Thorax & Lungs

Angle of Louis (sternal angle)

*marks trachea bifurcation into 2 main stem bronchi
*corresponds with upper border of atria
*continuous with 2nd rib

midaxillary line

left lung

2 lobes separated by oblique fissure

*upper lobe extends from apex to 5th rib/midaxillary line

right lung

3 lobes separated by horizontal and oblique fissures

*upper lobe extends from apex to horizontal fissure at 5th rib

*middle lobe extends from horizontal fissure down and forward to 6th rib

Laterally, the lung tissue extends from _____ to _____ fissure at _____ rib.

apex
horizontal
5th

pleura

thin, slippery double-layered membrane surrounding each lung; forms an envelope between the lungs and chest wall

visceral pleura

inner layer of pleura that envelopes the lung tissue

parietal pleura

outer layer of pleura lying closer to the ribs and chest wall

Swallowed foreign objects usually go into the _____ main bronchus.

right

*because it is shorter, wider, and more vertical than left main bronchus

4 major functions of respiration

1. supply oxygen for energy production
2. eliminate CO2 as a waste product
3. maintain homeostasis (acid-base balance)
4. thermoregulation (less essential)

hypercapnia

excessive CO2 in the blood

*normal stimulus to breath

hypoxemia

deficient oxygen in the blood

*also stimulates respiration, but not as effectively as hypercapnia

A cough is defined as "chronic" if it has been present for _____ months.

2+

continuous coughing is often a sign of...

an acute issue, such as a respiratory infection

intermittent coughing is often a sign of...

exposure to an irritant

night coughing is often a sign of...

postnasal drip or sinusitis

describing cough quality

hacking / dry / barking / congested

*dry cough common in early HF
*congested cough common in cold, bronchitis, pneumonia, etc.

dyspnea

difficulty breathing; also called "shortness of breath"

orthopnea

ability to breathe only in an upright position

hemoptysis

coughing up blood

subjective data: health history

current cough? if so, productive or non-productive?
dyspnea?
orthopnea? (# of pillows)
chest pain with breathing?
hemoptysis?
history of respiratory infections?
history of smoking? (pack years)
environmental exposures?
self-care measures?

1. inspect chest wall posteriorly

for shape, configuration, skin abnormalities, skin color changes

*anterior-posterior diameter should be 1/2 of transverse chest (EXCEPT neonates)
*spinous processes should be symmetric, midline
*scapulae should be symmetric b/l
*skin color should be consistent with patient's ethnic background
*costal angle should be < 90 degrees

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

*frequently seen in patients with COPD, such as chronic bronchitis and emphysema

pectus excavatum

sunken sternum and adjacent cartilages

pectus carinatum

forward protrusion of the sternum

scoliosis

abnormal lateral curvature of the spine

kyphosis

excessive outward curvature of the spine causing hunching of the back

2. inspect facial expression

to determine WOB

*position should be relaxed

tripod position

an upright position in which the patient leans forward onto two arms stretched forward and thrusts the head and chin forward; typically seen in patients having difficulty breathing

3. inspect respirations

for rate, rhythm, quality

*should be effortless, regular, even

tachypnea

abnormally rapid breathing (> 20 bpm). Lower tidal volume

causes: fever, pain, heavy exercise

bradypnea

abnormally slow breathing (< 12 bpm)

causes: some drugs, increased intracranial pressure

Cheyne-Stokes respirations

a distinct pattern of breathing characterized by quickening and deepening respirations followed by a period of apnea

causes: CHF, renal failure, increased intracranial pressure, dying patient

Biot's respirations/ ataxic

varying depth and rate of breathing, followed by periods of apnea; very irregular breathing pattern

causes: head trauma, brain abscess, heat stroke

chronic obstructive respirations

normal inspiration + prolonged expiration + air trapping

4. palpate posterior chest for symmetric expansion

1. place hands on posterior chest wall at T9 or T10 with thumbs along costal margins and pointing inward
2. ask patient to take a deep breath
3. watch thumbs move apart symmetrically and note smooth expansion

5. palpate posterior chest for tactile (local) fremitus

using palmar base of finger or ulnar edge, touch chest while patient says "99", moving in a zig-zag pattern from the apices and palpate from side to side or compare sides

*vibrations should be equal b/l
*increased tactile fremitus = consolidation of lung tissue (e.g. pneumonia)
*decreased tactile fremitus = obstruction in bronchi, PE, emphysema

6. percuss posterior chest for symmetry

sounds over lung tissue should be resonant b/l

hyperresonance = overinflation (e.g. emphysema)

7. percuss posterior chest for diaphragmatic excursion

1. ask patient to exhale and percuss down to dullness
2. ask patient to inhale and percuss down to dullness again
3. measure the distance between the 2 lines

*difference should be equal b/l (3 - 5 cm)
*not used in clinical practice very much anymore

8. auscultate posterior lung fields for breath sounds

patient sits with hands in their lap, leaning slightly forward while breathing thought their mouth, a bit deeper than usual (may need to pause to prevent patient from becoming lightheaded)

hold diaphragm of stethoscope firmly on chest wall, listening to 1 full breath in each spot

decreased lung sounds = bronchial tree obstruction (secretions or forcing body), emphysema, any obstruction between lung and stethoscope (e.g. fluid in pleural space)

increased lung sounds = pneumonia

adventitious breath sounds

abnormal breath sound heard over the lungs

crackles (rales, crepitations)

crackling sound heard usually during inspiration that indicates an accumulation of fluid

fine crackles

high-pitched, short (like rubbing hair with fingers outside ear)

causes: air coliding w/ secretions or small airways popping open

coarse crackles

low-pitched, gurgly (like velcro opening)

causes: air bubbles moving through secretions in the large bronchi

sonorous wheezes

low-pitched snoring (like a musical snoring), musical sound made upon expiration air moves through narrowed or partially obstructed airway passages

causes: bronchitis

sibilant wheezes

high-pitched, squeaking

causes: asthma, HF

stridor

crowing sound during inspiration

causes: croup, airway obstruction

MEDICAL EMERGENCY!

pleural rub (friction rub)

scratchy sound produced by pleural surfaces rubbing against each other

causes:

9. auscultate posterior lung fields for transmitted voice sounds

ask patient to speak while auscultating lung fields

*voice should be heard as a soft, muffled, indistinct sound

if abnormal (increased lung density enhances transmission of voice sounds), assess:

1. bronchophony

2. egophony

3. whispered pectoriloquy

bronchophony

• louder, clearer "99" reflecting transmission through airless tissue

• indicates abnormality like pneumonia

normal: sounds are muffled and indistinct

egophony

"E" to "A" changes which occur in lobar consolidation from pneumonia

whispered pectoriloquy

louder, clearer whispered words reflecting transmission through airless tissue

normal: usually heard faintly or indistinctly, if at all

10. palpate anterior chest for symmetric expansion

1. place hands on anterior chest wall with thumbs along costal margins and pointing inward towards the xyphoid process
2. ask patient to take a deep breath
3. watch thumbs move apart symmetrically and note smooth expansion

12. percuss anterior chest

not usually done because there isn't much to percuss without observing changes in sounds over heart, liver, stomach, etc.

atelectasis

collapsed, shrunken section of alveoli or entire lung

signs:

- trachea may be shifted toward involved side

- percussion dull over airless area

- breath sounds usually absent when bronchial plug?

- tactile fremitus usually absent

- no adventitious sounds (unless bronchi patent, then might hear a few crackles)

lobar pneumonia

infection of one or more lobes of the lung causing alveoli to fill with fluid, bacteria, blood, pus (consolidation)

◦ Health history: fever, cough w/ chest pain, blood-tinged sputum, chills, SOB, fatigue

signs:

- increased RR (24 bpm) and HR (> 100 bpm)

- guarding and lag upon expansion on affected side

- chest expansion decreased on affected side

- tactile fremitus increased if bronchus patent/decreased if bronchus obstructed

- percussion dull over pneumonia

- bronchial, late inspiratory crackles over involved area

bronchitis

• inflammation of the bronchi causing mucous build up

Signs

• Trachea - midline

• Tactile Fremitus - normal

• Percussion – resonant

• Breath sounds – vesicular except perhaps over large bronchi or trachea

• Adventitious sounds – none OR coarse crackles in early inspiration and/or sonorous wheezes (rhonchi)

emphysema

• Slowly progressive disorder (often due to smoking) in which the distal air
  spaces enlarge and lungs become hyperinflated

• Often also develops chronic bronchitis

Signs

• tachypnea

• tactile fremitus: decreased

• percussion: hyper-resonant

• breath sounds: decreased to absent

• adventitious sounds: none or scattered coarse crackles in early inspiration
  and perhaps expiration and/or sonorous wheezes (rhonchi) associated with chronic bronchitis

asthma

Widespread, usually reversible narrowing of the tracheobronchial tree
(bronchospasm and underlying inflammation), diminishing airflow

signs:

- SOB

- chest tightness

- tachypnea

- accessory muscles used to aid expiration

- some cyanosis

- retraction of intercostal spaces

- tactile fremitus: decreased during attacks

- percussion: resonant to hyper-resonant

- breath sounds: often obscured by sibilant wheezes

- adventitious sounds: wheezing during attacks

pleural effusion

Fluid accumulation in the pleural space, separating air-filled lung from
the chest wall, blocking the transmission of sound

*effusions may contain watery capillary fluid, protein, purulent matter, blood, lymphatic fluid

causes: HF (most common), infection, cancer

signs:

- tachypnea

- SOB

- tachycardia

- some cyanosis

- asymmetric expansion of lungs

- trachea shifted toward opposite side in large effusion

- tactile fremitus: decreased to absent

- percussion: dull to flat over fluid

- breath sounds: decreased to absent, but bronchial sounds may be heard near top of large effusion

- adventitious sounds: possible rub

pneumothorax

• Air leak into the pleural space, usually unilaterally, causing the lung to recoil
  from the chest wall

• Pleural air blocks the transmission of sound

• *usually unilateral

• *can be spontaneous, traumatic, tension

Signs

• unequal chest expansion

• trachea shifted toward opposite side if much air

• tactile fremitus: decreased to absent over pleural air

• percussion: hyper-resonant to tympanic over pleural air

• breath sounds: decreased to absent over pleural air

• adventitious sounds: possible pleural rub

congestive heart failure (CHF)

• aka pulmonary edema

• Increased pressure in pulmonary veins due to fluid overload, causing
  congestion and interstitial edema around the alveoli

• Bronchial mucosa
  may also be edematous

signs:

- tachypnea

- SOB upon exertion

- orthopnea

- paroxysmal nocturnal dyspnea

- nocturia

- ankle edema

- pallor in light-skinned patients

- tactile fremitus: normal decreased

- adventitious sounds: late inspiratory crackles in the dependent portions of lunges, possible wheezes

lung parenchyma

portion of the lung involved in gas transfer: the alveoli, alveolar ducts and respiratory bronchioles

Hyperventilation

• more tidal volume and more breathing

  • **ex. Kussmaul breathing

    • Type I diabetes bc their increase in glucose --> trying to blow off acid

Ex. of hyperventilation

Kussmaul breathing

• Type I diabetes bc their increase in glucose --> trying to blow off acid

What kind of breathing is common in a dying patient?

Cheyne-stokes

Consolidation

when the air that usually fills the small airway in your lungs is replaced with pus, blood, water, or a solid

Flat percussion sound

• very soft, high pitched, shorter duration

• heard over very dense tissue

  • Ex. bone or muscle

Dull percussion sound

• soft, muffled, moderate to high pitched, short duration

Resonance percussion sound

• moderate to loud, low pitched, moderate duration

• heard over healthy lung tissue

Hyperresonance

• loud booming, very low pitched, long duration

• hyper-inflated lungs as with COPD

Tympanic

• loud, drum like, musical sound

• heard over air/fluid filled cavities

• ex. stomach, bowel, bladder, lung w/ large pneumothorax

Vesicular lung sounds

• soft/low pitched breezy sound

• normal over peripheral lung fields

• length of inspiration > expiration

Bronchovesicular lung sounds

• medium pitched, moderately loud

• normal over mainstem bronchi

• length of inspiration = expiration

Bronchial (tracheal) lung sounds

• loud, coarse, blowing sound

• normal over trachea

• length of inspiration < or = expiration

Are breath sounds louder or quieter over areas of consolidation in the lung?

Louder bc sounds travels more easily through liquid or solid compared to air

Are breath sounds louder or quieter over areas where pus, abnormal fluid, or air is inside the pleural space?

quieter bc there is a physical barrier preventing the sound from making it to the stethescope

What do you asses if abnormal bronchovesicular or bronchial breath sounds are heard?

asses the transmitted voice sounds - bronchophony, egophony, whispered pectoriloquy

Where is the right middle lobe best auscultated?

Anterior chest

Summary of healthy lung findings

• Trachea - midline

• Tactile Fremitus – normal/symmetrical

• Percussion –resonant

• Breath sounds – vesicular except over large bronchi or trachea

• Adventitious sounds -none

• tracheobronchial tree and alveoli are clear; pleurae are thin and close together; mobility of chest wall is unimpaired

causes of atelectasis

mucous plug, foreign body, or surrounding pressure

pulmonary embolism

• Blockage in the arteries bringing blood to the lung tissue
  (usually a clot), which leads to lung tissue damage

  • Could be air or fat embolism too

Signs

• Trachea - midline

• Tactile Fremitus – normal

• Percussion – resonant

• Breath sounds – vesicular

• Adventitious sounds – usually none, may
  have few crackles (rales)

• Symptoms

  • Low O2 levels

  • Dyspnea

  • Possible cyanosis

  • Sharp chest pain with inspiration 

• PMH

  • Known deep vein thrombosis that breaks off and travels to lungs

  • Sedentary