consolidation, vesicular sounds upper lobes unless there is significant consolidation or can cause consolidation, loss or ↓ over possibly cavity) cavitation cavitation hyperresonant Egophony: Possible (may have “eee” → over cavities “aaa” if localized consolidation) Whispered Pectoriloquy: Distinct if consolidated, faint if cavitation dominates Reason: (Patchy/cavitary lesions produce variable conduction changes) COVID-19 Viral Pneumonia Fever, cough, Often normal Dull over Diminished breath Crackles, Bronchophony: Often normal or slightly Primarily interstitial and dyspnea, fatigue or slightly ↓ infiltrates sounds rhonchi (in decreased (words remain fairly muffled) alveolar inflammation severe cases) Egophony: Absent (no “eee” → “aaa”) typical of viral pneumonias Whispered Pectoriloquy: Faint (whispers not distinctly heard) Reason: (Diffuse/interstitial changes rather than Sputum Color Associated Condition(s) dense, lobar consolidation) White or Clear Colds, bronchitis, viral infections Yellow or Green Bacterial infections Rust-Colored Tuberculosis (TB), pneumococcal pneumonia Pulmonary edema, side effect of some Pink, Frothy sympathomimetic medications (pink-tinged mucus)  Conditions Related to External Compression or Mass Effects Percussion – dull Palpation of Vibration Condition Inspection Percussion Auscultation (Tactile Fremitus) Breath Sounds Adventitious Voice Sounds Pleural Effusion Dyspnea, ↓ Dull (fluid is Decreased or Possibly a Bronchophony: Muffled (words not Fluid or thickening in asymmetric (fluid/pleural relatively absent breath pleural rub if distinctly heard) pleural space separates expansion changes dense) sounds (lung is inflamed; Egophony: Absent or slightly lung from chest wall block “pushed away”) often none increased near fluid level (usually no vibration) clear “eee” → “aaa”) Whispered Pectoriloquy: Faint (whispers not distinctly heard) Reason: (Fluid or thickened pleura dampens conduction) Lung Cancer Weight loss, Variable— Dull over May have — Bronchophony: Variable (can be clear Tumor mass +/- hoarseness, may tumors decreased sounds, if post-obstructive post‐obstructive hemoptysis decrease if or bronchial pneumonia/consolidati