chap. 19 - thorax, lungs

inspiration

• diaphragm contracts + drops vertical chest expansion

• intercostal muscles lift ribs/sternum = horizontal expansion + increase in AP diameter

• creates negative pressure = air flows into lungs

expiration

• passive — diaphragm + intercostals relax

• chest cavity size decreases = positive pressure = air exits lungs

regulation

• hypercapnia = strongest stimulus to breathe

• hypoxemia = increases respirations, but less powerful

pulmonary - pleuritic pain

inflammation of parietal pleura (pneumonia, pulmonary infarction, neoplasm)

• location = chest wall overlying process

• quality = sharp, knife-like

• severity = often severe

• timing = persistent

• aggravated = inspiration, coughing, movement

• relieve = lying on affected side

• symptoms = chest tenderness

cardiovascular - angina pectoris

temporary myocardial ischemia

• location = retrosternal/across anterior (radiate to shoulders, arms, neck, lower jaw)

• quality = pressing, squeezing, tight, heavy, occasional burning

• severity = mild to moderate

• timing = 1-3 min (10 min if prolonged)

• aggravated = exertion, cold, meals, stress

• relieve = rest, nitroglycerin

• symptoms = dyspnea, nausea

cardiovascular - myocardial infarction

prolonged myocardial ischemia → irreversible muscle damage

• location = retrosternal/across anterior (radiate to shoulders, arms, neck, lower jaw)

• quality = pressure, squeezing, tightness, heaviness

• severity = severe

• timing = >20 min

• aggravated = not always triggered; at rest

• relieve = not relieved by rest

• symptoms = nausea, diaphoresis, dyspnea

cardiovascular - pericarditis

irritation of parietal pleura adjacent to pericardium

• location = retrosternal (radiate to shoulder, back)

• quality = sharp, knife-like

• severity = variable

• timing = persistent

• aggravated = breathing, swallowing, body position changes

• relieve = sitting forward

• symptoms = autoimmune conditions may present

aortic dissection

splitting of aortic wall

• location = anterior chest (radiate to baclk neck)

• quality = ripping, tearing

• severity = very severe

• timing = abrupt onset

• aggravated = hypertension

• relieve = nothing clearly relieves

• symptoms = syncope, unilateral weakness

gastrointestinal - reflux esophagitis

inflammation from reflux stomach acid

• location = retrosternal (radiate to back)

• quality = burning

• severity = mild to severe

• timing = variable

• aggravated = large meals, bending, lying down

• relieve = antacids, belching (burping)

• symptoms = regurgitation, dysphagia

diffuse esophageal spasm

variable motor dysfunction

• location = retrosternal (radiate to back, arms, jaw)

• quality = squeezing

• severity = mild to severe

• timing = variable

• aggravated = stress

• relieve = nitroglycerin

• symptoms = dysphagia

chest wall pain (costochondritis)

local inflammation of costal cartilage

• location = below left breast or along costal cartilages

• quality = stabbing. sticking, dull, aching

• severity = variable

• timing = hours to days

• aggravated = movement, pressing the area

• relieve = local heat, analgesics

• symptoms = tenderness at local sites

anxiety/panic disorder

unknown process

• location = precordial; below left breast or across chest

• quality = stabbing, sticking, dull, aching, or variable

• severity = variable

• timing = hours to days

• aggravated = emotional stress

• relieve = may come and go

• symptoms = breathlessness, tingling in lips + hands, dizziness

AP + transverse diameter (barrel chest)

commonly results from emphysema due to hyperinflation of the lungs

normal breathing

12-20 bpm + regular

tachypnea

more than 24 bpm + shallow

• fever, anxiety, exercise

bradypnea

less than 10 bpm + regular

• well-conditioned athletes, med-induced depression of respiratory center, diabetic coma, neurologic damage

hyperventilation

increased rate + increased depth

• extreme exercise, fear, anxiety

kussmaul

rapid, deep, labored

• diabetic ketoacidosis

hypoventilation

decreased rate, decreased depth, irregular pattern

• overdose of narcotics or anesthetics

cheyne-stokes respiration

regular pattern characterized by alternating periods of deep, rapid, breathing followed by periods of apnea

• severe congestive heart failure, drug overdose, increased intracranial pressure, renal fialure

blot respiration

irregular pattern characterized by varying depth + rate of respirations followed by periods of apnea

• meningitis or severe brain damage

ataxic

significant disorganization with irregular + varying depths of respirations

• respiratory compromise

air trapping

increasing difficulty in getting breath out

• COPD

decreased fremitus (99)

indicates consolidation (increases fremitus) or bronchial obstruction, aur trapping in emphysema, pleural effusion, or pneumothorax

chest expansion

unequal chest expansion can occur with severe atelectasis, pneumonia, chest trauma, or pneumothorax

bronchial sounds

high pitch, hard or hallow, loud, short during inspiration; long in expirations, trachea + thorax

bronchovesicular sounds

moderate pitch, mixed, moderate amplitude, same during inspiration + expiration

• over the major bronchi-posterior; between the scapulae; anterior'“ around the upper sternum in the first + second intercostal spaces

vesicular sounds

low pitch, breezy, soft amplitude, long in inspiration; short in expirations, peripheral lung fields

crackle (fine)

high-pitched, short, popping sounds heard during inspiration + not cleared with coughing

• crackles occurring LATE in inspiration associated with restrictive diseases (pneumonia, CHF)

• crackles occurring EARLY in inspiration associated with obstructive disorders (bronchitis, asthma, emphysema)

crackles (coarse)

low-pitches, bubbling, moist sounds that may persist from early inspiration to early expiration

• sofl separating velcro

• associated conditions → pneumonia, pulmonary edema, pulmonary fibrosis-long-term COPD

pleural friction rub

low-pitched, dry, grating sound

• sand paper or dry leather rubbing together

• similar to crackles only more superficial + occurring during both inspiration and expirations

• associated conditions → pleuritis (inflammation of the pleura = the thin, double-layered membrane surrounding the lungs + lining the chest cavity)

wheeze (sibilant)

high-pitched, musical sounds head primarily during expiration but may also be heard on inspiration (hissing sound)

• air passes through constricted passages caused by swelling, secretions, tumor

• associated conditions → acute asthma, chronic emphysema

wheeze (sonorous)

low-pitched snoring or moaning sounds heard primarily during expiration but may be heard throughout the respiratory cycle

• associated conditions → bronchitis or single obstructions + snoring before an episode of sleep apnea, may clear with coughing

bronchophony

• client says “99”

• normal = words sound soft, muffled, and indistinct

• abnormal = words easily understood + louder over areas of increased density (tumor, consolidation)

egophony

• client says “E”

• normal = soft + muffled, but “E” is distinguishable and heard as “eee”

• abnormal = louder + sounds like a bleating “aaa” sound over areas of consolidation

whispered pectoriloquy

• client says “one-two-three”

• normal = very faint + muffled, may be inaudible

• abnormal = sound transmitted very clearly + distinctly over areas of consolidation

chronic obstructive pulmonary disease (COPD)

progressive lung disease characterized by airflow limitations that it nos fully reversible

• 1. chronic bronchitis = inflammation + mucus production narrow the airways

• 2. emphysema = destruction of alveoli reduces surface area for gas exchange

• s/s → shortness of breath, chronic cough, exercise intolerance, reduced oxygenation over time

• risk factors → smoke exposure, having asthma, occupational exposure to dust + chemicals, exposure to fumes from burning fuels, genetics (rare)

lung cancer

• 1. small cell lung cancer (SCLC)

• 2. non-small cell lung cancer (NSCLC)

lung cancer risk factors

smoking, exposure to asbestos, radon, arsenic, diesel exhaust, air pollution, personal history of radiation exposure, personal or family history of lung cancer, exposure to many toxins

consolidation in lobe

filled with fluid, pus, blood, cells

• alveoli not longer ventilated with air

• causes → pneumonia, pulmonary edema, hemorrhage

obstructive atelectasis

air cannot reach alveoli, and trapped air is gradually absorbed, causing lung segment to collapse

• no ventilation to the affected alveoli

• causes → mucus, foreign body, tumor, shallow breathing

pneumothorax

air enters the pleural space, causing partial or complete lung collapse

• TENSION pneumothorax is a medical emergency!!!! due to impaired venous return

pneumothorax causes

trauma, spontaneous rupture of blebs, mechanical ventilation, underlying lung disease

pneumothorax physiology

air disrupts the negative pressure needed to keep the lung expanded

pneumothorax s/s

sudden sharp chest pain, dyspnea, absent breath sounds on affected side, hyper-resonance to percussion, tracheal shift away from affected side

pleural effusion

excess fluid accumulates in pleural space, compressing lung

• lung effusion may cause tracheal shift away from the affected side

pleural effusion causes

heart failure, infection (parapneumonic effusion), malignancy, liver/renal disease

pleural effusion physiology

fluid prevents full expansion leading to decreased ventilation

pleural effusion s/s

diminished or absent breath sounds over fluid, dullness to percussion, decreased fremitus, dyspnea, chest pressure

emphysema

type of COPD characterized by destruction of alveolar walls leading to the loss of elastic recoil + air trapping

• patients rely on hypoxic drive in advanced disease → important for oxygen titration

emphysema causes

long-term smoking (most common), alpha-1 antitrypsin deficiency

emphysema physiology

hyperinflated lungs (air trapping), reduced surface area for gas exchange, increased work of breathing

emphysema s/s

diminished breath sounds dur to hyper-inflation, hyper-resonance to percussion, barrel-shaped chest, prolonged expiration, dyspnea on exertion

barrel chest

AP lateral ratio 1:1

pectus excavatum

inverted sternum

pectus carinatum

everted sternum (protruding skin)

older adult considerations

• dyspnea with certain activities

• absent chest pain associated with pleuritis

• decreased ability to cough effectively

• kyphosis (rounding curvature of upper back)

• decreased thoracic expansion

• difficulty in deep breathing; fatigue easily

• tenderness or pain at costochondral junction of ribs (seen w/ fractures, especially w/ osteoporosis)