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The Pleurae:
Visceral pleura: covers the outer surface of the lung
Parietal pleura: lines the inner rib cage and the upper surface of the
diaphragm
Pleural fluid: lubricates the pleural surfaces allowing the lungs to move more
easily during inspiration and expiration.
Pleural Effusions: may be transudates, seen in atelectasis, heart failure,
and nephrotic syndrome, or exudates, seen in numerous conditions
including PNA, TB, PE, pancreatitis, and malignancy.
Breathing:
-controlled by respiratory centers in the brainstem to produce drive in the
respiratory muscles.
Principle muscle of inspiration: diaphragm
Scalenes and parasternal also contract to expand the thorax.
-During inspiration, as the thorax expands intrathoracic pressure decreases,
drawing air into the distal air sacs where O2 and CO2 are exchanged.
-During expiration, the chest wall and lungs recoil and the diaphragm relaxes
and rises passively
-Movements of the thorax in are more prominent in the sitting position rather
than lying down.
Exercise:
Accessory muscles used: sternomastoids, abdominal muscles, and
scalenes.
-"Have you had any difficulty breathing?" "When did this occur?"
"Exacerbating or factors?"
-try to determine the severity based on their daily activities: "How
many flights of stairs can you walk up?"
Anxiety driven:
-describe their SOB as not being able to get enough air (parasthesias)
or a smothering sensation
-also have a "pins and needles" sensation in extremities
-anxious patients may have episodic SOB with hyperventilation
during rest and exercise
Wheezes:
Occurs in partial airway obstruction from secretions and tissue
inflammation in asthma and foreign body.
Cough:
-reflex response to stimuli that irritate larynx, trachea, or lg bronchi.
-Cough can also be a sign of left sided heart failure
Durations:
<3 weeks: acute
3-8 weeks: subacute
>8 weeks: chronic
-Viral URIs are the most common cause of the acute cough.
Also consider acute bronchitis, PNA, left ventricular heart failure,
asthma, or FB.
-Subacute coughs: caused by bacterial sinusitis, postinfectious
cough, asthma
-Chronic: postnasal drip, asthma, GERD, chronic bronchitis,
bronchiectasis
Ask:
"Productive or nonproductive?" "Can you describe the sputum?"
-Mucoid sputum: translucent, white, or gray
-Purulent sputum: yellow or green
-Foul smelling: anareobic lung abscess, tenacious sputum in
CF
-Large volumes: bronchiectasis, lung abscess
-Other diagnostically helpful symptoms: fever, CP, SOB,
orthopnea, and wheezing
Hemoptysis:
-coughing up blood from the lung.
-make sure to assess where its coming from and associated symptoms
-Hemoptysis is rare in infants, children, and adolescents,
although common in cystic fibrosis.
-Blood originating in the stomach is usually darker than blood
from the respiratory tract and may be mixed with food particles.
Tobacco Cessation:
FACTS:
-21% of US adults still smoke
-80% start by 18 y/o
-Smoking accounts for 1/5 deaths each year
-1/2 of long term smokers die of smoking related disease
Techniques of exam:
-Inspection, palpation, percussion, auscultation
-For patients who cannot sit up, roll them from one side to another.
-Observe: rate, rhythm, depth, and effort of breathing
-assess color
-cyanosis signals hypoxia. Clubbing of the nails occurs in
bronchiectasis, congenital heart disease, pulmonary fibrosis,
cystic fibrosis, lung abscess, and malignancy
-listen to breathing
-Audible stridor, a high-pitched wheeze, is an ominous sign of
upper airway obstruction in the larynx or trachea.
-inspect the neck
-accessory muscle use in COPD signals difficulty breathing.
Lateral displacement of the trachea occurs in pneumothorax,
pleural effusion, or atelectasis.
-inspect shape
-AP diameter may increase in COPD
Palpation:
-tender areas:
Percussion:
The heart will produce an area of dullness to the left of the
sternum from the 3-5 intercostal spaces.
-The hyperresonance of COPD may totally replace cardiac
dullness.
-In females, unless you displace the right breast, you may miss a
right middle lobe PNA.
Recording Findings: