Respiratory Assessment Case Study with Lung Sounds!!

Blue bloaters have a poor respiratory drive.
Features include:
dyspnoea is quite mild
the patient is often obese
large volumes of sputum are produced
infective exacerbations
patient often oedematous
may develop cor pulmonale
Pink puffers have a good respiratory drive.
Features include:
purse-lip breathing with intense dyspnoea
patient is often thin and elderly
little sputum produced
oedema and overt heart failure are rare complications
Investigations:
blood gases are near normal until pre-terminally
there is very severe airways obstruction
total lung capacity is increased
reduction in transfer factor

http://www.gpnotebook.co.uk/simplepage.cfm?ID=-19922941&linkID=9524&cook=yes

gwenith, BSN, RN · Nov 7, 2004

I LIKE this one - it takes a running hit at the Blue Bloater/Pink Puffer classification which IS correct as those terms have been superceded but they still remain good memonics

There are no specific findings on examination, although signs of hyperinflation of the chest are highly suggestive of emphysema. These include a barrel shaped chest (increased antero-posterior diameter), use of accessory muscles of respiration, reduction of the cricosternal distance, tracheal tug, paradoxical indrawing of the lower ribs on inspiration (Hoover's sign), intercostal recession, hollowing out of the supraclavicular fossae, pursed lip breathing and reduced expansion. In addition the patient may have hyperresonant lung fields, prolongation of expiration, especially forced expiration >5s, and audible wheeze. None of these signs are specific to COPD and do not correlate very well with the severity of the disease which emphasises the need for objective assessment. Their presence, however, should alert the physician to the possible diagnosis of COPD.
As the disease progresses, signs of right ventricular dysfunction may develop (Cor pulmonale) because of the effects chronic hypoxaemia and hypercapnia which include peripheral oedema, raised jugular venous pressure, hepatic congestion, and the presence of metabolic flapping tremor. Despite the widely held belief that these signs are due to right ventricular failure, the pathophysiology cor pulmonale is likely to be due to altered renal function giving rise to salt and water retention rather than cardiac dysfunction secondary to pulmonary hypertension.

http://www.priory.com/cmol/diagnosi.htm

reading the above text are there any other symptoms that our man in the picture is displaying??

aimeee, BSN, RN · Nov 7, 2004

I'm going to have to try this at work. Those wav files take about 10 minutes each to download for me. Hard to see his hands but the nailbeds look like they are bluish too. He looks pretty bony. I'm betting he has poor appetite and weight loss history as well.

UM Review RN, ASN, RN · Nov 7, 2004

I agree with Aimee, the nailbeds and the lips are somewhat bluish, in addition to the orthopneic positioning, facial grimacing, pursed-lip breathing, sternal retractions.

OK, I'm playing. Here goes:

Inspection/auscultation:

Because he's losing consciousness AEB his inability to follow simple commands and his inability to talk, I would think he might need intubation before this gets much worse. The right lung has crackles at the top and expiratory wheezes that worsen throughout the mid and lower sections. Overall, the right lung sounds "tight" and constricted. The absence of sputum, the high WBC, and the rising temp seem to indicate pneumonia and possible atelectasis going on there.

The left lung sounds somewhat better till you get to the apex of the heart, where there's a noise that might be (and here I'm really going out on a limb but here goes) pulmonary stenosis. So this guy is having an exacerbation of a chronic condition, I'm still thinking a bacterial infection versus a viral type.

If this were an actual patient, I'd be on the phone to get Respiratory and trying a nonrebreather till we got ABGs and intubation equipment setup.

That high, irregular heart rate is scary. I have to wonder how the heck his EKG is showing NSR (which means his HR is regular and 60 BPM or less) according to the problem. Like, Dude, where's my monitor? So I'm ignoring the EKG results--they're inconsistent with the patient's condition. I'd put our staff on alert for possible Code, with the crash cart outside the door. Because You Never Know.

And that's as far as I got because shoot! hafta get hubby off to work....

This is a fascinating thread! Just what I needed today!

gwenith, BSN, RN · Nov 7, 2004

Here are a couple of lung sounds sites to help those who need a brush up on this skill.

http://www.lumen.luc.edu/lumen/MedEd/medicine/pulmonar/pd/a-sounds.htm

(Unfortunately the first two recordings don't seem to work but the rest on that site do)

This site shows lung sound measurement

http://www.ymec.com/hp/signal2/lung2.htm

This site has links to both the rale repository and the University of Loyola

http://www.rnceus.com/resp/respabn.html