Thorax and lungs Flashcards
Anatomy and physiology: External Thorax
- Thoracic cage protects most of respiratory system and consist of: 12 thoracic vertebrae, 12 pairs of ribs and a sternum
- Its the diaphragm that seperates the thoracic cavity from the abdomen
- Ribs connect to thoracic vertebrae posteriorly: First seven ribs also connected to sternum by costal cartilages. Costal cartilages 8- 10 ribs are connected immediately superior to ribs. 11 and 12 ribs are unattached anteriorly, thus the name “floating ribs”- free palpable tips
- costochondral junctions are the points at which the ribs join the cartilages- they are NOT palpable
Anatomy and physiology: Anterior Thoracic Cage
- Sternum/breastbone is about 7 inches long and has 3 components: manbrium, body and xiphoid process
- Manubrium and body articulate with first seven ribs; the manubrium also supports the clavicle
- Intercostal space (ICS) is the area between the ribs
- ICS named according to the rib immediately above it; thus, first ICS is located between the first and second ribs
Topographic Markers
surface landmarks helpful in locating underlying structures and in describing exact location of physical finding
Topographic Markers: The Reference Lines- Anterior Chest Wall
- Midsternal line: Imaginary vertical line through middle of sternum
- Costal angle: Intersection of costal margins, usually no more than 90 degrees- angle increases when the rib cage is chronically overinflated as in emphysema
- Clavicles: Bones extending out both sides of manubrium to shoulder; they cover first ribs
- Midclavicular lines: Imaginary vertical lines on right and left sides of chest that are drawn through clavicle midpoints, parallel to midsternal line
Topographic Markers: The Reference Lines- Lateral Chest Wall
- Anterior axillary lines: imaginary vertical lines on right and left sides of chest “drawn” from anterior axillary folds through anterolateral chest, parallel to midsternal line
- Posterior axillary lines: Imaginary vertical lines on right and left sides of chest “drawn” from posterior axillary folds along posterolateral thoracic wall with abducted lateral arm (raised arm)
- Midaxillary lines: imaginary vertical lines on right and left sides of chest “drawn” from axillary apices; midway between and parallel to anterior and posterior axillary lines
Topographic Markers: The Reference Lines- Posterior Chest Wall
- Vertebra prominence: Spinous processes of C7, visible and palpable with head bent forward
- Vertebral line: Imaginary vertical line “drawn” along posterior vertebral spinous processes
- Scapular line: Imaginary vertical lines on right and left side of chest “drawn” parallel to mid-spinal line; pass through inferior angles of scapulae in upright patient with arms at sides
3 main structures within thorax or chest
- Mediastinum
- Right pleural cavity
- Left pleural cavity
Mediastinum
- positioned in middle of chest
- within it are: heart, arch of aorta, superior vena cava, lower esophagus, lower part of trachea
- the right and left pleural cavities, on either side of the mediastinum, contain the lungs
Pleural cavities
- contain lungs
- lined with 2 types of serous membranes: parietal pleura, visceral pleura
- chest wall and diaphragm are protected by parietal pleura, and lungs are protected by visceral pleura
- small amount of fluid lubricates space between pleurae to reduce friction as lungs move during inspiration and expiration
The Lungs
- right lung has 3 lobes and left has 2
- the right lung is shorter than the left because of the underlying liver
- left lung is narrower than the right lung because the heart bulges to the left
- each lobe has a major, oblique fissure dividing upper and lower portions- however, right lung has a lesser horizontal fissure dividing upper lung into upper and middle lobes
- each lung extends anteriorly about 1.5 inches above first rib into base of neck in adults- posteriorly, lungs’ apices rise to level of T1 (first thoracic vertebrae); lower borders expand down to T12 and, on expiration, rise to T9
Mechanism of Breathing
- Diaphragm and intercostal muscles are primary muscles of inspiration
- During inspiration, diaphragm contracts and pushes abdominal contents down, while intercostal muscles push chest wall outward
- Combined efforts decrease intrathoracic pressure, creating negative pressure within lungs
- During expiration, muscles relax, expelling air as intrathoracic pressure rises
Physiological processes (Thorax and lungs)
- respiratory system supplies oxygen to cells and removes carbon dioxide using processes of ventilation and diffusion
- after inspiration, concentration of oxygen is higher in alveoli than in pulmonary capillaries, causing oxygen to diffuse across alveolar-capillary membrane, then carried by erythrocytes to cells
Ventilation
the process of moving gases in and out of lungs by inspiration and expiration
Diffusion
the process by which oxygen and carbon dioxide move from areas of high concentration to areas to lower concentration
Control of respiration
- Brainstem: pons and medulla
- Serum carbon dioxide levels: increased serum carbon dioxide is normal stimulus to breathe
- Serum oxygen levels: decreased oxygen in blood (hypoxemia) increases respirations, less effective than hypercapnia
Oxygenation
- At cellular level, oxygen diffuses into cells, and carbon dioxide diffuses from cells into capillaries, where it is carried by erythrocytes to alveoli
- carbon dioxide diffuses from pulmonary capillaries to alevoli and is exhaled
- CV system provides transportation oxygen and carbon dioxide between alveoli and cells
Subjective data to collect for thorax and lungs
- OPQRSTU
- Cough
- Shortness
- Chest pain with breathing
- History of respiratory infections
- Smoking history
- Environmental exposure
- Self-care behaviors
Collecting health history for cough and rationale
- Question 1: Do you have a cough? When did it start? Gradual or sudden? How long have you had it?
- Rationale 1: Acute chronic lasts less than 2 or 3 weeks; chronic cough lasts more than 2 months
- Question 2: How often do you cough? At any special time of day or just on arising? Does the cough wake you up at night?
- Rationale 2: In some conditions, the timing of a cough is characteristic: Continuous throughout day- acute illness e.g. respiratory infection, Afternoon/evening- may reflect exposure to irritants at work, Night- postnasal drip, sinusitis, Early morning- chronic bronchial inflammation inflammation of smokers
- Question 3: Do you cough up any phlegm or sputum? How much? What color is it? Cough up any blood (hemoptysis)?
- Rationale 3: Chronic bronchitis is characterized by a history of productive cough for 3 months of the year for 2 years in a row.
In some conditions, sputum production is characteristic:
White or clear mucoid: colds, bronchitis, viral infections
Yellow or green: bacterial infections
Rust colored: tuberculosis, pneumococcal pneumonia
Pink, frothy: pulmonary edema, some sympathomimetic medications (adverse effect of pink-tinged mucus) - Question 4: How would you describe your cough: hacking, dry, barking, hoarse, congested, bubbling?
- Rationale 4: Some conditions are accompanied by a characteristic cough:
Mycoplasma pneumonia: hacking
Early heart failure: dry
Croup: barking
Colds, bronchitis, pneumonia: congested
Collecting health history on shortness of breath and rationale
- Question 1: Ever had any shortness of breath or a hard-breathing spell? What brings it on? How severe is it? How long does it last?
- Rationale 1: Determine how much activity precipitates the shortness of breath; state specific number of blocks walked; number of stairs
- Question 2: Is it affected by position, such as lying down?
- Rationale 2: Orthopnea is difficulty breathing in the supine position. State number of pillows needed to achieve comfort e.g. two-pillow orthopnea
- Question 3: Does it occur at any specific time of day or night? Are the episodes associated with night sweats? Are they associated with cough, chest pain or bluish color around lips or nails? Wheezing sound? Do episodes seem to be related to food, pollen, dust, animals, season or emotion?
- Rationale 3: Paroxysmal nocturnal dyspnea is awakening from sleep with shortness of breath and needing to be upright to achieve comfort. This condition is diaphoresis. The bluish color is cyanosis. Asthma attacks may be associated with a specific allergen, extreme cold or anxiety
Collecting health history on chest pain with breathing and rationale
- Question 1: Any chest pain with breathing? Please point to the exact location
- Rationale 1: Chest pain of thoracic origin occurs with muscle soreness from coughing or from inflammation of pleura overlying pneumonia
- Question 2: Describe the pain: burning, stabbing?
- Rationale 2: Distinguish this from chest pain of cardiac origin or from heartburn of stomach acid
Collecting health history on history of respiratory infections and rationale
- Question: Any past history of breathing trouble or lung diseases such as bronchitis, emphysema, asthma, pneumonia? Have you had unusually frequent or unusually severe colds? Any family history of allergies, tuberculosis or asthma?
- Rationale: Consider sequelae after these conditions. Because most people have had some colds, it is more meaningful to ask about excess number or severity. Assess possible risk factors
Collecting health history on smoking history and rationale
- Question: Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long? Have you ever tried to quit? What helped?
- Rationale: State number of packs per day and the number of years smoked. Most people who smoke already know they should quit smoking. Instead of admonishing, assess smoking behavior and ways to mofidy daily smoking activities, identify triggers and manage withdrawal.
Collecting health history on environmental exposure and rationale
- Question: Do you live with someone who smokes? Are there any environmental conditiosn that may affected your breathing? Where do you work: at a factory, chemical plant, coal mine, farm, outdoors in a heavy traffic area? Do you have anything to protect your lungs, such as wear a mask or have the ventilatory system checked at work?
- Rationale: Pollution exposure, Farmers may be at risk for grain inhalation and pesticide inhalation. “Farmer’s lung”. Coal minners have a risk for pneumoconiosis. Stone cutters, miners and potters are at risk for silicosis. Other irritants include asbestos and radon
Collecting health history on use of devices and rationale (for lungs)
- Question 1: Do you require treatment devices to support your breathing? Home oxygen?
- Rationale 1: Low dose home oxygen via nasal prongs is noted in some individuals with chronic respiratory conditions such as COPD or pulmonary fibrosis
- Question 2: Continuous positive airway pressure (CPAP) machine?
- Rationale 2: CPAP is a form of positive airway pressure ventilator that applies mild air pressure on a continuous basis to keep the airways open in individuals who have obstructure sleep apnea
- Question 3: Do you know what specific symptoms to note that may signal breathing problems?
- Rationale 3: General symptoms- cough, shortness of breath; some gases produce specific symptoms e.g. CO= dizziness, headache, fatigue, sulphur dioxide= cough, congestion
Collecting health history on self-care behavior (lungs) and rationale
- Question: When was your most recent tuberculosis skin test, chest radiographic study, pneumonia immunization or influenze immunization?
- Rationale: “Flu” vaccine is modified yearly; it is recommended for adults with chronic medical conditions, for residents of nursing homes, for health care workers, and for people who are immunosuppressed
Collecting health history for infants and children respiratory illness and rationale
- Question 1: Has the child had any frequent or very severe colds?
- Rationale 1: No more than 4-6 uncomplicated upper respiratory infections per year are expected in early childhood
- Question 2: Is there any history of allergy in the family? At what age were new foods introduced? Was the child breastfed or formula-fed?
- Rationale 2: Consider new foods or formula as possible allergens
- Question 3: Does the child have a cough? Seem congested? Have noisy breathing or wheezing?
- Rationale 3: Document onset, and follow course of childhood chronic respiratory problems: asthma, bronchitis
- Question 4: What measure have you taken to childproof your home and yard? Is there any risk that the child could inhale or swallow toxic substances?
- Rationale 4: Young children are at risk for accidental aspiration, poisioning and injury
- Question 5: Any smokers in the home or in the care with the child?
- Rationale 5: Environmental tobacco smoke increases the risk for acute and chronic ear and respiratory infections in children
Collecting health history for older adults respiratory illness and rationale
- Question 1: Have you noticed any shortness of breath or fatigue with your daily activities?
- Rationale 1: In older adults, the respiratory system is less efficient (decreased vital capacity, less surface area for gas exchange), and so they have less toelrance for activity
- Question 2: Tell me about your usual amount of physical activity
- Rationale 2: Older patients may have reduced capacity to perform exercise because of pulmonary function deficits of aging. Sedentary or bedridden people are at risk for respiratory dysfunction
- Question 3: How about energy level? Do you tire more easily? How does your illness affect you at home? At work?
- Rationale 3: Activities may decrease because of increasing shortness of breath or pain
- Question 4: Do you have any chest pain with breathing?
- Rationale 4: Some older adults feel pleuritic pain less intensely than do younger adults
Thorax and lungs: Inspection
- Inspect patient for general appearance, posture and breathing effort
- Observe respirations for rate and quality, breathing pattern, and chest expansion
- Inspect nails, skin and lips for color
- Inspect posterior thorax for shape and symmetry, and muscle development
- Inspect anterior thorax for shape and symmetry, muscle development, anteroposterior diameter to lateral diameter, and costal angle
Posterior thorax: Inspection, Palpation, Percussion and Auscultation
- inspect for shape and symmetry and muscle development
- Palpate muscles for tenderness, bulges, and symmetry, thoracic expansion, vocal (tactile) fremitus
- Percuss posterior and lateral thorax for tone, diaphragmatic (respiratory) excursion
- Ausculate posterior and lateral thorax for breath sounds and vocal sounds (vocal resonance)
Posterior thorax: AP/Transverse diameter ratio- expected findings
ratio= 1:2
Posterior thorax: AP/Transverse diameter ratio-unexpected findings
ratio= 1:1 (COPD, emphysema)
Posterior thorax: Shape- expected findings
- spinous processes aligned
- symmetrical
- downward sloping ribs, ~45 degrees to spine
- scapulae symmetrical
Posterior thorax: skin color and condition- expected findings
- Color consistent with genetic background
- skin intact
Posterior thorax: skin color and condition- unexpected findings
- cyanosis (hypoxemia)
- pallor
- lesion changes
Posterior thorax: Breathing position- expected findings
relaxed posture, individual able to support own weight with arms comfortably at sides or in lap
Posterior thorax: Breathing position- unexpected findings
Tripod (COPD)
Anterior thorax: Palpation
Palpate trachea for position, anterior thoracic muscles for tenderness, bulges, symmetry, anterior chest wall for thoracic expansion
Chest wall: Expected findings
non tender, warm, dry
Chest wall: Unexpected findings
tender, moist, skin lesions, masses, subcutaneous emphysema
Posterior thorax: Palpation
Palpate posterior thorax wall for expansion, tenderness, bulges, symmetry, vocal (tactile) fremitus
Percussion of anterior, posterior and lateral chest walls- expected findings
- resonance: low-pitched, clear, hollow sound
- modified: muscular chest, obesity- subcutaneous tissue
Percussion of anterior, posterior and lateral chest walls- unexpected findings
- hyperresonance: low pitch, boom= too much air (emphysema, pneumothorax)
- dull: soft, muffled thud, abnormal density in lungs (pneumonia, pleural effusion, atelectasis, tumour)
Auscultation of anterior and posterior thorax/lungs
- patient sitting
- mouth breathing- a little deeper than usual
- clean the flat diaphragm endpiece of the stethoscope and hold it firmly on the patient’s chest wall
- listen one full cycle (inspiration and expiration) in each location
- side-to-side comparison is most important
- eliminate extraneous noises: patient shivering, hairy chest, rustling of paper gown or paper drapes
Adventitious sounds
- additional sounds not normally heard in lungs, often caused by: collision of moving air with secretions in the tracheobronchial passageways, popping open of previously deflated airways
- described by: inspiration or expiration, loudness, location
Adventitious sounds: Crackles- fine crackles
- inspiration
- crackling, popping, not cleared with cough
- inhaled air collides with deflated airways; airways pop open- crackling sound
- late inspiratory: restrictive disease (pneumonia, HF)
- early inspiratory: obstructive disease (chronic bronchitis, asthma, emphysema)
Adventitious sounds: Crackles- coarse crackles
- early inspiration, possibly expiration
- bubbling, gurgling- loud, low pitch
- suctioning may clear
- inhaled air collides with secretions in trachea and large bronchi
- pulmonary edema, pnuemonia
Adventitious sounds: Wheeze- high pitch wheeze
- inspiration and expiration (prominent)
- musical
- air squeezing through narrow passageways
- acute asthma, chronic emphysema
Adventitious sounds: Wheeze- low pitch wheeze
- inspiration and expiration (prominent)
- snoring, moaning
- vibration in narrow airways- airflow obstruction
- bronchitis, single bronchus obstruction, tumor
Adventitious sounds: Stridor
- inspiration
- high pitch, crowing sound
- louder in neck
- upper airway obstruction (swollen, inflamed tissues, foreign body)
- croup, epiglottitis (children)
- can be life threatening
Adventitious sounds: Pleural Friction Rub
- inspiration and expiration
- course grating sound
- pleura rubbing together- loss of pleural fluid with inflamed pleura
- pleuritis
Developmental considerations(lungs): infants, children, and adolescents
- During the first 5 weeks of fetal life, the primitive lung bud emerges; by 16 weeks, the conducting airways reach the same number as in the adult; at 32 weeks, surfactant, the complex lipid substance needed for sustained inflation of the air sacs, is present in adequate amounts; and by birth, the lungs have millions of alveoli ready to start the job of respiration
- infants must be undressed to diaper for examination
- keep infant covered when not examining to prevent exposure and cooling
- conduct examination while infant is calm; examining a crying infant is difficult
- by ages of 2-3 years, child is usually cooperative
- prior to that age, you need to develop a relationship with child to improve cooperation
Developmental considerations (lungs): older adults
- costal cartilages become calcified, which reduces the mobility of the thorax
- respiratory muscle strength declines
- decrease in elastic properties within lungs –> less distensible and lessens tendency to contract and recoil
- aging lung is a rigid structure that is hard to inflate
- gradual loss of intra-alveolar septa and a decrease in number of alveoli –> less SA available for gas exchange
- greater risk for postoperative pulmonary complications
- posterior thoracic stooping or bending or kyphosis may alter thorax wall configuration and make thoracic expansion more difficult
Common problems/conditions: Acute bronchitis
Inflammation of mucous membranes of bronchial tree caused by viruses or bacteria
Common problems/conditions: Acute bronchitis- Clinical findings
- cough initially non-productive but may become productive after few days
- patients may complain of substernal chest pain aggravated by coughing
- other clinical manifestations include fever, malaise, and tachypnea
- rhonchi and crackles frequently heard on auscultation, with wheezing heard after coughing
Common problems/conditions: Pneumonia
Inflammation of terminal bronchioles and alveoli; may be caused by bacteria, fungi, viruses, mycoplasma, or aspiration of gastric secretions
Common problems/conditions: Pneumonia- Clinical findings
- viral pneumonia tends to produce a non-productive cough or clear sputum
- bacterial pneumonia, however, causes productive cough that may produce white, yellow or green sputum
- other clinical findings associated with pneumonia include fever, tachypnea, and dyspnea
- crackles and wheezes may be heard on auscultation of lungs
Common problems/conditions: Tuberculosis
A contagious, bacterial infection caused by Mycobacterium tuberculosis. Primarily in lungs, but kidney, bone, lymph node and meninges can also be involved
Common problems/conditions: Tuberculosis- Clinical findings
- patient usually asymptomatic in early stages of disease; initial clinical manifestations consist of fatigue, anorexia, weight loss, fever
- characteristic finding later in disease is cough that becomes increasingly frequent, producing a mucopurulent sputum
Common problems/conditions: Pleural Effusion
Accumulation of serous fluid in pleural space between visceral and parietal pleurae
Common problems/conditions: Pleural Effusion- Clinical findings
- degree of manifestation depends on amount of fluid accumulation and position of patient
- if effusion occurs rapidly and if it is large, there may be dyspnea, intercostal bulging, or decreased chest wall movement
Common chronic conditions: Asthma
Hyperreactive airway disease characterized by: bronchoconstriction, airway obstruction, inflammation. Occurs in response to allergens or pollutants, infection, cold air, vigorous exercise, emotional stress
Common chronic conditions: Asthma- Clinical findings
- increased respiratory rate with prolonged expiration, audible wheeze, dyspnea, tachycardia, anxious appearance, possible use of accessory muscles, cough
- prolonged expiration, expiratory and occasionally inspiratory wheeze, and diminished breath sounds are common findings with auscultation
Common chronic conditions: Emphysema
Destruction of alevolar walls that causes permanent abnormal enlargement of air spaces
Common chronic conditions: Emphysema- Clinical findings
- classic appearance of a patient with advanced emphysema is underweight with barrel chest and short of breath with minimal exertion
- other findings reveal diminished breath and voice sounds, possible wheezing or crackles on auscultation, and decreased diaphragmatic excursion on percussion
Acute/traumatic conditions: Pneumothorax
- results from air in pleural spaces
- 3 types: closed= may be spontaneous, traumatic or iatrogenic, open= traumatic or iatrogenic, tension= develops when air leaks into pleura and cannot escape
Acute/traumatic conditions: Pneumothorax- Clinical findings
- shortness of breath, anxiety, chest pain or severe respiratory distress, including dyspnea, tachypnea and cyanosis
- decreased chest wall movement on affected side, paradoxical chest wall movement
- tracheal displacement toward unaffected side, with a mediastinal shift
Acute/traumatic conditiosn: Hemothorax
Results from blood in pleural space caused by injury to the chest or a complication of thoracic surgery
Acute/traumatic conditiosn: Hemothorax- Clinical findings
signs are similar to those described for pneumothorax, although it is common to note distant muffled breath sounds and dullness with percussion over affected area
Other pulmonary conditions: Atelectasis
- collapse of alveoli
- causes: external pressure from tumor, fluid, or air in pleural space
- types: compression atelectasis (removal of air due to hypoventilation), absorption atelectasis (due to obstruction by secretions)
Other pulmonary conditions: Atelectasis- Clinical findings
- affected lobe has diminished or absent breath sounds
- oxygen saturation may decrease to less than 90%
Other pulmonary conditions: Lung cancer
- uncontrolled growth of anaplastic cells in lung
- agents such as tobacco smoke, asbestos, ionizing radiation, and other noxious inhalants can be causative agents
Other pulmonary conditions: Lung cancer- Clinical Findings
- most common initial symptom reported is a persistent cough
- weight loss, congestion, wheezing, hemoptysis, labored breathing, or dyspnea are other manifestations that occur with advanced disease
- lung sounds may be normal or diminished over affected area; if there is a partial obstruction of airways from tumor, wheezes may be heard
- percussion tones may be normal or may be dull over tumor, particularly if cancer is large or patient has associated atelectasis
Sternal angle
- angle of Louis
- articulation of the manubrium and body of the sternum, and it is continuous with the second rib
- useful place to start counting ribs
- also marks the site of tracheal bifurcation into the right and left main bronchi
3 points to remember when using landmarks for lungs
1) The left lung has no middle lobe
2) The anterior chest contains mostly upper and middle lobe with very little lower lobe
3) The posterior chest contains almost all lower lobe
Developmental considerations (lungs): Pregnant women
- enlarging uterus elevates the diaphragm 4 cm during pregnancy. This decreases the vertical diameter of the thoracic cage, but this decrease is compensated for by an increase in horizontal diameter that happens as a result of increased estrogen level
- the growing fetus increases the oxygen demand on the mother’s body- demand is met easily by the increasing tidal volume (deeper breathing)
- little change occurs in the respiratory rate
Inspect the posterior chest- Thoracic cage: expected findings
- spinuous processes should appear in a straight line
- thorax is symmetrical, in an elliptical shape, with downward sloping ribs, angled at approx 45 degrees in relation to the spine
- the scapulae are symmetrically place in each hemithorax
- anteriorposterior diameter (AP) should be less than the transverse diameter- normal ratio of anteroposteror diameter to transverse= 1:2
- neck muscles and trapezius muscles should have developed normally for age and occupation
- note the position the patient takes to breathe- includes a relaxed posture and the ability to support one’s own wieght with arms comfortably at the side or in lap
- colour should be consistent with the patient’s genetic background, with allowance for sun-exposed areas on the chest and the back. No cyanosis or pallor should be present
Inspect the posterior chest- Thoracic cage: unexpected findings
- Slepetal deformities may limit thoracic cage excursion: scoliosis, kyphosis
- AP diameter= transverse diameter –> barrel chest
- ribs are horizontal, chest appears as if held in continuous inspiration –> occurs in chronic emphysema as a result of hyperinflation of lungs
- neck muscles are hypertrophied in COPD as a result of aiding in forced respirations
- patients with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair or bed. This gives them leverage so that their rectus abdominis, intercostal and accessory neck muscles all can aid in expiration
Palpate the posterior chest- Symmetrical expansion
Confirm symmetrical chest expansion by placing your warmed hands on the patient’s posterolateral chest wall, with your thumbs at the level of T9 and T10. Slide your hands medially to pinch up a small fold of skin between your thumb. Ask the patient to take a deep breath. Your hands serve as mechanical amplifiers; as the patient inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion
Palpate the posterior chest- Symmetrical expansion- unexpected findings
- chest expansion is unequal with marked atelectasis or pneumonia; with thoracic trauma such as fractured ribs; and with pneumothorax
- pain accompanies deep breathing when the pleurae are inflamed
Palpate the posterior chest- Tactile Fremitus
- Assess tactile (or vocal) fremitus
- fremitus= palpable vibration
- Use either the palmar base (the ball) of the fingers or the ulnar edge of one of your hands, and touch the patient’s chest while the patient repeats the words “ninety-nine” or “blue moon”- these are resonant phrases that generate strong vibrations
- symmetry is most important- the vibrations should feel the same in the corresponding area on each side
- avoid palpating over the scapulae because bone damps sound transmission
Factors that affect the normal intensity of tactile fremitus
- fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. It normally decreases as you progress down because more and more tissue impedes sound transmission
- fremitus feels greater over a thin chest wall than over an obese or heavily muscular one, in which thick tissue damps the vibration
- A loud,low pitched voice generates more fremitus than does a soft, high-pitched one
Palpate the posterior chest: Tactile Fremitus- unexpected findings
- decreased fremitus occurs when anything obstructs transmission of vibrations e.g. obstructed bronchus, pleural effusion or thickening, pneumothorax or emphysema
- increased fremitus occurs with compression or consolidation of lung tissue e.g. lobar pneumonia
Crepitus
coarse crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery
Percuss the posterior chest: Lung fields
- determine predominant note over the lung fields
- start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders
- then, percussing in the interspaces, make a side-to-side comparison all the way down the lung region
- percuss at 5 cm intervals
Characteristics of normal breath sounds
- Bronchial (tracheal)
a) pitch: high
b) amplitude: loud
c) duration: inspiration < expiration
d) quality:harsh, hollow, tubular
e) normal location: trachea and larynx - Bronchovesicular
a) pitch: moderate
b) amplitude: moderate
c) duration: inspiration=expiration
d) quality: mixed
e) normal location: over major bronchi, where fewer alveoli are located: posterior, between scapulae (especially on right); anterior, around upper sternum in first and second intercostal space - Vesicular
a) pitch: low
b) amplitude: soft
c) duration: inspiration>expiration
d) quality: rustling, like the sound of the wind in the trees
e) normal location: over peripheral lung fields, where air flows through smaller bronchioles and alveoli
Silent chest
means no air is moving in or out, which is an ominuous sign
Decreased or absent breath sounds are indications of the following situations…
- obstruction of the bronchial tree at some point by secretions, mucus plug, or a foreign body
- emphysema, as a result of loss of elasticity in the lung fibres and decreased force of inspired air; also, because the lungs are already hyperinflated, the inhaled air does not make as much noise
- obstruction of the transmission of sound between the lung and your stethoscope, as in pleurisy or pleural thickening or by air (pneumothorax) or fluid (pleural effusion) in the pleural space
Increased breath sounds occur when..
consolidation e.g. pneumonia or compression e.g. fluid in the intrapleural space increases the density in a lung area, which enhances the transmission of sound from the bronchi. When the inspired air reaches the alveoli, it hits solid lung tissue that conducts sound more efficiently to the surface
Type of adventitious sound: Atelectatic crackles
- short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths or disappear after a cough
- when sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions
Inspect the anterior chest- expected findings
- ribs are sloping downward with symmetrical interspaces
- costal angle is within 90 degrees
- facial expression should be relax and benign, indicating unconscious effort of breathing
- patient should be alert and cooperative
- lips and nail beds are free of cyanosis or unusual pallor. Nails are of normal configuration
- normal relaxed breathing is automatic and effortless, regular and even, and produces no noise. Chest expands symmetrically with each inspiration
- no retraction or bulging of the interspaces should occur on inspiration
- normally, accessory muscles are not used to augument respiratory effort- unless in heavy exercise
- respiratory rate is within normal limits and pattern of breathing is regular
Inspect the anterior chest- unexpected findings
- barrel chest is characterized by horizontal ribs and a costal angle exceeding 90 degrees
- hypertrophy of abdominal muscles occurs in chronic emphysema
- faces appear tense, strained, and tired in COPD
- cerebral hypoxia may be manifested by excessive drowsiness or by anxiety, restlessness, and irritability
- clubbing of nails occurs with chronic respiratory disease
- breathing may be noisy with severe asthma or chronic bronchitis
- accessory muscles are used in acute airway obstruction and massive atelectasis
Palpate the anterior chest- Symmetrical expansion
- place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process
- ask the patient to take a deep breath. Watch your thumbs move apart symmetrically, and note smooth chest expansion with your fingers. Any limitation in thoracic expansion is easier to detect on the anterior chest because the range of motion is greater with breathing here
Palpate the anterior chest- Tactile (vocal) fremitus
- being palpating over the lung apices in the supraclavicular areas
- compare vibrations from one side to the other as the patient says “ninety-nine”
- avoid palpating over female breast tissue because breast tissue normally damps sounds
Percuss the anterior chest
- begin percussing the apices in the supraclavicular areas
- then, percussing the interspaces and comparing one side with the other, move down the anterior chest
- interspaces are easier to palpate on the anterior chest than on the back
- do not percuss directly over female breast tissue because this would produce a dull note
