Oxingination- Thorax and the Lungs Flashcards
Anterior Thorax
12 pairs of ribs
Sternum
Posterior Thorax
12 thoracic vertebrae
Spinal column
Ribs
1-7 articulate with sternum
8-10 articulate with costal cartilage
11-12 do not articulate= free floating
All articulate with vertebrae
Right Lung
Three lobes: Upper, Middle, Lower
Shorter than left lung
Left lung
two lobes- upper and lower
Lung apex
Top of lung
Anterior - 2.5-4 cm above clavicles
Posterior at level of T1
Lung base
Bottom of lung
Anterior- 6th rib at MCL
Posterior- T10 on expiration and T12 on inspiration
Lateral 8th rib at MAL
Mediastinum
Extends from sternum to spine
Trachea and pulmonary vessels
Bronchi
Trachea bifurcates at sternal angle and level of 4th and 5th vertebrae
Right= shorter, more vertical
External intercostal muscles
elevates ribs and increase size of thoracic cavity on inspiration
internal intercostal muscles
draw ribs together during expiration
Accessory Muscles
Used when there is increased demand for oxygen
Scalene, sternocleidomastoid, trapezius, abdominal
Inferior angle of scapula
Level of 7th rib
Anterior landmark lines
Anterior axillary line
Midclavicular line
Midsternal (vertebral) line
Axillary landmark lines
Anterior axillary line
Midaxillary line
Posterior axillary line
Posterior Landmark lines
Posterior axillary line
Scapular line
Midspinal or vertebral line
Inspiration
active, Muscle contraction, Negative intra-pulmonic pressure
Expiration
Passive, Muscles relax, Positive intra-pulmonic pressure
Common chief complainst
Dyspnea, Cough, Sputum, chest pain
Generalized thorax approach
Compare right vs. left
systematic approach
Ask patient to displace breast tissue to palpate, auscultate, and percuss anterior thorax
Proceed from lung apices to the bases
Shape of thorax
Transverse diameter
Anteroposterior (AP) diameter- AP to transverse ratio 1:2 twice as wide as thick
Barrel chest
1:1 ratio–round chest
COPD–air trapped in alveoli
Pectus carinatum
Protrusion of sternum
Congenital, Rickets
Pectus excavatum
Depression of sternum= Can compress heart and lungs
Congenital
Posterior shape of thorax variations
Kyphosis-hunch back or scoliosis
Symmetry of Anterior chest wall
Note any differences between the two sides, shoulder height should be the same, Masses
Symmetry of posterior chest wall
Note any differences between the two sides, position of scapula and shoulder height- should be the same, Masses
Presence of superficial veins
Dilated veins should not be seen
Note pattern and symmetry, if present
Costal angle
Angle formed by ribs and bottom of sternum= Normal is 90
Angle is less during expiration and rest
Angle of ribs
Articulate with sternum at 45 degree angle
Intercostal spaces inspection
Observe through respiratory cycle
There should be no bulging or retraction
Abnormal: bulging during expiration/ retraction during inspiration
7 Inspections of Respirations
Rate, Pattern, Depth, Symmetry, Audibility, Patient position, Mode
Respiration Rate
full minute, do it slyly, in/out=1 cycle. Normal btw 12-20 breaths per min
Eupnea
12-20 breaths per minute (normal)
Tachypnea
> 20 breaths per minute (stress, respiratory illness)
Bradypnea
< 12 breaths per minute (increased intracranial pressure, drug overdose)
Apnea
No respiration for 10 or more seconds (brain injury, sleep apnea)
Respiration rhythm
Note rhythm or pattern of breathing- regularity or irregularity
Normal respirations should be regular and even
Cheyne-Stokes
Pattern of Regularly irregular with gradual increase in depth then gradual decrease and a period of apnea (brain injury, coma)
Agonal
Irregularly irregular with varying depths and patterns (impending death)
Respiratory Depth
Observe at inspiration
Inspiration should be nonexaggerated and effortless
Shallow depth
Minimal movement of chest (pain, lung problems)
Hyperpnea
Greater volume but rate and pattern is even (warm-up for exercise, emotions, high altitude)
Kussmaul’s
Increased rate and depth (diabetic acidosis)
Respiratory Symmetry
How chest rises and falls during respiratory cycle
R/L thorax should move in unison
Abnormal respiratory symmetry
Unilateral expansion (absent or collapsed lung) Paradoxical movement (fractured ribs)
Respiratory Audibility
Listen for audibility of respiration
Normally audible a few cms from nose or mouth
Abnormal Respiratory Audibility
Audible breaths when a few feet away (upper airway sounds)
Orthopnea
difficulty breathing when lying down (COPD, congestive heart failure)
Tripod position
easier to use accessory muscles (COPD)
Mode of breathing
nose, mouth, or both to breathe
Note which part of respiratory cycle each is used
Should be able to inhale and exhale through nose
Abnormal mode of breathing
Continuous mouth breathing (nasal or sinus blockage)
Pursed-lip breath–used to prolong expiration (COPD)
Sputum inspection
color, consistency, amount, and odor
Normal sputum findings
small amount clear or light yellow, odorless sputum, can be thick or thin depending on hydration
Palpation of Anterior Thorax
apex to base. Above clavicles to bottom of ribs- ribs and intercostal spaces
Palpation of Posterior Thorax
apex to base= Level of T1 to bottom of ribs
Palpate thoracic vertebrae, ribs, ICS
Palpate lateral thorax
Have patient lift arms- apex to base= Axilla to bottom of ribs
Palpate ribs, ICS
Pulsations
No pulsations should be present
Pulsation may indicate thoracic aortic aneurysm
Masses
no masses should be present
Palpation
Palpate Posterior, Anterior, and Lateral areas for all
Thoracic Tenderness
No tenderness should be present- may be due to fractured ribs, chest trauma
Crepitus
Beads of air are trapped in subcutaneous tissue= Crackling sensation when palpated (rice krispies
Causes of Crepitus
pneumothorax, chest trauma or surgery
Thoracic expansion
Assess extent and symmetry via thumbs at costal margins (A) and 10th vertebrae (P)
Normal thoracic expansion
3-5 cm symmetrically
Tactile fremitus definition
Palpable vibration of chest wall produced by spoken word, felt as buzzing
Assessing tactile fremitus
Use ulnar aspect of closed fist, patient says “99,”
Down either side of sternum/vertebrae, out to sides- Note increase or decrease fremitus
Lateral assessment of tactile fremitus
midaxillary, nipple level, xiphoid process level
Normal tactile fremitus findings
More fremitus near major bronchi = 2nd ICS anteriorly, T1 and T2 posteriorly
Less fremitus in periphery of lungs
Abnormal tactile fremitus findings
Increased= consolidation, decreased= increased air in lungs/thorax
Tracheal position
Place finger pad on the trachea in the suprasternal notch
Move laterally to right and left of trachea
Tracheal position Normal findings
midline in suprasternal notch
Tracheal position abnormal findings
deviation may be due to pressure in thorax or enlarged thyroid
General approach to percussion
indirect percussion, side-to-side/ top to bottom, compare sounds bilaterally, should be resonant
Percussion of Anterior thorax
clavicles down to 6th ribs, in ICS, zig-zag motion
Percussion of Posterior thorax
head bent forward, arms crossed
level of T1 to down to 10th rib btw scapula and vertebrae
Percussion of Left Lateral thorax
axilla to 8th rib- mid axilla, nipple level, xiphooid process level, 8th rib= curved L
Percussion of left lateral thorax
axilla to 8th rib- backwards z= axillary, posterior axillary line, anterior axillary line (nipply level), 8th rib
General approach to auscultation
use diaphram of stethoscope to hear breath sounds. take deep breath through mouth.compare side to side w/ same pattern as percussion
Bronchial breath sounds
I<E, Heard anteriorly near trachea
Bronchovesicular breath sounds
I=E
Heard at 1st and 2nd ICS adjacent to sternum and between the scapulae
Vesicular
I>E
Heard in peripheral lung tissue
Fine Crackle
Mostly heard on late inspiration- High-pitched crackle or popping
Due to moisture in small airways as they reinflate
coarse Crackle
Heard on inspiration- Low-pitched crackle or gurgling
Due to moisture in large airways as they reinflate
Adventitious Breath sounds
crackle, wheeze, pleural friction rub, stridor
Sonorous wheeze
Mostly heard on expiration- Low-pitched snoring sound
Due to narrowing of large airways or obstruction
Sibilant Wheeze
Heard on expiration- High-pitched musical sound
Due to narrowing of large airways or obstruction
Pleural Friction Rub
Heard on both inspiration and expiration- Creaking or grating sound
Due to inflammation of pleural membranes
Stridor
Heard on inspiration- Crowing sound
Due to partial obstruction of larynx or trachea
Bronchophony
“99”when stethoscope is moved side-to-side for comparison
Sound should be muffled
Abnormal if sound is clear and louder= consolidation
Egophony
“e” when stethoscope is moved side-to-side for comparison
Sound should be muffled
Abnormal if sounds like “ay”= consolidation
Whispered pectoriloquy
“99” when stethoscope is moved side-to-side for comparison
Sound should be muffled
Abnormal if sound is clear and louder= consolidation
