Unit 2 app thorax and lungs

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

Thorax and LungsThorax and Lungs

Advance Practice PreparationAdvance Practice Preparation

Unit 2Unit 2


Chapter 18: Thorax and LungsChapter 18: Thorax and Lungs

Structure and FunctionStructure and FunctionPosterior Thoracic CagePosterior Thoracic Cage

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

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Structure and FunctionStructure and Function

Position and surface landmarksPosition and surface landmarks Thoracic cageThoracic cage

• Defined by sternum, 12 pairs of ribs and 12 thoracic Defined by sternum, 12 pairs of ribs and 12 thoracic vertebraevertebrae

• Floor is the diaphragm, a musculotendinous septum that Floor is the diaphragm, a musculotendinous septum that separates thoracic cavity from abdomenseparates thoracic cavity from abdomen

• First seven ribs attach to sternum by costal cartilagesFirst seven ribs attach to sternum by costal cartilages

• Ribs 8, 9, and 10 attach to costal cartilage aboveRibs 8, 9, and 10 attach to costal cartilage above

• Ribs 11 and 12 are “floating,” with free palpable tipsRibs 11 and 12 are “floating,” with free palpable tips

• Costochondral junctions are points at which ribs join their Costochondral junctions are points at which ribs join their cartilages; they are not palpablecartilages; they are not palpable

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Structure and FunctionStructure and Function

Anterior Anterior thoracic thoracic landmarkslandmarks

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Structure and FunctionStructure and Function (cont.)(cont.)

Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarksAnterior thoracic landmarks

• Surface landmarks on thorax are signposts for Surface landmarks on thorax are signposts for underlying respiratory structuresunderlying respiratory structures

• Knowledge of landmarks will help you localize a finding Knowledge of landmarks will help you localize a finding and will facilitate communication of your findingsand will facilitate communication of your findings

Suprasternal notch: feel this hollow U-shaped depression Suprasternal notch: feel this hollow U-shaped depression just above sternum between claviclesjust above sternum between clavicles

Sternum: “breastbone” has three parts; manubrium, body, Sternum: “breastbone” has three parts; manubrium, body, and xiphoid processand xiphoid process

• Walk fingers down manubrium a few centimeters until Walk fingers down manubrium a few centimeters until you feel distinct bony ridge, the manubriosternal angleyou feel distinct bony ridge, the manubriosternal angle

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarks (cont.)Anterior thoracic landmarks (cont.)

• Manubriosternal angle: called “angle of Louis,” at Manubriosternal angle: called “angle of Louis,” at articulation of manubrium and sternum, and continuous articulation of manubrium and sternum, and continuous with second ribwith second rib

Angle of Louis is useful place to start counting ribsAngle of Louis is useful place to start counting ribs

• Identify angle of Louis, palpate lightly to second rib, and Identify angle of Louis, palpate lightly to second rib, and slide down to second intercostal spaceslide down to second intercostal space

• Each intercostal space is numbered by rib above it Each intercostal space is numbered by rib above it

• Continue counting ribs in middle of hemithorax, not close Continue counting ribs in middle of hemithorax, not close to sternum as costal cartilages lie too close to countto sternum as costal cartilages lie too close to count

• You can palpate easily down to the tenth ribYou can palpate easily down to the tenth rib

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Anterior thoracic landmarks (cont.)Anterior thoracic landmarks (cont.)

• Angle of Louis also marks site of tracheal bifurcation into Angle of Louis also marks site of tracheal bifurcation into right and left main bronchi; corresponds with upper right and left main bronchi; corresponds with upper border of atria of the heart, and it lies above fourth border of atria of the heart, and it lies above fourth thoracic vertebra on backthoracic vertebra on back

• Costal angle: the right and left costal margins form an Costal angle: the right and left costal margins form an angle where they meet at xiphoid processangle where they meet at xiphoid process

• Usually 90 degrees or less, this angle increases when rib Usually 90 degrees or less, this angle increases when rib cage is chronically overinflated, as in emphysemacage is chronically overinflated, as in emphysema

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Anterior Thoracic CageAnterior Thoracic Cage

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Posterior thoracic landmarksPosterior thoracic landmarks

• Counting ribs and intercostal spaces on back is harder Counting ribs and intercostal spaces on back is harder due to muscles and soft tissue surrounding ribs and due to muscles and soft tissue surrounding ribs and spinal columnspinal column

• Vertebra prominens: Start here; flex your head and feel Vertebra prominens: Start here; flex your head and feel for most prominent bony spur protruding at base of neckfor most prominent bony spur protruding at base of neck

• This is spinous process of C7; if two bumps seem This is spinous process of C7; if two bumps seem equally prominent, upper one is C7 and lower one is T1equally prominent, upper one is C7 and lower one is T1

• Spinous processes: count down these knobs on Spinous processes: count down these knobs on vertebrae, which stack together to form spinal columnvertebrae, which stack together to form spinal column

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Posterior thoracic landmarks (cont.)Posterior thoracic landmarks (cont.)

• Note that spinous processes align with their same Note that spinous processes align with their same numbered ribs only down to T4numbered ribs only down to T4

• After T4, spinous processes angle downward from their After T4, spinous processes angle downward from their vertebral body and overlie vertebral body and rib belowvertebral body and overlie vertebral body and rib below

• Inferior border of scapula: scapulae are located Inferior border of scapula: scapulae are located symmetrically in each hemithoraxsymmetrically in each hemithorax

• Lower tip usually at seventh or eighth ribLower tip usually at seventh or eighth rib

• Twelfth rib: palpate midway between spine and person’s Twelfth rib: palpate midway between spine and person’s side to identify its free tipside to identify its free tip

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Posterior Thoracic CagePosterior Thoracic Cage

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Reference linesReference lines

• Use reference lines to pinpoint finding vertically on chestUse reference lines to pinpoint finding vertically on chest

• On anterior chest note midsternal line and midclavicular On anterior chest note midsternal line and midclavicular lineline

• Midclavicular line bisects center of each clavicle at a Midclavicular line bisects center of each clavicle at a point halfway between palpated sternoclavicular and point halfway between palpated sternoclavicular and acromioclavicular jointsacromioclavicular joints

• Posterior chest wall has vertebral (or midspinal) line and Posterior chest wall has vertebral (or midspinal) line and scapular line, which extends through inferior angle of scapular line, which extends through inferior angle of scapula when arms at sides of bodyscapula when arms at sides of body

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Position and surface landmarksPosition and surface landmarks (cont.)(cont.) Reference lines (cont.)Reference lines (cont.)

• Lift up the person’s arm 90 degrees, and divide lateral Lift up the person’s arm 90 degrees, and divide lateral chest by three lines: chest by three lines:

Anterior axillary line: extends down from anterior axillary Anterior axillary line: extends down from anterior axillary fold where pectoralis major muscle insertsfold where pectoralis major muscle inserts

Posterior axillary line: continues down from posterior Posterior axillary line: continues down from posterior axillary fold where latissimus dorsi muscle insertsaxillary fold where latissimus dorsi muscle inserts

Midaxillary line: runs down from apex of axilla and lies Midaxillary line: runs down from apex of axilla and lies between and parallel to other twobetween and parallel to other two

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Anterior Reference LinesAnterior Reference Lines

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Posterior Reference LinesPosterior Reference Lines

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Lateral Reference LinesLateral Reference Lines

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Thoracic cavityThoracic cavity Mediastinum: middle section of thoracic cavity Mediastinum: middle section of thoracic cavity

containing esophagus, trachea, heart, and great containing esophagus, trachea, heart, and great vesselsvessels• Right and left pleural cavities, on either side of Right and left pleural cavities, on either side of

mediastinum, contain lungsmediastinum, contain lungs

• Lung borders: In anterior chest, apex of lung tissue is 3 Lung borders: In anterior chest, apex of lung tissue is 3 or 4 cm above inner third of claviclesor 4 cm above inner third of clavicles

• Base rests on diaphragm at about sixth rib in Base rests on diaphragm at about sixth rib in midclavicular linemidclavicular line

• Laterally, lung tissue extends from apex of axilla down to Laterally, lung tissue extends from apex of axilla down to seventh or eighth ribseventh or eighth rib

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Thoracic cavity (cont.)Thoracic cavity (cont.) Posteriorly, the location of C7 marks apex of lung Posteriorly, the location of C7 marks apex of lung

tissue, and T10 usually corresponds to basetissue, and T10 usually corresponds to base• Deep inspiration expands lungs, and their lower border Deep inspiration expands lungs, and their lower border

drops to level of T12drops to level of T12

Lobes of the lungLobes of the lung• Lungs are paired but not precisely symmetric structures Lungs are paired but not precisely symmetric structures

• Right lung shorter than left because of underlying liverRight lung shorter than left because of underlying liver

• Left lung narrower than right because heart bulges to leftLeft lung narrower than right because heart bulges to left

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

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Thoracic cavityThoracic cavity (cont.)(cont.) Lobes of the lung (cont.)Lobes of the lung (cont.)

• Lobes not arranged in horizontal bands; they stack in Lobes not arranged in horizontal bands; they stack in diagonal sloping segments and are separated by fissures diagonal sloping segments and are separated by fissures that run obliquely through chestthat run obliquely through chest

• Anterior chestAnterior chest On anterior chest, oblique fissure crosses fifth rib in On anterior chest, oblique fissure crosses fifth rib in

midaxillary line and terminates at sixth rib in midclavicular midaxillary line and terminates at sixth rib in midclavicular lineline

Right lung also contains horizontal (minor) fissure, which Right lung also contains horizontal (minor) fissure, which divides right upper and middle lobesdivides right upper and middle lobes

This fissure extends from fifth rib in right midaxillary line to This fissure extends from fifth rib in right midaxillary line to third intercostal space or fourth rib at right sternal borderthird intercostal space or fourth rib at right sternal border

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• Posterior chestPosterior chest Most remarkable point about posterior chest is that it is Most remarkable point about posterior chest is that it is

almost all lower lobealmost all lower lobe Upper lobes occupy a smaller band of tissue from their Upper lobes occupy a smaller band of tissue from their

apices at T1 down to T3 or T4apices at T1 down to T3 or T4 At this level, lower lobes begin, and their inferior border At this level, lower lobes begin, and their inferior border

reaches down to level of T10 on expiration and to T12 on reaches down to level of T10 on expiration and to T12 on inspirationinspiration

Right middle lobe does not project onto posterior chest at Right middle lobe does not project onto posterior chest at allall

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• Lateral chestLateral chest Lung tissue extends from apex of axilla down to seventh or Lung tissue extends from apex of axilla down to seventh or

eighth ribeighth rib Right upper lobe extends from apex of axilla down to Right upper lobe extends from apex of axilla down to

horizontal fissure at fifth ribhorizontal fissure at fifth rib Right middle lobe extends from horizontal fissure down and Right middle lobe extends from horizontal fissure down and

forward to sixth rib at midclavicular lineforward to sixth rib at midclavicular line Right lower lobe continues from fifth rib to eighth rib in Right lower lobe continues from fifth rib to eighth rib in

midaxillary linemidaxillary line

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• Left lung contains only two lobes, upper and lowerLeft lung contains only two lobes, upper and lower

• These are seen laterally as two triangular areas These are seen laterally as two triangular areas separated by oblique fissureseparated by oblique fissure

• Left upper lobe extends from apex of axilla down to fifth Left upper lobe extends from apex of axilla down to fifth rib at midaxillary linerib at midaxillary line

• Left lower lobe continues down to eighth rib in midaxillary Left lower lobe continues down to eighth rib in midaxillary lineline

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• Using these landmarks, take a marker and try tracing Using these landmarks, take a marker and try tracing outline of each lobe on a willing partneroutline of each lobe on a willing partner

• Take special note of three points that commonly confuse Take special note of three points that commonly confuse beginning examinersbeginning examiners

Left lung has no middle lobeLeft lung has no middle lobe Anterior chest contains mostly upper and middle lobe with Anterior chest contains mostly upper and middle lobe with

very little lower lobevery little lower lobe Posterior chest contains almost all lower lobePosterior chest contains almost all lower lobe

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Thoracic cavity (cont.)Thoracic cavity (cont.) PleuraePleurae

• The thin, slippery pleurae form an envelope between The thin, slippery pleurae form an envelope between lungs and chest walllungs and chest wall

• Visceral pleura lines outside of lungs, dipping down into Visceral pleura lines outside of lungs, dipping down into fissuresfissures

• It is continuous with parietal pleura lining inside of chest It is continuous with parietal pleura lining inside of chest wall and diaphragmwall and diaphragm

• Pleural cavity is potential space filled only with few Pleural cavity is potential space filled only with few milliliters of lubricating fluidmilliliters of lubricating fluid

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Thoracic cavity (cont.)Thoracic cavity (cont.) Pleurae (cont.)Pleurae (cont.)

• Pleural cavity normally has a vacuum, or negative Pleural cavity normally has a vacuum, or negative pressure, which holds lungs tightly against chest wallpressure, which holds lungs tightly against chest wall

Pleurae extend about 3 cm below level of lungs, forming Pleurae extend about 3 cm below level of lungs, forming the costodiaphragmatic recess the costodiaphragmatic recess

• Lungs slide smoothly and noiselessly up and down Lungs slide smoothly and noiselessly up and down during respiration, lubricated by a few milliliters of fluidduring respiration, lubricated by a few milliliters of fluid

• Similar to two glass slides with a drop of water between Similar to two glass slides with a drop of water between them; although it is difficult to separate slides, they slide them; although it is difficult to separate slides, they slide smoothly back and forthsmoothly back and forth

• This is a potential space; when it abnormally fills with air This is a potential space; when it abnormally fills with air or fluid, it compromises lung expansionor fluid, it compromises lung expansion

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Thoracic cavity (cont.)Thoracic cavity (cont.) Trachea and bronchial treeTrachea and bronchial tree

• Trachea lies anterior to esophagus and is 10 to 11 cm Trachea lies anterior to esophagus and is 10 to 11 cm long in the adultlong in the adult

• Begins at level of cricoid cartilage in neck and bifurcates Begins at level of cricoid cartilage in neck and bifurcates just below sternal angle into right and left main bronchi just below sternal angle into right and left main bronchi

• Posteriorly, tracheal bifurcation is at level of T4 or T5Posteriorly, tracheal bifurcation is at level of T4 or T5

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

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Thoracic cavity (cont.)Thoracic cavity (cont.) Trachea and bronchial treeTrachea and bronchial tree

• Trachea and bronchi transport gases between the Trachea and bronchi transport gases between the environment and lung parenchymaenvironment and lung parenchyma

• Constitute dead space, or space that is filled with air but Constitute dead space, or space that is filled with air but is not available for gaseous exchangeis not available for gaseous exchange

• This is about 150 ml in adultThis is about 150 ml in adult

• Bronchial tree also protects alveoli from small particulate Bronchial tree also protects alveoli from small particulate matter in inhaled airmatter in inhaled air

• Bronchi are lined with goblet cells, which secrete mucus Bronchi are lined with goblet cells, which secrete mucus that entraps particles; bronchi lined with cilia, which that entraps particles; bronchi lined with cilia, which sweep particles upward where they can be swallowed or sweep particles upward where they can be swallowed or expelledexpelled

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Thoracic cavityThoracic cavity (cont.)(cont.) Trachea and bronchial tree (cont.)Trachea and bronchial tree (cont.)

• Acinus is a functional respiratory unit that consists of Acinus is a functional respiratory unit that consists of bronchioles, alveolar ducts, alveolar sacs, and the alveolibronchioles, alveolar ducts, alveolar sacs, and the alveoli

• Gaseous exchange occurs across respiratory membrane Gaseous exchange occurs across respiratory membrane in alveolar duct and in millions of alveoliin alveolar duct and in millions of alveoli

• Alveoli clustered like grapes around each alveolar ductAlveoli clustered like grapes around each alveolar duct

• This creates millions of interalveolar septa (walls) that This creates millions of interalveolar septa (walls) that increase tremendously the working space available for increase tremendously the working space available for gas exchangegas exchange

• This bunched arrangement creates surface area for gas This bunched arrangement creates surface area for gas exchange that is as large as a tennis courtexchange that is as large as a tennis court

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Mechanics of respirationMechanics of respiration Four major functions of respiratory systemFour major functions of respiratory system

• Supplying oxygen to the body for energy production Supplying oxygen to the body for energy production

• Removing carbon dioxide as a waste product of energy Removing carbon dioxide as a waste product of energy reactionsreactions

• Maintaining homeostasis (acid-base balance) of arterial Maintaining homeostasis (acid-base balance) of arterial bloodblood

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

• Maintaining heat exchange (less important in humans)Maintaining heat exchange (less important in humans)

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Structures of Respiratory SystemStructures of Respiratory System

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Body tissues are bathed by blood that normally Body tissues are bathed by blood that normally

has a narrow acceptable range of pHhas a narrow acceptable range of pH• Although a number of compensatory mechanisms Although a number of compensatory mechanisms

regulate pH, lungs help maintain balance by adjusting regulate pH, lungs help maintain balance by adjusting level of carbon dioxide through respirationlevel of carbon dioxide through respiration

• Hypoventilation (slow, shallow breathing) causes carbon Hypoventilation (slow, shallow breathing) causes carbon dioxide to build up in blood, and hyperventilation (rapid, dioxide to build up in blood, and hyperventilation (rapid, deep breathing) causes carbon dioxide to be blown offdeep breathing) causes carbon dioxide to be blown off

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Control of respirationsControl of respirations

• Normally our breathing pattern changes without our Normally our breathing pattern changes without our awareness in response to cellular demandsawareness in response to cellular demands

This involuntary control of respirations is mediated by This involuntary control of respirations is mediated by respiratory center in brainstem (pons and medulla)respiratory center in brainstem (pons and medulla)

• Major feedback loop is humoral regulation, or change in Major feedback loop is humoral regulation, or change in carbon dioxide and oxygen levels in blood, and, less carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion levelimportant, hydrogen ion level

• Normal stimulus to breathe for most of us is an increase Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapniaof carbon dioxide in blood, or hypercapnia

• Decrease of oxygen in blood (hypoxemia) also increases Decrease of oxygen in blood (hypoxemia) also increases respirations but less effective than hypercapniarespirations but less effective than hypercapnia

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Mechanics of respiration (cont.)Mechanics of respiration (cont.) Changing chest sizeChanging chest size

• Respiration is the physical act of breathing; air rushes Respiration is the physical act of breathing; air rushes into the lungs as chest size increases (inspiration) and is into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration)expelled from lungs as chest recoils (expiration)

• Mechanical expansion and contraction of chest cavity Mechanical expansion and contraction of chest cavity alters size of thoracic container in two dimensionsalters size of thoracic container in two dimensions

Vertical diameter lengthens or shortens, which is Vertical diameter lengthens or shortens, which is accomplished by downward or upward movement of accomplished by downward or upward movement of diaphragmdiaphragm

Anteroposterior diameter increases or decreases, which is Anteroposterior diameter increases or decreases, which is accomplished by elevation or depression of ribsaccomplished by elevation or depression of ribs

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Mechanics of respirationMechanics of respiration (cont.)(cont.) Changing chest size (cont.)Changing chest size (cont.)

• In inspiration, increasing size of thoracic container In inspiration, increasing size of thoracic container creates slightly negative pressure in relation to creates slightly negative pressure in relation to atmosphere, so air rushes in to fill partial vacuumatmosphere, so air rushes in to fill partial vacuum

• Major muscle responsible for this increase is diaphragm Major muscle responsible for this increase is diaphragm

• During inspiration, contraction of bell-shaped diaphragm During inspiration, contraction of bell-shaped diaphragm causes it to descend and flatten; this lengthens the causes it to descend and flatten; this lengthens the vertical diametervertical diameter

• Intercostal muscles lift sternum and elevate ribs, making Intercostal muscles lift sternum and elevate ribs, making them more horizontal; this increases anteroposterior them more horizontal; this increases anteroposterior diameterdiameter

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• Expiration is primarily passive; as diaphragm muscle Expiration is primarily passive; as diaphragm muscle relaxes, elastic forces within lung, chest cage, and relaxes, elastic forces within lung, chest cage, and abdomen cause it to dome upabdomen cause it to dome up

• All this squeezing creates a relatively positive pressure All this squeezing creates a relatively positive pressure within alveoli, and air flows outwithin alveoli, and air flows out

• Forced inspiration, such as that after heavy exercise or Forced inspiration, such as that after heavy exercise or occurring pathologically with respiratory distress, occurring pathologically with respiratory distress, commands use of the accessory neck muscles to heave commands use of the accessory neck muscles to heave up sternum and rib cageup sternum and rib cage

• These neck muscles are the sternomastoids, scaleni, These neck muscles are the sternomastoids, scaleni, and the trapeziiand the trapezii

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• In forced expiration, abdominal muscles contract In forced expiration, abdominal muscles contract powerfully to push abdominal viscera forcefully in and up powerfully to push abdominal viscera forcefully in and up against diaphragm, making it dome upward, and making against diaphragm, making it dome upward, and making it squeeze against lungsit squeeze against lungs

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Mechanics of RespirationMechanics of Respiration

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

Infants and childrenInfants and children During first 5 weeks of fetal life, primitive lung bud During first 5 weeks of fetal life, primitive lung bud

emergesemerges• By 16 weeks of gestation, conducting airways reach By 16 weeks of gestation, conducting airways reach

same number as in adult; at 32 weeks, surfactant, same number as in adult; at 32 weeks, surfactant, complex lipid substance needed for sustained inflation of complex lipid substance needed for sustained inflation of air sacs, is present in adequate amountsair sacs, is present in adequate amounts

• At birth lungs have 70 million primitive alveoli ready to At birth lungs have 70 million primitive alveoli ready to start job of respirationstart job of respiration

• Breath is life; when newborn inhales first breath, the lusty Breath is life; when newborn inhales first breath, the lusty cry that follows reassures straining parents that their cry that follows reassures straining parents that their infant is all rightinfant is all right

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(cont.)(cont.) Infants and children (cont.)Infants and children (cont.)

Infant’s body systems all develop in utero, but the Infant’s body systems all develop in utero, but the respiratory system alone does not function until respiratory system alone does not function until birth; birth demands its instant performancebirth; birth demands its instant performance• When cord is cut, blood is cut off from placenta, and it When cord is cut, blood is cut off from placenta, and it

gushes into pulmonary circulationgushes into pulmonary circulation

• Relatively less resistance exists in pulmonary arteries Relatively less resistance exists in pulmonary arteries than in aorta, so foramen ovale in heart closes just after than in aorta, so foramen ovale in heart closes just after birthbirth

• Ductus arteriosus (linking pulmonary artery and aorta) Ductus arteriosus (linking pulmonary artery and aorta) contracts and closes some hours later, and pulmonary contracts and closes some hours later, and pulmonary and systemic circulation are functionaland systemic circulation are functional

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Respiratory development continues throughout Respiratory development continues throughout childhoodchildhood• Increases in diameter and length of airways, and Increases in diameter and length of airways, and

increases in size and number of alveoli continueincreases in size and number of alveoli continue

• Relatively smaller size and immaturity of children’s Relatively smaller size and immaturity of children’s pulmonary systems and presence of parents and pulmonary systems and presence of parents and caregivers who smoke result in enormous vulnerability caregivers who smoke result in enormous vulnerability and increased risks to child healthand increased risks to child health

• Prenatal exposure results in chronic hypoxia and low Prenatal exposure results in chronic hypoxia and low birth weight; postnatal exposure to environmental birth weight; postnatal exposure to environmental tobacco smoke (ETS) is linked to increased rates of otitis tobacco smoke (ETS) is linked to increased rates of otitis media, respiratory tract infections, and childhood asthmamedia, respiratory tract infections, and childhood asthma

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Other conditions associated with ETS exposure Other conditions associated with ETS exposure include sudden infant death syndrome, negative include sudden infant death syndrome, negative behavioral and cognitive functioning, and behavioral and cognitive functioning, and increased rates of adolescent smokingincreased rates of adolescent smoking

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(cont.)(cont.) Pregnant womanPregnant woman

Enlarging uterus elevates diaphragm 4 cm during Enlarging uterus elevates diaphragm 4 cm during pregnancypregnancy• This decreases vertical diameter of thoracic cage, but This decreases vertical diameter of thoracic cage, but

this decrease is compensated for by an increase in this decrease is compensated for by an increase in horizontal diameterhorizontal diameter

• Increase in estrogen level relaxes chest cage ligamentsIncrease in estrogen level relaxes chest cage ligaments

• This allows an increase in transverse diameter of chest This allows an increase in transverse diameter of chest cage by 2 cm, and costal angle widenscage by 2 cm, and costal angle widens

• Total circumference of chest cage increases by 6 cmTotal circumference of chest cage increases by 6 cm

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(cont.)(cont.) Pregnant woman (cont.)Pregnant woman (cont.)

Although diaphragm is elevated, it is not fixedAlthough diaphragm is elevated, it is not fixed• It moves with breathing even more during pregnancy, It moves with breathing even more during pregnancy,

which results in an increase in tidal volumewhich results in an increase in tidal volume

• Growing fetus increases oxygen demand on mother’s Growing fetus increases oxygen demand on mother’s bodybody

• This is met easily by increasing tidal volume (deeper This is met easily by increasing tidal volume (deeper breathing)breathing)

• Little change occurs in respiratory rateLittle change occurs in respiratory rate

• An increased awareness of need to breathe develops, An increased awareness of need to breathe develops, even early in pregnancyeven early in pregnancy

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(cont.)(cont.) Aging adultAging adult

Costal cartilages become calcified, which Costal cartilages become calcified, which produces a less mobile thoraxproduces a less mobile thorax• Respiratory muscle strength declines after age 50 years Respiratory muscle strength declines after age 50 years

and continues to decrease into 70sand continues to decrease into 70s

• More significant change is decrease in elastic properties More significant change is decrease in elastic properties within lungs, making them less distensible and lessening within lungs, making them less distensible and lessening their tendency to collapse and recoiltheir tendency to collapse and recoil

Aging lung is more rigid structure that is harder to Aging lung is more rigid structure that is harder to inflateinflate

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(cont.)(cont.) Aging adult (cont.)Aging adult (cont.)

These changes result in an increase in small These changes result in an increase in small airway closureairway closure• That yields a decreased vital capacity, maximum amount That yields a decreased vital capacity, maximum amount

of air that a person can expel from lungs after first filling of air that a person can expel from lungs after first filling lungs to maximumlungs to maximum

• And an increased residual volume, amount of air And an increased residual volume, amount of air remaining in lungs even after most forceful expirationremaining in lungs even after most forceful expiration

With aging, histologic changes (i.e., a gradual loss With aging, histologic changes (i.e., a gradual loss of intra-alveolar septa and a decreased number of of intra-alveolar septa and a decreased number of alveoli) also occur, so less surface area is alveoli) also occur, so less surface area is available for gas exchangeavailable for gas exchange

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Lung bases become less ventilated as a result of Lung bases become less ventilated as a result of closing off of a number of airwaysclosing off of a number of airways• This increases older person’s risk of dyspnea with This increases older person’s risk of dyspnea with

exertion beyond his or her usual workloadexertion beyond his or her usual workload

Histologic changes also increase the older Histologic changes also increase the older person’s risk of postoperative pulmonary person’s risk of postoperative pulmonary complicationscomplications• Older person has a greater risk of postoperative Older person has a greater risk of postoperative

atelectasis and infection from a decreased ability to atelectasis and infection from a decreased ability to cough, a loss of protective airway reflexes, and cough, a loss of protective airway reflexes, and increased secretionsincreased secretions

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

Incidence of tuberculosis (TB) has declined in the Incidence of tuberculosis (TB) has declined in the U.S.; however, persons who are foreign-born and U.S.; however, persons who are foreign-born and of racial or ethnic minorities have a of racial or ethnic minorities have a disproportionately large burden of TB diseasedisproportionately large burden of TB disease

In 2008 the TB rates wereIn 2008 the TB rates were• 10 times higher in foreign-born than in U.S.-born10 times higher in foreign-born than in U.S.-born

• 8 times higher among Hispanic and African Americans 8 times higher among Hispanic and African Americans than among whitesthan among whites

• 23 times higher among Asians than among whites23 times higher among Asians than among whites

• These data reflect high TB rates in countries of origin for These data reflect high TB rates in countries of origin for immigrants as well as barriers to early diagnosis, immigrants as well as barriers to early diagnosis, prevention, and treatment adherence for latent TBprevention, and treatment adherence for latent TB

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

Asthma occurs in about 5% to 12% of the U.S. Asthma occurs in about 5% to 12% of the U.S. population and is the most common chronic population and is the most common chronic disease in childhooddisease in childhood• Groups at increased risk include African Americans who Groups at increased risk include African Americans who

reside in inner cities and premature or low birth weight reside in inner cities and premature or low birth weight infantsinfants

• Asthma prevalence is highest among African American Asthma prevalence is highest among African American and native American adults; lowest among Asian and and native American adults; lowest among Asian and Hispanic adultsHispanic adults

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence (cont.)(cont.)

Biocultural differences in size of thoracic cavity Biocultural differences in size of thoracic cavity significantly influence pulmonary functioning as significantly influence pulmonary functioning as determined by vital capacity and forced expiratory determined by vital capacity and forced expiratory volumevolume• In descending order, the largest chest volumes are found In descending order, the largest chest volumes are found

in whites, African Americans, Asians, and American in whites, African Americans, Asians, and American IndiansIndians

• Even when shorter height of Asians is considered, their Even when shorter height of Asians is considered, their chest volume remains significantly lower than that of chest volume remains significantly lower than that of whites and African Americanswhites and African Americans

Slide 18-49



Subjective DataSubjective Data

CoughCough Shortness of breathShortness of breath Chest pain with breathingChest pain with breathing History of respiratory infectionsHistory of respiratory infections Smoking historySmoking history Environmental exposureEnvironmental exposure Self-care behaviorsSelf-care behaviors

Slide 18-50



Subjective DataSubjective Data (cont.)(cont.)

CoughCough Do you have a cough? When did it start? Gradual Do you have a cough? When did it start? Gradual

or sudden?or sudden?• How long have you had it?How long have you had it?

• How often do you cough? At any special time of day or How often do you cough? At any special time of day or just on arising? Cough wake you up at night?just on arising? Cough wake you up at night?

• Do you cough up any phlegm or sputum? How much? Do you cough up any phlegm or sputum? How much? What color is it?What color is it?

• Cough up any blood? Does this look like streaks or frank Cough up any blood? Does this look like streaks or frank blood? Does the sputum have a foul odor?blood? Does the sputum have a foul odor?

• How would you describe your cough: hacking, dry, How would you describe your cough: hacking, dry, barking, hoarse, congested, bubbling?barking, hoarse, congested, bubbling?

Slide 18-51




Cough (cont.)Cough (cont.) Cough seem to come with anything: activity, Cough seem to come with anything: activity,

position (lying), fever, congestion, talking, anxiety? position (lying), fever, congestion, talking, anxiety? • Activity make it better or worse?Activity make it better or worse?

• What treatment have you tried? Prescription or over-the-What treatment have you tried? Prescription or over-the-counter medications, vaporizer, rest, position change?counter medications, vaporizer, rest, position change?

• Does the cough bring on anything such as chest pain or Does the cough bring on anything such as chest pain or ear pain? Is it tiring? Are you concerned about it?ear pain? Is it tiring? Are you concerned about it?

Slide 18-52




Shortness of breathShortness of breath Ever had any shortness of breath or hard- Ever had any shortness of breath or hard-

breathing spells?breathing spells?• What brings it on? How severe is it? How long does it What brings it on? How severe is it? How long does it

last?last?

• Is it affected by position, such as lying down?Is it affected by position, such as lying down?

• Occur at any specific time of day or night?Occur at any specific time of day or night?

• Shortness of breath episodes associated with night Shortness of breath episodes associated with night sweats?sweats?

• Or cough, chest pain, or bluish color around lips or nails? Or cough, chest pain, or bluish color around lips or nails? Wheezing sound?Wheezing sound?

Slide 18-53




Shortness of breath (cont.)Shortness of breath (cont.) Do episodes seem to be related to food, pollen, Do episodes seem to be related to food, pollen,

dust, animals, season, or emotion?dust, animals, season, or emotion?• What do you do in a hard-breathing attack? Take a What do you do in a hard-breathing attack? Take a

special position, or use pursed-lip breathing? Do you use special position, or use pursed-lip breathing? Do you use any oxygen, inhalers, or medications?any oxygen, inhalers, or medications?

• How does the shortness of breath affect your work or How does the shortness of breath affect your work or home activities? Is it getting better or worse or staying home activities? Is it getting better or worse or staying about the same?about the same?

Slide 18-54




Chest pain with breathingChest pain with breathing Any chest pain with breathing? Please point to Any chest pain with breathing? Please point to

exact location.exact location.• When did it start? Is it constant or does it come and go?When did it start? Is it constant or does it come and go?

• Describe the pain: burning, stabbing?Describe the pain: burning, stabbing?

• Is it brought on by respiratory infection, coughing, or Is it brought on by respiratory infection, coughing, or trauma? Is it associated with fever, deep breathing, trauma? Is it associated with fever, deep breathing, unequal chest inflation?unequal chest inflation?

• What have you done to treat it? Have you tried What have you done to treat it? Have you tried medication or heat application?medication or heat application?

Slide 18-55




History of respiratory infectionsHistory of respiratory infections Any past history of breathing trouble or lung Any past history of breathing trouble or lung

diseases such as bronchitis, emphysema, asthma, diseases such as bronchitis, emphysema, asthma, or pneumonia?or pneumonia?• Any unusually frequent or unusually severe colds?Any unusually frequent or unusually severe colds?

• Any family history of allergies, tuberculosis, or asthma?Any family history of allergies, tuberculosis, or asthma?

Smoking historySmoking history• Do you smoke cigarettes or cigars? At what age did you Do you smoke cigarettes or cigars? At what age did you

start? How many packs per day do you smoke now? For start? How many packs per day do you smoke now? For how long? Do you live with someone who smokes?how long? Do you live with someone who smokes?

• Have you ever tried to quit? Why do you think it did not Have you ever tried to quit? Why do you think it did not work? What activities do you associate with smoking?work? What activities do you associate with smoking?

Slide 18-56




Environmental exposureEnvironmental exposure Are there any environmental conditions that may Are there any environmental conditions that may

affect your breathing?affect your breathing?• Where do you work? At a factory, chemical plant, coal Where do you work? At a factory, chemical plant, coal

mine, farming, outdoors in a heavy traffic area?mine, farming, outdoors in a heavy traffic area?

• Do you do anything to protect your lungs, such as wear a Do you do anything to protect your lungs, such as wear a mask or have ventilatory system checked at work? mask or have ventilatory system checked at work?

• Do you do anything to monitor your exposure? Do you Do you do anything to monitor your exposure? Do you have periodic examinations, pulmonary function tests, or have periodic examinations, pulmonary function tests, or x-ray examinations?x-ray examinations?

• Do you know what specific symptoms to note that may Do you know what specific symptoms to note that may signal breathing problems?signal breathing problems?

Slide 18-57




Self-care behaviorsSelf-care behaviors When was your last TB skin test, chest x-ray When was your last TB skin test, chest x-ray

study, pneumonia or influenza immunization?study, pneumonia or influenza immunization?

Slide 18-58




Additional history for infants and childrenAdditional history for infants and children Has the child had any frequent or very severe Has the child had any frequent or very severe

colds?colds? Is there any history of allergy in family?Is there any history of allergy in family?

• (For child under 2 years of age): At what age were new (For child under 2 years of age): At what age were new foods introduced? Was child breastfed or bottle-fed?foods introduced? Was child breastfed or bottle-fed?

Does child have a cough or seem congested? Does child have a cough or seem congested? Does child have noisy breathing or wheezing?Does child have noisy breathing or wheezing?

What measures have you taken to child-proof your What measures have you taken to child-proof your home and yard? Is there any possibility of child home and yard? Is there any possibility of child inhaling or swallowing toxic substances?inhaling or swallowing toxic substances?

Slide 18-59




Additional history for infants and children Additional history for infants and children (cont.)(cont.) Has anyone taught you emergency care measures Has anyone taught you emergency care measures

in case of accidental choking or a hard-breathing in case of accidental choking or a hard-breathing spell?spell?

Are any smokers in home or in car with child?Are any smokers in home or in car with child?

Slide 18-60




Additional history for aging adultAdditional history for aging adult Have you noticed any shortness of breath or fatigue Have you noticed any shortness of breath or fatigue

with your daily activities?with your daily activities?• Tell me about your usual amount of physical activityTell me about your usual amount of physical activity

• (For those with a history of chronic obstructive pulmonary (For those with a history of chronic obstructive pulmonary disease, lung cancer, or tuberculosis): How are you getting disease, lung cancer, or tuberculosis): How are you getting along each day? Any weight change in last 3 months? along each day? Any weight change in last 3 months? How much?How much?

• How is your energy level? Do you tire more easily? How How is your energy level? Do you tire more easily? How does your illness affect you at home and at work?does your illness affect you at home and at work?

• Do you have any chest pain with breathing?Do you have any chest pain with breathing?

• Do you have any chest pain after a bout of coughing or Do you have any chest pain after a bout of coughing or after a fall?after a fall?

Slide 18-61



Objective DataObjective Data (cont.)(cont.)

PreparationPreparation Ask person to sit upright and male to disrobe to Ask person to sit upright and male to disrobe to

waistwaist• For female, leave gown on and open at backFor female, leave gown on and open at back

When examining anterior chest, lift up gown and drape it When examining anterior chest, lift up gown and drape it on her shoulders rather than removing it completelyon her shoulders rather than removing it completely

This promotes comfort by giving her feeling of being This promotes comfort by giving her feeling of being somewhat clothedsomewhat clothed

• The following provisions will ensure further comfort: a The following provisions will ensure further comfort: a warm room, a warm diaphragm endpiece, and a private warm room, a warm diaphragm endpiece, and a private examination time with no interruptionsexamination time with no interruptions

Slide 18-62




Preparation (cont.)Preparation (cont.)• For smooth choreography in a complete examination, For smooth choreography in a complete examination,

begin the respiratory examination just after palpating begin the respiratory examination just after palpating thyroid gland when you are standing behind personthyroid gland when you are standing behind person

• Perform inspection, palpation, percussion, and Perform inspection, palpation, percussion, and auscultation on posterior and lateral thoraxauscultation on posterior and lateral thorax

• Then move to face person and repeat four maneuvers on Then move to face person and repeat four maneuvers on anterior chestanterior chest

This avoids repetitiously moving front to back of personThis avoids repetitiously moving front to back of person

• Clean stethoscope endpiece with an alcohol wipeClean stethoscope endpiece with an alcohol wipe Because your stethoscope touches many people, it could Because your stethoscope touches many people, it could

be a possible vector for both aerobic and anaerobic be a possible vector for both aerobic and anaerobic bacteriabacteria

Slide 18-63




Equipment neededEquipment needed StethoscopeStethoscope Small ruler, marked in centimetersSmall ruler, marked in centimeters Marking penMarking pen Alcohol wipeAlcohol wipe

Slide 18-64




Inspect the posterior chestInspect the posterior chest Thoracic cageThoracic cage

• Note shape and configuration of chest wallNote shape and configuration of chest wall

• Spinous processes should appear in a straight line; Spinous processes should appear in a straight line; thorax is symmetric, in an elliptical shape, with thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to downward sloping ribs, about 45 degrees relative to spine; scapulae are placed symmetrically in each spine; scapulae are placed symmetrically in each hemithoraxhemithorax

• Anteroposterior diameter should be less than transverse Anteroposterior diameter should be less than transverse diameter; ratio of anteroposterior to transverse diameter diameter; ratio of anteroposterior to transverse diameter is from 1:2 to 5:7is from 1:2 to 5:7

• The neck muscles and trapezius muscles should be The neck muscles and trapezius muscles should be developed normally for age and occupationdeveloped normally for age and occupation

Slide 18-65




Inspect the posterior chestInspect the posterior chest (cont.)(cont.) Thoracic cage (cont.)Thoracic cage (cont.)

• Note position person takes to breatheNote position person takes to breathe

• Includes relaxed posture and ability to support one’s own Includes relaxed posture and ability to support one’s own weight with arms comfortably at sides or in lapweight with arms comfortably at sides or in lap

• Assess skin color and conditionAssess skin color and condition

• Color should be consistent with person’s genetic Color should be consistent with person’s genetic background, with allowance for sun-exposed areas on background, with allowance for sun-exposed areas on chest and backchest and back

• No cyanosis or pallor should be presentNo cyanosis or pallor should be present

• Note any lesions; inquire about any change in nevus on Note any lesions; inquire about any change in nevus on backback

Slide 18-66




Palpate the posterior chest (cont.)Palpate the posterior chest (cont.) Symmetric expansionSymmetric expansion

• Confirm symmetric chest expansion by placing your Confirm symmetric chest expansion by placing your warmed hands on posterolateral chest wall with thumbs warmed hands on posterolateral chest wall with thumbs at level of T9 or T10at level of T9 or T10

• Slide your hands medially to pinch up a small fold of skin Slide your hands medially to pinch up a small fold of skin between your thumbs; ask person to take a deep breathbetween your thumbs; ask person to take a deep breath

• Your hands serve as mechanical amplifiers; as person Your hands serve as mechanical amplifiers; as person inhales deeply, your thumbs should move apart inhales deeply, your thumbs should move apart symmetrically; note any lag in expansionsymmetrically; note any lag in expansion

Slide 18-67




Palpate the posterior chest (cont.)Palpate the posterior chest (cont.) Tactile fremitusTactile fremitus

• Fremitus is a palpable vibrationFremitus is a palpable vibration

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

• Use either palmar base (ball) of fingers or ulnar edge of Use either palmar base (ball) of fingers or ulnar edge of one hand, and touch person’s chest while he or she one hand, and touch person’s chest while he or she repeats words “ninety-nine” or “blue moon” repeats words “ninety-nine” or “blue moon”

• These are resonant phrases that generate strong These are resonant phrases that generate strong vibrationsvibrations

Slide 18-68




Palpate the posterior chestPalpate the posterior chest (cont.)(cont.) Tactile fremitus (cont.)Tactile fremitus (cont.)

• Start over lung apices and palpate from one side to Start over lung apices and palpate from one side to anotheranother

• Fremitus varies among persons but symmetry is most Fremitus varies among persons but symmetry is most important; vibrations should feel same in corresponding important; vibrations should feel same in corresponding area on each sidearea on each side

• However, just between scapulae, fremitus may feel However, just between scapulae, fremitus may feel stronger on right side than on left side because right stronger on right side than on left side because right closer to bronchial bifurcation; avoid palpating over closer to bronchial bifurcation; avoid palpating over scapulae because bone damps out sound transmissionscapulae because bone damps out sound transmission

Slide 18-69





• Factors affecting normal intensity of tactile fremitusFactors affecting normal intensity of tactile fremitus Relative location of bronchi to chest wall; normally most Relative location of bronchi to chest wall; normally most

prominent between scapulae and around sternum, sites prominent between scapulae and around sternum, sites where major bronchi closest to chest wallwhere major bronchi closest to chest wall

Decreases as you progress down because more and more Decreases as you progress down because more and more tissue impedes sound transmissiontissue impedes sound transmission

Thickness of chest wallThickness of chest wall Feels greater over thin wall than over an obese or heavily Feels greater over thin wall than over an obese or heavily

muscular one where thick tissue dampens vibrationmuscular one where thick tissue dampens vibration Pitch and intensity; loud, low-pitched voice generates more Pitch and intensity; loud, low-pitched voice generates more

fremitus than soft, high-pitched onefremitus than soft, high-pitched one

Slide 18-70





• Note any areas of abnormal fremitusNote any areas of abnormal fremitus

• Conditions that increase density of lung tissue make a Conditions that increase density of lung tissue make a better conducting medium for sound vibrations and better conducting medium for sound vibrations and increase tactile fremitusincrease tactile fremitus

• Using fingers, gently palpate entire chest wallUsing fingers, gently palpate entire chest wall

• Enables noting any areas of tenderness, skin Enables noting any areas of tenderness, skin temperature and moisture, detecting any superficial temperature and moisture, detecting any superficial lumps or masses, and exploring any skin lesions noted lumps or masses, and exploring any skin lesions noted on inspectionon inspection

Slide 18-71




Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Lung fieldsLung fields

• Determine predominant note over lung fields; start at Determine predominant note over lung fields; start at apices and percuss band of normally resonant tissue apices and percuss band of normally resonant tissue across tops of both shouldersacross tops of both shoulders

• Then, percussing in interspaces, make side-to-side Then, percussing in interspaces, make side-to-side comparison all the way down lung regioncomparison all the way down lung region

• Percuss at 5-cm intervals; avoid damping effect of Percuss at 5-cm intervals; avoid damping effect of scapulae and ribsscapulae and ribs

• Resonance is low-pitched, clear, hollow sound that Resonance is low-pitched, clear, hollow sound that predominates in healthy lung tissue in adultpredominates in healthy lung tissue in adult

• Dull percussion indicates an abnormal density in the Dull percussion indicates an abnormal density in the lungslungs

Slide 18-72




Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Lung fields (cont.)Lung fields (cont.)

• However, resonance is relative term and has no constant However, resonance is relative term and has no constant standardstandard

• Resonant note may be modified somewhat in athlete with Resonant note may be modified somewhat in athlete with heavily muscular chest wall and in heavily obese adult in whom heavily muscular chest wall and in heavily obese adult in whom subcutaneous fat produces scattered dullnesssubcutaneous fat produces scattered dullness

• Percussion sets into motion only outer 5 to 7 cm of tissue; will Percussion sets into motion only outer 5 to 7 cm of tissue; will not penetrate to reveal any change in density deeper than thatnot penetrate to reveal any change in density deeper than that

• Abnormal findings must be 2 to 3 cm wide to yield an abnormal Abnormal findings must be 2 to 3 cm wide to yield an abnormal percussion percussion as seen in pneumonia, pleural effusion, atelectasis as seen in pneumonia, pleural effusion, atelectasis or tumors; lesions smaller than that are not detectable by or tumors; lesions smaller than that are not detectable by percussion.percussion.

Slide 18-73




Percuss the posterior chest (cont.)Percuss the posterior chest (cont.) Diaphragmatic excursionDiaphragmatic excursion

• Determine diaphragmatic excursionDetermine diaphragmatic excursion

• Percuss to map out lower lung border, both in expiration Percuss to map out lower lung border, both in expiration and in inspirationand in inspiration

• First, ask the person to “exhale and hold it” briefly while First, ask the person to “exhale and hold it” briefly while you percuss down scapular line until sound changes you percuss down scapular line until sound changes from resonant to dull on each sidefrom resonant to dull on each side

• This estimates level of diaphragm separating lungs from This estimates level of diaphragm separating lungs from abdominal viscera; may be somewhat higher on right abdominal viscera; may be somewhat higher on right side because of presence of liverside because of presence of liver

• Mark the spotMark the spot

Slide 18-74




Percuss the posterior chestPercuss the posterior chest (cont.)(cont.) Diaphragmatic excursion (cont.)Diaphragmatic excursion (cont.)

• Now ask person to “take a deep breath and hold it” Now ask person to “take a deep breath and hold it”

• Continue percussing down from your first mark and mark Continue percussing down from your first mark and mark level where sound changes to dull on deep inspiration level where sound changes to dull on deep inspiration

• Measure the difference; this diaphragmatic excursion Measure the difference; this diaphragmatic excursion should be equal bilaterally and measure about 3 to 5 cm should be equal bilaterally and measure about 3 to 5 cm in adults, although it may be up to 7 to 8 cm in well-in adults, although it may be up to 7 to 8 cm in well-conditioned peopleconditioned people

Slide 18-75




Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Passage of air through tracheobronchial tree Passage of air through tracheobronchial tree

creates a characteristic set of noises that are creates a characteristic set of noises that are audible through chest wallaudible through chest wall

Blockage of the tracheobronchial tree will have Blockage of the tracheobronchial tree will have decreased breath soundsdecreased breath sounds

These noises also may be modified by obstruction These noises also may be modified by obstruction within respiratory passageways or by changes in within respiratory passageways or by changes in lung parenchyma, the pleura, or chest walllung parenchyma, the pleura, or chest wall

Slide 18-76




Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Breath soundsBreath sounds

• Evaluate presence and quality of normal breath soundsEvaluate presence and quality of normal breath sounds

• Instruct person to breathe through mouth, a little bit Instruct person to breathe through mouth, a little bit deeper than usualdeeper than usual

• Use flat diaphragm endpiece of stethoscope and hold it Use flat diaphragm endpiece of stethoscope and hold it firmly on person’s chest wall; listen to at least one full firmly on person’s chest wall; listen to at least one full respiration in each locationrespiration in each location

• Side-to-side comparison is most importantSide-to-side comparison is most important

• Do not confuse background noise with lung soundsDo not confuse background noise with lung sounds

Slide 18-77




Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Breath sounds (cont.)Breath sounds (cont.)

• Become familiar with these extraneous noises that may Become familiar with these extraneous noises that may be confused with lung pathology if not recognizedbe confused with lung pathology if not recognized

Examiner’s breathing on stethoscope tubingExaminer’s breathing on stethoscope tubing Stethoscope tubing bumping togetherStethoscope tubing bumping together Patient shiveringPatient shivering Patient’s hairy chest; movement of hairs under stethoscope Patient’s hairy chest; movement of hairs under stethoscope

sounds like crackles (rales); minimize this by pressing sounds like crackles (rales); minimize this by pressing harder or by wetting the hair with damp clothharder or by wetting the hair with damp cloth

Rustling of paper gown or paper drapesRustling of paper gown or paper drapes

Slide 18-78





• While standing behind person, listen to following lung While standing behind person, listen to following lung areasareas

Posterior from apices at C7 to bases around T10 Posterior from apices at C7 to bases around T10 Laterally from axilla down to seventh or eighth ribLaterally from axilla down to seventh or eighth rib

• Continue to visualize approximate locations of lobes of Continue to visualize approximate locations of lobes of each lung so that you correlate your findings to each lung so that you correlate your findings to anatomical areasanatomical areas

• As you listen, think As you listen, think What am I hearing over this spot? What am I hearing over this spot? What should I expect to be hearing?What should I expect to be hearing?

Slide 18-79





• You should expect to hear three types of normal breath You should expect to hear three types of normal breath sounds in adult and older childsounds in adult and older child

Bronchial, sometimes called tracheal or tubularBronchial, sometimes called tracheal or tubular BronchovesicularBronchovesicular VesicularVesicular

• Study description of characteristics of these normal Study description of characteristics of these normal breath soundsbreath sounds

• Note normal location of three types of breath sounds on Note normal location of three types of breath sounds on the chest wall of adult and older childthe chest wall of adult and older child

Slide 18-80




Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Adventitious soundsAdventitious sounds

• Added sounds that are not normally heard in lungsAdded sounds that are not normally heard in lungs

• If present, are heard as superimposed on breath soundsIf present, are heard as superimposed on breath sounds

• Caused by moving air colliding with secretions in Caused by moving air colliding with secretions in tracheobronchial passageways or by popping open of tracheobronchial passageways or by popping open of previously deflated airwayspreviously deflated airways

• Sources differ as to the classification and nomenclature Sources differ as to the classification and nomenclature of these sounds but crackles (or rales) and wheeze (or of these sounds but crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examinersrhonchi) are terms commonly used by most examiners

Slide 18-81




Auscultate the posterior chestAuscultate the posterior chest (cont.)(cont.) Adventitious sounds (cont.)Adventitious sounds (cont.)

• Atelectatic crackles, a type of adventitious sound, is not Atelectatic crackles, a type of adventitious sound, is not pathologic; short, popping, crackling sounds that sound pathologic; short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breathslike fine crackles but do not last beyond a few breaths

• When sections of alveoli are not fully aerated (as in When sections of alveoli are not fully aerated (as in people who are asleep, or in elderly), they deflate slightly people who are asleep, or in elderly), they deflate slightly and accumulate secretionsand accumulate secretions

Crackles are heard when these sections are expanded by Crackles are heard when these sections are expanded by a few deep breathsa few deep breaths

• Atelectatic crackles are heard only in the periphery, and Atelectatic crackles are heard only in the periphery, and disappear after first few breaths or after a coughdisappear after first few breaths or after a cough

Slide 18-82




Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Voice soundsVoice sounds

• Determine quality of voice sounds or vocal resonanceDetermine quality of voice sounds or vocal resonance

• Voice can be auscultated over chest wall Voice can be auscultated over chest wall

• Ask person to repeat a phrase such as “ninety-nine” Ask person to repeat a phrase such as “ninety-nine” while you listen over chest wallwhile you listen over chest wall

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

• Pathology that increases lung density enhances Pathology that increases lung density enhances transmission of voice soundstransmission of voice sounds

Slide 18-83




Auscultate the posterior chest (cont.)Auscultate the posterior chest (cont.) Voice sounds (cont.)Voice sounds (cont.)

• Eliciting voice sounds usually not done in routine Eliciting voice sounds usually not done in routine examinationexamination

• Rather, these are supplemental maneuvers that are Rather, these are supplemental maneuvers that are performed if you suspect lung pathology on basis of performed if you suspect lung pathology on basis of earlier dataearlier data

• When they are performed, you are testing for possible When they are performed, you are testing for possible presence of bronchophony, egophony, and whispered presence of bronchophony, egophony, and whispered pectoriloquypectoriloquy

Slide 18-84




Inspect the anterior chestInspect the anterior chest Note shape and configuration of chest wallNote shape and configuration of chest wall

• Ribs are sloping downward with symmetric interspacesRibs are sloping downward with symmetric interspaces

• Costal angle is within 90 degrees; development of Costal angle is within 90 degrees; development of abdominal muscles as expected for person’s age, abdominal muscles as expected for person’s age, weight, and athletic conditionweight, and athletic condition

• Note person’s facial expression; facial expression should Note person’s facial expression; facial expression should be relaxed, indicating unconscious effort of breathingbe relaxed, indicating unconscious effort of breathing

• Assess the level of consciousness; level of Assess the level of consciousness; level of consciousness should be alert and cooperativeconsciousness should be alert and cooperative

• Note skin color and condition; lips and nail beds are free Note skin color and condition; lips and nail beds are free of cyanosis; nails of normal configurationof cyanosis; nails of normal configuration

Slide 18-85




Inspect the anterior chest (cont.)Inspect the anterior chest (cont.) Assess quality of respirationsAssess quality of respirations

• Normal relaxed breathing is automatic and effortless, Normal relaxed breathing is automatic and effortless, regular and even, and produces no noiseregular and even, and produces no noise

• Chest expands symmetrically with each inspiration; note Chest expands symmetrically with each inspiration; note any localized lag on inspirationany localized lag on inspiration

• No retraction or bulging of interspaces with inspirationNo retraction or bulging of interspaces with inspiration

• Normally, accessory muscles are not used to augment Normally, accessory muscles are not used to augment respiratory effortrespiratory effort

• Respiratory rate is within normal limits for person’s age Respiratory rate is within normal limits for person’s age and pattern of breathing is regularand pattern of breathing is regular

• Occasional sighs normally punctuate breathingOccasional sighs normally punctuate breathing

Slide 18-86




Palpate the anterior chest (cont.)Palpate the anterior chest (cont.) Palpate symmetric chest expansionPalpate symmetric chest expansion

• Place your hands on anterolateral wall with thumbs along Place your hands on anterolateral wall with thumbs along costal margins and pointing toward xiphoid processcostal margins and pointing toward xiphoid process

• Ask person to take a deep breath; watch thumbs move Ask person to take a deep breath; watch thumbs move apart symmetrically, and note smooth chest expansion apart symmetrically, and note smooth chest expansion with fingerswith fingers

• Any limitation in thoracic expansion is easier to detect on Any limitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists anterior chest because greater range of motion exists with breathing herewith breathing here

Slide 18-87



ObjectiveObjectiveAssessing Chest ExpansionAssessing Chest Expansion

Slide 5-88




Palpate the anterior chest (cont.)Palpate the anterior chest (cont.) Assess tactile (vocal) fremitusAssess tactile (vocal) fremitus

• Begin palpating over lung apices in supraclavicular areas Begin palpating over lung apices in supraclavicular areas

• Compare vibrations from one side to other as person Compare vibrations from one side to other as person repeats “ninety-nine”repeats “ninety-nine”

• Avoid palpating over female breast tissue because Avoid palpating over female breast tissue because breast tissue normally damps soundbreast tissue normally damps sound

Palpate anterior chest wall Palpate anterior chest wall • Note any tenderness; normally none is presentNote any tenderness; normally none is present

• Detect any superficial lumps or masses, again, normally Detect any superficial lumps or masses, again, normally none are presentnone are present

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

Slide 18-89



ObjectiveObjective

Assess tactile Assess tactile (vocal) (vocal) fremitusfremitus

Slide 23-90




Percuss the anterior chestPercuss the anterior chest Begin percussing apices in supraclavicular areasBegin percussing apices in supraclavicular areas

• Then, percussing interspaces and comparing one side to Then, percussing interspaces and comparing one side to other, move down anterior chestother, move down anterior chest

• Interspaces easier to palpate on anterior chest than on Interspaces easier to palpate on anterior chest than on backback

• Do not percuss directly over female breast tissue Do not percuss directly over female breast tissue because this would produce a dull note; shift breast because this would produce a dull note; shift breast tissue over slightly using edge of your stationary handtissue over slightly using edge of your stationary hand

• In females with large breasts, percussion may yield little In females with large breasts, percussion may yield little useful datauseful data

Slide 18-91



ObjectiveObjective

Percussion Percussion SequenceSequence

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Objective:Objective: Expected Percussion Sounds Expected Percussion Sounds

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Percuss the anterior chest (cont.)Percuss the anterior chest (cont.) Note borders of cardiac dullness normally found Note borders of cardiac dullness normally found

on anterior cheston anterior chest• Do not confuse these with suspected lung pathologyDo not confuse these with suspected lung pathology

• In right hemithorax upper border of liver dullness is In right hemithorax upper border of liver dullness is located in fifth intercostal space in right midclavicular linelocated in fifth intercostal space in right midclavicular line

• On left, tympany is evident over gastric spaceOn left, tympany is evident over gastric space

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Auscultate the anterior chestAuscultate the anterior chest Breath soundsBreath sounds

• Auscultate lung fields over anterior chest from apices in Auscultate lung fields over anterior chest from apices in supraclavicular areas down to sixth ribsupraclavicular areas down to sixth rib

• Progress from side to side as you move downward, and Progress from side to side as you move downward, and listen to one full respiration in each locationlisten to one full respiration in each location

• Use sequence indicated for percussion; do not place Use sequence indicated for percussion; do not place stethoscope directly over female breast; displace breast stethoscope directly over female breast; displace breast and listen directly over chest walland listen directly over chest wall

• Evaluate normal breath sounds, noting any abnormal Evaluate normal breath sounds, noting any abnormal breath sounds and any adventitious soundsbreath sounds and any adventitious sounds

• If situation warrants, assess voice soundsIf situation warrants, assess voice sounds

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ObjectiveObjective

Auscultation of Auscultation of Posterior Chest Posterior Chest Wall SequenceWall Sequence

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ObjectiveObjectiveExpected Lung SoundsExpected Lung Sounds

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Auscultate the anterior chest (cont.)Auscultate the anterior chest (cont.) Measurement of pulmonary function statusMeasurement of pulmonary function status

• Forced expiratory time is number of seconds it takes to Forced expiratory time is number of seconds it takes to exhale from total lung capacity to residual volumeexhale from total lung capacity to residual volume

• It is a screening measure of air flow obstructionIt is a screening measure of air flow obstruction

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

• Ask person to inhale deepest breath possible and then Ask person to inhale deepest breath possible and then blow it all out hard, as quickly as possible, with mouth blow it all out hard, as quickly as possible, with mouth openopen

• Listen with your stethoscope over sternum; normal time Listen with your stethoscope over sternum; normal time for full expiration is 4 seconds or lessfor full expiration is 4 seconds or less

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Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence

Infants and childrenInfants and children To prepare, let parent hold infant supported To prepare, let parent hold infant supported

against chest or shoulder; a child may sit upright against chest or shoulder; a child may sit upright on parent’s lapon parent’s lap

InspectionInspection• Infant has a rounded thorax with an equal Infant has a rounded thorax with an equal

anteroposterior-to-transverse chest diameteranteroposterior-to-transverse chest diameter

• By age 6 years, thorax reaches adult ratio of 1:2 By age 6 years, thorax reaches adult ratio of 1:2

• Newborn’s chest circumference is 30 to 36 cm and is 2 Newborn’s chest circumference is 30 to 36 cm and is 2 cm smaller than head circumference until 2 years of agecm smaller than head circumference until 2 years of age

• Chest wall is thin with little musculatureChest wall is thin with little musculature

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(cont.)(cont.) Infants and childrenInfants and children

Inspection (cont.)Inspection (cont.)• Ribs and xiphoid are prominent; you can see as well as Ribs and xiphoid are prominent; you can see as well as

feel sharp tip of xiphoid process; thoracic cage is soft feel sharp tip of xiphoid process; thoracic cage is soft and flexibleand flexible

• In newborn males and females, breasts may look In newborn males and females, breasts may look enlarged by second or third day from maternal estrogenenlarged by second or third day from maternal estrogen

• Occasionally a white fluid, sometimes referred to by the Occasionally a white fluid, sometimes referred to by the slang expression “witch’s milk,” can be expressed; this slang expression “witch’s milk,” can be expressed; this resolves within a weekresolves within a week

• In some children, “Harrison groove” occurs normally; this In some children, “Harrison groove” occurs normally; this is horizontal groove in rib cage at level of insertion of is horizontal groove in rib cage at level of insertion of diaphragm, extending from sternum to midaxillary linediaphragm, extending from sternum to midaxillary line

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Inspection (cont.)Inspection (cont.)• Newborn’s first respiratory assessment is part of Apgar Newborn’s first respiratory assessment is part of Apgar

scoring system to measure successful transition to scoring system to measure successful transition to extrauterine lifeextrauterine life

• Five standard parameters are scored at 1 minute and at Five standard parameters are scored at 1 minute and at 5 minutes after birth5 minutes after birth

• Infant breathes through nose rather than mouth and is Infant breathes through nose rather than mouth and is obligate nose breather until 3 monthsobligate nose breather until 3 months

• Slight flaring of lower costal margins may occur with Slight flaring of lower costal margins may occur with respirations, but normally no flaring of nostrils and no respirations, but normally no flaring of nostrils and no sternal retractions or intercostal retractions occursternal retractions or intercostal retractions occur

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Inspection (cont.)Inspection (cont.)• Diaphragm is newborn’s major respiratory muscleDiaphragm is newborn’s major respiratory muscle

• Intercostal muscles are not well developed; thus you Intercostal muscles are not well developed; thus you observe abdomen bulge with each inspiration but see observe abdomen bulge with each inspiration but see little thoracic expansionlittle thoracic expansion

• Count respiratory rate for 1 full minute; normal rates for Count respiratory rate for 1 full minute; normal rates for newborn are 30 to 40 breaths per minute but may spike newborn are 30 to 40 breaths per minute but may spike up to 60 per minuteup to 60 per minute

• Obtain the most accurate respiratory rate by counting Obtain the most accurate respiratory rate by counting when the infant is asleep because infants reach rapid when the infant is asleep because infants reach rapid rates with very little excitation when awakerates with very little excitation when awake

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Inspection (cont.)Inspection (cont.)• Respiratory pattern may be irregular when extremes in Respiratory pattern may be irregular when extremes in

room temperature occur or with feeding or sleepingroom temperature occur or with feeding or sleeping

• Brief periods of apnea less than 10 or 15 seconds are Brief periods of apnea less than 10 or 15 seconds are common; this periodic breathing more common in common; this periodic breathing more common in premature infantspremature infants

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PalpationPalpation• Palpate symmetric chest expansion by encircling infant’s Palpate symmetric chest expansion by encircling infant’s

thorax with both handsthorax with both hands

• Further palpation should yield no lumps, masses, or Further palpation should yield no lumps, masses, or crepitus, although you may feel costochondral junctions crepitus, although you may feel costochondral junctions in some normal infantsin some normal infants

PercussionPercussion• Percussion is of limited usefulness in newborn and Percussion is of limited usefulness in newborn and

especially in premature newborn because adult’s fingers especially in premature newborn because adult’s fingers are too large in relation to tiny chestare too large in relation to tiny chest

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Percussion (cont.)Percussion (cont.)• Percussion note of hyperresonance occurs normally in Percussion note of hyperresonance occurs normally in

infant and young child because of relatively thin chest infant and young child because of relatively thin chest wallwall

• Anything less than hyperresonance would have same Anything less than hyperresonance would have same clinical significance as dullness in adultclinical significance as dullness in adult

• If measured, diaphragmatic excursion measures about If measured, diaphragmatic excursion measures about one to two rib interspaces in childrenone to two rib interspaces in children

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AuscultationAuscultation• Auscultation normally yields bronchovesicular breath Auscultation normally yields bronchovesicular breath

sounds in peripheral lung fields of infant and young child sounds in peripheral lung fields of infant and young child up to age 5 to 6 yearsup to age 5 to 6 years

• Relatively thin chest walls with underdeveloped Relatively thin chest walls with underdeveloped musculature do not damp off sound as do thicker walls of musculature do not damp off sound as do thicker walls of adults, so breath sounds are louder and harsheradults, so breath sounds are louder and harsher

• Fine crackles are adventitious sounds commonly heard Fine crackles are adventitious sounds commonly heard in immediate newborn period from opening of airways in immediate newborn period from opening of airways and clearing of fluidand clearing of fluid

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Auscultation (cont.)Auscultation (cont.)• Because newborn’s chest wall is so thin, transmission of Because newborn’s chest wall is so thin, transmission of

sounds is enhanced and sound is heard easily all over sounds is enhanced and sound is heard easily all over chest, making localization of breath sounds a problemchest, making localization of breath sounds a problem

• Even bowel sounds are easily heard in chestEven bowel sounds are easily heard in chest

• Try using smaller pediatric diaphragm endpiece, or place Try using smaller pediatric diaphragm endpiece, or place bell over infant’s interspaces and not over ribsbell over infant’s interspaces and not over ribs

• Use pediatric diaphragm on an older infant or toddlerUse pediatric diaphragm on an older infant or toddler

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(cont.)(cont.) Pregnant womanPregnant woman

Thoracic cage may appear wider, and costal angle Thoracic cage may appear wider, and costal angle may feel wider than in nonpregnant state which may feel wider than in nonpregnant state which contributes to the feeling of short of breathcontributes to the feeling of short of breath• Respirations may be deeper, although this can be Respirations may be deeper, although this can be

quantified only with pulmonary function testsquantified only with pulmonary function tests

Aging adultAging adult Chest cage commonly shows an increased Chest cage commonly shows an increased

anteroposterior diameter, giving a round barrel anteroposterior diameter, giving a round barrel shape, and kyphosis or an outward curvature of shape, and kyphosis or an outward curvature of thoracic spinethoracic spine

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Person compensates by holding head extended Person compensates by holding head extended and tilted backand tilted back• May palpate marked bony prominences because of May palpate marked bony prominences because of

decreased subcutaneous fatdecreased subcutaneous fat

• Chest expansion may be somewhat decreased with Chest expansion may be somewhat decreased with older person, although it still should be symmetricolder person, although it still should be symmetric

• Costal cartilages become calcified with aging, resulting in Costal cartilages become calcified with aging, resulting in a less mobile thoraxa less mobile thorax

• The older person may fatigue easily, especially during The older person may fatigue easily, especially during auscultation when deep mouth breathing is requiredauscultation when deep mouth breathing is required

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Abnormal Findings: Abnormal Findings: Configurations of the ThoraxConfigurations of the Thorax

Barrel chestBarrel chest Pectus excavatumPectus excavatum Pectus carinatumPectus carinatum ScoliosisScoliosis KyphosisKyphosis

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Barrel ChestBarrel Chest

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Seen in chronic obstructivepulmonary disease



ScoliosisScoliosis

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KyphosisKyphosis

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Abnormal Findings: Abnormal Findings: Respiration PatternsRespiration Patterns

SighSigh TachypneaTachypnea BradypneaBradypnea HyperventilationHyperventilation HypoventilationHypoventilation Cheyne-Stokes respirationCheyne-Stokes respiration Biot’s respirationBiot’s respiration Chronic obstructive breathingChronic obstructive breathing

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Abnormal Findings:Abnormal Findings:Abnormal Tactile FremitusAbnormal Tactile Fremitus

Increased tactile fremitusIncreased tactile fremitus Decreased tactile fremitusDecreased tactile fremitus Rhonchial fremitusRhonchial fremitus Pleural friction fremitusPleural friction fremitus

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Abnormal Findings:Abnormal Findings:Adventitious Lung SoundsAdventitious Lung Sounds

Discontinuous soundsDiscontinuous sounds Crackles—fine Crackles—fine Crackles—course sensation over skin surface caused by air Crackles—course sensation over skin surface caused by air

escaping into tissueescaping into tissue Atelectatic cracklesAtelectatic crackles Pleural friction rubPleural friction rub

Continuous soundsContinuous sounds Wheeze—sibilant caused by air squeezed through passageWheeze—sibilant caused by air squeezed through passage Wheeze—sonorous rhonchiWheeze—sonorous rhonchi StridorStridor

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Abnormal Voice SoundsAbnormal Voice Sounds Voice soundsVoice sounds

Bronchophony Clear 99 is (+) consolidation and Bronchophony Clear 99 is (+) consolidation and ↑ denisty↑ denisty Egophony eeee to aaaa sound (+)Egophony eeee to aaaa sound (+) Whispered pectoriloquyWhispered pectoriloquy

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Abnormal Findings:Abnormal Findings:Common Respiratory ConditionsCommon Respiratory Conditions

AtelectasisAtelectasis Lobar pneumoniaLobar pneumonia BronchitisBronchitis EmphysemaEmphysema Asthma (reactive Asthma (reactive

airway disease)airway disease) Pleural effusion Pleural effusion

thickeningthickening PneumothoraxPneumothorax

Congestive heart Congestive heart failurefailure

Pneumocystis carinii Pneumocystis carinii pneumoniapneumonia

TuberculosisTuberculosis Pulmonary Pulmonary

embolismembolism Acute respiratory Acute respiratory

distress syndromedistress syndrome

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Unit 2 app thorax and lungs

Health & Medicine

Transcript of Unit 2 app thorax and lungs