chapter 19 thorax and lungs

Functions of the respiratory system:

1. Supplies oxygen to the body for energy production

2. Removes carbon dioxide as a waste product of energy reaction 

3. Maintains homeostasis (acid base balance) in arterial blood 

4. Maintains heat exchange

By supplying O2 to the blood and eliminating excess CO2, respiration maintains the pH or the acid/base balance of the blood)

Structure and function of thoracic

Thoracic cage is a bony structure with a conical shape, which is narrower at top

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

- 1-7 ribs attach to sternum by costal cartilages

- Ribs 8-10 attach to costal cartilage above

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

The costochondral junctions are the points at which the ribs join their cartilages. They are not palpable

Suprasternal Notch

shaped depression just above sternum between clavicles

sternum

breastbone

also has:

• manubrium

• body

• xiphoid process

Costal angle

the right and left costal margins form an angle where they meet at xiphoid process

• 90 degrees

Manubriosternal angle: “Angle of Louis”

located in the second intercostal space in the rib 

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

rationale: The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back

Evaluate presence and quality of normal breath sounds both anterior, laterally and posterior

Use flat diaphragm of stethoscope and listen to at least one full respiration in each location

Sputum of

pulmonary edema

Tuberculosis

Croup

Viral infection

PE= pink and frothy

TB=rust-colored sputum

Croup= barking cough not spectrum production

viral infections= white or clear mucoid sputum

apex of the lungs

highest point, of lung tissue is 3 to 4 cm above the inner third of the clavicles

apices of the lungs

the apices are at the level of C7.

base

rests on the diaphragm at about the 6th rib in the midclavicular line. Laterally lung tissue extends from the apex of the axilla down to the 7th or 8th rib

What is the correct method to use when progressing from one auscultatory site on the thorax to another

start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders Then, percussing in the interspaces, make a side-to-side comparison all the way down the lung region. Percuss at 5-cm intervals. Avoid the damping effect of the scapulae and ribs

Resonance

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

can be duller in the athlete

Assess tactile (or vocal) fremitus

Fremitus is a palpable vibration.

using 2 hands to palpate for sound

Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall, where you feel them as vibrations

-most intensely Between the scapulae and sternum (major bronchi are closest to chest wall)

severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds

wheezing

Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema

normal lung for comparison

inspection

palpation

percussion

auscultation

adventitious sounds

inspections: ap is greater than transverse diaper, 10-20 breaths/mins no cyanosis/pallor

palpation: symmetric chest expansion tactile remits present and equal bilaterally

percussion: resonant

auscultation: vesicular over peripheral fields, bronchovesicular anterior and between scapulae and posterior, infants bronchovesicular thought

crackles, is not pathologic. crackles are short, popping, crackling sounds that last only a few breaths

collapsed section of the alveoli

Inspection: a cough, a faster heart and breathing rate, cyanosis

Palpation:Chest expansion decreased on affected side. Tactile fremitus decreased or absent. With large collapse, tracheal shift toward affected side

Percussion: Dullness over area

Auscultation: Breath sounds decreased vesicular or absent over area

atelacsis (collapse)

inspection: cough initially nonproductive later purulent yellow green sputum

palpation: skin moist a night from nigh swearts

percussion: resonant initially dull over effusion

auscultation: normal/dereased vesicular breath sounds

adventitious sounds: crackles over upper lobes

tuberculosis

subjective: chest pain worse on deep inspiration, dyspenea

inspection: restles, aniety, cyanosis tachypnea,

palpation: diaphoresis (sweating) , hypotension

auscultation: tachycardia, accentuated pulmonic component of S2

adventitious sounds: crackles, wheezes

pulmonary embolism

An acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks.

Inspection Cough is productive or nonproductive. Also sore throat, low-grade fever, postnasal drip, fatigue, substernal aching.

Palpation No pain, no increased fremitus.

Percussion Resonance predominates.

Auscultation May be clear and equal bilaterally. No egophony.

Adventitious sounds: no

acute bronchitis

CA type of (COPD), g.

Inspection: rasping cough productive of thick mucoid sputum. Chronic—dyspnea, fatigue, cyanosis, possible clubbing of fingers.Acute exacerbations may have worsening dyspnea and increased cyanosis

Palpation: Tactile fremitus normal.

Percussion:Resonant.

AuscultationNormal vesicular. Voice sounds normal. Chronic—prolonged expiration.

Adventitious Sounds: Crackles over deflated areas. May have wheeze, especially with acute exacerbation.

Chronic bronchitis has a history of productive cough for 3 months of the year for 2 years in a row

Chronic Bronchitis

A patient has been admitted to the emergency department for a suspected drug overdose. Respirations are shallow, with an irregular pattern, at a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following?

Chronic obstructive breathing

Bradypnea

Cheyne-Stokes respirations

 Hypoventilation

Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. Cheyne-Stokes respirations are a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. Chronic obstructive breathing is characterized by normal inspiration and prolonged expiration to overcome increased airway resistance. This patient’s breathing is hypoventilation.

normal finding when assessing the respiratory system of an older adult

 

Decreased mobility of the thorax

The costal cartilages become calcified with aging, resulting in a less mobile thorax and thus also a slight decrease, not increase, in thoracic expansion

normal adult for comparison

Rate—10 to 20 breaths/min

hyperventilation

increases in both rate and dept

tachypnea

Rapid, shallow breathing. Increased rate, >24 per minute

sigh

Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction and also may lead to hyperventilation and dizziness.

bradypynea

Slow breathing. A decreased but regular rate (<10 per minute),

hypoventilation

An irregular shallow pattern caused by an overdose of narcotics or anesthetics

Cheyne-Stokes Respiration

respirations are a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing

Biot Respiration

Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (3 to 4) is followed by a period of apnea

Chronic Obstructive Breathing

Normal inspiration and prolonged expiration to overcome increased airway resistance

subjective data

1. Cough: Acute cough lasts less than 2 or 3 weeks; chronic cough lasts over 2 months

2. Shortness of breath: Orthopnea is difficulty breathing when supine, State number of pillows needed to achieve comfort (e.g., “two-pillow orthopnea

Paroxysmal nocturnal dyspnea is awakening from sleep with SOB and needing to be upright to achieve comfort

3. Chest pain with breathing

4. History of respiratory infections

5. Smoking history

6. Environmental exposure: self care

7. Patient-centered care

Voice sounds

are not elicited routinely

testing for the possible presence of bronchophony, egophony, and whispered pectoriloquy

Normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distinguish exactly what is being said.

 Muffled voice sounds and symmetric tactile fremitus

Bronchophony

repeat “ninety-nine” while you listen with the stethoscope over the chest wall

abnormal: you auscultate a clear “ninety-nine

Egophony

Greek: “the voice of a goat

Auscultate the chest while the person phonates a long “ee-ee-ee-ee” sound

abnormal: “eeee” sound changes to a bleating long “aaaaa” sound

Whispered Pectoriloquy

Ask the person to whisper a phrase such as “one-two-three” as you auscultate

abnormal: the whispered voice is transmitted very clearly and distinctly, although still somewhat faint

assessment of the left lung

The left lung has two lobes and is longer and narrower than the right lung.

It is narrower than the right lung because the heart bulges to the left. fissures

The right lung has three lobes and is shorter than the left lung because of the underlying liver. The posterior chest is almost all lower lobes.

What are the primary muscles involved in normal respiration?

diaphragm and intercostals

The major muscle of respiration is the diaphragm and the intercostal muscles are also involved in respiration as they lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter.

Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles

symptoms of a cough associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. Based on these findings, what is the most likely cause

Tuberculosis

TB often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers

Hemoptysis (sputum)

(1) white or clear mucoid—colds, bronchitis, viral infections;

(2) yellow or green—bacterial infections;

(3) rust colored—TB, pneumococcal pneumonia;

(4) pink, frothy—pulmonary edema, some sympathomimetic medications have a side effect of pink-tinged mucus

Hyperresonance

Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax.

A dull note (soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor

low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration

Vesicular breath sounds that are normal in that location

Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where airflows through smaller bronchioles and alveoli. Normally harsh, hollow, or tubular sounds (bronchial breath sounds) are heard over the trachea. Vesicular breath sounds, not bronchial or bronchovesicular breath sounds, are normally heard over the posterior lower lobes

aging adult

The costal cartilages become calcified; thus the thorax is less mobile

decrease in elastic properties within the lungs, making them less distensible and lessening their tendency to collapse and recoil

decrease number of alveoli therefore less surface area is available for gas exchange therefore increase in dyspnea

Condition: Infection in lung parenchyma leaves alveolar membrane edematous and porous; thus red blood cells (RBCs) and white blood cells (WBCs) pass from blood to alveoli. Alveoli progressively fill up (become consolidated) with bacteria, solid cellular debris, fluid, and blood cells, which replace alveolar air.

Subjective: Fever, cough with pleuritic chest pain, chills, SOB, fatigue, malaise.

Inspection: Increased respirations >24/min. Guarding and lag on expansion on affected side. Children—Sternal retraction, nasal flaring. Cyanosis with severe illness. Possible hypotension.

Palpation: Chest expansion decreased on affected side. Tactile fremitus increased if bronchus patent, decreased if bronchus obstructed.

Percussion: Dull over lobar pneumonia.

Auscultation: Tachycardia. Loud bronchial breathing with patent bronchus. Voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present. Children—Diminished breath sounds may occur early.

Adventitious Sounds: Crackles, fine to medium.

Lobar Pneumonia

Condition: Pump failure causes increased backward pressure toward the pulmonary circulation, leading to pulmonary vascular congestion (engorgement of pulmonary capillaries).

Inspection: Increased respiratory rate, SOB on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, pallor in light-skinned people. In acute heart failure, may have pulmonary edema with pink, frothy sputum.

Palpation: Skin moist, clammy. Tactile fremitus normal.

Percussion: Resonant.

Auscultation: Normal vesicular. Heart sounds include S3 gallop.

Adventitious Sounds: Crackles at lung bases

Heart Failure

Condition: Free air in pleural space causes partial or complete lung collapse. Air in pleural space neutralizes or reverses the usual negative pressure present; thus lung collapses. Usually unilateral. can be (1) spontaneous (air enters pleural space through rupture in lung wall, (2) traumatic (air enters through opening or injury in chest wall), or (3) tension (trapped air in pleural space increases, compressing lung and shifting mediastinum to the unaffected side).

Inspection: Unequal chest expansion. If large, tachypnea, cyanosis, apprehension, bulging interspaces.

Palpation: Tactile fremitus decreased or absent. With tension pneumothorax, may see tracheal shift to opposite (unaffected) side. Chest expansion decreased on affected side.

Percussion: Hyperresonant.

Auscultation: Breath sounds decreased or absent. Voice sounds decreased or absent.

Adventitious Sounds: None

Pneumothorax

Conditio: nCollection of excess fluid in the intrapleural space, with compression of overlying lung tissue. may contain watery capillary fluid

Inspection: Increased respirations, dyspnea; may have dry cough, tachycardia, cyanosis, asymmetric expansion, abdominal distention.

Palpation: Tactile fremitus decreased or absent. Tracheal shift away from affected side. Chest expansion decreased on affected side.

Percussion":Dull on affected side.

Auscultation:Breath sounds decreased or absent. Voice sounds decreased or absent. When remainder of lung is compressed near the effusion, may have bronchial breath sounds over the compression along with bronchophony, egophony, whispered pectoriloquy.

Adventitious Sounds:Crackles, pleural rub

Pleural Effusion (Fluid

Condition: An allergic hypersensitivity to certain inhaled allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness.

Inspection: During severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chronic, may have barrel chest.

Palpation:Tactile fremitus decreased, tachycardia.

Percussion:Resonant. May be hyperresonant if chronic.

Auscultation:Diminished air movement. Breath sounds decreased, with prolonged expiration. Voice sounds decreased.

Adventitious Sounds:Bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing

Asthma (Reactive Airway Disease)

fine crackles

pneumonia, bronchiolitis, or atelectasis

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true?

 

Expected near the major airways

Bronchovesicular breath sounds are moderate in pitch and amplitude and are equal in length in inspiration and expiration. They are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct

Conditions with characteristic timing of cough

(1) continuous throughout day—acute illness (e.g., respiratory infection);

(2) afternoon/evening—may be exposure to irritants at work;

(3) night—postnasal drip, sinusitis;

(4) early morning—chronic bronchial inflammation of smokers

what is the costochondral junctions

are the points at which the ribs join their cartilages. They are not palpable

what are the reference lines

1. Midsternal

2. Midclavicular

3. Axillary Line - posterior, mid and anterior axillary line

Posterior Thoracic Landmarks

1. Vertebra Prominens - most prominent bony spur at base of neck (C-7)

2. spinous process

3. Scapula - inferior border usually at 7th or 8th rib

Physical Exam/Assessment (Objective)

1. Inspect posterior chest – note symmetry

2. Skin color and condition

3. Palpate symmetric chest expansion

4. Tactile fremitus - palpable vibration (“99")

5. Palpate chest wall for tenderness, skin temperature and/or masses

6. Percussion - note resonance or dullness over the lung fields

7. Diaphragmatic excursion- not routinely done and not required

8. Auscultate lungs in all lung fields (note whether clear or adventitious sounds, decreased or absent sounds), not necessary to determine - bronchial, bronchovesicular, or vesicular)

Pulse oximeter

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

• SpO2, known as oxygen saturation, is a measure of the amount of oxygen-carrying hemoglobin in the blood

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

inspection

1. Thoracic cage, respirations, skin color, and condition

2. A person’s facial expression, and LOC

palpation

1. Confirm symmetric expansion and tactile fremitus.

2. Detection of any lumps, masses, or tenderness

Percussions

       a. Lung fields, assess for resonance

         4. Auscultation posterior, lateral and anterior chest

1. Assess breath sounds (presence and quality), 

2. normal and note any abnormal/adventitious breath sounds (crackles[rales] and wheezes [ronchi])

normal: Spinous processes appear in a straight line.

abnormal Skeletal deformities limiting excursion (e.g., scoliosis, kyphosis

normal: Thorax is symmetric and elliptical. Ribs slope downward at about a 45-degree angle to the spine

abnormal: Barrel chest" (AP diameter = transverse diameter), ribs are horizontal (often seen in COPD). Chronic emphysema, occurs normal with aging

normal Anteroposterior (AP) diameter is less than transverse diameter

abnormal: Tripod position (leaning forward, arms braced) to aid in expiration (COPD

abnormal findings

Pectus carinatum

breastbone sinks inward into the chest, creating a noticeable depression or "funnel" shape.T

he chest looks caved in.

(pigeon breast/chest) - forward protusion of the sternum(second rib level

Tachypnea

increased RR, rapid shallow breathing greather than 24

Bradypnea

slow breathing pattern, (<10 respirations per minute

Cheyne-Stokes respirations

respirations gradually wax and wane, with periods of apnea, in a regular pattern, usually a sign of a poor prognosis

Pleural Effusion

collection of excess fluid in the intrapleural space

Pneumothorax

free air in pleural space causes lung collapse

Bronchitis

Inflammation of bronchi, may have partial obstruction of bronchi from secretions or inflammation causing constriction. Characterized by hacking, “mucousy” wet and often productive cough. Crackles with auscultation, usually CXR will be clear.

Pneumonia

Infection of the lung parenchyma, alveoli become consolidated with bacteria and fluid. Lung sounds will auscultate crackles or be diminished, especially in the bases, percussion will illicit a dull sound

Asthma

Reactive airway disease, an allergic response or hypersensitivity to allergens, irritants, microorganisms, and exercise. Characterized by bronchospasm, inflammation and very thick mucous production in the airways

Chronic obstructive breathing

normal inspiration and prolonged expiration to overcome increased airway resistance chronic obstructive lung disease

Atelectasis (Collapsed Lung

Collapsed section of lung or entire lung. Significantly decreased or absent lung sounds over affected area

Rhonchal fremitus

Rhonchal fremitus is palpable with thick bronchial secretions.

Pleural friction fremitus is palpable with inflammation of the pleura).

Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as in tension pneumothorax or after open thoracic injury or surgery

Kyphosis

An exaggerated posterior curvature of the thoracic spine (humpback) that causes significant back pain and limited mobility. Severe deformities impair cardiopulmonary function. If the neck muscles are strong, compensation occurs by hyperextension of head to maintain level of vision

Increased Tactile Fremitus

occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations (e.g., compression or consolidation [pneumonia]

Decreased Tactile Fremitus

Occurs when anything obstructs transmission of vibrations (e.g., an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema). Any barrier that gets in the way of the sound and your palpating hand decreases fremitus

Rhonchal Fremitus

Vibration felt when inhaled air passes through thick secretions in the larger bronchi. This may decrease somewhat by coughing

Pleural Friction Fremitus

Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing.

Crackles—Fine (formerly called rales

Discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can simulate this sound by rolling a strand of hair between your fingers near your ear

Late inspiratory crackles occur with:
pneumonia, heart failure, and interstitial fibrosis

Early inspiratory crackles occur with obstructive disease: chronic bronchitis, asthma, and emphysema

crackles-course

Loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but reappear shortly—sounds like opening a Velcro fastener

Pulmonary edema, pneumonia, pulmonary fibrosis

Atelectatic

Sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths

Sound like fine crackles but do not last and are not pathologic; disappear after the first few breaths

Pleural friction rub

very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; sounds just like crackles, but close to the ear

Pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae

musical sounds

Wheeze—High-pitched (sibilant

High-pitched, musical squeaking sounds that sound polyphonic (multiple notes as in a musical chord);

acute asthma or chronic emphysema

Wheeze—Low-pitched (sonorous rhonch

Low-pitched; monophonic, single-note, musical snoring, moaning sounds;

Bronchitis

Stridor

High-pitched, monophonic, inspiratory, crowing sound; louder in neck than over chest wall

Croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-threatening

what is hypercapnia

increased carbon dioxide in the blood

which part of the lungs is assessed on the posterior chest

all parts of the lower lob

decreased tactile fremitus is consistent with which diagnosis

pleural effusion

decreased fremitus occurs what the bronchus si obstructed

• pleural effusion

• pneumothorax

• emphysema

which breath sounds would be considered normal

bronchovesicular

vesicular

bronchial

which finding would the nurse expect upon osculating the lung sounds of a pt with heart failure

crackles in the lung bases

rationale: The nurse is likely to hear crackles at the lung bases. Occasional wheezing may be identified while auscultating the patient with emphysema. Crackles over the upper lobes are heard in the patient with tuberculosis. Bilateral wheezing may be heard in the patient with asthma

Palpable rhonchal fremitus indicates which condition

Thick bronchial secretions

Fremitus is a palpable vibration. When the patient is asked to say something, the sounds generated from the larynx are transmitted through the patent bronchi and the lung parenchyma to the chest wall, and can be felt as vibrations. Rhonchal fremitus is found when bronchial secretions are thick. A pneumothorax may result in decreased fremitus. Inflammation of the pleura may cause pleural friction fremitus. Consolidation of lung tissues may cause increased fremitus.

Which statement precisely describes the "angle of Louis

It is the articulation of the manubrium and the body of the sternum.
It is a useful place to start counting the ribs

Which abnormality would the nurse expect in a patient with kyphosis

An exaggerated posterior curvature of the thoracic spine

humpback

Which condition does the nurse attribute the patient’s regular breathing rate of eight breaths per minute to?

Drug-induced depression

Which additional muscle would be involved in increasing the size of the thoracic cage during forced inspiration after heavy exercise? Select all that apply. One, some, or all responses may be correct

Intercostal muscles

Sternomastoids

Diaphragm

Trapezii

Scaleni

sternomastoid

trapezii

scaleni