L13: The Thorax and Lungs Flashcards
Principle muscles of inspiration? Accessory muscles?
- ) Principle: External intercostals, interchondral part of internal intercostals, diaphragm
- ) Accessory: SCM, scalenes
Muscles of expiration used in quiet vs active breathing?
- ) Quiet: passive recoil of lungs, no muscles
2. ) Active: internal intercostals except interchondral part, abdominal muscles
Why can patients with difficulty breathing have neck and pubic pain?
- Accessory muscles with inspiration = SCM and scalenes
- Active expiration uses abdominal muscles
At what level of the sternum does the trachea bifurcate?
- Sternal angle
To what vertebral level are the lungs seen in a lateral x-ray?
- T10
Clinical borders of the thorax
- Midsternal line
- Midclavicular line
- Anterior axillary line
- Midaxillary line
- Posterior axillary line
- Scapular line
- Vertebral line
What surface landmarks do the oblique and horizonal fissure(s) of the lungs correspond?
- ) Horizontal (right lung): 4th rib at sternum and 5th rib at midaxillary line
- ) Oblique (both): 6th rib at midaxillary line, posteriorly below spinous process of T3
* both with inhalation
Difference between right and left primary bronchi. Relevance
- Right more vertical/straighter than left, aspirated FB with more often be in right
Where are bronchial breath sounds heard?
- around the angle of Louis, not found deep in chest
Common or concerning symptoms involving thorax and lungs ordered from high to low seriousness
- Chest pain
- SOB (dyspnea)
- Wheezing
- Cough
- Hemoptysis (blood-streaked sputum)
Sources of chest pain?
- ) Cardiac: myocardium, pericardium, aorta
- ) Pulmonary: trachea, large bronchi, parietal pleura
- ) Other: chest wall, esophagus, extra thoracic
Sources of dyspnea/SOB?
- ) Lung: COPD (chronic bronchitis, emphysema), pneumonia, asthma, acute bronchitis, PE, pneumo
- ) Other: chest wall, compression fracture, phrenic nerve, neurogenic (central or peripheral), psychologic (panic attack), systemic (anemia, low volume, heart failure, sepsis), heart attack, epigastric
Sources of wheeze, cough, hemoptysis?
- ) Lung: cancer, COPD, pneumonia, asthma, acute bronchitis
- ) Nose and mouth: allergic rhinitis, aspiration, irritant
- ) Stomach: reflux, bulimia, cyclic vomiting syndrome
- ) Other: phrenic nerve, neurogenic (central or peripheral), psychological (habit cough or chronic throat clearing), systemic (bleeding problem)
Order of lung/thorax exam
- Look, listen, palpate, percuss
What are you looking for in the “look” part of the lung/thorax exam?
- Shape: barrel chest, pectus carinatum/excavatum, scoliosis, kyphosis
- Movement: paradoxical movement of chest / flailed chest – requires 3 ribs broken in two different places
- Posture: tripod posture (seen in COPD and epiglottitis)
- Acting: ill, agitate, calm
- Accessory muscle use
- Other: cyanosis, edema, bad breath, clubbing, needle marks
Bell or diaphragm for lung vs heart?
- Bell / diaphragm for heart
- Diaphragm for lung
What are you palpating for in the “palpate” part of the lung/thorax exam?
- Symmetry of rib motion
- Pulmonary embolism (can cause localized collapse of lungs, ribs won’t move over these area). Pleural effusion is more global
- Pneumonia with consolidations (fremitus)
- AP-diameter (COPD)
From what side of the thorax can the middle lobe be percussed?
- Anterior only
When percussing the thorax, how will pleurisy be detected?
- Painful to percussion
Sound of consolidation when percussed?
- Dull
Note for normal pt’s thorax/lung exam
- Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no rales, wheezes or rhonchi. Diaphragm descends 4 cm bilaterally
Note for COPD pt’s thorax/lung exam
- Thorax symmetric with moderate kyphosis and increased AP diameter, decreased expansion. Lungs are hyperresonant. Breath sound distant with delayed expiratory phase and scattered expiratory wheezes. Fremitus decreased; no bronchophony, egophony, or whisphered pectoriloquy. Diaphragms descend 2 cm bilaterally
Note for asthma pt’s thorax/lung exam
- Thorax symmetric with flattened kyphosis and normal AP diameter. Lungs are resonant. Broncho-vesicular breath sounds and scattered expiratory wheezes bilaterally. Wheezes strongly with forced expiration. No bronchopohony, egophony, or whisphered pectoriloquy. Diaphragms descend 4 cm bilaterally.
Note for pneumothorax pt’s thorax/lung exam
- Thorax asymmetric with decreased movement on the left. Lung is hyperresonant on the left. Breath sounds decreased on the left in all lobes. Diaphragm descends 4 cm on right, not percussed on left.
Retractions
- Chest wall caving in at sternum, between ribs, suprasternal notch, above clavicles and at lower costal margins
Stridor
- harsh, high-pitched sound caused by laryngeal or tracheal obstruction
Tactile fremitus
- Vibration
- Increased is suggestive of fluids/secretions or a solid mass
- Diminished or absent is suggestive of excess air in lungs caused by obstruction, emphysema, significant effusion or collapse of lung tissue
Percussion tones heard over chest
- ) Resonant
- ) Flat
- ) Dull
- ) Tympanic
- ) Hyperresonant
Percussion of chest. Direct or indirect?
- Indirect
How many areas of percussion/auscultation of chest? Where?
- 12 total
- 4 anteriorly, 2 laterally, 6 posteriorly
How to test for diaphragmatic excursion?
- ) Have pt take deep breath and hold it
- ) Percuss down back until hearing change from resonant to dull tone
- ) Mark this area as lower border
- ) Have pt relax, exhale and hold it
- ) Percuss up from marked area until change from dull to resonant tone
- ) Mark this area and measure
- ) Normal = 3-5 cm
What conditions limit diaphragmatic excursion?
- Emphysema, massive ascites, tumor and fractured ribs
4 adventitious breath sounds
- Crackles
- Rhonchi
- Wheezes
- Friction rubs
Crackles
- Formerly rales
- Disruption of air passage through small airways, sounds do not clear with coughing
- Usually heard with inspiration, discontinuously
Rhonchi
- Airway obstruction by thick secretions, muscular spasm or external pressure
- Usually heard with expiration continuously, may clear with coughing
Friction rubs
- dry, crackly, grating low-pitched sounds heard in both inspiration and expiration
- indicates inflammation
3 vocal resonance tests
- ) Bronchophony – having pt say 99
- ) Egophony – having pt say ee
- ) Whisphered pectoriloquy – having pt whispher 1,2, 3
Abnormal breathing patterns
- ) Cheyne-Stokes: alternating periods of apnea and hyperpnea (increased depth of breathing). Seen in 30% of pts with CHF and also in pts with neuro disorders, hemorrhage, infarction, tumors, meningitis, head trauma. Normal persons can have this during sleep or at high altitudes
- ) Kussmaul: very deep, gasing and rapid breathing seen in metabolic acidosis
- ) Grunting: short and explosive sounds, more common in children, but also in adults as sign of respiratory muscle fatigue
Asthma
- aka reactive airway disease
- small airway obstruction caused by inflammation and hyperactive airways
Atelectasis
- incomplete expansion of lung
Barrel chest
- increased AP diameter often with some kyphosis, commonly seen in COPD
Biot respirations
- irregular respirations varying in depth and interrupted by intervals of apnea that lacks repetitive pattern
Bronchiectasis
- chronic dilation of bronchi and bronchioles caused by repeated infections or bronchial obstructions
Bronchitis
- inflammation of large airways
Bronchophony
- exaggeration of vocal resonance emanating from bronchus surrounded by consolidated lung tissue
Bronchiolitis
- inflammation of bronchioles
COPD
- disease process which decreases ability of lungs to perform their function of ventilation
- this is non-specific diagnosis and includes: emphysema and chronic bronchitis
Egophony
- auditory quality associated with increased intensity of spoken voice along with nasal quality. May be present in any condition that consolidates lungs
3 types of normal breath sounds
- ) Vesicular: heart over most of the lung fields (low pitch, soft, short expirations)
- ) Tubular: heard only over trachea (high pitch, loud and long expirations, sometimes longer than inspiration)
- ) Bronchovesicular: heard over main bronchus area and over right upper posterior lung field (medium pitch, expiration = inspiration)
Orthopnea
- SOB increasing when pt lies down
Pectoriloquy
- striking transmission of voice sounds through the pulmonary structures, so that they are clearly audible through the stethoscope, commonly occurs from lung consolidation
Tactile fremitus
- Tremor or vibration in any part of the body detected on palpation
Whispered pectoriloquy
- increase in volume of voice sounds when lung is consolidated by pneumonia
