3Thorax and LungsThoracic cage is a bony structure defined by the sternum: 12 pairs of ribs, 12 thoracic vertebrae.Floor is the diaphragm (musculotendinous septum separates the thoracic cavity from abdomen).First seven ribs attach directly to the sternum via costal cartilages. Ribs 8, 9, 10 attach to costal cartilage above. Ribs 11 & 12 “floating” with free palpable tips costochondral junctions are points where ribs join their cartilages (not palpable).
4Anterior LandmarksSuprasternal Notch: “U” shaped depression above sternum-between clavicles.Sternum: “Breastbone” 3 parts:Manubrium, Body, Xiphoid Process“Angle of Louis” Marks site of tracheal bifurcation into Right and Left main bronchi. Approximately 2.5 cm below sternal notch.
5Anterior Landmarks (Cont). Costal Angle: Right and Left costal margins form an angle where they meet at the Xiphoid Process. Usually 90 degrees or less, greater emphysema.
6Posterior LandmarksVertebra Prominens: Most bony spur protruding at the base of the neck. This is the spinous process of C7.
7Thoracic CavityMediastinum: Middle section of the thoraic cavity-contains esophagus, trachea, heart, great vesselsPleural cavities: R & L lungLung Borders:Anterior chest: Apex-highest point lung tissue. 2-4 cm above inner third clavicles. Base lower border, rests on diaphragm 6th rib midclavicular.Laterally lung tissue goes from the apex of the axilla down to the 7th or 8th rib.
8Lobes of the Lungs Right lung shorter than left because of the liver. Right lung has 3 lobes.Left lung has 2 lobes.Lobes are stacked in diagonal sloping segments separated by fissures that run obliquely throughout the chest.Anterior chest almost all upper and middle lobe with very little lower lobe.Posterior chest contains almost all lower lobe.
11Pleura of The LungsParietal Pleura: The outer lining of each lung. It is attached to the chest wall.Viseral Pleura: The inner lining of each lung. It is attached to the lung itself.Pleural Space: Is the space created between these two linings and it is filled with a small amount of lubricating fluid called Pleural Fluid.Negative Pressure holds lungs tightly against chest wall and maintains inflation.
12Trachea & Bronchial Tree Trachea is anterior to the esophagus & transports air to the bronchi.Bronchi are large “air tubes” leading from the trachea that conducts air into lungs.Trachea & bronchi transport gases between environment and lung parenchyma.Alveoli are the primary site of gas exchange.
13Mechanics of Respiration The Mechanism of Breathing maintains PH of the blood by supplying oxygen & eliminating excess carbon dioxide.With Inspiration the size of the thoracic container increases creating a slightly negative pressure in relation to the atmosphere, air rushes in.Major muscle responsible for this increase is the diaphragm.Inspiration – contraction of the diaphragm causes it to descend and flatten.Expiration – passive, relaxation of the diaphragm
14Inspiration & Expiration Inspiration: Intercostal muscles lift the sternum and elevate the ribs, diaphragm descends.Expiration is primarily passive. As diaphragm relaxes - it is forced to dome up.This results in air flowing out due to positive pressure within the alveoli.Respiratory center in the brain stem (Pons & medulla).Normal stimulus to breathe is an increase in CO2 (Hypercapnia).
15Review Of Systems Smoking History Exposure to Smoke Environmental ExposuresOccupationSleeping PatternNutritional StatusMedical/Surgical HistoryMedications
16Inspection General Appearance Restless or agitated Flaring nostrils Supraclavicular retractionsIntercostal retractionsUse of accessory muscles
17Inspection (cont). Cyanosis: Central Cyanosis: Circumoral (around mouth), check lips, tongue, buccal mucosa.Peripheral Cyanosis: check nail beds and extremities.Check nails for clubbing.Cough: productive or non-productiveInspect appearance of sputum: Mucoid vs Purulent
18Inspection (cont).Musculature: Check accessory muscles: Sternomastoid, Intercostals, Scalene, Ala NasiSymmetry: Check symmetrical expansion of chest wall.Bilateral diminished expansion may be due to acute pleurisy, pleural fibrosis, atelectasis, chest pain (fx. ribs), Costochondritis.Unilateral diminished expansion may be due to pneumothorax.Check for asymmmetry of spine:Kyphosis, Lordosis, Scoliosis.
19Inspection (cont).Configuration & Contour: Check AP diameter (AP to transverse diameter).Abnormal:Barrel chestPectus CarinatumPectus Excavatum
20Inspection (cont).Movement: Breathing patterns, smooth & even breathing.Passive breathing: normal rate12-20Inspiration > ExpirationCheck Character of Breathing: type, rate, rhythmApneaHyperventilation/TachypneaKussmaulHypoventilation/respiratory depressionCheyne Stoking/Dying Sighs
21Palpation Trachea: Check for deviation Thorax: Check for crepitus, tenderness.Check for chest wall excursionCheck for tactile or vocal fremitus:Vibrations produced in the larynx that are transmitted to the chest wall.Technique: palpate with ball of handAsk Pt. to say “99”
22Tactile fremitus (cont). Normal finding is a mild purrlike sensation.Increased tactile fremitius occurs in conditions where solid conducts vibrations better than air. Ex. Pneumonia, tumor, pulmonary fibrosisDecreased tactile fremitus occurs when there is increased distance that sound has to travel before it reaches chest wall. Ex. Pleural Effusion, pneumothorax, COPD.
23Chest Wall ExcursionPalpation of Tactile Fremitus
24Palpation (cont).Check supra & infraclavicular nodes,check axillary nodes.
26Percussion (cont).Diaphragmatic Excursion: Checks ROM of the diaphragm.Procedure: Pt. sits upright.Tell Pt. To EXHALE and HOLD IT.Percuss downward posterior chest at scapular line.Continue until tone changes resonance to dullness, mark with marker.
27Diaphragmatic Excursion (cont). Tell Pt. To take a DEEP INHALATION AND HOLD IT.Continue percussing from first mark until changes from resonance to dullness.Mark with a marker, measure findings. DON’T FORGET TO TELL PT. TO BREATH!!!Normal finding 4-6 cm. Repeat on other side.
28Auscultation Pt. sit upright, breathe slowly through mouth. Use diaphragm.Auscultate anterior, lateral and posterior chest.
30Types of Breath Sounds Bronchial (Tracheal) Loud and high pitched Vesicular Breath SoundsSoft and low pitchedFine rustling/swishing sound.Heard on inspiration continuosly without pause until expiration.Heard over all post. Lung fields and anterior periph. Fields.Inspiration> ExpirationBronchial (Tracheal)Loud and high pitchedTubular qualityExpiration>InspirationHeard only anteriorly over trachea & larynxExpiration loud
31Types of Breath Sounds Bronchovesicular Breath Sounds Combination of vesicular and bronchial soundsRepresent a mixture of sounds produced by vibrations of bronchial and alveoli vibrations.No pause between inspiration and expirationInspiration = ExpirationHeard best anteriorly at 1&2 ICS, posteriorly between scapula, anywhere else = consolidation
34Adventitious SoundsRales (Crackles): Discontinuous sounds highpitched.Sounds like hair being rubbed togetherSound produced by air passing through fluid in air spaces (CHF, pneumonia).Usually on inspiration / not expirationCough doesn’t clear.
35Adventitious Sounds (cont). Rhonchi: Deeper, rumbling sounds.Low pitched, snoring quality> pronounced during expiration.Etiology: larger airways are obstructed with mucus or tumor in large airways.Clear with coughing.
36Adventitious Sounds (cont). Wheezing: High pitched, musical, whistling sounds.Produced by narrowed airway.R/t bronchospasm, asthma, tumor, foreign bodyCan occur during inspiration or expiration.Stridor: increased musical wheeze heard over trachea on inspiration; cause obstruction = MEDICAL EMERGENCY
37Adventitious Sounds (cont). Friction (Pleural) Rub: Course, dry, grating soundEtiology: Inflamed pleural surfaces rub.Sounds similar to cupping hand over ear, scratching back of hand with other hand.Usually heard anteriolateral chest wallContinuous during inspiration and expiration.Differentiate from cardiac origin: have Pt. hold breath-if continues Cardiac origin, if stops-Lung origin.
38Tests of Vocal Resonance BRONCOPHONY: “99”NL. Muffled soundAbnormal: hear, clear loud “99” (consolidation)WHISPERED PECTORILOQUAYWhisper “99”Normal-Don’t hear or very faintAbnormal hear “99” EGOPHONY Say “E”Normal- hear “E”, Abnormal-hear “A”