Respiratory Surface Anatomy Flashcards
What is the thorax?
- 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
What is the sternum?
- 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
Why is the sternal angle important?
- At the level of the costal cartilage of the 2nd rib
- Used as a landmark for counting the ribs
Why are the clavicles and sternal (jugular notch) important?
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
What does the sternal angle correspond with?
- 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
What are the landmarks of the thorax?
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
What are the parts and regions og the thorax?
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
What is the tracheo-bronchial tree?
- 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
What are some general points to remember for lung examinations?
- 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
What are the surface markings of the lungs?
- 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
What are the surface markings for lung fissures?
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
What are the surface marking of the pleura?
- 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
What are the 4 steps of Resp Examination?
- Inspect
- Palpate
- Percuss
- Auscultate
How is inspection performed?
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
How is palpation examined?
- 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
What does the laterilsation of the trachea suggest?
- Pneumothorax
- Tumour (superior lobe)
- Atelectasis
How is palpitation exmained by chest expansion?
- 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
What is vocal fremitus?
- 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
How is percussion examined?
- 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
How is ausculation examined?
- 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)
How is ausculation examined?
- 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.
What are bronchial breath sounds?
- 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
What are crrackles?
- 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
What are some adventitious sounds?
- 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
