ch 19 jarvis Thorax and lungs Flashcards
a musculotendinous septum that separates the thoracic cavity from the abdomen.
diaphragm
is a bony structure with a conical shape, which is narrower at the top (
thoracic cage
are the points at which the ribs join their cartilages. They are not palpable
costochondral junctions
b/w clavicles
Suprasternal Notch
“breastbone” has three parts:
the manubrium, the body, and the xiphoid process.
, this is the articulation of the manubrium and body of the sternum, and it is continuous with the 2nd rib
angle of Louis
is the middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels
mediastinum
anterior chest is 3 or 4 cm above the inner third of the clavicles
apex/apices of lungs
rests on the diaphragm at about the 6th rib in the midclavicular line
base, or lower border of lungs
T10 usually corresponds to the
base of lungs Posteriorly
the location of C7 marks the
apex of lung tissue Posteriorly
right lung is shorter than the left lung because of the
underlying liver
is narrower than the right lung because the heart bulges to the left
left lung
right lung has three lobes, and the left lung has two lobes
lobes in lungs
also contains the horizontal (minor) fissure, which divides the right upper and middle lobes
right lung
upper lobes occupy a smaller band of tissue from their apices at T1 down to T3 or T4.
posterior upper lobes
is that it is almost all lower lobe
posterior chest
level of T10 on expiration and T12 on inspiration
on inspiration lower lobe reaches
Laterally lung tissue extends from the apex of the axilla down to the
7th or 8th rib
extends from the apex of the axilla down to the 5th rib at the midaxillary line
left upper lobe
continues down to the 8th rib in the midaxillary line.
left lower lobe
- left lung has no middle lobe.
- The anterior chest contains mostly upper and middle lobe with very little lower lobe.
- The posterior chest contains almost all lower lobe.
three points that commonly confuse beginning examiners:
are serous membranes that form an envelope between the lungs and the chest wall
pleurae
lines the outside of the lungs, dipping down into the fissures
visceral pleura
lining the inside of the chest wall and diaphragm.
parietal pleura
lies anterior to the esophagus and is 10 to 11 cm long in the adult. It begins at the level of the cricoid cartilage in the neck and bifurcates just below the sternal angle into the right and left main bronchi
trachea
right main bronchus is shorter, wider, and more vertical than the left main bronchus.
difference b/w bronchus
transport gases between the environment and the lung parenchyma
-constitute the dead space, or space that is filled with air but is not available for gaseous exchange
trachea and bronchi
is a functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli
acinus
four major functions of the respiratory system:
(1) supplying oxygen to the body for energy production; (2) removing carbon dioxide as a waste product of energy reactions;
(3) maintaining homeostasis (acid-base balance) of arterial blood;
(4) maintaining heat exchange (less important in humans).
(slow, shallow breathing) causes carbon dioxide to build up in the blood
Hypoventilation
(rapid, deep breathing) causes carbon dioxide to be blown off.
hyperventilation
brainstem (pons and medulla)
involuntary control of respiration
the change in carbon dioxide and oxygen levels in the blood and, less important, the hydrogen ion level
major feedback loop is humoral regulation
increase of carbon dioxide in the blood, or
hypercapnia
decrease of oxygen in the blood
(hypoxemia)
(1) the vertical diameter lengthens or shortens, which is accomplished by downward or upward movement of the diaphragm;
(2) the anteroposterior (AP) diameter increases or decreases, which is accomplished by elevation or depression of the ribs
mechanical expansion and contraction of the chest cavity alters the size of the thoracic container in two dimensions:
inspiration increasing the size of the thoracic container creates a slightly
negative pressure
during expiration
positive pressure within the alveoli, and the air flows out
are the sternomastoids, the scaleni, and the trapezii
neck muscles
of fetal life the primitive lung bud emerges
first 5 weeks (infant lungs)
the conducting airways reach the same number as in the adult
16 weeks (3 months) (infant lungs)
surfactant, the complex lipid substance needed for sustained inflation of the air sacs, is present in adequate amounts
32 weeks (8 months) (infant lungs)
baby’s body systems all develop in utero, but the respiratory system alone does not function until
birth
After birth, SHS exposure increases the infant’s risk of upper and lower respiratory tract infections, otitis media, asthma, tooth decay, hearing loss, and metabolic syndrome, as well as later risks for attention-deficit/hyperactivity disorder, behavioral disorders, learning disabilities, cognitive disabilities, and problems at school.6 It is crucial for pregnant women and infants and children to avoid SHS
second hand smoke risks for infants
(pregnant woman) enlarging uterus elevates the diaphragm >decreases the vertical diameter of the thoracic cage> increase horizontal diameter
- total circumference of the chest cage increases by 6 cm
4 cm during pregnancy
affects close to 75% of women; does not alter activities of daily living; and is not associated with cough, wheezing, or exercise
physiologic dyspnea (pregnancy)
costal cartilages become calcified; thus the thorax is less mobile
-respiratory muscle declines
Aging adult
decrease in elastic properties within the lungs, making them less distensible and lessening their tendency to collapse and recoil
Aging adult
changes increase small airway closure, which yields a decreased vital capacity and increased residual volume
Aging adult
(the maximum amount of air that a person can expel from the lungs after first filling the lungs to maximum)
decreased vital capacity
(the amount of air remaining in the lungs even after the most forceful expiration).
increased residual volume
histologic changes (i.e., a gradual loss of intra-alveolar septa and a decreased number of alveoli) also occur= less gas exchange
Aging adult
Acute cough lasts
less than 2 or 3 weeks
chronic cough lasts
over 2 months.
continuous cough throughout day—
acute illness (e.g., respiratory infection)
afternoon/evening cough—
may be exposure to irritants at work
night cough—
postnasal drip, sinusitis;
early morning cough—
chronic bronchial inflammation of smokers.
white or clear mucoid—sputum
colds, bronchitis, viral infections
yellow or green sputum—
bacterial infections
rust colored sputum—
TB, pneumococcal pneumonia
pink, frothy sputum—
pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus.
mycoplasma pneumonia—
hacking cough
early heart failure—
dry cough
colds, bronchitis, pneumonia—
congested.
is SOB lasting >1 month and may have neurogenic, respiratory, or cardiac origin. It also occurs with anemia, anxiety, and deconditioning
Chronic dyspnea
often described as “chest tightness
Asthma attack
Traffic-related air pollution increases risk of
allergic rhinitis and asthma
may be at risk for grain or pesticide inhalation
Farmers
rural Midwest have risk for ;
histoplasmosis exposure (fungus infection from soil)
Coal miners have risk for
pneumoconiosis
Stone cutters, miners, and potters have risk for
silicosis
include. chronic bronchitis or emphysema (or both)
COPD
spirometry testing to confirm the diagnosis of COPD.
18 points or less= risk for COPD
anteroposterior (AP) diameter should be less than the transverse diameter
ratio of AP to transverse diameter is about 0.70 to 0.75 in adults, and it increases with age
is a palpable vibration
Fremitus
is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall
Fremitus
is palpable with inflammation of the pleura
Pleural friction fremitus
is palpable with thick bronchial secretions
Rhonchal fremitus
occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and the consolidation extends to the lung surface.
Increased fremitus
occurs with obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema. Any barrier that comes between the sound and your palpating hand decreases fremitus
Decreased fremitus
is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
Crepitus
is the low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult
Resonance
is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax
Hyperresonance
(soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor
dull note
technique of measuring diaphragmatic excursion using percussion is no longer recommended for two reasons:
(1) in persons with lung disease, evidence shows that clinicians usually overestimate diaphragmatic movement and that their results differ from chest image by 1 to 3 cm; and
(2) evidence shows that diaphragmatic excursion of <2 cm is an unreliable and infrequent sign of COPD.
three types of normal breath sounds in the adult and older child:
bronchial (sometimes called tracheal or tubular), bronchovesicular, and vesicular.
- pitch- high
- amplitude- loud
- Duration- inspiration< expiration
- Quality- harsh, hollow tubular
- normal location- Trachea and larynx
BRONCHIAL (TRACHEAL)
- pitch- Moderate
- amplitude- Moderate
- Duration- Inspiration = expiration
- Quality- Mixed
- normal location- Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces
BRONCHOVESICULAR
- pitch- Low
- amplitude- Soft
- Duration- inspiration> expiration
- Quality- Rustling, like the sound of the wind in the trees
- normal location- Over peripheral lung fields where air flows through smaller bronchioles and alveoli
VESICULAR
are discontinuous popping sounds heard over inspiration
Crackles
are continuous musical sounds heard mainly over expiration
wheezes
are short, popping, crackling sounds that last only a few breaths (not pathologic)
- sections of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions.
- heard only in peripherally
Atelectatic crackles
transmission is soft, muffled, and indistinct
Normal voice
Consolidation or compression of lung tissue will
enhance the voice sounds, making the words more distinct.
has horizontal ribs and costal angle >90 degrees.
Barrel chest
Hypertrophy of abdominal muscles
chronic emphysema.
Tense, strained, tired facies and purse-lipped breathing (the lips in a whistling position)
- Clubbing of distal phalanx
- Rectus abdominis and internal intercostal muscles (expiration)
accompany COPD
may be reflected by excessive drowsiness or anxiety, restlessness, and irritability.
Cerebral hypoxia
Cutaneous angiomas (spider nevi) aka cherry angiomas
associated with liver disease
occurs when part of the lung is obstructed (pneumonia) or collapsed or when guarding to avoid postoperative or pleurisy pain.
Unequal chest expansion
suggests obstruction of respiratory tract or that increased inspiratory effort is needed, as with atelectasis
Retraction (inspiration)
Bulging indicates trapped air as in the forced expiration associated with
emphysema or asthma (interspaces)
very heavy exercise the accessory neck muscles (scalene, sternomastoid, trapezius) are used momentarily to
enhance inspiration
is the number of seconds it takes for the person to exhale from total lung capacity to residual volume
-6 seconds or more occurs with obstructive lung disease
forced expiratory time
forced vital capacity (FVC) is the total volume of air exhaled. The forced expiratory volume in 1 second (FEV1) is the volume exhaled in the first measured second
-FEV1/FVC ratio of 75% or greater, meaning that no significant obstruction of airflow is present.
handheld spirometer measures lung health in chronic conditions such as asthma
> 300 meters in 6 minutes is more likely to engage in activities of daily living.
6-minute walk test (6 MWT) is a safer, simple, inexpensive, clinical measure of functional status in aging adults
By age ? years the thorax reaches the adult ratio of 1 : 2 (AP–to-transverse diameter)
-2 years head and chest are equal.
6 yrs
barrel shape persisting after age 6 years, which may develop with
chronic asthma or cystic fibrosis. (infant)
Apgar scoring system to measure the successful transition to extrauterine life infNT (respiratory response)
five standard parameters are scored at 1 minute and 5 minutes after birth
-1-minute Apgar with a total score of 7 to 10 indicates a newborn in good condition
0 to 2 indicates a severely depressed newborn needing full resuscitation, ventilatory assistance, and subsequent intensive care
Apgar scoring system to measure the successful transition to extrauterine life infNT (respiratory response)
1-minute Apgar with a total score of 3 to 6 indicates a moderately depressed newborn needing more resuscitation and subsequent close observation
Apgar scoring system to measure the successful transition to extrauterine life infNT (respiratory response)
infant breathes through the
nose rather than the mouth and is an obligate nose breather until 3 months
Slight flaring of the lower costal margins may occur with respirations, but normally no flaring of the nostrils and no sternal retractions or intercostal retractions occur. The diaphragm is the newborn’s major respiratory muscle. Intercostal muscles are not well developed. Thus you observe the abdomen bulge with each inspiration but see little thoracic expansion.
infants respiratory development
(infants) Marked retractions of sternum and intercostal muscles indicate increased inspiratory effort, as in
atelectasis, pneumonia, asthma, and acute airway obstruction.
infant tachypnea of 50 to 100 breaths/min during sleep may be an early sign of
heart failure.
Brief periods of apnea less than 10 to 15 seconds are
common in infants
periodic breathing is more common in
premature infants.
Asymmetric expansion occurs with
diaphragmatic hernia or pneumothorax (infants)
Crackles only in upper lung fields occur with
cystic fibrosis (infants)
crackles only in lower lung fields occur with
heart failure.(infants)
is a high-pitched inspiratory crowing sound heard without the stethoscope, occurring with upper airway obstruction (e.g., croup, foreign body aspiration, or acute epiglottitis).
Stridor
Persistent peristaltic sounds with diminished breath sounds on the same side may indicate
diaphragmatic hernia (infants)
occurs with lower airway obstruction (e.g., asthma or bronchiolitis). When unilateral, it may be foreign body aspiration
Expiratory wheezing (infants)
thoracic cage appears wider, and the costal angle widens by about 50%. Respirations are deeper, with a 40% increase in tidal volume.
pregnant woman
chest cage commonly shows an increased AP diameter, giving a round barrel shape and kyphosis or an outward curvature of the thoracic spine
Agining adult
is the smoke seen from the burning end of a tobacco product
Sidestream smoke
is the smoke exhaled from the person smoking
mainstream smoke
thorax has an elliptical shape with an anteroposterior-to-transverse diameter documented as 1 : 2 or 0.70.
Normal Adult (for Comparison) (thorax)
equal AP-to-transverse diameter and that ribs are horizontal instead of the normal downward slope. This is associated with normal aging and also with chronic emphysema and asthma as a result of hyperinflation of lungs.
Barrel Chest(thorax)
markedly sunken sternum and adjacent cartilages (also called funnel breast). Depression begins at second intercostal space, becoming depressed most at junction of xiphoid with body of sternum. More noticeable on inspiration. Congenital, usually not symptomatic. When severe, sternal depression may cause embarrassment and a negative self-concept. Surgery may be indicated
Pectus Excavatum(thorax)
forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast). Less common than pectus excavatum, this minor deformity requires no treatment. If severe, surgery may be indicated.
Pectus Carinatum(thorax)
lateral S-shaped curvature of the thoracic and lumbar spine, usually with involved vertebrae rotation. Note unequal shoulder and scapular height and unequal hip levels, rib interspaces flared on convex side. More prevalent in adolescent age-groups, especially girls. Mild deformities are asymptomatic. If severe (>45 degrees) deviation is present, scoliosis may reduce lung volume, and person is at risk for impaired cardiopulmonary function. Primary impairment is cosmetic deformity, negatively affecting self-image
Scoliosis(thorax)
exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Severe deformities impair cardiopulmonary function. If the neck muscles are strong, compensation occurs by hyperextension of head to maintain level of vision.
Kyphosis is associated with aging, especially the “dowager’s hump” of postmenopausal osteoporotic women. However, it is common well before menopause. Women with adequate exercise habits are less likely to have kyphosis.
Kyphosis(thorax)
Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction and also may lead to hyperventilation and dizziness.
Sigh (Respiratory Patterns)
Rapid, shallow breathing. Increased rate, >24 per minute. This is a normal response to fever, fear, or exercise. Rate also increases with respiratory insufficiency, pneumonia, alkalosis, pleurisy, and lesions in the pons
Tachypnea (Respiratory Patterns)
Increase in both rate and depth. Normally occurs with extreme exertion, fear, or anxiety. Also occurs with diabetic ketoacidosis (Kussmaul respirations), hepatic coma, salicylate overdose (producing a respiratory alkalosis to compensate for the metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (either an increase in CO2 or a decrease in oxygen). Hyperventilation blows off CO2, causing a decreased level in the blood (alkalosis).
Hyperventilation (Respiratory Patterns)
Slow breathing. A decreased but regular rate (<10 per minute), as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.
Bradypnea (Respiratory Patterns)
irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain
Hypoventilation(Respiratory Patterns)
cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. The breathing periods last 30 to 45 seconds, with periods of apnea (20 seconds) alternating the cycle. The most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure. Occurs normally in infants and older adults during sleep
Cheyne-Stokes Respiration(Respiratory Patterns)
Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (3 to 4) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.
Biot Respiration(Respiratory Patterns)
Normal inspiration and prolonged expiration to overcome increased airway resistance. In a person with chronic obstructive lung disease, any situation calling for increased heart rate (exercise) may lead to dyspneic episode (air trapping) because the person does not have enough time for full expiration.
Chronic Obstructive Breathing(Respiratory Patterns)
Occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations (e.g., compression or consolidation [pneumonia]). There must be a patent bronchus, and consolidation must extend to lung surface for increased fremitus to be apparent.
Increased Tactile Fremitus (
Abnormal Tactile Fremitus)
Occurs when anything obstructs transmission of vibrations (e.g., an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema). Any barrier that gets in the way of the sound and your palpating hand decreases fremitus.
Decreased Tactile Fremitus(Abnormal Tactile Fremitus)
Vibration felt when inhaled air passes through thick secretions in the larger bronchi. This may decrease somewhat by coughing
Rhonchal Fremitus(Abnormal Tactile Fremitus)
Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing. This sound is best detected by auscultation, but it may be palpable and feels like two pieces of leather grating together. It is synchronous with respiratory excursion. Also called a palpable friction rub.
Pleural Friction Fremitus (Abnormal Tactile Fremitus)
Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can simulate this sound by rolling a strand of hair between your fingers near your ear or by moistening your thumb and index finger and separating them near your ear
MECHANISM: Inspiratory crackles: inhaled air collides with previously deflated airways; airways suddenly pop open, creating explosive crackling sound
Expiratory crackles: sudden airway closing
-noticed with pneumonia, bronchiolitis, or atelectasis, new born.
Crackles—Fine (formerly called rales)// discontinuous sounds
Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but reappear shortly—sounds like opening a Velcro fastener
MECHANISM:Inhaled air collides with secretions in the trachea and large bronchi
Crackles——Coarse(formerly called rales)// discontinuous sounds
Sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths; heard in axillae and bases (usually dependent) of lungs
MECHANISM: When sections of alveoli are not fully aerated, they deflate and accumulate secretions; crackles are heard when these sections reexpand with a few deep breaths
Atelectatic crackles// discontinuous sounds
A very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto the chest wall; sound is inspiratory and expiratory
Pleural friction rub// discontinuous sounds
High-pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord); predominate in expiration but may occur in both expiration and inspiration
-Diffuse airway obstruction from acute asthma or chronic emphysema
Wheeze—High-pitched (sibilant)(Continuous Sounds)
Low-pitched; monophonic, single note, musical snoring, moaning sounds; they are heard throughout the cycle, although they are more prominent on expiration; may clear somewhat by coughing
-Bronchitis, single bronchus obstruction from airway tumo
Wheeze—Low-pitched (sonorous rhonchi)//Continuous Sounds)
High-pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall
-Croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-threatening
Stridor/Continuous Sounds)
Auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound
-Over area of consolidation or compression the spoken “eeee” sound changes to a bleating long “aaaaa” sound
Egophony
Ask the person to whisper a phrase such as “one-two-three” as you auscultate
- normal response is faint, muffled, and almost inaudible
Whispered Pectoriloquy
Ask the person to repeat “ninety-nine” while you listen with the stethoscope over the chest wall; listen especially if you suspect pathology
-Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said
Bronchophony
