Respiratory Mechanics of the ribs and diaphragm Flashcards
1
Q
which rib do you use as a landmark for numbering ribs
A
rib 2
2
Q
what are the main muscles for inspiration (3)
A
diaphragm
external intercostal
levator costarum
3
Q
what are the accessory muscles of inspiration
A
scalenes sternocleidomastoid serratous posterior superior lat dorsi pectoralis serratous anterior quadratus lumborum
4
Q
what are the main muscles of expiration
A
for quiet respiration the passive recoil of the lungs and diaphragm is what drives this
internal intercostals
5
Q
what are the main accessory muscles of expiration
A
Rectus Abdominis External Oblique Internal Oblique Transversus Abdominis Serratus Post Inferior Transversus Thoracis
6
Q
what does the quadratus lumborum do
A
stabilizes the lower ribs so the diaphragm has better motion
7
Q
how do rib dysfunctions affect SNS tone?
A
find out!
8
Q
which ribs are pump handle motion
A
1-5
9
Q
which ribs are bucket handle motion
A
6-10
10
Q
which ribs are caliper motion
A
11-12
11
Q
what happens when the diaphragm contracts
what is the function of this and what spaces are changed (dimensions)
what happens to the vena caval opening and the esophageal hiatus
A
When the diaphragm contracts it drops. This Increases the vertical dimensions of the thoracic cavity and decreases pressure which brings in air but also encourages blood and lymph flow.
Also important in micturation and defecation.
The diaphragm essectially moves in two phases. First the central tendon drops down.
Second, it increases the AP and Transverse diameters of the thoracic cage.
Vena caval opening dilates
Esophageal hiatus contracts
12
Q
what are the main structures that go through the diaphragm and spinal levels
A
Vena Cava at T8
Esophagus at T10
Aorta at T12
13
Q
what are the attachments of the diaphragm
A
Lower Six Ribs B/L
Xiphoid
Crura: L1-3 Right, L1-2 Left
14
Q
what are the true ribs
A
1-7
because they attach to the sternum
15
Q
what are the false ribs
A
8-12
16
Q
what are the typical ribs
A
3- 9
17
Q
what are the atypical ribs
A
1,2 10, 11, 12
18
Q
what makes ribs 3-9 typical ribs
A
heads necks tubercles angles shafts rib head to 2 facets vertebra above and below
19
Q
what makes rib 1 atypical
A
most curved
flat
no angle or groove
single facet with vertebral body
20
Q
what makes rib 2 atypical
A
demifacets with t1 and t2 bodies
21
Q
what makes rib 10 atypical
A
single facet with T10 body
22
Q
what makes ribs 11 and 12 atypical
A
no tubercles, tapered ends, single facets with bodies
23
Q
what are the rib articulations to the spine
A
costotransverse
costovertebral
24
Q
in pump handle motion what direction do the transverse processes move AND about what axis
A
Transverse processes of upper thoracics extend lateral = a largely transverse axis (the axis also angles slightly posteriorly)
25
in bucket handle motion what direction do the transverse processes move AND about which axis
Transverse processes of lower thoracics angle back posteriorly = a more AP axis is created
more motion in the coronal plane
26
where is pump handle motion best palpated
anteriorly
27
what diameter is increased with pump handle motion
what type of motion is this AND what happens to the front of the upper ribs on inhalation and exhalation
anteroposterior motion that increases A-P diameter
with inhalation the front of the upper ribs go up
exhalation go down
OPPosite in the back !!! so in the back on inhalation they go down and on exhalation they come up
28
where is bucket handle motion palpated best
laterally
29
what diameter increases with bucket handle motion
transverse diameter
30
what is the caliper motion
which ribs
antero-medial
and postero-lateral motion
ribs 11-12
31
what is the sign of inhaled ribs anteriorly and posteriorly
up in the front (prominent)
down in the back (divot)
RESISTS exhalation
32
what is the sign of exhaled ribs anteriorly and posteriorly
up in the back
down in the front
resists inhalation
33
what is the group effect of inhalation SD
holds up ribs above
34
what is the group effect of exhalation SD
holds down ribs below
35
what is the pneumonic BITE
Bottom inhaled
| Top exhaled
36
what is the landmark for rib 1
anteriorly at the manubrium
37
what is the landmark for rib 2
anteriorly at the sternal angle (aka angle of louis)
38
what is the landmark for rib 3
posteriorly with T3 at the spine of the scapula
39
what is the landmark for rib 7
Posteriorly with T7 at the inferior angle of the scapula
40
what is the landmark for rib 12
superior to the iliac crest
41
what is the landmark for T2 vertebra
suprasternal notch
42
what is the landmark for T4 vertebra
sternal angle
43
what is the landmark for T9 vertebra
Xiphoid process
44
what is the landmark for L3-4 vertebra
umbilicus
45
where does drainage of the pleural sac and lung tissues drain to?
right lymphatic duct
46
what does increased sympathetic tone cause
increased thickening of secretions
vasoconstriction to lung tissue
bronchiole dilation
47
what does impaired lymphatic flow cause
tissue congestion BAD
48
what does increased parasympathetic tone cause
thinning of secretions
profuse secretions
relative bronchiole constriction
49
when you find motion restriction/somatic Dysfunction of vertebral segments you should....
automatically look at the ribs b/c the ribs attach to the vertebral segments at the same level and above
50
where on the ribs are TART changes frequently palpated
over rib angles
51
how can you improve objectivity with diagnosing the rib cage
placing dominant eye over the patient's midline while palpating the rib cage
also use peripheral vision
abnormalities are often felt best at the end of deep inhalation or exhalation
52
what direction do the ribs take from the thoracic vertebrae
ribs angle inferiorly form the thoracic vertebrae so the costal attachment of each rib is inferior to the rib head
53
where is rib 6 usually located
at the level of the inferior border of the sternum
54
how do you know which rib has the somatic dysfunction?
the rib that has the greater amount of motion is normal while the one restricted has the SD
55
during inhalation what happens to the sternal angle
the sternal angle moves anteriorly and superiorly
56
where does the sympathetic change ganglia rest in relation the rib head
why is this important
rests directly anterior to the rib heads
| this makes the ribs an important area to treat when addressing sympathetic balance in the entire body
57
what is the proper set up for treating an anterior tenderpoint with counterstrain
patient is seated
physicians foot is placed on the table opposite side of the affected rib
patients arm draped over leg
Flexion, sidebending and rotation of torso towards affected side
58
what muscles are involved in the counterstrain treatment of anterior tenderpoint
external, internal and innermost intercostals
| serratous anterior
59
what is the set up for treating posterior tenderpoint for rib counterstrain
patient seated
physicians foot up on table on the same side as the patient's affected rib
patients arm draped over leg
slight extension, sidebending and rotation of the torso away from the affected rib
(if it is a left tenderpoint then side bend right)
60
what are the muscles involvedin the counterstrain treatment of posterior tenderpoint
external, internal and innermost intercostals
lat dorsi
rhomboids
61
where do the rib heads join the vertebral column
between the corresponding vertebral segment and the one above
62
where do you check for function of ribs 1 and 2
what is a common diagnosis of these ribs
posteriorly
common to find elevated ribs 1 and 2 (exhaled)
63
what is one way to check diagnosis of rib dysfunctions
often restricted ribs are very tender along the mid=axillary line
64
what is the treatment for exhaled rib 1 on right
which muscles are used
where do you place your caudal hand
muscles--> anterior and middle scalene muscles ipsilaterla
physician stands on the right
place cephalad hand on patient's right forearm
monitor posterior aspect of rib 2 with caudal hand
have patient hold deep inspiration AND flex their head and neck
65
what is the treatment for exhaled rib 2 on right
what muscles
hand placement
muscles--> ipsilateral posterior scalene muscle
turn patient's head to about 45 degrees opposite side of rib
place cephalad hand on their forearm (that is resting on their forehead)
instruct patient to hold their breath in inhalation and flex their head and neck
66
what is the MET for ribs 3-5 Exhaled
what muscles
hand placement
patient position
supine patient
muscles --> ipsilateral pectoralis muscle
contact patient s elbow with cephalad hand
monitor the posterior superior aspect of the rib with caudal hand
ABDUCT the patients right arm until the feather edge of the barrier is engaged
have the patient hold their breath on inhalation and push their elbow toward their hip (try and adduct)
67
what is the MET for ribs 6-10 (exhaled)
what muscles
hand placement
patient position
muscles --> serratous anterior muscle
contact the patients forearm with cephalad hand
monitor posterior superior aspect of the rib with caudal hand
instruct patient to hold breath inspiration
instruct patient to adduct their arm
68
what muscle do you use to fix somatic dysfunction of ribs 11-12 (caliper)
quadratus lumborum
69
what is the treatment set up (MET) for exhaled rib dysfunctions of ribs 11-12
patient prone with their hand reaching over their head to the opposite side of the rib dysfunction (to cause sidebending away from exhaled rib)
with cephalad hand, monitor motion over the posterior-medial aspect of rib 12
with caudal hand contact patients ASIS on the same side as the rib dysfunction
apply posterior pressure to the ASIS (liftin it off the table) AND anterior pressure to the rib
have patient hold their breath in deep inhalation
instruct patient to pull their hip toward the table
70
what is the difference of hand placement for exhaled and inhaled MET for ribs 11-12
exhaled dysfunction --> hand is placed more medially the rib over the rib tubercle
inhaled --> hand is placed more laterally over the rib angle
71
what is the MET for ribs 1-5 dysfunctions INHALED
used FLEXION and sidebending to the same side
patient supine
stand at the head of the table
monitor anterior aspect of rib with hand on the same side as the dysfuntion
flex patient's head
sidebend to the same side as rib
instruct patient to hold breath in exhalation
instruct patient to extend their head and neck while providing isometric counterforce
72
what is the MET for ribs 6-10 inhaled dysfunctions
use sidebending first
then flexion for fine tuning
patient supine
stand on the same side as rib dysfunction
with caudal hand monitor rib in question (superior and lateral aspect)
sidebend patient neck and shoulder to the same side as rib
slightly flex patient
instruct patient to hold breath in exhalation
instruct patient to return to neutral position (sidebend the other way and extend)
73
what is the difference in use of flexion versus sidebending with ribs 1-5 and 6-10 for inhaled dysfucntiosn
for 1-5 use flexion to localize initially and then sidebending to fine-tune and rib engagement
(b/c these ribs use pump handle motion)
for 6-10 use sidebending to localize initially and flexion for fine tuning and rib engagemtn (bc these use bucket handle)
