Chapter 19 - Thorax and Lungs (pg. 964-1048) Flashcards
Thoracic Cage
bony structure with a conical shape, narrower at the top
What parts make up the thoracic cage?
-sternum
-12 pairs of ribs
-12 thoracic vertebrae
Diaphragm
bottom of the thoracic cage, a musculotendinous septum
How do the anterior aspects ribs 1-7 attach?
directly to sternum via costal cartilage
How do ribs 8-10 attach?
to the costal cartilage above
Ribs 11 and 12 are _________ meaning…
floating; have free palpable tips
Costochondral Junctions
the points where the ribs join their cartilages, are non-palpable
Suprasternal Notch
hollow U-shaped depression just above the sternum, in between the clavicles
Sternum
aka breastbone: three parts are the manubrium, body, xiphoid process
Manubriosternal Angle
bony ridge
What is another name for the sternal angle?
angle of Louis
What is the sternal angle?
spot where the manubrium and sternum body articulate, continuous with the second rib
Each intercostal space is numbered by the rib ______ it
above
What does the angle of Louis mark?
the site of tracheal bifurcation into the right and left main bronchi, upper border of atria, above T4
Costal Angle
where the R and L costal margins meet at the xiphoid process
Where is C7 palpable?
flex head and most superior bump
Spinous processes align with their same numbered ribs only until ____
T4
Midsternal Line
middle of sternum
Midclavicular Line
bisects the centre of each clavicle halfway between SC and AC joints
Vertebral (midspinal) Line
posterior vertical separation
Scapular Line
posterior separation that extends through inferior angle of scapula when arms are at sides
Anterior Axillary Line
lift patients arm and observe how this extends from anterior axillary fold where pectoralis major inserts
Posterior Axillary Line
continues down from posterior axillary fold where latissimus dorsi inserts
Midaxillary Line
runs down from apex of the axilla and lies parallel and between the other two
Mediastinum
middle section of the thoracic cavity, contains esophagus, trachea, heart, great vessels
Pleural Cavities
R and L, contain the lungs
Apex
highest point of lung tissue, lies 3-4cm above inner clavicles
Base
lower border, rests on diaphragm around 6th rib in midclavicular line
Which lung is shorter? Why?
right is shorter due to liver underneath
Which lung is narrower? Why?
left is narrower due to heart bulging
The R lung has ___ lobes
3
The L lung has ____ lobes
2
Fissures
separate the lung lobes
Oblique Fissure (R and L)
anteriorly crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line
Horizontal Fissure
R lung, divides R upper and middle lobes, extends from fifth rib in R midaxillary line to third intercostal space or fourth rib at R sternal border
The posterior chest is almost all ___________ lobe
lower
Where do the posterior lower lobes begin?
T3-T4ish
Which lobe is not present posteriorly?
RML
Pleurae
thin, slippery envelope between the lungs and chest wall
Visceral Pleura
lines the outside of the lungs, dips into fissure
Parietal Pleura
lines the inside of the chest wall and diaphragm
Pleural Space
filled with lubricating fluid, has negative pressure, holds lungs to chest well
Costodiaphragmatic Recess
potential space about 3cm below lungs that can compromise lung expansion if full of fluid or air
Trachea
anterior to esophagus, 10-11cm long, begins at cricoid cartilage and bifurcates into R and L main bronchi
Where does tracheal bifurcation occur posteriorly?
T4-T5
How does the R main bronchus compare to the L?
it is shorter, wider, and more vertical
Dead Space
what the trachea and bronchi are, carry air but don’t exchange gas
Capacity of dead space in adults?
~150mL
What are the bronchi lined with?
goblet cells (secrete mucus) and cilia (filter particles)
Acinus
a functional respiratory unit that consists of bronchioles, alveolar ducts, alveolar sacs, and alveoli
4 Functions of Respiratory System:
-oxygen supply
-CO2 removal
-homeostasis
-heat exchange
Hypoventilation causes a __________ of CO2
build up
Where is respiratory patterns regulated?
pons and medulla
Which particle is most involved in the normal breath stimulus?
CO2 increase
Inspiration creates a ________ pressure that allows air to rush in
negative
What is the major inspiratory muscle?
diaphragm
Expiration is primarily _________
passive
When does surfactant present itself in infants?
32 weeks gestation
Surfactant
lipid substance needed for inflation of air sacs
When does the foramen ovale in infants close?
just after birth
Ductus Arteriosus
links pulmonary artery and aorta
Prenatal smoke exposure =
chronic hypoxia and low birth weight, nicotine sensitization, otitis media, SIDs, asthma, LRT infections
Enlarging uterus elevates diaphragm ____cm during pregnancy
4cm
__________ relaxes thoracic cage ligaments
estrogen
During pregnancy, thoracic cage circumference increases by __cm
6cm
Increased diaphragm movement during pregnancy results in a 40% increase in ______ _______
tidal volume
Physiologic Dyspnea during pregnancy:
-change in dimensions of thoracic cavity
-increased O2 demand
-affects 75% of women
-does not alter ADLs
-not associated with cough, wheezing, or exercise
What reduces the mobility of the thorax in older adults?
-calcified costal cartilages
-decreased muscle strength
-decreased elasticity of lungs
Older adults have a decreased _______ capacity and increased _________ volume
vital; residual
Vital Capacity
max amount of air a person can exhale from full lungs
Residual Volume
amount of air remaining in lungs, even after forceful expiration
Hemoptysis
coughing up blood
Orthopnea
difficulty breathing in the supine position
Paroxysmal Nocturnal Dyspneas
awakening from sleep with shortness of breath
tactile fremitus
vocal vibrations
Where is fremitus most prominent?
between scapulae and around sternum, sites where major bronchi are closes to the chest wall
resonanace
low-pitched, clear, hollow sound in healthy lung tissue in adults
What are some extraneous noises that can occur when auscultating?
-examiner breathing
-tubing bumping together
-patient shivering
-hairy chest
-rustling of paper
Bronchial sounds
-high pitch
-loud amplitude
-inspiration < expiration
Bronchovesicular Sounds
-moderate pitch and amplitude
-inspiration = expiration
Vesicular sound
-low pitch
-soft amplitude
-inspiration > expiration
Where are Bv sound heard?
near uppper spine posteriorly and near sternum anteriorly
Where are v sounds heard?
everywhere but scapulae posteriorly, and around rib case anteriorly
Where are b sounds heard?
only anteriorly on neck near trachea
Adventitious sounds
additional sounds that aren’t normally heard in lungs
What causes adventitious sounds?
collision of moving air with secretions or popping open of previously deflated airways
Rales
crackles
Ronchi
wheeze
Atelectatic Crackles
not pathological, short, popping sounds that don’t last beyond a few breaths, heard only in periphery
Why is limitation in thoracic expansion easier to assess anteriorly?
range of motion of breathing is greater here
6 minute walk test
monitor O2 sats while patient walks around for 6 minutes safely, patient who walks more than 300m in 6min is more likely to engage in ADLs
What does the Apgar scoring system measure?
success of transition to extrauterine life
When is the apgar score taken?
1 min and 5 mins after birth
What is a good apgar score?
7-10
Infants are obligate nose breathers until age…
3 months
Normal resp rate in newborn:
30-40 bpm
How do you test for bronchophony?
listen to chest wall with stethoscope while patient repeats “ninety-nine” - abnormal finding is when you can clearly hear the words
How do you test for egophony?
auscultate while patient says “eeeeeeee” - abnormal finding if you hear a bleating, long “aaaaaa”
How do you test for whispered pectoriloquy?
auscultate while patient whispers a phrase ie. “one-two-three” - abnormal if you can hear it clearly into the stethoscope
Diaphragmatic Excursioon
measurement of the distance between the base of the lungs on inspiration and expiration
Forced Expiratory Time
number of seconds it takes for the patient to exhale total lung capacity to residual volume
How do you measure forced expiratory time? When?
ask patient to inhale then blow it all out as quickly as possible with mouth open while listening over sternum - screens for airflow obstruction
What is a normal forced expiratory time?
4 seconds
Barrel Chest
associated with normal aging and chronic emphysema and asthma
Normal adult anteroposterior-to-transverse ration:
1:2 to 5:7
Pectus Excavatum
-sunken sternum and adjacent cartilages
-depression begins at second intercostal space
-more noticeable on inspiration
-congenital
-not usually symptomatic
Pectus Carinatum
forward protrusion of the sternum
Scoliosis
lateral S-shaped curve of the spine
Kyphosis
-exaggerated posterior curvature of the thoracic spine (humpback)
-causes back pain and limited mobility
Tachypnea
rapid, shallow breathing, >24 bpm, a normal response to fever fear or exercise
Hyperventilation
-increase in rate and depth
-normally occurs with exertion, fear, anxiety
-diabetic ketoacidosis
Bradypnea
-slow breathing
-<10 per minute
-due to depression of medulla, increased ICP, diabetic coma
Hypoventilation
-cause by OD of narcotics or anaesthetics, prolonged bed rest
Cheyne-Stokes Respiration
-cycle where respirations wax and wane in a regular pattern
-periods last 30-45 seconds with periods of apnea
-severe heart failure is common cause along with renal failure, meningitis, drug overdose, increased ICP
Biot’s Respirations
similar to cheyne-stokes except pattern is irregular
Chronic Obstructive Breathing
-normal inspiration and prolonged expiration to overcome increase airway resistance
Increased Tactile Fremitus
-occurs with increased density of lung tissue
Decreased Tactile Fremitus
-something obstructs transmission of vibrations
Rhonchal Fremitus
-vibration felt when inhaled air passes through thick secretions
Pleural Friction Fremitus
-produced when inflammation of pleura causes decrease in normal lubrication
Fine Crackles (rales)
-discontinuous
-high-pitched short crackling
-during inspiration
-not cleared by coughing
-occur when inhaled air collides with previously deflated airways
Coarse Crackles (rales)
-loud, low-pitched, bubbling, gurgling
-start early in inspiration and may be present in expiration
-occur when inhaled air collides with secretion in trachea and bronchi
Atelectatic Crackles
-not indicative of disease
Pleural Friction Rub
-coarse, low-pitched sound
-sound like crackles but close to the ear
-caused when pleurae become inflamed and lose their normal lubricating fluid
Discontinuous Sounds
discrete, crackling sounds
Continuous Sounds
connected, musical sounds
High-pitched Wheeze
-may occur on inspiration and expiration
-occur when air is squeezed or compressed through narrow passageways due to swelling, secretions, tumours
Low-pitched Wheeze
-single-note musical snoring
-more prominent on expiration
Stridor
-high-pitched, monophonic, inspiratory crowing
-louder in neck
-due to upper airway obstruction
Atelectasis
-collapsed section of alveoli or entire lung as a result of airway obstruction
I - cough, increased resp. rate and pulse, possible cyanosis
Pa - expansion decreased on affected side, tactile fremitus decreased over area, tracheal deviation
Pe - dull over area
A - decrease or absent v sounds, occasional fine crackles
Lobar Pneumonia
-alveolar membrane edema and porous
-blood cells pass into alveoli
-alveoli fill with bacteria, cell debris, and replace air
I - increased resp. rate, guarding, sternal retraction, nasal flaring
Pa - decreased chest expansion and increased tactile fremitus
Pe - dull
A - increased bronchophony, egophony, whispered pectoriloquy, fine to medium crackles
Bronchitis
-proliferation of mucous glands resulting in excess secretion
I - hacking, rasping cough with productive sputum, possible dyspnea, fatigue, cyanosis, clubbing
Pa - normal tactile fremitus
Pe - resonant
A - normal v sounds, crackles, maybe wheeze
Empysema
-caused by destruction of pulmonary connective tissue
-permanent enlargement of air sacs
-90% of cases from smoking
I - barrel chest, use of accessory muscles, tri-poding, shortness of breath, tachypnea
Pa - decreased TF on chest expansion
Pe - hyper-resonant
A - decreased breath sounds, muffled heart sounds, usually no adventitia
Asthma
-allergic hypersensitivity to inhaled allergens and irritants
-bronchospasm
-increased airway resistance
-wheezing
I - increased resp. rate, shortness of breath, audible wheeze, accessory muscle use, cyanosis, possible barrel chest
Pa - decreased TF
Pe - resonant, chronic = hyper-resonant
A - diminished air movement, breath and voice sounds decreased, bilateral wheezing
Pleural Effusion or Thickening
-collection of excess fluid in intrapleural space with compressing of lung tissue
I - increased respirations, dyspnea, cough, tachycardia, cyanosis, abd. distension
Pa - decreased or absent TF, decreased chest expansion
Pe - dull to faint
A - decreased or absent breath sounds, voice sounds decreased
Heart Failure
-pump failure with increased overload
-causes pulmonary congestion
I - increased resp. rate, shortness of breath, exertion, orthopnea, PND, ankle edema, pallor
Pa - skin is moist and clammy, normal TF
Pe - resonant
A - crackles at lung bases
Pneumothorax
-free air in pleural space causes partial or complete lung collapse
-usually unilateral
-spontaneous (air enters through lung wall rupture) or traumatic (air enters via injury) or tension (trapped air increases)
I - unequal chest expansion, tachypnea, cyanosis
Pa - TF decreased or absent, tachycardia, decreased BP
Pe - hyper-resonant, decreased diaphragmatic excursion
A - decreased or absent breath and voice sounds
Pneumocystis jiroveci Pneumonia
-viral form of pneumonia
-harmful to immunocompromised patients
I - anxiety, SOB, dyspnea on exertion, tachypnea, nonproductive cough, children (intercostal retractions), cyanosis
Pa - decreased chest expansion
Pe - dull
A - diminished breath sounds, crackles
Tuberculosis
-initial acute inflammatory response
-tubercle forms around bacilli
-scar tissue forms
I - initially nonproductive, then productive cough then purulent yellow-green sputum, dyspnea, orthopnea, fatigue
Pa - moist skin
Pe - dull over effusion
A - decreased v sounds, crackles over upper lobes
Pulmonary Embolism
-thrombus detaches and lodges in pulmonary vessels
-95% result from DVT
-chest pain worse on inspiration, dyspnea
I - changed mental status, cyanosis, tachypnea, cough, hemoptysis, resp. alkalosis
Pa - diaphoresis, hypotension
A - tachycardia, crackles, wheeze
Do not ___________ a suspected PE
percuss
Acute Respiratory Distress Syndrome (ARDS)
-acute pulmonary insult
-damage to alveolar capillaries
-pulmonary edema
-acute onset of dyspnea
I - disorientation, rapid shallow breathing, productive cough, resp. alkalosis
Pa - hypotension
A - tachycardia, crackles, rhonchi
