Thorax and Lungs
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Transcript of Thorax and Lungs
Thorax and Lungs
By B.Lokay, MD, PhDBy B.Lokay, MD, PhD
Anterior Thorax
(Suprasternal notch)
Posterior Thorax
Reference Lines
Lobes of Lungs
Lobes of Lungs
Trachea and Pleurae
Pleurae Visceral pleura – lines outside of
lungs, dipping down into the fissures
Parietal Pleura – lines inside of chest wall and diaphragm
Lubricating fluid between the pleurae prevents friction
Trachea and Bronchi Transport gasses between
environment and lung Dead space is space filled with
air (about 150 ml) but not available for gaseous exchange
Goblet cells in bronchi secrete mucus that entraps particles
Cilia in bronchi sweep particles upward
Terms
Developmental Considerations
Infants and Children When cord is cut, blood is cut off from placenta and rushes into
pulmonary circulation. Due to less resistance in pulmonary arteries, the foramen ovale closes, along with ductus arteriosus
Lungs grow until about 300 million alveoli in adolescence Pregnancy
The enlarging uterus elevates the diaphragm 4 cm during pregnancy, but the increased estrogen relaxes thoracic ligaments allowing compensation by increasing the transverse diameter
Mother’s tidal volume increases to meet demands of fetus Aging
kyphosis calcification of costal cartilage decreased vital capacity decreased number of alveoli decreased mucous production
Health History Cough
Onset? Gradual or sudden? Frequency?• Continuous throughout day – acute illness (respiratory infection)• Afternoon/evening – may reflect exposure to irritants at work• Night – postnasal drip, sinusitis• Early morning – chronic bronchial inflammation of smokers
Sputum? How much? Characteristic?• Chronic bronchitis – productive cough for 3 months of the year for 2
years in a row• Characteristics
• White of clear mucoid – colds, viral infection, bronchitis• Yellow or green – bacterial infection• Rust colored – TB, pneumococcal pneumonia• Pink, frothy – pulmonary edema, medications?
Cough up blood? Description of cough – dry, hacking Associative and Alleviating factors Painful?
Health History
Shortness of Breath (SOB) Onset, associative factors
• Determine how much activity precipitates SOB Affected by position?
• Orthopnea – difficulty breathing when supine (heart failure?) Time of day/night
• Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and needing to be upright to achieve comfort
Allergies?• Asthma attacks
Alleviating factors
Health History
Chest pain with breathing? Location, onset, duration, frequency, intensity,
associative and alleviative factors Past history of respiratory infections?
Bronchitis, emphysema, asthma, pneumonia Smoking history Environmental exposure Self – care behaviors
Immunizations, TB skin tests, chest X-rays
Assessment - Inspection
Inspect thorax Symmetry AP diameter
• Normal 1:2• AP diameter = transverse
diameter, “barrel chest”. Occurs with normal aging, chronic emphysema, and asthma
Symmetry and normal development of trapezius muscle
• Hypertrophied in COPD Position person takes to breathe
• COPD – tripod position
Posterior Chest
Symmetric chest expansion Place warmed hands on
posterolateral chest wall with thumbs at level of T9 or T10
Slide hands medially to pinch up a small fold of skin between thumbs
Ask person to take a deep breath As person inhales, the thumbs
should move apart symmetrically• Unequal chest expansion occurs
with atelectasis, pneumonia, thoracic trauma
• Pain accompanies deep breathing when pleurae are inflamed
Tactile Fremitus
Fremitus is a palpable vibration transmitted through patent bronchi and lung parenchyma to the chest wall where they can be felt as vibrations
Place either the palmar base of ulnar edge of one of the hands on the person’s back and ask to repeat “ninety-nine.” Start at lung apices and palpate from one side to another
Symmetry is most important Normally, fremitus most prominent
between scapulae and decreases as you progress down
Abnormalities in Fremitus
Decreased fremitus occurs when anything obstructs transmission of vibrations
• Obstructed bronchus• Pleural effusion or thickening• Pneumothorax• Emphysema
Increased fremitus occurs with compression or consolidation of lung tissue
• Lobar pneumonia Rhonchal fremitus – palpable with thick secretions Crepitus – coarse crackling sensation palpable over skin
surface. Occurs in subQ emphysema when air escapes from lung and enters subQ tissue
Percussion
Start at the apices and percuss across tops of both shoulders and down the lung region at approx. 5cm intervals
Make a side to side comparison Avoid damping effect of scapulae and
ribs Resonance predominates in healthy
lungs Hyperresonance is found when too
much air is present (emphysema or pneumothorax)
Dullness signals abnormal density (pneumonia, pleural effusion, atelectasis, tumor)
Expected Percussion Notes
Percussion Notes
Auscultating Posterior Chest
Breath sounds Instruct the person to breathe through
the mouth a little deeper than usual, but to stop if they feel dizzy. Hyperventilation may lead to fainting!
Use the flat diaphragm endpiece of the stethoscope and listen for at least one full respiration in each location
Continue to think:• What am I hearing?• What should I expect to be hearing?
• Bronchial• Bronchovesicular• Vesicular
Do not confuse background noise with lung sounds
• Stethoscope tubing bumping together• Shivering• Hairy chest• Rustling of gown
Characteristics of Normal Breath Sounds
Location of Normal Breath Sounds
Auscultation
Abnormal Findings Decreased breath sounds
• Obstruction of bronchial tree (by secretions, mucous plug, foreign body)• In emphysema due to loss of elasticity in the lung fibers and decreased
force of inspired air. The lungs are already hyperinflated so not much air will be coming in.
• Obstruction of sound by pleural thickening• Silent chest – no air moving in or out
Increased breath sounds – louder than normal• Bronchial sounds
• Heard in abnormal location, such as periphery• High pitched, with prolonged expiratory phase• Occur in consolidation (pneumonia) or compression (fluid in intrapleural
space). Dense lung tissue enhances transmission of sound.
Auscultating Adventitious Sounds
Adventitious sounds Sounds not normally heard in the lungs Caused by moving air colliding with secretions in trachea or
bronchi, or from popping open of previously deflated airways
Crackles (fine) Description: popping sounds heard during inspiration. May be
stimulated by rolling a strand of hair between fingers near the ear
Mechanism: Inhaled air collides with previously deflated airways. Airways suddenly pop open creating a crackling sound
Clinical example:• Early inspiratory – COPD• Late inspiratory – Pneumonia, heart failure, interstitial fibrosis
Crackles (coarse)
Description: • loud, low-pitched, bubbling and gurgling sounds
early in inspiration. Sound like Velcro
Mechanism: • Inhaled air collides with secretions in trachea and
large bronchi
Clinical example: • Pulmonary edema, pneumonia, pulmonary
fibrosis, depressed cough reflex
Pleural friction rub
Description: • Coarse and low pitched superficial sound.
Both inspiratory and expiratory. Mechanism:
• Caused when pleurae become inflamed and lose normal lubricating fluid. Pleural surfaces rub together during respiration. Heard best in anterolateral wall.
Clinical example: • Pleuritis
Wheeze
Description• High pitched musical squeaking sound
predominantly during expiration
Mechanism• Air squeezed or compressed through
narrowed airways (collapsing, swelling, secretions, tumors)
Clinical example• Acute asthma or chronic emphysema
Rhonchi (sonorous)
Description• Low-pitched, musical snoring
Mechanism• Airflow obstruction
Clinical example• Bronchitis, obstruction of bronchus from
obstruction or tumor
a.k.a. Wheeze
Stridor
Description• High pitched, inspiratory, crowing sound,
louder in neck than over chest wallMechanism
• Originates in larynx or trachea. Upper airway obstruction from inflamed tissue or obstruction
Clinical example• Croup and acute epiglottitis. Obstructed
airway.
Consolidation or compression of
voice sounds will enhance the voice
sounds
Assessing the Anterior Chest
Symmetric chest expansion Abnormally wide costal
angle occurs with emphysema
Tactile and vocal fremitus
Percussing and Auscultating Anterior Chest
Begin percussing the apices in supraclavicular ares, continuing down in intercostal spaces
Note cardiac and liver dullness and stomach tympany Chronic emphysema leads to
hyperinflation of lungs, resulting in hyperresonance where you would expect cardiac dullness
Auscultate lung fields down to the 6th rib. Progress from side to side moving downward and listen for one full respiration at each location
Pulmonary Function Test
Forced expiration of 6 seconds or more
occurs with obstructive lung disease
Developmental Considerations
Infants While infant is sleeping, can inspect and auscultate the lungs
• Infants normally have a rounded thorax, reaching a 1:2 (anteroposterior to transverse) diameter by age 6
• If a barrel shape persists after age 6, possible chronic asthma or cystic fibrosis
If baby begins to cry, it actually enhances the palpation of tactile fremitus
Pregnancy Wider thoracic cage
Aging Kyphosis – outward curvature of thoracic spine Calcification of costal cartilages leading to less mobility
Question 1
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client?1. Increased oxygen saturation with exercise
2. Hypocapnia
3. A hyperinflated chest on X-ray
4. A widened diaphragm noted on chest X-ray
Question 2
A nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which of the following would the nurse expect to note in the client?
1. Decreased respiratory rate2. Pallor3. Low arterial PaO24. An elevated arterial PaO2
Question 3
A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the ventilator’s high-pressure alarm sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of :1. Displaced endotracheal tube2. Acute respiratory distress syndrome (ARDS)3. Pulmonary embolism4. Right pneumothorax
Question 4
A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which of the following clients on the nursing unit is at the least risk for infection with tuberculosis?1. A newly immigrated woman from Korea2. An uninsured man who is homeless3. An elderly woman admitted from a long-
term care facility4. A man who is an inspector for the U.S.
Postal Service
Question 5
A nurse is caring for a patient after a bronchoscopy and biopsy. Which of the following signs if noted in the client should be reported immediately to the physician?
1. Blood-streaked sputum2. Dry cough3. Hematuria4. Stridor