Thoracic and Lung (complete) Flashcards
Functions of the Respiratory System
- supplies oxygen to the body
- eliminates carbon dioxide
- maintain homeostasis
- maintain heat exchange
- alveoli: exchange of oxygen and carbon dioxide
Oxygenation depends on:
- airway system to transport air to and from lungs
- alveolar system to exchange oxygen and carbon dioxide
- cardiovascular system and blood supply to carry nutrients and wastes to and from body cells
Anatomy of the upper respiratory tract
nose
oropharynx
Anatomy of the lower respiratory tract
trachea
bronchi: left and right
bronchioles
alveoli
Physiology of the lungs
control blood pH
what is the diaphragm
a dome-shaped muscle that separates pleural and abdominal cavities
Anterior chest wall landmarks (I can’t input a photo so just a list)
suprasternal notch
sternum:
- manubrium
- body
- xiphoid process
sternal angle (angle of Louis)
costal angle
What are the thoracic landmarks?
thoracic cage:
- sternum
- ribs (12 pairs)
thoracic vertebrae - 12
diaphragm
What are the 12 pairs of ribs
- ribs 1-7: attach to sternum - costal cartilages
- ribs 8, 9, and 10: attach costal cartilage above
- ribs 11 and 12: floating
costochondral junctions (joint): connect the ribs to the costal cartilage
What do the costochondral junctions (joints) do?
connect the ribs to the costal cartilage
Chest circumference
midsternal line
midclavicular line
anterior axillary line
midaxillary line
posterior axillary line
scapular line
vertebral line
Where is the midsternal line
vertical along the sternum
Where is the midclavicular line
vertical from the midpoint of the clavicle
Where is the anterior axillary line
vertical from the anterior axillary fold
Where is the midaxillary line
vertical from the apex of the axilla
Where is the posterior axillary line
vertical from the posterior axillary fold
Where is the scapular line
from the inferior angle of the scapula
Where is the vertebral line
overlie the thoracic spinous processes
Lungs: lobes and fissures anteriorly
apex: approximately 2-4cm above the inner third of the clavicle
lower border of the lung crosses the 6th rib at the midclavicular line and the 8th rib at the midaxillary line
Lungs: lobe and fissures posteriorly
lower border of the lung lies at the level of the T10 spinous process
Lungs: lobes and fissures lateral
right and left side of the lungs located under the axillae
Lungs lobes and fissures on inspiration
lungs and diaphragm descends
Lungs: right lobes and fissures
Right upper lobe (RUL), right middle lobe (RML), and right lower lobe (RLL)
oblique (major) fissure
horizontal (minor) fissure
Where does the oblique (major) fissure run?
From the T3 spinous process obliquely down and around the chest to the 6th rib at the midclavicular line
Where does the horizontal (minor) fissure run?
anteriorly; fissure runs close to the 4th rib and meets the oblique fissure in the midaxillary line near the 5th rib
Lungs: left lobes and fissure
left upper lobe (LUL) and left lower lobe (LLL)
oblique fissure
Anatomic descriptors of the chest
- supraclavicular (above the clavicles)
- infraclavicular (below the clavicles)
- interscapular (between the scapulae)
- infrascapular (below the scapulae)
- apices of the lungs (uppermost portions)
- bases of the lungs (lowermost portions)
- upper, middle, and lower lung fields
Respiratory development during pregnancy
- diaphragm elevated 4cm
- decrease vertical diameter thoracic cage
- increase horizontal diameter, increase tidal volume
Infant respiratory development
body systems develop in utero; respiratory system alone does not function until birth
Children respiratory development
respiratory development continues throughout childhood
Developmental Considerations - older adults
less mobile thoracic cavity: calcified costal cartilages
decreased elastic properties within lungs (decreases recoil)
increase risk of pneumonia
Developmental considerations
decreased number of alveoli - less surface area available for gas exchange
lung bases become less ventilated as a result of closing off a number of airways
Focused questions to ask patients regarding shortness of breath (SOB) or dyspnea?
- have you had any difficulty breathing
- rest, exertion, how much exertion
- supine (orthopnea) or at night (paroxysmal nocturnal dyspnea), relieved by sitting?
Focused questions to ask patients regarding cough
- what brings on a cough
- hemoptysis: do you cough up blood
– if so, what does it look like, what brings it on, when did it start, quantity - do you have any allergies? what kind and what happens?
Focused questions to ask patients regarding chest pain (CP) with breathing
do you have any chest pain or chest discomfort
Focused questions to ask patients regarding respiratory infection
have you had any respiratory infections? how often?
Focused questions to ask patients regarding smoking?
packs per day (PPD)? when did you start? cough with it, what kind?
Focused questions to ask patients about their environment
about work, animals, chemicals
Other focused questions/topics to ask about
medications (like ACE-inhibitor); self-care behaviors (cleaning; fragrances)
Focused questions to ask parents regarding infants and children
- any colds? frequency? are they very severe colds?
- allergy history
– children under 2: at what age were new foods introduced? breastfed or bottle-fed? any allergies? - cough or congested? noisy breathing or wheezing?
- does anyone smoke in home and/or in the car with the child?
- environmental or household hazards?
- has anyone taught you emergency care measures in case of accidental choking or a hard-breathing spell?
Focused questions to ask aging adult patients
- have you noticed any SOB or fatigue with your daily activities?
- tell me about your usual amount of physical activity
- history of COPD, lung cancer, or TB
– how are you getting along each day? any weight change in the last 3 months? increase or decrease? how much? - how is your energy level? do you tire more easily? how does your illness affect you at home and at work?
- do you have any chest pain with breathing?
- do you have any chest pain after a bout of coughing or after a fall?
Assessment of the lungs - survey respiration
- rate, rhythm, depth, effort of breathing, signs of respiratory distress
- describe size and shape of the chest
- relate findings to landmarks
Inspection (usually starting back working towards front)
- symmetry, deformities
- muscle retraction: intercostal spaces during inspiration
- lag: delay
- chest shape: normally wider than it is deep
- AP diameter to the lateral chest (AP:L): 1:2 - increases with age
- patient’s position
- skin: cyanosis, pallor, clubbing of fingers
Inspection: rate and rhythm of breathing
normal 10-20 breaths per minute, even pattern, normal depth (told us to stick with 10-20 for test)
tachypnea (>25 per minute; rapid, shallow)
bradypnea (<10 per minute)
apnea - periods of not breathing
hyperventilation (increase rate and depth)
hypoventilation (irregular shallow)
adventitious breath sounds
Palpation
tenderness
intercostal tenderness: over inflamed pleurae
crepitus: fractures
bruising
sinus tract: inflammatory, tube-like structures opening onto the skin
chest expansion
tactile fremitus
Palpation: how to assess chest expansion
- place thumbs at level of 10th ribs with fingers loosely grasping and parallel to the lateral rib cage
- position hands and slide them medially just enough to raise a loose fold of skin; thumbs over spine
- ask patient to inhale deeply
- watch the distance between your thumbs as they move apart during inspiration
- feel for the range and symmetry of the rib cage as it expands and contracts
Palpation: Assessing for Tactile Fremitus
- assess for symmetry
- use either the ball or ulnar surface of hand
- ask the patient to repeat the words “99” or “one one one”
- initially use for a side-by-side comparison
- both hands to palpate and compare symmetric
- identify and locate any areas of increased, decreased or absent fremitus
decreased/absent: voice is higher pitched or soft
– something obstructs the transmission of vibration
– COPD, pleural effusion, fibrosis, pneumothorax, infiltrating tumor, emphysema
increased
- compression or consolidation of lung tissue
- lobar pneumonia
Palpation: tactile fremitus - crepitus
coarse, crackling over skin surface
subcutaneous emphysema - when air gets into tissue and can feel it; happens with chest tubes
assess:
temperature
lesions
masses
wounds
Percussion - advanced assessment
- producing audible sound and palpable vibrations
- establish whether the underlying tissues are air-filled, fluid-filled, or consolidated
Normal: resonance
Abnormal: hyperresonance (COPD); dull (pneumonia)
Auscultation
assessing air flow through the tracheobronchial tree
listening for:
- breath sounds
- adventitious (added) sounds
- abnormalities
diaphragm on chest wall
listen to one full respiration: inspiratory and expiratory, side to side
- C7-T10
- lateral from axilla to 7th rib
Assessment of breath sounds (normal)
bronchial: over trachea and large bronchi; tubular sound, high pitched hollow sounds
bronchovesicular: medium- pitched sounds
vesicular: inspiration louder and longer than expiration, low pitched sounds
Auscultation: adventitious breath sounds
added sounds: caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of previously deflated airways
Auscultation - adventitious breath sound type
crackles (rales)
wheezes
rhonchi
stridor
diminished/decreased, absent
pleural friction rub
abnormal vocal sounds
What are crackles and types
discontinuous nonmusical, early inspiratory (COPD), late inspiratory (pulmonary fibrosis), or biphasic (pneumonia)
popping sound - inspiration; deflated - expiration
fine crackles
– softer, higher pitched, more frequent per breath than coarse crackles
– mid to late inspiration, dependent areas of the lung, varies with positioning –> fluid shifts
coarse crackles
– popping sound, are heard over any lung region, and do not vary with body position
– early inspiration and last throughout expiration
Adventitious breath sounds - wheezes
continuous musical sounds, occur during rapid airflow when bronchial airways are narrowed
heard throughout the lung
inspiratory, expiratory, or biphasic
asthma, mucous plug, tumor
Adventitious breath sounds - Rhonchi
variant of wheezes, same mechanism
lower in pitch
disappear with coughing
Adventitious breath sounds - stridor
high-frequency, high-pitched musical sound produced during airflow through a narrowing in the upper respiratory tract
obstruction - foreign body
Adventitious breath sounds - pleural friction rub
inflammation of the lung tissues
raspy breathing sounds
Abnormal assessment findings
SOB or dyspnea
Cough
– mucus, pus, blood as well
– allergens: dust, foreign bodies, hot or cold air
Chest pain (CP) w/ breathing
Respiratory infection
– viral upper airway, bacterial infection
– pneumonia
Orthopnea - supine
Cheyne-Stokes respirations
– periods of deep breathing alternate with periods of apnea; severe state
Biot’s (ataxic) breathing
– severe; irregular Cheyne-Stokes
– periods of apnea alternate with regular deep breaths which stop suddenly for short intervals
Abnormal vocal sounds - advanced
Abnormal vocal sounds (advanced assessment)
egophony, bronchophony, whispered pectoriloquy
Anterior chest wall
shape, symmetry, configuration
facial expression
difficulty breathing
level of consciousness
color
quality of respirations
respiratory rate - 30s x 2
- w/ pulse ox
Palpation - Anterior Chest Expansion
- place thumbs along each costal margin and hands along the lateral rib cage
- position your hands, slide them medially a bit to raise loose skin folds between your thumbs
- ask the patient to inhale deeply
- observe how far thumbs diverge as the thorax expands
- feel for the extent and symmetry of respiratory movement
Palpation: anterior tactile fremitus
- begins over supraclavicular areas for apices (have patient say 99 or “one one one”)
- compare both sides of the chest
- use the ball or ulnar surface of the hand
- fremitus is usually decreased or absent over the precordium
- for woman, gently displace the breasts
Percussion: anterior - advanced assessment
- percuss the anterior and lateral chest, comparing both sides
- the heart produces dullness to the left of the sternum from the 3rd to the 5th interspaces
- gently displace the breasts for women
Infant Auscultation
- diaphragm is newborn’s major respiratory muscle
- count respiratory rate for 1 full minute
- normal rates 30-40 breaths (may spike up to 60)
- most accurate respiratory rate when the infant is asleep
- brief periods of apnea (less than 10-15 seconds) are common
– is more common in premature infants
Pediatric auscultation
- bowel sounds are easily heard in the chest
- use smaller pediatric diaphragm end piece, or place bell over infant’s interspaces and not over ribs
- bronchovesicular breath sounds in peripheral lung fields of infant and young child up to ages 5-6 years
- fine crackles are commonly heard in immediate new born period from opening of airways and clearing of fluids
Older adults and illness
older adults:
- tire easily (don’t hyperventilate)
- increase AP diameter
illness:
- may need to roll from side to side
- limits comparison
