THORAX AND LUNGS

• Anterior Chest

  o   Midsternal line

  o   Midclavicular line

  o   Anterior axillary line
• Lateral Chest

  o   Anterior axillary line

  o   Midaxillary line

  o   Posterior axillary line
• Inspect the spine for mobility and configuration of the thoracic cage. Note for any structural deformity.
• Note the anteroposterior diameter in relation to the lateral diameter of the chest.
• Observe for skin characteristics, symmetry of the posterior chest, posture, mobility of the thorax on respiration. Note any bulges or reactions of the costal
• The thorax is normally symmetric; it moves easily and without impairment on respiration. There are no bulges or retractions of the intercostal spaces.
• The anteroposterior (AP) diameter of the thorax in relation to the lateral diameter is approximately 1:2 (the lateral diameter is wider than the AP diameter).
• To assess respiratory excursion, place the thumbs at the level of the 10th vertebra; with hands held parallel to the 10th ribs as they grasp the lateral rib cage, ask the patient to inhale deeply. Observe the movement of the thumbs while feeling the range and observe the symmetry of the hands.
• To assess for vocal or tactile fremitus (palpable vibrations transmitted through the bronchopulmonary system on speaking):
• Instruct the patient to say "99," palpate and compare symmetric areas of the lungs with the ball of one hand.
• Bronchophony is present if the "99" appears louder and more distinct over certain areas, suggesting underlying consolidation
• Begin across the top of each shoulder and proceed down between the scapulae and then under the scapula, both medially and laterally in the axillary lines.
• Percussion normally reveals resonance over symmetric areas of the lungs.
• Use stethoscope to listen to the lungs as the patient breathes somewhat more deeply than normally with open mouth.
• Place the stethoscope on the chest wall in the same areas as those percussed and listen to a complete inspiration and expiration in each area.
• Compare symmetric areas from the apex to the lung bases.
• On auscultation, breath sounds are louder and coarser near the large bronchi and over the anterior chest.
• On auscultation, breath sounds are softer and much finer (vesicular) at the periphery over the alveoli.
• Vesicular: heard in most areas of the lungs.
• Bronchovesicular: heard near the main stem bronchi (below the clavicles and between the scapulae)
• Bronchial (tracheal): heard over the trachea.
• Vesicular

  Pitch: Low

  Amplitude: Soft

  Duration: Inspiration > Expiration

  Quality: Rustling, sound of wind

  Normal Location: Over peripheral ling fields where air flows through smaller bronchioles and alveoli
• Bronchovesicular

  Pitch: Moderate

  Amplitude: Moderate

  Duration: Inspiration = Expiration

  Quality: Mixed

  Normal Location: Over major bronchi;

  posterior, between scapulae, especially on right, anterior, around upper
• Bronchial

  Pitch: High

  Amplitude: Loud

  Duration: Inspiration shorter than Expiration

  Quality: Harsh, hollow tubular

  Normal Location: Over tracher
• Observe rate and rhythm of breathing, any bulging or retraction of the intercostal space on respiration (sternocleidomastoid and trapezius muscle on inspiration and abdominal muscles on expiration)
• The thorax is normally symmetric and moves easily without, impairment on respiration. There are no bulges, or retractions of the intercostal spaces.
• The angle at the tip of the sternum is determined by the right and left rib margins at the xiphoid process (costal angle). Normally, the angle is less than 90 degrees.
• Hemoptysis: - Coughing up with blood.
• Orthopnea: Difficulty breathing when supine.
• Paroxysmal Nocturnal Dyspnea (PND): is awakening from sleep wịth SOB (shortness of breath) and needing to be upright to achieve comfort.
• Decreased fremitus: occurs when anything obstructs transmission of vibrations, e.g., obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema.
• Increased fremitus: occurs with compression or consolidation of lung tissue, e.g., lobar pneumonia.
• Crepitus: is a course crackling sensation palpable over the skin surface. It occurs when air escapes from the lung and enters the subcutaneous tissue (subcutaneous emphysema).
• Hyper resonance: a low - pitched, booming sound on percussion of the chest, when too much air is present in the lungs, e.g., emphysema, pneumothorax.
• Dullness: Soft, muffled thud, which signals abnormal density in the lungs, e.g., pneumonia, pleural effusion, atelectasis, tumor.
• Atelectasis: Collapse of the lungs.
• Unequal chest expansion: occurs when part of the lung is obstructed or collapsed.
• Retractions: indentations at the intercostal spaces. These suggest obstruction of respiratory tract or increased need for inspiratory effort.
• Tachypnea:  rapid, shallow, breathing.
• Hyperventilation: deep rapid breathing. Also called Kussmaul's breathing.