NURS 251 Exam 2 Respiratory

Thoracic cage

Bony structure with a conical shape, narrower at top

• Defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae

• First seven ribs attach to sternum by costal cartilages

• Ribs 8, 9, and 10 attach to costal cartilage above.

• Ribs 11 and 12 are “floating”, with free palpable tips

Anterior Thoracic

Suprasternal notch: U -shaped depression just above sternum between clavicles

Sternum: “breastbone”: manubrium, body, and xiphoid process

Sternal Angle:

• Angle of Louis (articulation of manubrium and body of sternum) - 2nd rib

• Tracheal bifurcation (left and right main bronchi split)

Costal angle: the right and left costal margins form an angle (usually 90 degrees or less) where they meet at xiphoid process

Posterior Thoracic Landmarks

Spinous processes: count down these knobs on vertebrae, which stack together to form spinal column.

Inferior border of scapula

Twelfth rib: Palpate midway between spine and a person’s side to identify its free tip

Anterior/Lateral Reference Lines

Anterior axillary line

Midclavicular line

Midsternal line

Posterior axillary line

Midaxillary line

Thoracic Cavity

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

AP (anterior/posterior): Transverse diameter - 1:2

Lungs: right and left pleural cavities contain lungs

Lobes of lungs

• right lung shorter than left because of underlying liver

• right lung has 3 lobes, and left has 2 lobes

• posterior chest contains almost all lower lobes

Pleurae

Visceral pleura lines outside of lungs, dipping into fissures

Pleural cavity normally has a vacuum, or negative pressure, which holds lungs tightly against chest wall

Pleural cavity is potential space filled only with few (~3) milliliters of lubricating fluid

Trachea and Bronchial Tree

Trachea lies anterior to esophagus

Trachea bifurcates at the sternal angle

• right main bronchus is shorter, wider and more vertical than left main bronchus, so it aspirates more

Trachea and bronchi transport gases between the environment and lung parenchyma

• Constitute dead space, or space that is filled with air but is not available for gaseous exchange (alveoli)

Mechanics of Respiration: function

1) supplying oxygen to the body for energy production

2) removing carbon dioxide as a waste product of energy reactions

3) maintaining homeostasis (acid-base balance) of arterial blood

• by supplying oxygen to blood and eliminating excess carbon dioxide, respiration maintains pH or acid-base balance of blood

4) maintaining heat exchange

Control of respirations

Major feedback loop is humoral regulation or change in carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion level.

• Normal stimulus to breath for most of us is an increase of carbon dioxide in blood, or hypercapnia.

• Decrease of oxygen in blood (hypoxemia) also increases respirations but is less effective than hypercapnia.

Changing chest size

Air rushes into lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration)

Mechanical expansion and contraction of chest cavity alters size of thorax

Across the Life cycle

Infants and children

• increased vulnerability of respiratory system: associated with environmental tobacco smoke (ETS) exposure

Pregnant Woman

• impact of enlarging uterus - hyperventilation

• impact of physiologic dyspnea

Aging adult

• decreased vital capacity and increased residual volume based on structural changes

• decreased gas exchange

Culture and genetics

Lung cancer: second most diagnosed cancer - smoking

Tuberculosis: affected more than 1/3 of the world’s population - social and migratory disease

Asthma: most common chronic disease in childhood

• ethnic and environmental factors play signifigant role

Objective Assessment: Posterior chest

Inspection: thoracic cage

• note shape and configuration of chest wall

• note the position the person takes to breath

• assess skin color and condition

Palpation

• symmetric expansion - confirm by using hands

• tactile (or vocal) fremitus - using hands to assess for palpable vibrations

  • repetition of phrases by patient (“99” or “blue moon”)

Posterior Chest

Percussion: Lung fields

• indirect fields

• indirect

• Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adult

• Hyperresonance with chronic lung disease (emphysema, etc.)

Auscultation

Passage of air through tracheobronchial tree creates a characteristic set of noises that are audible through chest wall

Posterior from the apices at C7 to the bases at T10

Move in a lateral movement

Assess bilateral axilla (armpit areas)

Take slow, deeper than usual breaths through the mouth

Breath Sounds

Bronchial - sometimes called tracheal or tubular harsh, hollow, loud, high-pitched, inspiration duration < expiration

Bronchovesicular - inspiration = expiration in duration, over major bronchi, moderate pitch and amplitude. Over major bronchi

Vesicular - covers largest area, located over peripheral lung fields, low, soft I> E duration

Fine Crackles/rales

Description:

Discontinuous, high-pitched, crackling, popping

Clinical Examples: Pneumonia, heart failure

Course Crackles

Description

Loud, low-pitched, bubbling and gurgling, early in inspiration

Clinical Examples: Pulmonary edema, pneumonia, pulmonary fibrosis

Wheezes

Description:

Continuous, high-pitched, musical, squeaking sounds

Clinical Examples: Asthma, emphysema

Rhonchi

Description:

Low-pitched, snoring (like a washing machine)

Clinical Examples: Airway obstruction, secretions from bronchitis

Stridor

Continuous during inspiration, high-pitched, louder in neck

Voice Sounds

Determine quality of voice sounds or vocal resonance as noted in tactile fremitus.

Normal transmission is soft, muffled, and indistinct

Bronchophony

Technique: say “99” while listening with stethoscope

Normal: soft, muffled

Abnormal: words more distinct

Egophony

Technique: auscultate chest while patient says “ee-ee-ee”

Normal: “eeee”

Abnormal: “aaaa” over area of consolidation

Whispered Pectoriloquy

Technique: Ask person to whisper “one-two-three” as you auscultate

Normal: faint, muffled

abnormal: very clear and distinct

Inspection of anterior chest

Note shape and configuration of chest wall, AP: Transverse

Note patient’s facial expression

Note skin color and condition

Assess quantity and quality of respirations

• respiratory rate - normal is 12 -20 for adult

• observe for symmetry

• determine if accessory muscles are being used

Palpation of anterior chest

Palpate for symmetric chest expansion

• any limitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists here while breathing

Assess tactile (vocal) fremitus

• compare vibrations from one side to other as person repeats “ninety-nine”

Palpate anterior chest wall

• note any tenderness or lumps

• note skin mobility, turgor, temperature, and moisture

Development Competence: infants and children

Infants and children

• apgar scoring system: newborn’s first respiratory assessment

Obligate nose breather until 3 months

Count respiratory rate for 1 min

• normal rates for newborn are 30 - 40 breaths per min but may spike up to 60

Periodic breathing possible

Pregnant woman + aging adult

Pregnant:

Diaphragm moves easily during pregnancy

growing fetus, increased oxygen demand on mother

• deeper respirations and increase in tidal volume by 40%

Aging adult:

increasing AP diameter, kyphosis, or an outward curvature of thoracic spine

Chest expansion may be somewhat decreased, although still symmetric

Tend to tire easily during auscultation

Abnormal Configurations of the Thorax

Pectus Excavatum: sunken sternum

Barrel Chest: Equal AP to transverse diameter and horizontal ribs

Pectus carinatum: forward protrusion of the sternum

Scoliosis: Lateral s-shaped curvature of the thoracic and lumbar spine

• unequal shoulder and hip levels

• adolescent age-groups, especially girls

Kyphosis: exaggerated posterior curvature of the thoracic spine (humpback)

Abnormal: Respiration Patterns

Tachypnea

• rapid, shallow breathing, increased rate > 25 per minute

• fever, fear, exercise, hypoxia

Hypoventilation

• irregular shallow pattern

• caused by overdose of narcotics or anesthetics

Hyperventilation

• increase in both rate and depth

• caused by extreme exertion, fear, or anxiety, in diabetic ketoacidosis, metabolic acidosis

Cheyne-Stokes Respiration

• Wax and wane pattern, increasing in rate and depth and then decreasing with periods of APNEA (20 secs of no breathing)

Chronic Obstructive Breathing

• normal inspiration and prolonged expiration to overcome increased airway resistance

Hypoxia

Low blood oxygen

ALL organs are affected

Signs and symptoms

Early: see change in neuro status, heart rate is tachycardic

Late - bradycardia

Respiratory: SOB, flaring, use of accessory muscles, tripod position

End organ perfusion:

• skin - cool, mottled, cyanotic

• urine - decreased urine production

Summary: Thorax and Lungs examination

Inspection

• respiratory rate and work of breathing

• thoracic cage, respirations, skin color, and condition

• a person’s facial expression, and LOC

Palpation

• confirm symmetric expansion and tactile fremitus

• detection of any lumps, masses, or tenderness

Percussion

• lung fields

Auscultation

• assess breath sounds and note any abnormal/adventitious breath sounds

• perform bronchophony, whispered pectoriloquy, or egophony as needed.

Orthopnea

SOB when laying flat

Dyspnea

SOB on exertion