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PA thorax and lungs
| Question | Answer |
|---|---|
| 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
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