Lung Examination: Abnormal

Lung Examination: Abnormal
By:Arcot J. Chandrasekhar, M.D.

Illustrative Pathological problems
* Consolidation
* Atelectasis
* Pleural effusion
* Pneumothorax
* Mass
* Diffuse lung disease

Steps
* General Examination
* Mediastinal position
* Chest expansion
* Lung resonance
* Breath sounds
* Adventitious sounds
* Voice transmission
* Respiratory rate
* Pattern of breathing
* Cyanosis
* Clubbing
* Weight
* Cough
* Hospital setting
* Effort of ventilation
* Shape of thorax

Respiratory Rate
* Bradypnea: rate less than 8 per minute
* Tachypnea: rate greater than 25 per minute

Pattern of Breathing
* Kussmals
* Sleep apnea
* Cheyne strokes
* Pursed lip breathing
* Orthopnoea: Short of breath in supine position, gets some relief by sitting or standing up.

Sleep apnea syndrome
Central Cyanosis
Corpulmonale
Clubbing
Significance: Clubbing Observed In:
* Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)
* Suppurative lung disease: (lung abscess, bronchiectasis, empyema)
* Diffuse interstitial fibrosis: Alveolar capillary block syndrome
* In association with other systemic disorders
Effort of Ventilation
* Person appears uncomfortable. Breathing seems voluntary.
* Accessory muscles are in use, expiratory muscles are active and expiration is not passive any more.
* The degree of negative pleural pressure is high.
* The respiratory rate is increased.

Resting Size and Shape of Thorax
* Barrel chest
* Kyphosis
* Scoliosis
* Pectus excavatum
* Gibbus
Barrel Chest
AP Diameter = Transverse Diameter
Tracheal Position: Mediastinum
Chest Expansion
Percussion: Decreased or Increased Resonance is Abnormal
* Dullness
* Hyper resonance
* Traube's space

Breath Sounds: Diminished or Absent
* Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.
* Breath sounds are markedly decreased in emphysema.
* Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal.
* Any form of pleural or pulmonary disease can give rise to decreased intensity.
* Harsh or increased: If the intensity increases there is more ventilation and vice versa.
* Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular space is abnormal.
* In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing.
* In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle.

Bronchial breathing
Rhonchi
Pleural Rub
Crackles
Voice Transmission (tactile fremitus, vocal resonance)
* Asymmetrical voice transmission points to disease on one side.
* Increased:
* Decreased
* Qualitative alteration:
Voice Transmission
Bronchophony
Whispering Pectoroliquy
Normal whisper
Egophony

Lung Examination: Abnormal.ppt

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Thoracic Trauma

Thoracic Trauma

Dave Lloyd, MD
Introduction to Thoracic Injury
* Vital Structures
* 25% of MVC deaths are due to thoracic trauma
* Abdominal injuries are common with chest trauma.
* Prevention Focus

Anatomy and Physiology of the Thorax
* Thoracic Skeleton
* Diaphragm
* Associated Musculature
* Physiology of Respiration
* Trachea, Bronchi & Lungs
* Mediastinum
* Heart
* Contraction Cycle
* Great Vessels
* Esophagus
* Blunt Trauma
* Penetrating Trauma
Pathophysiology of Thoracic Trauma
Injuries Associated with Penetrating Thoracic Trauma
* Closed pneumothorax
* Open pneumothorax (including sucking chest wound)
* Tension pneumothorax
* Pneumomediastinum
* Hemothorax
* Hemopneumothorax
* Laceration of vascular structures
* Tracheobronchial tree lacerations
* Esophageal lacerations
* Penetrating cardiac injuries
* Pericardial tamponade
* Spinal cord injuries
* Diaphragm trauma
* Intra-abdominal penetration with associated organ injury

Pathophysiology of Thoracic Trauma Chest Wall Injuries
* Contusion
* Rib Fractures
* Sternal Fracture & Dislocation
* Flail Chest
* Simple Pneumothorax
* Open Pneumothorax
* Tension Pneumothorax
* Dyspnea
* Progressive ventilation/perfusion mismatch
* Hypoxemia
* Hyperinflation of injured side of chest
* Hyperresonance of injured side of chest
* Diminished then absent breath sounds on injured side
* Cyanosis
* Diaphoresis
* AMS
* JVD
* Hypotension
* Hypovolemia
* Tracheal Shifting
* Hemothorax
* Blunt or penetrating chest trauma
* Shock
* Dull to percussion over injured side
* Pulmonary Contusion
* Myocardial Contusion
* Bruising of chest wall
* Tachycardia and/or irregular rhythm
* Retrosternal pain similar to MI
* Associated injuries
* Chest pain unrelieved by oxygen
* Pericardial Tamponade
* Dyspnea
* Possible cyanosis
* Beck’s Triad
* Weak, thready pulse
* Shock
* Kussmaul’s sign
* Pulsus Paradoxus
* Electrical Alterans
* PEA
* Myocardial Aneurysm or Rupture
* Traumatic Aneurysm or Aortic Rupture
* Other Vascular Injuries
* Traumatic Esophageal Rupture
* Tracheobronchial Injury
* Traumatic Asphyxia
* Scene Size-up
* Initial Assessment
* Rapid Trauma Assessment
* Ongoing Assessment
* Ensure ABC’s
* Anticipate Myocardial Compromise
* Shock Management
* Rib Fractures
* Sternoclavicular Dislocation
* Flail Chest
* Open Pneumothorax
* Tension Pneumothorax
* Hemothorax
* Myocardial Contusion
* Pericardial Tamponade
* Aortic Aneurysm
* Tracheobronchial Injury
* Traumatic Asphyxia

Thoracic Trauma.ppt

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Artificial Airways

Artificial Airways

Definition
* A tube or tube-like device that is inserted through the nose, mouth, or into the trachea to provide an opening for ventilation

Types of Artificial Airways
* Oropharyngeal airways
* Nasopharyngeal tubes
* Orotracheal tubes
* Nasotracheal tubes
* Tracheostomy tubes
* Esophageal obturator airway
* Cricothyroid tubes

Indications for Artificial Airways
* Relief of airway obstruction -guarantees the patency of upper airway regardless of soft tissue obstruction.
* Protecting or maintaining an airway N. have 4 main airway protect. reflexes 1. Pharyngeal reflex - 9th & 10th cranial nerves gag and swallowing
* Reflexes (cont’d) 2.Laryngeal -vagovagal reflex - will cause laryngospasm 3.Tracheal -vagovagal reflex - cough when a foreign body or irritation in trachea 4.Carinal -cough with irritation of carina
* Facilitation of tracheobronchial clearance
- mobilization of secretions from the trachea requires either an adequate cough or direct suctioning of the trachea
* Facilitation of artificial ventilation
- ventilation with a mask should on be used for short periods d/t gastric insufflation

Hazards of Artificial Airways
* Infection d/t bypassing the normal defense mechanisms that prevent bacterial contamination
* Ineffective cough maneuver
* Impaired verbal communication
* Loss of personal dignity

Oropharyngeal Airway
* Device designed for insertion along the tongue until the teeth &/or gingiva limit the insertion
* Lies between the posterior pharynx and the tongue and pushes the tongue forward
* Will activate the gag reflex, should use on unconscious patient
* Correct sizing of airway is imperative

Hazards of Oropharyngeal Airway
* If too small, may not displace tongue or may cause tongue to obstruct airway or may aspirated
* It too large, may cause epiglottis impaction
* Roof of mouth may be lacerated upon insertion
* Aspiration from intact gag reflex

Nasopharyngeal Airway
* Located so that it can provide a clear path for gas flow into the pharynx
* Is a soft rubber catheter
* Can be tolerated by the conscious patient
* Useful for patient with a soft tissue obstruction who have jaw injury or spasm of jaw muscles
* Proper sizing and insertion

Orotracheal Airway
* Used in conditions of, or leading to respiratory failure
* Usually the method of choice in emergencies that do not involve trauma to the mouth or mandible
* Oral route in usually easiest
* Accomplished by using a laryngoscope to directly visualize the trachea

Nasotracheal Airway
* More difficult route than oral
* Requires a longer and more flexible tracheal tube
* Insert through nose by touch and when in oropharynx use larynoscope and forceps (can perform “blind”)
* Usually N. T. tube is better tolerated by patient than oral

Tracheostomy Tube
* Tracheostomy is performed through the anterior tracheal wall either by the open method or percutaneous method
* Performed usually to prevent or treat long-term respiratory failure
* Decreases anatomic deadspace by 50%

Complications and Hazards of Tracheostomies
* Postsurgical bleeding
* Infection
* Mediastinal emphysema
* Pneumothorax
* Subcutaneous emphysema
* Stoma collapse (should not be moved or changed first 36 hours)

Esophageal Obturator Airway (EOA)
* Place in the esophagus to prevent stomach contents from entering the lungs while the patient is being artificially ventilated
* Cuff must be passed beyond carina before inflated
* Inflated cuff with 35 cc air
* Mask must fit tightly to ensure ventilation

Pharyngealtracheal Lumen Airway (PTL)
* Double-lumen airway combining an EOA and an endotracheal tube
* Designed to be inserted blindly
* Has an oropharyngeal cuff and a cuff that can seal off either the trachea or the esophagus

Other Specialized ET Tubes
* Rae Tube, directs the airway connection away from the surgical field
* Endotrol Tube, controls the distal tip for intubation
* Hi-Lo Jet Tube, for high freq. jet ventilation
* Laser Flex Tube, reflects a diffused beam if comes in contact with tube
* Endobronchial Tubes

Artificial Airways.ppt

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