Chapter 19: Thorax and Lungs Flashcards

Vocabulary flashcards covering anatomy, assessment landmarks, respiratory mechanics, diagnostic findings, thoracic configurations, and common pulmonary conditions from Chapter 19.

Thoracic Cage

A conical, bony structure narrower at the top, defined by the 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

 “floating,” with free palpable tips.

Anterior Thoracic Cage Landmarks

Anatomical landmarks including the suprasternal notch, manubrium, body of sternum, sternal angle (angle of Louis), costal cartilage, costochondral junction, xiphoid process, costal angle, and costal margin.

Costochondral Junctions

The points at which the ribs join their costal cartilages; they are not palpable.

Suprasternal Notch

A U-shaped depression located just above the sternum between the clavicles.

Angle of Louis

The manubriosternal angle located at the articulation of the manubrium and sternum; continuous with the second rib, it marks the site of tracheal bifurcation and corresponds with the upper border of the atria.

• Identify Angle of Louis, palpate lightly to second rib, and slide down to second intercostal space.

• Angle of Louis also marks site of tracheal bifurcation into right and left main bronchi

• Corresponds with upper border of atria of the heart, and it lies above fourth thoracic vertebra on back.

Costal Angle

The angle formed where the right and left costal margins meet at the xiphoid process.

Vertebra Prominens

The prominent spinous process of the C7 vertebra, serving as a landmark on the posterior chest.

Spinous processes

• ount down these knobs on vertebrae, which stack together to form spinal column.

Inferior border of scapula

• Scapulae are located symmetrically in each hemothorax.

Twelfth rib

Palpate midway between spine and a person’s side to identify its free tip.

Anterior Reference Lines

Vertical assessment lines on the front of the chest, including the midsternal line, midclavicular line, and anterior axillary line.

Posterior Reference Lines

Vertical assessment lines on the back of the chest, including the scapular line and vertebral line.

Lateral Reference Lines

Vertical assessment lines on the side of the chest, including the anterior axillary line, midaxillary line, and posterior axillary line.

Mediastinum

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

Lobes of lungs

• Lungs are paired but not precisely symmetric structures. 

• Right lung shorter than left because of underlying liver

• Left lung narrower than right because heart bulges to left

• Right lung has three lobes, and left lung has two lobes.

Anterior front chest

On anterior chest, oblique fissure crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line.

Posterior back chest

• Most remarkable point about posterior chest is that it is almost all lower lobes. 

Lateral chest side

Lung tissue extends from apex of axilla down to seventh or eighth rib.

Left lung

• Has no middle lobe

• Anterior chest contains mostly upper and middle 

lobe with very little lower lobe.

• Posterior chest contains almost all lower lobes.

Visceral Pleura

The slippery serous membrane lining the outside of the lungs and dipping into their fissures.

Parietal Pleura

The serous membrane that lines the inner surface of the chest cavity.

Pleural Cavity

A potential space between the visceral and parietal pleurae filled with lubricating fluid, maintaining a normal vacuum or negative pressure that holds the lungs against the chest wall.

Trachea lies anterior

esophagus and is 10 to 11 cm long in the adult.

Right main bronchus is shorter, wider, and more vertical than the left main bronchus.

• transport gases between the environment and lung parenchyma.

Trachea and bronchi

Dead Space

Space within the respiratory tract filled with air that is not available for gaseous exchange, measuring approximately $150\,\text{ml}$ in an adult.

Bronchial tree protests

alveoli from small particulate matter in inhaled air.

Lined with

goblet cells that secrete mucus

Acinus

The functional respiratory unit consisting of the bronchioles, alveolar ducts, alveolar sacs, and alveoli.

• to the body for energy production 

oxygen

• as a waste product of energy reactions

Removing carbon dioxide

arterial blood

Maintaining homeostasis (acid-base balance)

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

less important in humans

Maintaining heat exchange

change in carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion level. 

humoral regulation

• Second most commonly diagnosed cancer—smoking leading to mutational burden

lung cancer

• Affected more than 1/3 of the world’s population—social and migratory disease

• Need to identify and actively treat 

tb

• Most common chronic disease in childhood

• Highest burden seen in those living at or below the federal poverty level

• Ethnic and environmental factors play significant role. 

asthma

• Cough

• Shortness of breath

• Chest pain with breathing

• History of respiratory infections

• Smoking history

• Environmental exposure

• Patient-centered care

subjective data

inspection of thoracic cage

• Note shape and configuration of chest wall.

• Note the position the person takes to breath.

• Assess skin color and condition.

• Note any lesions; inquire about changes.

palpation

• Symmetric expansion—confirm by using hands 

• Tactile (or vocal) fremitus—using hands to assess for palpable vibrations

Tactile Fremitus

Palpable vibrations generated from the larynx and transmitted through the bronchopulmonary tree to the chest wall, assessed while the patient repeats phrases like "99".

Percussion: lungs

tissue across tops of both shoulders

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

Auscultation

directly on the skin

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

Three types of breath sounds heard normally in adults and older child:

• Bronchial, sometimes called tracheal or tubular

• Bronchovesicular

• Vesicular

Sources differ as to the classification and nomenclature of these sounds:

crackles

wheeze

Atelectatic Crackles

A type of non-pathologic adventitious sound consisting of short, popping, crackling sounds that do not persist beyond a few breaths.

Bronchial Breath Sounds

High-pitched, loud normal breath sounds heard over the trachea and larynx, characterized by a shorter inspiration phase than expiration phase.

Bronchovesicular Breath Sounds

Moderate-pitched normal breath sounds heard over major bronchi where fewer alveoli are located, equal in duration during inspiration and expiration.

Vesicular Breath Sounds

Low-pitched, soft normal breath sounds heard over peripheral lung fields, where inspiration duration is greater than expiration.

Forced Expiratory Time

The number of seconds it takes to exhale from total lung capacity to residual volume; functions as a screening measure for airflow obstruction.

tactile fremitus

vocal

anterior assessment

inspection

palpation

percussion

accusation

Palpate anterior chest wall. anterior

• Note any tenderness or lumps.

• Note skin mobility, turgor, temperature, and moisture.

accusation of anterior

apices in superaclavicular areas to 6th rib

Forced expiratory

• ime is number of seconds it takes to exhale from total lung capacity to residual volume.

• It is a screening measure of airflow obstruction.

• Although test is usually not performed in respiratory assessment, it is useful to screen for pulmonary function.

Spirometer

measure lung health

Pulse oximeter

SpO₂.

• A healthy person with no lung disease and no anemia normally has an SpO₂ of 97% to 98%.

• Every SpO₂ result must be evaluated in context of a person’s Hb level, acid-base balance, and ventilatory status.

The 6-minute walk test (6 MWT)

• is a safer, simple, inexpensive, clinical measure of functional status in aging adults.

• 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 when deep mouth breathing is required

Acutely ill patient

• Use of second examiner to assist with positional changes

• Use of rolling technique if solo examiner but can interfere with bilateral comparison

Barrel Chest

An abnormal chest configuration characterized by an increased anteroposterior (AP) diameter, equal AP-to-transverse ratio, and horizontal ribs, commonly associated with emphysema and aging.

Scoliosis

A lateral S-shaped curvature of the thoracic and lumbar spine, causing unequal shoulder and hip heights.

Pectus Excavatum

A markedly sunken sternum and adjacent cartilages, also known as funnel chest.

Pectus Carinatum

A forward protrusion of the sternum with ribs sloping back at either side, also known as pigeon breast.

• Discontinuous sounds

• Crackles—fine-aka rales listen

• Crackles—coarse listen

Atelectatic crackles:Pleural friction rub low pitch

• Continuous sounds

• Wheeze—sibilant-high pitch listen

• Wheeze—sonorous rhonchi- low pitched

• Stridor listen

Pulmonary

• Alveolar, interstitial, obstruction of airflow, restrictive, or vascular

Cardiac

• Dysrhythmia, heart failure, restrictive or constrictive pericardial disease, or valvular

• Gastrointestinal

Aspiration

Neuromuscular

• Respiratory muscle weakness

Anxiety

Psychological

Atelectasis

A condition involving collapsed alveoli or lung section due to airway obstruction, resulting in an expansion lag, dull percussion note, and decreased breath sounds.

abnormal findings

• Atelectasis, lobar pneumonia, or bronchitis (acute or chronic)

• Emphysema or asthma (reactive airway disease)

• Pleural effusion (fluid) or thickening

• Pneumocystis jiroveci (P. carinii) pneumonia

• Tuberculosis

• Pulmonary embolism

• Acute respiratory distress syndrome (ARDS)

• Lung cancer

Emphysema

A chronic condition caused by destruction of pulmonary connective tissue (elastin and collagen), producing permanent enlargement of air sacs, hyperinflated lungs, hyper-resonance, and barrel chest.

Asthma

An allergic hypersensitivity response triggering bronchospasm, mucosal edema, and thick mucus, resulting in dyspnea, labored prolonged expiration, and bilateral wheezing.

Pleural Effusion

An abnormal collection of fluid in the intrapleural space, which may consist of transudate, exudate, empyemic pus, blood (hemothorax), or chylothorax.

Lobar Pneumonia

Infection of lung tissue where porous alveolar membranes allow fluid, RBCs, WBCs, and bacteria to replace air in the alveoli, producing dull percussion and fine-to-medium crackles.

Chronic Bronchitis

Proliferation of mucus glands and bronchial inflammation leading to excessive mucus secretion, a hacking cough, deflated alveoli beyond obstruction, and prolonged expiration.

Pneumothorax

The presence of free air in the pleural space caused by a rupture in the lung wall or a leak in the chest wall, leading to lung collapse.

Pulmonary Embolism

Occlusion of pulmonary arterial blood flow by an embolus originating in the venous circulation (such as a thrombus, air, or fat), causing chest pain, anxiety, cyanosis, and tachycardia.

Acute Respiratory Distress Syndrome (ARDS)

Severe alveolar-capillary membrane damage leading to pulmonary edema, reduced gas exchange, acute dyspnea, frothy sputum, hypotension, and crackles/rhonchi.

normal lung

• Relaxed posture

• 10-18 brpm

• Symmetric expansion

• Resonant percussion

• No adventitious sounds

Atelectasis

• Collapsed section of alveoli

• Diaphragm fills in space

• Cough

• Expansion lag

• Increased RR & HR

• Dull percussion

• Decreased br sounds

• ? Fine crackles

Emphysema

• Destruction of elastin & collagen = permanent enlargement of air sacs → hyperinflated lungs 

• Associated with smoking hx

• ↑ AP diameter; barrel chest

• Tripod position

• Tachypnea

• Hyper-resonant

• ↓ Br sounds & muffled HR sounds

Asthma/Reactive Airway

• Allergic hypersensitivity

• Inhaled allergens, irritants, microbes

• dyspnea

• Audible wheeze

• Labored, prolonged expiration

• Diminished air mvmt

• Bilat expiratory wheezing

Pleural Effusion

• Collection of excess fluid in intrapleural space

  • Capillary fluid

  • Protein (exudate)

  • Purulent (empyemic)

  • Blood (hemothorax)

  • Lymphatic fluid

• ↑ RR & HR, dry cough, cyanosis

• Tracheal shift away from Eff

• Br sounds ↓ or absent

• crackles

Lobar Pneumonia

• Infection of lung

• Alveolar membrane is porous- RBC & WBC fill alveoli---then bacteria & fluid not air

• Fever, cough, CP, SOB, chills

• RR >24, HR >100 (tachy)

• Dull

• Crackle- fine to medium

Chronic Bronchitis

• Increased mucus & bronchial inflammation

• Deflated alveoli past obstruction

• Hacking cough

• Normal fremitus

• Resonant

• Prolonged expiration; crackles and wheezes possible

Pneumothorax

• Air in pleural space from rupture or leak in lung wall

• Spontaneous-

• Traumatic

• Tension

Pulmonary Embolism

• Embolism in venous circulation(venous thrombus, air, or fat) 

• Chest pain

• Restless, anxiety

• Diaphoresis, hypotension

• Tachycardia

• Crackles, wheezes

Acute Respiratory Distress Syndrome

• Damage to alveoli capillary membrane leads to pulmonary edema

• Severe infection, sepsis, shock, or trauma

• Acute dyspnea

• Restless disorientation

• Frothy sputum

• Hypotension, tachycardia

• Crackles, rhonchi

Lung Cancer

• Most fatal malignancy

• 85% cause=tobacco smoke

• Fatigue, n & v

• Weight loss

• Anemia, hemoptysis

Summary Checklist: Thorax and Lungs Examination IPPA

• Inspection

  • 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 and estimate diaphragmatic excursion

• Auscultation

  • Assess breath sounds, and note any abnormal/adventitious breath sounds.

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