Outline of chapter 8

Tuesday, November 1, 2016

11:04 PM

The Thorax and Lungs

* Anatomy note: the intercostal space is always named by the rib above it. And
if you find the suprasternal notch and go 5cm down to the sternal angle (the
angle of Louis), then you can move laterally to find the 2nd rib.
-T2 intercostal space is used as a landmark for a needle insertion for a tension
pneumothorax
-T4 is used to help determine the length that the ET tube should be placed on an
xray.
Ribs:
1-7: articulate with the sternum
8-10: articulate with the costal cartilages above them
11,12: considered "floating ribs"
-Landmark:
The inferior border of the scapula is at the level of T7. The T7-8 interspace
can be used as a landmark for thoracentesis.
Circumference of the chest:

Lung Fissures and Lobes:

-The apex of each lung rises approx. 2cm to 4cm above the inner 1/3 of the
clavicle. The lower border of the lung crosses the 6th rib at the midclavicular
line and the 8th rib at the midaxillary line. Posteriorly its at the T10 spinous
process.

Oblique Fissure: divides the lungs in half.

Horizontal Fissure: divides the right lung further so that the right lung has an
upper, middle, and lower lobe.

Locations on the Chest:

Supraclavicularabove the clavicles
Infraclavicularbelow the clavicles
Interscapularbetween the scapulae
Infrascapularbelow the scapulae
Bases of the lungsthe lowermost portions Upper, middle, and lower lung
fields
*Important note: sounds in the right middle lung field may be heard in the
upper, middle, and lower lung field.
Trachea and major bronchi:
-The trachea bifurcates at the level of the sternal angle anteriorly and the T4
spinous processes posteriorly

The Pleurae:
Visceral pleura: covers the outer surface of the lung
Parietal pleura: lines the inner rib cage and the upper surface of the
diaphragm
Pleural fluid: lubricates the pleural surfaces allowing the lungs to move more
easily during inspiration and expiration.
Pleural Effusions: may be transudates, seen in atelectasis, heart failure,
and nephrotic syndrome, or exudates, seen in numerous conditions
including PNA, TB, PE, pancreatitis, and malignancy.
Breathing:
-controlled by respiratory centers in the brainstem to produce drive in the
respiratory muscles.
Principle muscle of inspiration: diaphragm
Scalenes and parasternal also contract to expand the thorax.
-During inspiration, as the thorax expands intrathoracic pressure decreases,
drawing air into the distal air sacs where O2 and CO2 are exchanged.
-During expiration, the chest wall and lungs recoil and the diaphragm relaxes
and rises passively
-Movements of the thorax in are more prominent in the sitting position rather
than lying down.
Exercise:
Accessory muscles used: sternomastoids, abdominal muscles, and
scalenes.

Common or concerning symptoms:

Chest pain
SOB
Wheezing
Cough
Hemoptysis
Sources of Chest Pain:
Myocardium: angina pectoris, myocardial infarction, myocarditis
Pericardium: pericarditis
Aorta: dissecting aortic aneurysm
Trachea and large bronchi: bronchitis
Parietal Pleura: pericarditis, PNA, pneumothorax, pleural effusion,
pulmonary embolus
Chest wall: costochondritis, herpes zoster
Esophagus: GERD, esophageal spasm, esophageal tear
Extrathoracic structures: cervical arthritis, biliary colic, gastritis
Questions to a patient for chest pain:
Should be open ended: "Any discomfort in your chest?" "Can you point to
the pain?"
Watch the patient as they describe the symptoms.
-A clenched fist over the sternum suggests angina pectoris; a
finger pointing to a tender area on the wall suggests
musculoskeletal pain; hand moving from the neck to the
epigastrium suggest heartburn. Anxiety is the most frequent
cause of chest pain in children and costochondritis is also
common.
Lung tissue has NO PAIN FIBERS. Pain from lung conditions such as
PNA arise from inflammation.
Dyspnea and Wheezing:
Usually painless. Decipher whether cardiac or pulm related.
-the degree of dyspnea in patients with COPD predicts 5 year
survival better than FEV1.
Ask:

-"Have you had any difficulty breathing?" "When did this occur?"
"Exacerbating or factors?"
-try to determine the severity based on their daily activities: "How
many flights of stairs can you walk up?"
Anxiety driven:
-describe their SOB as not being able to get enough air (parasthesias)
or a smothering sensation
-also have a "pins and needles" sensation in extremities
-anxious patients may have episodic SOB with hyperventilation
during rest and exercise
Wheezes:
Occurs in partial airway obstruction from secretions and tissue
inflammation in asthma and foreign body.
Cough:
-reflex response to stimuli that irritate larynx, trachea, or lg bronchi.
-Cough can also be a sign of left sided heart failure
Durations:
<3 weeks: acute
3-8 weeks: subacute
>8 weeks: chronic
-Viral URIs are the most common cause of the acute cough.
Also consider acute bronchitis, PNA, left ventricular heart failure,
asthma, or FB.
-Subacute coughs: caused by bacterial sinusitis, postinfectious
cough, asthma
-Chronic: postnasal drip, asthma, GERD, chronic bronchitis,
bronchiectasis
Ask:
"Productive or nonproductive?" "Can you describe the sputum?"
-Mucoid sputum: translucent, white, or gray
-Purulent sputum: yellow or green
-Foul smelling: anareobic lung abscess, tenacious sputum in
CF
-Large volumes: bronchiectasis, lung abscess
-Other diagnostically helpful symptoms: fever, CP, SOB,
orthopnea, and wheezing
Hemoptysis:
-coughing up blood from the lung.
-make sure to assess where its coming from and associated symptoms
-Hemoptysis is rare in infants, children, and adolescents,
although common in cystic fibrosis.
-Blood originating in the stomach is usually darker than blood
from the respiratory tract and may be mixed with food particles.

Health Promotion and Counseling:

Tobacco Cessation:
FACTS:
-21% of US adults still smoke
-80% start by 18 y/o
-Smoking accounts for 1/5 deaths each year
-1/2 of long term smokers die of smoking related disease

-Contributes to at least 15 types of cancer

-increases risk of infertility, preterm birth, low birth weight, and SIDS
-Smoking is the leading preventable cause of death.
-70% of smokers see a physician and 70% of those express interest in
smoking so education on quitting is better prevention than using CT
screening tools

-3% of smokes successfully quit each year due to the stimulation of

nicotinic cholinergic receptors
-cognitive therapy has been shown to be helpful in combination with
pharmacotherapies such as nicotine replacement, bupropion, and
varencycline
Immunizations:
-influenza caused 36,000 deaths annually
-Flu shot: contains the inactivated vaccine containing the killed virus
-Nasal spray: attenuated live virus (ages 5-49)
-Recommended in all people ages 6 months and older.

-Steptococcus pneumonia: causes PNA and meningitis which can lead to

sepsis and death. Immunization has decreased incidence by 45%.

Techniques of exam:
-Inspection, palpation, percussion, auscultation
-For patients who cannot sit up, roll them from one side to another.
-Observe: rate, rhythm, depth, and effort of breathing
-assess color
-cyanosis signals hypoxia. Clubbing of the nails occurs in
bronchiectasis, congenital heart disease, pulmonary fibrosis,
cystic fibrosis, lung abscess, and malignancy
-listen to breathing
-Audible stridor, a high-pitched wheeze, is an ominous sign of
upper airway obstruction in the larynx or trachea.
-inspect the neck
-accessory muscle use in COPD signals difficulty breathing.
Lateral displacement of the trachea occurs in pneumothorax,
pleural effusion, or atelectasis.
-inspect shape
-AP diameter may increase in COPD
Palpation:
-tender areas:

-ecchymosis may signify fx of the ribs

-visible abnormalities:
-sinus tracts indicate infection of the underlying pleura and lung
(TB, actinomycosis)
-test chest expansion at the level of the 10th ribs
-unilateral decrease or delay occurs in chronic fibrosis of the
underlying lung or pleura, pleural effusion, lobar PNA, pleural
pain with associated splinting, and unilateral bronchial
obstruction

-test for tactile fremitus:

-palpable vibrations transmitted through bronchopulmonary tree
to chest wall as patient is speaking "99"
-Fremitus is absent or decreased when the voice is higher
pitched or soft or when the transmission of vibrations from the
larynx to the surface of the chest is impeded by a thick chest
wall, and obstructed bronchus, COPD, or pleural changes from
effusion, fibrosis, air, or infiltrating perfusion.

-Asymmetric decreased fremitus occurs in unilateral pleural

effusion, pneumothorax, neoplasm due to decreased
transmission of sounds; asymmetric increased fremitus
occurs in unilateral PNA from increased transmission through
consolidated tissue.

-fremitus is typically more prominent in the interscapular area as

well as the right side over the left
Percussion:
-sets the chest wall and underlying tissues in motion producing
sound.
-percussion penetrates only 5-7cm into t
he chest. (not good for deep lesions)

-a thick chest wall requires stronger percussion

-When percussion the lower posterior chest, stand to the side for
effective positioning.
-strike twice in each location
FIVE DIFFERENT PERCUSSION NOTES:

-dullness replaces resonance when fluid or solid tissue

replaces air-containing lung or occupies the pleural
space beneath your percussing fingers. Examples
include: lobar PNA, in which the alveoli are filled with
fluid and blood cells; and pleural accumulations of
serous fluid, blood, pus, fibrous tissue, or tumor.
Dullness makes pneumonic and pleural effusion 5-18
times more likely, respectively.
-generalized hyperresonance may be heard over the
hyperinflated lungs of COPD or asthma. Unilateral
hyperresonance suggests a large pneumothorax or
possible a large air-filled bullae.

-Important to identify the decent of the diaphragm or

diaphragmatic excursion.

-An abnormally high level suggest a pleural effusion, or a high

diaphragm as in atelectasis or phrenic nerve paralysis.
-Normal diaphragmatic excursion is about 3-5.5cm.
Auscultation:
-sounds from bedclothes, paper sounds, and the chest itself can
generate confusion in auscultation, Hair on chest may also
cause craskling sosunds. Either press hard or wet the hair.
-If the patient is cold or tense, you may here muscle contraction
sounds, muffled, low-pitched rumbling or roaring noises. A
change in the patient's position may eliminate the noise. You
can reproduce this sound on yourself by doing a Valsalva
maneuver (straining down) as you listen to your own chest.
Vesicular breath sounds: soft, or low pitched. Heard on
inspiration, expiration, and fade away about one third of the way
through expiration.

Bronchovesicular: inspiration is equal to expiration and

separated by a silent interval.
Bronchial: louder and harsher and higher in pitch, with short
silence between inspiration and expiration. Expiratory sounds
last longer than inspiration.

-If bronchovesicular or bronchial breath sounds are heard in

locations distant from those listed, suspect that air-filled lung
has been replaced by fluid-filled or solid lung tissue
-use the ladder pattern that was used for percussion to listen
-Breath sounds are usually louder in the lower posterior lung
fields
-Listen for pitch, intensity, and duration of breath sounds
Adventitious Sounds:
Crackles: sometimes called rales
-Fine late inspiratory crackles that persist from breath to
breath suggest abnormal lung tissue. Cleaning of crackles,
wheezes, or rhonchi after coughing or position change
suggests inspissated secretions seen in bronchitis or
atelectasis.

-From PNA, fibrosis, early heart failure, bronchitis, or

bronchiectasis
Wheezes: asthma, COPD, bronchitis
Rhonchi: secretions in large airways

Transmitted Voice Sounds:

-Increased voice sounds suggest that air-filled lung has become
airless.
-Bronchophony: louder voice sounds
-Egophony: where "ee" sounds like "aa", seen in lobar PNA. In a
patient with a fever and a cough, the presence of bronchial
breath sounds and egophony more than triples the likelihood of
PNA.
-Whispered pectoriloquy: heard clearly when there is an
abnormal process
Anterior chest examination:
Inspection:
Observe shape of chest, asymmetry, local lag, or abnormal
retractions.
-Abnormal retractions occurs in severe asthma, COPD, or upper
airway obstruction.
Palpation:
-Check for tenderness which would suggest a possible
musculoskeletal origin.
-Check for abnormalities and further assessment of chest
expansion.
-Assess for tactile fremitus.

Percussion:
The heart will produce an area of dullness to the left of the
sternum from the 3-5 intercostal spaces.
-The hyperresonance of COPD may totally replace cardiac
dullness.
-In females, unless you displace the right breast, you may miss a
right middle lobe PNA.

-above is just for reference of where the liver lies

Auscultation:
-listen to breath sounds noting intensity, adventitious sounds,
and listen for transmitted voices.
Clinical Assessment:
Walk test: the distance a pt can quickly walk on a flat, hard
surface in a period of 6 minutes. Used to assess
cardiopulmonary function.
Forced Expiratory Time: taking a deep breath and breathing
out as quickly and completely as possible with the mouth open.
Patients older than 60 yrs with a forced expiratory time of
6-8 seconds are twice as likely to have COPD, if more than
8 seconds, the likelihood increases to 4. Try to get 3
readings.
Fx of the rib: an increase in the local pain from
anteriorposterior compression suggests a rib fracture, rather
than a soft tissue injury.

Recording Findings:

-these findings suggest COPD