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PA thorax and lungs

Chest/thorax a cage of bone, cartilage, and muscle. sternum manubrium xiphoid process 12 pairs of ribs
o Diaphragm • Primary muscle of respiration • Contracts during inspiration
o External Intercostals • Increase the anterior-posterior chest diameter during inspiration
o Internal Intercostals: • Decrease transverse chest diameter during expiration
o Sternocleidomastoid and trapezius accessory muscles: • Brought into play when there are pulmonary problems and compromise
o Mediastinum • Situated between lungs • Contains all thoracic viscera except the lungs
o Right and left pleural cavities: • Lined with parietal and visceral pleura • Lungs enclosed by serous membrane
- Lungs highly elastic, paired but not symmetric
o Right lung: 3 lobes
o Left lung 2 lobes
- Tracheobronchial tree : tubular system that provides a pathway along which air is filtered, humidified, and warmed
o Trachea lies anterior to esophagus and posterior to isthmus of thyroid • Divides into the right and left main bronchi at about the level of T4 or T5 and just below the manubriosternal joint
o Bronchi • Main bronchi are divided into 3 branches on the right and 2 on the left • Branches begin to subdivide into terminal bronchioles and ultimately into respiratory bronchioles where gas exchange takes place
• Right bronchus wider, shorter, and more vertically placed than the left bronchus (more susceptible to aspiration of foreign bodies)
• Bronchial arteries branch from the anterior thoracic aorta and the intercostal arteries, supplying blood to the lung parenchyma and stroma
• Bronchial vein formed at the hilum of the lung
Anterior Thoracic landmarks suprasternal notch sternum (manubrium, body, xiphoid process) sternal angle (articulation of manubrium and sternum- at 2nd rib) costal angle (usually 90 degrees or less, meet at xiphoid)
Posterior Thoracic Landmarks verterbra prominens (spinous process of C7) spinous processes inferior border of scapula (7th-8th rib) 12th rib (free tip)
Fetal lungs contain no air; gas exchange is through placenta
Lungs at birth --> postnatal function • Relative decrease in pulmonary pressure most often leads to closure of the foramen ovale within minutes after birth • Increased oxygen tension in the arterial blood usually stimulates contraction and closure of ductus arteriosus
Chest of newborn generally round, circumference is same as head until about 2 years of age. Chest wall thinner and bony structure more prominent. With growth, chest assumes adult proportions, with lateral diameter exceeding the anterior posterior diameter
Respiration in Pregnant women o Mechanical and biochemical factors lead to changes in respiratory function • Enlarging uterus (elevates diaphragm 4 cm) • Increasing progesterone
Anatomic changes in chest during pregnancy • Lower ribs flare • Diaphragm rises • Diaphragm movement increases so that major work of breathing is done by diaphragm • Minute ventilation increases (deeper breaths) due to increased tidal volume • Respiratory rate remains unchanged
Respiration in Older adults o Barrel chest from loss of muscle strength in thorax and diaphragm and loss of lung resiliency o dorsal curve of thoracic spine o Alveoli less elastic, causing fatigue and DOE o Dec. in vital capacity/increase in residual volume o Mucous membranes dr
HPI: Coughing onset, nature, sputum, pattern, severity, associated symptoms, efforts to treat, medications
HPI: shortness of breath onset, pattern, position most comfortable, # pillows, related to exercise/activities, time of day, eating, harder to inhale or exhale, severity, associated symptoms, efforts to treat
HPI: chest pain onset and duration, associated symptoms, efforts to treat, medications, recreational drugs
PMI thoracic trauma, surgery, hospitalization, use of oxygen and ventilation assisting devices, chronic pulmonary diseases, other disorders, testing, immunization against strep pneumonia, influenza
Family History TB, cystic fibrosis, emphysema, allergy, asthma, atopic dermatitis, malignancy, bronchiectasis, bronchitis, clotting disorders (risk of PE)
Personal and Social History employment, home, tobacco use, exposure to infections, nutrition, use of herbs, travel, hobbies, alcohol/drugs, exercise tolerance
Pregnant Women- health history o Weeks of gestation o Presence of multiple fetuses, polyhydramnios, other conditions in which uterus displaces diaphragm o Exercise type and energy expenditure o Exposure to and frequency of respiratory infections, annual influenza immunization
Older Adults- health history exposure to infections, pneumococcal and flu vaccine, effects of weather on resp. efforts and infection occurrence, immobilization and sedentary habits, difficulty swallowing, altered activities
Inspection: chest shape and symmetry, chest wall movement, superficial venous patterns, prominence of ribs, anterior/posterior transverse diameter, sternal protrusion, spinal deviation
Inspection: bony structures looks for anterior deviations: pigeon chest funnel chest barrel chest
Inspection: peripheral clues fingers (clubbing) breath (odor) skin, nails, lips (cyanosis,pallor) nostrils (flaring)
Inspection: respiration rate, quality, pattern, cout while palpating pulse
dyspnea shortness of breath
• Tachypnea rapid, shallow breathing
• Bradypnea slow breathing
• Hyperventilation and hyperpnea faster and deeper than normal, blowing off CO2 - extreme exertion, fear, anxiety, acidosis
• Kussmaul deep, labored, gasping form of hyperventilation associated with severe metabolic acidosis (DKA)
• Cheyne Stokes waxing and waning breaths, with periods of apnea- regular pattern
sigh occasional, punctuate normal breathing pattern, expand alveoli
• Air trapping normal inspiration and prolonged expiration to overcome increased airway resistance
• Biot series of normal respirations (3-4) followed by apnea in an irregular pattern
apnea cessation of breathing
3 modes of respiration thoracic (costal) abdominal paradoxic
paradoxic respiration lung is deflated during inspiration and inflated during expiration (flail chest)
• Retractions chest wall seems to cave in at the sternum, between the ribs, at the suprasternal notch, above the clavicles, and at the lowest costal margins. (suggests obstruction)
Signs of Obstruction stridor, nostril flaring, cough, chest retraction
Palpation of thoracic muscles/skeleton pulsations, tenderness, bulges, depressions, massess, unusual movement/positions, elasticity of rib cage, immovability of sternum, rigidity of spine
Crepitus o Crackly or crinkly sensation, can be both palpated and heard o Indicates air in the subcutaneous tissue • Rupture somewhere in the respiratory system • Infection with a gas-producing organism
- Friction Rub o Palpable, coarse, grating vibration, usually on inspiration
- Thoracic Expansion: o Loss of symmetry in the movement of the thumbs suggests a problem on one or both sides
- Tactile Fremitus: o Palpable vibration of the chest wall that results from speech or other verbalizations o Have patient say 99
Percussion: chest anterior, lateral, posterior, compare tones bilaterally, measure diaphragmatic excursion
resonance normal percussion sound
hyperresonance hyperinflation of lungs
dullness indicates diminished air exchange
Auscultation of lungs listen to intensity, pitch, quality, duration
bronchial breath sounds heard over trachea and larynx -high pitch - high intensity - abnormal if heard over peripheral lung tissue
bronchovesicular breath sounds heard over major bronchi where fewer alveoli are located - moderate pitch -moderate intensity -abnormal is heard over peripheral lung tissue
vesicular breath sounds heard over peripheral lung fields where air flows through smaller bronchioles and alveoli • Low pitch • Low intensity
amphoric breath sounds breathing that resembles the noise made by blowing across the mouth of a bottle • Most often heard with a large, relatively stiff walled pulmonary cavity or a tension pneumothorax with bronchopleural fistula
cavernous breath sounds sounds as if coming from a cavern • Commonly heard over a pulmonary cavity in which the wall is rigid
o Crackles (Rales) • Abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds- like crackling paper or 2 pieces of hair together
fine crackles high pitched and relatively short in duration
coarse crackles low pitched, and relatively longer in duration
Rhonchi (sonorous wheezes) • Deeper, more rumbling, more pronounced during expiration, prolonged and continuous, and less discrete than crackles • Caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure
wheezes (sibilant wheeze) • Continuous, high pitched, musical sound (almost a whistle) head during inspiration or expiration • relatively high velocity air flow through a narrowed or obstructed airway • May be caused by the bronchospasm or asthma or acute or chronic bronchitis
friction rub • Dry, crackly, grating, low pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together
o Mediastinal Crunch (Hamman Sign): • Found with mediastinal emphysema • Variety of sounds- loud crackles, clicking and gurgling sounds are synchronous with the heartbeat and not particularly so with respiration
- Vocal Resonance spoken voice transmits sounds through the lung fields that may be heard with the stethoscope
• Bronchophony person says 99- greater clarity and increased loudness of spoken words (sign of increased density)
• Egophony person says eeeeee- intensity of the spoken voice is increased and there is a nasal quality, eeee becomes aaaa
• Pectoriloquy extreme bronchophony where even a whisper can be heard clearly through the stethoscope
Exam of Infant percussion less reliable, chest circumference 2-3 cm smaller than head, RR 40-60, periodic breathing followed by apnea as long as 10-15 sec is common, coughing rare, sneezing and hiccups frequent, paradoxic breathing, localization of breath sounds hard
stridor high pitched, piercing sound most often heard during inspiration, result of obstruction high in respiratory tree
respiratory grunting (infants) o Mechanism by which the infant tries to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels o Cause for concern if persistent
- Flaring of alae nasi indicator of respiratory distress i infants
Exam of children use intercostals by age 6-7, variable RR, decreases with age, adult rates by age 17, roundness of chest after 2 yrs indicates pulmonary problem, harder to evaluate wheezing in younger children, thinner/more resonant chest
breath sounds of child more resonant, hyperresonance common, easy to miss dullness, brinchovesicular sound may predominate
Exam of Pregnant Woman structural and ventilatory changes, dyspnea common, increases ventilation by breathing more deeply, not more frequently
Exam of older adults chest expansion decreased (muscle weakness, disability, sedentary lifestyle, calcification of rib articulations), marked bony prominences, kyphosis, inc. anterior posterior diameter, hyperresonance
asthma reactive airways disease- - small airways obstruction due to inflammation and hyperreactive airways
atelectasis : incomplete expansion of the lung at birth or the collapse of the lung at any age
Bronchitis inflammation of large airways; proliferation of mucous glands in passageways, resulting in excessive mucus secretion
Pleurisy: inflammatory process involving the visceral and parietal pleura, which becomes edematous and fibrinous
Pleural Effusion excessive nonpurulent fluid in the pleural space
Empyema : purulent exudative fluid collected in pleural space
Lung Abscess well defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis
Pneumonia inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral)
Influenza: viral infection of the lung - normally an upper respiratory infection, but de to alteration in the epithelial barrier, the infected host is more susceptible t secondary bacterial infections
Tuberculosis chronic infectious disease that most often begins in the lung but my the have widespread manifestations
Pneumothorax: presence of air or gas in the pleural cavity
Hemothorax presence of blood in the pleural cavity
Lung Cancer generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures
Cor pulmonale acute or chronic condition involving right sided heart failure Pulmonary Embolism:
Pulmonary Embolism - embolic occlusion of pulmonary arteries - relatively common condition - difficult to diagnose
- Respiratory distress syndrome (infant) preterm infant has great difficulty breathing
- Diaphragmatic hernia : result of an imperfectly structured diaphragm, occurs once in slightly more than 2000 births
- Cystic Fibrosis autosomal recessive disorder of exocrine glands involving lungs, pancreas, and sweat glands
- Epiglottis acute, life threatening infection involving the epiglottis and surrounding tissues
- Croup syndrome that generally results from infection with a variety of viral agents, particularly the parainfluenza viruses occurring most often in children from about 1 ½ to 3 years of age
- Tracheomalacia lack of rigidity or a floppiness of the trachea or airway
- Bronchiolitis bronchiolar (small airways) inflammation leading to hyperinflation of the lungs occurring most often in infants younger than 6 months
- Chronic Obstructive Pulmonary Disease a group of respiratory problems in which cough, chronic and often excessive sputum production, and dyspnea are prominent features o Not limited to older adults, smokers are at greatest risk o Emphysema, bronchiectasis, and chronic bronchitis
• Emphysema condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function
• Bronchiectasis chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction
• Chronic bronchitis large airway inflammation, usually result of chronic irritant exposure. More commonly a problem for patients older than 40
Created by: alexadianna