N314 EXAM1 Thorax & Lungs (Jarvis Ch18 + other)

What anatomical structures does the thoracic cage consist of?

The thoracic cage consists of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, and the diaphragm (which forms the floor.)

Surface landmarks of the anterior thorax include:

o The suprasternal notch;
o The sternum (or breastbone), which has a manubrium, body, and xiphoid process;
o The sternal angle (or angle of Louis), which is continuous with the second rib;
o And the costal angle, where the right and left costal margins me

Describe where the anatomical heart valve areas are on the anterior chest for auscultation

Anatomic areas for auscultation of the heart:
Aortic valve - Right 2nd ICS sternal border (top Rt base)
Pulmonic Valve - Left 2nd ICS sternal border (across from A)
Erbs Point- Left 3rd ICS sternal border (just under P)
Tricuspid Valve - - Left 5th ICS st

Describe where the lobes of each lung are:
How many on each side
Where they are in relation to other anatomical features

Apex of lungs: highest point of lung tissue, 3-4cm above inner third of clavicles
Base of lungs: lower border of ribs, rests on diaphragm @ 6th rib midclavicular line
Lower lungs are mostly posterior and upper/middle are mostly anterior
Right as 3 lobes,

Subjective Data on the Thorax & Lungs

Hx present illness
-including cough, chest pain, dyspnea
Hx past illness
-respiratory infections, smoke cigs, environmental
Self-care behaviors
-TB. flu shot, exercise
Do symptom analysis (PQRST) for each presenting symptom
-Ask about interference with AD

Assessment technique for Posterior Thorax:
& Describe what exactly assessing at each site

1. Inspection
a) Respiration (rate, rhythm, quality), Skin color (normal no erythema, ecchymosis, or cyanosis), Thoracic Cage (AP transverse ratio 1:2-5:7 aka barrel chest, scoliosis, kyphosis), Skin (lesions, masses)
2. Palpation
a) Chest Expansion (Make

Assessment technique for Anterior Thorax:
& Describe what exactly assessing at each site

1. Inspection
a) Respirations (rate, rhythm, quality), Skin color (face, lips, nail beds, pallor, cyanosis), Skin (lesions, masses)
2. Palpation
a) Symmetric expansion (make the shadow puppet bat w/hands again on chest, w/thumb/index finger "U" shape just

Define: costochondral junctions

Points at which the ribs join their cartilages

Manubriosternal angle also known as________?

The Angle of Louis: connection/angle between manubrium, & sternum

Fill in the blanks:
The costal angle is usually ____________ or less and the angle ______________ when the rib cage is chronically ____________, as in ____________ (disease).

90 degrees or less, this angle
when the rib cage is chronically
, as in

What is the difference between the right and left lungs? Why?

-Right lung is shorter than the left (because of the liver)
-Right has 3 lobes
-Left has 2 lobes
-Left is narrower than the right (because the heart is in the way)

Define: visceral pleura &
Define: parietal pleura

-lining along inside of lungs
-lining along outside of lungs

What are the 4 major functions of the respiratory system?

1. supply oxygen
2. remove carbon dioxide
3. maintain homeostasis
4. maintaing heat exchange

Define: hypercapnia

increase of carbon dioxide in the blood

Define: hypoxemia

decrease of oxygen in blood

increased residual volume

the amount of air remaining in the lungs even after the most forceful expiration.

Chronic bronchitis is characterized by

History of productive cough for 3 months out of the year for 2 years in a row

What might each mean/be a symptom of:
1. white or clear mucoid
2. rust colored
3. pink, frothy
4. yellow/green

1. colds, bronchitis, viral infections
2. TB, pneumococcal pneumonia
3. pulmonary edema
4. bacterial infections

Define: orthopnea

difficulty breathing when supine/laying down

Define: paroxysmal nocturnal dyspnea

awakening from sleep with SOB

Too much carbon monoxide may cause what symptoms?

dizziness, headache, fatigue

The ratio of anteroposterior to transverse diameter is from______ to _______?

1:2 to 5:7

Fremitus may feel stronger on the right side than on the left side because?

the right side is closer to the bronchial bifurcation
- fremitus decreases as you move down the thorax

What should you, as the examiner, do when you ask your pt to hold their breath during an assessment?

Hold yours as well (keeps examiner from forgetting or having pt hold breath for too long)

Breath sounds:
- bronchial (tracheal)

pitch = high
amplitude = loud
duration = inspiration < expiration
quality = harsh, hollow tubular
normal location = trachea and larynx

Breath sounds:
- bronchovesicular

pitch =moderate
amplitude = moderate
duration = inspiration = expiration
quality = mixed
normal location = over major bronchi where fewer alveoli are located

Breath sounds:
- vesicular

pitch = low
amplitude = soft
duration = inspiration > expiration
quality = rustling, like the sound of the wind in the trees
normal location = over peripheral lung fields

What are the 3 types of breath sounds?


Define: adventitious sounds

Added sounds that are not normally heard in the lungs.

Atelectatic crackles

Short popping, crackling sounds that sound like fine crackles but don't last beyond a few breaths.

Normal voice sounds when saying 99

soft, muffled, and indistinct

In the right hemithorax the upper border of liver dullness is located where?

In the 5th intercostal space in the right midclavicular line
5th ICS, Rt MCL

On the left hemithorax, tympany is evident over the ___________?

gastric space

Auscultate the lung fields over the anterior chest from the ________ in the _____________areas, down to the _____________.

in the
areas down to the
sixth rib

These are also known as: crackles


These are also known as: wheeze


Define: hyperresonance

A lower pitch, booming sound found when too much air is present, as in emphysema or pheumothorax

Dullness may signal____________?

Organs or over the lungs may signal abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis.

Diminished breath sounds occur with

pleural effusion,
or pneumothorax

Crackles only in upper lung fields occur with___?

cystic fibrosis

Crackles only in lower lung fields occur with___?

heart failure

In the elderly the chest cage commonly shows these abnormalities

round barrel shape (barrel chest) and kyphosis (humpback) "dowager's hump

Discontinuous Sounds
- Crackles-fine

popping sounds heard during inspiration that are not cleared by coughing.
-its like rolling a stand of hair btw your fingers near your ear
Late inspiratory crackles
-heart failure, pneumonia,
Early inspiratory crackles
-chronic bronchitis, asthma, emphyse

Discontinuous Sounds - Crackles-coarse rales
Sounds like___?
May be a symptom of___?
Occurs when___?

- loud, low pitched, that start in early inspiration and may be present in expiration.
- sounds like VELCRO FASTENER.
- pulmonary edema, pulmonary fibrosis, terminally ill.
- inhaled air collides with previously deflated airways

Discontinuous Sounds - Atelectatic crackles
Sounds like___?
May be a symptom of___?
Occurs when___?

- sounds like fine crackles but do not last and are not pathologic;
- in aging adults, bedridden person or someone that just arose from sleeping
- inhaled air collides with secretions in the trachea and large bronchi.

Discontinuous Sounds - Pleural friction rub
Sounds like___?
May be a symptom of___?
Occurs when___?

- sounds like 2 pieces of leather being rubbed together
- caused when pleurae become inflamed and lose their normal lubricating fluid
- when pt has painful breathing

Continuous sounds (connected musical sounds)- wheeze - high pitched (sibilant)
Sounds like___?
May be a symptom of___?
Occurs when___?

- musical squeaking sounds that sound polyphonic (multiple notes at once)
- air squeezed or compressed through passageways narrowed almost to closure
- diffused airway obstruction
- predominate in expiration but can occur in both inspiration and expiratio

continuous sounds- wheeze - low pitched (sonorous rhonchi)
Sounds like___?
May be a symptom of___?
Occurs when___?

- monophonic single note, musical snoring, moaning sounds
- more predominate with expiration; may clear some what with coughing
- bronchitis, single bronchus obstruction from airway tumor

continuous sounds - Stridor
Sounds like___?
May be a symptom of___?
Occurs when___?

- high pitched, monophonic, inspiratory, crowing sound, louder in neck than over chest wall
- originating in larynx or trachea, upper airway obstruction from swelling or foreign bodies.
- croup and acute epiglottis in children, and foreign inhalation obst

How to auscultate?
What does it sound like? and why?

- soft muffled and indistinct
- increase lung density will enhance transmission of voice sounds

How to auscultate?
What does it sound like? and why?

-Have pt say "eeeeeeeeee"
- normally you should hear "eeeeee" through your stethoscope

Whispered Pectoriloquy
How to auscultate?
What sounds like and why?

-ask the pt to say "one two three"
- the normal response is faint, muffled and almost inaudible
- with only small amounts of consolidation the whisper time is transmitted very clear.

Anatomy: Apex of lungs

highest point of lung tissue, 3-4cm above inner third of clavicles

Anatomy: Base of lungs

lower border of ribs, rests on diaphragm @ 6th rib midclavicular line

Anatomy: Potential space

filed only with a few milliliters of lubricating fluid, vacuum (negative pressure) which holds the lungs tightly against chest wall

Define: hypoventilation & hyperventilation

slow, shallow breathing, causes CO2 to build up in bloodrapid, deep breathing, causes CO2 to be blown off

Define: Hypercapnia

increase in CO2 in the blood, most effective normal stimulus for breathing

Define: Atelectasis
Symptoms of_____

-The collapse of part or (much less commonly) all of a lung.
-Symptoms: cough, increased respiration/pulse, cyanosis, tracheal shift toward affected side, decreased breath sounds

Define: Hemoptysis

the expectoration (coughing up) of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs

Define: Barrel chest
Symptoms of_____

equal AP diameter, rips are horizontal instead of normal downward slope (assoc. w/normal aging or w/chronic emphysema & asthma as result of hyperinflation of lungs)

Scoliosis - severe
Angle is > _________, may ________ lung volume, putting person at risk for ____________ __________ function

>45 degrees deviation is present, may reduce lung volume putting person at risk for decreased cardiopulmonary function (impairment: cosmetic deformity)

Define: Kyphosis
Causes ___________ and ___________
Associated with ____________ especially in ________

(Humpback) Exaggerated posterior curvature of thoracic spine causes significant back pain and limited mobility (associated w/aging especially women)

What 3 things to notice/document during respiration assessment

rate / depth (tidal volume) / pattern

Define: Cheyne-Stokes Respiration

cycle in which respiration increases in rate and depth, then decreasing (ie. heart failure, renal failure, meningitis, drug OD, increased cranial pressure)

Define: Alkalosis

decreased level in blood due to hyperventilation with blows off CO2

Biot's Respiration

series of normal respirations (3 to 4) followed by a period of apnea (ie. head trauma, brain abscess, heat stroke, spinal meningitis, encephalitis) similar to Cheyen-Stokes

What might cause decreased tactile fermitus?

Occurs when anything obstructs transmission of vibrations (ie. obstructed bronchus, pleural effusion, pneumothorax, emphysema)

Rhonchal fermitus is?

vibrations felt when inhaled air passes through thick secretions in the larger bronchi

Pleural friction fermitus is?

palpable friction rub - when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid

Define: Fermitus

palpable vibrations

Define: Crepitus

a coarse, cracking sensation palpable over the skin suface (ie. subQ emphysema, after thoracic injury or surgery)

Define: Diaphragmatic excursion

estimates the level of the diaphragm separating the lungs from the abdominal viscera - resonant to dull - 3-5cm bilaterally

Definition & Symptoms: Bronchitis

inflammation of bronchi w/partial obstruction of bronchi by mucous
symptoms: chronic prolonged expiration, crackles, may have wheeze

Definition & Symptoms: Emphysema

destruction of pulmonary tissue (elastin, collagen), hyperinflation lungs and increased lung volume mostly due to smoking (80-90%)
symptoms: barrel chest, tripod position, shortness of breath, tachypnea, muffled heart sounds, occasional wheeze

Definition & Symptoms: Asthma

Reactive Airway Disease - allergic hypersensitivity to inhaled allergens ie. pollen, tobacco, microbes
symptoms: bronchospasm, inflammation, edema in bronchiole walls, viscous mucous in airways, increased respiratory rate, audible wheeze, labored-prolonge

Definition & Symptoms: Pleura Effusion (Fluid) or Thickening

collection of excess fluid in the intrapleural space with compression of overlying lung tissue
symptoms: tracheal shift away from affected side, chest expansion decreased on affected side, no disph.excur. on affected side, breath/voice sounds decreased or

Heart Failure effects on the lungs and symptoms

pump failure with increasing pressure of cardiac overloads causes pulmonary congestion or increased amount of blood in pulmonary capillaries
symptoms: tachypnea, nocturnal dyspnea, nocturia, ankle edema, shortness of breath on exertion, crackles at base,

Definition & Symptoms: Pneumothorax

free air in pleural space causing partial or complete collapse
symptoms: unequal chest expansion, tachypnea, cyanosis, apprehension, tracheal shift to unaffected side, tachycardia, decreased BP, decreased/absent breath sounds, voice decreased/absent

Definition & Symptoms: Tuberculosis

inhalation of tubercle bacilli into alveolar wall
symptoms: cough, purulent, yellow-green blood-tinged sputum, dyspnea, orthopnea, fatigue, weakness, moist skin from night sweats, crackles over upper lobes

Definition & Symptoms: Pulmonary Embolism

undissolved materials originating in legs or pelvis, travel to right heart, become lodged to occlude pulmonary vessels
symptoms: decreased cardiac output, hypoxia, dyspnea, diaphoresis, hypotension, tachycardia, crackles, wheezes

Definition & Symptoms: Acute Respiratory Distress Syndrome

acute pulmonary insult damages alveolar capillary membrane, leasing to increased permeability of pulmonary capillaries & pulmonary edema
symptoms: restlessness, disorientation, rapid shallow breathing, productive cough, thin frothy sputum, hypotension, ta

What happens at the angle of louis?

the trachea splits into bronchii

What is mostly being heard on the posterior chest?

the lower lobes of the lungs

What is mostly being heard on the anterior chest?

the upper and middle lobes

What 3 positions do we inspect the thorax in?

1. posterior - patient seated and leaning over to expand the posterior chest
2. anterior - patient seated or supine
3. lateral

findings for inspecting bony structures of thorax

- conical
- symmetrical
- T > AP
- costal angle < 90
- slopes of ribs < 45
- no sternal deformities

What are we inspecting with respirations?

- rate - 12-20
- rhythm - regular or irregular
- depth
- effort - eupnea normal, dyspnea difficult
- peripheral cues - skin/nails/mucous membranes

What are we palpating on the thorax?

- skin over thorax - temp, moist, turgor, lesions
- trachea - midline
- bony structures - tenderness, crepitus, masses
- intercostal spaces - tenderness, masses, sub q crepitus
- tactile fremitus
- thoracic expansion

Facts about tactile fremitus

- rough screening tool
- palpate using ulnar side of hands with fist
- ask client to repeat "99"
- 2 hands at once, moving down each side to check symmetry in vibration
- pneumonia - increased vibrations
- emphysema, smoking = decrease vibrations

Facts about thoracic expansion

place thumbs at 9th or 10th ribs below breast
slide medially to raise loose skin
ask client to inhale
observe for bilateral outward movement of thumbs
should expand symmetrically
abnormal = decreased movement, no symmetry, delay in movement

We use Percussion to____?

to determine by audible sounds and palpable vibration whether or not the underlying tissues are air-filled, fluid-filled, or solid

Sounds of percussion and relative durations

flat = short and soft = kneecap
dull = medium = solid organs
resonance = long = lungs
hyperresonance = longer = child or smoker
tympany = intestines or puffed cheeks

How to percuss posteriorly

have patient cross arms in front
tap distal joint of finger
strike in intercostal spaces, skipping ribs at 5 cm intervals
alternate left/right and compare side to side

How to percuss anteriorly

patient sitting or lying
percuss side to side intercostal spaces
do not percuss over female breast tissue

What to report about percussion

- identify sound = intensity, pitch, duration, quality
- normal lungs = resonance
- abnormal lungs = hyperresonance or dullness
- percussion only penetrates 5-7 cm

Auscultation procedure

- client breathes deeply through mouth
- alternate side to side
- use diaphragm of steth
- compare side to side!
- identify pitch, intensity, quality, duration

Overview: List the abnormal breath sounds

- adventitious sounds = added sounds
- crackles/rales - brief on inspiration, fine and coarse
- wheezes - continuous, musical, inspiration and expiration, asthma, children
- ronchi - continuous, snoring
- rubs - creaking, scratching, grating, on inspirati

OVerview: What are the tests for vocal resonance?

egophony - posterior chest - say "eee" and auscultate
bronchophony - say "99" repeatedly and auscultate
whispered pectoriloquy - whisper "1, 2, 3" and auscultate
normal chest = not heard or muffled
consolidation = increase in sound or sound changes - "eee

age-related variations for the aging

- decreased chest expansion
- decreased vital capacity - amount inhaled decreases
- increased residual volume - can cause hyperresonance and rounded chest
- costal angle and rib angle both increase with rounded chest

Increased tactile fremitus would be evident in an individual who has which of the following conditions?
A) Emphysema
B) Pneumonia
C) Crepitus
D) Pneumothorax


A clinical manifestation common in an individual with chronic obstructive pulmonary disease (COPD) is:
A) periodic breathing patterns.
B) pursed-lip breathing.
C) unequal chest expansion.
D) hyperventilation.

pursed-lip breathing.

The thoracic cage is defined by all of the following except the:
A) sternum.
B) ribs.
C) costochondral junction.
D) diaphragm.

costochondral junction.

Inspiration is primarily facilitated by which of the following muscles?
A) Diaphragm and abdominus rectus
B) Trapezia and sternomastoids
C) Internal intercostals and abdominal
D) Diaphragm and intercostals

Diaphragm and intercostals

Which of the following voice sounds would be a normal finding?
A) The voice transmission is distinct and sounds close to the ear.
B) The "eeeee" sound is clear and sounds like "eeeee".
C) The whispered sound is transmitted clearly.
D) Whispered "1-2-3" is

The "eeeee" sound is clear and sounds like "eeeee".

The gradual loss of intraalveolar septa and a decreased number of alveoli in the lungs of the elderly cause:
A) hyperventilation.
B) spontaneous atelectasis.
C) decreased surface area for gas exchange.
D) decreased dead space.

decreased surface area for gas exchange.

The function of the trachea and bronchi is to:
A) transport gases between the environment and the lung parenchyma.
B) condense inspired air for better gas exchange.
C) moisturize air for optimum respiration.
D) increase air turbulence and velocity for max

transport gases between the environment and the lung parenchyma.

Stridor is a high-pitched, inspiratory crowing sound commonly associated with:
A) upper airway obstruction.
B) atelectasis.
C) congestive heart failure.
D) pneumothorax.

upper airway obstruction

Percussion of the chest is:
A) a useful technique for identifying small lesions in lung tissue.
B) helpful only in identifying surface alterations of lung tissue.
C) is not influenced by the overlying chest muscle and fat tissue.
D) normal if a dull note

helpful only in identifying surface alterations of lung tissue.

Which of the following correctly expresses the relationship to the lobes of the lungs and their anatomic position?
A) Upper lobes�lateral chest
B) Upper lobes�posterior chest
C) Lower lobes�posterior chest
D) Lower lobes�anterior chest

Lower lobes�posterior chest


an abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by bronchospams, wheezing, and dyspnea.


an abnormal respiratory condition characterized by collapsed, shrunken deflated section of alveoli


inflammation of the bronchi with partial obstruction of bronchi due to excessive mucus secretion

Chronic Obstructive Pulmonary Disease (COPD)

a functional category of abnormal respiratory conditions characterized by airflow obstruction (emphysema, chronic bronchitis)


the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia


(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration.


coarse, crackling sensation palpable over the skin when air abnormally escapes from the lung and enters the subcutaneous tissue

Dead space

passageways that transport air but are not available for gaseous exchange (trachea, bronchi)


the chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles


a palpable vibration from the spoken voice felt over the chest wall

Kussmaul respiration

a type of hyperventilation that occurs with diabetic ketoacidosis


low-pitched, musical, snoring, adventitious lung sound caused by airflow obstruction from secretions


high-pitched, musical, squeaking adventitious lung sound

Whispered pectoriloquy

a whispered phrase head through the stethoscope that sounds faint and inaudible over normal lung tissue

What are the three factors that affect normal intensity of tactile fremitus?

Relative location of bronchi to the chest wall
Thickness of the chest wall
Pitch and intensity of voice

What are 5 factors that can cause extraneous noise during auscultation?

Examiner's breathing on stethoscope tubing
Stethoscope tubing bumping together
Patient shivering
Patient's chest hair
Rustling of paper gown or paper drapes


functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.

Rhoncal fremitus

palpable with thick bronchial secretions.

Pleural friction fremitus

palpable with inflammation of the pleura

Forced expiratory time

the number of seconds it takes for the person to exhale from total lung capacity to residual volume. It is a screening measure of airflow obstruction.


Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.