Assessment ofAssessment of Thorax and Thorax and

LungsLungsChristine M. WilsonChristine M. Wilson

Viterbo UniversityViterbo University

ObjectivesObjectives

LandmarksLandmarks StructuresStructures Function Function Developmental/transculturalDevelopmental/transcultural Subjective dataSubjective data Objective dataObjective data

Anterior LandmarksAnterior Landmarks

ClavicleClavicle Suprasternal Suprasternal

notchnotch SternumSternum Sternal angleSternal angle Intercostal Intercostal

spacesspaces Xiphod processXiphod process Costal angleCostal angle

Posterior LandmarksPosterior Landmarks

Vertebra Vertebra prominens (C7)prominens (C7)

Spinous Spinous processesprocesses

ScapulaScapula

Reference LinesReference Lines

Anterior ChestAnterior Chest

MidsternalMidsternal

MidclavicularMidclavicular

Reference LinesReference Lines

Posterior WallPosterior Wall

Vertebral Vertebral LineLine

Scapular Scapular LineLine

Reference LinesReference Lines

Axillary AreaAxillary Area

MidaxillaryMidaxillary

Anterior AxillaryAnterior Axillary

Posterior Posterior AxillaryAxillary

Position in ChestPosition in Chest

Lobes of the Lobes of the lunglung

TracheaTrachea

Bronchial Bronchial TreeTree

Functions of RespirationFunctions of Respiration

Major FunctionsMajor Functions Supply oxygen to body for energy Supply oxygen to body for energy

productionproduction Remove carbon dioxide as a waste Remove carbon dioxide as a waste

from energy productionfrom energy production Maintain pH balance of arterial Maintain pH balance of arterial

bloodblood Maintain heat exchangeMaintain heat exchange

Developmental Developmental ConsiderationsConsiderations

Fetal LifeFetal Life At 5 weeks primitive lung buds At 5 weeks primitive lung buds

emergeemerge By 16 weeks there are the same # of By 16 weeks there are the same # of

conducting airways as in the adult.conducting airways as in the adult. At 32 weeks surfactant sufficient to At 32 weeks surfactant sufficient to

sustain lifesustain life At birth 70 million primitive alveoli At birth 70 million primitive alveoli

kick inkick in

Developmental Developmental ConsiderationsConsiderations

The Aging AdultThe Aging Adult Lungs more rigid; harder to inflateLungs more rigid; harder to inflate Less surface available for gas Less surface available for gas

exchangeexchange Common increase in AP diameter Common increase in AP diameter Kyphosis: Front to back curvature Kyphosis: Front to back curvature

spinespine May fatigue more easilyMay fatigue more easily

Transcultural Transcultural ConsiderationsConsiderations

Largest chests (descending Largest chests (descending order): whites, blacks, order): whites, blacks, Asians, Native AmericansAsians, Native Americans

Fetal lung maturity reached Fetal lung maturity reached earlier in black populationearlier in black population

Incidence of TB is higher in Incidence of TB is higher in Asian AmericansAsian Americans

Subjective DataSubjective Data

CoughCough Shortness of breathShortness of breath Chest pain with breathingChest pain with breathing History of respiratory infectionsHistory of respiratory infections Smoking historySmoking history Environmental exposureEnvironmental exposure Self care behaviorSelf care behavior

Objective Data-Posterior Objective Data-Posterior ChestChest

InspectInspect Shape and configurationShape and configuration

A/P diameter should be less A/P diameter should be less than transverse by 1:2than transverse by 1:2

PositionPosition Skin color and conditionSkin color and condition

Posterior ChestPosterior Chest

Symmetric chest Symmetric chest expansionexpansion

Place hands at Place hands at T9-T10T9-T10

Equal Equal movement of movement of thumbs with thumbs with inhalinginhaling

Posterior ChestPosterior Chest

Tactile fremitusTactile fremitus Place ulnar edge on Place ulnar edge on

skin; client repeats skin; client repeats 9999

Symmetry is Symmetry is expectedexpected

Decreases if sound Decreases if sound transmission is transmission is obstructedobstructed

Palpate chest wallPalpate chest wall

Posterior ChestPosterior Chest

PercussionPercussion Find Find

predominant note predominant note over lung fieldsover lung fields

Begin at apicesBegin at apices Use same Use same

pathway side to pathway side to sideside

Lung Percussion SoundsLung Percussion Sounds

ResonanceResonance: non-musical; healthy : non-musical; healthy lunglung

Hyper-resonanceHyper-resonance: slightly musical; : slightly musical; too much air, i.e. too much air, i.e. emphysema/pneumothoraxemphysema/pneumothorax

DullDull: muffled; organ or abnormal : muffled; organ or abnormal density, i.e. pneumoniadensity, i.e. pneumonia

FlatFlat: soft thud; i.e. muscle mass, bone: soft thud; i.e. muscle mass, bone

Posterior ChestPosterior Chest

Diaphragmatic Diaphragmatic ExcursionExcursion

Find lower lung Find lower lung border in border in expiration and expiration and inspirationinspiration

Measure: Should Measure: Should measure 3-5cm, measure 3-5cm, equal distance equal distance bilaterally. bilaterally.

Posterior ChestPosterior Chest

AuscultationAuscultation

Use diaphragm Use diaphragm of stethoscope; of stethoscope; place firmlyplace firmly

One full breath One full breath at each positionat each position

Use same Use same pathway pathway side to side side to side

comparisoncomparison

Breath SoundsBreath Sounds

BronchialBronchialLoud, harsh sounds over tracheaLoud, harsh sounds over trachea

BronchovesicularBronchovesicularModerate, mixed sounds over Moderate, mixed sounds over

bronchibronchi VesicularVesicular

Soft, rustling sounds over Soft, rustling sounds over peripheryperiphery

Decreased or AbsentDecreased or Absent

ObstructionObstructionSecretions, mucus plug, foreign Secretions, mucus plug, foreign

bodybody

EmphysemaEmphysemaLoss of elasticity; air already in Loss of elasticity; air already in

lungslungs

Silent chestSilent chestNo air is moving in or out of lungs; No air is moving in or out of lungs;

ominous signominous sign

Increased SoundsIncreased Sounds

Bronchial sounds heard over Bronchial sounds heard over wrong areawrong area

Solid tissue conducts sounds Solid tissue conducts sounds to surface betterto surface better

Found in pneumonia with Found in pneumonia with consolidation or fluid in intra-consolidation or fluid in intra-pleural spacepleural space

Adventitious SoundsAdventitious Sounds

Crackles (Rales): FineCrackles (Rales): Fine

Fine, discontinuous high-pitched, Fine, discontinuous high-pitched, short crackling sound on short crackling sound on

inspiration inspiration which are not which are not cleared by coughing. cleared by coughing. (Roll a (Roll a strand of hair at ear) strand of hair at ear)

Found in pneumonia and heart Found in pneumonia and heart failurefailure

Adventitious SoundsAdventitious Sounds

Crackles: CoarseCrackles: Coarse Loud, low-pitched bubbling or gurgling Loud, low-pitched bubbling or gurgling

soundssounds Start in inspiration, may be in Start in inspiration, may be in

expiration expiration Decrease with coughing, but comes Decrease with coughing, but comes

backback Found in pulmonary edema and Found in pulmonary edema and

terminally ill with suppressed cough terminally ill with suppressed cough reflexreflex

Adventitious SoundsAdventitious Sounds

Wheeze: High pitchWheeze: High pitch High-pitched, musical squeaking High-pitched, musical squeaking

sound that predominates sound that predominates with with expirationexpiration

Indicates narrowed passagewayIndicates narrowed passageway Obstruction from acute asthma Obstruction from acute asthma

or chronic emphysemaor chronic emphysema

Adventitious SoundsAdventitious Sounds

Wheeze Low-pitchWheeze Low-pitch Single note which is more Single note which is more

prominent on prominent on expirationexpiration Air flow obstructionAir flow obstruction

bronchitis or tumorbronchitis or tumor

Adventitious SoundsAdventitious Sounds

StridorStridor High-pitched, crowing sound High-pitched, crowing sound

with with inspirationinspiration Louder in neckLouder in neck Upper airway obstructionUpper airway obstruction Croup, acute epiglottis, or Croup, acute epiglottis, or

foreign foreign body inhalationbody inhalation

Objective Data-Anterior Objective Data-Anterior ChestChest

InspectInspect Shape and configurationShape and configuration Facial expressionFacial expression Level of consciousnessLevel of consciousness Color and conditionColor and condition Respiration rate/qualityRespiration rate/quality

Anterior ChestAnterior Chest

Symmetric chest Symmetric chest expansionexpansion

Place hands at Place hands at costal margins costal margins

Equal movement Equal movement of thumbs with of thumbs with inhalinginhaling

Anterior ChestAnterior Chest

Tactile fremitusTactile fremitus Apices to MCLApices to MCL Side to sideSide to side Symmetry Symmetry

expectedexpected

Palpate chest Palpate chest wallwall

Objective Data-Anterior Objective Data-Anterior ChestChest

PercussionPercussion Dullness over Dullness over

breast tissue, liver, breast tissue, liver, cardiac borderscardiac borders

Tympany over Tympany over gastricgastric

AuscultationAuscultation Displace breast Displace breast

and listen over and listen over chest wallchest wall

Visualize lungs beneath Visualize lungs beneath skinskin