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How do you identify the angle of Lewis???
palpate lightly to the second rib, and slide down to the second intercostal space.
The angle of Louis also marks the site of
tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.
The right and left costal margins form an angle where they meet at the xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is chronically overinflated, as in emphysema.
Assessing the Vertebra Prominens
Flex your head and feel for the most prominent bony spur protruding at the base of the neck. This is the spinous process of C7. If two bumps seem equally prominent, the upper one is C7 and the lower one is T1.
Count down these knobs on the vertebrae, which stack together to form the spinal column. Note that the spinous processes align with their same numbered ribs only down to T4. After T4, the spinous processes angle downward from their vertebral body and overlie the vertebral body and rib below
Inferior Border of the Scapula
The scapulae are located symmetrically in each hemithorax. The lower tip is usually at the seventh or eighth rib
How to palpate the Twelfth Rib
Palpate midway between the spine and the person's side to identify its free tip.
the middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels
Right and left pleural cavities, on either side of the mediastinum, contain ???
The right lung is shorter than the left lung because of
The left lung is narrower than the right lung because
the heart bulges to the left
The right lung has how many lobes????
The left lung has how many lobes???
On the anterior chest
fissure crosses the fifth rib in the midaxillary line and terminates at the sixth rib in the midclavicular line
the right lung
*(minor) fissure, which divides the right upper and middle lobes. This fissure extends from the fifth rib in the right midaxillary line to the third intercostal space or fourth rib at the right sternal border.
thin and slippery
form an envelope between the lungs and the chest wall
lines the outside of the lungs, dipping down into the fissures.
lining the inside of the chest wall and diaphragm.
a functional respiratory unit that consists of the bronchioles, alveolar ducts, alveolar sacs, and the alveoli.
There are four major functions of the respiratory system:
- (1) supplying oxygen to the body for energy production,
- (2) removing carbon dioxide as a waste product of energy reactions,
- (3) maintaining homeostasis (acid-base balance) of arterial blood, and
- (4) maintaining heat exchange (less important in humans).
Forced inspiration, such as that after heavy exercise or occurring pathologically with respiratory distress, commands the use of
the accessory neck muscles to heave up the sternum and rib cage.
Barrel Chest ='s
1:1 A-P Diameter
Normal chest ='s
1:2 A-P diameter
Respiratory muscle strength declines after age
- 50 years and continues to decrease into the 70s.
- **A more significant change is the decrease in elastic properties within the lungs, making them less distensible and lessening their tendency to collapse and recoil. In all, the aging lung is a more rigid structure that is harder to inflate
Skeletal deformities may limit thoracic cage excursion
Anteroposterior = transverse diameter, or “barrel chest.”
Ribs are horizontal, chest appears as if held in continuous inspiration. This occurs in chronic emphysema from hyperinflation of the lungs
Neck muscles are hypertrophied in
chronic obstructive pulmonary disease (COPD) from aiding in forced respirations.
People with COPD often sit in a tripod position, leaning
forward with arms braced against their knees, chair, or bed. This gives them leverage so that their rectus abdominis, intercostal, and accessory neck muscles all can aid in expiration.
symmetric chest expansion
- by placing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs
- **Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion.
Unequal chest expansion occurs with marked
- atelectasis or pneumonia; with thoracic trauma, such as fractured ribs; or with pneumothorax.
- **Pain accompanies deep breathing when the pleurae are inflamed.
tactile (or vocal) fremitus
- Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and through the lung parenchyma to the chest wall, where you feel them as vibrations.
- Use either the palmar base (the ball) of the fingers or the ulnar edge of one hand, and touch the person's chest while he or she repeats the words “ninety-nine” or “blue moon.” These are resonant phrases that generate strong vibrations. Start over the lung apices and palpate from one side to another
just between the scapulae, fremitus may feel stronger on the right side than on the left side because
the right side is closer to the bronchial bifurcation. Avoid palpating over the scapulae because bone damps out sound transmission.
The following factors affect the normal intensity of tactile fremitus:
- •Relative location of bronchi to the chest wall.
- Normally, fremitus is most prominent between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as you progress down because more and more tissue impedes sound transmission.
- •Thickness of the chest wall.
- Fremitus feels greater over a thin chest wall than over an obese or heavily muscular one where thick tissue damps the vibration.
- •Pitch and intensity.
occurs when anything obstructs transmission of vibrations (e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema). Any barrier that comes between the sound and your palpating hand will decrease fremitus.
occurs with compression or consolidation of lung tissue (e.g., lobar pneumonia). This is present only when the bronchus is patent and when the consolidation extends to the lung surface. Note that only gross changes increase fremitus. Small areas of early pneumonia do not significantly affect fremitus.
is palpable with thick bronchial secretions.
Pleural friction fremitus
is palpable with inflammation of the pleura
Determine the predominant note over the lung fields.
Start at the apices and percuss the band of normally resonant tissue across the tops of both shoulders. Then, percussing in the interspaces, make a side-to-side comparison all the way down the lung region. Percuss at 5-cm intervals. Avoid the damping effect of the scapulae and ribs.
is a lower-pitched, booming sound found when too much air is present, as in emphysema or pneumothorax
A dull note
(soft, muffled thud) signals abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
Determine diaphragmatic excursion
- Percuss to map out the lower lung border, both in expiration and in inspiration. First, ask the person to “exhale and hold it” briefly while you percuss down the scapular line until the sound changes from resonant to dull on each side. This estimates the level of the diaphragm separating the lungs from the abdominal viscera. It may be somewhat higher on the right side (about 1 to 2 cm) because of the presence of the liver. Mark the spot.
- Now ask the person to “take a deep breath and hold it.” Continue percussing down from your first mark and mark the level where the sound changes to dull on this deep inspiration. Measure the difference. This diaphragmatic excursion 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-conditioned people
- High Pitch
- Loud Amplitude
- Inspiration <expiration -Duration
- Harsh, hollow tubular -Quality
- Trachea and larynx - Normal findings
- Moderate- Pitch
- Moderate- Amplitude
- Inspiration = expiration Duration
- Mixed - Quality
- Over major bronchi where fewer alveoli are located: posterior, between scapulae especially on right; anterior, around upper sternum in first and second intercostal spaces - Normal Findings
- Low- Pitch
- Soft- Amplitude
- Inspiration > expiration Duration
- Rustling, like the sound of the wind in the trees - Quality
- Over peripheral lung fields where air flows through smaller bronchioles and alveoli- Normal Findings
Decreased or absent breath sounds occur:
- 1.When the bronchial tree is obstructed at some point by secretions, mucus plug, or a foreign body
- 2.In emphysema as a result of loss of elasticity in the lung fibers and decreased force of inspired air; also the lungs are already hyperinflated so the inhaled air does not make as much noise
- 3.When anything obstructs transmission of sound between the lung and your stethoscope, such as pleurisy or pleural thickening, or air (pneumothorax) or fluid (pleural effusion) in the pleural space
Increased breath sounds mean that
sounds are louder than they should be (e.g., bronchial sounds are abnormal when they are heard over an abnormal location, the peripheral lung fields). They have a high-pitched tubular quality, with a prolonged expiratory phase and a distinct pause between inspiration and expiration. They sound very close to your stethoscope, as if they were right in the tubing close to your ear. They occur when consolidation (e.g., pneumonia) or compression (e.g., fluid in the intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchi. When the inspired air reaches the alveoli, it hits solid lung tissue that conducts sound more efficiently to the surface.
During normal tidal flow, high-pitched wheeze occurs with
Cerebral hypoxia may be reflected by
excessive drowsiness or by anxiety, restlessness, and irritability
Noisy breathing occurs with severe
asthma or chronic bronchitis.
Accessory muscles are used in
acute airway obstruction and massive atelectasis.
Rectus abdominis and internal intercostal muscles are used to
force expiration in COPD.
A forced expiration of 6 seconds or more occurs with
obstructive lung disease. Refer this person for more precise pulmonary function studies.
a noninvasive method to assess arterial oxygen saturation (Spo2) and is described in Chapter 9. A healthy person with no lung disease and no anemia normally has an Spo2 of 97% to 98%. However, every Spo2 result must be evaluated in the context of the person's hemoglobin level, acid-base balance, and ventilatory status.
Rapid respiratory rates accompany
pneumonia, fever, pain, heart disease, and anemia
Asymmetric expansion occurs with
diaphragmatic hernia or pneumothorax.
Crepitus is palpable around a
fractured clavicle, which may occur with difficult forceps delivery.
Persistent fine crackles that are scattered over the chest occur with
pneumonia, bronchiolitis, or atelectasis.
Crackles only in upper lung fields occur with
cystic fibrosis; crackles only in lower lung fields occur with heart failure
Normal Adult (for Comparison)
- Rate—10 to 20 breaths per minute.
- Depth—500 ml to 800 ml.
- The ratio of pulse to respirations is fairly constant, about 4:1.
- Both values increase as a normal response to exercise, fear, or fever.
- Depth—air moving in and out with each respiration.