HA: Thorax and lungs

• Abnormal findings
• Vision quest
• This chapter is like a breath of fresh air
• Respiratory system


  The structures of the respiratory system (the airways, lungs, bony thorax, respiratory muscles, and central nervous system) work together to deliver oxygen to the bloodstream and remove excess carbon dioxide from the body
• Upper airways


  • Nasopharynx (nose)
  • Oropharynx (mouth)
  • Laryngopharynx
  • Larynx
• Lower airways


  • Trachea
  • Right and left mainstem bronchi
  • Alveoli
• Larynx


  Houses the vocal cords, transition point between upper and lower airways, epiglottis protects from aspiration
• Lungs


  • Right lung has 3 lobes: upper, middle, lower
  • Left lung has 2 lobes: upper, lower
• Mediastinum


  Space between the lungs
• Thorax


  Bony thorax includes clavicles, sternum, scapula, 12 sets of ribs, 12 thoracic vertebrae
• Respiratory muscles


  • Diaphragm
  • External intercostal muscles
  • Accessory inspiratory muscles: trapezius, sternocleidomastoid, scalenes
• Pleurae

  Visceral pleura wraps each lung, parietal pleura lines thoracic cavity, pleural fluid allows smooth sliding
• Respiratory assessment landmarks
• Inspecting the chest


  Observe chest-wall symmetry, masses, scars, respiratory rate and pattern, accessory muscle use
• Palpating the chest

  Feel for tenderness, alignment, bulging, retractions, crepitus, tactile fremitus, chest-wall symmetry and expansion
• Percussing the chest


  Reveals lung boundaries and whether lungs are filled with air, fluid or solid material
• Diaphragmatic excursion


  Distance the diaphragm moves between inhalation and exhalation
• Auscultation


  Listening to breath sounds to determine condition of alveoli and surrounding pleura
• Breath sounds


  • Sounds produced by breathing change as air moves from larger airways to smaller airways
  • Sounds change if they pass through fluid, mucus, or narrowed airways
• Auscultation


  Listening to the sounds produced by the body to determine the condition of the alveoli and surrounding pleura
• Classifying breath sounds


  1. Classify each sound according to its intensity, location, pitch, duration, and characteristic

  2. Note whether the sound occurs when the patient inhales, exhales, or both
• Have the patient breathe through his mouth; nose breathing alters the pitch of breath sounds
• If the patient has abundant chest hair, mat it down with a damp washcloth so the hair doesn't make sounds like crackles
• Auscultation sequence


  1. Press the diaphragm of the stethoscope firmly against the skin

  2. Listen to a full inspiration and a full expiration at each site in the sequence shown

  3. Compare sound variations from one side to the other

  4. Document adventitious sounds and include their locations
• Bronchophony


  Ask the patient to say "ninety-nine" - over normal lung tissue the words sound muffled, over consolidated areas the words sound unusually loud
• Egophony


  Ask the patient to say "E" - over normal lung tissue the sound is muffled, over consolidated lung tissue it will sound like the letter a
• Whispered pectoriloquy


  Ask the patient to whisper "1, 2, 3" - over normal lung tissue the numbers will be almost indistinguishable, over consolidated lung tissue the numbers will be loud and clear
• Vocal fremitus


  • Voice sounds resulting from chest vibrations that occur as the patient speaks
  • Abnormal transmission of voice sounds may occur over consolidated areas
• Abnormal voice sounds


  • Bronchophony
  • Egophony
  • Whispered pectoriloquy
• Qualities of normal breath sounds


  • Tracheal: Harsh, high-pitched
  • Bronchial: Loud, high-pitched
  • Bronchovesicular: Medium in loudness and pitch
  • Vesicular: Soft, low-pitched
• Locations of normal breath sounds

  • Tracheal: Above supraclavicular notch, over the trachea
  • Bronchial: Just above clavicles on each side of the sternum, over the manubrium
  • Bronchovesicular: Next to sternum, between scapulae
  • Vesicular: Remainder of lungs
• Chest-wall abnormalities


  • Barrel chest: Increased anteroposterior diameter
  • Funnel chest (pectus excavatum): Depressed lower sternum
  • Pigeon chest (pectus carinatum): Anteriorly displaced sternum
  • Thoracic kyphoscoliosis: Raised shoulder and scapula, thoracic convexity, and flared interspaces
• Paradoxical movement

  Abnormal, uneven movement of the chest wall that can occur as a result of chest-wall injury
• Abnormal respiratory patterns


  • Tachypnea: Shallow breathing with increased respiratory rate
  • Bradypnea: Decreased rate but regular breathing
  • Apnea: Absence of breathing; may be periodic
  • Hyperpnea: Increased depth of breathing
  • Kussmaul's respirations: Rapid, deep breathing without pauses
  • Cheyne-Stokes respirations: Breaths that gradually become faster and deeper than normal, then slower, and alternate with periods of apnea
  • Biot's respirations: Rapid, deep breathing with abrupt pauses between each breath
• Grading dyspnea


  A system to objectively assess shortness of breath based on how various activities affect the patient's breathing
• Grades of dyspnea


  • Grade 0: Not troubled by breathlessness except with strenuous exercise
  • Grade 1: Troubled by shortness of breath when hurrying on a level path or walking up a slight hill
  • Grade 2: Walks more slowly on a level path than people of the same age because of breathlessness or has to stop to breathe when walking on a level path at his own pace
  • Grade 3: Stops to breathe after walking approximately 100 yards (91 m) on a level path
  • Grade 4: Too breathless to leave the house or breathless when dressing or undressing
• Abnormal breath sounds


  Sounds heard in an area other than where you would expect to hear them, indicating the alveoli and small bronchioles in that area might be filled with fluid or exudate
• Adventitious sounds


  • Fine crackles
  • Coarse crackles
  • Wheezes
  • Rhonchi
  • Stridor
  • Pleural friction rub
• Discontinuous adventitious sounds


  • Intermittent, nonmusical, soft, high-pitched, short, cracking, popping sounds heard during inspiration (fine crackles)
  • Intermittent, nonmusical, loud, low-pitched, bubbling, gurgling sounds heard during early inspiration and possibly during expiration (coarse crackles)
• Continuous adventitious sounds

  • Musical, high-pitched, squeaky, whistling sounds predominantly heard during expiration but may also occur during inspiration (wheezes)
  • Musical, low-pitched, snoring, moaning sounds heard during both inspiration and expiration but are more prominent during expiration (rhonchi)