Assessing the Thorax and Lungs

What Does the Respiratory System Do?

1. Bring in oxygen

   • Your body needs oxygen to make energy,

   • You breathe in air, and oxygen goes into your lungs.

2. Get rid of carbon dioxide (CO₂)

   • As your body uses energy, it makes waste gas called carbon dioxide.

   • You breathe it out to keep your body clean and healthy.

3. Keep everything in balance (homeostasis)

   • Your body works best when everything is balanced—not too much oxygen or carbon dioxide.

   • This balance happens in tiny air sacs in your lungs called alveoli (say: al-VEE-oh-lye).

   • That’s where oxygen (O₂) goes into your blood and carbon dioxide (CO₂) comes out.
     🧠 Fun fact:

   • Oxygen is basic (it helps keep your blood less acidic).

   • Carbon dioxide is acidic, so your body needs to get rid of extra CO₂ to stay balanced.

4. Help with heat control (mostly in animals)

   • Some animals breathe to help cool down their bodies—like dogs panting!

 

🫁 Important Body Parts That Help You Breathe (Landmarks) 

🦴 Thoracic Cage (your chest "cage")

This is like the protective armor around your lungs and heart!

1. Sternum

   • This is the flat bone in the middle of your chest (where your ribs connect in the front).

2. Ribs – 12 pairs
   These bones wrap around your chest like a cage:

   • First 7 pairs connect right to the sternum.

   • Ribs 8, 9, and 10 connect to the cartilage above them, not straight to the sternum.

   • Ribs 11 and 12 are called “floating ribs” – they don’t attach in the front at all!

3. Thoracic Vertebrae – 12 bones

   • These are the spine bones in your upper back, behind your lungs.

 

💨 Diaphragm – The Breathing Muscle

• The diaphragm is a big, flat muscle under your lungs.

• It helps pull air into your lungs when you breathe in.

• When you inhale (breathe in), the diaphragm moves down to make space for your lungs to fill with air.

• It doesn’t go up—it goes down because the lungs expand like balloons!

• The diaphragm is the main muscle that helps you breathe.

Important Parts on the Anterior Chest:

1. Suprasternal Notch

   • A little dip or dent you can feel at the top of your chest, right between your collarbones.

2. Sternum – The bone in the middle of your chest
   It's made of 3 parts:

   • Manubrium – the top part

   • Body – the middle part

   • Xiphoid process – the small pointy part at the bottom

3. Sternal Angle (Angle of Louis)

   • Where the manubrium and body of the sternum meet

   • This is important because:

     • It lines up with rib #2 (that’s how we start counting ribs!)

     • It’s also where the lungs split into two big tubes (right and left main bronchi)

4. Costal Angle

   • This is the angle under your ribs at the bottom front of your chest.

   • It should be about a 90-degree angle in a healthy person.

5. Intercostal Spaces

   • These are the spaces between your ribs.

   • Doctors listen to your lungs by placing the stethoscope in these spaces!

Important Landmarks on Your Back (Posterior)

1. Vertebra Prominens

   • This is the bump you feel at the base of your neck when you bend your head forward.

   • It’s part of your spine and is called C7 (the 7th cervical vertebra).

   • The next one below it is T1 (the 1st thoracic vertebra).

2. Spinous Processes

   • These are the bony bumps you feel running down your spine.

   • They help us count the vertebrae (the bones of the spine).

3. Scapula

   • These are your shoulder blades, the flat bones on the upper part of your back.

4. 12th Rib

   • This is the last rib at the bottom of your rib cage.

   • It helps mark the end of the ribcage and is sometimes called a “floating rib.”

Midsternal line:

A line that runs straight down the middle of your chest over the breastbone (sternum).

Midclavicular line:

• A line that goes straight down from the middle of your collarbone.

Apex of the lung:

The top tip of your lung, which is just above the collarbone (about 3–4 cm higher).

Bottom of the lung (anterior):

Ends around the 6th rib in the front

Vertebral line:

A line that runs down your spine in the center of your back.

Scapular line:

A line that runs down through your shoulder blades.

Bottom of the lung (posterior):

• At rest: lungs end at T10 (10th thoracic vertebra).

• When you breathe in deeply: they stretch down to T12.

What’s Inside the Thoracic Cavity

1. Mediastinum
   This is the middle section of your chest. It holds:

   • Heart ❤

   • Trachea (windpipe)

   • Esophagus (tube for food)

   • Great vessels (like the aorta and vena cava—big blood tubes)

2. Pleural Cavities

   • These are the spaces on each side of your chest where your lungs sit.

   • Each lung is in its own little “room.”

🫁 Lungs: Left vs. Right

➤ Right Lung

• 3 Lobes:

  • Upper (RUL)

  • Middle (RML)

  • Lower (RLL)

• It’s a little shorter because the liver is right underneath it.

➤ Left Lung

• 2 Lobes:

  • Upper (LUL)

  • Lower (LLL)

• It’s narrower because the heart takes up space on the left side.

📏 How Far Do the Lungs Go?

From your back view (posterior):

• At rest (expiration) → Lungs go down to T10 (10th vertebra).

• When you breathe in deeply (inspiration) → Lungs stretch down to T12.

From the front view (anterior):

• Lungs end around the 6th rib at the midclavicular line (middle of the collarbone).

• The horizontal fissure separates the RUL and RML around the 4th rib.

• The oblique fissures (both sides) divide the upper and lower lobes.

Pleural Cavity Basics:

• The pleural cavity is the tiny space between your lungs and the chest wall.

• It normally has a vacuum (no air) and a tiny bit of fluid, so the lungs can slide smoothly—like butter on a pan.

• It’s quiet and gentle—you don’t feel it working!

💨 Pneumothorax (collapsed lung from air)

• This happens when air leaks into the pleural space.

• It pushes on the lung and makes it collapse.

• Can happen from:

  • Injury/trauma (like a car accident or fall)

  • Lung disease

Hemothorax

• Similar to pneumothorax, but it’s blood, not air, filling the space.

• Also causes the lung to collapse.

How Do You Know a Lung Collapsed?

• The chest may rise unevenly.

• You may feel less vibration (called tactile fremitus) on one side when a nurse touches your chest.

• It can feel hard to breathe

Atelectasis (say: AT-uh-LEK-tuh-sis)

• This is when part of the lung collapses, not the whole thing.

• It’s not the same as pneumothorax.

• It might happen after surgery or if a person isn't breathing deeply.

Pleurae Anatomy

1. Visceral pleura

   • This is the inner layer.

   • It sticks tightly to your lung, like shrink wrap.

2. Parietal pleura

   • This is the outer layer.

   • It lines the inside of your chest wall.

🫙 In Between? The Pleural Space

• This tiny space has just a few drops of fluid.

• It helps your lungs slide like butter on a pan when you breathe.

• No noise, no rubbing—just smooth gliding!

What Does the Trachea and Bronchial Tree Do?

• The trachea (windpipe) brings air from your nose and mouth down into your lungs.

• It splits at the Angle of Louis (the bump you feel at your 2nd rib) into:

  • The right main bronchus

  • The left main bronchus

These big tubes branch off like a tree into smaller bronchioles, which end in tiny air sacs called alveoli.

 How Does the Bronchial Keep the Air Clean?

Your lungs are like a smart air filter:

1. Goblet cells

   • These are mucus-makers!

   • They trap dust, germs, and tiny particles from the air you breathe.

2. Cilia

   • These are tiny hair-like sweepers.

   • They move the mucus (and trapped stuff) upward toward your throat so you can swallow it or cough it out.

What Happens in the Alveoli?

• Oxygen (O₂) from the air goes into your blood.

• Carbon dioxide (CO₂) from your blood comes out to be exhaled.

• This gas swap happens across something called the respiratory membrane — a super thin barrier that lets gases pass easily.

The Alveoli

• At the very end of the airways, you’ll find alveoli — tiny balloon-like sacs.

• They're grouped like grapes on a stem around tiny tubes called alveolar ducts.

🟣 Imagine this:

The trachea is the trunk,

the bronchi are the branches,

the alveoli are the grape clusters at the tips!

Breathing and Body Balance (Acid/Base Balance)

💨 If you breathe faster, you get rid of more CO₂, and your blood becomes less acidic.

😮‍💨 If you breathe slower, CO₂ builds up, and your blood becomes more acidic.

Your body is like a science lab that needs to stay in perfect balance—not too acidic and not too basic. Your lungs help keep that balance!

What Controls Breathing?

Normally, your brain tells you to breathe when there’s too much CO₂ in your body.

This is called hypercapnia — “hyper” means too much and “capnia” means CO₂.

🧠 So your brain says:

“Hey! There’s too much CO₂ — start breathing faster!”

COPD or Emphysema Drive to Breathe

People with COPD or emphysema often have high CO₂ all the time, so their body gets used to it.

⚠ Their brain stops using CO₂ levels to control breathing.

Instead, they breathe when their oxygen (O₂) is low.

 What is COPD?

 stands for Chronic Obstructive Pulmonary Disease.

It’s a long-term lung problem that makes it hard to breathe.

It means something is blocking the airways.

So when you try to breathe out, the air gets stuck inside your lungs.

What is Emphysema?

Emphysema is a type of COPD.

In emphysema:

• The tiny air sacs in your lungs, called alveoli, get damaged.

• These sacs normally stretch like balloons to hold air.

• But in emphysema, they get broken or floppy, so the lungs can’t push air out well.

• Lungs can't push out carbon dioxide (CO₂) well → it gets trapped.

• People start using low oxygen (O₂) levels to tell them when to breathe (instead of CO₂).

What Causes COPD and Emphysema?

• Smoking is the #1 cause.

• Breathing dirty air, chemicals, or fumes for many years can also cause it.

Accessory Muscles: The Backup Team for Breathing

When you’re sick, having trouble breathing, or working really hard to breathe, your body calls in extra help — the accessory muscles!

It can be a sign of trouble, like in asthma or COPD.

1. Sternocleidomastoid muscles

   • These are on the side of your neck.

   • They help lift your chest to get more air in.

2. Scalene muscles

   • These are also in your neck, near the sternocleidomastoids.

   • They help raise the top part of your ribs.

3. Abdominal muscles

   • Yep! Your belly muscles push up to help push air out of the lungs.

passive breathing

Normally, breathing is easy — your diaphragm and lungs do all the work without you thinking about it.

Lung Cancer

• It’s the 2nd most common cancer in both men and women.

• The #1 cause is smoking.

• Even secondhand smoke (being around someone who smokes) is very harmful.

Tuberculosis (TB)

• TB is an airborne disease (you breathe it in).

• It mostly happens in crowded or poor living conditions.

• It’s rare in the U.S., but:

  • Most cases happen in people born outside the U.S..

  • Often, it’s a “reactivation” — TB was already in the body, but not active.

  • HIV and being homeless make it more likely to get sick from TB.

Asthma

• Asthma is when airways get tight and inflamed, making it hard to breathe.

• It causes:

  • Wheezing (a whistling sound)

  • Coughing

  • Shortness of breath (SOB)

 Childhood (Pediatric) Asthma

• It’s the most common long-term disease in kids.

• Happens more in kids who live in poverty.

• Caused by:

  • Genes (runs in families)

  • Environment (like breathing in smoke, dust, or allergens)

🔄 Kids with asthma may be at higher risk for COPD later in life.

 Adult Asthma

• It’s a chronic condition (doesn’t go away).

• Caused by inflammation and blocked airflow.

• Avoid triggers like:

  • Perfume, pollen, strong smells, cold air

• Treated with medicine (Rx therapy) to help control symptoms.

Objective Data Assessment

• Inspect

• Palpate

• Percuss

• Auscultate

Resp patterns

• 12–20 breaths per minute for adults

• Even pattern — smooth in and out

• Normal depth — not too shallow or too deep

🧘 Imagine someone resting calmly — their chest goes up and down slowly and evenly. That’s what healthy breathing looks like.

Eupnea:

• Normal breathing

• Even, quiet, and 12–20 breaths per minute in adult

Apnea

• 😶 No breathing at all

• Very serious — can happen during sleep or after trauma

Tachypnea

• 🏃 Fast and shallow breathing (more than 25 breaths/min)

• Happens with fever, exercise, or fear

Bradypnea

• 🐢 Slow breathing (fewer than 10 breaths/min)

• Can happen from drugs or brain pressure

Hyperventilation

• 🌀 Fast and deep breathing

• Seen with anxiety, fever, or diabetic emergencies (like DKA)

• Person is trying to blow off too much CO₂

Hypoventilation

• 😴 Shallow and slow breathing

• Seen with narcotics or anesthesia

• Can cause CO₂ buildup → makes blood too acidic

Cheyne-Stokes (Periodic Breathing)

• 📈📉 Breathings gets faster, then slower, then stops (apnea) — then repeats

• Common with heart failure or when the body is shutting down

Biot’s Respirations

• 🧠 Random breathing and apnea

• No regular pattern — like chaotic Cheyne-Stokes

• Seen with brain injuries

Orthopnea

• 🛏 Trouble breathing when lying down

• Person may need to sleep sitting up

Kussmaul Breathing

• 😤 Very deep, fast breathing

• Happens when the body is trying to fix acid/base problems, especially with diabetic ketoacidosis (DKA)

Inspecting the Back of the Chest (Posterior Chest)

1. Patient’s Position

   • Is the person sitting up straight or leaning forward?

   • People with emphysema may sit in a tripod position (leaning forward with hands on knees) to help breathe better.

   • Are they comfortable or do they look like they’re struggling to breathe?

 

1. Skin Check

   • Is the skin pale (light-colored)?

   • Is there pallor (unhealthy paleness)?

   • Is there cyanosis (blue lips or fingertips from low oxygen)?

   • Does the skin look even and normal?

 

1. Thoracic Cage (Chest Shape)

   • this is a 1:2 ratio (AP:L).

   • If the chest is rounded or puffed out like a barrel (called barrel chest), it could be from long-term breathing problems like COPD.

   • Look at the angle where the ribs meet under the chest (costal angle) — it’s usually 90 degrees, but may change with disease.

🦅 "The Eagle is no longer 90 degrees" = the costal angle (rib angle) is too wide — this can be a sign of lung disease.

Abnormalities of Inspection

👉 1. Clubbing

• This is when the tips of the fingers get round and puffy, and the nails curve down.

• It happens slowly over time when the body doesn’t get enough oxygen.

🔺 What’s Normal?

• Normally, the angle between your nail and skin is about 160°.

🧲 With Clubbing:

• That angle becomes 180° or more.

• You lose the normal space when you do the “window test” (shown in the pictures where nails touch and there's no diamond-shaped gap).

 

🩸 2. Capillary Refill

• This checks how well blood flows through your fingers (called perfusion).

• Press on the nail until it turns white, then let go.

• Normal refill = color comes back in less than 2 seconds.

• If it takes longer, it might mean poor circulation or low oxygen.

 

🌫 3. Cyanosis

• If fingers or lips look blue or purple, it’s called cyanosis.

• This means there isn’t enough oxygen in the blood.

Palpation: Using Hands to Check the Lungs

🫁 Symmetric Chest Expansion

• When you take a deep breath, both sides of your back should move out the same way — that’s called symmetric expansion.

• It means your lungs are working equally on both sides.

 

⚠ What If It’s Uneven?

If one side doesn’t move as much, it could be a sign of a lung problem, like:

• Atelectasis – part of the lung has collapsed

• Lobar pneumonia – infection in one section (lobe) of the lung

• Trauma – injury to the chest (like broken ribs)

• Pneumothorax – air gets trapped and collapses a lung

 

Palpate Posterior Chest: Position

• place hand at T10

• asks to breath and thumbs should move apart equally

Tactile Fremitus: Feeling for Lung Vibrations

1. Start at the top of the back — around C7 (the bump at the base of the neck).

1. Ask the patient to say “99” or “blue moon.”

2. Use your hands to feel both sides of the chest at the same time.

3. Move down the back in a step-ladder pattern (one level at a time).

What Is Fremitus?

• Fremitus is a vibration you can feel with your hands when someone talks.

• These vibrations come from the larynx (voice box) and travel through the lungs.

What Do We Feel for in Tactile Fremitus?

🎯 Symmetry Is the Most Important Thing!

• Both sides should have equal vibrations.

• If one side feels different, something might be wrong.

 

⬇ Decreased Fremitus (Less Vibration)

This means vibrations are weaker or missing.

🔍 Why?

Something is blocking the vibrations or the lungs are too empty or damaged, like:

• Pneumothorax (collapsed lung with air in the chest)

• Tumor (neoplasm)

• Emphysema (damaged air sacs)

 

⬆ Increased Fremitus (More Vibration)

This means vibrations are stronger than normal.

🔍 Why?

Something is making the lungs more solid (like fluid or pus), so vibrations travel better, like:

• Lobar pneumonia (fluid-filled lung from infection)

📌 Only big, solid changes (called gross changes) cause increased fremitus.

💥 Crepitus (Say: “KREP-it-us”)

• Feels like: crackling or popping under the skin — kind of like bubble wrap!

• It happens when air leaks out of the lungs and gets trapped under the skin.

🩺 Called subcutaneous emphysema

😷 Often seen after surgery or if there’s been chest trauma

🖐 Other Things to Feel For During Palpation:

1. Skin Temperature

   • Is it warm, cold, or uneven?

   • Changes in temp could mean infection or poor blood flow.

2. Lesions or Masses

   • Feeling for lumps, bumps, or abnormal growths on or under the skin

What You Hear When You Tap on the Back (Percussion)

Healthy Lungs Sound

• Resonance is the normal sound over lungs

  • It’s low-pitched and sounds hollow — kind of like tapping on a drum.

  • That means there’s air inside, like there should be!

❗ Abnormal Sounds Mean

1. Hyperresonance

   • Too much air in the lungs

   • Sounds extra loud and hollow

   • Seen in people with emphysema or pneumothorax

2. Dullness (Dull Sound)

   • Too little air or something solid in the lungs

   • Sounds flat or quiet

   • Seen in pneumonia (lung filled with fluid or pus)

 Auscultation: how to listen to Lungs

• From the top of the back (C7) down to the bottom (T12)

• Also listen to the sides, from the armpit (axilla) down to the 7th rib

1. Ask the person to breathe through their mouth

   • They should take slightly deeper breaths than normal.

2. Use the flat part of the stethoscope (the diaphragm)

   • Place it directly on the skin, not over clothes.

3. Listen in a pattern

   • Move the stethoscope from side to side, not just straight down.

   • This helps you compare both lungs to see if they sound the same.

Normal Lung Sounds: What You Should Hear

🔊 1. Bronchial (B)

• Where: Over the trachea (the big airway in your neck)

• Sound:

  • High-pitched

  • Loud and harsh — like wind blowing

  • Expiration is longer than inspiration

• Think of this like a blow dryer sound

 

🔉 2. Bronchovesicular (BV)

• Where: Around the center of the chest, near the 1st and 2nd ribs and between the shoulder blades (on the back)

• Sound:

  • Medium pitch and loudness

  • Inspiration and expiration are equal

• Think of this like a gentler wind sound

 

🌬 3. Vesicular (V)

• Where: Over most of the lung fields — sides, back, and lower chest

• Sound:

  • Soft and low-pitched

  • Inspiration is longer than expiration

• Sounds like a gentle breeze through trees

Adventitious Sounds = Added Lung Sounds

🔊 1. Crackles (Rales)

These sound like popping or crackling — like when you pour milk over Rice Krispies!

• 🟣 Fine crackles

  • Tiny, short, high-pitched pops

  • Heard mostly on inspiration (breathing in)

  • Don’t go away with coughing

  • May change with position

  • Seen in: Pneumonia, CHF (heart failure)

• 🔵 Coarse crackles

  • Bigger, low-pitched bubbling/gurgling sounds

  • Heard on inspiration and maybe expiration

  • Don’t change with coughing or movement

  • Seen in: COPD, asthma, pneumonia

 

🌀 2. Wheezes (Also called Rhonchi)

Sound like a squeaky toy or whistling.

• 🟠 High-pitched wheeze

  • Sounds like musical notes

  • Mostly during expiration

  • Seen in: Asthma, chronic emphysema

• 🔴 Low-pitched wheeze (rhonchi)

  • Like a snoring or rumbling sound

  • One note, often during expiration

 

🫧 3. Atelectatic Crackles

• These are temporary crackles

• Go away after coughing or changing position

• Caused by airways that were briefly closed but open again

 

🚨 4. Stridor

• High-pitched, loud sound

• Heard mostly when breathing in

• Usually means something is blocking the upper airway (like the larynx or trachea)

• Could be from swelling, choking, or a foreign object

 

Adventitious sounds are extra sounds that can happen when:

• There’s mucus in the airways

• Air is trying to move through tight or blocked passages

• Airways are popping open after being closed

 Inspecting the Front of the Chest (Anterior Chest)

1. Shape & Configuration

   • Is the chest shaped normally?

   • Is it too round (barrel chest) or uneven?

2. Facial Expression

   • Does the person look calm or like they’re struggling to breathe?

   • Are they using extra effort (like flaring nostrils or grimacing)?

3. Level of Consciousness

   • Is the person alert and awake?

   • Are they confused or sleepy (a sign the brain isn’t getting enough oxygen)?

4. Skin Color & Condition

   • Is the skin normal color, pale, or blue (cyanosis)?

   • Is it sweaty or dry?

5. Quality of Respirations

   • Are breaths smooth and even?

   • Or are they labored, noisy, or fast?

6. Respiratory Rate

   • How many breaths per minute?

   • Normal for adults: 12–20 breaths per minute

Listening to the Front of the Lungs (Auscultation: Anterior Chest)

1. Start at the Top (Apices)

   • Listen above the collarbone (this is called the supraclavicular area).

   • That’s where the top of the lungs are.

2. Go Down to the 6th Rib

   • The nurse moves the stethoscope down the chest, listening to both sides, all the way to the 6th rib.

3. Displace the Female Breast if Needed

   • Gently move the breast out of the way to get to the right spot on the chest wall.

4. Listen for One Full Breath at Each Spot

   • That means one breath in and one breath out.

   • Move side-to-side to compare both lungs.

Measuring Pulmonary Function

• One easy way to check how well your lungs are working is by using a little tool called a pulse oximeter.

• A healthy person should have an SpO₂ (oxygen level) of 95% to 100%.

• If it’s lower than 95%, it could mean you’re not getting enough oxygen and might need help.

Health Promotion: Keeping Your Lungs Healthy

• Smoking is the #1 cause of preventable disease — that means people get sick from it even though they don’t have to.

• It damages the lungs, heart, blood vessels, and many other parts of your body.

• It also puts others at risk through secondhand smoke.