Respiratory Surface Anatomy

Question 1

What is the thorax?

Answer 1

• Superior portion of the trunk sandwhiched between the neck superiorly and the abdomen inferiorly
• Consists of the chest and upperback
• Anterior surface of the chest = clavicles and sternum

Question 2

What is the sternum?

Answer 2

• midline bony structure in the thorax
• Manubrium, body and xiphoid may also be palpated
• ## sternal angle can be felt as an elevation between the manubrium and the body

Question 3

Why is the sternal angle important?

Answer 3

• At the level of the costal cartilage of the 2nd rib
• Used as a landmark for counting the ribs

Question 4

Why are the clavicles and sternal (jugular notch) important?

Answer 4

represent the border between the thorax and the neck

Landmarks:
- Jugular notch: corresponds with the 2nd thoracic vertebra in males and 3rd thoracic vertebra in females

Question 5

What does the sternal angle correspond with?

Answer 5

• Connects 2nd costal cartilage laterally
• Lower border of 4th throacic vertebra
• Bifurcation of trachea in the adult
• Beginning or aortic arch which ends posteriorly at the same level
• Oesophagus is crossed by the left main bronchus

Question 6

What are the landmarks of the thorax?

Answer 6

Xiphoid process: Lies opposite the body of the 9th throacic vertebra
Clavicle: inferior fossa, coracoid process
Ribs and intercostal spaces
Costal arch
- infrasternal anffle
- Xiphocostal angle
- Papillae

Question 7

What are the parts and regions og the thorax?

Answer 7

Boundaries:
-superiorly- jugular notch, sternoclavicular joint, superior border of clavicle, acromion, spinous processes of C7
- Inferiorly- xiphoid process, costal arch, 12th and 11th ribs, vertebra T12

Regions:
- Thoracic wall
- Thoracic cavity

Question 8

What is the tracheo-bronchial tree?

Answer 8

• Trachea starts at cricoid (C6) inferior to the larynx
• Descends in the midline
• Bifurcates at around T4/5
• Hila situated at T5/6
• Hilum is opaque in the radiographs due to presence of fluid (blood vessels)
• Right main bronchus is more vertical than left

Question 9

What are some general points to remember for lung examinations?

Answer 9

• Lungs should be examined on the anterior, lateral and posterior thoracic walls
• Lung apex sits above the 1st rib and the medial third of the clavicle
• Costodiaprhagmatic recess is occupied by the lungs only during deep inspiration
• Abdominal organs sit under the diaphragm and therefore affect thoracic examination and can be seen on the thoracic diaphragms

Question 10

What are the surface markings of the lungs?

Answer 10

• Apex lies 2 cm above medial 1/3rd of clavicle
• Start above medial 1/3 of clavicle
• Heart occupies part of the left lung space (cardiac notch of the left lung)

Surface markings of the R and L lungs are similar except between the 4th and 6th costal cartilages

Question 11

What are the surface markings for lung fissures?

Answer 11

Oblique- T3/4 spinous process - 6th costal cartilage
Horizontal fissure- follows the 4th intercostal space from the sternum to meet the oblique fissure at 5th rib

Question 12

What are the surface marking of the pleura?

Answer 12

• Parietal p = vulnerable where it extends beyond the protection of the ribcage
• Pleura is exposed in the neck- above medial third of the clavicle
• Bare area of the pleura (exposed in cardiac notch between 4th and 6th costal cartilages
• Pleura can descend below 12th rib/ lower posteriorly
• Apical pleura lies 2 cm above medial 1/3rd of the clavicle in the neck with the lungs
• Inferiorly extebds two intercostal spaces lower than the lungs
• Reflection drops lower than the lungs to occupy the costodiaphragmatic recess

Question 13

What are the 4 steps of Resp Examination?

Answer 13

1. Inspect
2. Palpate
3. Percuss
4. Auscultate

Question 14

How is inspection performed?

Answer 14

Obeserve:

• Resp rate (difficult = dyspnoea, rapid- tachypnoea)
• Normal rate = 14-22 mins
• Assess if patient is using accessory muscles of resp
• Cough character - Dry/ productive
• Normal breathing sounds or any other additional sounds, e.g. rhonchi
• Thoracic shape: Normal. symmetrical, hyperinflated etc.
• Colour : cyanosis - look in mucous membranes (lips, gums, around eyes, nails)
• Look for finger clubbing - common in some resp conditions

Question 15

How is palpation examined?

Answer 15

• Explain to patient that the procedure might be uncomfortable
• Palpate the trachea by your index and middle fingers at the supra-sternal/jugular notch in betweeen the sternal heads of sternomastoid
• Assess if trachea centrally placed

Question 16

What does the laterilsation of the trachea suggest?

Answer 16

• Pneumothorax
• Tumour (superior lobe)
• Atelectasis

Question 17

How is palpitation exmained by chest expansion?

Answer 17

• Thumbs are placed at level of T10 with fingers grasping and level with ribcage
• Ask patient to take a depp breath in through their mouth
• Assess movement of your hands - compare both sides
• Assess it anteriorly
• Measure how much the chest expands outwardly and antero-posteriorly
• Reduction: Fibrosis, collapse, consolidation, effusion, pneumothorax

Question 18

What is vocal fremitus?

Answer 18

• Palm / ulnar side of the hand is placed on chest wall
• Patient should repeat the word ‘ninety-nine’
• used to detect vibrations from the chest wall
• Vibration is compared in both the left and right sides
• Vibrations should be normal on both sides
• Consolidation/masses lead to increased vibratuib ; it is decreased in effusion

Question 19

How is percussion examined?

Answer 19

• Left 3rd digit is placed in the intercostal spaces
• Tap sharply the left middle phalanx with the 3rd digit of the right hand
• Keep tapping with finger flexed and listen to the sound produced
• Withdraw dominant middle finger quickly after the tap
• Movement should be brisk, relaxed and bouncy
• Resonant- normal lungs
• Hyper-resonant- pneumothorax
• Tympanic- over hollow viscera
• Dull consolidation/collapse
• Stony dull- effusion, mass

Question 20

How is ausculation examined?

Answer 20

• Breath sounds are produced by air movements in and out of the lungs
• inspiratory phase
• Expiratory phase
• Basic sounds- vesicular normal heard over the peripheral lung
• Bronchial (tubular) - Heard normally over thr trachea and manubrium
• Additional/ adventitous sounds
• Crackles (interrupted)
• Wheezes (continuous)

Question 21

How is ausculation examined?

Answer 21

• Alveoli usually filter out turbulent sounds fromm the bronchi
• Patient is asked to breathe quietly through their mouth
• Bronchial breathing is normally heard centrally
• Bronchial b elsewhere in thorax= possibility of either fibrosis, consolidation or collapse of the lungs.

Question 22

What are bronchial breath sounds?

Answer 22

• Blowy sounf heard in peripheral lunf when alveolar air is replaced by solif lung tissue
• Equal length with a gap
• Heard over consolidated lung, collapsed lung, pleural effusion, fibrotic lung

Question 23

What are crrackles?

Answer 23

• Short explosive sounds superimposed onto breath sounds, may result from small airway collapse and reopening during breathing
• Late inspiration crackles - alveolar disease
• Medium crackles - left ventricular failure
• Coarse crackles - COPD
• Fine crackles - pneumonia and pulmonary oedema

Question 24

What are some adventitious sounds?

Answer 24

• Wheeze- high pitched sounf
• Inspiratory/expiratory or both (asthma)
• Stridor _ Wheeze only heard in inspiration, Indicated partial obstruction of the trachea or the larynx
• Rhonchi - low pitched sound with snoring quality . suggest secretions in the large airways
• Pleural rub - cracky in quality, produce due to two inflamed pleural surfaces being rubbed together
• Suggest pneumonia or pulmonary embolism