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AnnneMarie Palatnik MSN, APN, ACNS-BC AVP Clinical Learning and Academic Affiliations

Center for Learning Virtua Health

Skill Assessment: Pulmonary

Disclosures

I have no conflict of interest related to this presentation to disclose.

Objectives

Discuss pulmonary anatomy and physiology as it relates to physical assessment.

Identify normal and abnormal breath sounds.

Evaluate case presentations of patients with respiratory compromise.

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Overview

Respiratory Anatomy & physiology

Assessment

Acute respiratory distress syndrome

Pulmonary embolism

PULMONARY ANATOMY & PHYSIOLOGY

The Respiratory Tract

Upper respiratory tract Nostrils & nasal passages Sinuses & nasopharynx Oropharynx & laryngopharynx Larynx

Lower respiratory tract Conducting airways Acinus

Lungs Pleura & pleural cavities

Thoracic cavity Mediastinum Thoracic cage Anterior thoracic cage

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Pulmonary Anatomy

Pulmonary Circulation

Pulmonary artery

Arterioles

Venules

Pulmonary vein

Respirations External respirations

• Ventilation

• Pulmonary perfusion

• Diffusion

Internal respirations

RESPIRATORY ASSESSMENT

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Health History

Chief Complaint Dyspnea Orthopnea Cough Sputum Wheezing Chest pain Other signs & symptoms

History Patient & Family history\

• Operations • Respiratory diseases: pneumonia, tuberculosis

Smoking Allergies Environmental exposure to irritants

• Asbestosis • Mining, construction, or chemical manufacturers

Performing a Respiratory Physical Assessment

Inspection

Auscultation

Palpation

Percussion

Inspection

Inspecting the chest Back then front

Symmetry

Costal angle

Respiratory rate & pattern

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Inspection continued

Inspecting related structures Skin color & nailbeds

Mucous membranes

Clubbed fingers

Palpation the Chest

Crepitus

Pain

Tactile fremitus

Measure the symmetry

Patient position

Sitting upright or lying with HOB 45 to 60⁰

Unaware of “the counting”

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Inspection

RR for 1 minute

Note the depth

Shallow, normal, or deep

Pattern

Regularity and work

Normal – effortless and quiet

Abnormal – labored – accessory muscles, dyspnea, pursed lip breathing, nasal flaring

Characteristics

Slow, fast, shallow – inadequate ventilation or poor gas exchange

Cheyne-Stokes: irregular breathing pattern followed by short period of apnea

Kussmaul’s or air hunger: deep, rapid respirations (seen with DKA)

AP diameter

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Abnormal findings

Kyphosis Scoliosis

Tripod position Use of accessory muscles/retractions (a, b)

Skin – check for cyanosis

Central cyanosis – oral mucosa

Peripheral cyanosis – nail beds

Both may be result of hypoxemia, but peripheral may just be peripheral vasoconstriction

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Clubbing - thickening of finger/toe nails resulting in bulbous ends of fingers and toes

Commonly associated with chronic cardiac disease and respiratory disease

Mucous

Green, yellow, creamy sputum that is purulent – infection

White frothy or pink – pulmonary edema

Blood (frank blood hemoptysis) – could indicate carcinoma, pulmonary embolism, or trauma

Black specks – cigarette smoker or possible smoke inhalation

Palpation

Crepitus Crepitus

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Percussing the Chest

Percussion Sequence

Auscultation

Patient position Lying, sitting, standing

Remove clothing

Have patient breath through mouth

Stethoscope Diaphragm: press firmly against skin

Listen for a full inspiration & expiration

Classify breath sounds Intensity

Location

Pitch

Duration

Characteristics

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Auscultate

Normal – quiet and no noise

Use systematic approach

Ask patient to take deep breath through mouth

Listen for one complete respiratory cycle

Compare side to side from apex distally to the base of lungs

Abnormal Breath Sounds

Absent

Diminished

Crackles Fine

Coarse

Wheezes

Low-pitched wheezes (AKA Sibilant Rhonchi)

Stridor

Pleural friction rub

Auscultation Sequence

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Qualities of Normal Breath Sounds

Breath Sound Quality Inspiration-

expiration ratio

Location

Tracheal Harsh, high-

pitched

I < E Over trachea

Bronchial Loud, high-pitched I > E Next to trachea

Bronchovesicular Medium in

loudness and pitch

I = E Next to sternum,

between scapulae

Vesicular Soft, low-pitched I > E Remainder of

lungs

Location of Normal Breath Sounds

Trachial (anterior)

Bronchovesicular (anterior)

Trachial (posterior)

Normal breath sounds midlung (posterior)

Anterior Posterior

Abnormal Respiratory Patterns

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Respiratory Diagnostic Procedures Blood studies

WBC ABG

Sputum and pleural fluid Sputum culture Nasopharyngeal culture Throat culture

Endoscopy & imaging Bronchoscopy Chest X-ray Fluoroscopy Pulmonary angiography CT scan Thoracoscopy Ventilation-perfusion scan

Biopsies Lung biopsy Pleural biopsy

Pulmonary function tests Pulse oximetry Thoracentesis

Pulse Oximetry

The ratio of oxygen to hemoglobin Normal range 95% to 100% Treat the patient not the number Interfering factors

Elevated bilirubin Lipid emulsions Excessive light Severe peripheral vascular disease Hypothermia Hypotension Vasoconstriction Anemic conditions Vasopressors Nail polish or false finger nails

Arterial Blood Gases

pH Shows the bloods acidity or alkalinity

Normal 7.35-7.45

Partial pressure of carbon dioxide (PaCO2) Respiratory parameter

Reflects lung ventilation and CO2 elimination

Normal 35-45

Partial pressure of arterial oxygen (PaO2) Reflects body’s ability to pick up oxygen from lungs

Normal varies

Bicarbonate (HCO3-) Metabolic parameter

Reflects the kidneys ability to retain and excrete HCO3

Normal 22-26

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Rapid Interpretation of ABGs

Look at pH to obtain first and last name Look at CO2 and HCO3 to determine who gave the last name

First Name Middle Name Last Name Uncompensated Respiratory Acidosis Compensated Metabolic Alkalosis

Normal Values

pH Uncompensated Acidosis ← 7.35-7.45 → Uncompensated Alkalosis Compensated

CO2 Respiratory Alkalosis ← Respiratory Acid → Respiratory Acidosis 35-45 HCO3 Metabolic Acidosis ← Metabolic Base → Metabolic Alkalosis 23-27

Respiratory Acidosis: Accessive CO2 Retention

pH<7.35, PaCO2>45

Causes

Any condition that interferes with O2 & CO2 exchange

COPD, pneumonia, asthma, pulm edema, apnea, hypoventilation

Signs & Symptoms

Rapid deep breathing, light headed, anxiety, fear

Treatment

Tx cause, O2, BiPap, Mechanical Ventilation

Respiratory Alkalosis: Excessive CO2 Excretion

pH>7.45, PaCO2 <35

Causes Any condition that causes hypoventilation

Anxiety, pain, fear

Signs & Symptoms Diaphoresis, HA, tachycardia

Treatment Ask patient to take slow deep breaths

Breath into paper bag: rebreath CO2

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Metabolic Acidosis: HCO2 Loss, Acid Retention

pH<7.35, HCO3<22 Causes

Any condition that interferes with the kidneys ability to produce bicarb

Kidney failure, ASA overdose, diarrhea, shock, DKA

Signs & Symptoms Rapid breathing, fruity breath, fatigue, HA, coma, abd

pain

Treatment Treat underlying cause, give bicard

Metabolic Alkalosis: HCO3 Retention, Acid Loss pH>7.45, HCO3>36 Causes

Any condition that causes loss of acid form the GI tract, loss of K+ from increased renal excretion

Uncontrolled vomiting, excessive NG suctioning

Signs & Symptoms Slow shallow breathing, confusion, irritability, seizure,

coma

Treatment Treat underlying cause

CASE STUDIES

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PATIENTS IN RESPIRATORY DISTRESS

Acute Respiratory Distress Syndrome (ARDS)

A type of pulmonary edema not related to heart failure

Hallmark features of ARDs Bilateral patchy infiltrates on chest X-ray

No signs or symptoms of heart failure

No improvement in PaO2 despite increasing oxygen delivery

Causes Sepsis Trauma Shock

DIC Pancreatitis Massive blood transfusion

Burns Drug overdose Pneumonia

Progression of ARDs

Stage 1: Injury reduces normal blood flow to the lungs. Platelets aggregate and release histamine (H), serotonin (S), and bradykinin (B).

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Progression of ARDs

Stage 2: The released substances inflame and damage the alveolar capillary membrane, increasing capillary permeability. Fluids then shift into the interstitial space.

Progression of ARDs

Stage 3: Capillary permeability increases and proteins and fluids leak out, increasing interstitial osmotic pressure and causing pulmonary edema.

Progression of ARDs

Stage 4: Decreased blood flow and fluids in the alveoli damage surfactant and impair the cells’ ability to produce more. The alveoli then collapse, thus impairing gas exchange.

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Progression of ARDs

Stage 5: Oxygenation is impaired but carbon dioxide (CO2) easily crosses the alveolar capillary membrane, and is expired. Blood oxygen (O2) and CO2 levels are low.

Progression of ARDs

Stage 6: Pulmonary edema worsens and inflammation leads to fibrosis. Gas exchange is further impeded.

Stages of ARDS Stage I

Develops hours to days after initial injury Response to decreasing oxygen levels in blood Dyspnea, especially on exertion Respiratory and heart rates normal to high

Stage II Symptoms sometimes incorrectly attributed to trauma Marked increase respiratory distress Respiratory rate high with use of accessory muscles Restless, apprehensive, agitated Dry cough or frothy sputum Skin cool and clammy Bibasilar crackles

Stage III Obvious respiratory distress, tachypnea, accessory muscles, decrease mental acuity Tachycardia with PVCs, labile blood pressure Skin pale and cyanotic Diminished breath sounds, bibasilar crackles, rhonchi This stage generally requires intubation and mechanical ventilation

Stage IV Decreasing respiratory and heart rates Mental status nears loss of consciousness Skin cool and cyanotic Breath sounds diminished to absent

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Treatment of ARDS

A- antibiotics

R- respiratory support

D- diuretics

S- situate (place in prone position)

Pulmonary Embolism

An obstruction of the pulmonary arterial bed

Usually results from dislodged thrombi that originate in leg vein

If the embolus occludes the pulmonary artery, alveoli collapse and atelectasis develops

If embolus enlarges in can lead to death

Sites of Pulmonary Emboli

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At Risk for Pulmonary Embolism

What to Look For

Dyspnea, may be accompanied by anginal or pleuritic chest pain

Tachycardia

Productive cough (sputum may be blood tinged)

Splinting of chest

Cyanosis

Signs of hypoxia

Audible S3

Crackles and a pleural friction rub

Diagnostic Tests

Chest X-Ray R/O other pulmonary diseases Areas of atelectasis, diaphragm elevation, and pleural effusion

Lung scans Perfusion defects beyond occluded vessel

Pulmonary angiography The most definitive test

ECG Right axis deviation, RBBB Tall, peaked P waves, depressed ST, and inverted T Supraventricular tachycardias

ABGs Decrease PaO2 and PaCo2

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Treatment of Pulmonary Embolism

Prevent recurrence

Oxygen therapy

Anticoagulation

Fibrinolytics

Surgery

PATIENTS WITH CHEST TUBES

Assessment of a chest tube – “STOP”

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Chest tubes

Find out size (in French)

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“S” - Site

Check for subcutaneous emphysema (subcutaneous air, crepitus, tissue emphysema) under the skin around the chest tube, edematous area – can spread up

Lung sounds bilaterally

Dressing should be occlusive (good seal) and free of drainage

Bedside availability of additional Vaseline gauze pad

“T” - Tubing

Connections should be taped

No dependent loops

Should be secured to chest to prevent any

Avoid traction or pulling directly on insertion site

Should not be clamped

Drainage system should be below the chest

“O” - Output

Monitor drainage

Note the highest point of fluid level with the date and time with permanent marker at the end of each shift

If drainage is greater than 100mL/hour (or parameters as ordered), notify physician

Check for bubbling in water seal chamber after ensuring all connections (may indicate air leak)

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“P” - Patient

Drainage in tube and water seal chamber should fluctuate as patient inhales and exhales. This is also known as "tidaling"

Water level in water seal and suction chambers should be at correct level. Need to refill if evaporates.

JEOPARDY

QUESTIONS