Thorax and Lungs Jarvis-Chap 18

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Thorax and LungsThorax and Lungs

Chapter 18Chapter 18Ange M. Pompee-Synsmir, MSN, ARNP, FNP-CNUR 1060C- Adult Health AssessmentSpring 2012


Structure and FunctionStructure and Function Position and surface landmarksPosition and surface landmarks

Thoracic cage is a bony structure with a conical shape, Thoracic cage is a bony structure with a conical shape, which is narrower at top which is narrower at top Defined by sternum, 12 pairs of ribs and 12 thoracic Defined by sternum, 12 pairs of ribs and 12 thoracic

vertebraevertebrae Floor is the diaphragm, a musculotendinous septum Floor is the diaphragm, a musculotendinous septum

that separates thoracic cavity from abdomenthat separates thoracic cavity from abdomen First seven ribs attach to sternum by costal First seven ribs attach to sternum by costal

cartilagescartilages Ribs 8, 9, and 10 attach to costal cartilage aboveRibs 8, 9, and 10 attach to costal cartilage above Ribs 11 and 12 are “floating,” with free palpable tipsRibs 11 and 12 are “floating,” with free palpable tips Costochondral junctions are points at which ribs join Costochondral junctions are points at which ribs join

their cartilages; they are not palpabletheir cartilages; they are not palpable

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Structure and FunctionStructure and Function (cont.)(cont.)

Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarksAnterior thoracic landmarks

Surface landmarks on thorax are signposts for Surface landmarks on thorax are signposts for underlying respiratory structuresunderlying respiratory structures

Knowledge of landmarks will help you localize a Knowledge of landmarks will help you localize a finding and will facilitate communication of your finding and will facilitate communication of your findingsfindings Suprasternal notch: feel this hollow U-shaped Suprasternal notch: feel this hollow U-shaped

depression just above sternum between claviclesdepression just above sternum between clavicles Sternum: “breastbone” has three parts; Sternum: “breastbone” has three parts;

manubrium, body, and xiphoid processmanubrium, body, and xiphoid process Walk fingers down manubrium a few centimeters Walk fingers down manubrium a few centimeters

until you feel distinct bony ridge, the until you feel distinct bony ridge, the manubriosternal anglemanubriosternal angle

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarks (cont.)Anterior thoracic landmarks (cont.)

Manubriosternal angle: called “angle of Louis,” at Manubriosternal angle: called “angle of Louis,” at articulation of manubrium and sternum, and articulation of manubrium and sternum, and continuous with second ribcontinuous with second rib Angle of Louis is useful place to start counting ribsAngle of Louis is useful place to start counting ribs

Identify angle of Louis, palpate lightly to second rib, Identify angle of Louis, palpate lightly to second rib, and slide down to second intercostal spaceand slide down to second intercostal space

Each intercostal space is numbered by rib above it Each intercostal space is numbered by rib above it Continue counting ribs in middle of hemithorax, not Continue counting ribs in middle of hemithorax, not

close to sternum as costal cartilages lie too close to close to sternum as costal cartilages lie too close to countcount

You can palpate easily down to the tenth ribYou can palpate easily down to the tenth rib

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Posterior thoracic landmarksPosterior thoracic landmarks

Counting ribs and intercostal spaces on back is Counting ribs and intercostal spaces on back is harder due to muscles and soft tissue surrounding harder due to muscles and soft tissue surrounding ribs and spinal columnribs and spinal column

Vertebra prominens: Start here; flex your head and Vertebra prominens: Start here; flex your head and feel for most prominent bony spur protruding at feel for most prominent bony spur protruding at base of neckbase of neck

This is spinous process of C7; if two bumps seem This is spinous process of C7; if two bumps seem equally prominent, upper one is C7 and lower one is equally prominent, upper one is C7 and lower one is T1T1

Spinous processes: count down these knobs on Spinous processes: count down these knobs on vertebrae, which stack together to form spinal vertebrae, which stack together to form spinal columncolumn

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarks (cont.)Anterior thoracic landmarks (cont.)

Angle of Louis also marks site of tracheal bifurcation Angle of Louis also marks site of tracheal bifurcation into right and left main bronchi; corresponds with into right and left main bronchi; corresponds with upper border of atria of the heart, and it lies above upper border of atria of the heart, and it lies above fourth thoracic vertebra on backfourth thoracic vertebra on back

Costal angle: the right and left costal margins form Costal angle: the right and left costal margins form an angle where they meet at xiphoid processan angle where they meet at xiphoid process

Usually 90 degrees or less, this angle increases when Usually 90 degrees or less, this angle increases when rib cage is chronically overinflated, as in emphysemarib cage is chronically overinflated, as in emphysema

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Anterior Thoracic CageAnterior Thoracic Cage

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Posterior thoracic landmarks (cont.)Posterior thoracic landmarks (cont.)

Note that spinous processes align with their same Note that spinous processes align with their same numbered ribs only down to T4numbered ribs only down to T4

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

Inferior border of scapula: scapulae are located Inferior border of scapula: scapulae are located symmetrically in each hemithoraxsymmetrically in each hemithorax

Lower tip usually at seventh or eighth ribLower tip usually at seventh or eighth rib Twelfth rib: palpate midway between spine and Twelfth rib: palpate midway between spine and

person’s side to identify its free tipperson’s side to identify its free tip

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Posterior Thoracic CagePosterior Thoracic Cage

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Reference linesReference lines

Use reference lines to pinpoint finding vertically on Use reference lines to pinpoint finding vertically on chestchest

On anterior chest note midsternal line and On anterior chest note midsternal line and midclavicular linemidclavicular line

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

Posterior chest wall has vertebral (or midspinal) Posterior chest wall has vertebral (or midspinal) line and scapular line, which extends through line and scapular line, which extends through inferior angle of scapula when arms at sides of inferior angle of scapula when arms at sides of bodybody

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Reference lines (cont.)Reference lines (cont.)

Lift up the person’s arm 90 degrees, and divide Lift up the person’s arm 90 degrees, and divide lateral chest by three lines: lateral chest by three lines: Anterior axillary line: extends down from Anterior axillary line: extends down from

anterior axillary fold where pectoralis major anterior axillary fold where pectoralis major muscle insertsmuscle inserts

Posterior axillary line: continues down from Posterior axillary line: continues down from posterior axillary fold where latissimus dorsi posterior axillary fold where latissimus dorsi muscle insertsmuscle inserts

Midaxillary line: runs down from apex of axilla Midaxillary line: runs down from apex of axilla and lies between and parallel to other twoand lies between and parallel to other two

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Thoracic cavityThoracic cavity Mediastinum: middle section of thoracic Mediastinum: middle section of thoracic

cavity containing esophagus, trachea, heart, cavity containing esophagus, trachea, heart, and great vesselsand great vessels Right and left pleural cavities, on either side of Right and left pleural cavities, on either side of

mediastinum, contain lungsmediastinum, contain lungs Lung borders: In anterior chest, apex of lung Lung borders: In anterior chest, apex of lung

tissue is 3 or 4 cm above inner third of claviclestissue is 3 or 4 cm above inner third of clavicles Base rests on diaphragm at about sixth rib in Base rests on diaphragm at about sixth rib in

midclavicular linemidclavicular line Laterally, lung tissue extends from apex of Laterally, lung tissue extends from apex of

axilla down to seventh or eighth ribaxilla down to seventh or eighth rib

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Thoracic cavity (cont.)Thoracic cavity (cont.) Posteriorly, the location of C7 marks apex of lung tissue, Posteriorly, the location of C7 marks apex of lung tissue,

and T10 usually corresponds to baseand T10 usually corresponds to base Deep inspiration expands lungs, and their lower border Deep inspiration expands lungs, and their lower border

drops to level of T12drops to level of T12 Lobes of the lungLobes of the lung

Lungs are paired but not precisely symmetric Lungs are paired but not precisely symmetric structures structures

Right lung shorter than left because of underlying liverRight lung shorter than left because of underlying liver Left lung narrower than right because heart bulges to Left lung narrower than right because heart bulges to

leftleft Right lung has three lobes, and left lung has two lobesRight lung has three lobes, and left lung has two lobes

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Thoracic cavityThoracic cavity (cont.)(cont.) Lobes of the lung (cont.)Lobes of the lung (cont.)

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

Anterior chestAnterior chest On anterior chest, oblique fissure crosses fifth rib in On anterior chest, oblique fissure crosses fifth rib in

midaxillary line and terminates at sixth rib in midaxillary line and terminates at sixth rib in midclavicular linemidclavicular line

Right lung also contains horizontal (minor) fissure, Right lung also contains horizontal (minor) fissure, which divides right upper and middle lobeswhich divides right upper and middle lobes

This fissure extends from fifth rib in right midaxillary This fissure extends from fifth rib in right midaxillary line to third intercostal space or fourth rib at right line to third intercostal space or fourth rib at right sternal bordersternal border

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Posterior chestPosterior chest Most remarkable point about posterior chest is Most remarkable point about posterior chest is

that it is almost all lower lobethat it is almost all lower lobe Upper lobes occupy a smaller band of tissue Upper lobes occupy a smaller band of tissue

from their apices at T1 down to T3 or T4from their apices at T1 down to T3 or T4 At this level, lower lobes begin, and their inferior At this level, lower lobes begin, and their inferior

border reaches down to level of T10 on border reaches down to level of T10 on expiration and to T12 on inspirationexpiration and to T12 on inspiration

Right middle lobe does not project onto posterior Right middle lobe does not project onto posterior chest at allchest at all

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Lateral chestLateral chest Lung tissue extends from apex of axilla down to Lung tissue extends from apex of axilla down to

seventh or eighth ribseventh or eighth rib Right upper lobe extends from apex of axilla Right upper lobe extends from apex of axilla

down to horizontal fissure at fifth ribdown to horizontal fissure at fifth rib Right middle lobe extends from horizontal Right middle lobe extends from horizontal

fissure down and forward to sixth rib at fissure down and forward to sixth rib at midclavicular linemidclavicular line

Right lower lobe continues from fifth rib to Right lower lobe continues from fifth rib to eighth rib in midaxillary lineeighth rib in midaxillary line

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Left lung contains only two lobes, upper and Left lung contains only two lobes, upper and lowerlower

These are seen laterally as two triangular These are seen laterally as two triangular areas separated by oblique fissureareas separated by oblique fissure

Left upper lobe extends from apex of axilla Left upper lobe extends from apex of axilla down to fifth rib at midaxillary linedown to fifth rib at midaxillary line

Left lower lobe continues down to eighth rib Left lower lobe continues down to eighth rib in midaxillary linein midaxillary line

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Using these landmarks, take a marker and Using these landmarks, take a marker and try tracing outline of each lobe on a willing try tracing outline of each lobe on a willing partnerpartner

Take special note of three points that Take special note of three points that commonly confuse beginning examinerscommonly confuse beginning examiners Left lung has no middle lobeLeft lung has no middle lobe Anterior chest contains mostly upper and Anterior chest contains mostly upper and

middle lobe with very little lower lobemiddle lobe with very little lower lobe Posterior chest contains almost all lower lobePosterior chest contains almost all lower lobe

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Thoracic cavity (cont.)Thoracic cavity (cont.) PleuraePleurae

The thin, slippery pleurae form an envelope The thin, slippery pleurae form an envelope between lungs and chest wallbetween lungs and chest wall

Visceral pleura lines outside of lungs, Visceral pleura lines outside of lungs, dipping down into fissuresdipping down into fissures

It is continuous with parietal pleura lining It is continuous with parietal pleura lining inside of chest wall and diaphragminside of chest wall and diaphragm

Pleural cavity is potential space filled only Pleural cavity is potential space filled only with few milliliters of lubricating fluidwith few milliliters of lubricating fluid

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Thoracic cavity /Pleura (contThoracic cavity /Pleura (cont.).) Pleural cavity normally has a vacuum, or negative Pleural cavity normally has a vacuum, or negative

pressure, which holds lungs tightly against chest wallpressure, which holds lungs tightly against chest wall Pleurae extend about 3 cm below level of lungs, Pleurae extend about 3 cm below level of lungs,

forming the costodiaphragmatic recess forming the costodiaphragmatic recess Lungs slide smoothly and noiselessly up and down Lungs slide smoothly and noiselessly up and down

during respiration, lubricated by a few milliliters of fluidduring respiration, lubricated by a few milliliters of fluid Similar to two glass slides with a drop of water Similar to two glass slides with a drop of water

between them; although it is difficult to separate between them; although it is difficult to separate slides, they slide smoothly back and forthslides, they slide smoothly back and forth

This is a potential space; when it abnormally fills with This is a potential space; when it abnormally fills with air or fluid, it compromises lung expansionair or fluid, it compromises lung expansion

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Thoracic cavity (cont.)Thoracic cavity (cont.) Trachea and bronchial treeTrachea and bronchial tree

Trachea lies anterior to esophagus and is 10 Trachea lies anterior to esophagus and is 10 to 11 cm long in the adultto 11 cm long in the adult

Begins at level of cricoid cartilage in neck Begins at level of cricoid cartilage in neck and bifurcates just below sternal angle into and bifurcates just below sternal angle into right and left main bronchi right and left main bronchi

Posteriorly, tracheal bifurcation is at level of Posteriorly, tracheal bifurcation is at level of T4 or T5T4 or T5

Right main bronchus is shorter, wider, and Right main bronchus is shorter, wider, and more vertical than the left main bronchusmore vertical than the left main bronchus

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Thoracic cavity (cont.)Thoracic cavity (cont.) Trachea and bronchial treeTrachea and bronchial tree

Trachea and bronchi transport gases between the Trachea and bronchi transport gases between the environment and lung parenchymaenvironment and lung parenchyma

Constitute dead space, or space that is filled with air Constitute dead space, or space that is filled with air but is not available for gaseous exchangebut is not available for gaseous exchange

This is about 150 ml in adultThis is about 150 ml in adult Bronchial tree also protects alveoli from small Bronchial tree also protects alveoli from small

particulate matter in inhaled airparticulate matter in inhaled air Bronchi are lined with goblet cells, which secrete Bronchi are lined with goblet cells, which secrete

mucus that entraps particles; bronchi lined with cilia, mucus that entraps particles; bronchi lined with cilia, which sweep particles upward where they can be which sweep particles upward where they can be swallowed or expelledswallowed or expelled

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Thoracic cavityThoracic cavity (cont.)(cont.) Trachea and bronchial tree (cont.)Trachea and bronchial tree (cont.)

Acinus is a functional respiratory unit that consists of Acinus is a functional respiratory unit that consists of bronchioles, alveolar ducts, alveolar sacs, and the bronchioles, alveolar ducts, alveolar sacs, and the alveolialveoli

Gaseous exchange occurs across respiratory Gaseous exchange occurs across respiratory membrane in alveolar duct and in millions of alveolimembrane in alveolar duct and in millions of alveoli

Alveoli clustered like grapes around each alveolar ductAlveoli clustered like grapes around each alveolar duct This creates millions of interalveolar septa (walls) that This creates millions of interalveolar septa (walls) that

increase tremendously the working space available for increase tremendously the working space available for gas exchangegas exchange

This bunched arrangement creates surface area for gas This bunched arrangement creates surface area for gas exchange that is as large as a tennis courtexchange that is as large as a tennis court

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Mechanics of respirationMechanics of respiration Four major functions of respiratory systemFour major functions of respiratory system

Supplying oxygen to the body for energy production Supplying oxygen to the body for energy production Removing carbon dioxide as a waste product of energy Removing carbon dioxide as a waste product of energy

reactionsreactions Maintaining homeostasis (acid-base balance) of Maintaining homeostasis (acid-base balance) of

arterial bloodarterial blood By supplying oxygen to blood and eliminating By supplying oxygen to blood and eliminating

excess carbon dioxide, respiration maintains pH or excess carbon dioxide, respiration maintains pH or acid-base balance of bloodacid-base balance of blood

Maintaining heat exchange (less important in humans)Maintaining heat exchange (less important in humans)

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Structures of Respiratory SystemStructures of Respiratory System

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Body tissues are bathed by blood that normally Body tissues are bathed by blood that normally

has a narrow acceptable range of pHhas a narrow acceptable range of pH Although a number of compensatory Although a number of compensatory

mechanisms regulate pH, lungs help maintain mechanisms regulate pH, lungs help maintain balance by adjusting level of carbon dioxide balance by adjusting level of carbon dioxide through respirationthrough respiration

Hypoventilation (slow, shallow breathing) Hypoventilation (slow, shallow breathing) causes carbon dioxide to build up in blood, and causes carbon dioxide to build up in blood, and hyperventilation (rapid, deep breathing) hyperventilation (rapid, deep breathing) causes carbon dioxide to be blown offcauses carbon dioxide to be blown off

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Control of respirationsControl of respirations

Normally our breathing pattern changes without our Normally our breathing pattern changes without our awareness in response to cellular demandsawareness in response to cellular demands This involuntary control of respirations is mediated by This involuntary control of respirations is mediated by

respiratory center in brainstem (pons and medulla)respiratory center in brainstem (pons and medulla) Major feedback loop is humoral regulation, or change in Major feedback loop is humoral regulation, or change in

carbon dioxide and oxygen levels in blood, and, less carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion levelimportant, hydrogen ion level

Normal stimulus to breathe for most of us is an increase Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapniaof carbon dioxide in blood, or hypercapnia

Decrease of oxygen in blood (hypoxemia) also increases Decrease of oxygen in blood (hypoxemia) also increases respirations but less effective than hypercapniarespirations but less effective than hypercapnia

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Changing chest sizeChanging chest size

Respiration is the physical act of breathing; air rushes Respiration is the physical act of breathing; air rushes into the lungs as chest size increases (inspiration) into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils and is expelled from lungs as chest recoils (expiration)(expiration)

Mechanical expansion and contraction of chest cavity Mechanical expansion and contraction of chest cavity alters size of thoracic container in two dimensionsalters size of thoracic container in two dimensions Vertical diameter lengthens or shortens, which is Vertical diameter lengthens or shortens, which is

accomplished by downward or upward movement of accomplished by downward or upward movement of diaphragmdiaphragm

Anteroposterior diameter increases or decreases, which is Anteroposterior diameter increases or decreases, which is accomplished by elevation or depression of ribsaccomplished by elevation or depression of ribs

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Mechanics of respirationMechanics of respiration (cont.)(cont.) Changing chest size (cont.)Changing chest size (cont.)

In inspiration, increasing size of thoracic container In inspiration, increasing size of thoracic container creates slightly negative pressure in relation to creates slightly negative pressure in relation to atmosphere, so air rushes in to fill partial vacuumatmosphere, so air rushes in to fill partial vacuum

Major muscle responsible for this increase is Major muscle responsible for this increase is diaphragm diaphragm

During inspiration, contraction of bell-shaped During inspiration, contraction of bell-shaped diaphragm causes it to descend and flatten; this diaphragm causes it to descend and flatten; this lengthens the vertical diameterlengthens the vertical diameter

Intercostal muscles lift sternum and elevate ribs, Intercostal muscles lift sternum and elevate ribs, making them more horizontal; this increases making them more horizontal; this increases anteroposterior diameteranteroposterior diameter

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Mechanics of respirationMechanics of respiration (cont.)(cont.) Expiration is primarily passive; as diaphragm relaxes, Expiration is primarily passive; as diaphragm relaxes,

elastic forces within lung, chest cage, and abdomen elastic forces within lung, chest cage, and abdomen cause it to dome upcause it to dome up All this squeezing creates a relatively positive All this squeezing creates a relatively positive

pressure within alveoli, and air flows outpressure within alveoli, and air flows out Forced inspiration, such as that after heavy Forced inspiration, such as that after heavy

exercise or occurring pathologically with exercise or occurring pathologically with respiratory distress, commands use of the respiratory distress, commands use of the accessory neck muscles to heave up sternum and accessory neck muscles to heave up sternum and rib cagerib cage

These neck muscles are the sternomastoids, These neck muscles are the sternomastoids, scaleni, and the trapeziiscaleni, and the trapezii

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Mechanics of respirationMechanics of respiration (cont.)(cont.) Changing chest size (cont.)Changing chest size (cont.)

In forced expiration, abdominal muscles In forced expiration, abdominal muscles contract powerfully to push abdominal contract powerfully to push abdominal viscera forcefully in and up against viscera forcefully in and up against diaphragm, making it dome upward, and diaphragm, making it dome upward, and making it squeeze against lungsmaking it squeeze against lungs

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Mechanics of RespirationMechanics of Respiration

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

By 16 weeks of gestation, conducting By 16 weeks of gestation, conducting airways reach same number as in adult; at airways reach same number as in adult; at 32 weeks, surfactant, complex lipid 32 weeks, surfactant, complex lipid substance needed for sustained inflation of substance needed for sustained inflation of air sacs, is present in adequate amountsair sacs, is present in adequate amounts

At birth lungs have 70 million primitive At birth lungs have 70 million primitive alveoli ready to start job of respirationalveoli ready to start job of respiration

Breath is life; when newborn inhales first Breath is life; when newborn inhales first breath, the lusty cry that follows reassures breath, the lusty cry that follows reassures straining parents that their infant is all rightstraining parents that their infant is all right

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence (cont.)(cont.)

Pregnant womanPregnant woman Enlarging uterus elevates diaphragm 4 cm during Enlarging uterus elevates diaphragm 4 cm during

pregnancypregnancy This decreases vertical diameter of thoracic This decreases vertical diameter of thoracic

cage, but this decrease is compensated for by cage, but this decrease is compensated for by an increase in horizontal diameteran increase in horizontal diameter

Increase in estrogen level relaxes chest cage Increase in estrogen level relaxes chest cage ligamentsligaments

This allows an increase in transverse diameter of This allows an increase in transverse diameter of chest cage by 2 cm, and costal angle widenschest cage by 2 cm, and costal angle widens

Total circumference of chest cage increases by 6 Total circumference of chest cage increases by 6 cmcm

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Aging adultAging adult Costal cartilages become calcified, which produces Costal cartilages become calcified, which produces

a less mobile thoraxa less mobile thorax Respiratory muscle strength declines after age Respiratory muscle strength declines after age

50 years and continues to decrease into 70s50 years and continues to decrease into 70s More significant change is decrease in elastic More significant change is decrease in elastic

properties within lungs, making them less properties within lungs, making them less distensible and lessening their tendency to distensible and lessening their tendency to collapse and recoilcollapse and recoil

Aging lung is more rigid structure that is harder to Aging lung is more rigid structure that is harder to inflateinflate

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Lung bases become less ventilated as a result of Lung bases become less ventilated as a result of closing off of a number of airwaysclosing off of a number of airways This increases older person’s risk of dyspnea This increases older person’s risk of dyspnea

with exertion beyond his or her usual workloadwith exertion beyond his or her usual workload Histologic changes also increase the older person’s Histologic changes also increase the older person’s

risk of postoperative pulmonary complicationsrisk of postoperative pulmonary complications Older person has a greater risk of postoperative Older person has a greater risk of postoperative

atelectasis and infection from a decreased ability atelectasis and infection from a decreased ability to cough, a loss of protective airway reflexes, to cough, a loss of protective airway reflexes, and increased secretionsand increased secretions

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

Incidence of tuberculosis (TB) has declined in the U.S.; Incidence of tuberculosis (TB) has declined in the U.S.; however, persons who are foreign-born and of racial or however, persons who are foreign-born and of racial or ethnic minorities have a disproportionately large ethnic minorities have a disproportionately large burden of TB diseaseburden of TB disease

In 2008 the TB rates wereIn 2008 the TB rates were 10 times higher in foreign-born than in U.S.-born10 times higher in foreign-born than in U.S.-born 8 times higher among Hispanic and African 8 times higher among Hispanic and African

Americans than among whitesAmericans than among whites 23 times higher among Asians than among whites23 times higher among Asians than among whites These data reflect high TB rates in countries of These data reflect high TB rates in countries of

origin for immigrants as well as barriers to early origin for immigrants as well as barriers to early diagnosis, prevention, and treatment adherence for diagnosis, prevention, and treatment adherence for latent TBlatent TB

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

Asthma occurs in about 5% to 12% of the Asthma occurs in about 5% to 12% of the U.S. population and is the most common U.S. population and is the most common chronic disease in childhoodchronic disease in childhood Groups at increased risk include African Groups at increased risk include African

Americans who reside in inner cities and Americans who reside in inner cities and premature or low birth weight infantspremature or low birth weight infants

Asthma prevalence is highest among Asthma prevalence is highest among African American and native American African American and native American adults; lowest among Asian and Hispanic adults; lowest among Asian and Hispanic adultsadults

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

Biocultural differences in size of thoracic Biocultural differences in size of thoracic cavity significantly influence pulmonary cavity significantly influence pulmonary functioning as determined by vital functioning as determined by vital capacity and forced expiratory volumecapacity and forced expiratory volume In descending order, the largest chest In descending order, the largest chest

volumes are found in whites, African volumes are found in whites, African Americans, Asians, and American IndiansAmericans, Asians, and American Indians

Even when shorter height of Asians is Even when shorter height of Asians is considered, their chest volume remains considered, their chest volume remains significantly lower than that of whites and significantly lower than that of whites and African AmericansAfrican Americans

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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 behaviorsSelf-care behaviors

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Subjective DataSubjective Data (cont.)(cont.)

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

sudden?sudden? How long have you had it?How long have you had it? How often do you cough? At any special time of day How often do you cough? At any special time of day

or just on arising? Cough wake you up at night?or just on arising? Cough wake you up at night? Do you cough up any phlegm or sputum? How much? Do you cough up any phlegm or sputum? How much?

What color is it?What color is it? Cough up any blood? Does this look like streaks or Cough up any blood? Does this look like streaks or

frank blood? Does the sputum have a foul odor?frank blood? Does the sputum have a foul odor? How would you describe your cough: hacking, dry, How would you describe your cough: hacking, dry,

barking, hoarse, congested, bubbling?barking, hoarse, congested, bubbling?

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Cough (cont.)Cough (cont.) Cough seem to come with anything: activity, position Cough seem to come with anything: activity, position

(lying), fever, congestion, talking, anxiety? (lying), fever, congestion, talking, anxiety? Activity make it better or worse?Activity make it better or worse? What treatment have you tried? Prescription or What treatment have you tried? Prescription or

over-the-counter medications, vaporizer, rest, over-the-counter medications, vaporizer, rest, position change?position change?

Does the cough bring on anything such as chest Does the cough bring on anything such as chest pain or ear pain? Is it tiring? Are you concerned pain or ear pain? Is it tiring? Are you concerned about it?about it?

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Shortness of breathShortness of breath Ever had any shortness of breath or hard- breathing Ever had any shortness of breath or hard- breathing

spells?spells? What brings it on? How severe is it? How long What brings it on? How severe is it? How long

does it last?does it last? Is it affected by position, such as lying down?Is it affected by position, such as lying down? Occur at any specific time of day or night?Occur at any specific time of day or night? Shortness of breath episodes associated with night Shortness of breath episodes associated with night

sweats?sweats? Or cough, chest pain, or bluish color around lips or Or cough, chest pain, or bluish color around lips or

nails? Wheezing sound?nails? Wheezing sound?

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Shortness of breath (cont.)Shortness of breath (cont.) Do episodes seem to be related to food, Do episodes seem to be related to food,

pollen, dust, animals, season, or pollen, dust, animals, season, or emotion?emotion? What do you do in a hard-breathing attack? What do you do in a hard-breathing attack?

Take a special position, or use pursed-lip Take a special position, or use pursed-lip breathing? Do you use any oxygen, breathing? Do you use any oxygen, inhalers, or medications?inhalers, or medications?

How does the shortness of breath affect How does the shortness of breath affect your work or home activities? Is it getting your work or home activities? Is it getting better or worse or staying about the same?better or worse or staying about the same?

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Chest pain with breathingChest pain with breathing Any chest pain with breathing? Please point to exact Any chest pain with breathing? Please point to exact

location.location. When did it start? Is it constant or does it come When did it start? Is it constant or does it come

and go?and go? Describe the pain: burning, stabbing?Describe the pain: burning, stabbing? Is it brought on by respiratory infection, coughing, Is it brought on by respiratory infection, coughing,

or trauma? Is it associated with fever, deep or trauma? Is it associated with fever, deep breathing, unequal chest inflation?breathing, unequal chest inflation?

What have you done to treat it? Have you tried What have you done to treat it? Have you tried medication or heat application?medication or heat application?

Slide 18-45



History of respiratory infectionsHistory of respiratory infections Smoking historySmoking history Any past history of breathing trouble or lung diseases such Any past history of breathing trouble or lung diseases such

as bronchitis, emphysema, asthma, or pneumonia?as bronchitis, emphysema, asthma, or pneumonia? Any unusually frequent or unusually severe colds?Any unusually frequent or unusually severe colds? Any family history of allergies, tuberculosis, or asthma?Any family history of allergies, tuberculosis, or asthma? Do you smoke cigarettes or cigars? At what age did you Do you smoke cigarettes or cigars? At what age did you

start? How many packs per day do you smoke now? For start? How many packs per day do you smoke now? For how long? Do you live with someone who smokes?how long? Do you live with someone who smokes?

Have you ever tried to quit? Why do you think it did not Have you ever tried to quit? Why do you think it did not work? What activities do you associate with smoking?work? What activities do you associate with smoking?

Slide 18-46



Environmental exposureEnvironmental exposure Are there any environmental conditions that may affect Are there any environmental conditions that may affect

your breathing?your breathing? Where do you work? At a factory, chemical plant, Where do you work? At a factory, chemical plant,

coal mine, farming, outdoors in a heavy traffic area?coal mine, farming, outdoors in a heavy traffic area? Do you do anything to protect your lungs, such as Do you do anything to protect your lungs, such as

wear a mask or have ventilatory system checked at wear a mask or have ventilatory system checked at work? work?

Do you do anything to monitor your exposure? Do Do you do anything to monitor your exposure? Do you have periodic examinations, pulmonary function you have periodic examinations, pulmonary function tests, or x-ray examinations?tests, or x-ray examinations?

Do you know what specific symptoms to note that Do you know what specific symptoms to note that may signal breathing problems?may signal breathing problems?

Slide 18-47



Self-care behaviorsSelf-care behaviors When was your last TB skin test, chest x-When was your last TB skin test, chest x-

ray study, pneumonia or influenza ray study, pneumonia or influenza immunization?immunization?

Slide 18-48



Additional history for infants and childrenAdditional history for infants and children Has the child had any frequent or very severe colds?Has the child had any frequent or very severe colds? Is there any history of allergy in family?Is there any history of allergy in family?

(For child under 2 years of age): At what age were (For child under 2 years of age): At what age were new foods introduced? Was child breastfed or new foods introduced? Was child breastfed or bottle-fed?bottle-fed?

Does child have a cough or seem congested? Does Does child have a cough or seem congested? Does child have noisy breathing or wheezing?child have noisy breathing or wheezing?

What measures have you taken to child-proof your What measures have you taken to child-proof your home and yard? Is there any possibility of child home and yard? Is there any possibility of child inhaling or swallowing toxic substances?inhaling or swallowing toxic substances?

Slide 18-49



Additional history for infants and Additional history for infants and children (cont.)children (cont.) Has anyone taught you emergency care Has anyone taught you emergency care

measures in case of accidental choking measures in case of accidental choking or a hard-breathing spell?or a hard-breathing spell?

Are any smokers in home or in car with Are any smokers in home or in car with child?child?

Slide 18-50



Additional history for aging adultAdditional history for aging adult Have you noticed any shortness of breath or fatigue with Have you noticed any shortness of breath or fatigue with

your daily activities?your daily activities? Tell me about your usual amount of physical activityTell me about your usual amount of physical activity (For those with a history of chronic obstructive (For those with a history of chronic obstructive

pulmonary disease, lung cancer, or tuberculosis): How pulmonary disease, lung cancer, or tuberculosis): How are you getting along each day? Any weight change in are you getting along each day? Any weight change in last 3 months? How much?last 3 months? How much?

How is your energy level? Do you tire more easily? How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?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 with breathing? Do you have any chest pain after a bout of coughing Do you have any chest pain after a bout of coughing

or after a fall?or after a fall?

Slide 18-51


Objective DataObjective Data (cont.)(cont.)

PreparationPreparation Ask person to sit upright and male to disrobe to waistAsk person to sit upright and male to disrobe to waist

For female, leave gown on and open at backFor female, leave gown on and open at back When examining anterior chest, lift up gown When examining anterior chest, lift up gown

and drape it on her shoulders rather than and drape it on her shoulders rather than removing it completelyremoving it completely

This promotes comfort by giving her feeling of This promotes comfort by giving her feeling of being somewhat clothedbeing somewhat clothed

The following provisions will ensure further The following provisions will ensure further comfort: a warm room, a warm diaphragm comfort: a warm room, a warm diaphragm endpiece, and a private examination time with no endpiece, and a private examination time with no interruptionsinterruptions

Slide 18-52



Preparation (cont.)Preparation (cont.) For smooth choreography in a complete examination, For smooth choreography in a complete examination,

begin the respiratory examination just after palpating begin the respiratory examination just after palpating thyroid gland when you are standing behind personthyroid gland when you are standing behind person

Perform inspection, palpation, percussion, and Perform inspection, palpation, percussion, and auscultation on posterior and lateral thoraxauscultation on posterior and lateral thorax

Then move to face person and repeat four maneuvers Then move to face person and repeat four maneuvers on anterior cheston anterior chest This avoids repetitiously moving front to back of This avoids repetitiously moving front to back of

personperson Clean stethoscope endpiece with an alcohol wipeClean stethoscope endpiece with an alcohol wipe

Because your stethoscope touches many people, it Because your stethoscope touches many people, it could be a possible vector for both aerobic and could be a possible vector for both aerobic and anaerobic bacteriaanaerobic bacteria

Slide 18-53



Equipment neededEquipment needed StethoscopeStethoscope Small ruler, marked in centimetersSmall ruler, marked in centimeters Marking penMarking pen Alcohol wipeAlcohol wipe

Slide 18-54



Inspect the posterior chestInspect the posterior chest Thoracic cageThoracic cage

Note shape and configuration of chest wallNote shape and configuration of chest wall Spinous processes should appear in a straight line; Spinous processes should appear in a straight line;

thorax is symmetric, in an elliptical shape, with thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to downward sloping ribs, about 45 degrees relative to spine; scapulae are placed symmetrically in each spine; scapulae are placed symmetrically in each hemithoraxhemithorax

Anteroposterior diameter should be less than Anteroposterior diameter should be less than transverse diameter; ratio of anteroposterior to transverse diameter; ratio of anteroposterior to transverse diameter is from 1:2 to 5:7transverse diameter is from 1:2 to 5:7

The neck muscles and trapezius muscles should be The neck muscles and trapezius muscles should be developed normally for age and occupationdeveloped normally for age and occupation

Slide 18-55



Inspect the posterior chestInspect the posterior chest (cont.)(cont.) Thoracic cage (cont.)Thoracic cage (cont.)

Note position person takes to breatheNote position person takes to breathe Includes relaxed posture and ability to support one’s Includes relaxed posture and ability to support one’s

own weight with arms comfortably at sides or in lapown weight with arms comfortably at sides or in lap Assess skin color and conditionAssess skin color and condition Color should be consistent with person’s genetic Color should be consistent with person’s genetic

background, with allowance for sun-exposed areas on background, with allowance for sun-exposed areas on chest and backchest and back

No cyanosis or pallor should be presentNo cyanosis or pallor should be present Note any lesions; inquire about any change in nevus on Note any lesions; inquire about any change in nevus on

backback

Slide 18-56



Palpate the posterior chest (cont.)Palpate the posterior chest (cont.) Symmetric expansionSymmetric expansion

Confirm symmetric chest expansion by placing Confirm symmetric chest expansion by placing your warmed hands on posterolateral chest wall your warmed hands on posterolateral chest wall with thumbs at level of T9 or T10with thumbs at level of T9 or T10

Slide your hands medially to pinch up a small fold Slide your hands medially to pinch up a small fold of skin between your thumbs; ask person to take a of skin between your thumbs; ask person to take a deep breathdeep breath

Your hands serve as mechanical amplifiers; as Your hands serve as mechanical amplifiers; as person inhales deeply, your thumbs should move person inhales deeply, your thumbs should move apart symmetrically; note any lag in expansionapart symmetrically; note any lag in expansion

Slide 18-57



Palpate the posterior chest (cont.)Palpate the posterior chest (cont.) Tactile fremitusTactile fremitus

Fremitus is a palpable vibrationFremitus is a palpable vibration Sounds generated from larynx are transmitted through Sounds generated from larynx are transmitted through

patent bronchi and through lung parenchyma to chest patent bronchi and through lung parenchyma to chest wall, where you feel them as vibrationswall, where you feel them as vibrations

Use either palmar base (ball) of fingers or ulnar edge Use either palmar base (ball) of fingers or ulnar edge of one hand, and touch person’s chest while he or she of one hand, and touch person’s chest while he or she repeats words “ninety-nine” or “blue moon” repeats words “ninety-nine” or “blue moon”

These are resonant phrases that generate strong These are resonant phrases that generate strong vibrationsvibrations

Slide 18-58



Palpate the posterior chestPalpate the posterior chest (cont.)(cont.) Tactile fremitus (cont.)Tactile fremitus (cont.)

Start over lung apices and palpate from one side Start over lung apices and palpate from one side to anotherto another

Fremitus varies among persons but symmetry is Fremitus varies among persons but symmetry is most important; vibrations should feel same in most important; vibrations should feel same in corresponding area on each sidecorresponding area on each side

However, just between scapulae, fremitus may However, just between scapulae, fremitus may feel stronger on right side than on left side feel stronger on right side than on left side because right closer to bronchial bifurcation; avoid because right closer to bronchial bifurcation; avoid palpating over scapulae because bone damps out palpating over scapulae because bone damps out sound transmissionsound transmission

Slide 18-59



Palpate the posterior chest/tactile fremitusPalpate the posterior chest/tactile fremitus (cont.)(cont.) Factors affecting normal intensity of tactile fremitusFactors affecting normal intensity of tactile fremitus

Relative location of bronchi to chest wall; normally most Relative location of bronchi to chest wall; normally most prominent between scapulae and around sternum, sites prominent between scapulae and around sternum, sites where major bronchi closest to chest wallwhere major bronchi closest to chest wall

Decreases as you progress down because more and Decreases as you progress down because more and more tissue impedes sound transmissionmore tissue impedes sound transmission

Thickness of chest wallThickness of chest wall Feels greater over thin wall than over an obese or Feels greater over thin wall than over an obese or

heavily muscular one where thick tissue dampens heavily muscular one where thick tissue dampens vibrationvibration

Pitch and intensity; loud, low-pitched voice generates Pitch and intensity; loud, low-pitched voice generates more fremitus than soft, high-pitched onemore fremitus than soft, high-pitched one

Slide 18-60



Palpate the posterior chestPalpate the posterior chest (cont.)(cont.) Note any areas of abnormal fremitusNote any areas of abnormal fremitus Conditions that increase density of lung tissue make a Conditions that increase density of lung tissue make a

better conducting medium for sound vibrations and better conducting medium for sound vibrations and increase tactile fremitusincrease tactile fremitus

Using fingers, gently palpate entire chest wallUsing fingers, gently palpate entire chest wall Enables noting any areas of tenderness, skin Enables noting any areas of tenderness, skin

temperature and moisture, detecting any temperature and moisture, detecting any superficial lumps or masses, and exploring any superficial lumps or masses, and exploring any skin lesions noted on inspectionskin lesions noted on inspection

Slide 18-61



Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Lung fieldsLung fields

Determine predominant note over lung fields; Determine predominant note over lung fields; start at apices and percuss band of normally start at apices and percuss band of normally resonant tissue across tops of both shouldersresonant tissue across tops of both shoulders

Then, percussing in interspaces, make side-to-Then, percussing in interspaces, make side-to-side comparison all the way down lung regionside comparison all the way down lung region

Percuss at 5-cm intervals; avoid damping effect of Percuss at 5-cm intervals; avoid damping effect of scapulae and ribsscapulae and ribs

Resonance is low-pitched, clear, hollow sound that Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adultpredominates in healthy lung tissue in adult

Slide 18-62



Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Lung fields (cont.)Lung fields (cont.)

However, resonance is relative term and has no However, resonance is relative term and has no constant standardconstant standard

Resonant note may be modified somewhat in athlete Resonant note may be modified somewhat in athlete with heavily muscular chest wall and in heavily obese with heavily muscular chest wall and in heavily obese adult in whom subcutaneous fat produces scattered adult in whom subcutaneous fat produces scattered dullnessdullness

Percussion sets into motion only outer 5 to 7 cm of Percussion sets into motion only outer 5 to 7 cm of tissue; will not penetrate to reveal any change in tissue; will not penetrate to reveal any change in density deeper than thatdensity deeper than that

Abnormal findings must be 2 to 3 cm wide to yield an Abnormal findings must be 2 to 3 cm wide to yield an abnormal percussion note; lesions smaller than that abnormal percussion note; lesions smaller than that are not detectable by percussionare not detectable by percussion

Slide 18-63



Percuss the posterior chest (cont.)Percuss the posterior chest (cont.) Diaphragmatic excursionDiaphragmatic excursion

Determine diaphragmatic excursionDetermine diaphragmatic excursion Percuss to map out lower lung border, both in Percuss to map out lower lung border, both in

expiration and in inspirationexpiration and in inspiration First, ask the person to “exhale and hold it” briefly First, ask the person to “exhale and hold it” briefly

while you percuss down scapular line until sound while you percuss down scapular line until sound changes from resonant to dull on each sidechanges from resonant to dull on each side

This estimates level of diaphragm separating This estimates level of diaphragm separating lungs from abdominal viscera; may be somewhat lungs from abdominal viscera; may be somewhat higher on right side because of presence of liverhigher on right side because of presence of liver

Mark the spotMark the spot

Slide 18-64



Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Diaphragmatic excursion (cont.)Diaphragmatic excursion (cont.)

Now ask person to “take a deep breath and hold Now ask person to “take a deep breath and hold it” it”

Continue percussing down from your first mark Continue percussing down from your first mark and mark level where sound changes to dull on and mark level where sound changes to dull on deep inspiration deep inspiration

Measure the difference; this diaphragmatic Measure the difference; this diaphragmatic excursion should be equal bilaterally and measure excursion should be equal bilaterally and measure about 3 to 5 cm in adults, although it may be up to about 3 to 5 cm in adults, although it may be up to 7 to 8 cm in well-conditioned people7 to 8 cm in well-conditioned people

Slide 18-65



Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Passage of air through tracheobronchial Passage of air through tracheobronchial

tree creates a characteristic set of noises tree creates a characteristic set of noises that are audible through chest wallthat are audible through chest wall

These noises also may be modified by These noises also may be modified by obstruction within respiratory obstruction within respiratory passageways or by changes in lung passageways or by changes in lung parenchyma, the pleura, or chest wallparenchyma, the pleura, or chest wall

Slide 18-66



Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Breath soundsBreath sounds

Evaluate presence and quality of normal breath Evaluate presence and quality of normal breath soundssounds

Instruct person to breathe through mouth, a little Instruct person to breathe through mouth, a little bit deeper than usualbit deeper than usual

Use flat diaphragm endpiece of stethoscope and Use flat diaphragm endpiece of stethoscope and hold it firmly on person’s chest wall; listen to at hold it firmly on person’s chest wall; listen to at least one full respiration in each locationleast one full respiration in each location

Side-to-side comparison is most importantSide-to-side comparison is most important Do not confuse background noise with lung Do not confuse background noise with lung

soundssounds

Slide 18-67



Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Breath sounds (cont.)Breath sounds (cont.)

Become familiar with these extraneous noises that Become familiar with these extraneous noises that may be confused with lung pathology if not may be confused with lung pathology if not recognizedrecognized Examiner’s breathing on stethoscope tubingExaminer’s breathing on stethoscope tubing Stethoscope tubing bumping togetherStethoscope tubing bumping together Patient shiveringPatient shivering Patient’s hairy chest; movement of hairs under Patient’s hairy chest; movement of hairs under

stethoscope sounds like crackles (rales); minimize stethoscope sounds like crackles (rales); minimize this by pressing harder or by wetting the hair with this by pressing harder or by wetting the hair with damp clothdamp cloth

Rustling of paper gown or paper drapesRustling of paper gown or paper drapes

Slide 18-68




While standing behind person, listen to following While standing behind person, listen to following lung areaslung areas Posterior from apices at C7 to bases around Posterior from apices at C7 to bases around

T10 T10 Laterally from axilla down to seventh or eighth Laterally from axilla down to seventh or eighth

ribrib Continue to visualize approximate locations of Continue to visualize approximate locations of

lobes of each lung so that you correlate your lobes of each lung so that you correlate your findings to anatomical areasfindings to anatomical areas

Slide 18-69




You should expect to hear three types of You should expect to hear three types of normal breath sounds in adult and older normal breath sounds in adult and older childchild Bronchial, sometimes called tracheal or tubularBronchial, sometimes called tracheal or tubular BronchovesicularBronchovesicular VesicularVesicular

Slide 18-70



Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Adventitious soundsAdventitious sounds

Added sounds that are not normally heard in lungsAdded sounds that are not normally heard in lungs If present, are heard as superimposed on breath If present, are heard as superimposed on breath

soundssounds Caused by moving air colliding with secretions in Caused by moving air colliding with secretions in

tracheobronchial passageways or by popping open tracheobronchial passageways or by popping open of previously deflated airwaysof previously deflated airways

Sources differ as to the classification and Sources differ as to the classification and nomenclature of these sounds but crackles (or nomenclature of these sounds but crackles (or rales) and wheeze (or rhonchi) are terms rales) and wheeze (or rhonchi) are terms commonly used by most examinerscommonly used by most examiners

Slide 18-71



Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Adventitious sounds (cont.)Adventitious sounds (cont.)

Atelectatic crackles, a type of adventitious sound, is not Atelectatic crackles, a type of adventitious sound, is not pathologic; short, popping, crackling sounds that sound pathologic; short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breathslike fine crackles but do not last beyond a few breaths

When sections of alveoli are not fully aerated (as in When sections of alveoli are not fully aerated (as in people who are asleep, or in elderly), they deflate people who are asleep, or in elderly), they deflate slightly and accumulate secretionsslightly and accumulate secretions Crackles are heard when these sections are Crackles are heard when these sections are

expanded by a few deep breathsexpanded by a few deep breaths Atelectatic crackles are heard only in the periphery, Atelectatic crackles are heard only in the periphery,

and disappear after first few breaths or after a coughand disappear after first few breaths or after a cough

Slide 18-72



Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Voice soundsVoice sounds

Voice can be auscultated over chest wall Voice can be auscultated over chest wall Ask person to repeat a phrase such as “ninety-Ask person to repeat a phrase such as “ninety-

nine” while you listen over chest wallnine” while you listen over chest wall Normal voice transmission is soft, muffled, and Normal voice transmission is soft, muffled, and

indistinct; you can hear sound through indistinct; you can hear sound through stethoscope but cannot distinguish exactly what stethoscope but cannot distinguish exactly what is being saidis being said

Slide 18-73



Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Voice sounds (cont.)Voice sounds (cont.)

Eliciting voice sounds usually not done in Eliciting voice sounds usually not done in routine examinationroutine examination

Rather, these are supplemental Rather, these are supplemental maneuvers that are performed if you maneuvers that are performed if you suspect lung pathology on basis of earlier suspect lung pathology on basis of earlier datadata

When they are performed, you are testing When they are performed, you are testing for possible presence of bronchophony, for possible presence of bronchophony, egophony, and whispered pectoriloquyegophony, and whispered pectoriloquy

Slide 18-74



Inspect the anterior chestInspect the anterior chest Note shape and configuration of chest wallNote shape and configuration of chest wall

Ribs are sloping downward with symmetric interspacesRibs are sloping downward with symmetric interspaces Costal angle is within 90 degrees; development of Costal angle is within 90 degrees; development of

abdominal muscles as expected for person’s age, abdominal muscles as expected for person’s age, weight, and athletic conditionweight, and athletic condition

Note person’s facial expression; facial expression should Note person’s facial expression; facial expression should be relaxed, indicating unconscious effort of breathingbe relaxed, indicating unconscious effort of breathing

Assess the level of consciousness; level of Assess the level of consciousness; level of consciousness should be alert and cooperativeconsciousness should be alert and cooperative

Note skin color and condition; lips and nail beds are free Note skin color and condition; lips and nail beds are free of cyanosis; nails of normal configurationof cyanosis; nails of normal configuration

Slide 18-75



Inspect the anterior chest (cont.)Inspect the anterior chest (cont.) Assess quality of respirationsAssess quality of respirations

Normal relaxed breathing is automatic and effortless, Normal relaxed breathing is automatic and effortless, regular and even, and produces no noiseregular and even, and produces no noise

Chest expands symmetrically with each inspiration; Chest expands symmetrically with each inspiration; note any localized lag on inspirationnote any localized lag on inspiration

No retraction or bulging of interspaces with inspirationNo retraction or bulging of interspaces with inspiration Normally, accessory muscles are not used to augment Normally, accessory muscles are not used to augment

respiratory effortrespiratory effort Respiratory rate is within normal limits for person’s age Respiratory rate is within normal limits for person’s age

and pattern of breathing is regularand pattern of breathing is regular Occasional sighs normally punctuate breathingOccasional sighs normally punctuate breathing

Slide 18-76



Palpate the anterior chest (cont.)Palpate the anterior chest (cont.) Palpate symmetric chest expansionPalpate symmetric chest expansion

Place your hands on anterolateral wall Place your hands on anterolateral wall with thumbs along costal margins and with thumbs along costal margins and pointing toward xiphoid processpointing toward xiphoid process

Any limitation in thoracic expansion is Any limitation in thoracic expansion is easier to detect on anterior chest because easier to detect on anterior chest because greater range of motion exists with greater range of motion exists with breathing herebreathing here

Slide 18-77



Palpate the anterior chest (cont.)Palpate the anterior chest (cont.) Assess tactile (vocal) fremitusAssess tactile (vocal) fremitus

Begin palpating over lung apices in supraclavicular Begin palpating over lung apices in supraclavicular areas areas

Compare vibrations from one side to other as person Compare vibrations from one side to other as person repeats “ninety-nine”repeats “ninety-nine”

Avoid palpating over female breast tissue because Avoid palpating over female breast tissue because breast tissue normally damps soundbreast tissue normally damps sound

Palpate anterior chest wall Palpate anterior chest wall Note any tenderness; normally none is presentNote any tenderness; normally none is present Detect any superficial lumps or masses, again, normally Detect any superficial lumps or masses, again, normally

none are presentnone are present Note skin mobility, turgor, temperature, and moistureNote skin mobility, turgor, temperature, and moisture

Slide 18-78



Percuss the anterior chestPercuss the anterior chest Begin percussing apices in supraclavicular areasBegin percussing apices in supraclavicular areas

Then, percussing interspaces and comparing one Then, percussing interspaces and comparing one side to other, move down anterior chestside to other, move down anterior chest

Interspaces easier to palpate on anterior chest than Interspaces easier to palpate on anterior chest than on backon back

Do not percuss directly over female breast tissue Do not percuss directly over female breast tissue because this would produce a dull note; shift breast because this would produce a dull note; shift breast tissue over slightly using edge of your stationary tissue over slightly using edge of your stationary handhand

In females with large breasts, percussion may yield In females with large breasts, percussion may yield little useful datalittle useful data

Slide 18-79



Percuss the anterior chest (cont.)Percuss the anterior chest (cont.) Note borders of cardiac dullness Note borders of cardiac dullness

normally found on anterior chestnormally found on anterior chest Do not confuse these with suspected lung Do not confuse these with suspected lung

pathologypathology In right hemithorax upper border of liver In right hemithorax upper border of liver

dullness is located in fifth intercostal dullness is located in fifth intercostal space in right midclavicular linespace in right midclavicular line

On left, tympany is evident over gastric On left, tympany is evident over gastric spacespace

Slide 18-80



Auscultate the anterior chestAuscultate the anterior chest Breath soundsBreath sounds

Auscultate lung fields over anterior chest from apices Auscultate lung fields over anterior chest from apices in supraclavicular areas down to sixth ribin supraclavicular areas down to sixth rib

Progress from side to side as you move downward, Progress from side to side as you move downward, and listen to one full respiration in each locationand listen to one full respiration in each location

Use sequence indicated for percussion; do not place Use sequence indicated for percussion; do not place stethoscope directly over female breast; displace stethoscope directly over female breast; displace breast and listen directly over chest wallbreast and listen directly over chest wall

Evaluate normal breath sounds, noting any abnormal Evaluate normal breath sounds, noting any abnormal breath sounds and any adventitious soundsbreath sounds and any adventitious sounds

If situation warrants, assess voice soundsIf situation warrants, assess voice sounds

Slide 18-81



Auscultate the anterior chestAuscultate the anterior chest (cont.)(cont.) Measurement of pulmonary function status (cont.)Measurement of pulmonary function status (cont.)

Pulse oximeter is noninvasive method to assess Pulse oximeter is noninvasive method to assess arterial oxygen saturation (SpOarterial oxygen saturation (SpO22))

A healthy person with no lung disease and no anemia A healthy person with no lung disease and no anemia normally has an SpOnormally has an SpO22 of 97% to 98% of 97% to 98%

However, every SpOHowever, every SpO22 result must be evaluated in result must be evaluated in context of person’s hemoglobin level, acid-base context of person’s hemoglobin level, acid-base balance, and ventilatory statusbalance, and ventilatory status

The 6-minute distance (6MD) walk is a safer, simple, The 6-minute distance (6MD) walk is a safer, simple, inexpensive, clinical measure of functional status in inexpensive, clinical measure of functional status in aging adultsaging adults

Slide 18-82


Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence (cont.)(cont.)

Pregnant womanPregnant woman Thoracic cage may appear wider, and costal angle Thoracic cage may appear wider, and costal angle

may feel wider than in nonpregnant statemay feel wider than in nonpregnant state Respirations may be deeper, although this can Respirations may be deeper, although this can

be quantified only with pulmonary function testsbe quantified only with pulmonary function tests Aging adultAging adult

Chest cage commonly shows an increased Chest cage commonly shows an increased anteroposterior diameter, giving a round barrel anteroposterior diameter, giving a round barrel shape, and kyphosis or an outward curvature of shape, and kyphosis or an outward curvature of thoracic spinethoracic spine

Slide 18-83


Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence (cont.)(cont.)

Aging adult (cont.)Aging adult (cont.) Person compensates by holding head extended and tilted Person compensates by holding head extended and tilted

backback May palpate marked bony prominences because of May palpate marked bony prominences because of

decreased subcutaneous fatdecreased subcutaneous fat Chest expansion may be somewhat decreased with Chest expansion may be somewhat decreased with

older person, although it still should be symmetricolder person, although it still should be symmetric Costal cartilages become calcified with aging, resulting Costal cartilages become calcified with aging, resulting

in a less mobile thoraxin a less mobile thorax The older person may fatigue easily, especially during The older person may fatigue easily, especially during

auscultation when deep mouth breathing is requiredauscultation when deep mouth breathing is required

Slide 18-84


Sample charting

Slide 18-85


Sample chartingSample charting (cont.)(cont.)

Slide 18-86


Abnormal Findings: Abnormal Findings: Configurations of the ThoraxConfigurations of the Thorax Barrel chestBarrel chest Pectus excavatumPectus excavatum Pectus carinatumPectus carinatum ScoliosisScoliosis KyphosisKyphosis

Slide 18-87


Barrel ChestBarrel Chest

Slide 18-88


ScoliosisScoliosis

Slide 18-89


KyphosisKyphosis

Slide 18-90


Abnormal Findings: Abnormal Findings: Respiration PatternsRespiration Patterns SighSigh TachypneaTachypnea BradypneaBradypnea HyperventilationHyperventilation HypoventilationHypoventilation Cheyne-Stokes respirationCheyne-Stokes respiration Biot’s respirationBiot’s respiration Chronic obstructive breathingChronic obstructive breathing

Slide 18-91


Abnormal Findings:Abnormal Findings:Abnormal Tactile FremitusAbnormal Tactile Fremitus Increased tactile fremitusIncreased tactile fremitus Decreased tactile fremitusDecreased tactile fremitus Rhonchial fremitusRhonchial fremitus Pleural friction fremitusPleural friction fremitus

Slide 18-92


Abnormal Findings:Abnormal Findings:Adventitious Lung SoundsAdventitious Lung Sounds Discontinuous soundsDiscontinuous sounds

Crackles—fineCrackles—fine Crackles—courseCrackles—course Atelectatic cracklesAtelectatic crackles Pleural friction rubPleural friction rub

Continuous soundsContinuous sounds Wheeze—sibilantWheeze—sibilant Wheeze—sonorous rhonchiWheeze—sonorous rhonchi StridorStridor

Slide 18-93


Abnormal Findings:Abnormal Findings:Common Respiratory ConditionsCommon Respiratory Conditions

AtelectasisAtelectasis Lobar pneumoniaLobar pneumonia BronchitisBronchitis EmphysemaEmphysema Asthma (reactive Asthma (reactive

airway disease)airway disease) Pleural effusion Pleural effusion

thickeningthickening PneumothoraxPneumothorax

Congestive heart failureCongestive heart failure Pneumocystis carinii Pneumocystis carinii

pneumoniapneumonia TuberculosisTuberculosis Pulmonary embolismPulmonary embolism Acute respiratory distress Acute respiratory distress

syndromesyndrome

Slide 18-94

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Thorax and Lungs Jarvis-Chap 18