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Respiratory System Assessment: Quizzes, Anatomy, and Examination

Quizzes and Announcements

  • Quiz Frequency: Quizzes are announced on Mondays and due on Wednesdays.

  • Quiz Duration & Resources: Students have all day Wednesday to complete the quiz, with a time limit of 10 minutes. Utilizing resources such as books and collaborating with peers (working with a buddy or multiple friends) is encouraged.

  • Quiz Reopening Policy: Quizzes will generally not be reopened. The only exception is for a medical doctor's note explicitly stating an emergency room visit prevented the student from physically taking the quiz. Missed quizzes without a valid, documented excuse will result in a zero.

  • Quiz Two: Scheduled for Wednesday and will cover cardiac material. This quiz is intended to assist with a course referred to as "half of two" (likely referring to a course code like HAP 2).

    • It will be accessible from 12 AM until 11:59 PM on Wednesday.

  • Private Screening - Soul on Fire: An opportunity on October 10^{th} at 5 PM. Interested students should sign up via Google Forms. It's described as a good experience based on a true story.

  • Career Fair: Scheduled for Monday, the 29^{th}. Attendance is recommended, especially for first-year students, as it may lead to nursing internships or volunteer opportunities.

Anatomy Review: Thoracic and Respiratory Systems

Thorax and Lower Respiratory System

  • Thorax: Extends from the base of the neck to the diaphragm.

  • Lower Respiratory System Components: Includes the lower trachea, bronchi, and lungs.

Thoracic Cage

  • Composition: Made up of the sternum, 12 pairs of ribs (which happen bilaterally), thoracic vertebrae, muscles, and cartilage.

  • Function: Provides essential support and protection to internal organs.

Key Anatomical Landmarks

  • Xiphoid Process: The small bone located at the very end of the sternum.

  • Suprasternal Notch: A superior indentation felt at the top of the sternum, considered an anatomical starting point.

  • Ribs:

    • There are 12 pairs, numbered superior to inferior (top to bottom).

    • Intercostal Spaces: The areas immediately below each rib. These spaces are used for counting during physical assessment (e.g., locating the apical pulse at the 5^{th} intercostal space).

    • The first 7 pairs of ribs articulate directly with the sternum and curve under the clavicles.

    • Floating Ribs: Ribs 11 and 12 are called floating ribs as they do not attach anteriorly to the sternum or costal cartilage.

Topographic Thoracic Lines

These imaginary lines are used for precise location descriptions during assessment.

  • Anteriorly: External line, midclavicular line (dividing each clavicle in half, with right and left), and a middle line.

  • Laterally: Axillary line, posterior axillary line, and mid-axillary line.

  • Posteriorly: Left scapular line, right scapular line, and the vertebral line (along the spine).

Thoracic Cavity Structure

  • Mediastinum: Contains vital structures including the trachea, bronchi, esophagus, heart, and great vessels.

  • Lungs: Essential for respiration.

  • Pleural Membranes (Lining):

    • Parietal Pleura: The outer lining that adheres to the chest wall.

    • Visceral Pleura: The inner lining that covers the external surface of the lungs.

    • Parietal Space (Pleural Space): The potential space between the parietal and visceral pleura. This space can accumulate fluid in certain diseases or completely collapse (e.g., pneumothorax).

Trachea and Bronchi

  • Trachea: Located in the neck, it is a flexible structure anterior to the esophagus, beginning at the cricoid cartilage.

  • Bronchi:

    • Right Main Bronchus: Shorter and more vertical than the left.

    • Left Main Bronchus: The primary bronchus for the left lung.

    • The bronchi branch into smaller airways, eventually terminating at the alveolar ducts, which lead to the alveoli.

  • Function: Both the trachea and bronchi serve as passageways for inspired and expired air. They are lined with mucous membranes containing cilia that sweep dust, foreign bodies, and bacteria towards the mouth for removal, explaining phlegm production during illness.

Lungs

  • Shape and Elasticity: Cone-shaped and elastic, allowing them to stretch during respiration.

  • Apex: Located slightly above the clavicle, this is the starting point for assessing lung sounds.

  • Base: Rests at the level of the diaphragm.

    • Anteriorly: Extends to approximately the 6^{th} rib.

    • Posteriorly: Extends to approximately the 10^{th} rib.

    • Laterally: Extends to about the 8^{th} rib.

  • Lobes:

    • Right Lung: Composed of 3 lobes (a critical point for recollection).

    • Left Lung: Composed of 2 lobes (another critical point).

Respiratory Mechanics and Pressures

External Respiration

Also known as pulmonary ventilation or mechanical breathing, it involves two types of expansion:

  • Vertical Expansion: Occurs when the diaphragm contracts and moves downward. The diaphragm typically rests in a high position and lowers during inspiration.

  • Horizontal Expansion: Involves the intercostal muscles lifting the sternum and elevating the ribs, which increases the anterior-posterior diameter of the chest.

  • Pressure Changes:

    • Negative Pressure: Present during inspiration (breathing in).

    • Positive Pressure: Present during expiration (breathing out) as the chest wall and diaphragm relax.

Respiratory Pressures and Airway Resistance

  • Respiratory pressures are generally referred to as a relative pressure of zero; the difference between pressures is what primarily matters.

  • Airway Resistance: Conditions that narrow airways, such as asthma, increase resistance, making breathing more difficult.

  • Airway Dilation and Constriction:

    • Parasympathetic stimulation and histamine: Typically narrow the bronchioles, increasing resistance and decreasing airflow.

    • Epinephrine (hormone released during exercise): Dilates bronchioles, thereby decreasing resistance and increasing airflow.

Mechanics of Inhalation and Exhalation

  • Inhalation: The diaphragm presses abdominal organs downward and forward.

  • Exhalation: The diaphragm rises back and recoils to its resting position.

Genetic Variations, Lung Health, and Age-Related Changes

Genetic Variations and Lung Disease

  • Lung volumes and capacities can vary due to genetic factors.

  • Lung Diseases: Include both malignant and non-malignant conditions.

  • Smoking Impact: Smokers are at a significantly higher risk for lung issues, and the severity increases with the amount smoked. It is crucial to inquire not only if the patient smokes but also if anyone in their household smokes due to the risks of secondhand smoke.

  • Demographic Differences in Lung Conditions: Rates of lung cancer, asthma, and COPD vary among different ethnic groups and ages.

    • Asthma: Often diagnosed in younger children.

    • COPD: Typically diagnosed in older patients.

Abnormal Findings and Age-Related Lung Changes

  • Cyanosis: A bluish-purple discoloration of the skin, often observed around the lips, on the tongue, cheeks, and gums. The appearance can vary (e.g., grayish) depending on the patient's skin type.

  • Dyspnea (Trouble Breathing): Older adults may experience dyspnea with certain activities due to age-related physiological changes in the lungs, primarily the loss of elasticity.

    • Lungs naturally lose elasticity with age, making certain activities more challenging.

  • Pleurisy (Pleuritis): Inflammation of the pleura (the lining of the lungs), indicated by the -itis suffix. This condition can manifest as chest pain.

  • Decreased Cough Effectiveness: Older adults may have difficulty coughing effectively due to reduced lung elasticity, as effective coughing requires taking a deep breath and generating significant pressure.

  • Spinal Curvatures: These can affect lung assessment findings and thoracic expansion.

    • Scoliosis: An S-curvature of the spine.

    • Kyphosis: Also known as a humpback or hunchback, common in older adults.

    • Lordosis: A curvature in the lower back, often seen in pregnant women.

    • Impact: Thoracic expansion may be decreased in the presence of these curvatures, but it should still remain symmetrical.

  • General Age-Related Changes: As individuals age, deep breathing may become difficult, and they may experience easy fatigue. Tenderness or pain in the chest area can also occur due to the increased use of accessory muscles for breathing. This pain can also be associated with fractures, particularly in patients with osteoporosis (women are at a higher risk for osteoporosis).

Respiratory Assessment: Data Collection and Physical Examination

Subjective Data Collection

When a patient presents with respiratory issues, collecting subjective data is the first step, mirroring the approach for cardiac issues (e.g., asking about chest pain).

  • Difficulty Breathing (Dyspnea):

    • Ask: "Do you have difficulty breathing?" If yes, "When? Is it constant or only on exertion?"

  • Chest Pain:

    • Ask: "Do you have chest pain?" If yes, "Can you describe it? Is it sharp, stabbing, or shooting?"

  • Cough:

    • Ask: "Do you have a cough? Is it productive (producing sputum) or non-productive?"

    • If productive: "What is the color of the sputum?" (e.g., clear/white is less concerning than yellow/green).

  • Gastrointestinal (GI) Symptoms:

    • Inquire about nausea, vomiting, diarrhea, or acid reflux (e.g., GERD, which is often associated with conditions like asthma).

  • Personal Health History:

    • Ask about any past medical history of respiratory infections, respiratory illnesses, or GI illnesses.

    • Document their current health history and reason for presentation.

  • Family History:

    • Inquire about any family history of respiratory illnesses.

  • Lifestyle and Health Practices:

    • Smoking: Ask if they smoke, how much, and if they live with anyone who smokes (due to secondhand smoke risks).

    • Exercise Habits:

    • Religious, Cultural, Spiritual Beliefs: Always important to consider.

    • Work Environment: Assess for exposure to chemicals, fumes, or pollution.

    • Home Environment: Evaluate for cleanliness and potential airborne toxins.

    • Living Location: Consider environmental factors based on location (e.g., higher pollution in urban areas like New York City).

Objective Data Collection

Preparation for the physical examination.

  • Equipment: Gather necessary equipment including a gown or drape (or both), and a mask (to be worn when exposed to patients with certain respiratory disorders, not typically during lab practice).

  • Patient Preparation:

    • Instruct the patient to remove clothing from the waist up and provide a gown or drape.

    • Explain the assessment procedure clearly.

    • Position the patient sitting upright with arms relaxed at their sides. If the patient is older or unable to sit, the assessment can be performed while they are lying down.

    • Assess lung sounds bilaterally from top to bottom.

General Inspection

Visual assessment of the patient for any observable abnormalities.

  • Abnormal Findings Include:

    • Nasal Flaring: Widening of the nostrils with each breath, indicating increased respiratory effort.

    • Pursed-Lip Breathing: Breathing with the lips pursed, as if blowing through a straw, an attempt to prolong exhalation and improve air trapping.

    • Cyanosis: Bluish-purplish discoloration of the face, lips, or chest, indicating hypoxemia.

    • Nail Color and Shape: Assess capillary refill time, general color, and check for clubbing.

    • Configuration of Thorax: Inspect for symmetry. Abnormal findings include visible bones (indicating emaciation), movement only on one side (suggesting a collapsed lung), or retractions.

    • Retractions: Indrawing of the skin between the ribs or at the sternum during inspiration, indicating severe respiratory distress.

    • Patient Positioning:

      • Tripod Position: Characterized by the patient leaning forward with hands on knees or a table, indicating significant respiratory distress as they try to maximize lung expansion.

  • Labored Breathing Symptoms (Visual Cues):

    • Tachypnea: Very rapid breathing.

    • Intercostal retractions.

    • Stridor: A high-pitched, harsh sound heard on inspiration, indicative of upper airway obstruction.

    • Nasal flaring.

Palpation

Tactile assessment following a specific order.

  • Order of Palpation: Follows a systematic "snaking" or "ladder" pattern when assessing the patient's back (e.g., 10 points anteriorly, 12 posteriorly). It's crucial to lift and reposition the hand (or stethoscope) for each point, rather than sliding it, to avoid extraneous sensations.

  • What to Assess:

    • Tenderness: Palpate for any areas of pain or tenderness, which may be present in respiratory distress due to accessory muscle use or fractures.

    • Crepitus: A crackling sensation under the skin, feeling like bubble wrap, indicating escaped air (e.g., subcutaneous emphysema).

    • Tactile Fremitus: Performed by placing the hand on the patient's chest and having them repeat a phrase like "99." Normal finding is equal vibration felt on both sides. Unequal fremitus suggests an underlying issue. (Note: This is distinct from bronchophony, which involves listening rather than feeling.)

    • Surface Characteristics: Check for any lumps or bumps.

    • Chest Expansion: Should be symmetrical and even bilaterally.

Percussion

Using fingertips to tap the chest wall, following the same snaking/ladder pattern.

  • Normal Percussion Sounds:

    • Resonant: A clear, hollow sound heard over lung tissue (in intercostal spaces).

    • Flat: A dull sound heard over bones.

  • Abnormal Percussion Sound:

    • Hyperresonant: A very loud, booming sound, often indicating air trapping (e.g., emphysema or pneumothorax).

  • Diaphragmatic Excursion: Assess by placing hands on the patient's front and back while they breathe normally. Both hands should rise and fall symmetrically. Asymmetrical movement is an abnormal finding.

Auscultation (Listening to Breath Sounds)

Using a stethoscope, again following the snaking/ladder pattern, to listen to breath and voice sounds.

  • Normal Breath Sounds: Should be characterized by slight, clear air movement.

    • Bronchial: Heard primarily over the trachea and main bronchi.

    • Bronchovesicular: Heard over major airways where bronchi and alveoli are both present.

    • Vesicular: Soft, low-pitched sounds heard over most of the lung fields.

  • Adventitious (Abnormal) Breath Sounds:

    • Crackles (Rales): Discontinuous, popping sounds often indicating fluid in the lungs (e.g., pneumonia, bronchitis). Commonly described as sounding like "Rice Krispies."

    • Wheezes: High-pitched, whistling sounds, typically heard on expiration but can be heard on inspiration, characteristic of narrowed airways (e.g., asthma).

  • Voice Sounds (to assess for consolidation or altered air transmission):

    • Bronchophony: Have the patient say "99" while listening with a stethoscope.

      • Normal: The sound should be muffled and indistinct.

      • Abnormal: If the "99" is heard very clearly, it is an abnormal finding, indicating consolidation (e.g., in pneumonia). (Emphasize distinguishing this from tactile fremitus, which involves feeling vibration.)

    • Egophony: Have the patient repeatedly say the letter "e" while listening.

      • Normal: The sound of "e" should be clearly audible.

      • Abnormal: If the "e" sound is heard as an "a," it indicates an abnormal finding, often associated with consolidation.

    • Whispered Pectoriloquy: Have the patient whisper a sequence, such as "1-2-3," while listening.

      • Normal: The whispered words should be very faint or inaudible.

      • Abnormal: If the whispered words are heard clearly, it is an abnormal finding, indicating consolidation.

  • COPD: Patients with COPD may exhibit various abnormal findings, including wheezing, depending on their specific condition.

Anterior Thorax - Inspection

  • Shape: The chest should have a normal shape. Abnormal findings include a concave (caved-in) appearance of the sternum.
    (Transcript ends here, implying other abnormal shapes would also be discussed.)