Thorax and Lungs

Question 1

Thorax

Answer 1

Area that extends superiorly from base of neck to the level of diaphragm inferiorly

Contains lungs, distal portion of trachea, bronchi

Question 2

Thoracic cage

Answer 2

OUTER STRUCTURE of thorax that is constructed of sternum, 12 pairs of ribs, 12 thoracic vertebrae, muscles, cartilage

Provides support and protection of all internal organs and respiratory system

Question 3

Thoracic cavity

Answer 3

Contains heart, lungs, thymus, distal parts of trachea, most of esophagus

Question 4

Sternum

Answer 4

Lies anteriorly in the center of the chest; three parts: (1) manubrium, (2) body, (3) xiphoid; (angle of Louis join manubrium to body)

Thoracic cage - Ribs (12 pairs) & thoracic vertebrae:

1. Ribs 1-2 connect to the manubrium
2. Ribs 3-6 connect to the sternal body
3. Ribs 7-10 connect to rib pair 6 to create a 45-deg. angle between the right and left costal margins (costal angle)
4. Ribs 11-12: floating ribs

Question 5

Vertical reference lines

Answer 5

Anterior chest: midsternal, and R/L midclavicular lines

Posterior thorax: vertebral line, and R/L scapular lines

Lateral thorax: R/L midaxillary, and A/P axillary lines

Question 6

Structure of thoracic cavity

Answer 6

Mediastinum: central area in the thoracic cavity that separates the lungs (contains the trachea, bronchi, esophagus, heart, and great vessels)

Lungs: two cone-shaped, elastic structures (R lung has 3 lobes; L lung has 2 lobes); apex (top) extends slightly above the clavicle; base (bottom) at the level of the diaphragm and extents anteriorly to the 6th rib, and posteriorly to the 10th rib

Pleura: (1) Parietal pleura lines the chest cavity; (2) Pleural space; (3) Visceral pleura covers the external surface of lung

Question 7

Subjective assessment

Answer 7

PMHX: Asthma, surgeries/biopsies/tests/studies, vaccinations, TB, allergies

FHX: Lung CA, asthma, second-hand

Lifestyle and health practices: Travel history, diet, smoking, housing conditions, low/high risk occupations (exposure to toxins)

Medications: Asthma; HTN meds. (can cause prolonged cough; possible side effect of beta blockers or ACE-inhibitors)

Question 8

Particular interests

Answer 8

1. Dyspnea: H/O COPD, CHF, pneumonia, pneumothorax, asthma, MI
2. Cough: Sudden onset or infection-related; Assess: onset, aggravating factors (irritants), sputum, adventitious breath sounds, medications (prolonged use of beta-blockers, ACE inhibitors)
3. Orthopnea: dyspnea while supine (indicative of LHF)
4. PND: dyspnea that awakens an individual from sleep (indicative of LHF)
5. Sleep apnea: periods of breathing cessation during sleep (associated with snoring, depression, increased BP, stroke, DM)
6. GI symptoms (Heartburn, frequent hiccups, chronic cough; GERD-related asthma)
7. Asthma: evident by decreased air movement and wheezing upon auscultation (S/S: SOB, nocturnal cough, DOE)

Question 9

Sputum classification

Answer 9

White or mucoid: common cold or viral infection

Green or yellow: bacterial infection

Brown or black: hemoptysis

Rust: TB or pneumococcal pneumonia

Pink frothy: pulmonary edema

Question 10

Physical examination: preparation

Answer 10

WIPE

Gown and drape (remove clothes from waist up)

Positioning: Sitting/upright

Equipment: Gloves, stethoscope, light source, mask, skin marker, metric ruler

Question 11

Inspection

Answer 11

Color of face/lips, nail color/shape, chest, positioning

Position of scapula and shape/configuration of thorax

Note behavior (LOC, confusion)

Assess chest expansion, intercostal spaces (retraction), accessory muscle use

Question 12

Inspection of respirations

Answer 12

Quality and pattern; note S/S of labored breathing (flaring nostrils)

Characteristics:
1. Rate: normal = 12-20 bpm; bradypnea: <10 bpm, tachypnea: >24 bpm

2. Rhythm: even or uneven
3. Depth: shallow or deep

Question 13

Thoracic deformities and configurations

Answer 13

1. Barrel chest: lungs become chronically overinflated with air, forcing the rib cage to stay expanded for long periods of time (emphysema)
2. Pectus excavatum (funnel chest): congenital malformation characterized as depression of sternum; can compromise cardiopulmonary capacity; S/S: Self-consciousness (cosmetic)
3. Pectus carinatum (pigeon chest): sternum protrudes forward causing adjacent ribs to slip backward, restricting lung expansion and capacity
4. Scoliosis: abnormal lateral deviation (curve) of the spine that includes the cervical, thoracic, and lumbar vertebrae
5. Kyphosis: an exaggerated outward rounding of the thoracic vertebrae; often seen with osteoporosis and old age

Question 14

Tripod position

Answer 14

Commonly seen in COPD to increase breathing capacity; characterized by leaning forward, use of arms to support weight, and lifting chest

Question 15

Palpation

Answer 15

Sensation and tenderness

Surface characteristics (temp./skin lesions/masses)

Assess for:
1. Crepitus: the SENSATION of crackles when air passes through fluid or exudate, or collapsed alveoli (s/t subcutaneous emphysema); assessed after chest tube placement, thoracic surgery/injury

2. Posterior chest expansion: uneven chest expansion can occur with atelectasis, pneumonia, chest trauma, pneumothorax (deep breath while hands on T9 or T10)

Question 16

Palpatation: fremitus

Answer 16

A palpable VIBRATION produced during breathing, caused by partial airway obstruction (lung consolidation)

Use ball of hand and ask pt to say “99”; assess for symmetry and intensity

Variations:
1. Increased fremitus: indicates denser or inflamed lung tissue (pneumonia)

2. Decreased fremitus: suggests air or fluid in the pleural spaces or a decrease in lung tissue density (pneumothorax, pleural effusion; emphysema)

Question 17

Percussion

Answer 17

1. Resonance: elicited over normal lung tissue
2. Hyper-resonance: elicited over trapped air (emphysema, pneumothorax)
3. Dullness: elicited over dense tissue (consolidation, pleural effusion, tumor)
4. Diaphragmatic excursion: movement of diaphragm during breathing; measured by percussing dullness over diaphragm and resonance over lungs (3-5 cm.)

Question 18

Auscultation of breath sounds

Answer 18

Classified according to (1) intensity, (2) pitch, and (3) duration during inspiration/exhalation

ANTERIOR breath sounds:
1. Bronchial: harsh, loud, high-pitched breath sounds heard over the manubrium, trachea, main stem bronchi (expiratory sound lasts longer than inspiratory)

ANTERIOR/POSTERIOR breath sounds:
2. Bronchovesicular: intermediate pitch and intensity breath sounds (heard equally during inspiration and expiration)

3. Vesicular: very soft, low-pitched breath sounds (heard during inspiration and first-third of expiration)

Question 19

Auscultation of voice sounds

Answer 19

POSTERIOR voice sound tests:
1. Bronchophony: pt repeats phrase “99”; Normal: muffled; Abnormal: easily understood

2. Egophony: pt repeats letter “E”; Normal: “E” to muffled “E”; Abnormal: “E” to “A”
3. Whispered pectoriloquy: pt whispers “1, 2, 3”; Normal: muffled; Abnormal: transmitted clearly and distinctly

Question 20

Auscultation of adventitious breath sounds

Answer 20

Performed with diaphragm of stethoscope during one, full open mouth breath, symmetrical; cough to confirm identification of adventitious sound

CONTINUOUS abnormal sound:
1. Wheezing: high-pitched breath sound, resulting from narrowing of respiratory airway (asthma, COPD); more common during EXPIRATION, but also inspiration

NON-CONTINOUS abnormal sounds:
2. Crackles: popping sounds on INSPIRATION; types: (1) Fine: high-pitched, fire crackling (alveoli); (2) Coarse: low-pitched, wet bubbling (bronchi; pneumonia, LHF)

3. Pleural friction rub: harsh/grating sound during inspiration AND expiration (local or systemic effect of RA, lupus, plueritis, CA, PE, dehydration)

Question 21

Wheezing sounds

Answer 21

1. Sibilant: high-pitched musical sound (asthma, COPD, CHF, bronchitis); primarily heard during EXPIRATION
2. Sonorous: low-pitched snoring/moaning sound; mucus/lung secretions may clear with coughing (bronchitis, obstructive lung diseases); primarily heard during EXPIRATION
3. Stridor: high-pithed crowing sound (infants with bronchiolitis, FB, upper airway croup infection); primarily heard during INSPIRATION

Question 22

Respiration patterns

Answer 22

Normal; tachypneic; bradypneic

Hyperventilation: increased rate and depth of breathing (fear, anxiety)

Kussmaul: deep, rapid breathing pattern (increased serum CO2; DKA)

Hypoventilation: decreased rate and depth of breathing (narcotics, anesthetics)

Cheyenne-Stokes: progressively deeper, and sometimes faster breathing rate followed by a gradual decrease and apnea

Biot: groups of regular deep inspirations followed by regular or irregular periods of apnea

Ataxic: complete irregularity of breathing, with irregular pauses and increasing periods of apnea

Air-trapping: difficulty upon exhalation

Question 23

Lung CA

Answer 23

Leading cause of death in U.S. and E.U.

Risk factors: Smoking/second-hand, genetic (men), FHX, environmental toxins (asbestos, radon), occupation, Hodgkin disease (lympathic CA), poor diet, beta-carotene supplements (with smoking)

Health promotion: Smoking cessation, limit work/home exposure to asbestos/radon, diet, toxins, seeking medical assessment for respiratory S/S

Question 24

Older adult considerations

Answer 24

Tenderness/pain at costochondral junction (FX, osteoporosis)

DOE resulting from loss of lung elasticity/resiliency and fewer functional capillaries (observe RR and pattern)

Absence of pleuritic sharp/stabbing pain (alteration in pain perception)

Inability to cough, deep breath effectively (weaker muscles, increased thoracic wall rigidity)

Decreased thoracic expansion as a result of calcification of costal cartilages and loss of accessory musculature

Prominent sternum and ribs d/t loss of subcutaneous fat