Module 5

• The trachea (windpipe) is located in front of the esophagus. It begins at the lower edge of the cricoid cartilage of the larynx and extends to the level of the fourth or fifth thoracic vertebra. It branches into right and left mainstem bronchi.
• Bronchila tree: primary bronchi, begin at the carina. The right bronchus is slightly wider, shorter, and more vertical than the left bronchus. During aspiration it easily lodges at right bronchus.The mainstem bronchi each branch into the five secondary (lobar) bronchi that enter each of the five lobes of the lung. Each lobar bronchus is surrounded by connective tissue, blood vessels, nerves, and lymphatics, and each branches into progressively smaller divisions. The cartilage of these lobar bronchi is ring-shaped and resists collapse. The bronchi are lined with a ciliated, mucus-secreting membrane. The cilia move mucus up and away from the lower airway to the trachea, where the mucus is either spit out or swallowed.
• The bronchioles branch from the secondary bronchi and divide into smaller and smaller tubes, which are the terminal and respiratory bronchioles . These tubes are less than 1 mm in diameter. They have no cartilage and depend entirely on the elastic recoil of the lung to remain patent. The terminal bronchioles do not participate in gas exchange. Alveolar ducts branch from the respiratory bronchioles and resemble a bunch of grapes. Alveolar sacs arise from these ducts. The alveolar sacs contain groups of alveoli, which are the basic units of gas exchange

• Bronchial: or tubular, high-pitched, loud (harsh hollow sounds heard over the treachea and mainstem bronchi) Pause between inspiration and expiration.
• Bronchovesicular: heard over the branching bronchi. Moderate pitch, inspiration as long as expiration. Heard anteriorly, aroundupper sternum in first and second intercostal spaces. Posteroir, between scapulae(espiecially on right)
• Vesicular: soft resulting sound heard in theperiphery over small bronchioles. Low-pitch, rustling, likw the sound of the wind in the trees. Longer inspiration than expiration.
• Describe these sounds as normal, increased, diminished or absent

• DISCOUNTINUOUS
• Fine crackles: either early or late inspiration. Popping, disountinuous sounds. sounds like hair being roled between fingers.
• Coarse crackles: on expiration or early inspiration. Lower pitched, coarse, discountinous ratling sounds caused by fluid or secritions in large airways; likely to change with coughing or suctioning.
• CONTINUOUS
• Wheeze: on inspiraiton, expiration or both. Squeaky, musical, continuous sounds associated with air rushing through narrowed airways. Do not clear with coughing. Arise from small airways.
• Rhonchi: inxpiration and expiration but more prominent on expiration. Lower pitched, coarse, coninous snoring sounds. arise from large airways.
• PLUERAL FRICTION RUB: heard during both inxpiraiton and expiration, at the end of inxpiration and the beginning of expiration. Loud, rough, grating, scratching sounds caused by the inflamed surfaces of he pleura rubbing toghether; associated with pain on deep inspirations. Heard in lateral lung fields.
• Diminished breath sounds: heard with poor inspiratory effort, in the very muscular or obese, or with restricted airflow.
• Strider: A high-pitched, harsh, cowing, inspiratory sound caused by partial obstruction of the larynx or trachea. You can hear it without a stethoscope. require imideate care, can become complete obstruction.

• Components of the thoracic cage: Manibrium, Sternum, xiphoid process, vertebra, ribs.
• Land marks:
• horizontal and vertical landmarks of the anterior chest
• To locate sounds vertically, use the intercostals spaces (ICS). The 1st rib is tucked up next to the clavicle. The first ICS is between the 1st and 2nd rib. The space between the 2nd second and 3rd ribs is the 2nd ICS, and so forth.
• The left midclavicular line begins at the midpoint of the patient’s left clavicle and extends vertically down the length of the chest. The right midclavicular line begins at the midpoint of the right clavicle, and so on. The midsternal line is a vertical line running through the center of the sternum. The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest.
• horizontal and vertical landmarks of the posterior chest: To locate sounds vertically, use the vertebrae. The prominent vertebra at the base of the neck is the 7th cervical vertebra (C7). The next one down is T1 (first thoracic). Counting down to about T9 should be adequate.
• The vertebral line extends vertically down the spine. The right and left scapular lines are vertical lines through the inferior angle of the scapula.
• vertical landmarks of the lateral chest: The anterior axillary lines begin (on the right and on the left) at the anterior axillary folds. They are used to locate sounds both on the anterior and lateral chest. The posterior axillary lines are vertical lines through the posterior axillary fold. The midaxillary line is a vertical line from the middle of the axilla.

• Musculoskeletal changes associated with aging result in a gradual increase in the anterposterior diameter leading to barrel chest.With a barrel chest, the ratio between the anteroposterior (AP) diameter of the chest and its lateral diameter is 2:2 rather than the normal ratio of 1:2. This shape change results from lung overinflation and diaphragm flattening. Caused by aging and COPD
• Osteoporossi, a common disorder associated with aging, is associated with increased porosity of the vertebrae. As a result, vertebrae may comporess or collapse. shortening the lengh of the spine and pushing the ribs forward an downword.

• Rate: how fast you breath12 - 20
• Depth: is how much your lugns expand to take in air. shallow or deep
• Rhythm: regular or irregular
• The diaphragm is the major muscle of breathing. Inhalation begins when the diaphragm contracts and the chest cavity is pulled downward. The lung bases descend with the chest cavity, significantly enlarging the lungs. Intercostal muscles, the small muscles around the ribs, also contract and pull the ribs slightly outward, expanding the chest cavity and lungs. The overall effect is to enlarge the chest cavity and subsequently the lungs. The negative pressure created in the lungs draws air in through the only opening to the outside, the trachea. Exhalation occurs when the diaphragm and intercostals muscles relax, allowing the chest and lungs to return to their normal resting size. The reduction in size causes a rise in pressure inside the chest and lungs to above atmospheric pressure, which causes air to flow out of the lungs. Exhalation requires no energy or effort.

weak/absent pulse in the periphery, mottling(skin murbling), pale, ashen, or cyanotic skin and mucous membrances, and cool skin temp.shortness of breath, dyspnia, nasal flaring, head bobbing, retractions, use of acessory musls during inspiration, grunting, neding to sit upright to breathe, paroxysmal nocturnal dyspnea,conversatinal dyspnea, stridor and wheezing.

• Normal
• Bronchial
• Bronchovesicular
• Vesicular
• Abnormal lung sounds
• creckles (called rales)
• Rhonchi - muchus secritions in the large airways. Course, snoring, continuous low-ptiched sounds heard druing inspiraiton and expiraiton. may clear with cough.
• wheezes
• Stridor
• Friction rub -inflamed peural layers. A high - pitched grating or rubbing sound that me be heard thoughout the resp cycle. Loudest over lower lateral anterior surface.
• Grunting - retention of iar in the lungs. A high-pitched tubular sound heard on expiration.

• Basal insulin: given to cover the body's energy needs without taking the diet into account. Common basal insulins are NPH, insulin glargine(lantus), and insulin detemir (Levemir). Intermediate to long duration. Modified and cloudy.
• Prandial and preprandial insulin is given to prevent high blood sugar after eating a meal. Regular(unmodified insulin is this type. Should be clear and is rapid acting.
• Correction insulin: given to reduce an elevated blood sugar level to a normal range. This is a sliding scale type of managment.

Draw up regular(clear) insulin first, and then draw up the modified(cloudy) insulin.

• skin color - pink, intact
• AP:lateral ratio 1:2 cosntal range 90 degrees
• In barrel shaped: barrel chest 1:1 ration with costal angerl more than 90 degrees caused by COPD.

Apex - above the clavicles