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Chapter
15
Thorax and Lungs
N1037
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
A & P of Thorax
Sternum Ribs Intercostal spaces
Anatomy: Lungs
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Right lung: three lobes
Left lung: two lobes
Apex
Base
Midclavicular line
(MCL)
• Midaxillary line
(MAL)
Anatomy: Lungs
Thoracic Anatomic
Topography
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Anterior axillary line
Midspinal (vertebral) line
Midsternal line
Posterior axillary line
Scapular line
Thoracic Anatomic Topography
Physiology of Respiration
• Ventilation
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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
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pons & medulla = CNS structures responsible for involuntary respiration
stimulus for breathing =  Co2, PH, O2 levels
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)
Common Chief Complaints
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Dyspnea
Cough
Sputum
Chest pain
Characteristics of Chief
Complaint
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Quality
Quantity
Associated manifestations
Aggravating factors
Alleviating factors
Setting
Timing
Past Health History
• Medical
– Respiratory specific
– Nonrespiratory specific
• Surgical
• Medications
• Communicable diseases
• Allergies
• Injuries and accidents
• Special needs
• Childhood illnesses
Family Health History
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Allergies
Asthma
Bronchiectasis
Cancer
Cystic fibrosis
Emphysema
TB
Social History
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Alcohol, drug, or tobacco use
Travel history
Work and home environment
Hobbies and leisure activities
Stress
Economic status
Health Maintenance
Activities
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Sleep
Diet
Exercise
Use of safety devices
Health check-ups
Assessment of the Thorax and
Lungs
• Equipment
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Stethoscope
Centimeter ruler or tape measure
Washable marker
Watch with second hand
Inspection
• Shape of thorax
– Transverse diameter
– Anteroposterior (AP) diameter
• Symmetry of chest wall
• Presence of superficial veins
• Costal angle
(continues)
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
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barrel chest dt COPD
pectus carinatum dt congenital abn
kyphosis :humpback
scoliosis: curvature of spine
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
Respirations
• Rate N= 12-20 bpm for adult
• Abnormalities
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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)
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
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
Inspect Sputum
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Color N= light yellow or clear
Odor N= none
Amount N = small
Consistency N = thick or thin depends on hydration
• Abnormal
– Table 15-1
Assessing Patients with Respiratory
Assistive Devices
• Oxygen therapy
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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
–FiO2 setting
–Mode
–Amount of PEEP
–Rate and tidal volume
–Alarms
•Pulse oximeter
•Peak flow Meter
Thoracic Palpation
• Palpate the Anterior, Posterior & Lateral thorax
– Assess for
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Pulsations
Masses
Thoracic tenderness
Crepitus
N= no pulsations, masses, tenderness,crepitus
– Abnormal
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aortic aneurysm
tumor or cyst
chest trama
subcutaneous emphysema (air in subcutaneous tissue)
Thoracic Palpation
• Thoracic expansion
– Expansion
– Symmetry
• Tactile fremitus
– Anterior
– Posterior
– Lateral
(continues)
Thoracic Palpation
• Thoracic expansion
– Expansion
– Symmetry
Thoracic Palpation
• Tactile fremitus
– Anterior, Posterior, Lateral
N= buzzing over bronchi & trachea
Abnormal =  dt consolidation
=  dt pneumothorax, emphysema, asthma
Palpation Pattern for Tactile
Fremitus
Thoracic Percussion
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Anterior
Posterior
Right and left lateral
Diaphragmatic excursion
Pt position for Posterior Percussion
Percussion Patterns
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
Auscultation: Fields
• Anterior
• Posterior
• Lateral
• Lateral
Auscultation: Breath Sounds
• Bronchial
• Bronchovesicular
• Vesicular
Auscultation: Breath Sounds
• 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
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
Age-Related Changes
• Anatomic changes
– Limited chest wall expansion
– Muscle atrophy
– Increased work of breathing
• Alveolar gas exchange
– Decreased surface area for diffusion
(continues)
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