Thoracic and lung - جامعة آل البيت · PDF file · 2015-10-13Thoracic...

06/11/1431

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Thoracic and lung

Chapter 7

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Objectives Respiratory System• Discuss anatomy & Philology of respiratory system

• Specify landmarks of thorax / underlying structures

• State component of health hx

• Describe techniques of inspection, percussion, auscultation and palpation

• Distinguish tones of hyperresonance, resonance, tympany, dullness & flatness

• Compare characteristics of normal breath sounds

• Compare characteristics of abnormal /adventitious breath sounds

• Compare characteristics of sounds produced by vocal fremitus

• Distinguish the assessment findings that are frequently associated with common lung conditions

• Identify causes of abnormal lung sounds

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Structure and FunctionPosition and Surface Landmarks

• Thoracic cage—borders

• Anterior thoracic landmarks

– Suprasternal notch

– Sternum

– Manubriosternal angle

– Costal angle

• Posterior thoracic landmarks

– Vertebra prominens

– Spinous processes

– Inferior border of scapula

– Twelfth rib

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Location finding in the lung• Sternal angel best guide anteriorly • First 7 rips of costal cartilage articulate with

sternum • 8th , 9th ,10th, ribs articulate with costal cartilage just

above them • 11th , and 12th rip are flouting rip • Land mark posteriorly :• 12th rip.• inferior angel of the scapula lies at the level of the

7th ribs.• Spinous process C7 is the most prominent process• Second ICS at the level of Spinous process T1.

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Anterior Thoracic Cage

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Posterior Thoracic Cage

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Line at the chest

• Mid sternal line

• Mid claviculer line

• Anterior auxiliary line

• Mid auxiliary line

• Posterior auxiliary line

• Scapular line

• Vertebral line

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Reference Lines (Anterior)

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Reference Lines (Posterior)

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Reference Lines (Lateral)

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Lung fisher and lobes

• Aneriorly :• Apex of each lung rises about 2-4 cm

above the inner third of the clavicle• The lower border of the lung cross the

6th rib at the midclaviculer line and 8th

rib in the mid auxiliary line Posteriorly• The lower border of the lung lies at

about the level of T10 spinous process

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Lung fisher and lobes… continue ..

• Right lung dived into upper , middle and lower lobes

• Left lung dived into uper and lower lobes

• Supracaviculer : above the clavicle• Infraclaviculer: below the clavicle• Interscapular: between the scapula• Infrascapuler; below the scapula 14

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superior

superior

middle

Inf.

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Structures of the Respiratory System

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The trachea and major bronchi

• The trachea bifurcates intoo its mainstem bronchie at the level of the sternal angels anteriorly and on the T4 spinous posteriorly

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pleura

• Visceral pleura: serous membrane that cover the outer service of the lung

• Parietal pleura: serous membrane that line the inner rib cage of the upper surface of diaphragm

Function of the pleura: smooth the opposing service and lubricant by plural fluid to allow the ling to move easily with the rib cage

Pleural space: potential space between visceral and parietal pleura.

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Breathing

• The dome shaped diaphragm is the primary muscle of inspiration

• Muscle in the rib cage of the neck expand the thoracic during inspiration

• In supine postion : thorax movement slight and abdominal movement easy to see

• Sitting posion; thorax movement becom more promenent

• Accessory muscle : sternomastoed 19

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Inspiration & Expiration

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Mechanics of Respiration

© Pat Thomas, 2006.

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Changes with age

• The chest wall become stiffer and hardr to move

• Skeltal changes may produce kyphosis this produce barrel chest

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Health history • Chest pain• Dyspnya• Wheezing• Cough, sputum• Blood- streaked sputum ( hemoptysis)

• Breathing Patterns– Eupnea: normal, quiet breathing– Apnea: absence of breathing– Labored: increased work of breathing– Paradoxical: chest wall moves in on inspiration &out

on expiration

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Technique of Examination of theRespiratory System

Inspection:• Respiratory rate, depth , rythem, ahd effort of

brething• Colore of cyanoses• Supracalviculer retracio• Strider: a chiefly inspiratory wheezes• Shape of the finger nail• Positaion of tha trachia • Shape of the chest :Normal: interior posterior diameter : transverse

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Normal Adult

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Thoracic Configuration

• Barrel Chest.

• Pectus Carinatum (pigeon chest)• Pectus Excavatum (funnel chest)• Kyphosis• Scoliosis• Kyphoscoliosis• Trauma

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Barrel Chest

• increased AP dimeters.

• Normal in children

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Pectus Carinatum

• Pectus Carinatum (pigeon chest ) :

The sternum is displaced anteriorly , increase the AP diameter.

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Pectus Excavatum

• Pectus Excavatum (funnel chest) : characterized by a depression in the lower portion in the sternum

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Kyphosis

• Kyphosis is a curving of the spine that causes a bowing of the back, which leads to a hunchback or slouching posture.

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Scoliosis

• Scoliosis is a disorder that causes an abnormal curve of the spine

• is a side-to-side curvature of the spine

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Kyphoscoliosis

• Abnormal spinal curvature and vertebral rotation deform the chest

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Palpation

• palpation of Skin and Subcutaneous Tissues

• Vocal & Tactile Fremitus

• Thoracic Expansion

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Skin & Subcutaneous Tissues

• Pain

• Masses

• Subcutaneous Emphysema: air in the subcutaneous space resulting in a crackling sound and sensation when palpated

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Vocal & Tactile Fremitus

• Resonance transmitted through chest by speech When assessed, referred to as tactile fremitus

• Patient instructed to repeatedly say, ―ninety-nine.‖

• Fremetuse decrease with : COPD , pleura effusion, fibroses and tumor

• Fremetuse increase : labor pneumonia

• Fremetuse more prominent inner scapular and more prominent left side than right side

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Abnormal Tactile Fremitus

Increased

• Pneumonia

• Lung tumor

• Atelectasis

Decreased

• Unilateral– Pneumothorax

– Pleural Effusion

• COPD

• Muscular or obese chest wall

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Tactile Fremitus - Palpate

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Thoracic Expansion

• Assess for amount and symmetry of chest wall movement

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Chest Expansion - Palpate

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Percussion

• Assesses resonance of structures inside the thorax• Done by tapping fingers over intercostal spaces• Help to defie whether under luing tissue are air-

filled, fluid-filled or solid • Dullness replaces the resoance when fluid or a solid

tissue replaces air contaning lung • Dullness appear in labor pneumonia(alveoli filed with

flud and blood cells), pleural effusion, fibrous tissue or truma

• Hyper resonance : emphysema, asthma • Diaphragmatic dullness norma 5-6 cm

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Percussion Sounds

• Hyperresonance: heard over a hollow structure

• Resonance: heard over air-filled structure

• Dullness: heard over a solid organ

• Flatness: heard over bone

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Percussion Technique

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Sequence to Percussion

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Expected Percussion Findings

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Expected Percussion Findings

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Diaphragmatic Excursion -Percussion

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Auscultation

• The Stethoscope– Breath Sounds

• Normal Sounds

• Abnormal (Adventitious) Sounds

• Voice sound

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Sequence for Auscultation

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Breath Sounds

Normal Sounds (when heard in normal areas)– Tracheal– Bronchial– Vesicular– Bronchovesicular

Breathing sound decreased when air flow is deceased as in obstructive lung disease or muscle weakness

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Location where

heard normally

Pitch of

expiratory sound

Intensity of

expiratory sound

Duration of

sound

Over most of

both lung

Relatively lowSoftInspiratory sound

last longer than

expiratory sound

Vesicular

Often in the 1st

and 2nd ICS

anteriolrly and

between scapula

IntermediateIntermediateInspiratory and

expiratory sounds

are about equal

Broncho-

vesiculer

Over the

manubrium

Relatively highLoudExpiratory sound

last longer than

insiratory

Bronchial

Over the trachea Relatively high Very loudInspiratory and

expiratory are

equal

Tracheal

Characteristic of breathing sound

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Abnormal (Adventitious) Sounds

• Pleural Friction Rub

• Stridor

• Crackele (rales)

• Ronchi sound ( secretion in large air way).

• Weezes

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Bronchial

• Abnormal when heard over lung tissue

• Indicates an underlying density• Pneumonia with consolidation

• Large tumor

• NOT a pleural effusion

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Crackles

• Coarse– Low-pitched, sounds like the bubbling of air

through liquid– May be heard on inspiration and/or expiration

(usually expiration)– Caused by: Secretions in the airways or fluid or

secretion in the lung – May clear after suctioning or coughing– Abnormality of the lung as pnemonia, fibroses,

early congestive heart failer and bronchites

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Wheezes

• Continuous sound with a musical quality

• May be heard on inspiration and/or expiration (usually expiration only)

• Caused by narrowing of airway lumen (i.e. mucus, edema, bronchospasm or foreign body), heared also in asthma and COPD

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Stridor

• High-pitched wheeze-like sound

• May be heard on inspiration and/or expiration (usually inspiration)

• Caused by narrowing of subglottic area (i.e. inflammation, edema or foreign body)

• More dangerous in children & infants due to smaller airway size

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• If any abnormal sound detected should describe loudness, number, and timimg in respiratory cycle

• Clearing crackles, weezese or rhonchi by couph suggested that secretion caused them

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Voice Sounds( spoken or whispered sound)

• Egophany

• Bronchophony

• Whispered Pectoriloquy

• Increased transmeted voice sound suggested that air-filled lung has becom air less

• Normal should heared muffled and indistinct

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Bronchophony– Auscultate while patient repeats, ―99, 99 …‖

– Sounds are heard more clearly over consolidation

Ego phony: E heared A

Whispered Pectoriloquy– Auscultate while patient repeated whispers,―1-2-3‖

or ―99-99-99‖

– Sounds are heard more clearly over consolidation

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Normal Lung


Atelectasis


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Lobar Pneumonia


Bronchitis


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Emphysema


Asthma


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Pleural Effusion


Congestive Heart Failure (CHF)


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Pneumothorax


Tuberculosis (TB)


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Pulmonary Embolism (PE)


Acute Respiratory Distress Syndrome (ARDS)


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Questions?

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Thoracic and lung - جامعة آل البيت · PDF file · 2015-10-13Thoracic...

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