Objective - Mechanics of Breathing

Question 1

Muscles of Inspiration

Answer 1

> Active 
- Diaphragm + External intercostals 
\+ Accessory muscles
- Scalenes
- Sternocleidomastoid
- Pectoralis major and minor
- serratus anterior
- latissimus dorsi

Question 2

Muscles of expiration

Answer 2

> Passive elastic recoil of lungs 
\+ Accessory muscles 
- All 4 Abdominals
- Lowest fibres of iliocostalis
- longissimus 
- serratus posterior inferior

Question 3

Pump handle

Answer 3

> ‘apical’ - ie sternum moving superiorly and anteriorly
palpated by one hand horizontally across sternum or two hands vertically either side of sternum
*close eyes or look away to exaggerate

Question 4

Bucket handle

Answer 4

> Lateral costal - ie increase of lateral dimension of rib cage
palpated either side of chest on lower ribs

Question 5

Diaphragm

Answer 5

> Diaphragms ability to expand downwards (positioning will be key)
Abdomen should feel marshmallowy (wave motion across abdomen under rib cage)
palpate breathing pattern by resting hand horizontally across abdomen below xiphoid process

Question 6

Breathing patterns

Answer 6

> Normal = 10-20 bpm + symmetrical between sides (Eupnoea)
Abnormal
- Prolonged expiration (should be 1:2 ratio)
- Pursed lip breathing (may allow to clear some residual volume + better O2 retention)
- Apnoea - episodes of not breathing for ~15secs
- Dyspnoea - SoB
- Tachypnoea - high respiratory rate
- Hyperpnoea - high rate + depth
- Hypopnea - low rate
- Apneustic - deep breaths + insufficient expiration
- Ataxic - unco-ordinated

> Neuro Involvement

• Cheyne stoking - combo of apnoea, deep breaths + rapid shallow breaths (indicates impaired neural messaging
• Biot’s = prolonged cheyne stoking (~30 secs apnoea)
• Kussmaul’s - rapid rate of deep breaths

Question 7

What are we looking for when palpating/observing

Answer 7

> Depth (do they appear SoB)
Chest movement - all 3 diameters working together
- co-ordinated + symmetrical?
Indrawing/Recession of intercostal space - inspiratory effort pulls in
Tracheal Tug
Hoovers sign - breath in but diaphragm is already flattened so can only cross - pulls ribs in on inspiration
Flail ribs # - fractured in multiple places so pressure pulls fragment inwards

Question 8

What are we feeling for when palpating

Answer 8

> Tactile fremitus - transmission of crackles to outside of chest wall
Vocal fremitus - speech vibrations through chest wall (increased if solid, decreased with effusion or pneumothorax)
Sputum
Body temp + skin - temperature, clammy, sweaty (may indicate infection or cardiac issue) + hydration levels (axilla = velvety - trouble clearing sputum if dehydrated)
Surgical emphysema - air in subcutaneous tissue (chest/neck/face) - like bubble wrap will crackle to touch - PNEUMOTHORAX
Scars - previous injury/surgery
Response to touch - comfort etc. - may change breathing patterns when being touched

Question 9

Palpating Trachea

Answer 9

> Looking at position in relation to sternal notch
Deviation can indicate
- lung collapse (pulled to affected side)
- Bleed/air in thorax (push lungs away from affected side)
- Neck problem e.g goiter or tumour

> Technique

• 1st and 3rd finger on inside of SCM attachment
• 2nd finger on circoid cartilage (bump below adams apple) + trace down to sternal notch using other fingers as reference of deviation