THORAX AND LUNGS

• Lower airways

  It begins with the trachea, or windpipe, which extends from the cricoid cartilage to the carina. The trachea then divides into the right and left mainstem bronchi, which continue to divide all the way down to the alveoli, the gas-exchange units of the lungs.

  A) Trachea

  B) Apex of Lung

  C) Carina

  
• Upper airways

  The upper airways include the nasopharynx (nose), oropharynx (mouth), laryngopharynx, and larynx. These structures warm, filter, and humidify the inhaled air.

  A) Nasopharynx

  B) Oropharynx

  C) Laryngopharynx

  
• The larynx

  • It houses the vocal cords.
  • Transition point between the upper and lower airways.
  • Epiglottis - a flap of tissue that closes over the top of the larynx when the patient swallows, protects the patient from aspirating food or fluid into the lower airways.
• Lungs

  • The right lung has three lobes: upper, middle, and lower.
  • The left lung is smaller and has only an upper and a lower lobe.
  • The lungs share space in the thoracic cavity with the heart and great vessels, the trachea, the esophagus, and the bronchi.
  • The space between the lungs is called the mediastinum.
• Thorax

  The bony thorax includes the clavicles, sternum, scapula, 12 sets of ribs, and 12 thoracic vertebrae.
• Pleurae

  • Each lung is wrapped in a lining called the visceral pleura.
  • All areas of the thoracic cavity that come in contact with the lungs are lined with parietal pleura.
• Assessment

  Begin your respiratory assessment by first observing the patient’s general appearance. Then use inspection, palpation, percussion, and auscultation to perform a physical examination.
• Respiratory assessment landmarks

  A) Axillary line

  B) Midclavicular line

  C) Midsternal line

  
• Respiratory assessment landmarks 2

  A) Scapular Line

  B) Vertebral line

  
• Respiratory rate and pattern

  • Adults normally breathe at a rate of 12 to 20 breaths/minute.
  • An infant’s breathing rate may reach 40 breaths/minute.
• While inspecting the chest, look for these characteristics that may put a CRAMP in your patient’s respiratory system.

  • Chest-wall asymmetry
  • Respiratory rate and pattern (abnormal)
  • Accessory muscle use
  • Masses or scars
  • Paradoxical movement
• Palpating the chest

  • The chest wall should feel smooth, warm, and dry.
  • Gentle palpation shouldn’t cause the patient pain.
  • Pain may be caused by costochondritis, rib or vertebral fractures, or sore muscles as a result of protracted coughing.
• • Crepitus, which feels like puffed-rice cereal crackling under the skin, indicates that air is leaking from the airways or lungs.
  • Also palpate for tactile fremitus, palpable vibrations caused by the transmission of air through the bronchopulmonary system.
  • Then evaluate chest-wall symmetry and expansion.
• Percussing the chest

  Chest percussion reveals the boundaries of the lungs and helps to determine whether the lungs are filled with air or fluid or solid material.
• Flat

  Short, soft, high pitched, extremely dull, as found over the thigh.

  Consolidation, as in atelectasis and extensive pleural effusion
• Dull

  Medium in intensity and pitch, moderate length, thudlike, as found over the liver

  Solid area, as in lobar pneumonia
• Resonant

  • Long, loud, low pitched, hollow
  • Normal lung tissue; bronchitis
• Hyperresonant

  • Very loud, lower pitched, as found over the stomach
  • Hyperinflated lung, as in emphysema or pneumothorax
• Tympanic

  • Loud, high-pitched, moderate length, musical, drumlike, as found over a puffed-out cheek
  • Air collection, as in a large pneumo thora
• Diaphragmatic excursion - the distance the diaphragm moves between inhalation and exhalation
• Assessing voice sounds

  • Check the patient for vocal fremitus — voice sounds resulting from chest vibrations that occur as the patient speaks.
  • Abnormal transmission of voice sounds may occur over consolidated areas.

  A) Bronchophony

  B) Egophony

  C) Whispered pectoriloquy

  
• Locations of normal breath sounds

  A) Bronchial

  B) Tracheal

  C) Vesicular

  D) Bronchovesicular

  E) Bronchovesicular

  F) Vesicular

  
• Qualities of normal breath sounds

  A) Tracheal

  B) Bronchial

  C) Bronchovesicular

  D) Vesicular

  
• Chest deformities

  A) Barrel

  B) Funnel

  C) Pigeon

  D) Thoracic kyphoscoliosis

  
• Paradoxical (uneven) movement of the chest wall is abnormal.

  It can occur as a result of chest-wall injury, such as multiple rib fractures or blunt force trauma to the chest.
• Abnormal respiratory patterns

  A) Tachypnea

  B) Bradypnea

  C) Apnea

  D) Hyperapnea

  E) Kussmaul's respiration

  F) Cheyne-Strokes respiration

  G) Biot's respiration

  
• Kussmaul’s respirations

  • Rapid, deep breathing without pauses; in adults, more than 20 breaths/minute; breathing usually sounds labored with deep breaths that resemble sighs
• Cheyne-Stokes respirations

  • Breaths that gradually become faster and deeper than normal, then slower, and alternate with periods of apnea
• Biot's respiration

  • Rapid, deep breathing with abrupt pauses between each breath; equal depth to each breath
• Dyspnea - difficulty breathing, shortness of breath, or difficulty in breathing
• Adventitious sounds

  • Other breath sounds are abnormal, no matter where you hear them in the lungs.
• Stridor

  • a loud, high pitched crowing sound, usually heard without a stethoscope during auscultation. It’s caused by upper airway obstruction
• Pleural friction rub

  • a low-pitched, grating, rubbing sound heard on inspiration and expiration. It’s caused by pleural inflammation.
• Adventitious sound (Inspiration to Expiration)

  A) Fine crackles

  B) Coarse crackles

  C) Discontinuous

  D) Continuous

  E) Wheezes

  F) Rhonchi

  
• Auscultation findings for common disorders

  A) Asbestosis

  B) Asthma

  C) Atelectasis

  D) Bronchiectasis

  
• Auscultation findings for common disorders 2

  A) Chronic Obstructive Pulmonary disease

  B) Pleural effusion

  C) Pneumonia

  D) Pneumothorax

  E) Upper Airway obstruction