Asthma; small airway obstruction due to inflammation and hyperreactive airways

I-tachypnea, nasal flaring, intercostal retractions

P- Tachycardia diminished fremitus

P-Occasional hyperresonance

A-Prlonged expirtation, wheezes, diminished lung sounds

Chest pain is comon with a feeling of tightness, hypoxemia by PO, expiration becomes more prolonged with labored breathing, fatigue and anxious expression

Atelectasis; incomplete expansion of the lung at birth or the collapse of lung at any age

I- Delayed/diminished chest wall movement, narrowed intercostal spaces on affected side, tachypnea

P-Diminished fremitus, apical cardiac impulse deviated ipsillaterally

P-Dullness over affected lung

A- In upper lobe, bronchial breathing, egophony, whispered pecoriloguy

In lower lobe, diminished or absent breath sounds

Wheezes, rhonchi, and crackles in varying amounts depening on extent of collapse

Bronchitis; Inflmmation of large airways

I-Occasional tachypnea, shallow breathing

P-Tactile Fremitus undiminished

P-Resonance

A-Breath sounds may be prolonged, occasional crackles, experiratory wheezes and rhonchi

Bronchitis, subjective

Fever, chest pain, productive cough, or hacking non-productive cough

Bronchiectasis; chronic dilation of the bronchi or bronchioles caused by repeated pulmonary infections and bronchial obstruction

I-Tachypnea, Respiratory distress, hyperinflation

clubbing

P-Few if any

P-No unusual findings

A-A variety of crackles, usually coarse, and rhonchi sometimes disappearing after cough

Chronic Obstructive Pulmonary Disease

I-Respiratory distress, audible wheezing, cyanosis, distention of neck veins, peripheral edema(in R sided heart failure), clubbing-rare

P-Somewhat limited mobility of diaphragm, somewhat diminished vocal fremitus

P-Occasional hyperresonance

A-Postpertussive rhonchi and sibilant wheezing, inspirational crackles, breath sounds diminished

Emphysema; Conditions in which the lungs lose elasticity and alveoli enlarge

I-Tachypnea, Deep breathing, pursed lips, barrel chest, thin, underweight

P-Apical impulse may not be felt, liver edge displaced downward, diminished fremitus

P-Hyperresonance, limited descent of diaphragm on inspiration, upper border of liver dullness pushed downward

A-Diminished breath and voice sounds with occasional prolonged expiration, diminished audibility of heart sounds, only occasional adventitious sounds

Pleural Effusion; Excessive non-purulent fluid in pleural space

I-Dimished and delayed respiratory movement (lag) on affected side

P-Cardiac apical impulse shifted contralaterally, trachea shifted contralaterally, diminished fremitus, tachycardia

P-Dullness to flatness

Hyperresonant note in area superior to fusion

A-Diminished to absent breath sounds, bronchophony, wispered pectoriloquy, egophony and/or crackles in area superior to effusion, occasional friction rub

Pneumonia Consolidation; inflammatory response of the bronchioles and alveoli to an infective agent

I-Tachypnea, shallow breathing, flaring of nasi, occasional cyanosis, limited movement at times on involved side; splenting

P-Increased fremitus in presence of consolidation, decreased fremitus in presence of a concomitant empyema or pleural effusion, tachypnea

P-Dullness if consolidation is great

A-A variety of crackles with lobar and occasional rhonchi, bronchial breath sounds, egophony, bronchophony, whispered pectoriloguy

Pneumothorax; Presence of air or gas in the pleural cavity

I-Tachycardia, cyanosis, respiratory distress, bulging intercostal spaces, respiratory lag on affected side, tracheal deviation with tension pneumothorax

P-Diminished to absent fremitus, cardiac apical impulse, trachea, and mediastinum shifted contralaterally, dimished to absent tactile fremitus, tachycardia, subcutaneous crepitance from air leaking

P-Hyper-resonance

A-Diminished to absent breath sounds, Succusion splash audible if air and fluid mix, Sternal and precordial clicks and crackling, Diminished to absent whispered voice sounds

Mediastinal Crunch (Hamman Sign)

A great variety of sounds (loud crackles, clicking, and gurgling sounds are heard over the precordium, synchronous with heartbeat

Found with medistinal emphysema

Friction Rub

dry, crackly, grating, low-pitched sound heard on expiration and inspiration, heard over heart or lungs is caused by inflamed, roughened surfaces rubbing together

Heart- Pericarditis

Lungs-Pleurisy

Respiratory vs cardiac rub

Respiratory disappears when breath is held, cardiac does not

Normal Respiratory Rates

Newborn- 30-80

1 year-20-40

3 year-20-30

6 year-16-22

10 year-16-20

17 year- 12-20

Prego Women Resp Changes

Dyspnea (SHOB) common

breaths deeper not, increase RR

Increased tidal volume

Lateral diameter increases by 2cm

Circumference increases 5-7cm

Costal angle increases from 68.5-103.5

Diaphragm rises as much as 4cm above normal resting position, major work of breathing done by diaphragm

Minute ventilation increases

Older Adults Resp Changes

Barrel chest common

Loss of muscle strength in thorax & diaphragm

Loss of lung resiliency

Dorsal curve increased (kyphosis)

Increased AP diameter

Siffening and decreased expansion of the chest wall

Pleurisy; Inflammatory process involving the visceral and parietal pleura

Subjective: Usually sudden onset with chest pain when taking a breath (pleuritic)

rubbing of the pleural surfaces can be felt by the pt.

Pain can be referred to the ipsilateral shoulder if the pleural inflammation is close to the diaphragm

Objective: Respirations are rapid and shallow with diminished breath sounds

A pleural friction rub can be auscultated

Fever may be present

Empyema; Purulent exudative fluid collected in the pleural space

Subjective: Often Febrile and tachypneic, with cough, and chest pain, and patient appears ill, progressive dyspnea develops, cough may produce blood or sputum

Objective: Breath sounds are distant or absent in the affected area, percussion note is dull and vocal fremitus is absent, chest radiograph with pleural opacity that does not flow freely on lateral decubitus views

Lung Abscess; well-defined, circumscribed, inflammatory, and purulent mass that can develop central necrosis

Subjective: Malaise, fever, SHOB

Aspiration of food most common cause

Objective: Percussion note is dull and the breath sounds are distant or absent over the affected area

Pleural friction rub may be ausculated

cough may produce purulent, foul-swelling sputum

Influenza; Viral infection of the lung, upper respiratory infection

very old and very young susceptible

Subjective- Characterized by cough, fever, malaise, headache, coryza, and mild sore throat

Respiratory distress can develop

Objective-Crackles, rhonchi, and tachypnea are common

ILL sounding breath sounds

Rhonchi: coarse-low-pitched;may clear with cough

Wheeze-whistling, high-pitched bronchus

Bronchial-Coarse, loud; heard with consolidation

Rub-Scratchy-high-pitched

Crackles-fine-crackling-high pitched

Well Breath Sounds

Bronchial-Coarse-loud

Bronchovesicular-combination bronchial and vesicular, normal in some areas

Vesicular-Low pitched, breezy

Tuberculosis;Chronic infectious disease that most often begins in the lung then widespread

Subjective: Latent period: asymptomatic, some regional lymph nodes may be involved

Active infection: fever, cough, weight loss, night sweats

HIstory of travel

Objective:Latent-no pulm findings

Active-Consolidation and/or pleural effusion may develop with cough /blood streaked sputum

Positive tuberculin skin test and interferon-gamma assay

Pneumothorax; presence of air or gas in pleural cavity

Subjective:spontaneous often occurs when pt is at rest, larger collections provoke dyspnea and chest pain

Objective-Breath sounds over pneumothorax are distant, a medistinal shift with tracheal deviation away from involved side can be seen with tension pneumothorax

persistent tachycardia may be a clue to minimal pneumothorax

Hemothorax; presence of blood in the pleural cavity

Subjective-dysnpea, and lightheadedness

Objective-

Breath sounds will be distant or absent

Percussion will be dull

Tachycardia and hypotension with excessive blood loss

Lung CA- usually bronchogenic carcinoma

Subjective- May cause cough, wheeezing, variety of patterns of emphysema and atelectasis, pneumonitis, and hemoptysis

Peripheral tumors without airway obstruction may be asymptomatic

Objective-Findings are based on the extent of the tumor

Airway obstruction-->a postobstructive pneumonia can develop with consolidation

A malignant pleural effusion may develop

Pulmonary Embolism; embolic occlusion of pulmonary arteries

Subjective-

Pleuritic chest pain with or without dyspnea is a major CLUE

Objective-low grade fever or isolated tachycardia, hypoxia by pulse ox relevant

Risk factors for PE

>40yo

history of venous thromboembolism

Surgery with anesthesia longer than 30min

heart disease

cancer

fracture of pelvis and leg bones

obesity

Diaphragmatic Hernia (Infants, Peds)

Result of an imperfectly structed diaphragm, usually on L side away from liver

Subjective: respiratory distress can be slight or very severe depending on the extent to which the bowel has invaded chest

Objective-Bowel sounds are heard in the chest with a flat or scaphoid abdomen

Heart is usually displaced to the right

Tachypnea, retraction & grunting

Cystic Fibrosis

Autosomal recessive disorder involving lungs, pancreas, and sweat glands, thick mucous in bronchi and bronchioles

Subjective-Cough with sputum is hallmark in children <5yo

Salt loss in sweat is that skin tasts unusually salty

history of malabsorption, large, bulky stools, constipation, poor weight gain, frequent infection, meconium ileus, or intestinal obstruction

Objective- Bronchiectasis

Barrel Chest

Nasal polyps

Low body mass

Clubbing, pulm hypertension or cor pulmonale

Epiglottitis

Acute inflammation of epiglottis

Subjective-Begins suddenly and progresses rapidly without cough

painful sore throat with diff swallowing-muffled voice

Objective-

Child sits straight up with neck extended and head forward, anxious, drools, high fever, beefy red epiglottis

Croup (Laryngotracheal Bronchitis)

usually 1-3 yo, parainfluenza virus usually

Subjective-

episode begins with URS, mild symptoms

often awakens suddently after bed, often very frightened with a harsh, barking cough

Objective-

Labored breathing, retraction, hoarseness, barking cough, and inspiratory stridor, restless, irritable, fever sometimes,NO DROOLING

Tracheomalacia

Lack of rigidity or a floppiness of the trachea or airway r/t pressures

Subjective-noisy breathing, or wheezing in infancy is opten inspiratory stridor

Objective-

Stridor, wheezing, respiratory distress

Bronchiolitis

Bronchiolar (small airway) inflammation leading to hyperinflation of the lungs, usually <6MO

Subjective- begins with URS poor feeding, vomiting, diarrhea, lethargy, expiration becomes difficult, anxious

Objective-

Breaths rapid and short with generalized retractions and cyanosis

Wheezing, grunting, diminished breath sounds, altered status, lung hyperinflation, increased thoracic cage and abdomen, hyperresonant percussion

Bronchiectasis

Chronic dilation of bronchi or bronchioles by pulm infection/obstruction (cystic fibrosis)

Subjective- cough with expectoration of large amounts of sputum is most often

Severe hemoptysis

Objective-

Tachypnea and clubbing, crackles rhonchi sometimes after cough

*Malfunction of bronchial muscle tone and loss of elasticity

Chronic Bronchitis

Large airway inflammation

usually >40 yo

Large airway chronically inflamed leading to mucus production-recurrent bacterial infections

Subjective-Dyspnea may be present, cough and sputum production

Objective-Wheezing/crackles, hyperinflation with decreased breath sounds and flattened diaphragm,

*R Ventricular failure with dependent edema if severe

Infant Norms

Lateral=AP <2yo

>2yo Lateral>AP

thin chest wall makes bony structures more prominent than adult, more cartilaginous & yielding, xiphoid process more prominent

Breath s/s infection

Sweet, fruity- Diabetic ketoacidosis; starvation ketosis

Fishy-stale-uremia

Ammonia like-Uremia

Musty flish, clover- Fector hepaticus, hepatic failure, portal vein thrombosis, poracaval shunts

Foul-feculent-intestinal obstruction

Foul, putrid-Nasal sinus pathology; infection, foreign body, cancer, respiratory infections, empyema, lung abscess, bronchiectasis

Halitosis-Tonsillitis, gingivitis, respiratory infections, vincent angina, gastroesophageal reflux

Cinnamon-pulmonary tuberculosis

HOW to inspect

External to internal

Superior to inferior

Comparison

P & A & L

AP to Lateral

1:2

Palpation

Thoracic Expansion, located 10th rib with hands on each side, symmetrically

non-symmetrical-problem (COPD)

TACTILE Fremitus

Ulnar surface of hands, 99, above & below

Decreased or absent fremitus: excess air in lungs, ephysema, pleural thickening/effusion, pulmonary edema, bronchial obstruction

Increased Fremitus: Coarser/rougher feel occurs in presents of fluids or solid mass; may be caused by consolidation

Palpation of Trachea

Trachea should be midline above suprasternal notch

palpating with b/l thumbs, slight deviation to right can be normal

DEVIATION- Thyroid enlargement-effusion-deviate to unaffected side

Pneumothorax may deviate to or away from affected side-Tension pneumothorax away from side

Deviation of Trachea

Anterior Mediastinal tumors can push trachea posteriorly

Mediastinis-Trachea may be pushed forward

Tracheal tug- downward pulsatile tug from cricoid cartilage, indicative of aortic aneurysm

Percussion-Pt. body position

Resonant

Intensity Loud

Pitch Low

Duration Long

Quality Hollow

Ex NORMAL LUNG

Flat

Intensity Soft

Pitch High

Duration Short

Quality Very Dull

Ex Muscle, bone

Dull

Intensity- medium

Pitch- Medium to High

Duration-Medium

Quality-Dull Thud

Ex-pleural effusion, liver

Tympanic

Intensity-Loud

Pitch-High

Duration-Medium

Quality-Drumlike

Examples-Gastric Bubble

Hyperresonant

Intensity- Very Loud

Pitch-Very Low

Duration-Longer

Quality-Booming

Ex-Emphysemous lung

Excursion Distance

Usually 3-5cm

Dull over diaphragm

Resonant over Lung

Steps to Mark Diaphragmatic Excursion #1

Steps to Mark Diaphragmatic Excursion #2

Ausculation

Normal Breath Sounds

Vesicular- Heard over most of lung fields; low pitch; soft and short expirations, diminished in overweight or muscular person

Bronchovesicular- Heard over main bronchus area and over upper right posterior lung field; medium pitch, expiration equals inspiration

Bronchial/Tracheal- Heard only over trachea; high pitch; loud and lung expirations, sometimes a bit longer than inspirations

Breath Sounds cont

Crackles

Fine-High-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough

Medium-Lower, more moist sound heard during the midstage of inspiration; not cleared by cough

Coarse-Loud, bubbly noise heard during inspiration; not cleared by cough

Rhonchi

Loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucous accumulation in trachea or large bronchi)

Wheeze

musical noise sounding like a swueak; most often heard continuously during inspiration or expiration; usually louder during expiration

Pleural Friction Rub

dry, rubbing, or grating sound, usually caused by inflammation of pleural surfaces; heard during inspiration or expiration; loudest over lower lateral anterior surface

Vocal Resonance

•Bronchophony: greater clarity and increased loudness of spoken sounds with auscultation

•Abnormal if clarity with normal words

•Egophony: abnormal if “e” becomes stuffy broad “a”

Vocal Resonance

Expected Findings

Inspection: symmetry of movement on expansion

Absence of retractions

Palpation: Midline trachea without a tug, symmetric unaccentuated tactile fremitus

Percussion: Range of 3 to 5cm in the descent of diaphragm, Resonant and symmetric percussion notes

Auscultation: Absence of adventitious sounds, Vesicular breath sounds, except for bronchovesicular sounds beside the sternum and the more prominent bronchial components in the area of the larger bronchi

Clinical Pearl*

Think about the possibility of a foreign body when a patient, particularly a child, presents with wheezing for the first time, especially if asymmetric

Bronchophony

Can hear pt's laryngeal (bronchial) sounds while not being able to interpret the words

Pectoriloquy

The examiner can clearly distinguish the words a)spoken or b)whispered

Egophony

The spoken sound 'ee' sounds like 'a' bee-->bay

Newborn considerations

coughing is rare and is a problem

Sneezing is frequent and expected

Hiccups are frequent particularly after meals ,but frequent hicupping could suggest seizures, drug withdrawal or encephalopathy

Newborn/Infant Considerations

Newborns rely primarily on diaphragmatic breathing, only gradually adding the intercostal muscles

Infants quite commonly use the abdominal muscles

Paradoxic breathing(chest wall collapses as the abdomen distends on inspiration is common, especially during sleep

Newborn chest expansion a-symmetric

pneumothorax, atelectasis, diaphragmatic hernia

Newborn

Crepitus is a common finding after a forceps delivery with clavicle fractured (no pain)

Crackles and rhonchi are normal post-partum do to accumulation of fluid

Xiphoid process is easily moveable

Stridor

High pitched piercing sound most often heard during inspiration

I/E ratio 3:1 4:1

accompanied usually by cough, hoarsness, and retraction

Respiratory Grunting

mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain and increase oxygen levels

Procedures

Nebulizer

Peak Flow Meter

Arterial Blood Gas

Chest Radiography

PFT

Spirometry

Lung Volume

Diffusion

Flow Volume Loop