1. Thorax and Lungs N1037 Chapter 15

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 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 Tracheostomy tube –Size –Cuffed or cuffless –How tube is secured to neck Mechanical ventilation –Type of ventilator –FiO 2 setting –Mode –Amount of PEEP –Rate and tidal volume –Alarms Pulse oximeter Peak flow Meter

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

34. Bronchial Bronchovesicular Vesicular Auscultation: Breath Sounds

35. 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