landmark for needle insertion for tension pneumothorax
2nd intercostal space
landmark for chest tube insertion
4th intercostal space
landmark for lower margin of endotracheal tube on chest x-ray
T4
another possible starting point for counting ribs and interspaces
the 12th rib (posteriorly)
landmark that usually lies at the level of the 7th rib or interspace
inferior tip of the scapula
PRECISE lines that are used to locate findings around the circumference of the chest
the midsternal and vertebral lines
(the other lines are estimated)
line that drops vertically from the midpoint of the clavicle, located by identifying both ends of the clavicle accurately
the midclavicular line
the muscle masses that border the axilla
the anterior and posterior axillary folds
lines that drop vertically from the anterior and posterior axillary folds
the anterior and posterior axillary lines
the line that drops from the apex of the axilla
the midaxillary line
What does the vertebral line overlie posteriorly?
the spinous processes of the vertebrae
line that drops from the inferior angle of the scapula
the scapular line
Where is the apex of the lung located anteriorly?
2-4 cm above the inner 3rd of the clavicle
Where does the lower border of the lung cross the 6th rib inferiorly?
at MCL
Where does the lower border of the lung cross the 8th rib inferiorly?
at the AAL
Where is the lower lung posteriorly?
T10 spinous process
What divides each lung in half?
Major (Oblique) Fissure
How does the major (oblique) fissure run?
obliquely from T3 spinous process to 6th rib at MCL
What is the horizontal fissure that runs close to the 4th rib and meets oblique fissure in MAL at the 5th rib?
Minor Fissure
What is the right lobe divided into?
3 lobes - upper, middle, lower
What is the left lobe divided into?
2 lobes - upper, lower
above the clavicles
supraclavicular
below the clavicles
infraclavicular
between the scapulae
interscapular
below the scapulae
infrascapular
lower most portions of the lung
bases of the lung
Where do the breath sounds differ in quality?
breath sounds over trachea and bronchi have different quality than sounds over the lung parenchyma
What does the trachea bifurcate into?
right and left mainstem bronchi at sternal angle anteriorly and T4 spinous process posterior
What are serous membranes covering the outer surface of each lung, inner rib cage, and upper surface of diaphragm?
Pleura
What are the pleura lubricated by?
pleural fluid
Function of Pleura
allows lungs to move easily during inspiration and expiration
Which pleura lies adjacent to the lung?
visceral pleura
What is the potential space between visceral and parietal pleura?
pleural space
What is breathing controlled by?
breathing is AUTOMATIC and controlled by the BRAIN STEM
What is breathing mediated by?
muscles of respiration
What is the primary muscle of inspiration?
the dome-shaped diaphragm
What nerve innervates the diaphragm?
phrenic nerve
What expand the chest during inspiration?
thorax muscles and intercostals
What happens during the expiratory phase of breathing?
the chest wall and lungs recoil and the diaphragm relaxes
What does labored breathing require use of?
accessory muscles
What are the accessory muscles?
sternocleidomastoid (SCM), scalnes, pectoralis major and minor, latissimus dorsi, abdominals
What controls O2 and CO2 (acid/base balance in breathing)?
the brainstem
What are the major PO2 sensors in breathing?
carotid bodies
Higher Brain Centers that control respiration
cortex, spinal, cerebellar, lung receptors (stretch - smooth muscle; irritant - epithelia), and chest wall (joint, tendon, and muscle spindle receptors)
Causes of Irregular Breathing
Congestive Heart Failure (CHF), CNS Disease (midbrain and pons), Sleep Apnea, Metabolic Acidosis/Alkalosis, Hepatic Coma, ASA Intoxication, Psychogenic
Normal Respiration
the normal respiratory rate is about 14-20 per minute in normal adults and up to 44 per minute in infants
Slow Breathing
Bradypnea
Causes of Bradypnea (Slow Breathing)
diabetic coma, drug-induced respiratory depression, and increased intracranial pressure
Rapid Shallow Breathing
Tachypnea
Causes of Tachypnea (Rapid Shallow Breathing)
number of causes including restrictive lung disease, pleuritic chest pain, and an elevated diaphragm
What are periods of breathing alternating with periods of apnea (no breathing)?
Cheyne-Stokes Breathing
When may children and aging people normally show Cheyne-Stokes Breathing?
in sleep
Other Causes of Cheyne-Stokes Breathing
heart failure, uremia, drug-induced respiratory depression, and brain damage (typically on both sides of the cerebral hemispheres or diencephalon)
What type of breathing is characterized by unpredictable irregularity in which breaths may be shallow or deep, and stop for short periods?
Ataxic Breathing (Biot's Breathing)
Causes of Ataxic Breathing (Biot's Breathing)
respiratory depression and brain damage, typically at the medullary level
What is rapid, deep breathing?
Kussmaul's Breathing
When is Kussmaul's Breathing often seen?
in patients with metabolic acidosis
The Health History
chest pain, shortness of breath (dyspnea), wheezing, stridor, cough, blood-tinged sputum
What can chest pain originate from?
organs within the chest, neck, or abdomen
Where does chest pain usually originate from?
the lining of the lungs
Why does chest pain usually originate from the lining of the lungs?
because lung parenchyma has no pain receptors
More specifically, where does chest pain originate from?
lining of the lungs, heart, pericardium, musculoskeletal chest wall, nerves, gastrointestinal tract
Reasons for Chest Pain in the Musculoskeletal Chest Wall
muscles, collagen (SLE), ribs, vertebral fractures
Reasons for Chest Pain from the Nerves
Herpes Zoster (Shingles)
Reasons for Chest Pain from the Gastrointestinal Tract (GIT)
esophagus, stomach
chest pain originating from the myocardium
angina pectoris - myocardial infarction
chest pain originating from pericardium
pericarditis
chest pain originating from aorta
dissecting aortic aneurysm
chest pain originating from trachea and large bronchi
bronchitis
chest pain originating from parietal pleura
pericarditis, pneumonia
chest pain originating from chest wall
herpes zoster, costochondritis
chest pain originating from esophagus
reflux esophagitis, esophageal spasm
chest pain originating from extra-thoracic area
gall bladder (biliary colic), gastritis, PUD (peptic ulcer disease, hiatal hernia), cervical arthritis
What does a clenched fist over the sternum suggest?
angina pectoris
What does a finger pointing to a tender area on the chest wall suggest?
musculoskeletal pain
What is the most frequent cause of chest pain in children?
anxiety
What is also a common cause of chest pain in children?
costochondritis
What is a non-painful, but uncomfortable awareness of breathing?
dyspnea
Descriptive Information for Dyspnea (Shortness of Breath)
timing, onset, position (orthopnea/PND point to cardiac origin), exacerbating or alleviating factors, degree of impairment, associated symptoms (cough, chest pain, wheezing, edema), consider anxiety/psychological etiology
Causes of Exertional Dyspnea
exertional induced asthma or cardiac insufficiency
Causes of Resting Dyspnea
COPD, emphysema, severe CHF
Causes of Episodic Dyspnea
triggers such as allergy, exertion
Causes of Continuous Dyspnea
usually suggests chronic condition or uncontrolled acute condition (COPD, pneumonia)
Questions to Ask in Assessment of Dyspnea
Occurs at rest or with exertion (how much)? How far can they walk on level ground before having to stop? Can they climb a flight of stairs? What activity could they do a year ago that they cannot do today? Do they have difficulty taking a breath? Do they
Causes of Dyspnea
left sided heart failure or mitral stenosis, chronic obstructive lung disease (COPD), chronic bronchitis, asthma, diffuse interstitial lung disease, pneumonia, spontaneous pneumothorax, acute pulmonary embolism, anxiety with hyperventilation
symptoms associated with dyspnea in left sided heart failure or mitral stenosis
cough, PND, +/- wheeze
symptoms associated with dyspnea in COPD
cough with scant mucoid sputum
symptoms associated with dyspnea in chronic bronchitis
cough with phlegm daily in am for 3 consecutive months for 2 consecutive years - chronic productive cough, recurrent respiratory infections, +/- wheezing
symptoms associated with dyspnea in asthma
wheezing, cough, tightness in chest
symptoms associated with dyspnea in diffuse interstitial lung disease
weakness, fatigue, cough less common
symptoms associated with dyspnea in pneumonia
pleuritic pain, cough, sputum, +/- fever
symptoms associated with dyspnea in spontaneous pneumothorax
pleuritic pain, cough
symptoms associated with dyspnea in acute pulmonary embolism
retrosternal oppressive pain, pleuritic pain, cough, +/- hemoptysis
symptoms associated with dyspnea in anxiety with hyperventilation
lightheadedness, numbness and tingling hands or feet, palpitations, chest pain
What is a whistling noise in the chest?
wheezing
What does wheezing occur with?
airway obstruction
What are conditions associated with airway obstruction causing wheezing?
asthma, CHF, COPD
What does wheezing suggest partial airway obstruction from?
secretions, tissue inflammation, or a foreign body
What is a loud, harsh, low to high pitched sound resulting from turbulent air flow in the upper airway?
stridor
When is stridor usually heard?
on inspiration
What is stridor usually due to?
a problem with the trachea, pharynx, or larynx (upper airway)
Conditions Associated with Stridor
croup (laryngotracheobronchitis - 6mos-2yrs, barks like a seal)
epiglottitis (drooling and dysphagia)
retropharyngeal abscess (pain with swallowing)
inhaled foreign body
anaphylaxis (hoarsness with inspiratory stridor)
What does biphasic stridor suggest?
subglottic or glottic obstruction
steeple sign
croup
thumb sign
epiglottitis
What is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi?
cough
Stimuli of Cough
mucus, pus, and blood, external agents such as dust, foreign bodies, extremely hot or cold air
sputum that is translucent, white, or gray
mucoid sputum
sputum that is yellowish or greenish
purulent sputum
coughing up blood which may vary from blood-streaked phlegm to frank blood
hemoptysis
acute, dry cough (without sputum) that may become productive of variable amounts of sputum - a minor illness with hoarseness often associated with viral nasopharyngitis
laryngitis
acute, dry cough that may become productive, often a viral illness with burning retrosternal discomfort
tracheobronchitis
acute, dry hacking cough, often becoming productive of mucoid sputum - a febrile illness, often with malaise, headache, and possibly dyspnea
mycoplasma and viral pneumonias
acute, pneumococcal, cough with sputum mucoid or purulent that may be blood-streaked, diffusely pinkish, or rusty with chills, high fever, dyspnea, and chest pain, often preceded by acute upper respiratory infection
bacterial pneumonias
foul-smelling sputum
anaerobic lung abscess
tenacious sputum
cystic fibrosis
current jelly sputum
klebsiella
chronic cough with sputum mucoid or mucopurulent associated with chronic rhinitis, with out without sinusitis
postnasal drip
chronic cough with sputum mucoid to purulent that may be blood-streaked or even bloody often associated with long-standing cigarette smoking, recurrent superimposed infections, wheezing and dyspnea may develop
chronic bronchitis
chronic cough with sputum purulent, often copious and foul-smelling which may be blood-streaked or bloody associated with recurrent bronchopulmonary infections (common), sinusitis may coexist
bronchiectasis (dilitation of medium size bronchioles)
chronic cough dry or sputum that is mucoid or purulent that may be blood-streaked or bloody associated early with no symptoms and later with anorexia, weight loss, fatigue, and night sweats
pulmonary tuberculosis
chronic cough with sputum purulent and foul-smelling that may be bloody, a febrile illness often due to poor dental hygiene and a prior episode of impaired consciousness
lung abscess
chronic cough, especially at night or early in the morning, associated with wheezing, especially at night (often mistaken for asthma), early morning hoarseness, often with a history of heartburn and regurgitation
gastroesophageal reflux
chronic cough dry to productive with sputum that may be blood-streaked or bloody associated usually with a long history of cigarette smoking
cancer of the lung
chronic cough, often dry, especially on exertion or at night that may progress to the pink frothy sputum of pulmonary edema or to frank hemoptysis associated with dyspnea, orthopnea, paroxysmal nocturnal dyspnea
left ventricular failure or mitral stenosis
chronic cough, dry to productive with sputum that may be dark, bright red, or mixed with blood, associated with dyspnea, anxiety, chest pain, fever, and factors that predispose to deep venous thrombosis
pulmonary emboli
Health Promotion and Counseling
tobacco cessation, protective pulmonary filters (occupational), and immunizations (pneumovax - children and adults, Tdap - children and booster for adults ages 11-64, influenza, and Hib vaccine)
harmful effects of tobacco on Coronary Artery Disease
2-3x higher
harmful effects of tobacco on Strokes
2x higher
harmful effects of tobacco on Peripheral Vascular Disease
10x higher
harmful effects of tobacco with COPD Mortality
10x higher
harmful affects of tobacco on Lung Cancer Mortality in Men
23x higher
harmful effects of tobacco on Lunch Cancer Mortality in Women
13x higher
The "5 A's" to Assess Readiness to Quit Smoking
ASK about tobacco use
ADVISE to quit through clear, personalized messages
ASSESS willingness to quit
ASSIST to quit
ARRANGE follow-up and support
The "5th" Vital Sign
1- Blood Pressure
2- Pulse
3- Respirations
4- Temperature
5- PULSE OXIMETRY
What is the indirect measurement of O2 saturation?
pulse oximetry
Uses for Pulse Oximetry
especially good in COPD and sleep disorders with apnea and hypopnea, ICU and ER monitoring
What is more accurate than pulse oximetry?
arterial O2 level as determined by an arterial blood gas
position of patient when examining the posterior thorax and lungs
sitting (if patient can't sit, ask for assistance or have patient roll onto their side)
position of patient when examining the anterior thorax and lungs
supine
Inspection of Breathing
observe the rate, rhythm, depth, and effort of breathing (normal 14-20/min) - note whether the expiratory phase is prolonged, use of accessory muscles (SCM, scalenes, neck, abdomen), chest wall normal diameter 2:1 but AP diameter in COPD 1:1
normal thorax in the normal adult
wider than it is deep, its lateral diameter is larger than its anteroposterior diameter
depression in the lower portion of the sternum
funnel chest (pectus excavatum)
What may compression of the heart and great vessels, found in funnel chest, cause?
murmurs
AD congenital disorder considered a type of dwarfism which has similar physical findings as Turner's Syndrome with a male:female ratio of 1:1 and occurrence of 1:1000-2500 world wide with a genetic defect being mutations in the RAS-MAPK signaling pathway
Noonan's Syndrome
Features of Noonan's Syndrome
CHD, short stature, learning problems, pectus excavatum, impaired blood clotting, characteristic facies (webbed neck, hypertelorism, low set ears)
increased anteroposterior diameter of the chest, this shape is normal during infancy and often accompanies again and COPD
barrel chest
sternum is displaced anteriorly, increasing the anteroposterior diameter with costal cartilages adjacent to the protruding sternum depressed
pigeon chest (pectus carinatum)
multiple rib fractures may result in paradoxical movements of the thorax - as descent of the diaphragm decreases intrathoracic pressure, on inspiration injured area caves inward, on expiration moves outward (requires emergent chest tube insertion)
traumatic flail chest
abnormal spinal curvatures and vertebral rotation deform the chest - distortion of the underlying lungs may make interpretation of lung findings very difficult (truncal rotation is measured with a scoliometer)
thoracic kyphoscoliosis
a condition in which a plug in a mainstem bronchus (as from mucus or a foreign object) obstructs air flow, affected tissue collapses into an airless state and trachea may be shifted TOWARDS the involved side
ATELECTASIS
a condition in which fluid accumulates in the pleural space, separates air-filled lung from the chest wall, blocking the transmission of sound, and the trachea shifts toward the OPPOSITE side with large effusion
PLEURAL EFFUSION
a condition in which air leaks into the pleural space, usually unilaterally, the lung recoils from the chest wall, pleural air blocks transmission of sound, and the trachea shifts towards the OPPOSITE side when large
PNEUMOTHORAX
increased effort for sustained period with normal rate of breathing
hyperpnea
palpable vibrations transmitted through lungs when patient speaks
tactile fremitus
When does tactile fremitus decrease?
with obstructed bronchus, atelectasis, COPD, pleural effusion, pleural thickening
When does tactile fremitus increase?
in pneumonia
What happens during percussion when fluid or solid tissue replaces air-containing lung or occupies the pleural space?
dullness replaces resonance
What can only be detected anteriorly by percussion because pleural fluid usually sinks to the lowest part of the pleural space?
a very large effusion
percussion of a normal, healthy lung
resonance
percussion associated with lobar pneumonia, pleural effusion, hemothorax, emphysema
dullness or flat
percussion associated with COPD, asthma, pneumothorax, bullae
hyperresonance
What does an abnormally high level of the descent of the diaphragm suggest?
pleural effusion, high diaphragm (atelectasis, diaphragmatic paralysis)
What type of lung often displaces the upper border of the liver downward and also lowers the level of diaphragmatic dullness posteriorly?
a lung affected by COPD
assesses air flow through tracheobronchial tree
auscultation
normal auscultation of the lungs
vesicular, bronchovesicular, bronchial
an adventitious lung sound characterized by a series of tiny explosions when small airways, deflated during expiration, pop open during inspiration and air bubbles flowing through secretions or lightly closed airways during respiration found in chronic br
crackles
an adventitious lung sound characterized by air flowing rapidly through bronchi that are narrowed nearly to the point of closure that can be found with asthma, chronic bronchitis, COPD, and congestive heart failure (cardiac asthma), localized if foreign b
wheezes
an adventitious lung sound which suggests secretions in the larger air ways found in bronchitis
rhonchi
a harsh wheeze that is predominantly inspiratory indicating partial obstruction of the larynx or trachea and can be found in croup or epiglottitis which demands emergent attention
stridor
usually confined to small area of chest and heard in both inspiration and expiration - have patient hold their breath to differentiate from a pericardial rub
pleural rub
precordial crackles synonymous with heart beat heard in left lateral decubitus position (pneumomediastinum) aka mediastinal emphysema
mediastinal crunch (Hamman's Sign)
special voice test in which patient says EEEEE and it sounds like AAAAA (greek word for voice of the goat)
egophony
special voice test in which the patient says 99, increases with consolidation
bronchophony
special voice test in which the patient whispers 1, 2, 3 and increased transmission with consolidation
whispered pectoriloquy
How are all special voice tests performed?
while listening with stethoscope
a disorder affecting the lungs in which the heart cannot pump at a volume adequate to meet metabolic demands of the body
congestive heart failure
clinical symptoms of congestive heart failure
dyspnea, fatigue, weakness, peripheral edema, hepatic congestion, renal failure
a disorder affecting the lungs associated with increased resistance to air flow from spasm, excess mucuous, and airway collapse
obstructive lung disease
What are the 4 obstructive lung diseases?
chronic bronchitis, asthma, emphysema, COPD
a condition diagnosed by a chronic productive cough of more than 3 months duration for 2 or more consecutive years, characterized as an obstruction due to inflammation of major and smaller airways (edema, excess mucous, most common from chronic irritation
chronic bronchitis
a chronic inflammatory airway disease secondary to increased smooth muscle contraction, excess mucous production, and inflammation which causes airway narrowing and thickening of muscular lining of airway walls
asthma
What is asthma triggered by?
infection, cold, exercise, allergens, chemical irritants
a condition characterized by a loss of lung elasticity and supporting airway structures, abnormal enlargement of air spaces distal to the terminal bronchioles, and destruction of alveolar walls with a tobacco etiology in which stimulated inflammatory cell
emphysema
alpha 1 antitrypsin deficiency (genetic)
deficiency of alpha 1 antitrypsin (an anti-protease enzyme that protects the lung) leads to early emphysema
a combination of chronic bronchitis and emphysema characterized by enlargement of air spaces and destruction of lung tissue as seen in emphysema, obstruction of small airways with increase mucous as seen in chronic bronchitis, and destruction of alveolar
Chronic Obstructive Pulmonary Disease (COPD)
When destruction of alveolar tissue causes decreased surface area for gas exchange, what does this result in?
hypoxemia
When destruction of alveolar tissue causes loss of elastic fibers, what does this lead to?
impairment of expiratory flow rate which increases air trapping and predisposes to airway collapse
Physical Findings in COPD
Vitals: tachypnea, tachycardia, fever
HEENT: +/- cyanosis, JVD
Lungs: use accessory muscles, increased AP diameter 1:1 barrel chest, wheeze, rhonchi, rales/crackles, pursed lip breathing, tripoding
Percussion: hyperresonant
Breath Sounds: decreased to abs
inflammation of lung parenchyma which is the 6th leading cause of death in the US and the most common infectious cause of death
pneumonia
What normally happens to bacteria that enter the lung?
cleared by host defense mechanisms
What happens to bacteria that enter the lung in pneumonia?
pneumonia occurs with large innoculum of virulent organism or with impaired host defenses
mechanism of contraction of pneumonia
inhalation, aspiration, direct contiguous spread, hematogenous
When is aspiration more common?
with NG tubes and ET tubes
types of pneumonia
community vs nocosomial
clinical presentation of pneumonia
fever, cough (dry or productive), chills, dyspnea on exertion, easy fatigability, pleuritic chest pain
PE Findings with Pneumonia
Vitals: tachycardia, tachypnea, elevated temp
Percussion: dull over the area of percussion
Breath Sounds: bronchial sounds, rhonchi, rales
Tactile Fremitus and Voice Transmission: increased egophony, bronchophony, and whispered pectoriloquy
Chest XR: cons
an autosomal recessive mutation in the gene for protein cystic fibrosis transmembrane conductance regulator (CFTR) in which there is a loss of phenylalanine on the 508th position on the protein
cystic fibrosis
What does CFTR regulate?
an epithelial chloride channel expressed in a number of tissues including the lungs, testes, and pancreas
organs affected in cystic fibrosis
lungs, pancreas, testes
How is Cystic Fibrosis diagnosed?
newborn screening (trypsinogen), sweat test, gene test
What leads to recurrent lung infections in cystic fibrosis?
viscous mucous with staph aureus and pseudomonas aeruginosa the most common
What is characterized by localized, irreversible dilation of part of the bronchial tree in which the involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions which usually result
bronchiectasis
What is incomplete expansion of the lung or portion of the lung that can be due to obstruction from mucous plug (most common), foreign body, mass, loss of lung recoil with decreased pulmonary surfactant, compression from pleural effusion, or pneumothorax?
atelectasis
How is atelectasis treated?
often with medication, ambulation, and pulmonary PT - supplemental oxygen may be needed
PE Findings with Atelectasis
Percussion: dull over area of atelectasis
Breath Sounds: usually absent over area
Tactile Fremitus and Voice Transmission: usually absent
Adventitious Sound: usually none
Trachea: +/- shifter to involved side
What is characterized by fluid in the pleural space that may be transudate (low protein <2.0), exudate, or blood?
pleural effusion
pus in pleural cavity
empyema
lymph in pleural cavity
chylothorax
blunting costophrenic angle and fluid in major fissure
lateral CXR
Conditions Associated with Pleural Effusion
Congestive Heart Failure, Pneumonia and Rheumatoid Arthritis (increased capillary permeability), Liver and Kidney Disease (decreased colloid osmotic pressure), Atelectasis (increased negative intrapleural pressure), and Mediastinal Carcinoma (obstruction
PE Findings with Pleural Effusion
Trachea: may shift to opposite side
Percussion: dull
Breath Sounds: decreased to absent
Tactile Fremitus and Voice Transmission: decreased to absent
Adventitious Sounds: none
What is a blood clot that develops in a blood vessel elsewhere in the body (most commonly from the leg) which travels to the right side of the heart to the pulmonary artery to the lung and forms an occlusion (blockage) of the artery?
Pulmonary Embolism
What is a pulmonary embolism a complication of?
venous embolism
What do 70% of patients who have a pulmonary embolism have a history of?
deep vein thrombus (DVT)
Risk Factors for Pulmonary Embolism
Virchow's Triad:
Venous Stasis - immobilization, surgery, MI, CHF, long trips, plane rides
Venous Trauma - injury, surgery
Hypercoaguable State - cancer, pregnancy, oral contraceptives, estrogens (ERT), genetic disorders (deficiency antithrombin III, Fact
Risks for Venous Embolism
hereditary, smoking, varicose veins, trauma, cancer, pregnancy, surgery, airplane flight, medication (HRT), HTN, COPD, CVA, MI, obesity, age
PE Findings in Pulmonary Embolism
tachypnea, tachycardia
dyspnea, pleuritic chest pain
PE Finding in Massive Pulmonary Embolism
right sided heart failure
KEY FINDING of Pulmonary Embolism
DYSPNEA OUT OF PROPORTION OF LUNG EXAM!!
Patient feels like they are suffocating!!
What allows for lung expansion?
negative vacuum in chest
What happens if air enters the pleural space?
the lung will collapse - pneumothorax
Where can air enter the lung?
can enter from outside (trauma) or within (rupture emphysematous bleb)
partial vs incomplete pneumothorax
minor injuries: incomplete lung collapse
What is a pneumothorax caused by a ruptured emphysematous bleb that is more common in tall males ages 10-30?
spontaneous pneumothorax
What is a pneumothorax that results from trauma to the chest wall in which air enters chest during inspiration but cannot exit during expiration, trachea is pushed to opposite side, and hypotension from increased thoracic pressure prevents blood from retu
tension pneumothorax
air in the pleural space with subsequent lung collapse
pneumothorax
Treatment of Pneumothorax
may require immediate treatment with tube thoracostomy or insertion of chest tube - tube is attached to suction device which allows for re-expansion of lungs
Clinical Symptoms in Pneumothorax
usually acute onset with sharp/stabbing/pleuritic type chest pain and dyspnea (symptoms may be subtle or absent if pneumothorax is small [<15%]), tachycardia is common, and relieved somewhat when pt leans forward
PE Findings in Pneumothorax
Trachea: may shift to opposite side
Percussion: hyperresonant or tympanic over the pleural air
Breath Sounds: decreased to absent
Tactile Fremitus and Voice Transmission: decreased to absent
Adventitious Sounds: none
What is a localized or diffuse dilation of an artery with a diameter at least 50% greater than the normal size of the artery?
an aneurysm (dissecting thoracic aneurysm)
wall of aneurysm involves all 3 layers and aneurysm is contained inside the endothelium
true aneurysm
aneurysm involves only the outer layer and is contained by the adventitia
false aneurysm (pseudoaneurysm)
formed by an intimal tear and is contained by the media - MC site (abdomen - AAA), also thoracic and thoracoabdominal
aortic dissection
Thoracic Aneurysms - 3 Groups By Location
ascending aortic, aortic arch, descending thoracic
What type of aneurysm affects 15,000 people a year, with rupture causing <10% of people to make it to hospital alive and 20-30% survival if get to hospital?
dissecting thoracic aneurysm
What type of aneurysm results from an intimal tear causing separation of aortic walls in which blood dissects between the layers?
dissecting thoracic aneurysm
shape of a fusiform aneurysm (true aneurysm)
symmetrical dilatation
shape of a saccular aneurysm (pseudoaneurysm)
localized outpouching
most common cause of a dissecting thoracic aneurysm
ATHEROSCLEROSIS
risks for dissecting thoracic aneurysm
HTN, tobacco, high cholesterol, family history of an aneurysm
symptoms of dissecting thoracic aneurysm
ripping" chest pain
How is a dissecting thoracic aneurysm diagnosed?
CXR - widened mediastinum or loss of retrosternal air space on lateral view, echocardiography, ultrasonography, aortography, CT or CTA, MRA
Treatment of a Dissecting Thoracic Aneurysm
open surgical procedure with a stent graft
Normal Lung
Breath Sounds: vesicular
Percussion: resonant
Voice Tests: normal
Lobar Pneumonia
Breath Sounds: bronchial or bronchovesicular over the involved area
Percussion: dull
Voice Tests/Palpation: increased tactile fremitus, + egophony, bronchophony, and whispered pectoriloquoy
Normal Lungs
Percussion Note: resonant
Trachea: midline
Breath Sounds: vesicular, perhaps bronchovesicular and bronchial
Adventitious Sounds: none, +/- few transient inspiratory at lung bases
Tactile Fremitus and Voice Sounds: normal
Chronic Bronchitis
Percussion Note: resonant
Trachea: midline
Breath Sounds: vesicular (normal)
Adventitious Sounds: none; or scattered coarse crackles or rhonchi
Tactile Fremitus and Voice Sounds: normal
Left Heart Failure
Percussion Note: resonant
Trachea: midline
Breath Sounds: vesicular
Adventitious Sounds: late inspiratory crackles; possibly wheezes
Tactile Fremitus and Voice Sounds: normal
Atelectasis (Mucous Plug Collapses Lung Tissue)
Percussion Note: dull to flat
Trachea: may shift toward involved side
Breath Sounds: usually absent
Adventitious Sounds: none
Tactile Fremitus and Voice Sounds: usually absent
Pleural Effusion
Percussion Note: dull to flat
Trachea: shifted opposite
Breath Sounds: decreased to absent
Adventitious Sounds: none
Tactile Fremitus and Voice Sounds: decreased to absent
Pneumothorax
Percussion Note: hyperresonant
Trachea: shifted opposite
Breath Sounds: decreased to absent
Adventitious Sounds: none
Tactile Fremitus and Voice Sounds: decreased to absent
COPD
Percussion Note: hyperresonant
Trachea: midline
Breath Sounds: decreased to absent
Adventitious Sounds: none, crackles, wheeze, rhonchi
Tactile Fremitus and Voice Sounds: decreased
Asthma
Percussion Note: resonant to hyperresonant
Trachea: midline
Breath Sounds: often obscured by wheeze
Adventitious Sounds: wheezes; +/- crackles
Tactile Fremitus and Voice Sounds: decreased
Sample Write-Up
Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragms descend 4cm bilaterally.
Sample Write-Up 2
Thorax symmetric with moderate kyphosis and increased anteroposterior (AP) diameter, decreased expansion. Lungs are hyperresonant. Breath sounds distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, e