Pulmonary Eval

Question 1

what is the purpose of Pulmonary Function Tests? (3)

Answer 1

1. tests of lung volumes and capacity
2. tests of gas flow rates
3. tests of diffusion

Question 2

list tests of lung volumes and capacity

Answer 2

1. tidal volume: normal breathing
2. inspiratory reserve volume: the amount of air a person can inhale forcefully after normal tidal volume inspiration
3. expiratory reserve volume: the amount of extra air — above a normal breath — exhaled during a forceful breath out.
4. vital capacity (4000-5000 ml): the total volume of air that can be displaced from the lungs by maximal expiratory effort
5. residual volume: what’s left in the lungs

Question 3

list tests of gas flow rates

Answer 3

1. FVC
2. FEV1
3. FEV1/FVC
4. Forced midexpiratory flow (FEF)
5. Maximum voluntary ventilation (MVV)

Question 4

describe MVV

Answer 4

maximum voluntary ventilation

“breath as deeply and as rapidly as possible for 10, 12, 15 seconds”

measures the max amount of air that can be inhaled and exhaled in a determined time

Question 5

list tests for diffusion

• what does it measure?
• what is it?

Answer 5

D_L or DL_CO

diffusing capacity of the lung or the amount of gas entering the pulmonary blood flow per unit time

measures the integrity of the functional unit of the lung

Question 6

what is included in the evaluation/physical examination of a pulmonary exam?

Answer 6

1. general appearance
2. use of supplemental oxygen
3. evaluation of neck
4. resting chest eval
5. breathing patterns
6. speech
7. lung sounds
8. cough/sputum
9. palpation
10. percussion

Question 7

general appearance examination during a physical exam

Answer 7

1. posture → kyphosis and scoliosis are 2 postures that functionally limit VC
2. positioning → can they tolerate supine?
3. skin color → cyanosis
4. presence of external monitoring and equipment
5. effort of breathing
6. clubbing → distal enlargement of fingers w/down slopping nails

Question 8

Physical exam: supplemental oxygen

Answer 8

1. check to ensure that it is being used properly
2. check the flow rate
3. breath in a manner that makes use of the supplemental O2
4. check facial signs of pulmonary distress including nasal flaring, sweating, paleness, and focused, or enlarged pupils
5. pursed-lip breathing → clinical sign of COPD

Question 9

Physical exam → evaluation of the neck

Answer 9

1. check of hypertrophy of SCM
2. chronic forward-bent posture → shortening of SCM
3. adaptive changes of the SCM may indicate chronic pulmonary condition
4. JVD
5. position of clavicle → often very prominent in pulmonary pathologies

Question 10

the resting chest is evaluated for what?

Answer 10

1. symmetry
2. rib angles
3. muscles

Question 11

describe chest symmetry

what is the normal ratio of the AP diameter to the transverse diameter? What would it be in a COPD patient?

Answer 11

normal AP diameter (measurement from xiphoid to the vertebrae) is ½ of the transverse diameter (lateral side to lateral side)

hyperinflated chest → ratio approaches 1

1: 2 in a normal patient
1: 1 in a barrel chested patient (COPD, etc.)

Question 12

a normal chest will have what shape?

Answer 12

jelly bean

with obstructive disorders and air trapping you see the AP direction grow resulting in a barrel chest

Question 13

chest eval → rib angles

Answer 13

1. rib angles should be observed for abnormalities that might suggest the presence of chronic disease
2. normally, rib angles measure less than 90⁰ and they attach to the vertebrae at approximately 45⁰ angles

Question 14

how does chronic hyperinflation impact rib angles?

what does this do to the diaphragm?

Answer 14

causes rib angles to increase placing an increased stretch on the diaphragm causing it to become flatter and less effective

Question 15

chest-evaluation → muscles

Answer 15

check for hypertrophy and/or adaptive shortening of the SCM → may indicate a chronic pulmonary condition

Question 16

list normal RR ranges across age groups

Answer 16

1. infants → 30-60 bpm
2. 3-6 years → 22-34 bpm
3. 6-12 years → 18-30 bpm
4. 12-18 years → 12-20 bpm

Question 17

list and describe different breathing patterns

• eupnea
• bradypnea
• tachypnea
• hyperpnea
• hyperventalation

Answer 17

1. Eupnea → normal rate, depth and regular rhythm
2. Bradypnea → slow rate, shallow or normal depth, regular rhythm
3. Tachypnea → fast rate, shallow depth
4. Hyperpnea → normal rate, increased depth, regular rhythm
5. Hyperventilation → fast rate, increased depth, regular rhythm
   
   1. results in decreased arterial CO2

Question 18

describe things to look for relating to pt speech

Answer 18

1. dyspnea of phonation → when speech is interrupted for a breath
2. ID how many words can be expressed before the next breath
3. one-word dyspnea would mean that speech is interrupted for a breath between every word
   
   1. great to write goals off of

Question 19

things to consider relating to lung sounds

Answer 19

1. produced from the turbulence of airflow in the airways
2. heard through a stethoscope
3. an increase in lung tissue density causes increased sound transmission
4. a decrease in lung tissue density, as in the empysematous lung, would cause decreased sound transmission
5. normal breath sounds → normal noises of breathing

Question 20

list and describe several different lung sounds

• adventitious
• wheezes
• rhonci
• crackles
• pleural rub

Answer 20

1. adventitious breath sounds → abnormal noises heard only with stethoscope
2. wheezes → continuous but high pitched
3. rhonchi → subtype of wheeze; low pitched like a snore; implies obstruction f larger airway
4. crackles → are discontinuous adventitious lung sounds that sound like brief bursts of popping bubbles
5. pleural rub → sounds like 2 pieces of leather or sandpaper rubbing together
   
   1. occurs with both inspiration and expiration

Question 21

what are you looking at with a cough during the physical exam?

Answer 21

1. strength
2. duration
3. effectiveness
   
   1. intrathoracic pressures of up to 300 mmHg and expiratory velocities approaching 500 mph
4. qualities of the cough-strength, depth and length

Question 22

describe mucous

Answer 22

a material from the lungs that is produced (brought up) by coughing

is sticky and this helps to trap dust particles, bacteria and other inhaled debris

Question 23

what to consider/look at with sputum during the physical exam

Answer 23

1. is there mucous?
2. amount
3. consistency
4. color → white, opaque, grey, orange, green, brown
   
   1. yellow, orange = bacterial infection
5. change over time
6. mucoid, purulent, mucopurulent, frothy, viscous
7. bloodstained?

Question 24

describe the 2 types of cough

what is one thing they are each associated with?

Answer 24

1. productive cough
   
   1. produces mucus or sputum
   2. generally should not be suppressed
   3. associated with lung infections
2. non-productive cough
   
   1. dry and does not produce sputum
   2. lung neoplasms

Question 25

assessing breathing during the physical exam

Answer 25

1. rate 2. use of diaphragm 3. effort 4. accessory muscle use 5. paradoxical breathing?

Question 26

describe paradoxical breathing

Answer 26

1. chest moves inward instead of outward during inhalation 2. can be caused by a strong contraction of the diaphragm with no support from the intercostals or abdominal muscles. Excessive and rapid abdominal rise and upper chest collapses. Inefficient but sufficient 3. weak diaphragm but strong accessory muscles 1. the abdomen is drawn inward during inspiration 2. chest rises and abdomen falls

Question 27

what could cause paradoxical breathing? (5)

Answer 27

1. presence of airway obstruction 2. mechanical disruption of the chest wall (trauma) 3. phrenic nerve injury 4. flail chest → broken ribs 5. diaphragmatic dysfunction

Question 28

what is included with palpation during the pulmonary physical exam?

Answer 28

1. assess muscle tone esp. accessory muscles in neck 2. tracheal position (mediastinum) 3. assess use of diaphragm 4. symmetry of costal expansion 5. presence of crepitus 6. assess for tactile fremitus

Question 29

describe how to assess tracheal position

Answer 29

place an index finger n the medial aspect of the suprasternal notch. Repeat on opposite side. An equal distance between the clavicle and the trachea should exist bilaterally

Question 30

list conditions that cause tracheal deviation

Answer 30

1. Atelectasis → complete or partial collapse of a lung or lobe of a lung. trachea moves toward the collapsed side 2. Pneumothorax → an abnormal collection of air or gas in the pleural space that causes an uncoupling of the lung from the chest wall. Air leaks into the space between one's lungs and chest wall and creates a restrictive lung situation. Traches deviates away

Question 31

list some repercussions of a pneumothorax (5)

Answer 31

1. tachypnea 2. asymmetric lung expansion 3. distant or absent breath sounds 4. decreased tactile fremitus 5. adventitious lung sounds → ipsilateral crackles, wheezes

Question 32

how would the presence of a tumor impact tracheal position?

Answer 32

ipsilateral pull towards the atelectasis

Question 33

describe how to assess tracheal position

Answer 33

place an index finger n the medial aspect of the suprasternal notch. Repeat on opposite side. An equal distance between the clavicle and the trachea should exist bilaterally

Question 34

describe chest expansion measurement

Answer 34

can be measured with tape meter around the chest at about the level of the nipples or 4th intercostal space in males, or just below the breasts in females on deep max inspiration and on max forced expiration. take the difference between these 2 measurements

Question 35

list norms for chest expansion measurements

Answer 35

1. in children → 2 cm 2. in a fit young man may expand 5 cm (ranges from 5-8 cm) 3. in severe emphysema → may expand less than 1 cm

Question 36

describe crepitus

Answer 36

hallmark sign is increasing edema chest \> scapula \> neck to face with rice crispy feeling and crackling when skin palpated (or like popping those plastic air bubbles)

Question 37

what causes crepitus?

Answer 37

1. due to presence of air in the subcutaneous tissue 2. air leaks out of the lungs follows fascial planes and enters the subcutaneous layer of the skin 3. called subcutaneous emphysema

Question 38

describe tactile fremitus

Answer 38

1. spoken words produce vibration over the chest wall 2. when the PT's hands are placed over the chest wall, the vibrations of a spoken word can be felt 3. the presence of absence of these vibrations of tactile fremitus provides info about the density of the underlying lungs and thoracic cavity 4. sound waves are transmitted with less decay in a solid medium (the consolidation) than in a gas medium (aerated lungs)

Question 39

when is tactile fremitus decreased?

Answer 39

decreased or absent over areas of pleural effusion or pneumothorax when there is air outside of the lung in the chest cavity, preventing lung expansion and creating more space in the lung and limiting or preventing sound transmission

Question 40

describe percussion technique ## Footnote *when will percussion sound dull versus resonant?*

Answer 40

makes use of the fact that striking a surface which covers an air-filled structure (normal lung) will produce a resonant note while repeating the same maneuver over a fluid or tissue filled cavity generates a relatively dull sound

Question 41

what would create a deadened tone during percussion? ## Footnote *list the two conditions associated with either of these circumstances.*

Answer 41

if the normal, air-filled tissue has been displaced by fluid (pleural effusion) or infiltrated with white cells and bacteria (pneumonia)

Question 42

what would create a hyper-resonant/drum-like sound during percussion?

Answer 42

air-trapping

Question 43

describe the process of performing percussion

Answer 43

1. try to focus on striking the distal inter-phalangeal joint of your L middle finger with the tip of the R middle finger 2. the last 2 phalanges of your L middle finger should rest firmly on the pt's back. Try to keep the remainder of your fingers from touching the pt, or rest only the tips on them 3. when percussing any one spot, 2-3 sharp taps should suffice

Question 44

with percussion, as you move down towards the base of the lungs \_\_\_\_\_\_\_\_

Answer 44

the quality of the sound changes

Question 45

list 3 different sounds that could be heard with auscultation

Answer 45

1. Egophony 2. Bronchophony 3. Whispered pectoriloquy

Question 46

describe egophony

Answer 46

increased resonance of voice sounds 1. say “Eeeeee” 1. healthy = Eeeee heard on auscultation 2. unhealthy = nasal “A” or “goat call” sound auscultated

Question 47

describe bronchophony

Answer 47

abnormal transmission from lungs or bronchi 1. say “99” repeatedly 1. healthy = not understandable 2. unhealthy/consolidation = “99” understood

Question 48

describe whispered pectoriloquy

Answer 48

increased loudness heard upon whispering 1. whisper "1, 2, 3' 1. healthy = not understood 2. unhealthy = understood “1, 2, 3” or a clear separation in sound