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Name the parts of the sternum
- Xiphoid Process
Where is the suprasternal notch located, and what is it?
Just above the sternum ( ridged top of manubrium) Hollow U- shaped depression, in between the clavicles.
What is another name for Manubriosternal Angle?
Angle of Louis or Sternal angle
What is the manubriosternal angle?
- Bony ridge ( articulation of manubrim & body of sternum)
- Useful place to start counting ribs. Continuous with 2nd rib (count ribs & ICS from this point)
- Site of tracheal bifurcation into right & left main bronchi
- Corresponds with upper boarder of atria
What is intercostal space (ICS) and how is it counted?
- It is the space below each rib
- ICS is numbered by the rib above it
How many pairs of ribs are there?
What is the costochondral junction?
Where the rib attaches to cartilage
What are the floating ribs, where are they attached, and where can you palpate to find them?
- Ribs 11- 12
- attached to spinal column only ( where they get the name "floating")
- 12th rib tip is palpable midway between spine & side
- 11 is on side 12 is more posterior
What is the costal angle and what is the normal angle that it forms?
- It is where the right and left costal margins meet to form an angle.
- The angle is usually 90 degrees or less to be considered normal
What does it mean if the angle is greater than 90 degrees? An give an example.
- It is an abnormal finding when greater than 90
- The angle increases when the rib cage is chronically overinflated, ( hyperinflation)
- An example is emphysema
What is the first vertebral prominens you can palpate, and how do you palpate for it?
- Palpate with head flexed
If you feel two bumps when palpating for C7 what is the other one?
How many Thoracic Vertebrae are there? What are they?
- They are spinous processes (knobs on vertebrea) - most are palpable..you should be able to count them.
Where is the scapula located?
Lower tip (inferior border) at 7th- 8th rib
Where is the midsternal line?
On the anterior chest, right down the middle over the sternum.
Where is the Midclavicular line (MCL) ?
- Anterior chest
- It bisects the center of each clavicle
Where is the Vertebral line?
- Posterior chest wall
- Also called midspinal line
- Goes right down the vertebra ( the middle of the back)
Where is the Scapular line?
Extends through the inferior angle of the scapula when the arms at the sides of the body.
What are the lateral reference lines, and how do you find them?
First lift up the person's arm 90 degrees, and divide the lateral chest by three lines.
- Anterior axillary line (AAL) - at anterior axillary fold
- Midaxillary line (MAL) - midway between AAL & PAL
- Posterior axillary line (PAL) - at posterior axillary fold
What are three other land marks and where are they located?
- Supraclavicular ( above clavicle)
- Infraclavicular ( below clavicle)
- Infrascapular ( below tip of scapula)
What is the mediastinum?
Is the middle section of the thoracic cavity containing esophagus, trachea, heart, and great vessels.
What are the pleural cavities?
They contain the lungs (right and left sides)
What is the diaphragm?
Floor of thorax, major muscle of respiration
Where are the anterior lung borders?
- Apex (3-4 cm above 1st rib) - highest point o flung tissue
- Base( rests on diaphragm)- bottom of lungs
- on the right side found at 5th ICS, MCL ( this sits higher due to liver)
- on left side found at 6th ICS, MCL
Where are the lateral lung borders?
From the apex of axilla to the 7th - 8th rib.
Where are the posterior lung borders?
- C7 to T10 or T12 ( with inspiration)
- Upper lobes: T1 to T3/ T4
- Lower lobes: T3 to T10( with expiration) or T12 ( with inspiration)
Describe each lung...How many lobes?? How does it sit, what is it's size?
- Right ( 3 lobes: upper/middle/lower) it is shorter due to liver
- Left ( 2 lobes: upper and lower) it is more narrow due to heart border
Describe the Horizontal Fissures
- They separate lung lobes
- Horizontal fissure: right side only, 4th rib right sternal border to 5th rib MAL
- Separates upper and middle lobe
Describe the Anterior Oblique Fissures
- Anterior Oblique Fissures (bilateral)- 5th rib MAL to 6th rib MCL
- Right( separates middle & lower lobes)
- Left ( separates upper & lower lobes)
What is the pleura, and what are the types?
- It forms a thin slippery envelope between the lungs and the chest wall.
- Visceral- lines the lungs surface
- Parietal- lines the chest wall and diaphragm
What is the pleural cavity?
Negative pressure that holds lungs against the chest wall
What is the costodiaphragmatic recess?
- When the pleurae extends 3cm below the level of the lung, it forms the costodiaphragmatic recess.
- This is potential space, when abnormally fills with air or fluid, it can compromise lung expansion.
Give a quick summary about lungs and their lobes....(left lung, anterior chest, posterior chest)
- Left lung....no middle lobe
- Anterior chest ( mostly upper & middle lobes)
- Posterior chest ( mostly lower lobes)
Describe the trachea
- Trachea is anterior to the esophagus
- Starts at the cricoid process ( 10- 11cm long)
- Bifurcates at manubriosternal angle ( anteriorly)
- Bifurcates at T4 (posteriorly)
Describe the Bronchial Tree and its component.
- Right Main Stem Bronchus (shorter & straighter) - increased risk of aspiration
- Dead space (trachea & bronchi) -filled with air, but no gas exchange
- Bronchial tree lined with goblet cells(secret mucus that entrap particles) & cilia (sweep particles upward); smoking paralyzes the cilia and results in mucus pooling
- Acinus (functional respiratory unit) -bronchioles, alveolar ducts, alveolar sacs & alveoli
- Alveoli (300 million)
What is the Mechanism of Respiration?
- Supplies O2 and
- Eliminates CO2
- Helps maintain acid - base balance
- Maintaining heat exchange
What is respiratory acidosis?
What is respiratory alkalosis?
excessive excretion of CO2 through respirations
Where is the respiratory center in the body and how does it work?
- (Brain stem) pons & medulla
- When it senses increased CO2, its normal stimulus is to breath
- Chronic hypoxia desensitzes CO2 receptors in the brain; thus low O2
- levels become the stimulus to breath (delivery of high O2 concentrations may result in apnea)
Give some examples of subjective data of someone who is having problems with their lungs might have. Then what would be their symptoms with each
- Cough (timing) Is it...Continuous (respiratory infection), Nighttime when recumbent (post nasal drip; sinusitis, GERD), Morning, upon awakening (chronic bronchitis, "smokers cough"), Specific settings (allergies)
- Cough (character) Hacking (mycoplasm pneumonia), Dry, non productive (early CHF, allergies, meds [ACEI]), Barking (croup), Congested (bronchitis, pneumonia)
- Sputum (amount, color, odor)....Is it...Clear/white (viral bronchitis/pneumonia), Translucent white/gray (noninfectious, chronic bronchits, smoker), Green/yellow (bacterial bronchitis/pneumonia), Rust (pneumococcal pneumonia) – blood mixed with yellow sputum, Pink - frothy (pulmonary edema), Blood (hemoptysis) - cancer, TB, Foul odor (bacterial)
- Shortness of Breath (SOB) & Dyspnea, (difficult, labored breathing) Orthopnea (difficulty breathing supine - 2 pillow, etc.) – heart failure, Paroxysmal nocturnal dyspnea (PND) - awakens from sleep with SOB (heart failure), DOE (dyspnea on exertion)
- Past History- Lung Disease, COPD, asthma, pneumonia, cystic fibrosis. Allergies ( dust, pollen, animals, mold)
- Miscellaneous symptoms- Diaphoresis (night sweats) - TB, HIV, other infection, Fever, chills, sweats (f/c/s) – infection, Unintentional weight loss – cancer, Dependent edema, PND, orthopnea – heart failure, Confusion, restlessness - hypoxia, Pleurisy (chest pain with breathing ) - inflammation of pleura
- Smoking History- cigs, cigars, pipes, marijuanna. Could indicate never past or present. Pack years
- Family History- allergies, asthma, TB, cystic fibrosis, lung cancer, emphysema( the genetic form), antitripsin deficiency, etc)
- Environmental Exposure- Grain/pesticide, Histoplasmosis(inhaled fungus), Coccididomycosis or "valley fever", Pneumoconiosis ( coal miners), Silicosis( stone cutters), Asbestos(plumbers)
- Health Promotion (PPD, influenza immunization, pneumococal vaccine)
What are some important facts about children?
- Upper respiratory infections ( 4-6 yr = normal)
- Asthma- may outgrow as bronchial tubes enlarge
- Accidental aspiration - child-proof the home
What are some important facts about the Aging adult?
- SOB fatigue with daily activities ( they have decreased vital capacity (exhaled air after max inspiration) as measured by spirometry)
- Lung disease
- Chest pain with breathing ( rib fractures- spontaneous or r/t trauma/abuse/falls)
For the inspection part of the posterior lungs assessment what would you do?
- Measure respiratory rate, rhythm, effort
- Normal shape & symmetry of chest wall ( AP diameter < transverse 1:2 to 5:7 (increase with age))
- Spine-(assess for abnormal curvatures)
- Body position- Are they relaxed? Or not... professorial or tripod position (abnormal)- aids in expiration
When inspecting the spine what would you look for?
- Assess for abnormal curvatures- these may impair cardiopulmonary function
- Scoliosis(lateral curve)- entire spine affected. More common in girls. Assess uneven shoulders, scapular, hip heights. Observe gait- if uneven abnormal hip height. Severe curvature- >45 degrees- this may decrease lung volumes
- Kyphosis- (hump back)
- Lordosis- (sway back)
When palpating the posterior lungs what should you do?
- Palpate entire chest wall ( tenderness, lumps masses)
- Symmetric chest expansion( at level T9 or T10)
- Tactile Fremitus( vocal fremitus)
How do you palpate symmetric chest expansion on the posterior lungs, and what are some abnormal findings?
Placing your warmed hands on posterlateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up small fold of skin between thumbs. Ask person to take a deep breath. Should be symmetric.
Symmetric chest expansion( at level T9 or T10)- may be uneven with atelectasis, pneumothorax, pleural effusion, phrenic nerve damage.
What is tactile fermitus?
Is a palpable vocal vibration.
How do you palpate for tactile fermitus on the posterior lungs?
- This is where you would ask them to repeat "99" or "blue moon"
- Use the base of fingers at MCP joint or ulnar surface
- Start at lung apices ( symmetry is most important)
- Most prominent between scapulae & sternum, progressively decreases down thorax
- Greater in thin persons ( due to decreased thickness of chest wall
What is decreased fremitus?
- Occurs when anything obstructs transmission of vibrations.
- Any barrier that comes between the sound and your palpating hand will decrease fremitus.
- Ex....pneumothorax, bronchial obstructions, pleural effusion, COPD( emphysema)
What is increased fremitus?
Consolidation extending to lung surfaces (pneumonia)
What is Crepitus?
- Is a course crackling sensation palpable over the skin surface.
- It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue.
- Ex....open thoracic injury, chest surgery, tracheostomy
How do you percuss the posterior lungs?
- Percuss ICS (intercostal spaces)
- Start at apices ( above clavicle) & percuss side-to-side down back
- Avoid scapula, ribs & spine
- Listen for sounds
What sounds might you find when percussing the posterior lungs?
- Resonant (normal) hollow sound
- Hyperresonant ( emphysema, pneumothorax)
- Dull ( increased density) - atelectasis, pneumonia, pleural effusion
What is CVA, and why do you do it?
CVA- costal vertebral angle tenderness ( sign of kidney infection).
Why do you percuss to find diaphragmatic excursion of the posterior lungs?
So you can map out the lower lung border, both in inspiration and expiration.
How do you auscultate the posterior lungs?
- Tell patient to lean forward, breath deeply through mouth( hug chest to open interspaces)
- Use diaphragm of stethoscope ( assess symmetry & don't forget lateral lung fields
- Progress from top to bottom & side to side
- Listen at each location for a full respiratory cycle. (inspiration & expiration)
What sounds are you listening for when ausculating the posterior lungs?
What are bronchial sounds?
- Loud, harsh
- Normal over neck ( trachea & larynx)
- Abnormal if heard over peripheral lung fields ( indicates consolidation)
- Pitch: High Amplitude:Loud Duration:Inspiration< expiration
What are bronchovesicular sounds?
- Moderately loud/harsh
- Normal over midsternum & between scapula in back ( major bronchi)
- Pitch:Moderate Amplitude:Moderate Duration:Inspiration= expiration
What are vesicular sounds?
- Low, soft, like rustling wind in the trees
- Normal over peripheral lung fields
- Absent (mucus plug, collapsed lung) - this is serious report immediately!
- Pitch:Low Amplitude:Soft Duration:Inspiration> expiration
What is an adventitous sound?
- Added sounds, not normally present.
- Pleural Friction Rub
What is a crackle?
- Sounds like velcro opening
- Produced when there is fluid inside a bronchus causing a collapse of the distal (smaller) airways and alveoli. Occurs when there is a sudden equalization of pressure causing some of the airways to pop open.
- Heard on inspiration, doesn't clear with coughing.
What are fine crackles?
High-pitched, short duration, cracking & popping sounds
What are coarse crackles?
- Low-pitched, longer duration, bubbling & gurgling sounds.
- Causes: atelectasis, pneumonia, fibrosis, heart failure, pulmonary edema.
What are rhonchi?
- Airflow through an airway obstructed by thick secretions, spasm, or tumor...ex bronchitis, decreased cough reflux)
- Loud, low, coarse sounds (like a snore or rumble) most often heard continuously during inspiration or expiration.
- Often clears with coughing or suctioning.
What is a wheeze?
- Airflow through a constricted airway
- High-pitched squeaking sound ( like a whistle)
- Primarily heard on expiration, but may also be heard on inspiration
- Assess breath sounds with forced expiration in an asthma patient to check for bronchoconstriction.
What is a stridor?
- A sign of respiratory distress
- Partial airway obstruction ( foreign body)
- Characterized by an inspiratory wheeze
- Louder in neck than chest
What is a pleural friction rub?
- Caused by inflammation of pleural surfaces ( pleurisy)
- Coarse rubbing or grating sound during inspiration or expiration (disappears with breath holding)
What should the normal voice sounds you hear when auscultating sound like?
- Soft , muffled and indistinct.
- You can hear sound, but can't distinguish what is being said.
What are the different voice sounds and what are normal and abnormal findings?
- Bronchophony ( repeat "99" or "blue moon") Normal: 99 is muffled and indistinct....Abnormal: clear 99- this could mean increased lung density
- Egophony (repeat "E") Normal: "EEE" sound Abnormal: E to A changes, consolidation
- Whispered pectoriloquy ( whisper 1-2-3) Normal: sounds faint, muffled, almost inaudible Abnormal: sounds clear & distinct, consolidation
When inspecting the anterior thorax what might you look at/ or look for?
- Skin (pallor or cyanosis)
- Pursed Lips
- Quality of respirations
- Tracheal Position
- Costal Angle
- LOC- Drowsiness r/t cerebral hypoxia
- Retraction of bulging of ICS
- Use of accessory neck muscles to lift sternum & rib cage
- Respiratory Rate & Patterns
What does pursed lips mean/look like?
- Seen in obstructive disease
- prolongs expiration to allow for exhalation of trapped air
What is splinting?
Shallow breaths to control pain
What should the quality of breaths look like?
Quiet, easy & non labored
What is an abnormal finding when looking at the tracheal position?
Tension pneumothorax- trachea shifts to the opposite side of lung collapse ( called tracheal tug)
What is pectus excavatum?
Sunken sternum, funnel chest
What is pectus carinatum?
Forward protrusion, pigeon chest
What is barrel chest?
Increased AP diameter- associated with aging, emphysema, asthma
What should the costal angle be?
< 90 degrees ( barrel chest > 90)
What is retraction of ICS?
Obstruction or increased respiratory effort
What is bulging of ICS?
Trapped air- emphysema- caused by barrel chest
If neck muscles are overdeveloped what might this mean?
- That the patient is using the accessory neck muscles to lift sternum & rib cage.
- This is a sign of a chronic respiratory disease.
What are some respiratory rates and patterns?
- Normal ( rate 10-20/min adult with occasional sigh
What is Tachypnea?
Tachypnea ( rapid shallow breathing >20/min) caused by fever, fear, anxiety, exercise
What is hyperventilation?
- Rapid, deep breathing
- Caused by extreme exertion, fear, anxiety, diabetic ketoacidosis.
- CO2 is excreted thru respirations (increasing the alkalinity of the blood)
What is bradypnea?
- Regular, slow breathing <10/min.
- Depressant drugs, increased intracranial pressure (ICP), diabetic coma
What is hypoventilation?
- Irregular, shallow breathing
- Caused by narcotic OD, anesthetics, prolonged bedrest, splinting with pain
- CO2 is retained (may cause acidosis)
What are Cheyne-stokes?
- Regular, cyclic breaths 30-40 secs, then apnea x 20sec
- CHF and other causes
What are biots?
Ataxic- irregular, deep, slow with periods of apnea.
What are stertorous?
What are stridors?
Croup, foreign body, growth on vocal cords, high pitched on inspiration
When palpating the anterior thorax what should you look for?
- Symmetric chest expansion (thumbs on xyphiod process)
- Tactile fremitus (chest wall vibrations while repeating "99")- start at apices and work down avoid breast tissue.
- Palpate chest wall for tenderness, lumps, masses
How do you percuss the anterior thorax?
- Start at apices
- Percuss interspaces for resonance
- Compare sides
- Avoid breast tissue
- Note cardiac dullness
- Border of liver (dullness at 5th ICS MCL)
- Gastric bubble on left (tympanic)
How do you auscultate the anterior chest?
- Start at supraclavicular space & progress down to 6th rib
- Follow same pattern as percussion
What are some respiratory conditions to know?
- Atelectasis(collapsed alveoli, predisposes pneumonia)
- Bronchitis(inflammation of bronchi) - acute or chronic
- Emphysema(destruction of alveoli, decreased gas exchange)
- Asthma(intermittent bronchospasm/constriction) may lead to chronic lung disease
- Pleural effusion (fluid in pleural space)
- Pneumothorax(air in pleural space, collapsed lung)
- Hemothorax(blood in pleural space)
When is surfactant produced?
At 32 weeks gestation- problems with collapse of alveoli if born before this.
Infants less than 3 months old only breath....?
- Out of their noses.
- That is why nasal obstruction can cause death.
In 5-6 year olds you can hear?
Bronchovesicular breath sounds in peripheral lung fields. This is normal