Thorax and lungs Flashcards
1
Q
Anatomy and physiology: External Thorax
A
- 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
2
Q
Anatomy and physiology: Anterior Thoracic Cage
A
- 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
3
Q
Topographic Markers
A
surface landmarks helpful in locating underlying structures and in describing exact location of physical finding
4
Q
Topographic Markers: The Reference Lines- Anterior Chest Wall
A
- 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
5
Q
Topographic Markers: The Reference Lines- Lateral Chest Wall
A
- 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
6
Q
Topographic Markers: The Reference Lines- Posterior Chest Wall
A
- 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
7
Q
3 main structures within thorax or chest
A
- Mediastinum
- Right pleural cavity
- Left pleural cavity
8
Q
Mediastinum
A
- 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
9
Q
Pleural cavities
A
- 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
10
Q
The Lungs
A
- 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
11
Q
Mechanism of Breathing
A
- 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
12
Q
Physiological processes (Thorax and lungs)
A
- 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
13
Q
Ventilation
A
the process of moving gases in and out of lungs by inspiration and expiration
14
Q
Diffusion
A
the process by which oxygen and carbon dioxide move from areas of high concentration to areas to lower concentration
15
Q
Control of respiration
A
- 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
16
Q
Oxygenation
A
- 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
17
Q
Subjective data to collect for thorax and lungs
A
- OPQRSTU
- Cough
- Shortness
- Chest pain with breathing
- History of respiratory infections
- Smoking history
- Environmental exposure
- Self-care behaviors
18
Q
Collecting health history for cough and rationale
A
- 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
19
Q
Collecting health history on shortness of breath and rationale
A
- 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
20
Q
Collecting health history on chest pain with breathing and rationale
A
- 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
21
Q
Collecting health history on history of respiratory infections and rationale
A
- 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
22
Q
Collecting health history on smoking history and rationale
A
- 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.
23
Q
Collecting health history on environmental exposure and rationale
A
- 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
24
Q
Collecting health history on use of devices and rationale (for lungs)
A
- 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
25
Q
Collecting health history on self-care behavior (lungs) and rationale
A
- 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
26
Q
Collecting health history for infants and children respiratory illness and rationale
A
- 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
27
Q
Collecting health history for older adults respiratory illness and rationale
A
- 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
28
Q
Thorax and lungs: Inspection
A
- 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
29
Q
Posterior thorax: Inspection, Palpation, Percussion and Auscultation
A
- 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)
30
Q
Posterior thorax: AP/Transverse diameter ratio- expected findings
A
ratio= 1:2
31
Q
Posterior thorax: AP/Transverse diameter ratio-unexpected findings
A
ratio= 1:1 (COPD, emphysema)
32
Q
Posterior thorax: Shape- expected findings
A
- spinous processes aligned
- symmetrical
- downward sloping ribs, ~45 degrees to spine
- scapulae symmetrical
33
Q
Posterior thorax: skin color and condition- expected findings
A
- Color consistent with genetic background
- skin intact
34
Q
Posterior thorax: skin color and condition- unexpected findings
A
- cyanosis (hypoxemia)
- pallor
- lesion changes
35
Q
Posterior thorax: Breathing position- expected findings
A
relaxed posture, individual able to support own weight with arms comfortably at sides or in lap
36
Q
Posterior thorax: Breathing position- unexpected findings
A
Tripod (COPD)
37
Q
Anterior thorax: Palpation
A
Palpate trachea for position, anterior thoracic muscles for tenderness, bulges, symmetry, anterior chest wall for thoracic expansion
73
Q
Sternal angle
A
- 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
74
Q
3 points to remember when using landmarks for lungs
A
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
78
Q
Palpate the posterior chest- Symmetrical expansion
A
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
80
Q
Palpate the posterior chest- Tactile Fremitus
A
- 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
84
Q
Percuss the posterior chest: Lung fields
A
- 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
92
Q
Palpate the anterior chest- Symmetrical expansion
A
- 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
93
Q
Palpate the anterior chest- Tactile (vocal) fremitus
A
- 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
94
Q
Percuss the anterior chest
A
- 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
