Clinicians are exhorted to always place their stethoscopes directly on a patient’s skin. Yet, when patients are examined in hallways and prehospital settings or in locations where cultural norms prevent patients from disrobing, this rule is often violated. That is not a problem: By applying pressure on the stethoscope head, clinicians can hear all the sounds normally heard on bare skin, through up to two layers of indoor clothing—including double-layered flannel shirts. Of course, inspection and percussion cannot be done through clothing, and clothing-induced acoustic artifacts may create problems.1
QUANTIFYING PLEURAL FLUID USING ULTRASOUND
Estimate the amount of pleural fluid using an ultrasound examination on supine patients. Elevate the chest to 15 degrees and move the probe perpendicular to the body axis along the posterior axillary line. Measure the maximal pleural separation, which is usually visible at the lung base. The simplified formula is: Volume of pleural fluid (mL) = 20 × Maximal distance between parietal and visceral pleura in end expiration (mm).2
The use of aerosol spacers more than doubles the amount of medication delivered to the lungs from metered-dose inhalers (MDIs); for steroid inhalers, an aerosol spacer diminishes the incidence of oral candidiasis by decreasing deposition in the oropharynx. The tube from a roll of toilet paper works well as an aerosol spacer, as does a piece of ventilator tubing.
Dr. Lara Zibners-Lohr wrote that in remote areas of the world, she uses large Styrofoam cups. The cup lip (open end) goes over the nose and mouth. The MDI goes through a hole in the bottom end of the cup. She uses just the blue tubing from a nebulizer for older children: they close their mouth around one end and put the MDI in the other. (Personal written communication, June 5, 2007.)
Dr. Karen Schneider uses a dry water bottle with a hole in the bottom for the MDI. The hole is sealed with tape, leaving a small opening to allow air movement from the outside when the child inhales. The inside of the bottle must be dry; otherwise, the aerosolized particles will stick to the water. When the MDI is activated, the child places his or her mouth over the drinking end and inhales a few times until the mist is cleared (Fig. 9-1). It is important that the child not exhale into the bottle because this will blow the mist out the small hole. (Written communication, June 5, 2007.)
Improvised spacers have been shown to be just as effective as the expensive commercial spacers.3
Water bottle used as spacer by Dr. Schneider in Peru. (Drawn from a photo contributed by Dr. Karen Schneider.)