Thorax and Lungs

Anterior Thorax

(Suprasternal notch)

Posterior Thorax

Reference Lines

Lobes of Lungs

Lobes of Lungs

Trachea and Pleurae

Pleurae Visceral pleura – lines outside of

lungs, dipping down into the fissures

Parietal Pleura – lines inside of chest wall and diaphragm

Lubricating fluid between the pleurae prevents friction

Trachea and Bronchi Transport gasses between

environment and lung Dead space is space filled with

air (about 150 ml) but not available for gaseous exchange

Goblet cells in bronchi secrete mucus that entraps particles

Cilia in bronchi sweep particles upward

Terms

Developmental Considerations

Infants and Children When cord is cut, blood is cut off from placenta and rushes into

pulmonary circulation. Due to less resistance in pulmonary arteries, the foramen ovale closes, along with ductus arteriosus

Lungs grow until about 300 million alveoli in adolescence Pregnancy

The enlarging uterus elevates the diaphragm 4 cm during pregnancy, but the increased estrogen relaxes thoracic ligaments allowing compensation by increasing the transverse diameter

Mother’s tidal volume increases to meet demands of fetus Aging

kyphosis calcification of costal cartilage decreased vital capacity decreased number of alveoli decreased mucous production

Health History Cough

Onset? Gradual or sudden? Frequency?• Continuous throughout day – acute illness (respiratory infection)• Afternoon/evening – may reflect exposure to irritants at work• Night – postnasal drip, sinusitis• Early morning – chronic bronchial inflammation of smokers

Sputum? How much? Characteristic?• Chronic bronchitis – productive cough for 3 months of the year for 2

years in a row• Characteristics

• White of clear mucoid – colds, viral infection, bronchitis• Yellow or green – bacterial infection• Rust colored – TB, pneumococcal pneumonia• Pink, frothy – pulmonary edema, medications?

Cough up blood? Description of cough – dry, hacking Associative and Alleviating factors Painful?

Health History

Shortness of Breath (SOB) Onset, associative factors

• Determine how much activity precipitates SOB Affected by position?

• Orthopnea – difficulty breathing when supine (heart failure?) Time of day/night

• Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and needing to be upright to achieve comfort

Allergies?• Asthma attacks

Alleviating factors

Health History

Chest pain with breathing? Location, onset, duration, frequency, intensity,

associative and alleviative factors Past history of respiratory infections?

Bronchitis, emphysema, asthma, pneumonia Smoking history Environmental exposure Self – care behaviors

Immunizations, TB skin tests, chest X-rays

Assessment - Inspection

Inspect thorax Symmetry AP diameter

• Normal 1:2• AP diameter = transverse

diameter, “barrel chest”. Occurs with normal aging, chronic emphysema, and asthma

Symmetry and normal development of trapezius muscle

• Hypertrophied in COPD Position person takes to breathe

• COPD – tripod position

Posterior Chest

Symmetric chest expansion Place warmed hands on

posterolateral chest wall with thumbs at level of T9 or T10

Slide hands medially to pinch up a small fold of skin between thumbs

Ask person to take a deep breath As person inhales, the thumbs

should move apart symmetrically• Unequal chest expansion occurs

with atelectasis, pneumonia, thoracic trauma

• Pain accompanies deep breathing when pleurae are inflamed

Tactile Fremitus

Fremitus is a palpable vibration transmitted through patent bronchi and lung parenchyma to the chest wall where they can be felt as vibrations

Place either the palmar base of ulnar edge of one of the hands on the person’s back and ask to repeat “ninety-nine.” Start at lung apices and palpate from one side to another

Symmetry is most important Normally, fremitus most prominent

between scapulae and decreases as you progress down

Abnormalities in Fremitus

Decreased fremitus occurs when anything obstructs transmission of vibrations

• Obstructed bronchus• Pleural effusion or thickening• Pneumothorax• Emphysema

Increased fremitus occurs with compression or consolidation of lung tissue

• Lobar pneumonia Rhonchal fremitus – palpable with thick secretions Crepitus – coarse crackling sensation palpable over skin

surface. Occurs in subQ emphysema when air escapes from lung and enters subQ tissue

Percussion

Start at the apices and percuss across tops of both shoulders and down the lung region at approx. 5cm intervals

Make a side to side comparison Avoid damping effect of scapulae and

ribs Resonance predominates in healthy

lungs Hyperresonance is found when too

much air is present (emphysema or pneumothorax)

Dullness signals abnormal density (pneumonia, pleural effusion, atelectasis, tumor)

Expected Percussion Notes

Percussion Notes

Auscultating Posterior Chest

Breath sounds Instruct the person to breathe through

the mouth a little deeper than usual, but to stop if they feel dizzy. Hyperventilation may lead to fainting!

Use the flat diaphragm endpiece of the stethoscope and listen for at least one full respiration in each location

Continue to think:• What am I hearing?• What should I expect to be hearing?

• Bronchial• Bronchovesicular• Vesicular

Do not confuse background noise with lung sounds

• Stethoscope tubing bumping together• Shivering• Hairy chest• Rustling of gown

Characteristics of Normal Breath Sounds

Location of Normal Breath Sounds

Auscultation

Abnormal Findings Decreased breath sounds

• Obstruction of bronchial tree (by secretions, mucous plug, foreign body)• In emphysema due to loss of elasticity in the lung fibers and decreased

force of inspired air. The lungs are already hyperinflated so not much air will be coming in.

• Obstruction of sound by pleural thickening• Silent chest – no air moving in or out

Increased breath sounds – louder than normal• Bronchial sounds

• Heard in abnormal location, such as periphery• High pitched, with prolonged expiratory phase• Occur in consolidation (pneumonia) or compression (fluid in intrapleural

space). Dense lung tissue enhances transmission of sound.

Auscultating Adventitious Sounds

Adventitious sounds Sounds not normally heard in the lungs Caused by moving air colliding with secretions in trachea or

bronchi, or from popping open of previously deflated airways

Crackles (fine) Description: popping sounds heard during inspiration. May be

stimulated by rolling a strand of hair between fingers near the ear

Mechanism: Inhaled air collides with previously deflated airways. Airways suddenly pop open creating a crackling sound

Clinical example:• Early inspiratory – COPD• Late inspiratory – Pneumonia, heart failure, interstitial fibrosis

Crackles (coarse)

Description: • loud, low-pitched, bubbling and gurgling sounds

early in inspiration. Sound like Velcro

Mechanism: • Inhaled air collides with secretions in trachea and

large bronchi

Clinical example: • Pulmonary edema, pneumonia, pulmonary

fibrosis, depressed cough reflex

Pleural friction rub

Description: • Coarse and low pitched superficial sound.

Both inspiratory and expiratory. Mechanism:

• Caused when pleurae become inflamed and lose normal lubricating fluid. Pleural surfaces rub together during respiration. Heard best in anterolateral wall.

Clinical example: • Pleuritis

Wheeze

Description• High pitched musical squeaking sound

predominantly during expiration

Mechanism• Air squeezed or compressed through

narrowed airways (collapsing, swelling, secretions, tumors)

Clinical example• Acute asthma or chronic emphysema

Rhonchi (sonorous)

Description• Low-pitched, musical snoring

Mechanism• Airflow obstruction

Clinical example• Bronchitis, obstruction of bronchus from

obstruction or tumor

a.k.a. Wheeze

Stridor

Description• High pitched, inspiratory, crowing sound,

louder in neck than over chest wallMechanism

• Originates in larynx or trachea. Upper airway obstruction from inflamed tissue or obstruction

Clinical example• Croup and acute epiglottitis. Obstructed

airway.

Consolidation or compression of

voice sounds will enhance the voice

sounds

Assessing the Anterior Chest

Symmetric chest expansion Abnormally wide costal

angle occurs with emphysema

Tactile and vocal fremitus

Percussing and Auscultating Anterior Chest

Begin percussing the apices in supraclavicular ares, continuing down in intercostal spaces

Note cardiac and liver dullness and stomach tympany Chronic emphysema leads to

hyperinflation of lungs, resulting in hyperresonance where you would expect cardiac dullness

Auscultate lung fields down to the 6th rib. Progress from side to side moving downward and listen for one full respiration at each location

Pulmonary Function Test

Forced expiration of 6 seconds or more

occurs with obstructive lung disease

Developmental Considerations

Infants While infant is sleeping, can inspect and auscultate the lungs

• Infants normally have a rounded thorax, reaching a 1:2 (anteroposterior to transverse) diameter by age 6

• If a barrel shape persists after age 6, possible chronic asthma or cystic fibrosis

If baby begins to cry, it actually enhances the palpation of tactile fremitus

Pregnancy Wider thoracic cage

Aging Kyphosis – outward curvature of thoracic spine Calcification of costal cartilages leading to less mobility