Thorax and Lung Chapter 19

thoracic cage

bony structure surrounding the heart and lungs in the thoracic cavity; composed of the ribs, sternum, and thoracic vertebrae12 ribs & 12 thoracic vertebrae

7

The first _ ribs are attached to the sternum by costal cartilages

8,9,1

11,12

Which ribs are floating with free palpable tips?

costochondral junctions

the points at which the ribs join their cartilages; not palpable

suprasternal notch

U-shaped depression just above the sternum, between the clavicles

sternum

breast bone- composed of manubrium, body and xiphoid process

manubriosternal angle

"Angle of Louis", this is the articulation of the manubrium and the body of the sternum, and is continuous with the second rib.

Angle of Louis

-palpate lightly next to second rib, and slide down to second intercostal space-also marks the site of tracheal bifurcation into right and left main bronchi-corresponds with upper broader atria of the heart and it lies above the fourth thoracic vertebra on back

costal angle

-the right and left costal margins form an angle where they meet at the xiphoid process-usually less than 9

vertebra prominens (c7)

-Typically, the First Spinous Process You can Feel in the Back of Your Neck-flex your head and feel for most prominent bony spur protruding at the base of the neck

spinous process

-Count down these knobs on vertebrae which stack together to form spinal column

inferior border of the scapula

-The scapulae are located symmetrically in each hemithorax. The lower tip is usually at the seventh or eighth rib.

twelfth rib

-palpate midway between the spine and the person's side to identify its free tip

midsternal line

a vertical line down the middle of the sternum

midclavicular line

-imaginary vertical line bisecting the middle of the clavicle in each hemithorax

anterior axillary line

- a line that is parallel to the mid-axillary line and passes through the anterior axillary skinfold-arm must be raised 9

posterior axillary line

-imaginary line on the back that runs vertically from the shoulder down on the outer edge of the rib cage

midaxillary line

An imaginary vertical line that starts at the middle of the axilla (armpit) and extends down the side of the chest.

midspinal line

vertical line drawn from the midpoint of the spinous processes

scapular line

extends through the inferior angle of the scapula when the arms are at the sides of the body

mediastinum

middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels

pleurae cavity

What contains the lungs?

3-4 cm above clavicle

Where is the apex (highest border) of the lung

diaphragm at 6 rib (midclavicular line)

Where is the base (lowest border) of the lung

apex of axilla to the 7th or 8th rib (posteriorly C7- apex and T-1

base)

t12

During deep inspiration where does the lower border drop to?

symmetric

Lungs are paired but are not precisely \______________ structures

right

Which lung is shorter because of the underlying liver?

left

Which lung is narrower because of the heart bulging to the left?

right

Which lung has 3 lobes?

left

Which lung has 2 lobes?

5,6

On the anterior chest, oblique fissures crosses \____ rib in midaxillary line and terminates at \___ midclavicular line

lower lobes

Posterior chest is almost all?

left lung (characteristics of the lobes)

- no middle lobe- anterior chest contains mostly upper and middle lobe with very little lower lobe- posterior chest contains almost all lower lobes

pleurae

-serous membranes that form an envelope between the lungs and the chest wall-2 layers

visceral pleura

-lines the outside of lungs dipping into fissures- continuous with parietal

parietal pleura

- lines the thoracic cavity

pleural cavity

-contains the lungs-normally has a vacuum or negative pressure which holds lungs tightly against the chest wall-potential space only filled with a few ml of lubricating fluids

trechea

anterior to esophagus1

bronchial tree

-branched airways that lead from the trachea to the alveoli-right main bronchus is shorter and wider and more vertical than left

transport gas between environment and lungs (constitute dead space = space that is filled with air but is not available for gas exchange approx 15

mL in adults) ( bronchial tree protects alveoli from small particulate matter in inhaled air) (lined with goblet cells that produce mucus)

acinus

- functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.

supplying oxygen to the body, removing CO2, homeostatis of arterial blood, maintiaing heat echange

What are the main 4 functions of respiration?

maintaining homeostasis

-acid base balance of the arterial blood- by supplying oxygen to blood and eliminating excess CO2, respiration maintains pH or acid base balance of blood

mechanics of respiration

-control of respirations-changing chest size

humoral regulation

What is the major feedback loop for controlling respirations?

humoral regulation

-change in carbon dioxide and oxygen levels in blood-also hydrogen ion level-normal stimulus to breathe for most of us is an increase of carbon dioxide in blood (hypercapnia)-decrease in oxygen in blood (hypoxemia) also increases respirations but is less effective than hypercapnia

hypercapnia

excessive carbon dioxide in the blood

inspiration

air rushes into the lungs as chest size increases

expiration

air expelled from the lungs as chest recoils

vertical diameter and anteroposterior diameter

- What are the two ways that mechanical expansion and contraction can alter the size of the chest cavity?

vertical diameter

lengthens or shortens, which is accomplished by downward or upward movement of diaphragm

anteroposterior diameter

- diameter from the back to the front chest- diaphragm can increase size of the chest cavity through a negative air pressure and the intercostal muscles compensate increasing AP diameter

accessory muscles

-The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.-should not be used in normal passive breathing-may be present after exercise etc

aging adult

~Costal cartilage becomes calcified~Thorax is LESS mobile~Lungs LESS elastic and harder to inflateleads to decreased vital capacity and increased residual volume~↓ number of alveoli and decreased gas exchangewhich increases the risk for DOE~↑ risk for atelectasis and infection → cough and ↑ secretions

decreased vital capacity

- the maximum amount of air that a person can expel from the lungs after first filling the lungs to maximum

increased residual volume

the amount of air remaining in the lungs even after the most forceful expiration

decrease

The aging adult has an increase/decrease in the ability to cough?

histologic changes (aftermath)

- Less alveoli leads to-increased risk for older adult to have post-op pulmonary complications-greater risk for post-op atelectasis and infection from decreased ability to cough-loss of protective airway reflexes and increased secretions

atelectasis

-partial collapsed lung

residual volume

Amount of air remaining in the lungs after a forced exhalation

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

lung(caused by smoking is largest percentage)

What is the 2nd most common cancer?

tuberculosis

-airborne lung disease that has infected 1/3 of world population-social and migratory disease-need to actively treat after identifying

asthma

-A chronic allergic disorder characterized by episodes of severe breathing difficulty, coughing, and wheezing.-most common chronic disease in childhood-highest burden seen in those living at/below poverty line-ethnic and environmental factors play big role

cough (Subjective data)

-Do you have a cough?-When did it start? gradual? sudden?-how long have you had it?- how often do you cough? any times of day? cough wakes you up at night?-phlegm? sputum? how much? what color?-cough up blood? streaks? frank? odor?-describe the cough: hacking? dry? barking? congested?-note the severity and accompanying factors

acute cough

less than 3 weeks

chronic cough

8 weeks

chronic bronchitis cough

history of productive cough for 3 months of the year for 2 years in a row

hemopytsis

coughing up blood

SOB (subjective data)

Any SOB now?within the day?dyspneaoccur with changes in position/orthopneaoccur at specific time day/night?SOB with night sweats?color changes? blue?any allergies?what do you do when you get SOB?how does it affect your day to day life?

dyspnea

difficulty breathing

chronic dyspnea

-SOB lasting \>1 month and may have neurogenic, respiratory, or cardiac origin-can also be anemia, anxiety, deconditioning

orthopnea

-difficulty breathing when lying down-state in number of pillows needed "2 pillow orthopnea"

paraoxysmal nocturnal dyspnea

awakening from sleep with SOB and needing to be upright to achieve comfort

night sweats

-excessive sweating during sleep

chest pain with breathing (subjective data)

- Any chest pain with breathing?-when did it start?-describe: burning, stabbing-brought on by respiratory infection, coughing, trauma?-associated with fever, deep breathing, unequal chest inflation-tx or meds?

History of Respiratory Infections

-Any past history of breathing trouble or lung diseases such as bronchitis, emphysema, asthma, or pneumonia?-any fam history of allergies, TB, asthma

smoking history (subjective data)

-Do you smoke cigarettes/cigars?-What age did you start?-How many packs do you smoke a day?-For how long?

Five A's

AskAdviseAssessAssistArrange-way to counsel smoking cessation

environmental exposure

Are there any environmental conditions that may affect your breathing?Ask about\----occupational factors and exposure-protection from exposure-monitoring and follow-up exposure-awareness of symptoms that might signal breathing problems

self care behavior (subjective data)

- vaccines, protection etc

Ask

ask about use of tobacco and record response1st A

Advise 2nd A

give clear nonjudgemental and personal suggestions for quitting

assess

3rd aassess persons readiness and interest for quitting

assist

4th Aeach person has an individualized cessation plan

arrange

5th Aarrange follow-up visits

subjective data for aging adult

- Have you noticed any SOB or fatigue with ADLs?-- tell me about your usual amount of activityhow is your energy level? do you tire more easily? how does your illnesses affect you at work?do you have any chest pain with breathing?do you have any chest pain after a bout of coughing or after a fall?

COPD, lung cancer, TB

What diseases should you use the Lung Function Questionaire?

white clear

colds, bronchitis, viral infections

yellow green

bacterial infections

rust colored

TB, pneumococcal pneumonia

pink frothy

pulmonary edema

lung function questionaire

-questionnaire that scores likelihood of being at risk for COPD-score 18 or less is increased risk

inspection of anterior and posterior thorax

-LOC-shape and configuration: ribs slope down and costal cartilages 9

horizontal

Barrel chest has \_______________ ribs

chronic emphysema

Hypertrophy of abdominal muscles occurs in

COPD

- Tense, strained, tired facies and purse-lipped breathing accompany \________________________-by exhaling slowly and against narrow opening, the pressure in the bronchial tree remains positive and fewer airways collapse

cerebral hypoxia

- lack of oxygen to the brain-excessive drowsiness, anxiety, restlessness and irritability