Review on Thorax and Lungs

Before trying to study a particular system, it is very important to have a good lecture on the anatomy and physiology.

In this nursing lecture, you will be able grasp the lessons easily and adapt it in your nursing study.

1. Outline
   • Structure and Function
   • Subjective Data
   • Objective Data
   • Abnormal Findings
2. Structure and Function
3. Thoracic Cage /Cavity
   • Shape- bony, conical shape, narrower at top borders – it is defined by:
   • Sternum – 3 parts: manubrium, body, xiphoid process
   • Ribs – 12 pairs, 1 st seven attach to the sternum (costal cartilages) Ribs 8,9,&10 attach to the costal cartilage above, Ribs 11 & 12 are floating ribs
   • 12 Thoracic vertebrae
   • Diaphragm – the floor, separates the thoracic cavity from the abdomen
4. Anterior Thoracic Landmarks
   • Suprasternal Notch – U shaped depression
   • Sternum – “breastbone” = 3 parts
   • Manubrium
   • Body
   • Xiphoid process
   • Angle of Louis – manubriosternal angle continuous with the 2 nd Rib
   • Costal angle- usually 90 0 or <. (increases when rib cage is chronically overinflated)
6. Posterior Thoracic Landmarks
   • Vertebra Prominens – Flex head, feel most prominent bony projection at base of neck = C7 next lower one is T1
   • Spinous Processes – spinal column-
   • Scapula – symmetrical , lower tip at the 7 -8 th Rib
   • 12 th Rib = midway b/t spine & side
8. Reference Lines
   • Anterior Chest
   • Midsternal line
   • Midclavicular line
   • Posterior Chest
   • Vertebral line – midspinal
   • Scapular line
9. • Lateral Chest
   • Anterior Axillary line
   • Posterior Axillary line
   • Mid–axillary line
13. The Thoracic Cavity
    • Mediastinum middle of the thoracic cavity & contains;
    • Esophagus
    • Trachea
    • Heart
    • Great Vessels
    • Pleural Cavities on either side of the mediastinum contain the lungs
14. Lung Borders
    • Anterior Chest –
    • Apex 3 -4 cm. ↑ inner 1/3 of the clavicles
    • Base – rests on the diaphragm, 6 th rib, MCL
    • Lateral Chest
    • Extends from Axilla apex to 7 th –8 th rib
    • Posteriorly
    • Apex of lung is at C7 – Base T10 (on deep inspiration to T12)
15. Lobes of Lung
    • Right Lung
    • 3 lobes, upper, middle , lower
    • Shorter due to liver
    • Left Lung
    • LUL = Left Upper and Lower ( 2 lobes)
    • Narrower due to heart
20. • Lobes
    • Diagonal sloping segments
    • Oblique fissures
21. 3 Important Points
    • Left Lung – no middle lobe
    • Anterior chest contains upper & middle lobes with very little lower lobe
    • Posterior chest has almost all lower lobe. Rt middle lobe does not project into the posterior chest
22. Pleurae
    • The Pleurae form an envelope b/t the lungs & chest wall
    • Visceral pleura – lines outside of lungs
    • Parietal pleura – lines inside of chest wall & diaphragm
    • Pleural Cavity – the inside of the envelope- space b/t visceral & parietal pleura, lubrication. Normally has a vacuum or neg. pressure
24. Tracheal & Bronchial Tree
    • Trachea – anterior to esophagus-
    • 10-11 cm.long, begins at cricoid cartilage
    • Bifurcates just below the sternal angle ( AKA angle of Louis, manubriosternal angle) into the
    • Right Main Stem Bronchus – shorter, wider, more vertical ( Intubation – listen to breath sounds bilaterally)
    • Left Main Stem Bronchus
25. Tracheal & Bronchial Tree
    • The trachea & bronchi provide the passage for air to get into the lungs from the environment = Dead Space (no air exchange takes place here)
26. • Bronchi
    • Secrete mucus – captures particles
    • Cilia – moves the trapped particles up to be expelled or swallowed
    • Acinus
    • Functional respiratory unit consisting of,
    • Bronchioles, alveolar ducts, alveolar sacs, & alveoli
    • Gaseous exchange in alveolar duct & alveoli
27. Mechanics of Respiration
    • 4 Major Functions of the Respiratory System
    • Supply O 2 for energy production
    • Remove CO 2 , waste product of energy reactions
    • Homeostasis, acid-base balance of arterial blood
    • Heat exchange
28. • Respiration maintains pH ( acid- base balance) of the blood by supplying O 2 & eliminating CO 2 .
    • Normal Range Values of Arterial Bld. Gases
    • pH= 7.35- 7.45
    • Pa CO 2 = 35-45mmHg
    • PaO 2 = 80-100mmHg
    • SaO 2 = 94-98%
29. • Lungs help to maintain the pH balance by adjusting the amt. of CO 2 through:
    • Hypoventilation
    • Hyperventilation
30. Respiration = breathing
    • Inspiration
    • Expiration
    • Control of Respiration
    • Involuntary control by respiratory center in the brain stem consisting of the pons & medulla
    • Hypercapnia is an ↑ in CO 2 in the Bld. And provides the normal stimulus to breath
    • Hypoxemia
32. Subjective Data
    • Cough
    • SOB
    • Chest Pain
    • Respiratory Infections
    • Smoking
    • Environmental Exposure
    • Self-care behaviors
33. Objective Data
    • Inspect
    • Palpate
    • Percuss
    • Auscultate
    • After Posterior Thyroid Exam
    • Posterior chest, Lateral chest, then Anterior chest
34. • Remember to clean stethoscope end piece and warm prior to use on client.
    • Quiet environment conducive to hearing lung sounds
35. Equipment for Exam
    • Stethoscope
    • Ruler – 15cm.
    • Tape measure
    • Washable marker
    • Alcohol swabs
36. Posterior Chest
    • Inspect Thoracic Cage
    • Shape and configuration
    • Anteroposterior Diameter should be < diameter =" Ratio">
    • Note Position of Person to breathe.
    • ? orthopnea
    • Skin Color & Condition, nail color
38. Barrel Chest
39. Pectus Carinatum (Pigeon)
40. Pectus Excavatum (Funnel)
41. Posterior Chest
    • Palpate
    • Symmetric Expansion- warmed hands – thumbs @ T9-T10- pinch sm. Fold of skin
43. Posterior chest
    • Tactile Fremitus – palpable vibration of sound from the larynx- use palmer base of fingers- “99” or Blue Moon
    • Symmetry important – vibration should feel the same bilaterally.
    • Avoid palpating over scapulae because bone dampens out sound
44. • ↓ fremitus = obstructed bronchi, pleural effusion, pneumothorax or emphysema
    • Note any barrier that is b/t the sound and your hand will↓ fremitus
    • ↑ fremitus occurs only with gross changes (Lobar pneumonia).
46. • Entire Chest wall – gently palpate. Note
    • Tenderness, skin temp., moisture, lumps, lesions
    • Crepitus = coarse crackling sensation palpable over skin surface. (Subcutaneous emphysema when air escapes from lung into S/C tissue)
47. Posterior Chest
    • Percuss start at the apices, across shoulders, then interspaces side to side (5cm. Intervals) Avoid scapulae & ribs
    • Resonance predominates in healthy lung
    • Hyperresonance – too much air, emphysema, pneumothorax
    • Dull = abnormal density, pneumonia, tumor, atelectasis
48. Expected Percussion notes
49. Diaphragmatic Expansion
    • Lower lung borders in expiration & inspiration
    • 1 st Exhale & hold- percuss down the scapulae line until sound changes from resonant to dull. Mark with marker
    • Estimates the level of the diaphragm separating the abd cavity. May be higher on Rt. Due to liver
50. Diaphragmatic Expansion
    • Now take deep breath & hold.
    • Percuss from mark to dull sound and mark.
    • Measure the difference. Should be + bilaterally 3-5cm in adult may be 7-8 cm in well conditioned person
    • Note hold your own breath when conducting this test!!!!!!!!!
51. Exhale Inhale
52. Posterior Chest
    • Auscultate
    • Position client
    • Instruct to breath through mouth, little deeper than usual
    • Tell you if becomes light headed
    • Use flat diaphragm & hold firmly on chest
    • Must listen to at least 1 full respiration before moving stethoscope side to side
    • Compare both sides (lung fields)
53. Auscultation Sequence
54. Normal Breath Sounds
    • Bronchial – Anterior Chest only = over trachea & larynx
    • Quality = harsh, hollow, tubular
    • Inspiration <>
    • Amplitude = Loud
55. Breath Sounds
    • Bronchovesicular both anterior & posterior
    • Over major bronchi, posterior b/t scapulae, anterior upper sternum, 1 st & 2 nd ICS
    • Pitch = high
    • Inspiration = Expiration
    • Moderate amplitude
56. • Vesicular – Anterior & posterior
    • Quality = rustling, wind in trees
    • Inspiration > Expiration
    • Soft amplitude
57. Location of Breath Sounds
58. • Decreased or Absent Breath Sounds
    • Causes =
    • obstruction of the bronchial tree by secretions, mucous plug, F.B
    • ↓ lung elasticity, emphysema = lungs hyperinflated
    • Pleurisy, pleural thickening, pneumothorax (air), pleural effusion (fld.) in the pleural space
59. • Increased Breath Sounds = dense lung tissue enhances sound transmission as in consolidation ie. pneumonia
    • Silent chest = ominous
60. Adventitious Sounds
    • Not normally heard in the lungs. Caused by moving air colliding with secretions or by popping open of previously deflated airways
    • Crackles (Rales)
    • Fine – high pitched popping- not cleared by coughing. Simulate sound by rolling strand of hair b/t fingers near ear or moisten thumb& index finger & separate them near your ear
    • Course crackles- (opening a velcro fastener)
    • Pleural Friction Rub – coarse & low pitched, 2 pieces of leather rubbed together close to ear
61. Adventitious Sounds
    • Wheeze (Rhonchi)
    • High pitched, musical squeaking = air squeezes - asthma
    • Low pitched musical snoring, moaning, =obstruction
    • Stridor – high pitched, inspiratory, crowing, louder in neck = croup, acute epiglottitis
62. Coarse Crackles
63. Fine Crackles
64. • Voice Sounds normal voice transmission is soft, muffled & indistinct. Pathology that ↑ lung density makes words clearer
    • Bronchophony – “99”
    • Egophony- ee-ee-ee if disease sounds like aa-aa-aa Record as “E -> A changes”
    • Whisper pectoriloquy 1-2-3
    • These tests are only done if lung pathology is suspected
65. Anterior Chest
    • Inspect
    • Shape & Configuration
    • Expression- relaxed
    • LOC – alert & cooperative
    • Skin color & condition
    • Quality of Respirations – reg. & even, no retraction or use of accessory muscles
66. Anterior Chest
    • Palpate
    • Symmetric Chest Expansion
    • Tenderness, turgor, temp., moisture
    • Tactile Fremitus
    • Compare both sides
67. Symmetric Expansion
68. Sequence for percussion & auscultation
69. Tactile fremitus
70. Percussion
    • Apices in Supraclavicular Areas
    • Interspaces = Resonance
    • Dullness
    • Female breast tissue
    • Liver – Rt. 5 th intercostal space midclavicular
    • Heart – Lt. 3 rd intercostal space midclavicular
    • Flat = muscle & bone
    • Tympany = stomach (Lt. Side)
71. Expected Percussion Notes
72. Auscultate
    • Apices (supraclavicular) to 6 th rib
    • Bilateral moving down
    • One full respiration
    • Directly over chest wall – displace female breast tissue
73. Location Of Breath Sounds
74. Pulse Oximeter
    • Noninvasive measurement of arterial oxygen saturation = SpO 2 by measuring the relative amt. of light absorbed by oxyhemoglobin and unoxygenated hemoglobin. It compares light emitted to amt absorbed. Normally 97 -98%
75. Terms for Documentation
    • Rate
    • Eupnea 12 – 20 bpm normal
    • Tachypnea > 24, rapid, shallow
    • Bradypnea <>
    • Apnea = No respirations for 10 sec. or more
76. • Pattern = breathing rhythm. Normal respirations are regular and even.
    • Cheyne – stokes = resp wax & wane in reg pattern with periods of apnea(20sec)
    • Biot’s or ataxisic Sim. To cheyne –stokes but pattern irreg.
77. • Depth – on inspiration the normal depth is nonexaggerated and effortless.
    • Shallow
    • Sighing – purposeful to expand the alveoli
78. • Symmetry – bilateral rise and fall of the chest with respiration
    • Audibility – normally be heard by the unaided ear several centimeters from the patient’s nose/mouth
79. • Patient position – healthy person breathes comfortably in supine, prone or upright position
    • Orthopnea
    • Mode of Breathing – normally inhale/exhale through nose
80. • Sputum
    • Sample
    • Color
    • Mucoid, yellow/green, rust/blood tinged, black, pink
    • Odor
    • Amount
    • Consistency