Lung Exam 2023 Hull.pdf

Examination of the Thorax and Lungs C L A I R E E. H U L L , M H S , PA - C J U LY 1 2 , 2 0 2 3 Basic Lung Anatomy  Right Side  Upper lobe (RUL)  Middle lobe (RML)  Lower lobe (RLL)  Left Side:  Upper lobe (LUL)  Lower lobe (LLL) Lobes are separated by fissures Lingula is the tongue-shaped a...

Examination of the Thorax and Lungs C L A I R E E. H U L L , M H S , PA - C J U LY 1 2 , 2 0 2 3 Basic Lung Anatomy  Right Side  Upper lobe (RUL)  Middle lobe (RML)  Lower lobe (RLL)  Left Side:  Upper lobe (LUL)  Lower lobe (LLL) Lobes are separated by fissures Lingula is the tongue-shaped are of the left upper lobe Position of Lungs in the Thorax  Anterior  Posterior Position of Lungs in the Thorax - Lateral Landmarks INSPECTION: Assessment of Breathing  What is the rate, pattern, and depth?  What does the breathing sound like? Audible sounds Breathing through mouth or nose?  Any signs of respiratory distress? LOOK AT THE PATIENT  Nasal flaring  Anxious  Clutching  Accessory muscle use  Cyanosis  Gasping, grunting, stridor  Diaphoresis Acrocyanosis Central Cyanosis Clubbing of the Fingernails  Angle between the nail plate and the nail fold is > 180o  Classified as primary (idiopathic, hereditary) or secondary forms.  Associated with various underlying pulmonary, cardiovascular, neoplastic, infectious, hepatobiliary, mediastinal, endocrine, and gastrointestinal diseases.  Mechanism not really known but probably relates to vasodilation of the tips (e.g. in chronic hypoxia) Shamrock Cyanosis AND Clubbing Inspection of the Thorax  Shape and symmetry  Pectus carinatum, pectus excavatum  Scoliosis, lordosis, kyphosis  Anterior/posterior (A-P) diameter:  The A-P diameter should be less than the lateral diameter  May be increased in emphysema Scoliosis COPD Increased A-P diameter Pectus excavatum Increased A-P diameter Pectus carinatum stat Inspecting Mediastinal/Tracheal Position  Inspecting the trachea provides an index of upper mediastinal position.  Mediastinum is the "middle" section of chest cavity.  Includes the heart, the aorta, the thymus gland, the chest portion of the trachea, the esophagus, lymph nodes and important nerves. 813 Tracheal Deviation  Pleural pressures on either side determine the position of the mediastinum.  The mediastinum will shift towards the side with relatively higher negative pressure compared to the opposite side.  Away from diseased side Tension pneumothorax Pleural effusion Large mass Towards diseased side Atelectasis Agenesis of lung Pneumonectomy Pleural fibrosis Deviated trachea Trail sign: prominence of clavicular head of sternocleidomastoid muscle of the side in which trachea is deviated. Tracheal Deviation due to a mass on the left side of the neck. Whitten C R et al. Radiographics 2007;27:657-671 ©2007 by Radiological Society of North America Pneumothorax Hazy is BN shrived up longy Left tension pneumothorax with tracheal shift to the right PALPATION  Assess for pain  Assess for structural abnormalities  Chest wall movement  Respiratory expansion  Tactile fremitus Palpation: Respiratory Expansion recording  Normally the chest should starts at 20 expand 2-5 inches in circumference.  Fibrosis, unilateral obstruction, lobar pneumonia, pleural effusions, neuromuscular disease may cause asymmetrical movements. https://www.ccjm.org/content/84/12/943 Tactile Fremitus  Normal palpable vibrations transmitted through the chest wall when the patient speaks.  Increased or decreased vibrations tells you about the density of the underlying lung tissue and chest wall.  Wide variations from person-to-person: Important thing to note is symmetry Technique for Eliciting Tactile Fremitus “99” “99” watch the video Tactile Fremitus  Increased:  Increases when lung density within the lung increases  Consolidation (fluid or pus in the lung) or compression of lung tissue: Lobar pneumonia  Tumor  Pulmonary edema  https://www.youtube.com/watch?v=ITQWS_jdPXs  Decreased:  Space between visceral and parietal pleura is filled with fluid or air Pleural effusion  Pneumothorax   Airway obstruction that blocks transmission of vibrations Airway obstruction  Atelectasis  Foreign body  https://www.youtube.com/watch?v=uzgdaJCf0Mk https://iplungclinic.com/condition/pleural-effusion/ PERCUSSION  Assesses the density of lungs. Are underlying tissues fluid-filled, air-filled, or solid?  When done correctly, only penetrates 5cm-7cm.  Compare one area to the area on the opposite side  Patient should cross arms in front of chest Technique https://stanfordmedicine25.stanford.edu/the25/pulmonary.html Areas of Percussion Note not only the locations, but the order in which you should percuss. Side-to-side so you can compare more easily Types of Percussion Sounds Diaphragmatic Excursion: Technique  Patient takes full breath and     then exhales fully & HOLDS IT. Percuss the posterior lung fields until the tone is dull (indicating you’re over the diaphragm) and mark area with a pen. Patient takes a full breath in and HOLDS IT. Begin at marked point and percuss DOWN until you hear dullness – mark with a pen Measure distance between the two points: normally 3-5 cm Abnormal Diaphragmatic Excursion  Decreased when lung is unable to expand: Pleural effusion Pneumonia Atelectasis Hemothorax Neuromuscular disease  Decreased when lung is already expanded: Emphysema Asthma AUSCULTATION  Listen to breath sounds with the diaphragm of the stethoscope with patient breathing deeply through an open mouth  NEVER listen through clothes. Always have stethoscope on the patient’s skin  Listen for any adventitious (added) sounds  Listen to sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall (vocal fremitus) Types of Breath Sounds  Vesicular: Soft, relatively low-pitched sounds heard over most of the lungs.  Bronchovesicular: Medium-pitched sounds heard mostly in the 1st & 2nd interspaces anteriorly, and between the scapulae  Bronchial: Relatively high pitched; heard over the manubrium, if heard at all.  Tracheal: Relatively high-pitched, harsh; heard over the trachea and neck. Adventitious Breath Sounds  Wheezes: High pitched, musical, hissing Suggest narrowed smaller airways such as in asthma, COPD, bronchitis  Stridor: A wheeze that is entirely or predominantly inspiratory. Indicates partial obstruction of the trachea or larynx and warrants immediate attention (seen commonly in foreign body aspiration, croup) Adventitious Breath Sounds  Rhonchi: Low-pitched, snoring, honking sounds caused by the rattling of secretions in the large airways; transient airway plugging (bronchitis, cystic fibrosis, bronchiectasis)  Crackles (also called rales): Excess secretions in small airways  Pleural friction rub: Indicates inflammation of the pleural lining of the lung Adventitious Breath Sounds  Things to note:  Timing: inspiratory and/or expiratory  Location: e.g. LUL, RML, scattered, posterior  Number: intermittent, continuous  Change with coughing or patient’s position? Vocal Fremitus (Transmitted Voice Sounds)  BRONCHOPHONY – “Bronchial sounds” - spoken words are louder than normal consolidation  WHISPERED PECTORILOQUY – “Voice of the chest” – whispered words have increased intensity and pitch – pneumonia, fibrosis  EGOPHONY – “Voice of the goat”– Has a bleating quality E A change PUTTING IT ALL TOGETHER PATIENT SCENARIOS PNEUMONIA (Consolidation) PNEUMONIA I: May observe respiratory distress P: Increased tactile fremitus; +/- decreased expansion over area P: Dullness on percussion in area of consolidation A: Bronchial breath sounds, crackles, egophony, pectoriloquy PLEURAL EFFUSION I: P: P: A: Respiratory distress, +/- mediastinal deviation to opp side Decreased expansion, absent or fremitus over area Dullness or flat; decreased excursion Absent or breath sounds over effusion; +/- Pleural rub PNEUMOTHORAX I: Respiratory distress; signs of trauma P: Decreased expansion, absent fremitus over area P: Tympany on percussion A: Absent breath sounds over pneumothorax ASTHMA I: P: P: A: Respiratory distress Decreased fremitus, diminished expansion Hyperresonance Wheezes (may have crackles, rhonchi too) CHRONIC BRONCHITIS I: P: P: A: Barrel chest, respiratory distress, mucousy cough Decreased expansion, decreased fremitus May be normal or hyperresonant Crackles, wheezing, rhonchi EMPHYSEMA I: P: P: A: Barrel chest or cachectic, respiratory distress, pursed-lip breathing Decreased expansion, decreased tactile fremitus Hyperresonance; decreased diaphragmatic excursion Breath sounds often decreased or absent but may have wheezes, crackles, rhonchi’ transmitted voice sounds are decreased Why Smoking is Bad CLINICAL CORRELATES Block II Cardiopulmonary, Abdominal, Lymphatic & Genitourinary Examinations CLINICAL CORRELATES The Respiratory System CLINICAL CORRELATES The Cardiovascular System Normal Color vs. Pallor Erythema vs. Rubor CLINICAL CORRELATES THE LYMPHATIC EXAMINATION CLINICAL CORRELATES The Abdominal Exam CLINICAL CORRELATES The Genitourinary Examination