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
increases
when the rib cage is chronically
overinflated
, as in
emphysema.
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?
Bronchial
Bronchovesicular
Vesicular
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 _____________.
the
apices
in the
supraclavicular
areas down to the
sixth rib
These are also known as: crackles
#NAME?
These are also known as: wheeze
#NAME?
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
pneumonia,
atelectasis,
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
Bronchophony
How to auscultate?
What does it sound like? and why?
99
- soft muffled and indistinct
- increase lung density will enhance transmission of voice sounds
Egophony
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
Pneumonia
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
Asthma
an abnormal respiratory condition associated with allergic hypersensitivity to certain inhaled allergens, characterized by bronchospams, wheezing, and dyspnea.
Atelectasis
an abnormal respiratory condition characterized by collapsed, shrunken deflated section of alveoli
Bronchitis
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)
Consolidation
the solidification of portions of lung tissue as it fills up with infectious exudate, as in pneumonia
Crackles
(rales) abnormal, discontinuous, adventitious lung sounds heard on inspiration.
Crepitus
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)
Emphysema
the chronic obstructive pulmonary disease characterized by enlargement of alveoli distal to terminal bronchioles
Fremitus
a palpable vibration from the spoken voice felt over the chest wall
Kussmaul respiration
a type of hyperventilation that occurs with diabetic ketoacidosis
Rhonchi
low-pitched, musical, snoring, adventitious lung sound caused by airflow obstruction from secretions
Wheeze
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
Acinus
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
Stridor is associated with upper airway obstruction from swollen, inflamed tissues or a lodged foreign body.