Exam 1 Thorax

Cough seems to come with anything: activity, position (lying), fever, congestion, talking, anxiety

Activity make it better or worse? What treatment have you tried? Prescription or over-the-counter medications, vaporizer, rest, position change? Does the cough bring on anything such as chest pain or ear pain? Is it tiring? Are you concerned about it?

History of Respiratory Infections

Any past history of breathing trouble or lung diseases, such as bronchitis, emphysema, asthma, or pneumonia? Any unusually frequent or unusually severe colds? Any family history of allergies, tuberculosis, or asthma? Smoking history Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long? Do you live with someone who smokes? Have you ever tried to quit? Why do you think it did not work? What activities do you associate with smoking?

Common Respiratory Conditions

Atelectasis Lobar pneumonia Bronchitis Emphysema Asthma (reactive airway disease) Pleural effusion thickening Pneumothorax Congestive heart failure Pneumocystis carinii pneumonia Tuberculosis Pulmonary embolism Acute respiratory distress syndrome

Atelectatic crackles:

Atelectatic crackles: a type of adventitious sound, is not pathologic; short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths When sections of alveoli are not fully aerated (as in people who are asleep, or in older adult), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard in the periphery only, and disappear after first few breaths or after a cough.

Auscultate Breath Sounds

Auscultate lung fields over anterior chest from apices in supraclavicular areas down to sixth rib. Progress from side to side as you move downward, and listen to one full respiration in each location. Use sequence indicated for percussion; do not place stethoscope directly over female breast; displace breast and listen directly over chest wall. Evaluate normal breath sounds, noting any abnormal breath sounds and any adventitious sounds. If situation warrants, assess voice sounds.

Percussion of Anterior Chest

Begin percussing apices in supraclavicular areas. Then, percussing interspaces and comparing one side to other, move down anterior chest. Interspaces are easier to palpate on anterior chest than on back. Do not percuss directly over female breast tissue because this would produce a dull note; shift breast tissue over slightly using edge of your stationary hand. In females with large breasts, percussion may yield little useful data.

Symmetric Expansion

Confirm symmetric chest expansion by placing your warmed hands on posterolateral chest wall with thumbs at level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs; ask person to take a deep breath. Your hands serve as mechanical amplifiers; as person inhales deeply, your thumbs should move apart symmetrically; note any lag in expansion.

Developmental Competence Aging adult

Costal cartilages become calcified, which produces a less mobile thorax. Aging lung is more rigid structure that is harder to inflate. These changes result in an increase in small airway closure. With aging, histologic changes (i.e., a gradual loss of intra-alveolar septa and a decreased number of alveoli) also occur, so less surface area is available for gas exchange. Lung bases become less ventilated as a result of closing off of a number of airways. Histologic changes also increase the older person's risk of postoperative pulmonary complications.

Subjective Data

Cough Shortness of breath Chest pain with breathing History of respiratory infections Smoking history Environmental exposure Self-care behaviors

Posterior Thoracic Landmarks I

Counting ribs and intercostal spaces on back is harder due to muscles and soft tissue surrounding ribs and spinal column. Vertebra prominens: start here; flex your head and feel for most prominent bony spur protruding at base of neck. This is spinous process of C7; if two bumps seem equally prominent, upper one is C7 and lower one is T1. Spinous processes: count down these knobs on vertebrae, which stack together to form spinal column.

Voice Sounds I

Determine quality of voice sounds or vocal resonance. Voice can be auscultated over chest wall. Ask person to repeat a phrase, such as "ninety-nine" while you listen over chest wall. Normal voice transmission is soft, muffled, and indistinct; you can hear sound through stethoscope but cannot distinguish exactly what is being said.

Adventitious Lung Sounds

Discontinuous sounds Crackles—fine Crackles—course Atelectatic crackles Pleural friction rub Continuous sounds Wheeze—sibilant Wheeze—sonorous rhonchi Stridor

Tactile Fremitus I

Fremitus is a palpable vibration. Sounds generated from larynx are transmitted through patent bronchi and through lung parenchyma to chest wall, where you feel them as vibrations. Use either palmar base (ball) of fingers or ulnar edge of one hand, and touch person's chest while he or she repeats words, "ninety-nine" or "blue moon." These are resonant phrases that generate strong vibrations.

Do you have a cough? When did it start? Gradual or sudden?

How long have you had it? How often do you cough? At any special time of day or just on arising? Cough wake you up at night? Do you cough up any phlegm or sputum? How much? What color is it? Cough up any blood? Does this look like streaks or frank blood? Does the sputum have a foul odor? How would you describe your cough: hacking, dry, barking, hoarse, congested, bubbling?

Abnormal Tactile Fremitus

Increased tactile fremitus Decreased tactile fremitus Rhonchial fremitus Pleural friction fremitus

Lobes of the Lung Left

Left lung contains only two lobes, upper and lower. These are seen laterally as two triangular areas separated by oblique fissure. Left upper lobe extends from apex of axilla down to fifth rib at midaxillary line. Left lower lobe continues down to eighth rib in midaxillary line. Using these landmarks, take a marker and try tracing outline of each lobe on a willing partner. Take special note of three points that commonly confuse beginning examiners. Left lung has no middle lobe. Anterior chest contains mostly upper and middle lobe with very little lower lobe. Posterior chest contains almost all lower lobe

Reference Lines II

Lift up the person's arm 90 degrees, and divide lateral chest by three lines:

Lobes of the Lung Anterior Chest Lobes not arranged in horizontal bands; they stack in diagonal sloping segments and are separated by______that run obliquely through chest

Lobes not arranged in horizontal bands; they stack in diagonal sloping segments and are separated by fissures that run obliquely through chest

Percussion Posterior Chest I

Lung fields Determine predominant note over lung fields; start at apices and percuss band of normally resonant tissue across tops of both shoulders. Then, percussing in interspaces, make side-to-side comparison all the way down lung region. Percuss at 5-cm intervals; avoid damping effect of scapulae and ribs. Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult.

Lateral chest Lung tissue extends from_____down to _______or __________ rib.

Lung tissue extends from apex of axilla down to seventh or eighth rib. Right upper lobe extends from apex of axilla down to horizontal fissure at fifth rib. Right middle lobe extends from horizontal fissure down and forward to sixth rib at midclavicular line. Right lower lobe continues from fifth rib to eighth rib in midaxillary line.

Lobes of the lung are lung symmetric in structure?

Lungs are paired but not precisely symmetric structures. Right lung shorter than left because of underlying liver Left lung narrower than right because heart bulges to left. Right lung has three lobes, and left lung has two lobes

lateral chest reference lines

anterior, mid, post axillary line

Lung borders: - Apex of lung tissue is ____ cm above inner ____ of clavicles - Base rests on ____ at ______ rib in midclavicular line - laterally, lung tissue extends from ____ of axillary down to ____ rib

apex of lung tissue is 3 or 4 cm above inner third of clavicles. Base rests on diaphragm at about sixth rib in midclavicular line. Laterally, lung tissue extends from apex of axilla down to seventh or eighth rib.

Lobes of the Lung Posterior Chest Upper lobes occupy a smaller band of tissue from their apices at ______ down to ______ Lower lobe is from ____ to _____

Most remarkable point about posterior chest is that it is almost all lower lobe. Upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4. At this level, lower lobes begin, and their inferior border reaches down to level of T10 on expiration and to T12 on inspiration. Right middle lobe does not project onto posterior chest at all.

Control of respirations

Normally our breathing pattern changes without our awareness in response to cellular demands. Major feedback loop is humoral regulation, or change in carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion level. Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapnia. Decrease of oxygen in blood (hypoxemia) also increases respirations but is less effective than hypercapnia.

Inspection of the Anterior Chest

Note shape and configuration of chest wall. Ribs are sloping downward with symmetric interspaces. Costal angle is within 90 degrees; development of abdominal muscles as expected for person's age, weight, and athletic condition. Note person's facial expression; facial expression should be relaxed, indicating unconscious effort of breathing. Assess the level of consciousness; level of consciousness should be alert and cooperative. Note skin color and condition; lips and nail beds are free of cyanosis; nails are of normal configuration.

Posterior Thoracic Landmarks II

Note that spinous processes align with their same numbered ribs only down to T4. After T4, spinous processes angle downward from their vertebral body and overlie vertebral body and rib below. Inferior border of scapula: scapulae are located symmetrically in each hemithorax. Lower tip is usually at seventh or eighth rib. Twelfth rib: palpate midway between spine and person's side to identify its free tip.

Spinous processes:

count down these knobs on vertebrae, which stack together to form spinal column.

tactile fremitus indicates

denser or inflamed lung tissue, which can be caused by diseases such as pneumonia. A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma.

Mediastinum contains

esophagus, trachea, heart, and great vessels

scapular line

extends through inferior angle of scapula when arms are at sides of body.

On anterior chest, oblique fissure crosses _____ rib in midaxillary line and terminates at _____ rib in midclavicular line. Right lung also contains horizontal (minor) fissure, which divides right upper and middle lobes. This fissure extends from ______ rib in right midaxillary line to third intercostal space or ________ rib at right sternal border.

On anterior chest, oblique fissure crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line. Right lung also contains horizontal (minor) fissure, which divides right upper and middle lobes. This fissure extends from fifth rib in right midaxillary line to third intercostal space or fourth rib at right sternal border.

Palpation of Anterior Chest I

Palpate symmetric chest expansion. Place your hands on anterolateral wall with thumbs along costal margins and pointing toward xiphoid process. Ask person to take a deep breath; watch thumbs move apart symmetrically, and note smooth chest expansion with fingers. Any limitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists here with breathing.

Auscultate the Posterior Chest

Passage of air through tracheobronchial tree creates a characteristic set of noises that are audible through chest wall. These noises also may be modified by obstruction within respiratory passageways or by changes in lung parenchyma, the pleura, or chest wall.

Diaphragmatic Excursion

Percuss to map out lower lung border, in expiration & inspiration First, ask to "exhale & hold it" percuss down scapular line until sound changes from resonant to dull on each side This estimates level of diaphragm separating lungs from ABD viscera; may be higher on right side because of liver Mark the spot Now ask to "take a deep breath & hold it" Continue percussing down from your first mark & mark level where sound changes to dull Measure the difference; this diaphragmatic excursion should be equal bilaterally & measure about 3 to 5 cm in adults, up to 7 - 8 cm in well-conditioned people

Any chest pain with breathing?

Please point to exact location. When did it start? Is it constant or does it come and go? Describe the pain: burning, stabbing? Is it brought on by respiratory infection, coughing, or trauma? Is it associated with fever, deep breathing, unequal chest inflation? What have you done to treat it? Have you tried medication or heat application?

Structure and Function

Position and surface landmarks Thoracic cage is a bony structure with a conical shape, which is narrower at top. Defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae Floor is the diaphragm, a musculotendinous septum that separates thoracic cavity from abdomen. First seven ribs attach to sternum by costal cartilages. Ribs 8, 9, and 10 attach to costal cartilage above. Ribs 11 and 12 are "floating," with free palpable tips. Costochondral junctions are points at which ribs join their cartilages; they are not palpable.

Lungs border, posterior the location of ____ marks apex of lung tissue, and _____ usually corresponds to base. Deep inspiration expands lungs, and their lower border drops to level of _____

Posteriorly, the location of C7 marks apex of lung tissue, and T10 usually corresponds to base. Deep inspiration expands lungs, and their lower border drops to level of T12.

Changing chest size

Respiration is the physical act of breathing; air rushes into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration). Mechanical expansion and contraction of chest cavity alters size of thoracic container in two dimensions. Vertical diameter lengthens or shortens, which is accomplished by downward or upward movement of diaphragm. Anteroposterior diameter increases or decreases, which is accomplished by elevation or depression of ribs.

Anterior Thoracic Landmarks I

Surface landmarks on thorax are sign posts for underlying respiratory structures. Knowledge of landmarks will help you localize a finding and will facilitate communication of your findings. Suprasternal notch: feel this hollow U-shaped depression just above sternum between clavicles. Sternum: "breastbone" has three parts; manubrium, body, and xiphoid process. Walk fingers down manubrium a few centimeters until you feel distinct bony ridge, the manubriosternal angle.

t spinous processes align with their same numbered ribs only down to____

T4 After T4, spinous processes angle downward from their vertebral body and overlie vertebral body and rib below

Have you noticed any shortness of breath or fatigue with your daily activities?

Tell me about your usual amount of physical activity. (For those with a history of chronic obstructive pulmonary disease, lung cancer, or tuberculosis): How are you getting along each day? Any weight change in last 3 months? How much? How is your energy level? Do you tire more easily? How does your illness affect you at home and at work? Do you have any chest pain with breathing? Do you have any chest pain after a bout of coughing or after a fall?

Inspect the Posterior Chest I

Thoracic cage Note shape and configuration of chest wall. Spinous processes should appear in a straight line; thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to spine; scapulae are placed symmetrically in each hemithorax. Anteroposterior diameter should be less than transverse diameter. The neck muscles and trapezius muscles should be developed normally for age and occupation

Reference Lines I

Use reference lines to pinpoint finding vertically on chest.

Counting ribs in back start from

Vertebra prominens

manubrium

Walk fingers down manubrium a few centimeters until you feel distinct bony ridge, the manubriosternal angle.

Do episodes seem to be related to food, pollen, dust, animals, season, or emotion?

What do you do in a hard-breathing attack? Take a special position, or use pursed-lip breathing? Do you use any oxygen, inhalers, or medications? How does the shortness of breath affect your work or home activities? Is it getting better or worse or staying about the same?

Self-care behaviors

When was the last time you had the following? TB skin test Chest x-ray study Pneumonia or influenza immunization

Are there any environmental conditions that may affect your breathing?

Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area? Do you do anything to protect your lungs, such as wear a mask or have ventilatory system checked at work? Do you do anything to monitor your exposure? Do you have periodic examinations, pulmonary function tests, or x-ray examinations? Do you know what specific symptoms to note that may signal breathing problems?

Types of Breath Sounds

You should expect to hear three types of normal breath sounds in adult and older child. Study description of characteristics of these normal breath sounds. Note normal location of three types of breath sounds on the chest wall of adult and older child.

Inferior border of scapula-Lower tip is usually at _____ rib

located symmetrically in each hemithorax. seventh or eighth rib.

On anterior chest, note

midsternal line and midclavicular line.

Vertebra prominens

most prominent bony spur protruding at base of neck. This is spinous process of C7; if two bumps seem equally prominent, upper one is C7 and lower one is T1.

Angle of Louis also marks site of ____ into right and left main bronchi; corresponds with ______ of heart, and lies above _____ thoracic vertebra on back

of tracheal bifurcation into right and left main bronchi; corresponds with upper border of atria of the heart, and it lies above fourth thoracic vertebra on back.

Body tissues are bathed by blood that normally has a narrow acceptable range of

pH. Although a number of compensatory mechanisms regulate pH, lungs help maintain balance by adjusting level of carbon dioxide through respiration. Hypoventilation (slow, shallow breathing) causes carbon dioxide to build up in blood, and hyperventilation (rapid, deep breathing) causes carbon dioxide to be blown off.

12 ribs

palpate midway between spine and person's side to identify its free tip.

Posterior chest wall reference lines include

vertebral (or midspinal) line and scapular line, which extends through inferior angle of scapula when arms are at sides of body.

Hemithorax

1 haft of thorax

Manubriosternal angle is also called

"Angle of Louis," at articulation of manubrium and sternum, and continuous with second rib

Breath Sounds

Evaluate presence and quality of normal breath sounds. Instruct person to breathe through mouth, a little bit deeper than usual. Use flat diaphragm endpiece of stethoscope and hold it firmly on person's chest wall; listen to at least one full respiration in each location. Side-to-side comparison is most important. Do not confuse background noise with lung sounds.

Shortness of Breath (SOB)

Ever had any shortness of breath or hard- breathing spells? What brings it on? How severe is it? How long does it last? Is it affected by position, such as lying down? Occur at any specific time of day or night? Shortness of breath episodes associated with night sweats? Or cough, chest pain, or bluish color around lips or nails? Wheezing sound?

Anterior Thoracic Landmarks II

Manubriosternal angle: "Angle of Louis," at articulation of manubrium and sternum, and continuous with second rib Identify Angle of Louis, palpate lightly to second rib, and slide down to second intercostal space. Each intercostal space is numbered by rib above it. Continue counting ribs in middle of hemithorax, not close to sternum because costal cartilages lie too close to count. You can palpate easily down to the tenth rib.

Thoracic Cavity I

Mediastinum: middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels Right and left pleural cavities, on either side of mediastinum, contain lungs. Lung borders: In anterior chest, apex of lung tissue is 3 or 4 cm above inner third of clavicles. Base rests on diaphragm at about sixth rib in midclavicular line. Laterally, lung tissue extends from apex of axilla down to seventh or eighth rib.

How to find midclavicular line

Midclavicular line bisects center of each clavicle at a point halfway between palpated sternoclavicular and acromioclavicular joints.

Barrel Chest

Scoliosis

Abnormal Findings: Respiration Patterns

Sigh Tachypnea Bradypnea Hyperventilation Hypoventilation Cheyne-Stokes respiration Biot's respiration Chronic obstructive breathing

Suprasternal notch:

hollow U-shaped depression just above sternum between clavicles.

Costal angle degree

the right and left costal margins form an angle where they meet at xiphoid process. Usually 90 degrees or less, this angle increases when rib cage is chronically overinflated, as in emphysema.