LUNG WORKUP SUPPLEMENT
Generally, the dictator tells by observation how the patient appears in general. On checking the lungs, you might hear, “an increase in AP diameter.” That means the chest muscles are working harder to get enough breath. Accessory muscles are sometimes used for overbreathing. You might hear, “barrel chest,” “pectus carinatum” (pigeon-shaped), “pectus excavatum” (funnel-shaped), or “kyphosis” or “kyphoscoliosis.”
The chest is palpated with the hands of the examiner. S/he may then mention diaphragmatic excursion, inspiratory effort, atelectasis (lung tissue collapse), percussion (tapping on the chest). Healthy lung tissue percusses with a hollow sound. Percussion of the liver has a more solid sound. Hyperresonance to percussion indicates a problem. Tympany or tymanitic sounds are sometimes heard. Auscultation is the final step of the exam. The examiner is listening for normal breath sounds (vesicular). Adventitious or adventitial sounds are not normal. Rhonchi (plural of rhonchus) are abnormal noises (sound like rubbing or grunting). Rales (French word, heard as riles or rolls) are crackling or scratching sounds. Wheezes are whiny sounds that occur with inspiration or expiration. Breath sounds are also described sometimes as diminished or distant.
Presume the examiner noted a respiratory problem. It might be an obstructive type, e.g., asthma (status asthmaticus), chronic obstructive pulmonary disease, bronchitis, emphysema, cystic fibrosis, bronchiolitis. So s/he decides the problem needs workup. One of the tests would be: Arterial blood gas (ABG). This is a test of blood taken from an artery rather than a vein. These are the parameters:
Arterial Blood Gases would appear under “Laboratory Data,” but could be discussed in the History of Present illness or the Hospital Course as well.
o pH, with a scale ranging from 0 to 14, with an average of 7 being normal. You might hear in reference to this test, the terms metabolic and/or respiratory acidosis or alkalosis.
o pO2, which is partial pressure of oxygen in the blood. If this is low, the patient is hypoxemic. A healthy reading is 99%.
o pCO2 is partial pressure of carbon dioxide in the blood. If the reading is high, the patient is hypercarbic.
o Bicarbonate content of blood
o O2 saturation: This reading is always expressed with a %. Patients on supplemental oxygen by nasal cannula, mask, etc., or mechanical ventilation may have pO2s of greater than 100%.
o Base excess: This is a negative number and is sometimes called a base deficit.
Other Labs might include:
A VQ (ventilation-perfusion) scan to assess pulmonary emboli. Words related to that are probabilities for emboli, mismatch, good and poor perfusion, anatomic dead space (inspired air not reaching the alveoli). Pulmonary scintigraphy might be done too. A radioactive agent such as gallium 67 or indium 111 is injected into the patient’s vein. X-rays are done in real time and the path of the radioactivity traced.
Pulmonary function studies (spirometry) may also be done. These have acronyms:
o RV/TLC ratio
o FEV1/FVC ratio (This test is done with the patient sitting, inhaling and exhaling as instructed. The test produces flow volume loop tracings and evaluates lung mechanics.
Bronchoscopy: A flexible fiberoptic scope is passed down the trachea and into the various bronchi; washings, biopsies and brushings may be done. Specimens are retrieved through a suction trap. The specimens are sent for cytology. Gram stains may also be done (AFB, acid-fast bacilli looking for mycobacterium tuberculosis, etc., and fungal life).
Sputum culture may be done or thoracentesis (tapping the lung for fluid removal using a needle). A thoracostomy could be ordered with placement of the tube, (18 or 20-French, 32-French), attached to a Pleur-evac hooked to suction. This device collects and measures the fluid being drained. Thoracotomy is a surgical opening in the chest. Pleurodesis involves instilling a chemical (talc, tetracycline, bleomycin) into the pleural cavity. The chemical causes irritation and inflammation of the visceral and parietal pleurae, causing scarring and adherence to each other to eliminate air pockets and bullae, which hopefully prevents lung collapse and/or pneumothorax.
Oxygen is often administered and is provided as liter by the minute (L/min) and is administered with nasal cannula, Venti mask, nonrebreather mask and various types of ventilators (Bear, Bennett, Bird, etc.). Oxygen may be given with intubation too.
The oxygen parameters are: FiO2 (fraction of inspired oxygen), rate (flow rate or ventilator breaths per minute, usually starting at about 12), tidal volume (amount of air forced into the lungs with each breath, average setting around 800 mL), CMV (continuous mandatory ventilation – when the patient cannot breathe alone), IMV (intermittent mandatory ventilation (patient breathing some on his or her own), SIMV (synchronized IMV), PEEP (positive end-expiratory pressure), CPAP (continuous positive airway pressure), BiPAP (bilevel positive airway pressure), and cuffed endotracheal tube (ET tube).
Chest x-ray. When doing x-rays, if the patient can stand up, a PA (posteroanterior) and lateral film(s) will be obtained. If unable to stand, the patient will have an AP (anteroposterior) film. The difference between the PA and AP is the patient’s position. The AP film (view) may not be as good as it tends to accentuate the heart size. Inspiratory effort is also usually poor in a sick patient, and the lung views are not as reliable. On occasion, lateral decubitus films may be requested with the patient lying on either side. If fluid is present in the lungs, it will “layer out” like water in a tilted glass. The oblique or angled views may be useful for analyzing artifacts and rib fractures.
Plain films may be over or underpenetrated, meaning the film exposure is not optimal with light or dark pictures.
X-ray anatomic words: Apical (top), fissure (major, minor, horizontal, oblique), pleura or pleural (visceral, parietal diaphragmatic, mediastinal), trachea, lobes (right upper, middle and lower, left upper and lower), lingula (small lobe), pulmonary vasculature (markings of blood supply), carina (the point where the trachea bifurcates and splits into the right and left main stem bronchi), hilum and perihilar (area near the carina), retrocardiac (behind the heart), alveoli (air sacs), costophrenic angle (you hear “blunting” meaning the area does not appear sharp due to fluid obscuring).
Findings on x-rays include: Lesions (coin, solitary or cavitating), nodules, atelectasis, plate-like or segmental collapse, air bronchograms (lucency areas in opacified lung), bronchiectasis (dilation of the bronchus), loculations, empyema (pus collection), ectasia and tortuosity of the aorta, granulomas (caseating or calcified), effusions, infiltrates (patchy), bulla (plural: bullae), bullous emphysema, pneumothorax, hemothorax, chylothorax, hyperinflation, interstitial edema, miliary tuberculosis, pleural thickening, hypoventilation, nipple shadows, parenchymal consolidation, parapneumonic effusion, adenopathy and bronchopleural fistula.
Related Pharmaceuticals: With breathing problems, medications include beta agonists and combinations like albuterol (Ventolin, Proventil), levabuterol (Xopenex), metaproterenol (Alupent), pirbuterol (Maxair), salmeterol (Serevent), and Combivent (ipratropium/albuterol). These may be administered via nebulizers or MDI (metered-dose inhalers). Inhaled steroids include AeroBid, Pulmicort Turbuhaler, Fovent, and Azmacort. Leukotriene inhibitors include Singulair and Accolate. Others include Mucomyst, Intal, and various theophylline preparations (Slo-Phyllin, Theo-Dur, Slo-bid, Theolate).
Please note the differences in capitalization with the above words relate to brand names and generics (brand names are capped). See the Pharmaceutical Section of the Training Sessions.
Physiotherapy: Physical measures may be used including chest physiotherapy, postural drainage, incentive spirometry, suctioning, and other methods to increase lung expansion and decrease atelectasis, helping the patient to cough and get rid of secretions.
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