1. Thorax and Lungs
Chapter 18

2. Structure and Function
Subjective Data—Health History Questions
Objective Data—The Physical Exam
Abnormal Findings

3. Anterior thoracic landmarks
Suprasternal notch
Sternum
Manubriosternal angle
Costal angle

4. Structure and Function Position and Surface Landmarks
Posterior thoracic landmarks
Vertebra prominens
Spinous processes
Inferior border of scapula
Twelfth rib

5. Reference lines-Anterior
Midsternal line
Midclavicular line
Scapular line
Vertebral line
Anterior, posterior, midaxillary lines

6. Reference Lines (Posterior)
Vertebral Line
Scapular Line

7. Reference Lines (Lateral)
Anterior Axillary
Midaxillary
Posterior Axillary

10. Structures of the Respiratory System

11. Mechanics of respiration
Four functions of respiratory system
Changing chest size during respiration
Inspiration
Expiration
Control of respiration

12. Mechanics of Respiration (cont.)
© Pat Thomas, 2006.

13. Infants & Children Infants and children
During first 5 weeks of fetal life, primitive lung bud emerges
By 16 weeks of gestation, conducting airways reach same number as in adult; at 32 weeks, surfactant, complex lipid substance needed for sustained inflation of air sacs, is present in adequate amounts
At birth lungs have 70 million primitive alveoli ready to start job of respiration
Breath is life; when newborn inhales first breath, the lusty cry that follows reassures straining parents that their infant is all right

14. Pregnant Women Pregnant woman
Enlarging uterus elevates diaphragm 4 cm during pregnancy
This decreases vertical diameter of thoracic cage, but this decrease is compensated for by an increase in horizontal diameter
Increase in estrogen level relaxes chest cage ligaments
This allows an increase in transverse diameter of chest cage by 2 cm, and costal angle widens
Total circumference of chest cage increases by 6 cm

15. Elderly
Aging adult
Costal cartilages become calcified, which produces a less mobile thorax
Respiratory muscle strength declines after age 50 years and continues to decrease into 70s
More significant change is decrease in elastic properties within lungs, making them less distensible and lessening their tendency to collapse and recoil
Aging lung is more rigid structure that is harder to inflate

16. Asthma
Asthma occurs in about 5% to 12% of the U.S. population and is the most common chronic disease in childhood
Groups at increased risk include African Americans who reside in inner cities and premature or low birth weight infants
Asthma prevalence is highest among African American and native American adults; lowest among Asian and Hispanic adults

17. Cultural Differences
Biocultural differences in size of thoracic cavity significantly influence pulmonary functioning as determined by vital capacity and forced expiratory volume
In descending order, the largest chest volumes are found in whites, African Americans, Asians, and American Indians
Even when shorter height of Asians is considered, their chest volume remains significantly lower than that of whites and African Americans

18. Subjective Data— Health History Questions
Cough
Shortness of breath
Chest pain with breathing
History of respiratory infections
Smoking history
Environmental exposure
Self-care behaviors
Cough. Do you have a cough? When did it start? Gradual or sudden?
Shortness of breath. Have you ever had any shortness of breath or hard-breathing spells? What brings it on? How severe is it? How long does it last?
Chest pain with breathing. Do you have any chest pain with breathing? Please point to the exact location.
Past history of respiratory infections. Do you have any past history of breathing trouble or lung diseases like bronchitis, emphysema, asthma, pneumonia?
Smoking history. Do you smoke cigarettes or cigars? At what age did you start? How many packs per day do you smoke now? For how long?
Environmental exposure. Are there any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, coal mine, farming, outdoors in a heavy traffic area?
Self-care behaviors. Last tuberculosis skin test, chest x-ray study, pneumonia or influenza immunization?

19. Objective Data—The Physical Exam
Preparation
Position- sitting up, leaning forward.
Draping
Timing during a complete examination
Cleaning stethoscope endpiece
Equipment needed
Stethoscope
Small ruler marked in centimeters
Marking pen
Alcohol swab

20. Objective Assessment Anterior and Posterior chest Inspection Palpation
Percussion
Auscultation

21. Objective Data—The Physical Exam
INSPECT Anterior and Posterior Chest
Position of person, Facial expression, Level of consciousness
Skin color and condition
Quality of respirations
Thoracic cage
Shape and configuration of chest wall, rib interspaces
Anteroposterior/transverse diameter
Use of Accessory muscles

22. Objective Data—The Physical Exam
PALPATE Anterior and Posterior Chest
Palpate the entire chest wall (crepitus, masses)
Symmetric expansion
Tactile (or vocal) fremitus
Pt says “99” while examiner palpates chest

23. PERCUSSAnterior,Posterior and Lateral Chest
Predominant note= RESONANCE
Diagphragmatic Excursion
3-6cm
R side higher than L

24. Objective Data—The Physical Exam
Auscultate- Anterior, Posterior and lateral Chest
Breath sounds- Technique
Listen with diaphragm of stethoscope.
Listen systematically, top to bottom, compare side to side
Listen to complete inhalation/exhalation at all sites

26. Breath Sounds Bronchial (Tracheal) breath sounds
location/characteristics
Bronchovesicular breath sounds
Vesicular breath sounds
YouTube- Breath Sounds

28. Bronchial/Tracheal
Broncho-vesicular
Vesicular

29. Adventitious Breath Sounds
Crackles- discontinous, early or late inspiration
Fine or coarse
Wheeze- continuous, musical, inspiration or expiration, high/low pitched
Atelectatic crackles- Early inspiration, clears with coughing
Fine Crackles
Coarse Crackles
High-pitched
Low-pitched

30. Voice Sounds
Used to help determine if lung consolidation is present. Perform if abnormal lung sounds detected
Bronchophony- “99”
Egophony- “eeee”
Whispered pectoriloquy “1,2,3”

31. Abnormal Findings Configurations of the Thorax
Barrel chest
Pectus excavatum
Pectus carinatum
Scoliosis
Kyphosis

32. Abnormal Findings Respiration Patterns
Sigh
Tachypnea
Bradypnea
Hyperventilation
Hypoventilation
Cheyne-Stokes respiration
Biot’s respiration
Chronic obstructive breathing

33. Abnormal Findings Abnormal Tactile Fremitus
Increased tactile fremitus
Decreased tactile fremitus
Rhonchial fremitus
Pleural friction fremitus

34. Abnormal Findings Adventitious Lung Sounds
Discontinuous sounds
Crackles—fine
Crackles—course
Atelectatic crackles
Pleural friction rub
Continuous sounds
Wheeze—sibilant
Wheeze—sonorous rhonchi
Stridor

35. Abnormal Findings Common Respiratory Conditions
Atelectasis
Lobar pneumonia
Bronchitis
Emphysema
Asthma (reactive airway disease)
Pleural effusion thickening
Congestive heart failure
Pneumothorax
Pneumocystis carinii pneumonia
Tuberculosis
Pulmonary embolism
Acute respiratory distress syndrome (ARDS)