Chest and lungs

• Functions of the Respiratory System

  • Ventilation
  • Diffusion and Perfusion
  • Control of Breathing
• Ventilation


  1. Movement of air into and out of the lungs

  2. Inspiratory phase

  3. Expiratory phase
• Hypoventilation


  Slow, shallow breathing that causes CO2 to build up in the blood
• Hyperventilation


  Rapid, deep breathing that causes CO2 to be blown off
• Diffusion and Perfusion


  Gas exchange across the alveolar-pulmonary capillary membranes
• Control of breathing

  Influenced by neural and chemical factors in the pons, medulla, and chemoreceptors in the carotid body
• Stimulus for breathing


  Increased carbon dioxide is the PRIMARY stimulus
• Topographical Landmarks


  • Nipples
  • Manubriosternal junction (Angle of Louis)
  • Suprasternal notch
  • Costal Angle
  • Clavicles
• Reference Lines - Anterior Chest


  • Midsternal line
  • Anterior axillary lines
  • Midclavicular lines
• Reference Lines - Posterior Chest


  • Vertebral line
  • Midscapular lines
  • Anterior axillary lines
  • Midaxillary lines
  • Posterior axillary lines
• Lungs are symmetric and divided into lobes
• Right lung has 3 lobes, left lung has 2 lobes
• Primary muscles of respiration


  • Diaphragm
  • External intercostal muscles
• Accessory muscles of respiration
• Upper Airway


  • Nose
  • Pharynx
  • Larynx
  • Intrathoracic trachea
• Functions of the Upper Airway


  • Conduct air to lower airway
  • Filter to protect lower airway
  • Warm and humidify inspired air
• Lower Airway


  • Trachea
  • Bronchi
  • Bronchioles
• Functions of the Lower Airway


  • Conduct air to alveoli
  • Clear mucociliary structures
• Alveoli are the functional unit for gas exchange and surfactant production
• The right bronchus is shorter, wider, and more upright than the left
• Chief complaints include cough and shortness of breath/dyspnea
• Characteristics of cough


  • Onset (sudden, gradual)
  • Duration
  • Nature (dry, moist, hacking, barking)
  • Sputum (amount, color, odor)
  • Severity (disrupts activities)
  • Associated symptoms
  • What brings it on?
  • What makes it better?
  • What has been tried?
  • Anything similar in the past?
• Past Health History


  • Lung disease or breathing problems
  • Last PPD and/or chest x-ray
  • Allergies
  • Medication use
• Personal and Social History


  • Tobacco
  • Alcohol
  • Drugs
  • Home environment
  • Occupational environment
  • Travel
  • Health Promotional Activities
• Equipment for Physical Examination


  • Stethoscope
• Techniques for Physical Examination


  • Inspection
  • Palpation
  • Percussion
  • Auscultation
• General Inspection


  • Appearance
  • Posturing
  • Breathing effort
  • Trachea position (midline)
• Chest Wall Configuration


  • Form
  • Symmetry
  • Muscle development
  • Anterior-Posterior (AP) diameter (approximately 1/2 the transverse diameter)
  • Costal angle (90 degrees or less)
• Oxygenation


  Cyanosis (nails, skin, lips)
• Respiratory Effort


  • Respiratory rate and depth
  • Breathing pattern
  • Chest expansion
• Palpation


  • Trachea position
  • Chest wall symmetry
  • Thoracic expansion (bilateral, symmetric)
• Vocal (Tactile) Fremitus


  Normal: bilaterally symmetrical vibrations

  Decreased/absent: obstruction of transmission

  Increased: consolidation of lung tissue
• Auscultation


  Evaluate in a systematic manner

  Compare one side to the other

  Listen one full respiration at each spot

  Displace breast tissue to listen directly over chest wall
• Normal Lung Sounds

  • Bronchial (high pitch, loud, blowing/hollow, I<E)

  Bronchovesicular (moderate pitch/intensity, combination, I=E)

  Vesicular (low pitch, soft, gentle rustling/breezy, I>E)
• Adventitious Lung Sounds


  • Crackles (soft/fine or loud/coarse, discontinuous, nonmusical, brief, I)

  Wheezes (high pitch, continuous musical, E)

  Rhonchi (low pitch, continuous snoring, E)

  Pleural Friction Rub (continuous or discontinuous creaking/brushing, I&E)

  Stridor (continuous, crowing, I)
• Neonates have a round chest, are obligate nose breathers, and have periodic breathing
• Infants and young children have a more rounded chest, louder breath sounds, and bronchovesicular sounds throughout the chest
• In pregnancy, the costal angle increases to about 105 degrees, and dyspnea and orthopnea are common
• In older adults, chest expansion is often decreased, bony prominences are marked, and the anterior-posterior diameter is increased relative to the transverse diameter