Pulmonary and Thorax Examination PDF

Pulmonary and Thorax Examination Four Cardinal Exam Techniques: - Inspection - Palpation - Percussion - Auscultation Anatomy - Be able to count the rubs by finding the sternal angle - The adjacent rib is the 2^nd^ - Get to the point where you can "see" the location of the...

Pulmonary and Thorax Examination Four Cardinal Exam Techniques: - Inspection - Palpation - Percussion - Auscultation Anatomy - Be able to count the rubs by finding the sternal angle - The adjacent rib is the 2^nd^ - Get to the point where you can "see" the location of the different pulmonary lobes when you look at a thorax - Note that the number of the intercostal spaces b/w two ribs is the same as the rib above it - 2^nd^ intercostal space for needle insertion for decompression of a tension pneumothorax - Intercostal space b/w the 4^th^ and 5^th^ ribs for chest tube insertion (midaxillary line) A diagram of the internal organs of a person Description automatically generated  Important Landmarks: - These landmarks are important and should be used as a way for you to accurately document any area of concern on physical exam - For example: - "Rhonchi present on auscultation heard best at the level of the right 5th rib at the midclavicular line anteriorly"  A close-up of a person\'s chest Description automatically generated *Supraclavicular*---above the clavicles *Infraclavicular*---below the clavicles *Interscapular*---between the scapulae *Infrascapular*---below the scapulae *Apices* of the lungs---the uppermost portions *Bases* of the lungs---the lowermost portions *Upper, middle,* and *lower lung fields* Common Pulmonary Complaints: - Shortness of breath (dyspnea) and wheezing - At rest or with exertion? Severity based on ADLs? Anxiety/hyperventilation - Wheezing from partial lower airway obstruction: secretions, asthma, FB - Cough - From a viral UTI to CHF. The DDx list is long (smoking, ACE inhibitors, FB, GERD) - Blood-streaked sputum (hemoptysis) - Rare in young patients - Blood coughed up from the respiratory tract. Bronchitis, malignancy, TB - Chest pain - PAPA (remember: always r/o the life-threatening causes first) - Pericarditis, ACS, Pneumothorax, PE, Aortic rupture/dissection (thoracic) - Levine sign-clenched fist over the chest - Daytime sleepiness, snoring and disordered sleeping Pulmonary Physical Exam: - This exam begins during the interview process - Having a systemic approach to the exam will help you to perform all aspects of the exam without skipping portions - Start with: Initial survey - An initial survey should take the trained clinical only a few seconds to complete - Observe the patients: - RR, rhythm, depth, and effort of breathing - Are they breathing well, choking, coughing, in respiratory distress? - After the Initial survey, the following sequence is appropriate: - Inspection - From a midline position in front of or behind the pt, note the shape of the chest and how the chest moves - Assess for: - Any deformities or asymmetry - Abnormal retraction in the interspaces with inspiration - **Accessory muscle use** can signal increased ventilatory requirements due to airways and/or parenchymal lung disease or respiratory muscle fatigue. - Severe asthma, COPD, upper airway obstruction - Impaired respiratory movement of one or both sides - Unilateral impairment or lagging suggests pleural disease like asbestosis, can also see in phrenic nerve damage or trauma - Assess for peripheral and central cyanosis - During a pulmonary exam, always check for nail clubbing can be indicative of a chronic lung disease - Inspect the neck for any signs of accessory muscle contraction: sternomastoid, scalenes - Are there supraclavicular retractions? - Is the trachea at the midline? - Inspect the chest from the side to assess the A-P diameter - This can increase w/ aging or may be a sign of COPD - "barrel chest" - Also observe the shape of the chest, which is normally wider than it is deep. - The ratio of the anteroposterior (AP) diameter (depth) to the lateral chest diameter (width) is usually 75 to 90% the person should look wider than deeper - Xray -- flat diaphragm, more trapped air - Palpation - Ask the pt if they have any areas of tenderness - Carefully palpate tender regions or areas where bruising is evident - Broken ribs will often come with bruising - SubQ emphysema -- can be caused by a broken rib that punctures the lung. Air gets trapped - May also feel crepitus with breathing - Crepitus may be originating from bone to bone or from subcutaneous emphysema due to air escaping into the sub-Q tissue - Acute tenderness to palpation over pectoral muscles or at the costal cartilage corroborates, but does not prove, that the chest pain has a musculoskeletal origin - Such as pulled muscle, costochondritis, etc - Chest expansion - Test the pts chest expansion in the following manner: (anterior and posterior chest) - Place your thumbs at approximately the level of the 10th rib posteriorly (or at inferior sternum anteriorly). - Slide your hands medially just enough to raise a fold of skin on each side. - Then ask the pt to inhale deeply - If the chest expansion is normal, you will watch the instance b/w your thumbs as they move apart during inspiration - Several pathologic conditions can cause unilateral decreased chest expansion, or a delay in chest expansion including: - Chronic Pulmonary Fibrosis - Pleural effusion - Significant lobar pneumonia - Pneumothorax - Unilateral bronchial obstruction - Tactile Fremitus - Fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks - Palpate and compare symmetric areas as the patient reports the works "ninety-nine" - The phrase ninety-nine is a diphthong - To detect fremitus, use either the ball or ulnar surface of your hand to optimize vibratory sensitivity of the bones in your hand - Can do one side at a time, comparing symmetrically, or can do both sides at once - Identify any areas of increased, decreased, or absent fremitus +-----------------------------------+-----------------------------------+ | **Increased Fremitus in:** | **Decreased Fremitus in:** | +===================================+===================================+ | Conditions that make the lung | Conditions that make the lung | | more solid so vibrations are | less solid or pull the lung away | | transmitted more easily | from the thoracic wall | | | | | Ex: PNA, pulmonary edema (within | Ex: overexpansion (like | | alveoli), heavy bronchial | emphysema), pneumothorax, pleural | | secretions, solid mass within the | effusion, increased body fat | | lung | | +-----------------------------------+-----------------------------------+ - Percussion - Percussion sets the chest wall in motion, producing audible sounds and palpable vibrations - It helps you establish whether underlying tissues are air-filled, fluid-filled, or solid - Hyperextended, non-dominant middle finger - Pleximeter finger is the one being struck - Do not want any other fingers touching the pt other than the one that you are striking. If you have additional fingers on the pt, it will dull the sound - With a quick, sharp wrist motion, stroke the hyperextended finger - Listen for flatness, dullness, resonance, hyperresonance and tympany **Relative Intensity** **Relative pitch** **Relative duration** **Location example** **Pathologic example** ------------------- ------------------------ -------------------- ----------------------- ---------------------- --------------------------- **Flatness** Soft High Short Thigh Large pleural effusion **Dullness** Medium Medium Medium Liver Lobar PNA **Resonant** Loud Low Long Healthy lung Simple chronic bronchitis **Hyperresonant** Very loud Lower Longer Usually none COPD/Pneumothorax **Tympany** Loud High timbre Depends Puffed-out cheek Large pneumothorax *Intensity is volume / Pitch is frequency of a sound wave, highness or lowness* - Diaphragmatic Excursion - This test measures the descent of the diaphragm - At the scapular line, percuss downward until resonance turns to dullness - This is the diaphragm level - Mark where dullness replaces resonance bilaterally during: - Held full expiration - Held full inspiration - Normally 5-6 cm - Dullness should replace resonance at about the same level bilaterally - An abnormal high level on one side suggests pathology - Could be a large pleural effusion - Could be high diaphragm as in atelectasis or diaphragm paralysis - Auscultation - The most important examination technique for assessing airflow through the tracheobronchial tree - Involves: - Listening to sounds generated by breathing - Listening for adventitious sounds - Wheezes, rails, rhonchi - If abnormalities are suspected, listen to patients spoken or whispered voice - Breath sounds are identified by relative duration of their normal inspiration/expiration phase and are normal - Tracheal breath sounds - Heard over the trachea in the neck - The intensity of the sound is very loud - The pitch is relatively high - Inspiratory and expiratory sounds are about equal in pitch, intensity and duration - Bronchial breath sounds - Heard best over the manubrium and in the first and second interspaces - Pitch is relatively high - Expiratory sounds last slightly longer than inspiratory sounds - Vesicular breath sounds - Heard over most on both lung fields, both anteriorly and posteriorly - The intensity is soft - The pitch is relatively low compared to tracheal and bronchial sounds - Inspiratory sounds last longer than expiratory sounds - This is the predominant sound you will hear when doing a respiratory exam - If bronchial (or bronchovesicular) sounds are heard over lateral lung regions (where vesicular sounds should be)... - This suggests that normal air-filled lungs had been replaced by fluid-filled or solid lung tissue - This is often the case in lobar consolidation PNA - If this auscultation finding is discovered, assess. Transmitted voice sounds in that area - Adventitious (added) sounds are abnormal sounds superimposed on the usual breath sounds - Wheezing - Occurs when air flows rapidly through bronchi that are narrowed nearly to the point of closure - High-pitched hissing or squeaking sound - Usually heard during expiration, but may be heard both during inspiration and expiration - Common causes include asthma, COPD, congestive HF, and sometimes PNA - In severe obstructive disease, the pt is unable to force enough air through the bronchi to produce wheezing - "silent chest" -- ominous sign - Crackles (rales) - Rales have two essential explanations: - When bronchioles and alveoli that deflate during expiration explode or pop open during inspiration - When air bubbles flow through secretions or lightly closed airways during respiration - Causes include interstitial lung disease, pulmonary edema of CHF, PNA, and sometimes COPD/asthma - Sounds like discontinuous crackles or popping ("snap, crackle, pop") - Rhonchi - Rhonchi are course, relatively low-pitched sounds that have a distinct "snorting: quality - Can be during both inspiration and expiration - The discovery of rhonchi suggests the presence of abnormal secretions in bronchi and perhaps even bronchioles - Common causes include PNA, COPD exacerbations, CF, and bronchitis - in COPD or bronchitis, rhonchi often clear with coughing - Stridor and pleural friction rubs are other abnormal sounds - Stridor - Stridor is a high-pitched wheeze that is entirely or predominantly inspiratory - It is often louder in the neck than over the chest wall - Usually indicates partial obstruction of the trachea or larynx and demands immediate attention - Causes include epiglottitis, croup, and foreign body obstruction - Pleural Rub - Inflamed pleura often become rough and the two layers will rub together during respiration - This increased friction is often heard as "creaking", sandpaper-like sound - Resembles crackles acoustically, but more "creaky" and in both phases of respiration - A rub is usually confined to a very localized region of the chest wall - Causes include infection, nearby cancer - Transmitted voice sounds are assessed when you discover abnormally located bronchial or bronchovesicular sounds - These sounds over lung fields (instead of vesicular) suggest the lung space is now fluid-filled or solid - Types of transmitted voice assessments - Egophony - Auscultate the lung fields while your patient says "eeee" - Normally, you will hear a muffled "eee" sound - In conditions like lobar consolidation pneumonia, you may hear a nasally "ay" instead of an "eeee" - This E-to-A change is known as egophony and is an abnormal transmitted voice finding and suggests fluid-filled (or pus-filled) region of lung - Whispered pectoriloquy - Auscultate the lung fields while your pt whispers "one-two-three" - Normally, the whispered voice is heard indistinctly and faintly if at all - Hearing louder, more clear whispered sounds is abnormal, and called Whispered Pectoriloquy - Just like Egophony, this finding occurs in conditions like lobar consolidation pneumonia - Secondary to a fluid0filled or more solid area of lung space - Its often best to completely examine the posterior chest (or anterior) first, and then do the other side **Recording clinical findings:** Initially you may use sentences, later you will use phrases. Develop good habits early. "Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles, wheezes, or rhonchi. Diaphragms descend 4 cm bilaterally." **OR** "Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whispered pectoriloquy. Diaphragms descend 2 cm bilaterally."