1. Intro
   1. Clinical Reasoning & Decision Making Process
   2. – Although patients may be referred to the PT for a primary cardiovascular &/or pulmonary impairment, they may also have a 2° cardiovascular &/or pulmonary impairment that may or may not have been diagnosed or identified – Screening for risk factors for cardiovascular & pulmonary issues is essential in all patients
2. History: Review & Interview
   1. Medical Chart REview
   2. Pt/Fam Interview
      1. Example Strat for Reviewing Chartings:
         1. Subtopic 11. Read Hx & physical & admission medical notes (i.e. the preadmission symptoms, past medical history) – this includes the physicians notes & nurses notes 2. Read the most recent medical notes 3. Scan the remainder of the chart 4. Read any reports from medical specialists & consultants, such as pulmonologist, neurologist, or oncologists 5. Review any pertinent lab tests such as chest radiography, arterial blood gases (ABGs), CBC, cardiac tests, CAT scans, & MRIs 6. Review medications – in particular, pulmonary & cardiac drugs 7. Review any procedures performed (i.e. surgery, intubation, chest tubes, NG tubes) 8. Review the psychosocial information (i.e. family, support systems, education, financial concerns, psychological issues, architectural barriers)
      2. PT should consider the following questions:
         1. 1. What is the patient's smoking history? 2. Does the patient have a family history of premature coronary artery disease (i.e. parent/sibling=MI) 3. Can the symptoms presented also be signs of a cardiovascular pulmonary illness? 4. Does the patient have an active or a sedentary lifestyle? 5. What activities precipitate the patient's symptoms? 6. Does the symptoms include breathlessness? 7. Are there problems with airway clearance, congestion, etc.?
      3. FYI: Pt describing/c/o cramping leg pain is suggestive of peripheral vascular disease (PVD)
3. System Review & Test & Measures
   1. Physical Exam of Chest
      1. 1. First examine muscle strength, ROM, activity & function 2. Next Examine the chest A. Begin by obtaining vital signs (BP, HR, T, etc) B. Then progress to examination of chest wall & auscultation of heart & lungs
4. Topographic Anatomic Landmarks
   1. Key Anatomical Structures:
      1. 1. Sternum 2. Clavicle's 3. Suprasternal notch 4. Sternomanubrial angle (angle of Louis for ID of Rib 2) 5. Costal angle 6. Vertebral prominens
   2. Anterior View of Thorax=3 Verticle lines
      1. 1. (1) Midsternal Line (MSL) – a vertical line bisecting the sternum 2. (2) Midclavicular Lines (MCLs) – parallel to the MSL, bisecting each clavicle; the borders of the lower longer cross Rib 6 @ the MCLs
   3. Lateral View of Thorax=3 vertical lines originating in their respective axillary folds
      1. 1. (1) Anterior Axillary Line (AAL) 2. (2) Mid-axillary (MAL) 3. (3) Posterior Axillary Line (PAL) – like the MCLs, these lines are (B)
   4. Posterior View of Thorax=3 lines:
      1. 1. (1) Vertebral or Midspinal Line – runs through the spinous processes of the vertebrae 2. (2) Midscapular Lines (MSLs) – parallel to the midspinal line, bisecting the inferior angles of the scapulae
5. Visual Inspection
   1. General Appearance
      1. Examples of questions typical for acute care setting:
         1. 1. Does the patient appear comfortable? 2. Is there any facial grimacing? 3. Is the patient awake & alert or somnolent for disoriented? 4. Is there any nasal flaring, wheezing, or pursed lip breathing? (Signs of respiratory distress) 5. Are the accessory muscles of respiration hypertrophied? 6. How was the patient position? 7. Is the patient resting comfortably or leaning forward over the bedside table & struggling for breath? 8. What is the patient's build – stocky, thin, or cachectic? 9. Is the patient's mobility limited? 10. Can the patient sit unsupported? 11. Should the assessment be performed in stages? 12. Is there any extra equipment and the patient surroundings? 13. Is a patient using supplemental oxygen? 14. Is oxygen delivered through a nasal cannula or other device? 15. What is the fraction of inspired oxygen (FiO2)? 16. Are there any monitoring lines & where are they located (if the arterial line is present, is it placed in the radial or femoral artery?) 17. Are there any ECG leads? 18. Is it a hard line (directly connected to a monitor) or a telemetry line (communicating through radio transmitter)? 19. Are there IV sites? Are they peripheral (antecubital) or central (subclavian or jugular)? 20. Is there a urinary catheter? 21. Are there chest tubes?
      2. Visual inspection of general appearance does not apply only to the patient but also to the immediate surroundings, including in equipment or devices that may be attached to the patient
   2. Skin
      1. 1. Skin Pink, healthy color or pallor? 2. Is cyanosis present? 3. Scars, bruises, or ecchymosis observe? 4. Any reddened areas suggestive of prolonged pressure? 5. Any bony landmarks appear more prominent than usual? 6. Signs of trauma? 7. Edema? 8. Surgical incisions, new or old? 9. Evidence of clubbing of the digits?
      2. Cyanosis: bluish tinge central or peripheral
         1. Central Cyanosis
            1. – A result of insufficient gas exchange within the lungs & is not usually seen unless oxygen saturation is less than 80% – may be seen at the mucous membranes (i.e. tongue & lips)
         2. Peripheral Cynaosis
            1. – Occurs when oxygen extraction at the periphery is excessive – Is more closely associated with states of low cardiac output – observed in: fingertips, toes, nose & nail beds
         3. Central vs Peripheral Cyanosis
            1. – Peripheral cyanosis normally occurs in the cooler body parts, such as the nail beds, & usually vanishes when the part is warmed – Central cyanosis does not disappear when the area is warmed
   3. Neck
      1. – Are the accessory muscles of respiration being recruited for a resting breathing pattern? – Do the SCM or trapezius muscles appear prominent? – This is an early sign of obstructive lung disease
   4. Jugular Venous Distention
      1. – Right atrial pressure (RAP) is evident based on the extent to which the jugular venous pulse (JVP) can be visualized – The more superficial external jugular veins may be seen superior to the clavicles – The internal jugular veins, though larger, light deep beneath the SCMs & are less visible
      2. - Jugular venous distention (JVD) can be best seen when the patient lies with the head & neck at an angle of 45° & presence or absence of symmetry should be noted
         1. - The veins are distended bilaterally if there is a cardiac cause such as CHF
         2. - A unilateral distention is an indication of a localized problem
6. Chest Wall Configuration
   1. – The anteroposterior to lateral dimension is 1:2 or 5:7 – The angle the ribs is less than 90° – COPD patients: the ribs become more horizontal & the AP diameter increases = barrel chest
   2. Structural defects of the anterior chest may include:
      1. Pectus Excavatum or Funnel Chest
         1. A depressed lower sternum that usually causes restriction only when it is severe
      2. Pectus Carinatum or Pigeon Chest
         1. A prominent upper sternum that does not restrict chest wall movements
      3. Flail Chest
         1. An inward movement of the chest wall with inspiration, such as with multiple rib fxs
7. Breathing Patterns
   1. RR (normal)
      1. – Adults (ages 15+): 14-20 breaths/min – Newborns: 30-60 breaths/min – Early childhood: 20-40 breaths/min – Late childhood: 15-25 breaths/min
   2. Abnormalities:
      1. 1. Eupnea – normal breathing cycle 2. Apnea – temporary halt in breathing 3. Tachypnea – rapid, shallow breathing pattern; indicator of respiratory distress 4. Bradypnea – exist when respiration is slow to less than 12 breaths/min 5. Kussmaul Breathing – increased rate & depth of respiration & is associated with metabolic acidosis 6. Dyspnea – patient subjective feeling of SOB
         1. Document Dyspnea:
            1. Easy Method: Count the number of words that the patient is able to speak per breath
            2. 1. The Borg Scale 2. The Ventilator Response Index (VRI) 3. The American Thoracic Society Dyspnea Scale, the Bog Scale of Perceived Exertion
   3. – The normal ratio of inspiratory time to expiratory time is 1:2 – the ratio decreases to 1:1 when the respiratory rate increases which is seen in respiratory distress; as the patient struggles to breathe and, the expiratory phase a shortened & vicious cycle con't's – With pursed lip breathing the idea is to prolong the expiratory phase & slow the breathing pattern
8. Auscultation
   1. Def: art of listening to sounds produced by the body
   2. Stethoscope
      1. – Functions more as a filter to the extraneous noises than an amplifier – Bell portion: assesses low pitch sounds (i.e. heart sounds) – Diaphragm portion: discerns high-pitched sounds – Tubing = 30-35 cm long
   3. Technique
      1. – Quiet room – Clothing removed or draped – Patient sitting – The anterior, lateral, & posterior aspects of the check should be auscultated both craniocaudally and side to side
      2. 1 Method of auscultating the chest (chest & back)
   4. Chest Sounds
      1. Divided into 4 Categories:
         1. Breath Sounds
            1. normal, abnormal, adventitious
         2. Extrapulmonary sounds
            1. pleural or friction rubs
         3. Voice Sounds
            1. egophony, bronchophony, whispered pectoriloquy
         4. Heart Sounds
   5. Breath Sounds
      1. (Normal) Can be broken down into:
         1. Bronchial Sounds
            1. – High pitched & heard in both the inspiratory & expiratory phase – distinguishing feature = the pause between inspiratory & expiratory phases – also described as tracheal because they are normal location is over the trachea – loud, high-pitched; hollow quality; heard over manubrium; louder on expiration; distinct pause between inspiration & expiration
         2. Bronchovesicular Sounds
            1. – High-pitched & equal inspiratory & expiratory cycles – distinguishing feature = lack of pause – Heard best whenever the bronchi, or central lung tissue are close to the surface – Mixture of bronchial & vesicular; I:E is 1:1; heard over main stem bronchi anteriorly, ICS #1 & #2; posteriorly, btwn scapulae
         3. Vesicular Sounds
            1. – Heard over the remaining peripheral lung fields – Have primarily and inspiratory component, with only the initial one third of the expiratory phase audible – Intensity = softer – Soft, low pitched; heard over peripheral lung tissue; no pause between I & E; ratio is 3:1
      2. Abnormal Breath Sounds
         1. – Sound is filtered by the lung tissues because these organs are air filled; thus sound transmission is dampened over the bases more than over the apices – Sound transmission is enhanced when a liquid or solid is the medium
         2. Divided into 3 Types:
            1. Bronchial Sounds
            2. – Occur in peripheral lung tissue when it becomes careless – either partially or completely – a.k.a. Tubular breath sounds (means abnormal bronchial breath sounds)
            3. Decreased Sounds and Absent Sounds
            4. – Occur when sound transmission is diminished or abolished – Can be caused by an internal pulmonary pathology or can be secondary to an initially non-pulmonary condition
            5. Decreased
            6. Occurs when the normal vesicular sounds are further diminished
            7. Absent
            8. No sounds are audible
      3. Adventitious Breath Sounds
         1. Are the extraneous noises produced over the bronchopulmonary tree & are an indication of an abnormal processor condition
         2. Classified as:
            1. Crackles (rales)
            2. – Discontinuous, low pitched sounds – occur predominantly during inspiration – simulated by sound of rubbing here between fingers or Velcro popping – Usually indicates a peripheral airway process
            3. Rhonchi
            4. – Low pitched but continuous sounds – occur in both inspiration & expiration – it's quality described as "snoring" – Attributed to an obstructive process in the larger, more central airways
            5. Wheezes
            6. – Continuous but high-pitched – Testing or whistling quality is present – Wheezes that occur predominantly during inspiration = bronchospasm ~inspiratory wheezing indicates a bronchodilator is needed – Wheezes during exhalation = airway secretions ~expiratory wheezing suggest the need for airway clearance techniques
      4. Extrapulmonary Sounds
         1. – An adventitious sound that is nonpulmonary is the friction rub – Can be described as a rubbing or leathery found & it occurs during both inspiration & expiration – Sound is produced when the visceral (and are) pleural lining rubs against the parietal (outer) pleural and is a sign of a primary pleural process, such as inflammation or neoplasm – Pain is usually associated with a friction rub
      5. Voice Sounds
         1. – The voices sounds or vibrations heard through a stethoscope & produced by the speaking voice as it travels down the tracheobronchial tree & through the lung parenchyma – The sounds, over the normal lung, or low pitched & have a muffled or mumbled quality – Voice sounds or method of confirming abnormal breath sounds – To the patient was significant atelectasis 2° to compression of lung tissue presents with bronchial breath sounds, then egophony & bronchophony are also audible
         2. Bronchophony
            1. – Describes the phenomenon of increased vocal transmission – Were the letters are louder & clear – Caused by conditions in which there is increased lung density, as in consolidation due to pneumonia – Assessed by asking patient to repeat "blue Moon" or "one, two, three"
         3. Egophony
            1. – May be present when there is increase transmission of the vocal vibrations – Patient may be asked to say "eeee" – The underlying process distorts the "eee" sounds so that an "aaa" sound is heard over the peripheral area – Coexist with bronchophony
         4. Whispered Voice
            1. – Also produces low pitched vibrations over the chest that are muffled by normal lung parenchyma – Whispered pectoriloquy= whispered voice sounds become distinct & clear; "one, two, three" or "99" are used to evaluate the sound ~Can be present when bronchophony & egophony are absent ~The sound is helpful in identifying smaller patchy areas of lung consolidation
9. Heart Sounds
   1. – The left ventricular apex is normally located at the midclavicular line in the fifth intercostal space – Cardiac apex is also known as the point of maximum impulse (PMI), where the pulse is most strongly heard
   2. 4 Reference Areas for Cardiac Auscultation:
      1. 1. Aortic: 2nd intercostal space (ICS), @ right sternal border (RSB) 2. Pulmonic: 2nd intercostal space (ICS), @ left sternal border (LSB) 3. Tricuspid: 4th & 5th ICS, LSB 4. Mitral: Cardiac apex, 5th ICS, midclavicular line (MCL)
   3. Technique
      1. 1. Supine – used for all areas 2. Sidelying (left lateral decubitus) – listening to cardiac apex or mitral area, Bell usually used *most valuable because the pathological S3 and S4 sounds are heard most clearly 3. Sitting – used for all areas
   4. Normal Heart Sounds
      1. First heart sounds (S1) = closing of the atrioventricular valves – heard the loudest at the cardiac apex – 2 components of S1 = tricuspid & mitral Second heart sounds (S2) = closing of the semi lunar valves & end of ventricular systole – 2 components = aortic & pulmonic – During inspiration a splitting of S2 is audible; which results from the increased venous return to the right heart secondary to the decreased intrathoracic pressure that occurs during inspiration; the split is commonly heard in children & young adults; use the diaphragm of the stethoscope to hear it –Pulmonic component is the softer sound best heard at the LSB in the 2nd-4th ICS – when the split is heard in both phases of respiration, and underlying cardiac abnormality is suspected: right bundle branch block & pulmonary hypertension
   5. Gallops
      1. Third heart sounds (S3)= St., low frequency sound & reflects the early (diastolic) ventricular filling that occurs after the atrioventricular valves open – Normal and children & young adults; abnormal and individuals over age 40 – The bell of the stethoscope should be used – Ideal position to hear = side lying with Bell placed over cardiac apex – causes a pathological S3= ventricular failure, tachycardia, mitral regurgitation – Ken-TUCK-y= one sound that has been used to approximate the sound sequencing of S3 in the cardiac cycle (S1, S2, S3) Fourth heart sounds (S4) = rapid ventricular filling that occurs after atrial contraction – Heard before S1 – May be heard in the normal individual with left ventricular hypertrophy – Sound described as old because of the sudden motion of stiff ventricles in response to increased atrial contraction – Pathologies = systemic hypertension, cardiomyopathyies, & coarctation of the aorta – TENN-es-see= a sound that approximates the sound sequencing when S4 is present (S4, S1, S2)
   6. Murmurs
      1. – Cardiac murmurs are the vibrations resulting from turbulent blood flow – Occur between S1 & S2; diastolic murmurs occur between S2 & S1 – Murmurs that are grade III or higher are usually associated with cardiovascular pathology
      2. Grading:
10. Mediate Percussion
    1. – Mediate or indirect, percussion allows the PT to assess the density of the underlying organs – Striking the chest wall produces vibrations in the underlying structures that give rise to sound waves or percussion tones (louder over air-filled structures)
    2. Tones:
       1. Resonant
          1. –Loud or high amplitude, low pitch, longer duration; – heard over air filled organs such as the lungs
       2. Dull
          1. – Low amplitude, medium to high pitched, short duration; – heard over solid organs such as the liver
       3. Flat
          1. – High-pitched, short duration – Heard over muscle mass such as the thigh
       4. Tympanic
          1. – High-pitched, medium duration; – heard over hollow structures such as the stomach
       5. Hyperresonant
          1. – Very low pitch, prolonged duration – Heard over tissue with decreased density (increased air – two – tissue ratio) – Abnormal and adults – Heard over lungs with emphysema
    3. Technique
       1. – Middle finger of nondominant hand placed firmly on chest wall in and intercostal space & parallel to the ribs – Top of middle finger of dominant hand strikes distal phalanx of stationary hand with a quick short motion – PT must follow sequence of apices to bases & side to side so that comparisons can be made
    4. Diaphragmatic Excursion
       1. – Patient is asked to breathe deeply & hold that breath – Lowest level of diaphragm on maximal inspiration coincides with the lowest point where a resident tone is heard – Patient is then asked to exhale & immediate percussion is repeated – Lowest area of residence now moves higher, as diaphragm ascends with relaxation – Distance between these two points = diaphragmatic excursions; normal range is 3 – 5 cm – Diaphragmatic movement is decreased in patients with COPD
11. Palpation
    1. Tenderness
       1. – Areas of tenderness can be assessed for degree of discomfort & reproducibility – In a patient complaining of chest pain, angina may be rolled out if the PT can reproducer increase the discomfort by increasing tactile pressure – Angina or chest pain secondary to myocardial ischemia usually results from exertion & may be relieved by rest – Crepitus is a crunchy sound often associated with articular structures; however when bubbles of air occur within subcutaneous tissue, a crackling sensation may be palpated – Crepitus can also be secondary to a plural or friction rub
    2. Edema
       1. – Assessment of edema is performed by pressing 2 fingers into the articular areas for 2 – 3 seconds – If an impression is left once fingers are removed, then pitting or dependent edema is present – Degree of edema is based on the length of time that the indentation lasts 1+ is the least degree; 4+ is the worst
    3. Chest Wall Excursion
       1. – Symmetrical decrease in chest wall motion occurs in patients with COPD – Normal chest wall excursion is about 3.25 inches (8.5 cm) in a young adult between 20 – 30 years of age – 1 method = use a tape measurer at the level of the axilla & side forward – Most common method involves direct hand contact which is performed in all planes & from top to bottom (Table 15-2 p. 210)
       2. Methods for Evaluation Thoracic Expansion
    4. Tactile Fremitus
       1. – Spoken words produce vibration over the chest wall – When the PT's hands are placed on the chest wall, vibrations of spoken words can be felt; described as tactile fremitus – Presence or absence of tactile fremitus provides information about the density of the underlying lungs & thoracic cavity
    5. Technique
       1. 2 methods: 1. PT uses palmar surface of one or both hands 2. Involves the use of older border of 1 hand – With both techniques, sequence is cephalocaudal & side to side – In either step the next step is to ask patient to speak up predetermined phrase "ninety-nine" & "one, two, three"
    6. Tracheal Deviation
       1. – PT places index finger in the medial aspect of the supra sternal notch – Is repeated on the opposite side – An equal distance between the clavicle & trachea should exist bilaterally – Tracheal deviation may be caused by pneumothorax,atelectasis, or tumor – Right pneumothorax or pleural effusion deviates the trachea away from the affected side – A left lower lobe atelectasis deviates the trachea toward the affected side
12. Differentiation of Common Pulmonary Conditions