Respiratory system 2: Thorax and Lungs

Question 1

Inspect the Posterior Chest

Answer 1

Thoracic Cage
● Note the shape and configuration of the chest wall
● The spinous process should appear in a straight line
● The thorax should be symmetrical, in an elliptical shape, with downward-sloping ribs, angled at 45 degrees
● The scapulae are symmetrically placed in each hemithorax
● The anterior-posterior diameter should to transverse diameter is approximately 1:2
● The neck muscles and trapezius muscles should be developed normally same as the pt’s age
● Position for breathing should be relaxed posture and the ability to support his or her weight with arms comfortably at the side or in the lap
● Assess the skin condition and color (should be consistent with the pt’s genetic background, with no lesions, no cyanosis, or pallor)

Question 2

Palpate the Posterior Chest

Answer 2

Symmetrical Expansion
● Place hands on the pt’s posterior chest wall with the thumbs at the level of T9 to T10
● Ask the pt to take a deep breath
● The thumbs should move apart symmetrical when the pt is taking a deep breath
● Note for any lag in expansion

Tactile Fremitus
● Fremitus is a palpable vibration
● Use either the palmar base of the fingers or the ulnar edge of one of your hands
● Touch the pt’s chest while he or she repeats the words “ninety-nine” or “Blue moon” these words generate strong vibrations
● Symmetry is important and the vibrations should feel the same in both areas of each side.
- Fremitus may feel stronger on the right side because it is near the bronchial bifurcation

Question 3

Percuss the Posterior Chest

Answer 3

Lung Fields
● Determine the predominant note over the lung fields
● Start at the apex and percuss the band of normally resonant tissue across the tops of both shoulders
● Make a side-to-side comparison all the way down the lung region
● Percussing it in 5 cm intervals

Question 4

Auscultate the Posterior Chest

Answer 4

Breathe Sounds
● Evaluate the presence and quality of the normal breath Sounds
● Put the pt into a normal sitting position, leaning forward slightly, and having their arms resting comfortably in their lap.
● Tell the pt to breathe through the mouth, a little deeper than usual, and stop if he or she feels dizzy
● Monitor the breathing throughout the examination and allow rest before breathing deeper again
● Using the diaphragm listen for one full respiration in each location side to side comparison

Procedure
● While standing behind the patient listen posterior from the apices at C7 to the bases (around T10) and laterally from the axilla down to rib 7 or 8
● As you listen at each spot think about (a) what you are hearing (b) what you should be hearing

Bronchovesicular sounds
● Moderate pitch, moderate amplitude, equally heard during inspiration and expiration, the quality of sound is a mix between bronchial (harsh, hollow) and vesicular (rustling like wind)

Vesicular
● Low pitch, soft amplitude, heard more during inspiration, the quality of sound is rustling, like the sound of the wind in trees
● Note the presence of any adventitious sounds (crackles and wheezes)
● Chart your findings (good bilateral air entry, normal breath sounds, no adventitia noted

Question 5

Inspect the Anterior Chest

Answer 5

• Make sure the shirt is off
• Note for the shape and configuration of the chest wall
  
  • Ribs are sloping downward with symmetrical interspaces
• Costal angle should be within 90 degrees.
• Abdominal muscles should be expected for the pt’s age, weight, and athletic condition.
• Facial expression should be relaxed, and benign, indicating unconscious effort of breathing
• LOC should be alert and cooperative
• Note color and skin condition, lips and nails should be free from pallor and cyanosis.
• Quality of respirations should be effortless, regular, and even, and produces no noise.
• The chest expands symmetrically with each inspiration, with no retraction or bulging of the interspaces, and normal limits for pt’s age.

Question 6

Palpate the Anterior Chest

Answer 6

• I will palpate for symmetrical chest expansion.
• Hands-on the anterolateral wall with thumbs along the costal margins towards the xiphoid process.
• Ask the pt. to take a deep breath. Watch the thumbs move apart symmetrically, and note for smooth chest expansion.
• Assess tactile fremitus by palpating over the lung apices in the supraclavicular area.
  
  • Compare vibrations from one side to the other and ask pt to say “ninety-nine.”
• Do not palpate over the female breast because it dampens the sound.
• Palpate anterior chest note for tenderness and detect any superficial lumps or masses.
• Note skin mobility, turgor, skin temperature, and moisture.

Question 7

Percuss the Anterior Chest

Answer 7

• Percuss the apices in the supraclavicular areas and compare one side with the other.
• Do not percuss the female breast tissue because the sound will be dull.
• Note for any borders of cardiac dullness normally found on the anterior chest. Do not confuse suspected lung disease.

Question 8

Auscultate the Anterior Chest (Breath sounds)

Answer 8

• Auscultate lung fields over the anterior chest from the apices in the supraclavicular areas down to the six ribs.
  
  • Move downward, side to side, and listen to one full respiration
• Displace the breast and listen directly over the chest wall
• Evaluate normal breath sounds, noting any abnormal and adventitious sounds.