Patient Assessment and Care Management

Published on 12/06/2015 by admin

Filed under Pulmolory and Respiratory

Last modified 22/04/2025

Print this page

rate 1 star rate 2 star rate 3 star rate 4 star rate 5 star
Your rating: none, Average: 0 (0 votes)

This article have been viewed 3294 times

1 Patient Assessment and Care Management

Note 1: This book is written to cover every item listed as testable on the Entry Level Examination (ELE), Written Registry Examination (WRE), and Clinical Simulation Examination (CSE).

The listed code for each item is taken from the National Board for Respiratory Care’s (NBRC) Summary Content Outline for CRT (Certified Respiratory Therapist) and Written RRT (Registered Respiratory Therapist) Examinations (http://evolve.elsevier.com/Sills/resptherapist/). For example, if an item is testable on both the ELE and WRE, it is shown simply as (Code: …). If an item is testable only on the ELE, it is shown as (ELE code: …). If an item is testable only on the WRE, it is shown as (WRE code: …).

Following each item’s code, the difficulty level is indicated for the questions on that item on the ELE and WRE. (See the Introduction for a full explanation of the three question difficulty levels.) Recall [R] level questions typically expect the exam taker to recall factual information. Application [Ap] level questions are harder, because the exam taker may have to apply factual information to a clinical situation. Analysis [An] level questions are the most challenging because the exam taker may have to use critical thinking to evaluate patient data to make a clinical decision.

Note 2: A review of the most recent Entry Level Examinations (ELE) has shown that an average of 9 questions out of 140 (7% of the exam) cover patient assessment and care management. A review of the most recent Written Registry Examinations (WRE) has shown that an average of 15 questions out of 100 (15% of the exam) cover patient assessment and care management. Of these 15 questions, an average of 11 cover patient assessment and an average of 4 cover care management. Typically, 9 of the patient assessment questions deal with adult patients. The remaining two patient assessment questions deal with neonatal or pediatric patients. The Clinical Simulation Examination is comprehensive.

Note 3: The Entry Level Examination has shown an average of 2 questions that directly cover a cardiopulmonary pathology issue; the Written Registry Examination has shown an average of 1 question. It is beyond the scope of this book to cover all the cardiopulmonary diseases and conditions that befall patients for whom respiratory therapists may provide care. It is recommended that asthma, chronic obstructive pulmonary disease (COPD; emphysema or chronic bronchitis or both), pneumonia, pneumothorax, flail chest, congestive heart failure with pulmonary edema, myasthenia gravis, Guillain-Barré syndrome, head (brain) injury with increased intracranial pressure, pediatric croup and epiglottitis, infant respiratory distress syndrome, acute respiratory distress syndrome (ARDS), and smoke inhalation with carbon monoxide poisoning be studied. Some limited discussion of these topics is covered in this book. The Written Registry Examination frequently ask questions about the respiratory therapy procedures that patients with these types of problems are receiving. In addition, the 11 Clinical Simulation Examination scenarios are built around the care of patients with these types of diseases and conditions. See Box 1 in the Introduction.

PART 1. PATIENT ASSESSMENT

MODULE A

Review the patient’s chart for the following data and recommend the following diagnostic procedures based on current information

Note: The following discussion involves noninvasive, bedside activities that apply to adults in most respiratory care settings. Some assessment items have been placed in later chapters, because they are procedure specific. Topics that relate to neonates and children are included in Module H.

1. Review the patient’s history: present illness, admission notes, progress notes, diagnoses, respiratory care orders, medication history, do not resuscitate (DNR) status, and previous patient education (Code: IA1) [Difficulty: ELE is R; WRE: Ap]

a. Patient history

Review the complete initial patient history and note the following:

1. Date of history taking
2. Patient data: name, age, gender, race, and occupation
3. Primary complaints
4. Secondary complaints
5. Present illness history and symptoms
6. Family history
7. Medical history of cardiopulmonary disease(s), including smoking history, cough, sputum production, and activities of daily living
8. Review of body systems

It is important that the respiratory therapist obtain a brief history before beginning therapeutic procedures. Determine how the patient has been doing since the last treatment. Has there been a change in dyspnea, cough and secretions, chest pain, and so on? This will help guide therapy as effectively as possible.

b. Admission notes

The attending physician writes up his or her key findings and how they are related to the reason the patient was admitted to the hospital.

c. Progress notes

Review the physician’s, nurse’s, and respiratory therapist’s patient progress notes before seeing the patient and beginning the therapeutic procedure. Look for any cardiopulmonary or other organ-system changes that will have an impact on the patient’s ability to take the treatment. You may need to revise the therapy, get different equipment, or seek help. Check for new patient care orders if the physician notes a change in the patient’s care plan.

d. Diagnoses

After the medical history, physical exam, and laboratory tests are completed, the patient will be placed into one of the following four diagnostic categories. Refer to Table 1-1 for examples of each category:

• Crisis/acute onset of illness
• Intermittent but repeated illness
• Progressive worsening
• Mixed patterns/multiple problems

TABLE 1-1 Patient Illness Categories

Category Examples
Crisis/acute onset of illness Trauma, heart attack, allergic reaction, aspiration of a foreign body, pneumothorax, pulmonary embolism, and some pneumonias
Intermittent but repeated Illness Asthma, chronic bronchitis, congestive heart failure, angina pectoris, myasthenia gravis, and some pneumonias
Progressive worsening Congestive heart failure, chronic bronchitis, emphysema, and upper respiratory tract infection leading to bronchitis or pneumonia
Mixed patterns/multiple problems Chronic obstructive pulmonary disease and cystic fibrosis complicated by multiple problems, mucous plugging or infection; mixes of congestive heart failure and chronic lung disease; mixes of neuromuscular and lung disease; mixes of renal failure and congestive heart failure with chronic lung disease

e. Current respiratory care orders

Physician orders must have the patient’s name, date, time, complete and proper orders for each therapeutic procedure, and the physician’s signature. Verbal orders from the physician to the nurse or respiratory therapist must follow hospital guidelines and include the preceding information. Incomplete, improper, or questionable orders must be confirmed by calling the physician for clarification or correction.

f. Medication history

Note the respiratory medications that the patient is currently taking. In addition, note any medications used to help manage cardiovascular, renal, or neurological problems that may also affect the patient’s respiratory status.

g. Do not resuscitate (DNR) status

The physician, patient, and family should determine the patient’s cardiopulmonary resuscitation status. A patient with a terminal condition, such as end-stage chronic obstructive pulmonary disease (COPD), often will choose not to be resuscitated. If it has been determined that the patient does not want to be resuscitated, his or her DNR status should be clearly posted in the chart and in the patient’s room. All members of the health care team should be aware of the patient’s decision.

h. Previous patient education

If the patient has asthma or COPD and has been admitted before, check for any record of a respiratory therapist teaching the patient about the disease and how it can be better managed.

2. Review the results of the patient’s physical examination and vital signs (Code: IA2) [Difficulty: ELE: R; WRE: Ap]

Review the results of the physical examinations performed by physicians, nurses, and respiratory therapists. Review the following organ systems:

• Pulmonary
• Cardiovascular
• Neuromuscular
• Renal

a. Current vital signs

Review the current vital signs in the patient’s chart. Compare them with the admission vital signs and what you observe in the patient now. Look for a change in pattern that suggests either worsening or improvement in the patient.

b. Temperature

The textbook “normal” oral body temperature is 98.6° F (37° C). However, some range from 96.5° F to 99.5° F (35.8° C to 37.4° C) is normal. Make sure the patient has not eaten any hot or cold foods recently and has not been smoking before taking an oral temperature.

A rectal or core temperature is commonly taken in very sick patients, because it is more accurate and reliable. The normal rectal temperature is 97.5° F to 100.4° F (36.4° C to 38° C). Some variance is normal, but less so than with oral temperatures. Axillary temperatures are used as a last resort in stable patients. These run 1° F lower than oral temperatures and are less accurate and reliable.

The variations in temperature noted depend on the time of day, activity level and, in women, stage of the menstrual cycle. For example, a lower body temperature is normal when a person is in a deep sleep. An oral temperature higher than 99.4° F (37.4° C) in a patient with a history of respiratory disease indicates a fever. Typically, it can be caused by atelectasis or a pulmonary or systemic infection. Patients commonly are treated to keep their temperature below 103° F, if possible. In general, a rectal temperature below 97° F (36° C) is considered hypothermic. In some procedures, such as open-heart surgery, a patient’s temperature is lowered to reduce metabolism and oxygen needs. The rectal temperature must be kept above 90° F (32° C) to prevent cardiac dysrhythmias caused by the cold.

c. Respiratory rate

The respiratory rate (f for frequency) is the number of breaths the patient takes in 1 minute. The number is counted by looking at or feeling the chest or abdominal movements, or both. The normal rate varies with age (Table 1-2). It is assumed that the patient is resting but awake and has a normal temperature and metabolic rate. A respiratory rate above or below normal is cause for alarm.

TABLE 1-2 Normal Resting Respiratory Rates

Age (Years) Male Female
0 31 ± 8 30 ± 6
1-2 26 ± 4 27 ± 4
2-4 25 ± 4 25 ± 3
5-7 22 ± 2 21 ± 2
8-11 19 ± 2 19 ± 2
12-14 19 ± 2 18 ± 2
15-16 17 ± 3 18 ± 3
17-18 16 ± 3 17 ± 3
Older 16 ± 3 17 ± 3

Modified from Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.

Hyperthermia (fever), acidemia, hypoxemia, fear, anxiety, and pain cause a patient to breathe more rapidly. Hypothermia, alkalemia, and hyperoxia in a patient breathing on hypoxic drive, sedation, and coma cause a patient to breathe more slowly.

Remember that even in healthy people, considerable variation is found in the respiratory rate. It is best to consider the respiratory rate and the patient’s tidal volume and minute volume to get a more complete impression of how the patient is breathing. Carefully measure the respiratory rate of any patient with cardiopulmonary disease or with a respiratory rate outside the normal range. The rate should be checked as often as needed to monitor the patient’s condition.

d. Blood pressure

The blood pressure (BP) is the result of the pumping ability of the left ventricle (made up of the heart rate and stroke volume), arterial resistance, and blood volume. Normal BP results when all three factors are in balance with each other. If one factor is abnormal, the other two have some ability to compensate. For example, if the patient has lost a lot of blood, the body attempts to maintain BP by increasing both arterial resistance and the heart rate.

Normal Blood Pressures

• Adults: lower than 120/80 mm Hg
• Infants and children younger than 10 years old: 60 to 100/20 to 70 mm Hg

As with the other vital signs, some variation in BP is noted among individuals. It is important to know the patient’s normal BP to compare it with the current value. Carefully measure the BP in any patient who has cardiopulmonary disease or a history of hypotension or hypertension.

Hypotension in the adult is a systolic BP of less than 80 mm Hg. Recommend a BP measurement for any patient who has a history of hypotension, appears to be in shock, has lost a lot of blood, has a weak pulse, shows mental confusion, is unconscious, or has low urine output.

Hypertension in the adult is a systolic BP of 140 mm Hg or greater or a diastolic BP of 90 mm Hg or greater, or both. Carefully measure the BP of any patient with a history of hypertension, bounding pulse, or symptoms of a stroke (mental confusion, headache, and sudden weakness or partial paralysis). Fear, anxiety, and pain also cause the patient’s BP to increase temporarily.

e. Heart/pulse rate

The heart/pulse rate (HR) is the number of heartbeats per minute. It can be counted by listening to the heart tones with a stethoscope or by feeling any of the common sites where an artery is easy to locate. Table 1-3 shows the normal pulse rates based on age. It is assumed that the patient is alert but resting when the pulse is counted. Carefully measure the heart/pulse rate in any patient with cardiopulmonary disease or any of the aforementioned conditions for hypotension or hypertension.

TABLE 1-3 Normal Pulse Rates According to Age

Age Beats/min
Birth 70–170
Neonate 120–140
1 year 80–140
2 years 80–130
3 years 80–120
4 years 70–115
Adult 60–100

From Eubanks DH, Bone RC: Comprehensive respiratory care, ed 2, St Louis, 1990, Mosby.

3. Serum electrolytes and other blood chemistries

a. Review the results of the patient’s serum electrolyte levels and other blood chemistries (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend blood tests, such as the potassium level, to obtain additional data (WRE code: IC1) [Difficulty: WRE: R, Ap, An]

The serum (blood) electrolytes are measured in most patients when they are admitted to the hospital and as needed thereafter. This is to determine whether the values are within the normal ranges listed in Table 1-4. Any abnormality should be promptly corrected so that the patient’s nervous system, muscle function, and cellular processes can be optimized. Diet and a number of medications can affect the various electrolytes. Most abnormalities can be corrected by dietary adjustments or, if necessary, by oral or intravenous supplementation.

TABLE 1-4 Normal Serum Electrolyte and Glucose Levels

NORMAL ELECTROLYTE VALUES*
Chloride (Cl−) 95–106 mEq/L
Potassium (K+) 3.5–5.5 mEq/L
Sodium (Na+) 135–145 mEq/L
Calcium (Ca++) 4.5–5.5 mEq/L
Bicarbonate (HCO3−) 22–25 mEq/L
NORMAL GLUCOSE VALUES*  
Serum or plasma 70–110 mg/100 mL (dL)
Whole blood 60–100 mg/100 mL (dL)

* These values may vary somewhat among references.

1. Potassium (K+)

Potassium is the most important electrolyte to monitor because of its effect on general nerve function and cardiac function. Hyperkalemia is a high blood level of potas-sium. It causes the following electrocardiographic (ECG) changes: high, peaked T waves and depressed S-T segments; widening QRS complex; and bradycardia. Hypokalemia is a low blood level of potassium. It causes the following ECG changes: flat or inverted T waves, depression of the S-T segments, premature ventricular contractions (PVCs), and ventricular fibrillation (if severe enough). Chapter 11 offers a more complete discussion of ECG interpretation.

Exam Hint 1-1 (WRE)

Hypokalemia can be caused by the use of diuretic medications such as furosemide (Lasix). Signs of hypokalemia include the cardiac rhythm disturbances noted previously and muscle weakness. In addition, a metabolic alkalosis is found when the results of an arterial blood gas analysis are interpreted. Be prepared to recommend the administration of potassium if the serum level is low.

2. Chloride (Cl−)

Hyperchloremia is a high blood level of chloride, which causes significant prolongation of the ST segment and the QT interval on the ECG. Hypochloremia is a low blood level of chloride, which shortens the QT interval and perhaps widens and rounds off the T waves on the ECG.

3. Sodium (Na+)

Hypernatremia is a high blood level of sodium. It might be seen in a patient who is dehydrated or who has lost many gastrointestinal secretions because of vomiting, nasogastric tube drainage, or diarrhea. Hyponatremia is a low blood sodium level, which might be seen in a patient who is fluid overloaded.

4. Bicarbonate (HCO3−)

Altered bicarbonate levels are commonly seen in patients with pulmonary conditions. The kidneys of patients with a chronically elevated arterial partial pressure of carbon dioxide (Paco2) typically retain bicarbonate to moderate the respiratory acidosis caused by the elevated carbon dioxide level. Conversely, the kidneys of patients with a chronically decreased Paco2 level excrete bicarbonate to moderate the respiratory alkalosis caused by the decreased Paco2 level.

5. Calcium (Ca++)

Hypercalcemia is an elevated calcium level, which may be associated with patients taking diuretics. ECG changes associated with an increased calcium level include a shortened QT interval and widened, rounded T waves. Hypocalcemia is a decreased calcium level. It causes ECG changes such as lengthening of the S-T segment and the QT interval.

6. Glucose

The blood glucose level is important to monitor, because it directly relates to how much glucose is available to the patient for energy for daily activities. The normal values are listed in Table 1-4. Hypoglycemia is a low blood level of glucose; it can mean that the patient is malnourished. Hyperglycemia is a high blood level of glucose; this may indicate that the patient has diabetes mellitus or Cushing’s disease or is being treated with corticosteroids. More specific testing must be done to prove the diagnosis.

4. Complete blood count

a. Review the results of the patient’s complete blood count (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

b. Recommend a complete blood count for additional data. (Code: IC1) [Difficulty: WRE: R, Ap, An]

A complete blood count (CBC) is routinely done for all hospitalized patients, as well as for patients seen for a variety of illnesses and for routine physical examinations. The red blood cell (RBC, or erythrocyte) count, white blood cell (WBC, or leukocyte) count, and differential (Diff) provide a great deal of information about the hematologic system and many other organ systems.

The key normal values for the RBC count are listed in Table 1-5. The hemoglobin and hematocrit values also are important, because they directly relate to the patient’s oxygen-carrying capacity. Decreased hemoglobin and hematocrit values indicate that the patient is anemic. An anemic patient has less oxygen-carrying capacity, and as a result, more stress is placed on the heart during exercise. Hypoxemia resulting from a cardiopulmonary abnormality places this patient at great risk. A transfusion is indicated if the hematocrit is below the level the physician considers clinically safe.

TABLE 1-5 Normal Hemoglobin, Hematocrit, and Red Blood Cell Counts for Adults and Children *

image

An increased number of circulating erythrocytes indicates that the patient has polycythemia. When this is seen as a response to chronic hypoxemia from COPD, cyanotic congenital heart disease, or another disorder, it is labeled secondary polycythemia. This patient is at added risk because the thickened blood causes an increased afterload against which the heart must pump. These patients also are more prone to blood clots. With supplemental oxygen or other clinical treatment to increase the arterial partial pressure of oxygen (Pao2) to at least 55 to 60 torr, the erythrocyte and hematocrit levels, over time, return to normal.

The key normal leukocyte count and differential are listed in Table 1-6. A normal leukocyte count and a normal differential reveal two things about the patient. First, no active bacterial infection is present. Second, the patient’s body is able to produce the normal number and variety of WBCs to combat an infection.

TABLE 1-6 White Blood Cell and Differential Counts*

WHITE BLOOD CELL COUNT (mm3)
Adult 4,500-11,000
Infant and child 9,000-33,000
DIFFERENTIAL COUNT
Segmented neutrophil 40%
Lymphocytes 20%
Monocytes 2%
Eosinophils 0%
Bands 0%
Basophils 0%

* These values may vary somewhat among references.

A mild to moderate increase in the leukocyte count is called leukocytosis. It is seen as a WBC count of 11,000 to 17,000 per cubic millimeter (mm3). Usually, the higher the count, the more severe the infection. A WBC count above 17,000/mm3 is seen in patients with severe sepsis, miliary tuberculosis, and other overwhelming infections. When a patient has an acute, severe bacterial infection, the WBC differential count shows an increased number of neutrophils. Exceptions to this are patients who are elderly, those who have acquired immunodeficiency syndrome (AIDS), and those with other immunodeficiencies. These patients may have an infection but show only a mildly elevated WBC count.

Leukopenia is a low absolute WBC count of 3,000 to 5,000/mm3 or less. An acute viral infection can cause a mild to moderate decrease in the neutrophil count. A patient with a low WBC count is at great risk of bacterial or other infections.

5. Review the patient’s coagulation study results (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

Coagulation studies are routinely done for many hospitalized patients; for those who are to have surgery; and for those who have or are suspected of having a blood-clotting disorder. Also, many medications speed or slow clotting time (so-called blood thinners). It is important to review a patient’s coagulation studies before drawing a blood sample or performing a procedure that may lead to bleeding. Table 1-7 lists normal coagulation study results. If the patient’s clotting time is increased, the individual is at risk of bleeding. Be prepared to apply pressure to a blood sampling site (especially and arterial one) longer than expected.

TABLE 1-7 Normal Coagulation Study Results

Test Name Normal Value Critical Value
Bleeding time 1-9 min >15 min
Prothrombin time (PT or Pro-time) 11.0-12.5 sec; 85%-100% >20 sec
Partial thromboplastin time (PTT) 60-70 sec >100 sec
Activated partial thromboplastin time (APTT) 30-40 sec >70 sec

6. Gram stain results, culture results, and antibiotic sensitivity results

a. Review the patient’s Gram stain results, culture results, and antibiotic sensitivity results (Code: IA3) [Difficulty: ELE: R; WRE: Ap]

The first step in the microbial analysis of sputum, mucus, or other body fluids or tissues is a Gram stain. Gram staining is a special process for colorizing bacteria that divides them into two groups. Gram-positive (g+) bacteria are stained violet. These are the most common types of bacteria that cause bronchitis and pneumonia. In general, penicillin or related drugs and sulfa-type antibiotics kill gram-positive bacteria. Gram-negative (g−) bacteria are stained pink. These organisms, unfortunately, are found in many of the sickest and weakest patients. Often the only way to kill gram-negative bacteria is with a specific antibiotic to which they have been proven sensitive. So-called broad-spectrum antibiotics, such as tetracycline, also may be used.

After Gram staining of the sample of fluid or tissue, a culture and sensitivity (C & S) study is performed. Culturing involves actively growing the organism or organisms to determine what they are. In a sensitivity test, the cultured organism is exposed to a variety of antimicrobial drugs. The goal is to determine which drug or drugs kill the pathogen most effectively. The patient then is treated with that antibiotic. It may take 1 to 3 days to get back the C & S results.

Gram staining cannot be used to identify Mycobacterium tuberculosis (TB) bacteria. Instead, the Ziehl-Neelson stain must be used. This is an acid-fast stain, and it gives the TB bacteria a red coloration. Other pathogens, such as viruses, protozoa, and fungi, cannot be identified by Gram staining. Protozoa and fungi must be identified with specialized stains. Fungi and M. tuberculosis may take 6 to 8 weeks to culture.

b. Recommend a Gram stain and C & S study for additional data (Code: IC4) [Difficulty: ELE: R, Ap; WRE: An]

Whenever an infection is suspected, it is important to obtain a sample of fluid or tissue from the site in question. This patient material is tested for possible bacterial infection by Gram staining and C & S study. Whenever bronchitis or pneumonia is suspected, it is important to obtain a mucus or sputum sample for evaluation. A sample of mucus suctioned from the lungs should show only pulmonary organisms. Sputum is the mix of mucus from the lungs and saliva from the mouth; therefore the organisms found in it may have come from either place. If the patient has pleural fluid, that also must be sampled. Often a blood sample also is taken to look for evidence of septicemia.

Note: The following two items have been listed as testable on the previous NBRC Content Outlines. They are included here in case they are tested again.

7. Review the patient’s urinalysis results

A urine sample routinely is taken from every patient admitted to the hospital and from pregnant women and presurgical patients. Much information about the functioning of the kidneys and other metabolic processes can be gathered from the urinalysis results. A urinalysis also is done for diagnostic purposes in patients with abdominal or back pain, hematuria, and chronic renal disease. Table 1-8 lists the normal findings for a urinalysis. Any abnormal findings should be further investigated to discover the cause.

TABLE 1-8 Normal Urinalysis Results

Test Item Normal Value
Appearance Clear
Color Amber yellow
pH 4.6-8.0 (average 6.0)
Specific gravity Adult: 1.005-1.030 (usually 1.010-1.025)
Newborn: 1.001-1.020
White blood cells 0-4
Red blood cells 0-2

8. Review the patient’s pleural fluid study results

If a patient has had a thoracentesis procedure to remove pleural fluid, the fluid is sent to the laboratory for further analysis. The fluid may turn out to be watery, bloody, infected, or lymphatic. See Chapter 18 for a complete discussion of the types of pleural fluids.

MODULE B

RADIOGRAPHIC IMAGING

Note: It is beyond the scope of this text to cover all the features of normal radiographic images. Review standard textbooks for this as needed. This discussion is limited to items listed as testable by the NBRC.

1. Review the patient’s imaging findings (Code: IA6) [Difficulty: ELE: R; WRE: Ap]

Look for the results of radiographs (x-rays), computed tomography (CT) scans, and magnetic resonance imaging (MRI) studies of the chest or upper airway. If possible, view these results to gain a better understanding of the patient’s condition. (Although not specified by the NBRC, the following should be studied, if possible: positron emission tomography [PET] scans, ventilation/perfusion [V/Q] scans of the lungs, angiograms, and barium swallow studies.)

2. Recommend radiographic and other imaging studies to obtain additional data (Code: IC2) [Difficulty: ELE: R, Ap; WRE: An]

a. Chest radiograph

A chest radiograph should be recommended in the following situations:

• After an endotracheal or tracheostomy tube has been placed or repositioned
• After the jugular/subclavian route has been used to insert a central venous pressure (CVP) or pulmonary artery (Swan-Ganz) catheter
• After a chest tube has been placed in the pleural space to remove air or fluids
• Hemoptysis (bloody sputum) is noted
• A sudden deleterious change is noted in the patient’s cardiopulmonary condition
• The balloon on the pulmonary artery (Swan-Ganz) catheter has been inflated for a prolonged period, and a pulmonary infarct is suspected
• A pneumothorax is suspected

Exam Hint 1-2 (ELE, WRE)

Expect to see at least one question on the Entry Level Examination and the Written Registry Examination in which the respiratory therapist should recommend a chest radiograph to rule out or confirm a pneumothorax. Signs and symptoms that the patient may have a pneumothorax include the following: sudden chest pain with an increase in dyspnea and shortness of breath (SOB), absent breath sounds over a lung field, tracheal deviation and heart sounds shifted to the side opposite the pneumothorax, asymmetrical chest movement, hyperresonant percussion noted over the pneumothorax, a sudden increase in peak pressure or plateau pressure or both on the patient’s ventilator, or air in the soft tissues, or a combination of these.

b. Upper airway radiograph

An upper airway radiograph (anterior or lateral or both) should be recommended for a patient who presents with indications of upper airway obstruction. This can include:

• Aspirated foreign body
• Laryngeal edema
• Laryngeal tumor
• Laryngotracheal bronchitis (LTB or croup) versus epiglottitis (see Module H for more information)

c. CT scan

A CT scan provides a more detailed image than a conventional radiograph. It is able to depict abnormalities of the lungs and mediastinum. Indications include, but are not limited to, the following:

• Tumor
• Hematoma
• Abscess and cyst
• Pleural effusion
• Aortic or other vascular abnormalities (after an intravenous contrast material has been administered)

d. MRI scan

An MRI scan provides images of body organs without the use of radioactive materials. The images are created when the powerful magnet of the MRI machine is turned on and off, affecting the way hydrogen atoms align within the body. A limitation of MRI is that the patient cannot have any metallic implants. In addition, most mechanical ventilators cannot be used during an MRI scan because the magnetic field will interfere with the unit. Indications for an MRI scan include, but are not limited to, the following:

• Imaging of the head, spinal cord, and surrounding structures
• Imaging of the heart and great vessels
• Imaging of the kidneys, liver, and other organs

Although not specified by the NBRC, the following should be studied, if possible: PET scans, V/Q scans of the lungs, angiograms, and barium swallow studies.

e. PET scan

A PET scan is performed using a radioactive substance that is either inhaled or given intravenously. As the radioactive substance breaks down in the target organ, it emits a positron (a positive electron). When the positron combines with an electron, they annihilate each other with the release of two gamma rays. Detectors outside the body identify the origin of the gamma rays and can determine the functioning and metabolism of the target organ. Indications for a PET scan include, but are not limited to, the following:

• Determining the regional metabolism of the heart and brain
• Measuring the size of a myocardial infarction
• Measuring the effects of treatment on a cancerous tumor
• Determining pulmonary perfusion or ventilation

f. Ventilation/perfusion (V./Q.) scan

A ventilation/perfusion (V./Q.) scan is used to identify where air moves into the lungs during breathing and blood flows through the lungs. A ventilation scan (V. scan) is performed to verify or refute the clinical suspicion that a patient has an area of the lung or lungs that is underventilated. Abnormal ventilation is seen in the case of a bronchial obstruction from a tumor or foreign body or with an alveolar problem, such as atelectasis, consolidation, or emphysema. Radioactive xenon (133Xe) is mixed with oxygen and inhaled to show the lung fields. A special scanner is used to pick up the radioactivity through the chest wall. Areas of normal ventilation can be compared with underventilated areas.

A perfusion scan (Q. scan) is performed to verify or refute the clinical suspicion that a patient has an area of pulmonary circulation that is underperfused. Abnormal perfusion is seen in the case of a pulmonary embolism, tumor, or vascular problem, such as pulmonary hypertension. Radioactive technetium (99 mTc) is injected into the patient’s venous system, where it is filtered out by the pulmonary circulation. As previously described, a special scanner is used to pick up the radioactivity through the chest wall. Areas of normal perfusion can be compared with underperfused areas. The ventilation scan and perfusion scan tests can be done singly or as a set.

Comparing the ventilation and perfusion results side by side enables the physician to look for areas of mismatching. Normally, ventilation and perfusion match fairly closely and result in a 1 : 1 mix of air and blood at the alveolar capillary membrane. A pulmonary embolism results in a V./Q. ratio of 2 (or greater):1 (or less), because normal ventilation is present, and perfusion is reduced or absent. An obstructed airway with resulting atelectasis results in a V./Q. ratio of 1 (or less):2 (or greater), because ventilation is reduced or absent, and perfusion is normal.

g. Angiogram

An angiogram involves the placement of a catheter into an artery or a vein. Commonly, a radiopaque dye is injected so that the flow of blood through the vessel can be observed. If a blockage is found, a balloon at the tip of the catheter may be inflated (balloon angioplasty) to flatten the blockage. Indications for an angiogram include, but are not limited to, the following:

• Check blood flow through the carotid arteries and into the brain
• Check blood flow through the coronary arteries and the chambers of the heart
• Check blood flow through the pulmonary arteries when perfusion study results are inconclusive
• Perform a procedure to remove a blockage from an artery (this could include balloon angioplasty, laser atherectomy, or embolectomy)

h. Barium swallow (esophagogram)

A barium swallow (esophagogram) enables a radiographic image to be taken of the esophagus, stomach, and small intestine. Indications for a barium swallow include, but are not limited to, the following:

• Dysphagia
• Noncardiac chest pain
• Gastroesophageal reflux

3. Review the chest radiograph to determine the quality of the imaging (WRE code: IB7a) [Difficulty: R, Ap, An]

a. Patient identification

It is standard practice for the patient’s name and identification number to be incorporated into the chest radiograph (chest radiograph film).

b. Patient positioning

The patient is positioned between the radiograph machine and the film cassette so that the electromagnetic (x-ray) radiation penetrates the patient’s body, hits the film, and provides the desired view of the internal organs. Figure 1-1 shows the most common radiographic projections used for patients with cardiopulmonary problems. Examples of some of these positions are shown in this chapter.

image

Figure 1-1 Common radiographic projections of the chest to evaluate the heart and lungs. A, Anteroposterior (AP) projection; B, Posteroanterior (PA) projection; C, Lateral projections; D, Right anterior oblique (RAO) position; E, PA oblique projection, left anterior (LA) projection; F, AP oblique position, left posterior oblique (LPO) position; G, AP oblique projection, right posterior oblique (RPO) position; H, Left lateral decubitus; I, Right lateral decubitus; J, Dorsal decubitus; K, Ventral decubitus.

(From Long BW, Frank ED, Ehrlich RA: Radiography essentials for limited practice, ed 3, St. Louis, 2010, Saunders).

If possible, the patient should be moved to the radiography department, and the chest radiograph should be taken from the posterior to anterior (posteroanterior, P-A, or PA) position. The patient’s chest is placed against the film cassette with the shoulders rolled forward. Because radiographs penetrate from back to front, the size of the heart is close to normal. Normally, the patient is instructed to take in and hold a deep breath. This reveals more clearly the lung fields, heart, and other structures. This may be contrasted with a chest radiograph taken after the patient has exhaled completely. If the patient has been correctly positioned perpendicular to the film cassette, the radiograph image will show the clavicle bones to be symmetrical.

If a portable chest radiograph must be taken because the patient is too ill to be moved from his or her bed, the anterior to posterior (anteroposterior, A-P, or AP) position must be used. The radiographs penetrate the body from front to back. This should be noted in the chart, because this view of the organs shows the heart’s size to be larger than that seen in a PA radiograph.

The standard lateral view is taken with the patient standing upright with both arms raised above the head and the left side against the film cassette. This is done because the heart is left of center in the chest. A lateral view is used to see behind the heart and hemidiaphragms. It can be combined with an AP or a PA view to localize lesions within the chest. This view also is used to measure the patient’s anterior-to-posterior chest diameter. This is often enlarged in patients with air trapping from emphysema.

The oblique position provides a third angle for viewing the internal chest structures. This is especially helpful when the physician is checking the heart borders, mediastinal structures, hilar structures, and lung masses.

The lateral decubitus position enables fluid within the pleural space to be viewed. As little as 25 to 50 mL of fluid can be detected in an adult as it flows to the horizontal position. An air/fluid level in a lung cavity (cyst) also can be evaluated by the shifting of the fluid line by gravity. The dorsal decubitus position is used to help identify a small pneumothorax in an infant.

The lordotic (apical lordotic) position is used when the upper lung fields must be viewed without the clavicles and first and second ribs obscuring them. The apices, right middle lobe, and lingula can be clearly seen.

Make sure, when viewing any chest radiograph, that you are looking at the film correctly. That is, the film should be viewed as if you were looking directly at the patient’s chest. For example, in a PA or AP film, if you reached out your right hand, you would touch the image of the patient’s left shoulder. To help with correct viewing, the film should show the letter L over the patient’s left shoulder (on your right as you look at the film). Note that sometimes the film will show the letter R over the patient’s right shoulder (on your left as you look at the film).

c. Exposure

The radiology technologist is responsible for exposing the patient to x-rays long enough to acquire the proper exposure of the internal organs. In all chest radiograph positions, the patient must take and hold a deep breath without moving as the picture is taken. If the patient is on a mechanical ventilator when an AP chest radiograph is obtained, a sigh breath should be delivered and held by the respiratory therapist to inflate the lungs fully.

It must be understood that the image seen on a chest radiograph film is the negative, or reverse, image of the densities of the structures within the chest. When viewing an radiograph film, a range of shadings will be seen progressing from white to black. Radiopaque items are very dense. They absorb most radiographs, preventing them from striking the film, and therefore appear white on the film. Radiolucent items have little density. They absorb few radiographs, allowing them to strike the film, and therefore appear dark on the film. Altogether, four densities are seen on a chest radiograph:

1. Air

Because air is the least dense substance, it blocks very few radiographs; most hit the film in the cassette. This causes the film to turn black. Notice that the film around the patient’s body is completely black. Because the normal lungs are air filled with little tissue, they appear almost black. Normally some lung tissue markings can be seen as wispy white shadows. Air in the stomach or intestine also appears dark compared with the surrounding tissues.

2. Tissue

The tissues of the lungs, heart, diaphragm, breasts, and so on partially block the radiographs. This results in white shadows of varying opacity, depending on the density of the tissues. For example, the heart appears as a fairly solid white organ. Fluid also partially blocks radiographs. A pleural effusion is seen as a white shadow around one or both lungs.

3. Bone

The calcium in bone makes it dense enough to block most x-ray penetration; therefore the ribs, clavicles, and vertebrae are seen as fairly solid white lines. Broken ribs can be easily identified by the misalignment of their shadows.

4. Metallic

Bullets, wire sutures, metal plates, artificial heart valves, and coins completely block all radiograph penetration. This results in a sharply outlined white shadow. Medical devices, such as an endotracheal or a tracheostomy tube, nasogastric tube, or heart catheter, contain materials that completely block radiographs. Therefore these radiopaque items can be easily seen within the patient on a chest radiograph.

When the radiograph is obtained with the proper penetration and exposure, the intervertebral spaces of the spinal column are just visible. If the film is underexposed (the overall color of the film and body tissues is too white), the carina or an internal catheter may not be seen. If the film is overexposed (the overall color of the film and body tissues is too black), the air-filled lung fields will be too black, and it may not be possible to detect a pneumothorax.

4. Recommend and review the patient’s chest radiograph to evaluate and monitor the patient’s response to respiratory care procedures (Code: IIIE1) [Difficulty: ELE: R, Ap; WRE: An]

A chest radiograph should be taken whenever a significant change occurs in the patient’s cardiopulmonary condition or whenever an invasive thoracic procedure is performed (chest tube insertion, endotracheal intubation, or placement of a pulmonary artery catheter).

5. Look for the presence of, or any changes in, pneumothorax (ELE code: IB7c) [Difficulty: R, Ap, An]

Free air that leaks into the interstitial spaces of the lung or body cavities is abnormal in any patient. Causes of an air leak include barotrauma/volutrauma (alveolar rupture related to the use of a mechanical ventilator), a ruptured bleb (congenital or acquired blister on the visceral pleura), puncture wound through the chest wall, and needle puncture through the pleural space during the insertion of a CVP or pulmonary artery catheter via the subclavian or jugular vein. Once air under pressure is forced through a bronchial or alveolar tear into the interstitial tissues, it tends to follow the path of least resistance. This may result in air being found in any of the following areas, singly or in combination.

a. Pneumothorax

Pneumothorax is air in the pleural space. The lung tends to collapse toward the hilum. A pneumothorax is identified on the chest radiograph as an area of black, indicating air that surrounds the collapsed lung. No lung markings are visible in the air-filled space, and the edge of the lung can be seen (Figure 1-2). If the air is under sufficient pressure to shift the lung and mediastinal structures to the opposite side, the condition is called a tension pneumothorax. This is a serious condition that can lead to the death of the patient if it is not quickly identified and treated. A pleural chest tube is always placed into the affected side to remove the air so that the lung can re-expand.

image

Figure 1-2 Frontal radiograph of an adult male with a left-sided tension pneumothorax. The edge of the collapsed lung is shown (arrows). Note how the mediastinum is shifted to the right, the right lung is compressed, and the left hemidiaphragm is depressed.

(From Des Jardins TR: Clinical manifestations of respiratory disease, ed 5, St Louis, 2006, Mosby.)

In addition, the following are other locations where free air can be found:

b. Subcutaneous emphysema

Subcutaneous emphysema is air found in the soft tissues, such as the skin, axilla, shoulder, neck, or breast, of the affected side. In extreme cases, the air forces its way into skin and soft tissues throughout the body. Scattered dark areas (air pockets) appear in the various soft tissues on the chest radiograph (Figure 1-3). Pneumomediastinum is air in the mediastinal space (Figure 1-3). Pneumopericardium is air in the pericardial space (Figure 1-4). Both of these conditions can be very serious. Cardiac tamponade is created if the pressure around the heart is great enough to interfere with its function. Pneumoperitoneum is air in the peritoneal space. This condition can be dangerous in an infant if a large enough volume of air is below the diaphragm and its movement is limited. Pulmonary interstitial emphysema (PIE) is air that has disseminated throughout the interstitial spaces of the injured lung or lungs. The lungs appear “bubbly” on the chest radiograph (Figure 1-4). The air may further leak into any of the previously listed locations. PIE is most commonly seen in infants with infant respiratory distress syndrome (RDS) who require mechanical ventilation (MV).

image

Figure 1-3 Frontal radiograph of a neonate showing subcutaneous emphysema in the shoulders and neck area. Other abnormal air in the patient’s chest includes a pneumomediastinum, which outlines the right lobe of the thymus gland (arrow), and a left anterior pneumothorax.

(From Carlo C: Neonatal respiratory care, St Louis, 1988, Mosby.)

image

Figure 1-4 Frontal radiograph of a neonate showing a pneumopericardium that resulted from pulmonary interstitial emphysema. Note the dark outline of air around the heart. Chest tubes have been placed to remove air from around the heart and the right pleural space from an earlier pneumothorax. An endotracheal tube also is seen.

(From Koff PB, Eitzman DV, Neu J: Neonatal and pediatric respiratory care, St Louis, 1988, Mosby.)

Exam Hint 1-3 (ELE)

The NBRC often has a question about how to identify the location of an endotracheal tube on a chest radiograph. The distal tip of the tube should be seen in the middle of the trachea. An endotracheal tube that has been inserted too deeply will enter the right mainstem bronchus.

6. Look for the presence of, or any changes in, mediastinal shift (Code: IB7f) [Difficulty: ELE: R, Ap; WRE: An]

The mediastinum is the area between the lungs that contains the heart and great vessels, trachea, hilar structures, and esophagus. In the neonate, the heart and other mediastinal structures should be approximately in the center of the chest, with the left ventricle to the left of center. In the adult, the majority of the heart and mediastinal structures should be left of center in the chest. A shift of the mediastinum (and heart) is abnormal, as shown in several conditions in Figures 1-2 and 1-5. Either atelectasis or pulmonary fibrosis, if unilateral and great enough, can result in a shift toward the problem area. Tension pneumothorax results in a shift away from the problem area. Fluid in the pleural space, if great enough, results in a shift away from the problem area.

image

Figure 1-5 Conditions causing tracheal deviation and mediastinal shift (simulated chest radiograph findings). A, Unilateral atelectasis with tracheal deviation toward the affected lung. B, Unilateral pulmonary fibrosis with tracheal deviation toward the affected lung. C, Tension pneumothorax with tracheal deviation away from the affected lung. D, Pleural fluid with tracheal deviation away from the affected lung. The normal lung expands more than the abnormal lung during inspiration.

7. Look for the position of indwelling tubes and catheters (Code: IB7d) [Difficulty: ELE: R, Ap; WRE: An]

All medical devices placed into the body are made of radiopaque material. They can be seen on a chest radiograph as a white object or line.

Chest tubes are placed to remove any abnormal collection of air or fluid from the thoracic cavity so that the function of the heart and lungs returns to normal. A pleural chest tube is placed to remove air or fluid from the pleural space (see Figure 1-4). The insertion site and depth of insertion of the tube depend on the patient’s disorder. (See Chapter 18 for more discussion on the placement of pleural chest tubes.)

A mediastinal or pericardial chest tube is placed to remove air or fluid from either of these spaces (see Figures 1-4 and 1-6). Cardiac tamponade can result from the pressure of either air or fluid compressing the heart. Most postoperative open-heart surgery patients have one or more mediastinal chest tubes in place for several days to remove any blood from around the heart. The insertion site is below the sternum, and the tube or tubes are placed posterior to the heart in the pericardial or mediastinal space or both.

image

Figure 1-6 Frontal radiograph of an adult postoperative open-heart surgery patient with several medically necessary devices. A properly placed pulmonary artery (Swan-Ganz) catheter is noted to loop through the right side of the heart and out into the right pulmonary artery. The catheter tip is marked CT. Other foreign bodies include a properly placed endotracheal tube (marked TT), sternal wire sutures, ECG chest leads on each shoulder, and pericardial chest tubes (marked ChT).

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

On the chest radiograph, a nasogastric tube appears as a white line from the patient’s nose or mouth through the esophagus and into the stomach (on the left side below the diaphragm). A feeding tube may be placed as a nasogastric tube or may be surgically placed through the abdominal wall and into the stomach or small intestine. A white line on the radiograph shows its position.

A cardiac pacemaker is placed in two ways. An external pacemaker is identified on the chest radiograph by the long electrode leads that run through a vein in the right arm, through the superior vena cava, and into the right ventricle. The battery and control unit of an internal pacemaker are placed under the skin below a clavicle. The electrode leads run through the superior vena cava into the right ventricle.

The various venous catheters (pulmonary artery catheter, central venous pressure [CVP] catheter, umbilical artery catheter [UAC], and umbilical vein catheter [UVC]) should be seen on the chest radiograph from their insertion points to their end points. (See Figures 1-6 and 1-7 for the placement of several catheters.)

image

Figure 1-7 Lateral radiograph (A) and diagram (B) of the course of umbilical venous and arterial catheters. The umbilical venous catheter enters through the umbilicus and passes through the umbilical vein (1), portal vein (2), ductus venosus (3), and inferior vena cava (4) and stops in the right atrium (5). The umbilical arterial catheter enters through the umbilicus and passes through the umbilical artery (A), hypogastric artery (B), internal iliac artery (C), common iliac artery (D), and abdominal aorta (E), and stops in the thoracic aorta (F).

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

8. Look for the presence of, or any changes in, consolidation (ELE code: IB7c) [Difficulty: R, Ap, An]

A consolidation is a filling of the alveoli with fluid from a pulmonary infiltrate, aspirated vomitus, blood, or water. It is often segmental or lobar. A pulmonary infiltrate occurs when blood plasma (water) passes from the pulmonary vascular bed into the lung tissues. Usually this fluid moves into the lung, because the alveolar capillary membrane is damaged. On a chest radiograph, an infiltrate often appears as a faint white blurring of the lung and other associated structures. Consolidation is noticed on the chest radiograph as a dense white shadow, because fluid has completely replaced the air. The mediastinum and heart are seen in their normal locations. Figure 1-8 shows a PA and lateral chest radiograph, indicating consolidation in each of the segments of both lungs. Air bronchograms also may be noticed on a radiograph that reveals consolidation.

image

Figure 1-8 Simulated frontal and lateral radiographic findings for consolidation in the various segments of both lungs. LLL, Left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.

(From Cherniack RM, Cherniack L: Respiration in health and disease, ed 3, Philadelphia, 1983, WB Saunders.)

9. Look for the positions of, or any changes in, the hemidiaphragms (Code: IB7f) [Difficulty: ELE: R, Ap; WRE: An]

The normal infant’s and adult’s AP or PA chest radiograph reveals a domed shape to the hemidiaphragms, with the edges turning down to acute costophrenic angles. A lateral chest radiograph reveals the same domed shape with the edges turning down to acute costophrenic angles. The edges of the hemidiaphragms should be smooth; any dips or peaks indicate an abnormality.

Both hemidiaphragms, and each separately, can be either elevated or depressed, depending on the condition of the lungs (underinflated or overinflated [hyperinflation]) and the abdominal contents. The following are commonly encountered clinical situations:

• Unilateral elevation: Atelectasis and pulmonary fibrosis (see Figure 1-5) decrease the lung’s volume; an enlarged liver pushes up on the right hemidiaphragm.
• Unilateral depression: Excessive pleural fluid, tension pneumothorax (see Figure 1-2), check-valve bronchial obstruction from a foreign body, or an airway tumor can cause unilateral depression.
• Bilateral elevation: Free abdominal fluid, as seen with peritoneal dialysis, can push up on both hemidiaphragms.
• Bilateral depression: Asthma attack and COPD (Figures 1-9 and 1-10) result in overinflation of both lungs and depression of both hemidiaphragms.
image

Figure 1-9 Frontal radiograph of an adult with advanced chronic obstructive pulmonary disease (COPD). Both lungs are overinflated and hyperlucent. The ribs are spread more widely than normal. Often these patients have a cardiothoracic ratio that is smaller than normal because the heart is elongated and the lateral chest diameter is increased.

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

image

Figure 1-10 Lateral radiograph of an adult with advanced chronic obstructive pulmonary disease. Note the characteristic shape of a “barrel chest” from the overinflated lungs. The anteroposterior (AP) diameter of the chest is increased. AA marks an increased anterior air space between the heart and sternum. The angle of the manubrium and body of the sternum is more obtuse than normal. DD marks depressed hemidiaphragms that are flattened.

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

In a person with asthma, bronchitis, or emphysema (COPD), and in a newborn with meconium aspiration, both lungs are overinflated and both hemidiaphragms are depressed. Other radiographic findings include widened intercostal spaces; hyperlucent lung fields; a small, vertical heart; a small cardiothoracic diameter; and decreased vascularity of peripheral areas of the lungs, with enlarged hilar vessels. The lateral chest radiographic findings in the patient with COPD are the same, and they include anterior bowing of the sternum, increased retrosternal air space, and kyphosis. In any of the previously mentioned conditions, improvement should result in a return of the hemidiaphragm or hemidiaphragms to a position closer to normal.

10. Look for the presence of, or any changes in, pleural fluid (ELE code: IB7c) [Difficulty: R, AP, An]

Pleural fluid typically is shown on a PA or AP film as obscuring the costophrenic angle. This is because gravity tends to draw the fluid to the lowest level. Often this results in an obscuring or a blunting of the costophrenic angle of the affected side (Figure 1-11). In some cases, an air/fluid level is seen within the intrapleural space. The term meniscus is used to describe the upward curve seen in the fluid part of this intrapleural air/fluid level. Small amounts of fluid sometimes can be better visualized by taking a lateral decubitus radiograph. If the fluid is able to move freely in the pleural space, it shifts in a few minutes to the lower side (Figure 1-12). An empyema that is loculated (fixed) by adhesions does not move when the patient lies on his or her side. If large amounts of fluid are removed by a thoracentesis procedure, a chest radiograph should be taken to confirm the removal of fluid, the re-expansion of the lung, and that a pneumothorax did not result.

image

Figure 1-11 Frontal radiograph of an adult showing a small pleural effusion in the right chest. Note how the costophrenic angle and hemidiaphragm are obscured by the white shadow of fluid.

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

image

Figure 1-12 Lateral decubitus radiograph of an adult showing the shift of a small pleural effusion to the now-dependent part of the pleural space. The layer of fluid is marked by arrows.

(From Wilkins RL, Dexter JR, Heuer A: Clinical assessment in respiratory care, ed 6, St Louis, 2010, Mosby.)

11. Look for the presence of, or any changes in, pulmonary edema (ELE code: IB7c) [Difficulty: R, Ap, An]

Pulmonary edema is watery fluid (plasma) that has leaked out of the pulmonary capillary bed into the interstitial spaces and alveoli. It is most commonly caused by left ventricular failure (also known as congestive heart failure), but it can be the result of fluid overload, pulmonary capillary damage, or decreased osmotic pressure in the blood from a low level of protein.

Pulmonary edema appears on a PA or AP chest radiograph as fluffy, white infiltrates in either or both lung fields. These tend to be seen more extensively in the lower lobes as a result of gravity pulling the fluid to the basilar vessels, where it leaks out. If the root cause is left ventricular failure, the vessels in the hila also are engorged, and the left ventricle is enlarged (Figure 1-13). A worsening problem results in more fluid leaking into the lungs and the appearance of more white infiltrates on succeeding chest radiographs. Once the problem has been corrected, the lungs return to normal as the fluid is reabsorbed and removed.

image

Figure 1-13 Frontal radiograph of an adult showing pulmonary edema, increased pulmonary vascular markings, and an enlarged left ventricle. The cardiothoracic diameter is increased, and the arrow shows where the border of the left ventricle normally would be seen.

(From Des Jardins T, Burton GG: Clinical manifestations and assessment of respiratory disease, ed 5, St Louis, 2006, Mosby.)

12. Look for the presence of any foreign bodies (Code: IB7e) [Difficulty: ELE: R, Ap; WRE: An]

A foreign body is anything that is not naturally found in the chest. Metallic objects (e.g., bullets or swallowed or aspirated coins or metal buttons) are easily noticed, because they completely block any radiograph penetration through the chest and are clearly outlined on the film as solid, white shadows (Figure 1-14). Nonmetallic foreign objects (e.g., plastic pieces from toys and foods, such as peanuts) are much more difficult to identify, because they have about the same densities as normal body tissues. Determining the exact location of a foreign body may require taking PA, lateral, and oblique chest radiographs. Lung volumes can be compared by taking inspiratory and expiratory films. A CT scan may be the most successful method of finding a nonmetallic foreign body.

image

Figure 1-14 Foreign body obstruction in an 18-month-old girl. A, Frontal radiograph with the solid white disk of a coin clearly seen in the hypopharynx. B, Lateral view of the chest with the edge of the coin seen as a solid white line.

(From Hunter TB, Bragg DG: Radiologic guide to medical devices and foreign bodies, St Louis, 1994, Mosby.)

13. Check the chest radiograph for the position of the patient’s endotracheal or tracheostomy tube (Code: IB7b) [Difficulty: ELE: R, Ap; WRE: An]

The distal ends of these tubes should be seen within the lumen of the trachea and about midway between the larynx and the tracheal bifurcation to the right and left mainstem bronchi (see Figures 1-4 and 1-6 for endotracheal tube placement). The proximal end of the tracheostomy tube (or transtracheal oxygen catheter) is seen on the film coming out of the surgical insertion site in the suprasternal notch. The distal end should be centered within the trachea above the carina (see Figure 1-6). All these tubes are made of a radiopaque material or have a line of radiopaque material embedded in them so that they can be easily seen on the radiograph.

Care must be taken not to push the endotracheal tube deeper into a bronchus (usually the right) or to pull it out. The tracheostomy tube and transtracheal oxygen catheter are less likely to be displaced if they receive proper care. Another radiograph should be taken to check the position of any of these tubes if clinical evidence suggests that a position may have changed.

Note: The following items have been listed as testable on previous exams and should be reviewed, if possible.

14. Check the chest radiograph for a sign that the cuff on the endotracheal or tracheostomy tube is overinflated

A properly inflated cuff fills the space between the tube and the patient’s trachea so that an airtight seal is made. If the cuff is overinflated, it places excessive pressure on the trachea. This can cause it to dilate and be seen as a wider dark area than the rest of the tracheal air column. If this is noticed, the cuff pressure should be measured. Excessive pressure should be reduced to a safer level.

15. Check the chest radiograph for the size and patency of the patient’s major airways

The trachea and both the right and left mainstem bronchi should be seen on a properly taken chest radiograph. They appear as straight, dark air columns in contrast to the white shadows of the various surrounding tissues. A white shadow within the airway may be a foreign body or a tumor. A lung tumor that presses on an airway causes the airway to narrow or be occluded.

16. Look for the presence of, or any changes in, atelectasis

Atelectasis is the collapse of alveoli; no air is found in them. This problem is commonly seen postoperatively in the lower lobes of patients who have had abdominal or thoracic surgery and who do not breathe deeply because of pain. The radiograph of atelectasis shows an increase in lung markings and a decrease in the lung volumes. If it is one sided, the mediastinum may shift toward the affected side (see Figure 1-5, A). If it is bilateral, the mediastinum is properly located. If it is severe enough, the lungs appear a uniform white (Figure 1-15).

image

Figure 1-15 Frontal radiograph of a neonate with severe atelectasis from infant respiratory distress syndrome (RDS). Also note the right pleural chest tube and wires to various monitoring systems.

(From Des Jardins T, Burton GG: Clinical manifestations and assessment of respiratory disease, ed 5, St Louis, 2006, Mosby.)

Exam Hint 1-4 (WRE)

Past exams have had at least one question that requires the identification of the cause of an abnormal chest radiograph. Typically the question refers to a patient who has a pneumothorax or pleural effusion. In addition, expect a question that requires the identification of the location of an endotracheal tube or the tip of a CVP catheter or pulmonary artery catheter. Also be prepared for questions related to recommendation of a chest radiograph to check for a foreign body obstructing the upper airway or a bronchus.

MODULE C

Interview the patient

1. What is the patient’s level of consciousness or sedation? (Code: IB5a) [Difficulty: ELE: R, Ap; WRE: An]

One common way to evaluate a patient’s level of consciousness is to categorize him or her as alert, stuporous, semicomatose, or comatose.

a. Alert

This is the normal mental state. The patient is conscious or can be fully awakened from sleep by calling his or her name. The patient can voluntarily ask logical questions and answer questions logically. The conversation is relevant to the topic under discussion. The patient’s movements and actions are willful and purposeful.

b. Stuporous or lethargic

The patient is sleepy or seems to be in a trance. He or she can be aroused to respond with willful, purposeful movements and actions, but the patient may be slow. The patient may not respond to questions in a totally appropriate way.

c. Semicomatose

The patient does not perform requested movements or actions. The patient does not answer questions in an appropriate way. He or she responds defensively to pain. For example, if the right arm is pinched, it is withdrawn. Posturing of semicomatose patients includes the following:

1. Decerebrate

Legs are extended; arms are extended and rotated either inward or outward.

2. Decorticate

Legs are extended; arms are flexed, and the forearms may be rotated either inward or outward.

3. Opisthotonic

Legs, arms, and neck are extended, and the body is arched forward.

d. Comatose or coma

The patient has no spontaneous, oriented responses to the environment. Pain causes no defensive movement, but an increase in the heart and respiratory rates may occur.

Another common way to evaluate a patient’s level of consciousness is to use the Glasgow Coma Scale (GCS). With this scale, a range of 3 to 15 points is possible; the larger the total number, the more normal the patient. A score of 15 is achieved in a patient normally awake and alert; a score of 3 is found in an unresponsive patient. Table 1-9 presents the details of the scale.

TABLE 1-9 Glasgow Coma Scale

Test Parameter Response Score*
EYES
Open Spontaneously 4
To verbal command 3
To pain 2
No response 1
BEST MOTOR RESPONSE
To verbal command Obeys command 6
Moves arms to painful stimulus of knuckles against sternum Localizes pain 5
Flexion—withdrawal 4
Flexion—abnormal movement (decorticate rigidity) 3
Extension—abnormal movement (decerebrate rigidity) 2
No response 1
BEST VERBAL RESPONSE (MAY AROUSE BY PAINFUL STIMULUS IF NECESSARY)
  Oriented and converses 5
Disoriented and converses 4
Inappropriate words used 3
Incomprehensible sounds 2
No response 1

* The total is obtained by adding the scores in all three areas. The range is 3 to 15.

From Teasdale G, Jennett B: Management of head injuries, Philadelphia, 1981, FA Davis.

2. Is the patient oriented to time, place, and person? (Code: IB5a) [Difficulty: ELE: R, Ap; WRE: An]

Time refers to the patient knowing the calendar date, the day of the week, and the time of day. Ask the patient, “Do you know what day of the week it is? Do you know what the date is?” (The patient must be able to see a calendar.) “Do you know what time it is?” (The patient must be able to see a clock.) If the patient can answer these questions, he or she is oriented to time. If not, inform and show him or her. Tell the patient that you will return at a certain time. Ask the same questions when you return.

Place refers to the patient knowing where he or she is located (e.g., hospital, nursing care unit, extended care facility, home). Ask the patient, “Do you know where you are?” If the patient knows, he or she is oriented to place. If not, inform the patient of the location. Tell the patient that you will return at a certain time. Ask the same question when you return.

Person refers to the patient knowing his or her own name, address, and telephone number. The patient also should know the names of obviously important people. Ask the patient, “Do you know who the president (or the physician) is?” If not, inform the patient. Tell the patient who you are and what your job is. When you return for your next treatment, ask the patient if he remembers who you are and what you do. If the patient remembers who the president (or the physician) is and your name or job, he or she is oriented to person.

Orienting a stuporous or lethargic patient to person, place, and time may encourage the individual to cooperate more in his or her care. Pain-relieving and sedative drugs, stroke, injury to or edema of the brain, and other illnesses may cause disorientation to person, place, or time.

3. What is the patient’s emotional state? (Code: IB5a) [Difficulty: ELE: R, Ap; WRE: An]

Acute illness or injury with great pain may result in some patients feeling fear, anxiety, or panic. Because of these feelings, the patient may be unable to concentrate closely on what you are telling him or her. This can result in directions not being understood or followed. It is important to tell the patient that you are there to help and that you need the patient to calm down so that you can help.

Chronic illness has been approached by a number of authors from varying points of view. Table 1-10 gives a presentation of a patient’s reaction to chronic illness. Substitute “respiratory therapists” for “nurses” as needed.

TABLE 1-10 Teaching-Learning Process in Adaptation to Chronic Illness

image

A patient’s statements and actions that indicate the disbelief stage of adaptation include the following:

• “I don’t have (fill in the disease or condition).”
• “There is nothing really wrong with me.”
• “The laboratory results are wrong.”
• “The equipment is faulty.”
• “The doctor/nurse/therapist is incompetent.”
• Refusal to take medications.
• Refusal to take treatments or follow other physician orders.

A patient’s statements and actions that indicate the developing awareness state of adaptation include the following:

• “The doctor/nurse/therapist doesn’t know what he or she is doing.”
• “It’s all their fault.”
• “Why is this happening to me?”
• The patient is angry about his or her illness.
• The patient may strike out verbally or physically at staff members.
• Some patients who do not get angry withdraw into a depression and wish to be left alone.

A patient’s statements and actions that indicate that he or she is progressing from the reorganization to the successful adaptation stage include the following:

• “I’ll never be able to do that again.” (Fill in the activity.)
• “I have to get on with my life.”
• “At least I’m still alive and can do this for myself.”
• The patient may be sad and cry often.
• The patient may invent a nickname for his or her defect or diseased body part.
• The patient accepts the disability and focuses on his or her abilities.
• The patient works with family and others in planning for the future.

4. What is the patient’s ability to cooperate? (Code: IB5a) [Difficulty: ELE: R, Ap; WRE: An]

You should be able to judge the patient’s ability to cooperate. This should be based on his or her responses to your questions on level of consciousness; orientation to time, place, and person; and emotional state. An alert patient should be able to understand and follow directions. He or she should be able to take an effective treatment or cooperate in a procedure. Conversely, if the patient truly refuses the treatment or procedure, it should not be forced. Contact the patient’s nurse or physician about the refusal. The physician must then decide what to do.

An alert but panicked, fearful, or anxious patient may be unable to cooperate fully until he or she is calmed by understanding who you are, what you are there to do, and why the treatment or procedure is important. Try to reassure the patient to improve cooperation.

If the patient appears alert but does not follow what you are saying, check to see whether he or she is deaf or does not speak English. An effective way to communicate must be found. Writing materials, a picture board, or a sign language interpreter is needed to communicate with a patient who is deaf. A native language translator will be needed to communicate with a patient who does not speak English.

A stuporous or very lethargic patient may be roused if you talk louder or shake the person gently. He or she may or may not be able to cooperate fully. The practitioner may have to modify the treatment plan or how it is administered to compensate for the patient’s lack of cooperation.

Pain relievers and sedatives may make a normally alert patient seem stuporous. If the patient has not been medicated, check with the nurse or physician to see what may have recently changed in the patient’s condition.

A semicomatose patient may present the greatest problems in providing treatment or performing a procedure. These patients do not cooperate in any way but are unlikely to fight treatment either. In addition, some of their involuntary body posturings make correct positioning impossible. You must modify your equipment or procedure to accommodate the patient’s inability to cooperate.

5. Does the patient complain of dyspnea? (Code: IB5c) [Difficulty: ELE: R, Ap; WRE: An]

Dyspnea is the patient’s subjective feeling of shortness of breath (SOB) or labored breathing. This is normal after vigorous exercise but abnormal in a resting patient. Orthopnea is the condition in which a patient must sit erect or stand to breathe comfortably. Lying flat causes dyspnea.

Box 1-1 classifies the degrees of dyspnea, and Table 1-11 lists different kinds of dyspnea, including orthopnea. Only class I is normal dyspnea (on severe exertion). Classes II to V are progressively severe and limiting for the patient. Any orthopnea is abnormal, and the more the patient must sit up to breathe, the more limited the patient.

BOX 1-1 Degrees of Dyspnea

Modified from Burton GG: Practical physical diagnosis in respiratory care. In Burton GG, Hodgkin JE, editors: Respiratory care: a guide to clinical practice, ed 2, Philadelphia, 1984, JB Lippincott.)

Class I Dyspnea only on rigorous exertion (“appropriate” dyspnea)
Class II Able to keep pace with person of same age and build on level ground without breathlessness but not on inclines
Class III Able to walk a mile at own pace without dyspnea but cannot keep pace on level ground with normal person
Class IV Dyspnea present after walking about 100 yards on level ground or ascending 1 flight of stairs
Class V Dyspnea on low-level activity or at rest

TABLE 1-11 Causes of Dyspnea Related to Preferred Body Position

Type of Dyspnea Clinical Correlations
Orthopnea (must sit up to breathe; often occurs at night as paroxysmal nocturnal dyspnea) Congestive heart failure
Obstructive sleep apnea (periodically stops breathing, particularly when lying on back) Obesity; obstructive sleep apnea syndromes
Emphysematous habitus Chronic obstructive pulmonary disease (COPD)
Platypnea Pleural effusion; dyspnea associated with various body positions
Orthodeoxia Pulmonary fibrosis; improvement in dyspnea when patient lies flat

From Burton GG: Patient assessment procedures. In Barnes TA, editor: Respiratory care practice, Chicago, 1990, Mosby.

The following are examples of questions to ask in evaluating dyspnea:

1. “How far can you walk before you feel short of breath?”
2. “How many flights of stairs can you climb before you experience SOB?”
3. “How far can you walk when walking as fast as your spouse?”
4. “Is there anything you do that makes the SOB worse?”
5. “Is there anything you do that makes the SOB better?”
6. “How long does the SOB last after you stop to rest?”
7. “Is the SOB worse at any particular time of the day?”
8. “Is the SOB worse at any particular time of the year?”

The following are examples of questions to ask in evaluating orthopnea:

1. “Do you wake up at night with SOB?”
2. “Does your nighttime SOB get better after you sit up on the side of your bed or in a chair?”
3. “Do you get SOB when lying down to take a nap?”
4. “Do you use extra pillows behind your head and back to help you not get SOB at night or during a nap?”
5. “How many pillows do you need to keep you from getting SOB at night or when taking a nap?”

Dyspnea, like pain, is based on the patient’s level of discomfort. Some patients may complain of dyspnea, whereas others may not. The therapist can get an impression of the patient’s dyspnea by how many words can be spoken continuously. A patient with severe dyspnea cannot complete even a short sentence on a single breath.

6. What is the patient’s sputum production like? (Code: IB5c) [Difficulty: ELE: R, Ap; WRE: An]

a. Time of maximal and minimal expectoration

Interview the patient to determine the following:

1. Time of maximal expectoration

Ask the patient, “When do you cough up the most? For example, is it in the morning; after eating spicy foods; after a breathing treatment; after smoking, work, or other exposure to dusts?”

2. Time of minimal expectoration

Ask the patient, “When do you cough up the least? For example, during certain nonallergic seasons of the year, after a breathing treatment, after consuming milk or milk products?”

b. Quantity

Some practitioners prefer to know of a specific amount such as a teaspoon, tablespoon, 10 mL, and so on. Others prefer to use subjective measures, such as “a little” or “a lot.” Interview the patient to determine the following:

1. How does the quantity of sputum relate to the times of maximal and minimal expectoration and the patient’s lifestyle?

Ask the patient, “Is there anything you do that increases or decreases the amount you cough out?” For example, the patient states that he coughs up 20 mL after breathing treatments but can cough up nothing after eating a bowl of ice cream.

2. Does the amount coughed up change in a cyclical way?

Ask the patient, “Do you cough up the most in the mornings or at night? Is there a work or lifestyle habit that changes how much you cough up? Is there a seasonal allergic condition that influences your asthma and sputum production?”

c. Adhesiveness of the sputum

Interview the patient to determine the following:

1. Are there times of the day or things that you do in the day that seem to result in your secretions becoming thicker or thinner?

2. Do your medications (like acetylcysteine [Mucomyst]) make the secretions easier to cough out?

3. Do some foods make your secretions easier to cough out?

7. What is the patient’s exercise tolerance? (Code: IB5c) [Difficulty: ELE: R, Ap; WRE: An]

Exercise tolerance refers to how active a person can be before feeling the need to slow down or stop. A normal person at rest should feel no difficulty breathing. During vigorous exercise, a person should be aware that he or she is working harder than normal to breathe. This is to be expected. However, after recovering from exercise, the work of breathing should again be easy.

In a person with cardiopulmonary disease, work of breathing (WOB) refers to the patient’s subjective feeling of how difficult it is to breathe during a given activity. Patients with acute or chronic lung disease often feel that they are breathing with some difficulty with little or no activity. Because this is a subjective feeling of the patient, it is helpful to have the patient quantify it. Ask the patient to rate his or her WOB on a 1-to-10 scale with 1 being easy breathing and 10 being extremely difficult.

If bronchospasm or secretions have increased, the patient will tell you that his or her WOB has worsened. If medications such as bronchodilators or mucolytics are effective, the patient should feel that his or her breathing is easier. Because of this, the patient can exercise more vigorously.

MODULE D

Use observation (inspection) to determine the patient’s overall cardiopulmonary condition

1. Evaluate the patient’s general appearance (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Start by quickly inspecting the patient from head to toe, including how he or she is dressed and found in the room. Ideally, this is done without the patient knowing that he or she is being observed. The patient who does not have cardiopulmonary disease should be able to lie flat in bed or on either side without any breathing difficulty. The patient with one-sided lung disease may prefer to lie with the good side down. This might be the case with lobar pneumonia, pleurisy, or broken ribs. The patient with severe airway obstruction, as seen in asthma, bronchitis, or emphysema, tends to sit up in a chair or on the edge of the bed and use locked arms and shoulders for support. This enables the patient to use accessory muscles (Figure 1-16). The patient with orthopnea will not want to lie down flat because of the resulting SOB. This is commonly seen in patients with congestive heart failure and pulmonary edema.

image

Figure 1-16 Typical posture seen in patients using accessory muscles of respiration. The shoulders are locked so that the accessory muscles can be used more effectively.

(Adapted from Burton GC, Hodgkin JE, editors: Respiratory care, ed 2, Philadelphia, 1984, Lippincott, Williams and Wilkins.)

2. Determine whether the patient is cyanotic (Code: IB1a) [Difficulty: ELE: R, Ap: WRE: An]

Cyanosis is an abnormal blue or ashen gray coloration of the skin and mucous membranes. It is most easily seen in white persons by looking at the lips and nail beds. It can be seen in darker pigmented people by looking at the inner portion of the lip, the inner portion of the lower eyelid, and the nail beds. Commonly, cyanosis is said to be caused by hypoxemia, and that the more bluish a patient’s color, the more hypoxemic he or she is. This often is the case, but cyanosis is not an accurate measurement of a patient’s oxygenation. To be safe, a patient with cyanosis should have an arterial blood gas sample drawn for Pao2 measurement or a pulse oximetry (Spo2) measurement performed to evaluate oxygenation.

3. Determine whether the patient is diaphoretic (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Diaphoresis is profuse sweating. It normally is seen after vigorous exercise. A patient is expected to sweat after a stress test or even an oxygen-assisted walk. Diaphoresis in a patient who is resting in bed should be investigated. When the body is severely stressed, it releases adrenaline into the bloodstream. Diaphoresis is one of many bodily effects caused by the release of the hormone adrenaline. Similar sweating may be seen if a large enough dose of the drug epinephrine is given.

Diaphoresis is a nonspecific sign of serious cardiopulmonary difficulties. It may be seen any time the patient is in shock or hypoxemic. Patients with a myocardial infarct are commonly diaphoretic. The practitioner should promptly evaluate the diaphoretic patient’s pulse, respiratory rate, blood pressure, and arterial blood gases.

4. Determine whether the patient has clubbing of the fingers (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Clubbing of the fingers (also known as digital clubbing) is an abnormal thickening of the ends of the fingers. It also can occur in the toes. The key finding is an angle of more than 160 degrees between the top of the finger and the nail when seen from the side. Clinically, you will notice both a lateral and an AP thickening of the ends of the fingers (Figure 1-17 shows a comparison of normal fingers and clubbed fingers). The fingernail and toenail beds may be cyanotic.

image

Figure 1-17 Clubbing. A, Normal fingernail angle is 160 degrees. B, Early mild clubbing appears as a flattened angle between nail and skin (180 degrees). C, Advanced clubbing shows a rounded (clubbed) fingertip and nail. To assess clubbing by Schamroth’s diagnostic method (D and E), place the nails of the second digits together. Obliteration of the normal diamond-shaped space between the nails is an abnormal finding, signifying clubbing.

(From Copstead-Kirkhorn LC, Banasik JL: Pathophysiology, ed 4, St Louis, 2010, Saunders.)

The underlying cause is not completely understood but at least in part seems to be chronic hypoxemia. This results in arteriovenous anastomosis with thickening of the tissues. The list of diseases in which clubbing is seen includes COPD, bronchogenic carcinoma, bronchiectasis, sarcoidosis, and infective endocarditis.

5. Determine whether the patient has edema (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Edema is an abnormal accumulation of fluid in the interstitial spaces of the tissues and potential spaces of the body. Peripheral edema is seen when fluid leaks from the capillary bed into the tissues beneath the skin in the ankles and feet or along the back when the patient is lying supine in bed. The extent of the edema is measured by pressing a finger into the tissues. Normal skin springs back, whereas edematous skin is pitted or depressed. The pitting edema is graded as 1+ for less than ¼;-inch (mild), 2+ for ¼- to ½-inch (moderate), and 3+ for ½- to 1-inch (severe) indentation. Obviously, the deeper the pitting, the more peripheral edema the patient has.

Peripheral edema is most commonly seen in patients with congestive heart failure and those who have a fluid overload. Patients with septicemia often have peripheral edema because the blood-borne pathogen (usually Staphylococcus) causes abnormal capillary leakage.

Many patients with edema from heart failure also have excessive venous distention of the neck veins. The internal jugular vein and external/anterior jugular vein are observed in the normal patient by having him or her lie supine with the head elevated 30 degrees. The crest of the vein column should be seen just above the border of the mid-clavicle. Make a rough measure of the intravascular volume and CVP by pressing on the veins at the base of the neck. The returning blood should fill the veins and make them distend (Figure 1-18). When the pressure is released, the veins should return to their previous level of distention just above the level of the mid-clavicle. Increased venous distention is noted when the veins stand out at a level above the clavicle. This is seen in patients with right-sided heart failure (cor pulmonale), cardiac tamponade, fluid overload, and COPD and when high airway pressures and positive end-expiratory pressure (PEEP) are needed for mechanical ventilation. The more the veins are distended, the more the patient is compromised.

image

Figure 1-18 Evaluating distention of the external jugular vein. These photographs show a patient with right-sided heart failure. Note that the left photograph shows the external jugular vein distended above the level of the clavicle. The right photograph shows how pressing a finger over the external jugular vein results in its further filling with blood and distending. In a normal person, when the pressure is released, the vein collapses to just above the superior border of the midclavicle. See the text for further discussion.

(From Daily EK, Schroder JS: Techniques in bedside hemodynamic monitoring, ed 5, St Louis, 1994, Mosby.)

It is not normal for the veins to collapse below the clavicle when the obstructing finger is removed. If this is seen, the patient should then have his or her head laid flat. Normally, when flat, the external jugular vein should be seen as partially distended. If the vein collapses on inspiration, low venous pressure is confirmed, and the patient probably is hypovolemic. This is commonly seen with dehydration, hemorrhage, or increased urine output after the use of diuretics.

A patient with heart failure also commonly has decreased capillary refill. Capillary refill is the time needed for blood to refill the capillary bed after it has been forced out. The procedure is to pinch the finger or toenail until it blanches and then release the pressure. The pink color of the nailbed should return in less than 3 seconds. Any delay in the return to pink color indicates reduced blood flow to the extremities. Cyanotic nail beds also are seen with reduced blood flow. Examples of conditions that result in decreased capillary refill include decreased cardiac output, low blood pressure from any cause, and the use of vasopressor medications.

6. Determine the patient’s chest wall movement (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Normal infants and adults have symmetrical chest movement when breathing at rest or during exercise. All breathing efforts are best observed when the patient is sitting up straight or standing erect and shirtless. Ideally, look at the patient from the front, back, and both sides to see the symmetry. In female patients, it may be necessary to observe only the uncovered back to judge chest movement. Any kind of asymmetrical chest movement is abnormal. The asymmetrical movement may result from an abnormality of the chest wall or abdomen or from a pulmonary disorder.

a. Thoracic scoliosis or kyphoscoliosis

Several variations on curvature of the spine are found. Kyphosis is an exaggerated AP curvature of the upper portion of the spine. Lordosis is an exaggerated AP curvature of the lower portion of the spine. Scoliosis is either a right or left lateral curvature of the spine. Kyphoscoliosis is either a right or left lateral curvature combined with an AP curvature of the spine.

Figure 1-19 shows the back view of a patient with thoracic scoliosis or kyphoscoliosis. The patient with scoliosis in Figure 1-19 tends to have more chest movement on the right side because of the right spinal curvature. The left side of the chest and left lung would inflate more than the right if the spine curved to the left. These same findings are seen in a patient with kyphoscoliosis.

image

Figure 1-19 Normal and abnormal spinal curves. The patient should sit or stand erect during examination.

b. Flail chest

The flail segment moves in the opposite direction from the rest of the chest (this is also known as paradoxical movement). That is, with inspiration, the flail segment moves inward while the rest of the chest moves outward, and during expiration, the flail segment moves outward as the rest of the chest moves inward. As the ribs heal, the segment stabilizes and moves with the rest of the chest.

c. Pneumothorax

The side with the collapsed lung does not move as much as the chest wall over the normal lung (see Figure 1-2).

d. Atelectasis/pneumonia

The side with the atelectasis or pneumonia does not move as much as the chest wall over the normal lung (see Figure 1-5).

Normally, an adult’s diaphragm moves downward several centimeters toward the abdomen during inspiration as the chest wall moves outward. This is seen when the abdomen protrudes as its contents are forced forward. The chest and abdomen should rise and fall together during quiet and vigorous breathing efforts. In two conditions, this normal chest and abdominal movement does not occur.

First, in patients with emphysema, severe air trapping, and a barrel chest, the diaphragm is depressed and flat rather than domed because of the air that is trapped in the lungs. On inspiration, the diaphragm still contracts, but it is unable to displace the abdominal contents downward to permit air to be drawn into the lungs. These patients do not have the expected abdominal movement during inspiration. They use the accessory muscles of inspiration to assist breathing.

Second, the normal movement does not occur in any condition in which airway resistance is increased or lung compliance is decreased. The greater negative intrathoracic pressure needed to draw the tidal volume into the lungs can cause the chest wall to collapse inward as the abdominal contents are displaced outward. The result is a kind of “seesaw” or paradoxical movement relation between the chest wall and abdomen. On inspiration, the chest wall may move inward as the abdomen moves outward. Patients with RDS typically demonstrate this because the premature neonate’s rib cage is relatively compliant compared with the stiff lungs (Figure 1-20).

image

Figure 1-20 Physical indications of labored breathing in a newborn.

Exam Hint 1-5 (WRE)

Frequently a question relates to physical signs that a patient has a pneumothorax. This could include asymmetrical chest movement. The chest wall on the side with the pneumothorax will not move as much as the normal side during breathing.

7. Determine whether the patient uses accessory muscles when breathing (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

Accessory muscles of respiration should not be needed during passive, resting breathing. They are normally used when a person is breathing vigorously during exercise. A dyspneic patient likely will use them even when resting; this indicates that the WOB is greatly increased. The primary accessory muscles of inspiration are the intercostal, scalene, sternocleidomastoid, trapezius, and rhomboid muscles. The abdominal muscles are used during active expiration. The easiest accessory muscles of inspiration to observe in action are the sternocleidomastoids from the front and side of the patient and the trapezius from the back of the patient (Figure 1-21). Their use is not specific for any one condition but is commonly seen in an adult patient with emphysema (see Figure 1-16).

image

Figure 1-21 Sternocleidomastoid and trapezius accessory muscles of respiration.

Contraction of the dilator nares muscles (so-called nasal flaring) during inspiration further opens the nasal passages. A person breathing comfortably should have little or no nasal flaring. A person who is exercising vigorously may show nasal flaring in an attempt to reduce airway resistance. Nasal flaring is abnormal in a patient resting in bed, and it is a sign of increased work of breathing, especially in a neonate. Examples of conditions in which nasal flaring is seen include RDS (see Figure 1-20), acute respiratory distress syndrome (ARDS), and any condition in which pulmonary compliance is decreased or airway resistance is increased.

When a person with cardiopulmonary disease is using the inspiratory accessory muscles, intercostal or sternal retractions often are seen. A normal person breathing at rest should not have any retractions. That same person may have some minor retractions during vigorous exercise. Retractions of any kind are abnormal in any patient of any age who is resting in bed. Retractions are commonly seen in conditions in which airway resistance is increased or lung compliance is decreased. Both increase a patient’s WOB. The patient must generate a more negative intrathoracic pressure to breathe, and as a result, the various soft tissues are drawn inward during inspiration.

Intercostal retractions are noticed when the soft tissues between the ribs are drawn inward during inspiration as the chest wall moves outward. Suprasternal retractions are noticed when the soft tissues above the sternum are drawn inward during an inspiration as the chest wall moves outward. Substernal retractions are noticed when the soft tissues below the sternum are drawn inward during an inspiration as the chest wall moves outward (see Figure 1-20). Conditions in which retractions are seen include RDS, ARDS, pulmonary edema, pneumonia, asthma, bronchitis, and emphysema.

8. Determine the patient’s breathing pattern (Code: IB1a) [Difficulty: ELE: R, Ap; WRE: An]

The various respiratory patterns can be identified by their characteristic respiratory rate, respiratory cycle, and tidal volume. Figure 1-22 shows a normal adult breathing pattern, and Figure 1-23 shows examples of normal and abnormal breathing patterns.

image

Figure 1-22 Eupnea. Pause is the time from the end of exhalation to the beginning of inspiration. I, Inspiratory time; E, expiratory time.

image

Figure 1-23 Representative drawings of normal and abnormal respiratory patterns.

(Modified from Seidel HM, Ball JW, Dains JE, et al: Mosby’s guide to physical examination, ed 6, St Louis, 2006, Mosby.)

a. Eupnea (normal breathing)

1. Normal respiratory rate for the age of the patient (see Table 1-2)
2. Normal respiratory cycle. When timing the flow of air into and out of the lungs, the inspiratory/ expiratory (I : E) ratio is about 1 : 2. A pause of variable time may follow exhalation of the tidal volume. This could change the true I : E ratio from 1 : 2 to 1 : 4
3. Tidal volume is normal for the size of the patient. (See Chapter 4 for calculation of a predicted tidal volume.) Inspiration is achieved without the use of accessory muscles of inspiration; exhalation is passive
4. A person usually sighs every few minutes; especially when inactive. A sigh breath typically is about 1.5 times as large as a tidal volume. It is thought to help prevent atelectasis. Frequent sighing may indicate a problem

b. Hypopnea (shallow breathing)

1. Respiratory rate usually somewhat slower than normal
2. Normal respiratory cycle
3. Tidal volume decreased for the size of the patient
4. Possible causes: deep sleep, sedation, coma, hypothermia, alkalemia, restrictive lung disease
5. May be combined with bradypnea

Related posts:

Intermittent Positive-Pressure Breathing Home Care and Pulmonary Rehabilitation Humidity and Aerosol Therapy Special Procedures Blood Gas Sampling, Analysis, Monitoring, and Interpretation Mechanical Ventilation of the Adult