bronchi, lungs, pleura and diaphragm

Question 1

List the markings for the right parietal pleura

Answer 1

(A) the apex of the pleura- above the medial 1/3rd of the clavicle in the root of the neck
(B) just over the stern clavicular joint
(C) just to the right of Anterior Median line at centre of the sternal angle
(D)- Just to the right of the AML at the 4th costal cartilage
(E)- Just to the right of the AML at the 6th costal cartilage (xiphoid process)
(F)- MCL at level of the 8th rib (just above costal margin)
(G)- MAL at level of 10th rib (lowest point of costal margin)
(H)- Scapular line (lateral margin of erector spinae muscles) crossing the 12th rib
(I)- TRANSVERSE PROCESS of L1 vertebrae (subcostal pleura below 12th rib)
(J)- Transverse process of T1 vertebrae

Connect all points A to J, FINALLY CONNECT J TO A around the root of the neck

Question 2

Outline the markings for the left parietal pleura

Answer 2

Mark all points similarly to the right side
With the exceptions of D and E
The left pleura deflects sharply to the left to allow for the cardiac notch
The pleural deflection is shallower than the cardiac notch of the left Lung

Question 3

What are lung markings based on

Answer 3

“Lung markings are drawn approximately as they lie in mid-inspiration. They are more extensive at full inspiration but lesser at full expiration.”

Question 4

Outline the surface markings for the right lung

Answer 4

(A)-(E). From the apex, the right lung closely follows the pleural reflection down to the level of the 6th costal cartilage.

From here, the lower border of the lungs follows two ribs above the pleural reflection around the chest wall.

(f) MCL at 6th rib (anteriorly)
(g) MAL at 8th rib (laterally)
(h) Scapular line at 10th rib (posteriorly)

Question 5

What is meant by the scapular line

Answer 5

Median border of scapula

Question 6

Where is the lung hilum located

Answer 6

midpoint of scapular and posterior median line opposite spines of T4-T6

Question 7

What is T12

Answer 7

mid point between inferior angle of scapula and top of iliac bone along scapular line

Question 8

What happens at the costovertebral angle

Answer 8

the pleural margin extends below the 12th rib

it is also related to the upper poles of the kidney

Question 9

Outline the markings for the left lung

Answer 9

Same as the right except for the mediastinal reflection below the 4th costal cartilage
Below the 4th costal cartilage, the cardiac notch deviates by 2-3cm lateral at the level of the 5th CC
The lower border follows the same course as the right

Question 10

Outline the markings for the oblique fissure

Answer 10

Posteriorly- at level of lung border at T3
Anteriorly- lower border of the lung at the 6th costal cartilage
Connect these two points with a smooth curved line running around the lateral thoracic wall.

Question 11

What is a quick short cut to outline the oblique fissure

Answer 11

the oblique fissure closely follows the medial border of the scapula when the arm is raised above the head of the subject
extrapolate this line anteriorly to meet the lower border of the lung

Question 12

Outline the markings for the horizontal fissure (right lung only)

Answer 12

Palpate the 4th CC on the right side and draw a line along the 4th CC and rib backwards to meet the oblique fissure in the MAL
This marks the horizontal fissure separating the upper and middle lobes of the right lung.
It passes above the nipple in males

Question 13

Highlight the key components of the physical examination

Answer 13

“There are four elements that form the main part of physical examination: 1) inspection, 2) palpation 3) percussion and 4) auscultation. These are usually performed in this order. By convention, the patients (in our case the living subjects) are examined from the right side of the bed (or couch).”

Question 14

How does the sounds in percussion differ

Answer 14

“Tapping the chest wall produces a hollow, drum-like sound over air-filled spaces such as the lung, but a dull sound over solid organs (such as the heart) or over liquids. ”

Question 15

What positions should the subjects be in whilst we perform percussion

Answer 15

“Percussion of the posterior chest wall is easiest to perform while subject sits on the edge of the couch. Percussion of the anterior chest wall is easiest to perform while the subject lies supine (useful in female subjects as breasts will move laterally or ask the subject to move the breast for you).”

Question 16

how should percussion be performed

Answer 16

“Percussion should be performed symmetrically and systematically on the anterior, posterior and axillary regions of the chest wall. ”

Question 17

Where different lobes on the lung are found

Answer 17

See diagram!

Question 18

How can we protract (move laterally) the scapula

Answer 18

The patient can cross the arms in front of their chest

Question 19

What are the lung sounds due to

Answer 19

“Auscultation of lungs is listening to breath (lung) sounds with a stethoscope. Normal breath sounds are heard over all parts of the chest. These sounds are produced by air turbulence in airways (not produced in the alveoli). Two types of normal breath sounds are recognized: 1) bronchial sound and 2) vesicular sound.
”

Question 20

Describe the bronchial sounds

Answer 20

“(The bronchial sounds (high pitched) are normally heard over trachea (neck), suprasternal notch, manubrium, sternal angle, and sternoclavicular joints. In these areas, the airways are not surrounded by alveolar tissue, and therefore, the air turbulence in them is heard without any filtering. ”

Question 21

Describe the vesicular sounds

Answer 21

“The vesicular sounds (low pitched) are heard all over the rest of the chest area where normal lung tissue is present and filters the sounds of air turbulence to the chest wall).
”

Question 22

How should auscultation of the lungs be performed

Answer 22

“Auscultation should be performed symmetrically and systematically on the anterior, posterior and axillary regions of the chest wall. Auscultation of the posterior chest wall is easiest to perform while subject sits over the edge of the couch. Auscultation of the anterior chest wall is easiest to perform while the subject lies supine (useful in female subjects as breasts will move laterally or ask the subject to move the breast for you)”

Question 23

Where should you never for lung sounds

Answer 23

Never listen through clothing

Also, do not listen over the female breast because lung sounds won’t be transmitted through breast tissue (fat)

Question 24

What can make listening to the lung sounds easier

Answer 24

Ask the subject to take deep breaths through the mouth

Question 25

Which part of the stethoscope should you use to ausculate the lungs

Answer 25

Diaphragm to listen to all areas except for areas 1 and 2- use the bell

Question 26

Where should you observe bronchial breathing

Answer 26

Listen over the trachea, manubrium and sternal angle

Question 27

What is different for females

Answer 27

Area 9 is specifically for the middle lobe in females.

In females the lower lobes on the anterior chest wall are below the base of the bread (6th rib)

Question 28

Do the lung sounds sound the same

Answer 28

Expiration is shorter and there is no pause between inspiration and expiration. The intensity of breath sound is higher in bases in erect position and dependent lung in decubitus position.

The breath sounds are symmetrical and louder in intensity in bases compared to apices in erect position. No adventitious sounds are heard.

Question 29

Which conditions are cheater drains indicated in

Answer 29

“Chest drains are indicated in a number of conditions including:
Pneumothorax,
Pleural effusion
Haemothorax
Post-operative”

Question 30

Describe the placement of a chest drain

Answer 30

“
A knowledge of the relevant anatomy is essential for the safe and effective placement of a drain tube. The most common position for chest drain insertion is anterior to the mid-axillary line avoiding the long thoracic nerve lying behind, in the ‘safe triangle’. This is the triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a horizontal line at the 5th intercostal space at the mid-axillary line (superior to the horizontal level of the male nipple), and an apex below the axilla”

Question 31

How may chest drains differ for apical pneumothoraces

Answer 31

“For apical pneumothoraces, the second intercostal space in the mid-clavicular line may also be used”

Question 32

What are the borders for the safe triangle for a chest drain

Answer 32

posterior- latissimus dorsi- posterior axillary fold
anterior- pectorals major- anterior axillary fold
inferio- 5TH intercostal space at MAL
superior- below apex of axilla