NURS202 Lungs and Thorax

• Manubrium
• Body
• Xiphoid Process

Just above the sternum ( ridged top of manubrium) Hollow U- shaped depression, in between the clavicles.

Angle of Louis or Sternal angle

• Bony ridge ( articulation of manubrim & body of sternum)
• Useful place to start counting ribs. Continuous with 2nd rib (count ribs & ICS from this point)
• Site of tracheal bifurcation into right & left main bronchi
• Corresponds with upper boarder of atria

• It is the space below each rib
• ICS is numbered by the rib above it

12

Where the rib attaches to cartilage

• Ribs 11- 12
• attached to spinal column only ( where they get the name "floating")
• 12th rib tip is palpable midway between spine & side
• 11 is on side 12 is more posterior

• It is where the right and left costal margins meet to form an angle.
• The angle is usually 90 degrees or less to be considered normal

• It is an abnormal finding when greater than 90
• The angle increases when the rib cage is chronically overinflated, ( hyperinflation)
• An example is emphysema

• C7
• Palpate with head flexed

T1

• 12
• They are spinous processes (knobs on vertebrea) - most are palpable..you should be able to count them.

Lower tip (inferior border) at 7th- 8th rib

On the anterior chest, right down the middle over the sternum.

• Anterior chest
• It bisects the center of each clavicle

• Posterior chest wall
• Also called midspinal line
• Goes right down the vertebra ( the middle of the back)

Extends through the inferior angle of the scapula when the arms at the sides of the body.

First lift up the person's arm 90 degrees, and divide the lateral chest by three lines.

• Anterior axillary line (AAL) - at anterior axillary fold
• Midaxillary line (MAL) - midway between AAL & PAL
• Posterior axillary line (PAL) - at posterior axillary fold

• Supraclavicular ( above clavicle)
• Infraclavicular ( below clavicle)
• Infrascapular ( below tip of scapula)

Is the middle section of the thoracic cavity containing esophagus, trachea, heart, and great vessels.

They contain the lungs (right and left sides)

Floor of thorax, major muscle of respiration

• Anterior
• Apex (3-4 cm above 1st rib) - highest point o flung tissue
• Base( rests on diaphragm)- bottom of lungs
• on the right side found at 5th ICS, MCL ( this sits higher due to liver)
• on left side found at 6th ICS, MCL

From the apex of axilla to the 7th - 8th rib.

• C7 to T10 or T12 ( with inspiration)
• Upper lobes: T1 to T3/ T4
• Lower lobes: T3 to T10( with expiration) or T12 ( with inspiration)

• Right ( 3 lobes: upper/middle/lower) it is shorter due to liver
• Left ( 2 lobes: upper and lower) it is more narrow due to heart border

• They separate lung lobes
• Horizontal fissure: right side only, 4th rib right sternal border to 5th rib MAL
• Separates upper and middle lobe

• Anterior Oblique Fissures (bilateral)- 5th rib MAL to 6th rib MCL
• Right( separates middle & lower lobes)
• Left ( separates upper & lower lobes)

• It forms a thin slippery envelope between the lungs and the chest wall.
• Visceral- lines the lungs surface
• Parietal- lines the chest wall and diaphragm

Negative pressure that holds lungs against the chest wall

• When the pleurae extends 3cm below the level of the lung, it forms the costodiaphragmatic recess.
• This is potential space, when abnormally fills with air or fluid, it can compromise lung expansion.

• Left lung....no middle lobe
• Anterior chest ( mostly upper & middle lobes)
• Posterior chest ( mostly lower lobes)

• Trachea is anterior to the esophagus
• Starts at the cricoid process ( 10- 11cm long)
• Bifurcates at manubriosternal angle ( anteriorly)
• Bifurcates at T4 (posteriorly)

• Right Main Stem Bronchus (shorter & straighter) - increased risk of aspiration
• Dead space (trachea & bronchi) -filled with air, but no gas exchange
• Bronchial tree lined with goblet cells(secret mucus that entrap particles) & cilia (sweep particles upward); smoking paralyzes the cilia and results in mucus pooling
• Acinus (functional respiratory unit) -bronchioles, alveolar ducts, alveolar sacs & alveoli
• Alveoli (300 million)

• Supplies O2 and
• Eliminates CO2
• Helps maintain acid - base balance
• Maintaining heat exchange

retained CO2

excessive excretion of CO2 through respirations

• (Brain stem) pons & medulla
• When it senses increased CO2, its normal stimulus is to breath
• Chronic hypoxia desensitzes CO2 receptors in the brain; thus low O2
• levels become the stimulus to breath (delivery of high O2 concentrations may result in apnea)

• Cough (timing) Is it...Continuous (respiratory infection), Nighttime when recumbent (post nasal drip; sinusitis, GERD), Morning, upon awakening (chronic bronchitis, "smokers cough"), Specific settings (allergies)
• Cough (character) Hacking (mycoplasm pneumonia), Dry, non productive (early CHF, allergies, meds [ACEI]), Barking (croup), Congested (bronchitis, pneumonia)
• Sputum (amount, color, odor)....Is it...Clear/white (viral bronchitis/pneumonia), Translucent white/gray (noninfectious, chronic bronchits, smoker), Green/yellow (bacterial bronchitis/pneumonia), Rust (pneumococcal pneumonia) – blood mixed with yellow sputum, Pink - frothy (pulmonary edema), Blood (hemoptysis) - cancer, TB, Foul odor (bacterial)
• Shortness of Breath (SOB) & Dyspnea, (difficult, labored breathing) Orthopnea (difficulty breathing supine - 2 pillow, etc.) – heart failure, Paroxysmal nocturnal dyspnea (PND) - awakens from sleep with SOB (heart failure), DOE (dyspnea on exertion)
• Past History- Lung Disease, COPD, asthma, pneumonia, cystic fibrosis. Allergies ( dust, pollen, animals, mold)
• Miscellaneous symptoms- Diaphoresis (night sweats) - TB, HIV, other infection, Fever, chills, sweats (f/c/s) – infection, Unintentional weight loss – cancer, Dependent edema, PND, orthopnea – heart failure, Confusion, restlessness - hypoxia, Pleurisy (chest pain with breathing ) - inflammation of pleura
• Smoking History- cigs, cigars, pipes, marijuanna. Could indicate never past or present. Pack years
• Family History- allergies, asthma, TB, cystic fibrosis, lung cancer, emphysema( the genetic form), antitripsin deficiency, etc)
• Environmental Exposure- Grain/pesticide, Histoplasmosis(inhaled fungus), Coccididomycosis or "valley fever", Pneumoconiosis ( coal miners), Silicosis( stone cutters), Asbestos(plumbers)
• Health Promotion (PPD, influenza immunization, pneumococal vaccine)

• Upper respiratory infections ( 4-6 yr = normal)
• Asthma- may outgrow as bronchial tubes enlarge
• Accidental aspiration - child-proof the home

• SOB fatigue with daily activities ( they have decreased vital capacity (exhaled air after max inspiration) as measured by spirometry)
• Lung disease
• Chest pain with breathing ( rib fractures- spontaneous or r/t trauma/abuse/falls)

• Measure respiratory rate, rhythm, effort
• Normal shape & symmetry of chest wall ( AP diameter < transverse 1:2 to 5:7 (increase with age))
• Spine-(assess for abnormal curvatures)
• Body position- Are they relaxed? Or not... professorial or tripod position (abnormal)- aids in expiration

• Assess for abnormal curvatures- these may impair cardiopulmonary function
• Scoliosis(lateral curve)- entire spine affected. More common in girls. Assess uneven shoulders, scapular, hip heights. Observe gait- if uneven abnormal hip height. Severe curvature- >45 degrees- this may decrease lung volumes
• Kyphosis- (hump back)
• Lordosis- (sway back)

• Palpate entire chest wall ( tenderness, lumps masses)
• Symmetric chest expansion( at level T9 or T10)
• Tactile Fremitus( vocal fremitus)

Placing your warmed hands on posterlateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up small fold of skin between thumbs. Ask person to take a deep breath. Should be symmetric.

Symmetric chest expansion( at level T9 or T10)- may be uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage.

Is a palpable vocal vibration.

• This is where you would ask them to repeat "99" or "blue moon"
• Use the base of fingers at MCP joint or ulnar surface
• Start at lung apices ( symmetry is most important)
• Most prominent between scapulae & sternum, progressively decreases down thorax
• Greater in thin persons ( due to decreased thickness of chest wall

• Occurs when anything obstructs transmission of vibrations.
• Any barrier that comes between the sound and your palpating hand will decrease fremitus.
• Ex....pneumothorax, bronchial obstructions, pleural effusion, COPD( emphysema)

Consolidation extending to lung surfaces (pneumonia)

• Is a course crackling sensation palpable over the skin surface.
• It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue.
• Ex....open thoracic injury, chest surgery, tracheostomy

• Percuss ICS (intercostal spaces)
• Start at apices ( above clavicle) & percuss side-to-side down back
• Avoid scapula, ribs & spine
• Listen for sounds

• Resonant (normal) hollow sound
• Hyperresonant ( emphysema, pneumothorax)
• Dull ( increased density) - atelectasis, pneumonia, pleural effusion

CVA- costal vertebral angle tenderness ( sign of kidney infection).

So you can map out the lower lung border, both in inspiration and expiration.

• Tell patient to lean forward, breath deeply through mouth( hug chest to open interspaces)
• Use diaphragm of stethoscope ( assess symmetry & don't forget lateral lung fields
• Progress from top to bottom & side to side
• Listen at each location for a full respiratory cycle. (inspiration & expiration)

• Bronchial
• Bronchovesicular
• Vesicular

• Loud, harsh
• Normal over neck ( trachea & larynx)
• Abnormal if heard over peripheral lung fields ( indicates consolidation)
• Pitch: High Amplitude:Loud Duration:Inspiration< expiration

• Moderately loud/harsh
• Normal over midsternum & between scapula in back ( major bronchi)
• Pitch:Moderate Amplitude:Moderate Duration:Inspiration= expiration

• Low, soft, like rustling wind in the trees
• Normal over peripheral lung fields
• Absent (mucus plug, collapsed lung) - this is serious report immediately!
• Pitch:Low Amplitude:Soft Duration:Inspiration> expiration

• Added sounds, not normally present.
• Crackles
• Rhonchi
• Wheeze
• Stridor
• Pleural Friction Rub

• Sounds like velcro opening
• Produced when there is fluid inside a bronchus causing a collapse of the distal (smaller) airways and alveoli. Occurs when there is a sudden equalization of pressure causing some of the airways to pop open.
• Heard on inspiration, doesn't clear with coughing.

High-pitched, short duration, cracking & popping sounds

• Low-pitched, longer duration, bubbling & gurgling sounds.
• Causes: atelectasis, pneumonia, fibrosis, heart failure, pulmonary edema.

• Airflow through an airway obstructed by thick secretions, spasm, or tumor...ex bronchitis, decreased cough reflux)
• Loud, low, coarse sounds (like a snore or rumble) most often heard continuously during inspiration or expiration.
• Often clears with coughing or suctioning.

• Airflow through a constricted airway
• High-pitched squeaking sound ( like a whistle)
• Primarily heard on expiration, but may also be heard on inspiration
• Assess breath sounds with forced expiration in an asthma patient to check for bronchoconstriction.

• A sign of respiratory distress
• Partial airway obstruction ( foreign body)
• Characterized by an inspiratory wheeze
• Louder in neck than chest

• Caused by inflammation of pleural surfaces ( pleurisy)
• Coarse rubbing or grating sound during inspiration or expiration (disappears with breath holding)

• Soft , muffled and indistinct.
• You can hear sound, but can't distinguish what is being said.

• Bronchophony ( repeat "99" or "blue moon") Normal: 99 is muffled and indistinct....Abnormal: clear 99- this could mean increased lung density
• Egophony (repeat "E") Normal: "EEE" sound Abnormal: E to A changes, consolidation
• Whispered pectoriloquy ( whisper 1-2-3) Normal: sounds faint, muffled, almost inaudible Abnormal: sounds clear & distinct, consolidation

• Skin (pallor or cyanosis)
• Nails(clubbing)
• Pursed Lips
• Splinting
• Quality of respirations
• Tracheal Position
• Chest
• Costal Angle
• LOC- Drowsiness r/t cerebral hypoxia
• Retraction of bulging of ICS
• Use of accessory neck muscles to lift sternum & rib cage
• Respiratory Rate & Patterns

• Seen in obstructive disease
• prolongs expiration to allow for exhalation of trapped air

Shallow breaths to control pain

Quiet, easy & non labored

Tension pneumothorax- trachea shifts to the opposite side of lung collapse ( called tracheal tug)

Sunken sternum, funnel chest

Forward protrusion, pigeon chest

Increased AP diameter- associated with aging, emphysema, asthma

< 90 degrees ( barrel chest > 90)

Obstruction or increased respiratory effort

Trapped air- emphysema- caused by barrel chest

• That the patient is using the accessory neck muscles to lift sternum & rib cage.
• This is a sign of a chronic respiratory disease.

• Normal ( rate 10-20/min adult with occasional sigh
• Tachypnea
• Hyperventilation
• Bradypnea
• Hypoventilation
• Cheyne-stokes
• Biots
• Stertorous
• Stridor

Tachypnea ( rapid shallow breathing >20/min) caused by fever, fear, anxiety, exercise

• Rapid, deep breathing
• Caused by extreme exertion, fear, anxiety, diabetic ketoacidosis.
• CO2 is excreted thru respirations (increasing the alkalinity of the blood)

• Regular, slow breathing <10/min.
• Depressant drugs, increased intracranial pressure (ICP), diabetic coma

• Irregular, shallow breathing
• Caused by narcotic OD, anesthetics, prolonged bedrest, splinting with pain
• CO2 is retained (may cause acidosis)

• Regular, cyclic breaths 30-40 secs, then apnea x 20sec
• CHF and other causes

Ataxic- irregular, deep, slow with periods of apnea.

Snoring

Croup, foreign body, growth on vocal cords, high pitched on inspiration

• Symmetric chest expansion (thumbs on xyphiod process)
• Tactile fremitus (chest wall vibrations while repeating "99")- start at apices and work down avoid breast tissue.
• Palpate chest wall for tenderness, lumps, masses

• Start at apices
• Percuss interspaces for resonance
• Compare sides
• Avoid breast tissue
• Note cardiac dullness
• Border of liver (dullness at 5th ICS MCL)
• Gastric bubble on left (tympanic)

• Start at supraclavicular space & progress down to 6th rib
• Follow same pattern as percussion

• Atelectasis(collapsed alveoli, predisposes pneumonia)
• Pneumonia
• Bronchitis(inflammation of bronchi) - acute or chronic
• Emphysema(destruction of alveoli, decreased gas exchange)
• Asthma(intermittent bronchospasm/constriction) may lead to chronic lung disease
• Pleural effusion (fluid in pleural space)
• Pneumothorax(air in pleural space, collapsed lung)
• Hemothorax(blood in pleural space)

At 32 weeks gestation- problems with collapse of alveoli if born before this.

• Out of their noses.
• That is why nasal obstruction can cause death.

Bronchovesicular breath sounds in peripheral lung fields. This is normal