seidels chapter 14 (chest/lungs) skills unit 3

what does the thorax consist of?

anteriorly: sternum, manubrium, xiphoid process, costal cartilages

laterally: 12 pairs of ribs

posteriorly: 12 thoracic vertebrae

ribs 1-7

attached anteriorly to sternum by costal cartilages

AKA TRUE RIBS

ribs 8, 9, 10

join w/ costal cartilages just above them

ribs 11 & 12

attach posteriorly but not anteriorly

AKA FLOATING RIBS

lateral diameter of the chest is _____ than AP diameter in adults

greater

what are the primary muscles of inspiration

diaphragm

intercostal

diaphragm's role during inspiration

contracts and moves DOWNWARD to lower abdominal contents to INCREASE interthoracic space

external intercostal muscle's role during inspiration

INCREASE AP chest diameter

internal intercostal muscle's role during expiration

DECREASE lateral diameter during forceful expiration

what accessory muscles can be used during exercise/pulmonary compromise to help w/ breathing

sternocleidomastoid

trapezius

3 major spaces of interior chest

right pleural cavity

left pleural cavity

mediastinum

what is the lingula

inferior tongue like protrusion on upper left lobe

oblique fissure

major fissure on each lung that divides upper and lower portions

lesser horizontal fissure

divides upper portion of right lung into upper and middle lobes @ 5th rib in axilla and 4th rib anteriorly

where do the apices of the lungs rise to

posteriorly to T1 level

where do the lower borders of the lung descend to during deep inspiration

T12 level

where do the lower borders of the lung rise to on forced expiration

T9 level

what is the tracheobronchial tree

tubular system which provides pathway along which air is filtered, humidified, and warmed as it moves from upper airway to alveoli

length and width of trachea

10-11 cm long and 2cm in diameter

location of trachea

anterior to esophagus and posterior to isthmus of thyroid

division of trachea

divides into right and left main bronchi at T4/T5 level and just below sternal angle

right bronchus is _________ than left bronchus and therefore more susceptible to aspiration of foreign bodies

right bronchus is wider, shorter, and more vertically placed than left bronchus

divisions of main bronchi

3 branches on right and 2 on left (each branch supplying lobe of lung)

bronchial branches divisions

subdivides into terminal bronchioles then into respiratory bronchioles

what supplies blood to lung tissue

bronchial arteries branch from anterior thoracic aorta and intercostal arteries

what closes in the fetal heart shortly after birth

foramen ovale and patent ductus arteriosus

why does the foramen ovale close after birth

the decrease in pulmonary pressure from the pulm arteries relaxing/expanding

why does patent ductus arteriosus close after birth

increased oxygen tension in arterial blood usually stimulates contraction and closure of PDA

what can a large patent ductus arteriosus sound like on a auscultation

machine like murmur

what can an open patent ductus arteriosis lead to as complications

left ventricular overload and heart failure

sputum characteristics of a bacterial infection

yellow, green, rust (blood mixed w/ yellow sputum), clear/transparent, purulent, blood streaked, sticky

sputum characteristics of a viral infection

blood streaked (not common)

sputum characteristics of chronic infectious diseases

can be any color

abundant in early morning

slight blood streaking w/ occasionally large amounts of blood

sputum characteristics of cancer

slight, persistent, and intermittently blood streaking

sputum characteristics of infarction

blood clotted + large amounts of blood

sputum characteristics of tuberculosis cavity

occasional large amounts of blood

orthopnea

SOB that begins/increases when pt lies down (do they have to sleep on more than 1 pillow?)

paroxysmal nocturnal dyspnea

sudden onset of SOB after period of sleep - sitting upright is helpful

Platypnea

dyspnea increases in the upright position

chest pain does not generally originate in the heart when...

there is a constant achiness that lasts all day

it does not radiate

it is made worse by pressing on chest wall

it is a fleeting, needle-like jab that lasts only a few seconds

it is situated in shoulders or b/w shoulder blades

cocaine use can cause...

tachycardia

hypertension

coronary artery spasm (w/ infarction)

pneumothorax (severe acute chest pain)

barrel chest causes an ____ in AP diameter

increase in AP diameter

the AP diameter is _____ than the lateral diameter

less

expected thoracic AP to lateral ratio

0.70 to 0.75

what can cause barrel chest

progressing age

chronic asthma

emphysema

cystic fibrosis

pigeon chest is also called

pectus carinatum

(prominent steneral protrusion)

funnel chest is also called

pectus excavatum

(indentation of lower sternum above xiphoid process)

sequence of steps in examination of the chest and lungs

inspection, palpation, percussion, auscultation

dullness on percussion can indicate...

pleural effusion

lobar pneumonia

tactile fremitus is absent when...

effusion is present

tactile fremitus is increased with...

lobar pneumonia

what is the ratio of respirations to heartbeats

1:4

risk factors for respiratory disability

advancing age

family history of asthma, cystic fibrosis, Tb

smoking

sedentary lifestyle

occupational exposures to asbestos, dust, toxins

extreme obesity

weakened diaphragm and chest muscles (scoliosis, polymyositis)

tachypnea

persistent RR above 16

hyperventilation is often a symptom of protective splinting from...

broken rib or pleurisy

what can cause bradypnea (12 resp or less)

neurological or electrolyte disturbance

infection

conscious response to protect against pain of pleurisy or irritatives

good cardiorespiratory fitness

kussmaul breathing

rapid, deep, labored

respiratory effort associated w/ metabolic acidosis

Cheyne-stokes respiration

varying periods of increasing depth interspersed w/ apnea (crescendo-descrescendo sequence)

- children/adults can have this during sleep but it indicates illness otherwise (drug induced respiratory compromise or CHF)

the rate and depth of breathing will increase with...

acidosis (metabolic)

central nervous system lesions (pons & medulla)

anxiety

aspirin poisoning

oxygen need (hypoxemia)

pain

rate and depth of breathing will decrease with...

alkalosis (metabolic)

central nervous system lesions (cerebrum)

myasthenia gravis

narcotic overdose

extreme obesity

biot or ataxic respiration

irregular respirations varying in depth and interrupted by intervals of apnea lacking repetitive pattern of periodic respiration

biot respirations is associated with...

increased intracranial pressure

respiratory compromise from drug poisoning

brain damage at level of medulla

chest asymmetry can be associated with...

unequal expansion and respiratory compromise caused by pneumonia, collapsed lung, limited lung expansion from extrapleural air, fluid, mass

prolonged expiration and bulging on expiration are probably caused by...

airway outflow obstruction

valve like action of compression by tumor

aneurysm

enlarged heart

(all will cause costal angle to widen beyond 90 degrees)

primary apnea

self-limited condition not uncommon after blow to the head

noted immediately after birth of newborn who will breath spontaneously when sufficient carbon dioxide accumulates in circulation

secondary apnea

breathing stops and will not begin spontaneously unless resuscitative measures are made

any event that severely limits absorption of O2 into bloodstream will lead to secondary apnea

reflex apnea

when irritating/nausea provoking vapors/gases are inhaled there can be an involuntary and temporary halt to respiration

sleep apnea

periods of absent breathing and oxygenation during sleep

airflow not maintained through nose/mouth due to blockage when soft tissue in back of throat collapses during sleep

Apneustic breathing

long inspiration and expiration apnea

pons and medulla are affected = breathing becomes gasping bc inspirations are prolonged and expiration is constrained

periodic apnea of the newborn

normal condition of irregular pattern of rapid breathing interspersed w/ brief periods of apnea - usually associated w/ REM sleep

what are retractions

when chest wall seems to cave in at the sternum, b/w ribs, at suprasternal notch, above clavicles, and @ lowest costal margins

what do retractions suggest?

obstruction to inspiration at any point in respiratory tract

pathophys of retractions

as intrapleural pressure becomes more negative the muscles pull back in an effort to overcome blockage

when obstruction is high in respiratory tree (trachea/larynx involvement) breathing is characterized by...

stridor

(Stridor = Superior involvement)

paradoxical breathing makes the lower thorax ______ during ______

lower thorax is drawn in during inspiration

signs of upper airway obstruction

inspiratory stridor

hoarse cry/cough

flaring nostrils

retraction @suprasternal notch

signs of severe obstruction of upper airway

stridor on inspiration AND expiration

barking cough

more retractions

cyanosis

signs of obstruction above glottis

quieter stridor

muffled voice

difficulty swallowing

awkward position of head/neck to maintain airway

conditions associated with clubbing

emphysema

lung cancer

cirrhosis

cystic fibrosis

what does pleural rub feel like on palpation

palpable, coarse, grating vibration usually on inspiration

*feel of leather rubbing on leather*

what are the most useful PE findings for pleural effusion

dullness to percussion

decreased tactile fremitus

causes of decreased/absent fremitus

excess air in lungs: emphysema, pleural thickening/effusion, bronchial obstruction

causes of increased fremitus (coarser/rougher feeling)

fluids or solid mass within lungs

volume loss (from fibrosis or atelectasis) pulls the trachea ______

towards the affected lung

causes of trachea deviation away from affected side

thyroid enlargement

pleural effusion

trachea deviation w/ pneumothorax

pressure builds up on side of collapsed lung (tension pneumo) = deviation away from affected side

simple collapsed lung (not tension pneumo) = trachea deviated toward affected side

cause of posterior tracheal deviation

anterior mediastinal tumors

cause of anterior tracheal deviation

mediastinitis (inflammation of mediastinum)

what is the expected lung sound to be heard over all lung areas

resonance

associated causes of hyperresonance

hyperinflation: emphysema, pneumothorax, asthma

associated causes of hyporesonance (dullness)

pneumonia, atelectasis, pleural effusion, asthma

description of resonance sound

loud intensity, low pitch, long duration, and hollow quality

description of flat lung sound

soft intensity, high pitch, short duration, very dull quality

description of dull lung sound

medium intensity, medium-high pitch, medium duration, dull thud quality

description of tympanic lung sound

loud intensity, high pitch, medium duration, drum-like quality

description of hyperresonant lung sound

very loud intensity, very low pitch, longer duration, booming quality

what does sweet/fruity smelling breath indicate

diabetic ketoacidosis, starvation ketosis

what does fishy/stale smelling breath indicate

uremia (trimethylamies) - type of kidney failure

what does ammonia-like smelling breath indicate

uremia (ammonia) - type of kidney failure

what does musty fish/clover smelling breath indicate

fetor hepaticus: hepatic failure, portal vein thrombosis, portacaval shunts