Thorax and Lungs

1
Chapter 15

• Thorax and Lungs
• N1037

2
A P of Thorax

• Thorax
• Pleura
• Parietal external surface
• Visceral internal surface
• Mediastinum or interpleural space
• Bronchi bifurcate T4/5 post, sternal angle ant
• Right - more vertical, ?risk aspiration
• Left
• Alveoli
• Diaphragm (R5 ICS MCL, L6ICS MCL)
• phrenic nerve
• External intercostal muscles
• inspir ext ICM contract
• expir int ICM contract
• Accessory muscles
• scalene, sternocleidomastoid, trapezius,
  abdominal rectus

3
A P of Thorax Sternum Ribs Intercostal
spaces
4
Anatomy Lungs

• Right lung three lobes
• Left lung two lobes
• Apex
• Base
• Midclavicular line (MCL)
• Midaxillary line (MAL)

5
Anatomy Lungs
6
Thoracic Anatomic Topography

• Anterior axillary line
• Midspinal (vertebral) line
• Midsternal line
• Posterior axillary line
• Scapular line

7
Thoracic Anatomic Topography
8
Physiology of Respiration

• Ventilation
• active inspiration and passive expiration
• during inspiration ? pressure inside lungs
  subatmospheric as diaphragm ext ICM contract
  ?diaphragm lowers ribs elevate which
  ?intrapulmonic volume creating a neg
  intra-alveolar pressure gradient with the
  atmosphere so air is pulled into the lungs until
  the intra-alveolar pressure air pressure, thus
  lungs become full with air.
• Expiration occurs more rapidly. The diaphragm and
  ext ICM relax, which means the diaphragm rises
  the ribs move closer ?volume in the thoracic
  cavity causing a ? intrapulmonic volume ?
  intrapulmonic pressure above atmospheric
  pressure, the lungs recoil and expel air until
  the intrapulmonic pressure atmospheric
  pressure.
• External respiration- O2 diffuses from alveoli to
  blood
• Internal respiration - O2 in the blood diffuses
  into tissues
• Control of breathing- neural and chemical factors
• pons medulla CNS structures responsible for
  involuntary respiration
• stimulus for breathing ? Co2, ?PH, ?O2 levels

9
Health History

• Patient profile
• Age
• Children and young adults bronchiectasis, cystic
  fibrosis
• Adults and older adults lung cancer, chronic
  bronchitis, pneumonia, emphysema
• Gender
• Patient profile (contd)
• Race
• African American sarcoidosis
• Caucasian cystic fibrosis

(continues)
10
Common Chief Complaints

• Dyspnea
• Cough
• Sputum
• Chest pain

11
Characteristics of Chief Complaint

• Quality
• Quantity
• Associated manifestations
• Aggravating factors
• Alleviating factors
• Setting
• Timing

12
Past Health History

• Medical
• Respiratory specific
• Nonrespiratory specific
• Surgical
• Medications
• Communicable diseases
• Allergies
• Injuries and accidents
• Special needs
• Childhood illnesses

13
Family Health History

• Allergies
• Asthma
• Bronchiectasis
• Cancer
• Cystic fibrosis
• Emphysema
• TB

14
Social History

• Alcohol, drug, or tobacco use
• Travel history
• Work and home environment
• Hobbies and leisure activities
• Stress
• Economic status

15
Health Maintenance Activities

• Sleep
• Diet
• Exercise
• Use of safety devices
• Health check-ups

16
Assessment of the Thorax and Lungs

• Equipment
• Stethoscope
• Centimeter ruler or tape measure
• Washable marker
• Watch with second hand

17
Inspection

• Shape of thorax
• Transverse diameter
• Anteroposterior (AP) diameter
• Symmetry of chest wall
• Presence of superficial veins
• Costal angle

(continues)
18
Assessment of Thorax Lungs

• Inspect shape of thorax
• Transverse diameter
• Anteroposterior (AP) diameter
• NAP to transverse 12
• Symmetry of chest wall
• Presence of superficial veins
• Abnormal
• barrel chest dt COPD
• pectus carinatum dt congenital abn
• kyphosis humpback
• scoliosis curvature of spine

19
Assessment of Thorax Lungs

• Costal angle
• Nlt90 ?with inspir expir
• Angle of the ribs
• N ribs articulate at 45 ?angle
• Intercostal spaces
• N No retractions or bulging in ICS
• Muscles of respiration
• N no use of accessory muscles

20
Respirations

• Rate N 12-20 bpm for adult
• Abnormalities
• Eupnea 1220 breaths per minute
• Tachypnea gt 20 breaths per minute
• Bradypnea lt 12 breaths per minute
• Apnea no respiration for 10 or more seconds

(continues)
21
Inspect Respiration

• Patterns
• N regular and even in rhythm
• Cheyne-Stokes-brain injury
• Biots or ataxic -damaged medulla
• Apneustic -injured pons
• Agonal - impending death
• Depth
• N nonexaggerated effortless
• Shallow -obese, pain, PE, puemonia, pneumothorax
• Hyperpnea - exercise, emotional, high altitudes
• Air trapping-COPD
• Kussmauls-diabetic ketoacidosis
• Sighing- N or CNS lesions

22
Inspect Respirations

• Symmetry -
• N thorax rises falls in unison, no paradoxical
  movement
• Abnormal unilateral expansion dt collapsed lung
• paradoxical movement dt broken
  ribs
• Audibility
• N respirations are audible by ear
• Patient position
• N breaths comfortably upright, supine
• Abnormal Orthopnea dt COPD, CHF, PE
• Mode of breathing
• N inhale exhale through nose

23
Inspect Sputum

• Color N light yellow or clear
• Odor N none
• Amount N small
• Consistency N thick or thin depends on
  hydration
• Abnormal
• Table 15-1

24
Assessing Patients with Respiratory Assistive
Devices

• Oxygen therapy
• Mode of delivery
• Percentage of oxygen
• Flow rate
• Humidification
• Incentive spirometer
• Frequency of use, volume achieved, number of
  repetitions
• Endotracheal tube
• Size
• Nasal or oral insertion
• Length of tube as it exits mouth or nose
• Cuff inflated or deflated

• Tracheostomy tube
• Size
• Cuffed or cuffless
• How tube is secured to neck
• Mechanical ventilation
• Type of ventilator
• FiO2 setting
• Mode
• Amount of PEEP
• Rate and tidal volume
• Alarms
• Pulse oximeter
• Peak flow Meter

25
Thoracic Palpation

• Palpate the Anterior, Posterior Lateral thorax
• Assess for
• Pulsations
• Masses
• Thoracic tenderness
• Crepitus
• N no pulsations, masses, tenderness,crepitus
• Abnormal
• aortic aneurysm
• tumor or cyst
• chest trama
• subcutaneous emphysema (air in subcutaneous
  tissue)

26
Thoracic Palpation

• Thoracic expansion
• Expansion
• Symmetry
• Tactile fremitus
• Anterior
• Posterior
• Lateral

(continues)
27
Thoracic Palpation

• Thoracic expansion
• Expansion
• Symmetry

28
Thoracic Palpation

• Tactile fremitus
• Anterior, Posterior, Lateral
• N buzzing over bronchi trachea
• Abnormal ? dt consolidation
• ? dt pneumothorax,
  emphysema, asthma

29
Palpation Pattern for Tactile Fremitus
30
Thoracic Percussion

• Anterior
• Posterior
• Right and left lateral
• Diaphragmatic excursion
• 
  Pt position for Posterior Percussion

31
Percussion Patterns
32
Diaphragmatic Excursion

• Percuss lung while pt resting mark thorax
• Percuss lung while pt takes a deep breath mark
  thorax
• Measure distance btwn two marks
• Repeat other lung
• N T12 on inspir, T 10 on expir

33
Auscultation Fields

• Posterior

• Anterior

• Lateral

• Lateral

34
Auscultation Breath Sounds

• Bronchial
• Bronchovesicular
• Vesicular

35
Auscultation Breath Sounds

• Assess for Pitch, Intensity, Quality, Duration,
  Location
• N Table 15-2
• Abnormal
• Adventitious Breath Sounds
• Crackles - moisture in airways
• Wheeze - narrowing of airway
• Pleural friction rub - inflamed parietal
  viseral pleura
• Stridor - partial obstruction

36
Assessment of Voice Sounds

• Reveals if lungs are full of air, fluid or solid
• Instruct pt to say 99 each time you place
  stethescope
• N Muffled or unclear transmission
• Abnormal dt any type of consolidation
• Bronchophony - clear transmission of 99
• Egophony - transmission of ee to ay with
  ?intensity
• Whispered pectoriloquy - clear transmission of
  99
• Voice sounds absent - dt ?air in lungs from
  disease - emphysema,asthma pneumothorax

37
Age-Related Changes

• Anatomic changes
• Limited chest wall expansion
• Muscle atrophy
• Increased work of breathing
• Alveolar gas exchange
• Decreased surface area for diffusion

(continues)
38
Age-Related Changes

• Regulation of ventilation
• Decreased sensitivity to changes in carbon
  dioxide and oxygen
• Lung defense mechanisms
• Decreased ciliary action
• Diminished cough reflex
• Increased susceptibility to infection