Pulmonary Evaluation

Authors
Affiliations

Nate Yomogida, B.S., SPT

Doctor of Physical Therapy

B.S. in Kinesiology

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Subjective

Patient history/chart review—as per all patients

Environment

  • Environmental or occupational toxins

History

  • Smoking history
  • History of pneumonia, thoracic procedures or surgery
  • History of assisted ventilation or mechanical ventilation
  • History or current reports of dyspnea
  • History of baseline sputum production
    • Color
    • Consistency (is it sticky, thin, fluid) (if smelly– cld indicate infection)
    • Amount
  • Sleeping position, number of pillows

Physical Exam

Observation

  • General appearance, alertness
  • Ease of phonation
  • Skin color
  • Posture and chest shape
  • Breathing pattern
  • Supplemental O2 needs (nasal cannula, mask, ventilator etc)
  • Surgical incisions

Auscultation

Normal

  • Example
  • Tracheal or bronchial (normal, named where u should hear them)
  • Bronchovesicular
  • Vesicular

Abnormal

  • Adventitious (crackles, rales)
  • Added (showing up in areas where they should not be)
  • Location: Abnormal if heard outside normal location or changed in some way
  • Bronchial (where should be vesicular):
    • Could mean there is fluid or secretion consolidation; pneumonia
  • Decreased or diminished
    • Hypoventilation, severe congestion, emphysema
  • Absent
    • Pneumothorax or lung collapse (emergency situation- chest tube needed)
  • Adventitious breath sounds:
    • Continuous
      • Wheezes
      • Rhonchi
      • Stridor
    • Discontinuous
      • Crackles

Documentation

  • Location: (base, Right vs Left etc)
  • Phase of respiration (inspiration, expiration)
  • Comparison to opposite lung

Pulmonary Palpation

  • Presence of fremitus (where u can feel chest pain/congestion location)
  • Presence of pain, tenderness
  • Skin temp (ie could mean pneumonia on R vs L)
  • Bony abnormalities, rib fx
  • Chest expansion (try to breathe in to my hands, PT - put your hands around bottom of rib cage on side)

Cough Evaluation

  • Effectiveness
  • Control
  • Quality
  • Frequency
  • Sputum Production
  • Hemoptysis

Effectiveness

  • Effectiveness (clearing secretions) → weak cough = hear junk in lungs, they cant cough well, OR sci injury, cant produce enough force to clear secretions)
  • Example: SCI may not be able to produce enough force to clear their airway

Control

  • Control (start and stop cough)– can they voluntarily cough then stop?

Quality

  • Wet vs Dry
  • Cough and if you hear wet stuff, or is it dry

Frequency

  • Do they cough every couple of min
  • Do they cough w activity
  • etc

Sputum Production

  • look what they are coughing up
  • Color
  • Quantity
  • Odor
  • Consistency– tenacious, clinging to sides of someone’s lungs– sticky, clay, silly putty

Hemoptysis

  • Color: Dark red vs. bright red (blood)
    • Dark red= after surgery (like a scab type)
    • Bright red= someone actively bleeding. Can make difference in if you continue clearance or no
  • Volume
    • <5ml CAN continue airway clearance techniques (about a teaspoon)
    • .>5ml—unclear
      • Autogenic drainage (gentle)
        • Focused on breathing– can use in combo w postural drainage, but focused on moving it up the mucociliary ladder she says
      • Active cycle of breathing

Oximetry

  • Signs and symptoms of hypoxemia (cld indicate lack of o2)
    • Tachypnea
    • Tachycardia
    • Restlessness
    • Malaise
    • Impaired judgment
    • Incoordination
    • Vertigo
    • Nausea
    • Labored respiration
    • Cardiac dysrhythmia
    • Confusion

Arterial blood gas

  • Acid base balance (pH) – ie respiratory or metabolic alkalosis or acidosis can affect it)
  • Ventilation (CO2)
  • Oxygenation (O2)
  • Imbalances due to pulmonary or metabolic reasons
    • Acidosis
      • Respiratory or metabolic
    • Alkalosis
      • Respiratory or metabolic

Normal ABG values

  • PaO2 >80 mmHg
  • PaCO2 35-45 mmHg
  • pH 7.35-7.45
  • HCO3 → 22-26 mEq/liter

flowchart TD

  pH[pH] --> low-ph[Low pH]
  pH --> normal-ph[Normal pH]
  pH --> high-pH[High pH]

  low-ph --> acidemia[Acidemia]
  acidemia --> highPCO2[high PCO2]
  acidemia --> lowHCO3[Low HCO3]
  highPCO2 --> respiratory-acidosis[Respiratory Acidosis]
  lowHCO3 --> metabolic-acidosis[Metabolic Acidosis]

  normal-ph --> normal-acid-base[No abnormally or Mixed Acid-base Disorder]

  high-pH --> alkalemia[Alkelemia]
  alkalemia --> low-PCO2[Low PCO2]
  alkalemia --> high-HCO3[High HCO3]
  low-PCO2 --> respiratory-alkalosis[Respiratory Alkalosis]
  high-HCO3 --> metabolic-alkalosis[Metabolic Alkalosis]

Note

Another step after metabolic vs respiratory== compensated vs uncompensated (dont need to know but interesting)

Venous Blood gases

  • Also called mixed blood gases
  • Less common that ABG
  • Provides info about body’s metabolic workload/efficiecy
  • Large inc in Sv CO2 (in venous system= co2)
    • Inefficient/deconditioned peripheral mm
    • Overall deconditioning

Chest X-rays

Diagnosis and monitor progression

Sputum analysis

  • (cough sputum in clean tube)
  • Identify organisms in lungs for treatment
  • Indications
    • Rise in pt temp
    • Change in sputum color or consistency
    • Sterile containers req’d
    • PT may assist or collect during bronchopulmonary hygiene

Bronchoscopy

  • Directly visualize and aspirate the bronchopulmonary tree (trying to see blockage, and try to clear)
    • If struggling to maintain appropriate O2 ventilation
    • Pts are FATIGUED after this
    • Box 4-2 , p 71 for indications
  • Fatigue post procedure

Pulmonary Function Tests

  • Measures lung volumes, capacities, flow rates
  • Distinguishes between obstructive or restrictive dx
  • Determines contribution of pulmonary function to activity limitations
  • Compare between normal and previous test results
  • TOTAL LUNG CAPACITY INC = Obstructive! - widened rib cage, lots of capacity, not good air exchange at alveoli
  • Reduced total lung capacity - restrictive

Pulmonary Embolism

Diagnosing PE

  • V/Q scan (if u see this scan, WITHHOLD PT TXT, bc cld have PE)
    • Rule out pulmonary embolism
    • Looking for mismatch in ventilation and perfusion
  • Computed tomographic pulmonary angiography (CT-PA) (if u see this scan, WITHHOLD PT TXT, bc cld have PE)
    • Direct visualization of pulmonary artery
    • Rapid detection of thrombus
    • Now preferred method of diagnosing PE

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