Thorax and Lungs N1037

1. Chapter 15 Thorax and Lungs N1037

2. A & P of Thorax • Thorax • Pleura • Parietal = external surface • Visceral = internal surface • Mediastinum or interpleural space • Bronchi bifurcate T4/5 post, sternal angle ant • Right - more vertical, risk aspiration • Left • Alveoli • Diaphragm (R5 ICS MCL, L6ICS MCL) • phrenic nerve • External intercostal muscles • inspir = ext ICM contract • expir = int ICM contract • Accessory muscles • scalene, sternocleidomastoid, trapezius, abdominal rectus

3. A & P of Thorax Sternum Ribs Intercostal spaces

4. Anatomy: Lungs • Right lung: three lobes • Left lung: two lobes • Apex • Base • Midclavicular line (MCL) • Midaxillary line (MAL)

5. Anatomy: Lungs

6. Thoracic Anatomic Topography • Anterior axillary line • Midspinal (vertebral) line • Midsternal line • Posterior axillary line • Scapular line

7. Thoracic Anatomic Topography

8. Physiology of Respiration • Ventilation • active = inspiration and passive = expiration • during inspiration  pressure inside lungs = subatmospheric as diaphragm & ext ICM contract diaphragm lowers & ribs elevate which intrapulmonic volume creating a neg intra-alveolar pressure gradient with the atmosphere so air is pulled into the lungs until the intra-alveolar pressure= air pressure, thus lungs become full with air. • Expiration occurs more rapidly. The diaphragm and ext ICM relax, which means the diaphragm rises & the ribs move closer = volume in the thoracic cavity causing a  intrapulmonic volume &  intrapulmonic pressure above atmospheric pressure, the lungs recoil and expel air until the intrapulmonic pressure = atmospheric pressure. • External respiration- O2 diffuses from alveoli to blood • Internal respiration - O2 in the blood diffuses into tissues • Control of breathing- neural and chemical factors • pons & medulla = CNS structures responsible for involuntary respiration • stimulus for breathing =  Co2, PH, O2 levels

9. Health History • Patient profile • Age • Children and young adults: bronchiectasis, cystic fibrosis • Adults and older adults: lung cancer, chronic bronchitis, pneumonia, emphysema • Gender • Patient profile (cont’d) • Race • African American: sarcoidosis • Caucasian: cystic fibrosis (continues)

10. Common Chief Complaints • Dyspnea • Cough • Sputum • Chest pain

11. Characteristics of Chief Complaint • Quality • Quantity • Associated manifestations • Aggravating factors • Alleviating factors • Setting • Timing

12. Past Health History • Medical • Respiratory specific • Nonrespiratory specific • Surgical • Medications • Communicable diseases • Allergies • Injuries and accidents • Special needs • Childhood illnesses

13. Family Health History • Allergies • Asthma • Bronchiectasis • Cancer • Cystic fibrosis • Emphysema • TB

14. Social History • Alcohol, drug, or tobacco use • Travel history • Work and home environment • Hobbies and leisure activities • Stress • Economic status

15. Health Maintenance Activities • Sleep • Diet • Exercise • Use of safety devices • Health check-ups

16. Assessment of the Thorax and Lungs • Equipment • Stethoscope • Centimeter ruler or tape measure • Washable marker • Watch with second hand

17. Inspection • Shape of thorax • Transverse diameter • Anteroposterior (AP) diameter • Symmetry of chest wall • Presence of superficial veins • Costal angle (continues)

18. Assessment of Thorax & Lungs • Inspect shape of thorax • Transverse diameter • Anteroposterior (AP) diameter • N=AP to transverse = 1:2 • Symmetry of chest wall • Presence of superficial veins • Abnormal • barrel chest dt COPD • pectus carinatum dt congenital abn • kyphosis :humpback • scoliosis: curvature of spine

19. Assessment of Thorax & Lungs • Costal angle • N=<90 with inspir & expir • Angle of the ribs • N= ribs articulate at 45 angle • Intercostal spaces • N= No retractions or bulging in ICS • Muscles of respiration • N= no use of accessory muscles

20. Respirations • Rate N= 12-20 bpm for adult • Abnormalities • Eupnea: 12–20 breaths per minute • Tachypnea: > 20 breaths per minute • Bradypnea: < 12 breaths per minute • Apnea: no respiration for 10 or more seconds (continues)

21. Inspect Respiration • Patterns N= regular and even in rhythm • Cheyne-Stokes-brain injury • Biot’s or ataxic -damaged medulla • Apneustic -injured pons • Agonal - impending death • Depth N= nonexaggerated &effortless • Shallow -obese, pain, PE, puemonia, pneumothorax • Hyperpnea - exercise, emotional, high altitudes • Air trapping-COPD • Kussmaul’s-diabetic ketoacidosis • Sighing- N or CNS lesions

22. Inspect Respirations • Symmetry - N= thorax rises & falls in unison, no paradoxical movement Abnormal = unilateral expansion dt collapsed lung = paradoxical movement dt broken ribs • Audibility N= respirations are audible by ear • Patient position N= breaths comfortably upright, supine Abnormal = Orthopnea dt COPD, CHF, PE • Mode of breathing N= inhale & exhale through nose

23. Inspect Sputum • Color N= light yellow or clear • Odor N= none • Amount N = small • Consistency N = thick or thin depends on hydration • Abnormal • Table 15-1

24. Assessing Patients with Respiratory Assistive Devices • Tracheostomy tube • Size • Cuffed or cuffless • How tube is secured to neck • Mechanical ventilation • Type of ventilator • FiO2 setting • Mode • Amount of PEEP • Rate and tidal volume • Alarms • Pulse oximeter • Peak flow Meter • Oxygen therapy • Mode of delivery • Percentage of oxygen • Flow rate • Humidification • Incentive spirometer • Frequency of use, volume achieved, number of repetitions • Endotracheal tube • Size • Nasal or oral insertion • Length of tube as it exits mouth or nose • Cuff inflated or deflated

25. Thoracic Palpation • Palpate the Anterior, Posterior & Lateral thorax • Assess for • Pulsations • Masses • Thoracic tenderness • Crepitus N= no pulsations, masses, tenderness,crepitus • Abnormal • aortic aneurysm • tumor or cyst • chest trama • subcutaneous emphysema (air in subcutaneous tissue)

26. Thoracic Palpation • Thoracic expansion • Expansion • Symmetry • Tactile fremitus • Anterior • Posterior • Lateral (continues)

27. Thoracic Palpation • Thoracic expansion • Expansion • Symmetry

28. Thoracic Palpation • Tactile fremitus • Anterior, Posterior, Lateral N= buzzing over bronchi & trachea Abnormal =  dt consolidation =  dt pneumothorax, emphysema, asthma

29. Palpation Pattern for Tactile Fremitus

30. Thoracic Percussion • Anterior • Posterior • Right and left lateral • Diaphragmatic excursion Pt position for Posterior Percussion

31. Percussion Patterns

32. Diaphragmatic Excursion • Percuss lung while pt resting & mark thorax • Percuss lung while pt takes a deep breath & mark thorax • Measure distance btwn two marks • Repeat other lung N= T12 on inspir, T 10 on expir

33. Auscultation: Fields Anterior Posterior Lateral Lateral

34. Auscultation: Breath Sounds • Bronchial • Bronchovesicular • Vesicular

35. Auscultation: Breath Sounds • Assess for Pitch, Intensity, Quality, Duration, Location N= Table 15-2 • Abnormal • Adventitious Breath Sounds • Crackles - moisture in airways • Wheeze - narrowing of airway • Pleural friction rub - inflamed parietal & viseral pleura • Stridor - partial obstruction

36. Assessment of Voice Sounds • Reveals if lungs are full of air, fluid or solid • Instruct pt to say “99” each time you place stethescope N= Muffled or unclear transmission Abnormal dt any type of consolidation • Bronchophony - clear transmission of “99” • Egophony - transmission of “ee” to “ay” with intensity • Whispered pectoriloquy - clear transmission of “99” • Voice sounds absent - dt air in lungs from disease - emphysema,asthma pneumothorax

37. Age-Related Changes • Anatomic changes • Limited chest wall expansion • Muscle atrophy • Increased work of breathing • Alveolar gas exchange • Decreased surface area for diffusion (continues)

38. Age-Related Changes • Regulation of ventilation • Decreased sensitivity to changes in carbon dioxide and oxygen • Lung defense mechanisms • Decreased ciliary action • Diminished cough reflex • Increased susceptibility to infection