Assessment of the Thorax

1
Assessment of the Thorax Lungs

• Week 6

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Functions of the Lungs

• Supply oxygen to body for energy production -
  needs normal blood counts
• Remove carbon dioxide waste product  
• Maintain homeostasis through regulation of
  acid-base balance
• Hypoventilation ? ?CO2 in blood ?pH
• Hyperventilation ? ?CO2 in blood ?pH   
• Contribute to heat regulation.

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Normal Blood Values
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Anterior Thoracic Cage 18 -1
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Posterior Thoracic Cage 18 - 2
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Mid-Sternal, Mid-Clavicular Reference Lines 18-3
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Vertebral, Scapular Reference Lines Fig. 18-4
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Anterior, Posterior, Midaxillary Reference Lines
Fig 18-5
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Anterior Location of the Lungs Fig. 18-6
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   Posterior Location of the Lungs FIGURE 18-7.
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   Right Lateral Location of the Lung. FIGURE
18-8.
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   Left Lateral Location of the Lung. FIGURE
18-9.
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Remember ...

• Left lung has no middle lobe
• Anterior lung field contains mostly upper lobe
  and middle lobe (in R) with very little lower
  lobe
• Posterior lung field is mostly lower lobe.

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  Structure of the Lungs FIGURE 18-10.
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   Mechanics of Respiration. FIGURE 18-11.
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Respiratory Control

• Respiratory centre in brain stem unconsciously
  mediates respiration based on metabolic needs
• Receptors in blood vessels monitor CO2, O2 pH
• Most efficient stimulus to breathe - hypercapnia
  (? CO2)
• Hypoxemia (? O2) less efficient stimulus
• Also changes in blood pH influence respiratory
  rate.

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Developmental Considerations - Elderly

• Costal cartilages become calcified less mobile
• Respiratory muscle strength deteriorates
• Decrease in elasticity of lung tissue lose
  smaller airways as they do not inflate
• Gradual loss of alveoli surface area for gas
  exchange
• Decrease in ventilation, greater risk of dyspnea
  and pulmonary complications.

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Subjective Data Collection

• Cough
• Shortness of breath
• Chest pain with breathing
• Past history of respiratory infections
• Smoking history
• Environmental exposure
• Self-care behaviours
• Medications.

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Objective Data Collection Inspection Palpation

• Start with posterior chest
• Note chest shape configuration
• Note position person takes to breathe
• Assess skin colour condition
• Palpate symmetric chest expansion, thumbs _at_ T9/10
  
• Palpate for tactile (or vocal) fremitus (palpable
  vibrations due to sounds generated in larynx)
• Gently palpate entire chest wall for temperature,
  moisture, lumps, masses or lesions.

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Configurations of the Thorax Normal Adult
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 Symmetric Chest Expansion FIGURE 18-13. 
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Tactile Fremitus Fig. 18-13
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Percussion

• Percuss entire lung fields side to side, top to
  bottom - Resonance predominates healthy lung
  tissue
• Percuss diaphragmatic excursion - Map out lower
  lung border on inspiration expiration
• Percuss lower border on exp. mark where sound ?s
  
• Percuss lower border on insp. mark where sound
  ?s
• Measure distance between marks
• Diaphragmatic excursion should be equally
  bilaterally measure about 3 to 5 cm in adults
  could be up to 7 or 8 cm in well-conditioned
  people.

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Sequence for Percussion Fig. 18-15
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Expected Percussion Notes 18-16
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Percussion Tones Throughout Chest

• http//www.coursewareobjects.com/objects/hao/anim/
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Diaphragmatic Excursion 18-17
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Auscultation

• Auscultate entire lung fields side to side, top
  to bottom
• Evaluate presence quality of breath sounds
  Normal
• Bronchial insp.lt exp., loud, high pitched,
  heard over trachea at front
• Bronchovesicular insp. exp., moderately loud,
  moderately pitched, heard over major bronchi
  posterior between scapula, anteriorly over 1st
  2nd intercostal spaces
• Vesicular inspiration gt expiration, soft, low
  pitched, over rest of lung field
• Note assess for abnormal (adventitious) breath
  sounds e.g. crackles wheeze.

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Auscultate Breath Sounds 18-18
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Posterior Location of Breath Sounds 18-19
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Anterior Location of Breath Sounds 18-20
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Normal Lung Sounds

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Voice Sounds or Resonance

• Similar to tactile fremitus, only use stethoscope
• Normal voice transmission soft, muffled,
  indistinct
• Pathology that increases lung density enhances
  transmission of voice sounds
• Bronchophony listen while patient says 99
• Egophony patient says ee-ee-ee-ee, should
  hear ee if hear aa-aa-aa indicates ? lung
  density
• Whispered pectoriloquy patient whispers one,
  two, three, normally heard faintly, with
  consolidation will transmit very clearly.

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Vocal Resonance Egophony (Expected and
Unexpected)

• http//www.coursewareobjects.com/objects/hao/anim/
  12-010ap.htm
• http//www.coursewareobjects.com/objects/hao/anim/
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Anterior Chest Assessment - Inspection

• Inspect chest shape configuration
• Note patients facial expression during
  respiration
• Note level of consciousness, skin/nail colour
  condition
• Note effort of respiration should be relaxed,
  normally accessory muscles are not used
• Note respiratory rate.

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Anterior Chest Assessment Palpate, Percuss
Auscultate

• Palpate chest expansion, tactile fremitus,
  anterior chest wall for lumps/masses, skin
  temperature, moisture, mobility turgor
• Percuss top to bottom, side to side, noting
  resonance, flatness, dullness, tympany
• Auscultate breath sounds.

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Palpate Symmetric Chest Expansion 18-21
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Assess Tactile Fremitus 18-22
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Sequence for Percussion Auscultation 18-23
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Expected Percussion Notes 18- 24
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Other Tests

• Forced expiratory time
• Have patient breathe out forcefully and listen
  with stethoscope, should be about 4 seconds, gt 6
  seconds occurs in obstructive lung disease
• Pulse oximetry assesses arterial oxygen
  saturation should be gt 92.

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Abnormal Findings Respiration Patterns
Chapter 18
Thorax and Lungs

• Sigh
• Tachypnea
• Bradypnea
• Hyperventilation
• Hypoventilation
• Cheyne-Stokes respiration
• Biots respiration
• Chronic obstructive breathing

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Patterns of Respiration

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  12-014ap.htm

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Abnormal Findings Configurations of the Thorax
Chapter 18
Thorax and Lungs

• Barrel chest
• Pectus excavatum
• Pectus carinatum
• Scoliosis
• Kyphosis

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Barrel Chest 18-4
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Pectus Excavatum 18-4
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Pectus Carinatum
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Scoliosis 18-4
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Kyphosis -18-4
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Abnormal FindingsAdventitious Lung Sounds
Chapter 18
Thorax and Lungs

• Discontinuous sounds
• Cracklesfine
• Cracklescourse
• Atelectatic crackles
• Pleural friction rub
• Continuous sounds
• Wheezesibilant
• Wheezesonorous rhonchi
• Stridor

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Adventitious Lung Sounds

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• http//www.coursewareobjects.com/objects/hao/anim/
  12-009ap.htm
• http//www.coursewareobjects.com/objects/hao/audio
  /12-009sp.htm

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Abnormal FindingsCommon Respiratory Conditions
Chapter 18
Thorax and Lungs

• Congestive heart failure
• Pneumothorax
• Pneumocystis carinii pneumonia
• Tuberculosis
• Pulmonary embolism
• Acute respiratory distress syndrome (ARDS)

• Atelectasis
• Lobar pneumonia
• Bronchitis
• Emphysema
• Asthma (reactive airway disease)
• Pleural effusion thickening