consolidation - replacement of alveolar air with solidified lung that can transmitt higher frequency sounds better; decreases air/fluid ratio

atelectasis is a type of consolidation in which air is reabsorbed into the blood serum distal to a physicla obstruction of an airway => aveolar collapse => dense infiltrates, crowding of the ribs, and shifting of the affected interlobal fissures on x-ray; also decreases air/fluid ratio

obstructive lung disease - decreased expiratory flow resulting from increased airway resistance => air trapping => pulmonary hyperinflation => increases air/fluid ratio

asthma, emphysema, bronchitis, bronchiectasis, cystic fibrosis,

restrictive lung disease - decreased inspiratory flow resulting from decreased pulmonary compliance => air can't get in, because lungs are stiff => decreases air/fluid ratio

pulmonary fibrosis

pneumothorax - atmospheric air pressure enters the pleural space, causing lung collapsechest wall expanding outward, and visceral and parietal pleura to separate from each other

symptoms of a pneumothorax are determined by the size of the air leak and the speed by which it occurs; they may include chest pain in most cases and shortness of breath in many. The diagnosis can be made by physical examination in severe cases but usually requires a chest X-ray or computed tomography (CT scan) in milder forms. In a small proportion, the pneumothorax leads to severe oxygen shortage and low blood pressure, progressing to cardiac arrest unless treated; this situation is termed tension pneumothorax.

History: tension pneumothorax - a stab wound or gunshot wound, allows air to enter the pleural space, or because of injury to the lung; receiving mechanical ventilation

pneumothorax - lung disease, or spontanous

lung boundaries

superiorly - lungs extend 3-4 cm above the clavicles

inferiorly - lunch extend to the 6th rib in the midclavicular line; 8th rib in midaxillary line, and 9-12 rib posteriorly

trachea bifurcates at the level of the sternomanubrial angle anteriorly, and T4 posteriorly

anteriorly - upper lobes and right middle lobe dominate the findings

laterally - right middle lobe (well over the lateral chest wall)

posteriorly - lung sounds from lower obes dominate the surface area of chest wall; above the scapula (T3) is where you can hear upper lobes posteriorly

normally, abdominal wall moves synchronously outward with the chest wall during inspiration and retracts synchronously with the chest wall during expiration

respiratory paradox - chest wall moves outward, but abdominal wall moves inward with inspiration

significance => diaphragmatic weakness or paralysis

less than 4 cm is abnormal

obstructive lung disease - since there's increased air/fluid ratio, you'd expect thoracic expansion to increase, but it decreases

restrictive lung disease - thoracic expansion decreases

also in pneumothorax

tactile fremitus - when larynx generates sound, the sound is transmitted downward through the tracheobronchial tree, into the lung parenchyma, across the pleural surface and chest wall => palapble thrill on surface of chest wall

measured symmetrically from side/side and top/bottom

pulmonary edema - since consildation dec. air/fluid ratio, expect increased tactile fremitus

tumor obstructing an airway - expect dec. tactile fremitus, since a large airway obstruction lessens the intensity of VTF

pneumothorax - since it inc. air/fluid ratio, expect dec. tactile fremitius

atelectasis - since it dec. air/fluid ratio, expect inc. tactile fremitus

emphysema - since it inc air/fluid ratio, expect dec. tactile fremitus

pneumonia - since it dec. air/fluid ratio, expet inc. tactile fremitis

foreign body obstruction - since it obstructs large airways, less air can be used to produce a VTF => dec. tactile fremitis

tracheal deviation - relative volumes on the thoracic cage, and tractive forces on the large airwas can pull the trachea away from the midline

atelectasis on the right - pulls trachea toward right

pneumothorax on the right - pulls trachea towards left

massive pleural effusion on right -> pulls trachea towards left

tension pneumothorax on the right -> pulls trachea to left

pneumonia on right -> pulls trachea to left

character of note - density of the tissue through which the sound waves pass. Water-dense tissue  - high pitched note of low intensity; air -dense tissue produces a low-pithced note of high intensity

tympany - lowest pitched and loudest of the notes - highest air/fluid ratio - pneumothorax

hyperresonnce - low pitched note high air/fluid ratio -> emphysema or smaller pneumorthorax

resonance - low pitched during normal breathing

dullness - low air/fluid ratio - consolidation or pulmonary fibrosis

flatness - lowest air/fluid ratio - large pleural effusion

normal limits of excursion - 3-6 cm

the right hemi-diaphragm normally percusses 1 to 2 cm higher than the left hemi-daiphgram, each hemi-diaphragm should move about the same distance

the left hemidiaphragm will percuss higher than the right hemidiaphgram when there is paralysis of the left hemi-diaphragm

dullness to percussion - implies consolidation either due to pneumonia (local) or pulmonary fibrosis (widespread)

increased tactile fremitus - implies consolidation

egophony at the tip of left scapula - pulmonary consolidation

vesicular - long inspiratory, short expiratory, normally heard on periphery of lung

bronchovesicular - equal inspiratory and expiratory, normally heard over central large airways parasternal or between the scapula

bronchial breath sounds - short inspiratory, long expiratory, heart over the intrathoracic trachea

expiratory breath sounds - turbulent flow in the large bronchi and trachea

inspiratory breath sounds - vorticose airflow in the smaller branching lobar and segmental airways

bronchial/bronchovesicular breath sounds over the periphery - implies decrease in air/water ratio

crackle has two mechanisms

(1) opening of small airways due to the sudden equalization of pressures between the small airways and the alveoli

(2) breaking of small bubbles or mucus films located in the medium to large conducting airways

velcro crackles => pulmonary fibrosis

small bronchioles and aveolar ducts opening

early-mid inspiratory crackles => large-to-medium sized airways => bubbling of air through thin secretions

obstructive disease

late-inspiratory crackles => small bronchioles and alveolar ducts -> popping open during inspiration

consolidation - pulmonary edema or pneumonia

or pulmonary fibrosis

wheezes - caused by vibrations of the opposing walls of narrowed airways

best predictor of airway obstruction

inspiratory wheezes - severe obstruction

expiratory wheezes - obstruction due to asthma, intrabronchial tumor, or foreign body

polyphonic wheezing - asthma

monophonic wheezing - intrabronchial tumor or foreign body

localized wheezing - more likely to be focal airway obstruction (foreign body aspiration, or tumor)

diffuse wheezing - more likely to be asthma

stridor - loud, long, high-pitched musical inspiratory sound

=> upper airway obstruction

inspiration stridor -> tracheal, epiglottic, or laryngeal obstruction => medical emergency (croup)

expiratory stridor -> aspirated foreign body

bronchial breath sounds over the midthoracic vertebrae (d'Espine's sign) =>

mass located in the posterior mediastinum

lymph node enlargement

low frequncy conversational speech is transmitted; higher frequency is lost normally

bronchophony - spoken voice increased transmission over chest wall

whisphered pectoriloquy - increased in transmission of high-pitched whisphered sounds (66 please); periphery is compared to the trachea

egophony - long e -> long 'a' -> most sensitive finding for pulmonary consolidation