PA thorax and lungs
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| Chest/thorax | a cage of bone, cartilage, and muscle.
sternum
manubrium
xiphoid process
12 pairs of ribs
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| o Diaphragm | • Primary muscle of respiration
• Contracts during inspiration
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| o External Intercostals | • Increase the anterior-posterior chest diameter during inspiration
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| o Internal Intercostals: | • Decrease transverse chest diameter during expiration
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| o Sternocleidomastoid and trapezius accessory muscles: | • Brought into play when there are pulmonary problems and compromise
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| o Mediastinum | • Situated between lungs
• Contains all thoracic viscera except the lungs
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| o Right and left pleural cavities: | • Lined with parietal and visceral pleura
• Lungs enclosed by serous membrane
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| - Lungs | highly elastic, paired but not symmetric
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| o Right lung: | 3 lobes
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| o Left lung | 2 lobes
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| - Tracheobronchial tree | : tubular system that provides a pathway along which air is filtered, humidified, and warmed
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| 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
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| 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
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| • Right bronchus | wider, shorter, and more vertically placed than the left bronchus (more susceptible to aspiration of foreign bodies)
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| • Bronchial arteries | branch from the anterior thoracic aorta and the intercostal arteries, supplying blood to the lung parenchyma and stroma
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| • Bronchial vein | formed at the hilum of the lung
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| 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)
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| Posterior Thoracic Landmarks | verterbra prominens (spinous process of C7)
spinous processes
inferior border of scapula (7th-8th rib)
12th rib (free tip)
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| Fetal lungs | contain no air; gas exchange is through placenta
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| 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
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| 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
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| Respiration in Pregnant women | o Mechanical and biochemical factors lead to changes in respiratory function
• Enlarging uterus (elevates diaphragm 4 cm)
• Increasing progesterone
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| 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
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| 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
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| HPI: Coughing | onset, nature, sputum, pattern, severity, associated symptoms, efforts to treat, medications
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| 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
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| HPI: chest pain | onset and duration, associated symptoms, efforts to treat, medications, recreational drugs
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| PMI | thoracic trauma, surgery, hospitalization, use of oxygen and ventilation assisting devices, chronic pulmonary diseases, other disorders, testing, immunization against strep pneumonia, influenza
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| Family History | TB, cystic fibrosis, emphysema, allergy, asthma, atopic dermatitis, malignancy, bronchiectasis, bronchitis, clotting disorders (risk of PE)
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| Personal and Social History | employment, home, tobacco use, exposure to infections, nutrition, use of herbs, travel, hobbies, alcohol/drugs, exercise tolerance
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| 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
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| 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
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| Inspection: chest | shape and symmetry, chest wall movement, superficial venous patterns, prominence of ribs, anterior/posterior transverse diameter, sternal protrusion, spinal deviation
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| Inspection: bony structures | looks for anterior deviations:
pigeon chest
funnel chest
barrel chest
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| Inspection: peripheral clues | fingers (clubbing)
breath (odor)
skin, nails, lips (cyanosis,pallor)
nostrils (flaring)
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| Inspection: respiration | rate, quality, pattern, cout while palpating pulse
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| dyspnea | shortness of breath
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| • Tachypnea | rapid, shallow breathing
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| • Bradypnea | slow breathing
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| • Hyperventilation and hyperpnea | faster and deeper than normal, blowing off CO2
- extreme exertion, fear, anxiety, acidosis
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| • Kussmaul | deep, labored, gasping form of hyperventilation associated with severe metabolic acidosis (DKA)
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| • Cheyne Stokes | waxing and waning breaths, with periods of apnea- regular pattern
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| sigh | occasional, punctuate normal breathing pattern, expand alveoli
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| • Air trapping | normal inspiration and prolonged expiration to overcome increased airway resistance
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| • Biot | series of normal respirations (3-4) followed by apnea in an irregular pattern
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| apnea | cessation of breathing
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| 3 modes of respiration | thoracic (costal)
abdominal
paradoxic
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| paradoxic respiration | lung is deflated during inspiration and inflated during expiration (flail chest)
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| • 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)
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| Signs of Obstruction | stridor, nostril flaring, cough, chest retraction
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| Palpation of thoracic muscles/skeleton | pulsations, tenderness, bulges, depressions, massess, unusual movement/positions, elasticity of rib cage, immovability of sternum, rigidity of spine
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| 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
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| - Friction Rub | o Palpable, coarse, grating vibration, usually on inspiration
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| - Thoracic Expansion: | o Loss of symmetry in the movement of the thumbs suggests a problem on one or both sides
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| - Tactile Fremitus: | o Palpable vibration of the chest wall that results from speech or other verbalizations
o Have patient say 99
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| Percussion: chest | anterior, lateral, posterior, compare tones bilaterally, measure diaphragmatic excursion
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| resonance | normal percussion sound
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| hyperresonance | hyperinflation of lungs
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| dullness | indicates diminished air exchange
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| Auscultation of lungs | listen to intensity, pitch, quality, duration
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| bronchial breath sounds | heard over trachea and larynx
-high pitch
- high intensity
- abnormal if heard over peripheral lung tissue
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| bronchovesicular breath sounds | heard over major bronchi where fewer alveoli are located
- moderate pitch
-moderate intensity
-abnormal is heard over peripheral lung tissue
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| vesicular breath sounds | heard over peripheral lung fields where air flows through smaller bronchioles and alveoli
• Low pitch
• Low intensity
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| 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
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| cavernous breath sounds | sounds as if coming from a cavern
• Commonly heard over a pulmonary cavity in which the wall is rigid
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| 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
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| fine crackles | high pitched and relatively short in duration
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| coarse crackles | low pitched, and relatively longer in duration
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| 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
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| 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
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| friction rub | • Dry, crackly, grating, low pitched sound and is heard in both expiration and inspiration
• Caused by inflamed, roughened surfaces rubbing together
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| 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
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| - Vocal Resonance | spoken voice transmits sounds through the lung fields that may be heard with the stethoscope
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| • Bronchophony | person says 99- greater clarity and increased loudness of spoken words (sign of increased density)
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| • Egophony | person says eeeeee- intensity of the spoken voice is increased and there is a nasal quality, eeee becomes aaaa
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| • Pectoriloquy | extreme bronchophony where even a whisper can be heard clearly through the stethoscope
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| 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
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| stridor | high pitched, piercing sound most often heard during inspiration, result of obstruction high in respiratory tree
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| 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
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| - Flaring of alae nasi | indicator of respiratory distress i infants
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| 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
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| breath sounds of child | more resonant, hyperresonance common, easy to miss dullness, brinchovesicular sound may predominate
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| Exam of Pregnant Woman | structural and ventilatory changes, dyspnea common, increases ventilation by breathing more deeply, not more frequently
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| 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
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| asthma | reactive airways disease- - small airways obstruction due to inflammation and hyperreactive airways
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| atelectasis | : incomplete expansion of the lung at birth or the collapse of the lung at any age
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| Bronchitis | inflammation of large airways; proliferation of mucous glands in passageways, resulting in excessive mucus secretion
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| Pleurisy: | inflammatory process involving the visceral and parietal pleura, which becomes edematous and fibrinous
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| Pleural Effusion | excessive nonpurulent fluid in the pleural space
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| Empyema | : purulent exudative fluid collected in pleural space
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| Lung Abscess | well defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis
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| Pneumonia | inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral)
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| 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
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| Tuberculosis | chronic infectious disease that most often begins in the lung but my the have widespread manifestations
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| Pneumothorax: | presence of air or gas in the pleural cavity
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| Hemothorax | presence of blood in the pleural cavity
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| Lung Cancer | generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures
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| Cor pulmonale | acute or chronic condition involving right sided heart failure
Pulmonary Embolism:
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| Pulmonary Embolism | - embolic occlusion of pulmonary arteries
- relatively common condition
- difficult to diagnose
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| - Respiratory distress syndrome (infant) | preterm infant has great difficulty breathing
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| - Diaphragmatic hernia | : result of an imperfectly structured diaphragm, occurs once in slightly more than 2000 births
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| - Cystic Fibrosis | autosomal recessive disorder of exocrine glands involving lungs, pancreas, and sweat glands
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| - Epiglottis | acute, life threatening infection involving the epiglottis and surrounding tissues
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| - 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
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| - Tracheomalacia | lack of rigidity or a floppiness of the trachea or airway
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| - Bronchiolitis | bronchiolar (small airways) inflammation leading to hyperinflation of the lungs occurring most often in infants younger than 6 months
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| - 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
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| • Emphysema | condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function
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| • Bronchiectasis | chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction
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| • Chronic bronchitis | large airway inflammation, usually result of chronic irritant exposure. More commonly a problem for patients older than 40
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