1. Thorax and Lungs
By InnaKorda

2. Anterior Thorax
(Suprasternal notch)

3. Posterior Thorax

4. Reference Lines

5. Lobes of Lungs

6. Lobes of Lungs

7. Trachea and Pleurae Pleurae Trachea and Bronchi
Visceral pleura – lines outside of lungs, dipping down into the fissures
Parietal Pleura – lines inside of chest wall and diaphragm
Lubricating fluid between the pleurae prevents friction
Trachea and Bronchi
Transport gasses between environment and lung
Dead space is space filled with air (about 150 ml) but not available for gaseous exchange
Goblet cells in bronchi secrete mucus that entraps particles
Cilia in bronchi sweep particles upward

9. Terms

10. Developmental Considerations
Infants and Children
When cord is cut, blood is cut off from placenta and rushes into pulmonary circulation. Due to less resistance in pulmonary arteries, the foramen ovale closes, along with ductus arteriosus
Lungs grow until about 300 million alveoli in adolescence
Pregnancy
The enlarging uterus elevates the diaphragm 4 cm during pregnancy, but the increased estrogen relaxes thoracic ligaments allowing compensation by increasing the transverse diameter
Mother’s tidal volume increases to meet demands of fetus
Aging
kyphosis
calcification of costal cartilage
decreased vital capacity
decreased number of alveoli
decreased mucous production

11. Health History Cough Onset? Gradual or sudden? Frequency?
Continuous throughout day – acute illness (respiratory infection)
Afternoon/evening – may reflect exposure to irritants at work
Night – postnasal drip, sinusitis
Early morning – chronic bronchial inflammation of smokers
Sputum? How much? Characteristic?
Chronic bronchitis – productive cough for 3 months of the year for 2 years in a row
Characteristics
White of clear mucoid – colds, viral infection, bronchitis
Yellow or green – bacterial infection
Rust colored – TB, pneumococcal pneumonia
Pink, frothy – pulmonary edema, medications?
Cough up blood?
Description of cough – dry, hacking
Associative and Alleviating factors
Painful?

12. Health History Shortness of Breath (SOB) Onset, associative factors
Determine how much activity precipitates SOB
Affected by position?
Orthopnea – difficulty breathing when supine (heart failure?)
Time of day/night
Paroxysmal nocturnal dyspnea – awakening from sleep with SOB and needing to be upright to achieve comfort
Allergies?
Asthma attacks
Alleviating factors

13. Health History Chest pain with breathing?
Location, onset, duration, frequency, intensity, associative and alleviative factors
Past history of respiratory infections?
Bronchitis, emphysema, asthma, pneumonia
Smoking history
Environmental exposure
Self – care behaviors
Immunizations, TB skin tests, chest X-rays

14. Assessment - Inspection
Inspect thorax
Symmetry
AP diameter
Normal 1:2
AP diameter = transverse diameter, “barrel chest”. Occurs with normal aging, chronic emphysema, and asthma
Symmetry and normal development of trapezius muscle
Hypertrophied in COPD
Position person takes to breathe
COPD – tripod position

15. Posterior Chest Symmetric chest expansion
Place warmed hands on posterolateral chest wall with thumbs at level of T9 or T10
Slide hands medially to pinch up a small fold of skin between thumbs
Ask person to take a deep breath
As person inhales, the thumbs should move apart symmetrically
Unequal chest expansion occurs with atelectasis, pneumonia, thoracic trauma
Pain accompanies deep breathing when pleurae are inflamed

16. Tactile Fremitus
Fremitus is a palpable vibration transmitted through patent bronchi and lung parenchyma to the chest wall where they can be felt as vibrations
Place either the palmar base of ulnar edge of one of the hands on the person’s back and ask to repeat “ninety-nine.” Start at lung apices and palpate from one side to another
Symmetry is most important
Normally, fremitus most prominent between scapulae and decreases as you progress down

17. Abnormalities in Fremitus
Decreased fremitus occurs when anything obstructs transmission of vibrations
Obstructed bronchus
Pleural effusion or thickening
Pneumothorax
Emphysema
Increased fremitus occurs with compression or consolidation of lung tissue
Lobar pneumonia
Rhonchal fremitus – palpable with thick secretions
Crepitus – coarse crackling sensation palpable over skin surface. Occurs in subQ emphysema when air escapes from lung and enters subQ tissue

18. Percussion
Start at the apices and percuss across tops of both shoulders and down the lung region at approx. 5cm intervals
Make a side to side comparison
Avoid damping effect of scapulae and ribs
Resonance predominates in healthy lungs
Hyperresonance is found when too much air is present (emphysema or pneumothorax)
Dullness signals abnormal density (pneumonia, pleural effusion, atelectasis, tumor)

19. Expected Percussion Notes

20. Percussion Notes

21. Auscultating Posterior Chest
Breath sounds
Instruct the person to breathe through the mouth a little deeper than usual, but to stop if they feel dizzy. Hyperventilation may lead to fainting!
Use the flat diaphragm endpiece of the stethoscope and listen for at least one full respiration in each location
Continue to think:
What am I hearing?
What should I expect to be hearing?
Bronchial
Bronchovesicular
Vesicular
Do not confuse background noise with lung sounds
Stethoscope tubing bumping together
Pt. shivering
Hairy chest
Rustling of gown

22. Characteristics of Normal Breath Sounds
Table 18.1

23. Location of Normal Breath Sounds

24. Auscultation Abnormal Findings Decreased breath sounds
Obstruction of bronchial tree (by secretions, mucous plug, foreign body)
In emphysema due to loss of elasticity in the lung fibers and decreased force of inspired air. The lungs are already hyperinflated so not much air will be coming in.
Obstruction of sound by pleural thickening
Silent chest – no air moving in or out
Increased breath sounds – louder than normal
Bronchial sounds
Heard in abnormal location, such as periphery
High pitched, with prolonged expiratory phase
Occur in consolidation (pneumonia) or compression (fluid in intrapleural space). Dense lung tissue enhances transmission of sound.

25. Auscultating Adventitious Sounds
Sounds not normally heard in the lungs
Caused by moving air colliding with secretions in trachea or bronchi, or from popping open of previously deflated airways
Crackles (fine)
Description: popping sounds heard during inspiration. May be stimulated by rolling a strand of hair between fingers near the ear
Mechanism: Inhaled air collides with previously deflated airways. Airways suddenly pop open creating a crackling sound
Clinical example:
Early inspiratory – COPD
Late inspiratory – Pneumonia, heart failure, interstitial fibrosis
Table 18.17

26. Crackles (coarse) Description: Mechanism: Clinical example:
loud, low-pitched, bubbling and gurgling sounds early in inspiration. Sound like Velcro
Mechanism:
Inhaled air collides with secretions in trachea and large bronchi
Clinical example:
Pulmonary edema, pneumonia, pulmonary fibrosis, depressed cough reflex

27. Pleural friction rub Description: Mechanism: Clinical example:
Coarse and low pitched superficial sound. Both inspiratory and expiratory.
Mechanism:
Caused when pleurae become inflamed and lose normal lubricating fluid. Pleural surfaces rub together during respiration. Heard best in anterolateral wall.
Clinical example:
Pleuritis

28. Wheeze Description Mechanism Clinical example
High pitched musical squeaking sound predominantly during expiration
Mechanism
Air squeezed or compressed through narrowed airways (collapsing, swelling, secretions, tumors)
Clinical example
Acute asthma or chronic emphysema

29. Rhonchi (sonorous) Description Mechanism Clinical example
a.k.a. Wheeze
Description
Low-pitched, musical snoring
Mechanism
Airflow obstruction
Clinical example
Bronchitis, obstruction of bronchus from obstruction or tumor

30. Stridor Description Mechanism Clinical example
High pitched, inspiratory, crowing sound, louder in neck than over chest wall
Mechanism
Originates in larynx or trachea. Upper airway obstruction from inflamed tissue or obstruction
Clinical example
Croup and acute epiglottitis. Obstructed airway.

31. Consolidation or compression of voice sounds will enhance the voice sounds
Table 18.2

32. Assessing the Anterior Chest
Symmetric chest expansion
Abnormally wide costal angle occurs with emphysema
Tactile and vocal fremitus

33. Percussing and Auscultating Anterior Chest
Begin percussing the apices in supraclavicular ares, continuing down in intercostal spaces
Note cardiac and liver dullness and stomach tympany
Chronic emphysema leads to hyperinflation of lungs, resulting in hyperresonance where you would expect cardiac dullness
Auscultate lung fields down to the 6th rib. Progress from side to side moving downward and listen for one full respiration at each location

34. Pulmonary Function Test
Forced expiration of 6 seconds or more occurs with obstructive lung disease

35. Developmental Considerations
Infants
While infant is sleeping, can inspect and auscultate the lungs
Infants normally have a rounded thorax, reaching a 1:2 (anteroposterior to transverse) diameter by age 6
If a barrel shape persists after age 6, possible chronic asthma or cystic fibrosis
If baby begins to cry, it actually enhances the palpation of tactile fremitus
Pregnancy
Wider thoracic cage
Aging
Kyphosis – outward curvature of thoracic spine
Calcification of costal cartilages leading to less mobility

49. Question 1
A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client?
Increased oxygen saturation with exercise
Hypocapnia
A hyperinflated chest on X-ray
A widened diaphragm noted on chest X-ray

50. Question 2
A nurse is caring for a client with acute respiratory distress syndrome (ARDS). Which of the following would the nurse expect to note in the client?
Decreased respiratory rate
Pallor
Low arterial PaO2
An elevated arterial PaO2

51. Question 3
A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the ventilator’s high-pressure alarm sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of :
Displaced endotracheal tube
Acute respiratory distress syndrome (ARDS)
Pulmonary embolism
Right pneumothorax

52. Question 4
A nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which of the following clients on the nursing unit is at the least risk for infection with tuberculosis?
A newly immigrated woman from Korea
An uninsured man who is homeless
An elderly woman admitted from a long-term care facility
A man who is an inspector for the U.S. Postal Service

53. Question 5
A nurse is caring for a patient after a bronchoscopy and biopsy. Which of the following signs if noted in the client should be reported immediately to the physician?
Blood-streaked sputum
Dry cough
Hematuria
Stridor