Thorax and Lungs

N1037

Chapter

15

A & P of Thorax• Thorax• Pleura

– Parietal = external surface– Visceral = internal surface

• Mediastinum or interpleural space• Bronchi bifurcate T4/5 post, sternal angle ant

– Right - more vertical, risk aspiration

– Left

• Alveoli• Diaphragm (R5 ICS MCL, L6ICS MCL)

– phrenic nerve

• External intercostal muscles– inspir = ext ICM contract– expir = int ICM contract

• Accessory muscles– scalene, sternocleidomastoid, trapezius, abdominal

rectus

A & P of Thorax Sternum Ribs Intercostal spaces

Anatomy: Lungs

• Right lung: three lobes• Left lung: two lobes• Apex• Base• Midclavicular line

(MCL)• Midaxillary line

(MAL)

Anatomy: Lungs

Thoracic Anatomic Topography

• Anterior axillary line

• Midspinal (vertebral) line

• Midsternal line

• Posterior axillary line

• Scapular line

Thoracic Anatomic Topography

Physiology of Respiration• Ventilation

– active = inspiration and passive = expiration

– during inspiration pressure inside lungs = subatmospheric as diaphragm & ext ICM contract diaphragm lowers & ribs elevate which intrapulmonic volume creating a neg intra-alveolar pressure gradient with the atmosphere so air is pulled into the lungs until the intra-alveolar pressure= air pressure, thus lungs become full with air.

– Expiration occurs more rapidly. The diaphragm and ext ICM relax, which means the diaphragm rises & the ribs move closer = volume in the thoracic cavity causing a intrapulmonic volume & intrapulmonic pressure above atmospheric pressure, the lungs recoil and expel air until the intrapulmonic pressure = atmospheric pressure.

• External respiration- O2 diffuses from alveoli to blood

• Internal respiration - O2 in the blood diffuses into tissues

• Control of breathing- neural and chemical factors

– pons & medulla = CNS structures responsible for involuntary respiration

– stimulus for breathing = Co2, PH, O2 levels

Health History

• Patient profile– Age

• Children and young adults: bronchiectasis, cystic fibrosis• Adults and older adults: lung cancer, chronic bronchitis, pneumonia,

emphysema

– Gender

• Patient profile (cont’d)– Race

• African American: sarcoidosis• Caucasian: cystic fibrosis

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Common Chief Complaints

• Dyspnea

• Cough

• Sputum

• Chest pain

Characteristics of Chief Complaint

• Quality

• Quantity

• Associated manifestations

• Aggravating factors

• Alleviating factors

• Setting

• Timing

Past Health History• Medical

– Respiratory specific– Nonrespiratory specific

• Surgical• Medications• Communicable diseases• Allergies• Injuries and accidents• Special needs• Childhood illnesses

Family Health History

• Allergies

• Asthma

• Bronchiectasis

• Cancer

• Cystic fibrosis

• Emphysema

• TB

Social History

• Alcohol, drug, or tobacco use

• Travel history

• Work and home environment

• Hobbies and leisure activities

• Stress

• Economic status

Health Maintenance Activities

• Sleep

• Diet

• Exercise

• Use of safety devices

• Health check-ups

Assessment of the Thorax and Lungs

• Equipment– Stethoscope– Centimeter ruler or tape measure– Washable marker– Watch with second hand

Inspection

• Shape of thorax– Transverse diameter– Anteroposterior (AP) diameter

• Symmetry of chest wall

• Presence of superficial veins

• Costal angle

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Assessment of Thorax & Lungs• Inspect shape of thorax

– Transverse diameter– Anteroposterior (AP) diameter

– N=AP to transverse = 1:2

• Symmetry of chest wall

• Presence of superficial veins

• Abnormal– barrel chest dt COPD

– pectus carinatum dt congenital abn

– kyphosis :humpback

– scoliosis: curvature of spine

Assessment of Thorax & Lungs

• Costal angle – N=<90 with inspir & expir

• Angle of the ribs– N= ribs articulate at 45 angle

• Intercostal spaces– N= No retractions or bulging in ICS

• Muscles of respiration– N= no use of accessory muscles

Respirations

• Rate N= 12-20 bpm for adult

• Abnormalities– Eupnea: 12–20 breaths per minute– Tachypnea: > 20 breaths per minute– Bradypnea: < 12 breaths per minute– Apnea: no respiration for 10 or more seconds

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Inspect Respiration• Patterns

N= regular and even in rhythm– Cheyne-Stokes-brain injury

– Biot’s or ataxic -damaged medulla

– Apneustic -injured pons

– Agonal - impending death

• DepthN= nonexaggerated & effortless– Shallow -obese, pain, PE, puemonia,

pneumothorax

– Hyperpnea - exercise, emotional, high altitudes

– Air trapping-COPD

– Kussmaul’s-diabetic ketoacidosis

– Sighing- N or CNS lesions

Inspect Respirations• Symmetry -

N= thorax rises & falls in unison, no paradoxical movement

Abnormal = unilateral expansion dt collapsed lung

= paradoxical movement dt broken ribs

• AudibilityN= respirations are audible by ear

• Patient positionN= breaths comfortably upright, supine

Abnormal = Orthopnea dt COPD, CHF, PE

• Mode of breathingN= inhale & exhale through nose

Inspect Sputum

• Color N= light yellow or clear

• Odor N= none

• Amount N = small • Consistency N = thick or thin depends on hydration

• Abnormal – Table 15-1

Assessing Patients with Respiratory Assistive Devices

• Oxygen therapy– Mode of delivery– Percentage of oxygen– Flow rate– Humidification

• Incentive spirometer– Frequency of use, volume achieved, number of

repetitions

• Endotracheal tube– Size– Nasal or oral insertion– Length of tube as it exits mouth or nose– Cuff inflated or deflated

•Tracheostomy tube–Size–Cuffed or cuffless–How tube is secured to neck

•Mechanical ventilation–Type of ventilator–FiO2 setting–Mode–Amount of PEEP–Rate and tidal volume–Alarms

•Pulse oximeter

•Peak flow Meter

Thoracic Palpation• Palpate the Anterior, Posterior & Lateral thorax

– Assess for• Pulsations• Masses• Thoracic tenderness• Crepitus

N= no pulsations, masses, tenderness,crepitus

– Abnormal• aortic aneurysm• tumor or cyst• chest trama • subcutaneous emphysema (air in subcutaneous tissue)

Thoracic Palpation

• Thoracic expansion– Expansion– Symmetry

• Tactile fremitus– Anterior– Posterior– Lateral

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Thoracic Palpation• Thoracic expansion

– Expansion

– Symmetry

Thoracic Palpation• Tactile fremitus

– Anterior, Posterior, Lateral

N= buzzing over bronchi & trachea

Abnormal = dt consolidation

= dt pneumothorax, emphysema, asthma

Palpation Pattern for Tactile Fremitus

Thoracic Percussion

• Anterior

• Posterior

• Right and left lateral

• Diaphragmatic excursion

Pt position for Posterior Percussion

Percussion Patterns

Diaphragmatic Excursion

• Percuss lung while pt resting & mark thorax

• Percuss lung while pt takes a deep breath & mark thorax

• Measure distance btwn two marks

• Repeat other lung

N= T12 on inspir, T 10 on expir

Auscultation: Fields• Anterior • Posterior

• Lateral • Lateral

• Bronchial• Bronchovesicular• Vesicular

Auscultation: Breath Sounds

Auscultation: Breath Sounds• Assess for Pitch, Intensity, Quality, Duration, Location N= Table 15-2• Abnormal

– Adventitious Breath Sounds• Crackles - moisture in airways

• Wheeze - narrowing of airway

• Pleural friction rub - inflamed parietal & viseral pleura

• Stridor - partial obstruction

Assessment of Voice Sounds

• Reveals if lungs are full of air, fluid or solid– Instruct pt to say “99” each time you place stethescope

N= Muffled or unclear transmission

Abnormal dt any type of consolidation• Bronchophony - clear transmission of “99”

• Egophony - transmission of “ee” to “ay” with intensity

• Whispered pectoriloquy - clear transmission of “99”

• Voice sounds absent - dt air in lungs from disease - emphysema,asthma pneumothorax

Age-Related Changes

• Anatomic changes– Limited chest wall expansion– Muscle atrophy– Increased work of breathing

• Alveolar gas exchange– Decreased surface area for diffusion

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Age-Related Changes

• Regulation of ventilation– Decreased sensitivity to changes in carbon

dioxide and oxygen

• Lung defense mechanisms– Decreased ciliary action– Diminished cough reflex– Increased susceptibility to infection