Cardio Practical 1

1. Surface anatomy
- Lung and heart
Anterior apex: palpate 3 cm above medial 1/3 of clavicle
2nd chondrosternal junction: palpate immediately after the space inferior to clavicle
4th and 6th chondrosternal junction: palpate along sternum
6th rib in mid-clavicular line: palpate along course of 6th rib
8th rib in mid-axillary line: deep breath to find 12th rib and palpate upwards
10th rib: palpate from T7 (inferior angle of scapula)
Posterior apex: slightly higher than anterior apex
Heart: from 4th chondrosternal junction to 6th rib in mid-clavicular line

- Fissure
Oblique fissure: draw a line from T3 (spine of scapula) to 6th rib in mid-clavicular line
Horizontal fissure: draw a line horizontally along 4th chondrosternal junction to meet
oblique fissure in mid-axillary line

2. Auscultation
Ask patient breath in and out through mouth
Upper lobe
 Apical (anterior): supraclavicular fossa
 Anterior (anterior): 1st intercostal space, 3rd chondrosternal junction
 Posterior (posterior): 3rd rib
Middle lobe
 Medial and lateral (anterior): 5th chondrosternal junction, 5th rib
Lingular lobe
 Superior and inferior (anterior): 5th chondrosternal junction, 5th rib
Lower lobe
 Lateral basal (anterior): 6th rib
 Superior (posterior): 5th and 6th rib
 Posterior basal (posterior): 8th rib
 Lateral basal (posterior): 9th rib

- O/E
Intensity of sound: loud, moderate, soft
Pitch of sound: high, moderate, low
 Normal lung: filter high-pitched sound
 Consolidation: filter low-pitched sound
 Pleural effusion: reflect most of the sound
Inspiratory and expiratory sound: E≥I, E=I, E<I
Differentiate between tracheal sound, bronchovesicular sound, vesicular sound
Added sound: wheeze, crackle, stridor
Heartbeat and pericardial rub
Added sound Characteristics Phase Causes
Wheeze High-pitched E Bronchospasm
 Low-pitched (rhonchi) Both Sputum
Crackle Fine I Fibrosis, pulmonary edema,
pneumonia, atelectasis
E Secretion (peripheral)
Coarse I Bronchiectasis, bronchitis
E Secretion (central)

3. Breathing pattern assessment

Starting position: half-lying with back supported, relaxed
Predominant chest wall movement: upper chest or diaphragm
Increase in chest wall diameter: AP, transverse
Use of accessory muscles
Symmetry and synchrony of chest wall movement
Regularity of breathing
Breathing rate (breath/min)

4. Breathing control
Starting position: half-lying with back supported, relaxed
Place our hands over patient’s subcostal angle
Ask patient to breath in slowly with nose and breath out slowly with mouth
Push-in during expiration: stretch diaphragm for better contraction next breath
 Do not hyperventilate patient
 Increase lung volume and oxygenation

- Active cycle of breathing technique (ACBT)

Breathing control
TEE +/- secretion removal technique
Breathing control
Huffing
Breathing control

5. Thoracic expansion exercise (TEE)

Starting position: half-lying with back supported, relaxed
Place our hands on patient’s side of chest wall
Ask patient to take a deep breath in with nose and push against our hands
Ask patient to breath out fully with mouth
Push-in during expiration: stretch diaphragm for better contraction next breath
 In the 3rd time: inspiratory hold for 3s
 Collective ventilation and elasticity: increase lung volume and oxygenation

6. Incentive spirometer
- Triflo (1 ball: 300ml/s 2 balls: 600ml/s 3 balls: 1200ml/s)
Ask patient to take a slow deep breath in and hold the balls at the top for at least 2s
 Remind them to focus on holding but not number of balls raised
 Rest after several attempts: avoid hyperventilation
Contraindication: COPD (hyperinflated lung)
May use Voldyne (yellowish)

7. Spirometry (similar to peak flow meter)

Starting position: sitting with back straight, knee in 90° F, feet supported
Ask patient clip the nose and take a deep breath fully
Ask patient place the mouthpiece in and blow maximally and quickly
Keep the expiration for 6s and ask patient to take a deep breath in
 Minimum 3 test trials but not more than 8
 Reliable: difference<0.15 or percentage change<5%

8. Forced expiratory technique (FET)

- Coughing
Ask patient to take a deep breath and cough
 Shift secretion from distal airway to proximal airway
 Only up to 6th and 7th generation of the bronchial tree
Contraindication: COPD, head injury (increase ICP), low cardiac output

- Huffing
Ask patient to breath out, making a mist on mirror forcefully
 Shift secretion from distal airway to proximal airway
 Usually done in low lung volume
Contraindication: COPD

9. Postural drainage
Upper lobe
 Apical: sitting upright
 Anterior: supine with knee F
 L posterior: side-lying on R at 45°, 3 pillows under trunk
 R posterior: side-lying on L at 45°, 1 pillow under trunk
Middle lobe: side-lying on L, 2 pillows under pelvis (15°)
 1 pillow behind trunk for support
Lingular lobe: side-lying on R, 2 pillows under pelvis (15°)
 1 pillow behind trunk for support
Lower lobe
 Superior: prone, 1 pillow under abdomen
 Anterior basal: supine with knee F, 3 pillows under pelvis (20°)
 R lateral basal: side-lying on L, 3 pillows under pelvis (20°)
 R medial basal and L lateral basal: side-lying on R, 3 pillows under pelvis (20°)
 Posterior basal: prone, 3 pillows under pelvis (20°)
Contraindication: unstable vital sign, pulmonary edema, post-cranial surgery

10. Percussion and vibration

Percussion: relax shoulder, elbow, wrist and clap with cupped hands at 5Hz
 Cupped hands: air cushion
Vibration: intermittent chest wall compression at 20Hz to dislodge thick secretion
 Force applied downward and inward
 Initiate at the peak of inspiration and continue throughout expiration
Rib springing: vibration, quick release of hands to stimulate deeper breath
Contraindication: # rib, hemoptysis, subcutaneous emphysema, bronchospasm

11. Positive expiratory pressure (PEP)

Ask patient to take a deep breath and hold for 2-3s
Exhale fully and adjust angle to obtain maximal vibration
 10-15 mins per session, 2-3 times per day
 Flutter, shaker, acapella

12. 6MWT
Ask patient to walk back and forth along a 30m path
Walk as far as possible with 6 mins: measure total distance walked
 Monitor SpO2 and HR pre- and every 1 minute during the test
 Dyspnea: can rest but encourage to resume walking

13. Suctioning
 Unable to clear secretion by normal physiological mechanism
Starting position: Fowler’s position
Identify patient: check vital signs, explain the procedure, ask for consent
 Do not swallow the catheter
Perform hand hygiene and wear PPE
Pre-oxygenate patient 2 mins: avoid hypoxia after suction
Open catheter packet and pull a little out
Turn on wall suctioning unit and adjust pressure to 100 mmHg
 Portable suction unit: pressure to 1 unit
Attach catheter to tubing: wear gloves and take the rest of catheter out
Lubricate catheter using saline
Insert catheter: withdraw 1-2 cm if carina is felt
 No cough: insert wrongly into esophagus
Intermittent suction: whole process 15s, suction time maximum 5s
 Twist the catheter when pulling out
Discard catheter together with gloves and clean suction tubing
Turn off wall suctioning unit and re-check vital sign
Contraindication: pulmonary edema, hemoptysis, bronchospasm, post-cranial
surgery, severe hypoxemia (SpO2<85%), severe shock (SBP<70mmHg)
CXR
1. AP view

Scapula in the way

Clavicle more horizontal
Heart and big vessels magnified (cardiothoracic ratio=50%)

2. PA view

Scapula out of the way

Clavicle more slanting
Heart size normal (cardiothoracic ratio<50%)
Ribs more rounded
Lungs shorter
Diaphragm descends to 9th or 10th rib

3. Lateral view
Decubitus position: confirm pleural effusion

4. Checklist
Orientation: AP/PA
Patient un-rotated: medial ends of clavicle at equal distance from spinous process
Scapula: in the way/out of way
Clavicle: more horizontal/more slanting
Heart size: heart and big vessels magnified/cardiothoracic ratio
Diaphragm (R higher than L): collapse lung
Exposure: too dark (over-exposed)/too white (under-exposed)
Costophrenic angle: pleural effusion
Tracheal deviation
Breast shadow
Mediastinum: COPD
Opacity: consolidation
Pneumothorax: dark intensity