Transcript Assessment of Thorax and Lungs

Thorax and Lungs
By B.Lokay, MD, PhD
Anterior Thorax
(Suprasternal notch)
Posterior Thorax
Reference Lines
Lobes of Lungs
Lobes of Lungs
Trachea and Pleurae
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Pleurae
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Visceral pleura – lines outside of
lungs, dipping down into the
fissures
Parietal Pleura – lines inside of
chest wall and diaphragm
Lubricating fluid between the
pleurae prevents friction
Trachea and Bronchi
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Transport gasses between
environment and lung
Dead space is space filled with
air (about 150 ml) but not
available for gaseous exchange
Goblet cells in bronchi secrete
mucus that entraps particles
Cilia in bronchi sweep particles
upward
Terms
Developmental
Considerations
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Infants and Children
 When cord is cut, blood is cut off from placenta and rushes into
pulmonary circulation. Due to less resistance in pulmonary
arteries, the foramen ovale closes, along with ductus arteriosus
 Lungs grow until about 300 million alveoli in adolescence
Pregnancy
 The enlarging uterus elevates the diaphragm 4 cm during
pregnancy, but the increased estrogen relaxes thoracic ligaments
allowing compensation by increasing the transverse diameter
 Mother’s tidal volume increases to meet demands of fetus
Aging
 kyphosis
 calcification of costal cartilage
 decreased vital capacity
 decreased number of alveoli
 decreased mucous production
Health History
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Cough
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Onset? Gradual or sudden? Frequency?
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Continuous throughout day – acute illness (respiratory infection)
Afternoon/evening – may reflect exposure to irritants at work
Night – postnasal drip, sinusitis
Early morning – chronic bronchial inflammation of smokers
Sputum? How much? Characteristic?
• Chronic bronchitis – productive cough for 3 months of the year for 2
years in a row
• Characteristics
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White of clear mucoid – colds, viral infection, bronchitis
Yellow or green – bacterial infection
Rust colored – TB, pneumococcal pneumonia
Pink, frothy – pulmonary edema, medications?
Cough up blood?
Description of cough – dry, hacking
Associative and Alleviating factors
Painful?
Health History
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Shortness of Breath (SOB)
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Onset, associative factors
• Determine how much activity precipitates SOB
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Affected by position?
• Orthopnea – difficulty breathing when supine (heart failure?)
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Time of day/night
• Paroxysmal nocturnal dyspnea – awakening from sleep with
SOB and needing to be upright to achieve comfort
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Allergies?
• Asthma attacks
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Alleviating factors
Health History
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Chest pain with breathing?
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Past history of respiratory infections?
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Location, onset, duration, frequency, intensity,
associative and alleviative factors
Bronchitis, emphysema, asthma, pneumonia
Smoking history
Environmental exposure
Self – care behaviors
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Immunizations, TB skin tests, chest X-rays
Assessment - Inspection
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Inspect thorax
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Symmetry
AP diameter
• Normal 1:2
• AP diameter = transverse
diameter, “barrel chest”. Occurs
with normal aging, chronic
emphysema, and asthma
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Symmetry and normal
development of trapezius muscle
• Hypertrophied in COPD
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Position person takes to breathe
• COPD – tripod position
Posterior Chest
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Symmetric chest expansion
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Place warmed hands on
posterolateral chest wall with
thumbs at level of T9 or T10
Slide hands medially to pinch up
a small fold of skin between
thumbs
Ask person to take a deep breath
As person inhales, the thumbs
should move apart symmetrically
• Unequal chest expansion occurs
with atelectasis, pneumonia,
thoracic trauma
• Pain accompanies deep
breathing when pleurae are
inflamed
Tactile Fremitus
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Fremitus is a palpable vibration
transmitted through patent bronchi
and lung parenchyma to the chest
wall where they can be felt as
vibrations
Place either the palmar base of
ulnar edge of one of the hands on
the person’s back and ask to
repeat “ninety-nine.” Start at lung
apices and palpate from one side
to another
Symmetry is most important
Normally, fremitus most prominent
between scapulae and decreases
as you progress down
Abnormalities in Fremitus
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Decreased fremitus occurs when anything obstructs
transmission of vibrations
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Obstructed bronchus
Pleural effusion or thickening
Pneumothorax
Emphysema
Increased fremitus occurs with compression or consolidation
of lung tissue
• Lobar pneumonia
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Rhonchal fremitus – palpable with thick secretions
Crepitus – coarse crackling sensation palpable over skin
surface. Occurs in subQ emphysema when air escapes
from lung and enters subQ tissue
Percussion
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Start at the apices and percuss across
tops of both shoulders and down the
lung region at approx. 5cm intervals
Make a side to side comparison
Avoid damping effect of scapulae and
ribs
Resonance predominates in healthy
lungs
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Hyperresonance is found when too
much air is present (emphysema or
pneumothorax)
Dullness signals abnormal density
(pneumonia, pleural effusion,
atelectasis, tumor)
Expected Percussion Notes
Percussion Notes
Auscultating Posterior Chest
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Breath sounds
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Instruct the person to breathe through
the mouth a little deeper than usual, but
to stop if they feel dizzy.
Hyperventilation may lead to fainting!
Use the flat diaphragm endpiece of the
stethoscope and listen for at least one
full respiration in each location
Continue to think:
• What am I hearing?
• What should I expect to be hearing?
• Bronchial
• Bronchovesicular
• Vesicular
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Do not confuse background noise with
lung sounds
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Stethoscope tubing bumping together
Shivering
Hairy chest
Rustling of gown
Characteristics of Normal
Breath Sounds
Location of Normal Breath
Sounds
Auscultation
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Abnormal Findings
 Decreased breath sounds
• Obstruction of bronchial tree (by secretions, mucous plug, foreign body)
• In emphysema due to loss of elasticity in the lung fibers and decreased
force of inspired air. The lungs are already hyperinflated so not much
air will be coming in.
• Obstruction of sound by pleural thickening
• Silent chest – no air moving in or out
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Increased breath sounds – louder than normal
• Bronchial sounds
• Heard in abnormal location, such as periphery
• High pitched, with prolonged expiratory phase
• Occur in consolidation (pneumonia) or compression (fluid in intrapleural
space). Dense lung tissue enhances transmission of sound.
Auscultating Adventitious
Sounds
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Adventitious sounds
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Sounds not normally heard in the lungs
Caused by moving air colliding with secretions in trachea or
bronchi, or from popping open of previously deflated airways
Crackles (fine)
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Description: popping sounds heard during inspiration. May be
stimulated by rolling a strand of hair between fingers near the
ear
Mechanism: Inhaled air collides with previously deflated
airways. Airways suddenly pop open creating a crackling
sound
Clinical example:
• Early inspiratory – COPD
• Late inspiratory – Pneumonia, heart failure, interstitial fibrosis
Crackles (coarse)
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Description:
• loud, low-pitched, bubbling and gurgling sounds
early in inspiration. Sound like Velcro
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Mechanism:
• Inhaled air collides with secretions in trachea and
large bronchi
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Clinical example:
• Pulmonary edema, pneumonia, pulmonary
fibrosis, depressed cough reflex
Pleural friction rub
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Description:
• Coarse and low pitched superficial sound.
Both inspiratory and expiratory.
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Mechanism:
• Caused when pleurae become inflamed
and lose normal lubricating fluid. Pleural
surfaces rub together during respiration.
Heard best in anterolateral wall.
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Clinical example:
• Pleuritis
Wheeze
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Description
• High pitched musical squeaking sound
predominantly during expiration
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Mechanism
• Air squeezed or compressed through
narrowed airways (collapsing, swelling,
secretions, tumors)
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Clinical example
• Acute asthma or chronic emphysema
Rhonchi (sonorous)
a.k.a. Wheeze
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Description
• Low-pitched, musical snoring
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Mechanism
• Airflow obstruction
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Clinical example
• Bronchitis, obstruction of bronchus from
obstruction or tumor
Stridor
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Description
• High pitched, inspiratory, crowing sound,
louder in neck than over chest wall
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Mechanism
• Originates in larynx or trachea. Upper
airway obstruction from inflamed tissue or
obstruction
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Clinical example
• Croup and acute epiglottitis. Obstructed
airway.
Consolidation or
compression of
voice sounds will
enhance the voice
sounds
Assessing the
Anterior Chest
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Symmetric chest expansion
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Abnormally wide costal
angle occurs with
emphysema
Tactile and vocal fremitus
Percussing and
Auscultating
Anterior Chest
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Begin percussing the apices in
supraclavicular ares, continuing
down in intercostal spaces
Note cardiac and liver dullness
and stomach tympany
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Chronic emphysema leads to
hyperinflation of lungs,
resulting in hyperresonance
where you would expect
cardiac dullness
Auscultate lung fields down to
the 6th rib. Progress from side
to side moving downward and
listen for one full respiration at
each location
Pulmonary Function Test
Forced expiration of 6
seconds or more
occurs with obstructive
lung disease
Developmental Considerations
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Infants
 While infant is sleeping, can inspect and auscultate the lungs
• Infants normally have a rounded thorax, reaching a 1:2
(anteroposterior to transverse) diameter by age 6
• If a barrel shape persists after age 6, possible chronic asthma or
cystic fibrosis
If baby begins to cry, it actually enhances the palpation of
tactile fremitus
Pregnancy
 Wider thoracic cage
Aging
 Kyphosis – outward curvature of thoracic spine
 Calcification of costal cartilages leading to less mobility
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Question 1
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A nurse is caring for a client hospitalized
with acute exacerbation of chronic
obstructive pulmonary disease (COPD).
Which of the following would the nurse
expect to note in evaluating this client?
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2.
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4.
Increased oxygen saturation with exercise
Hypocapnia
A hyperinflated chest on X-ray
A widened diaphragm noted on chest X-ray
Question 2
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A nurse is caring for a client with
acute respiratory distress syndrome
(ARDS). Which of the following
would the nurse expect to note in the
client?
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2.
3.
4.
Decreased respiratory rate
Pallor
Low arterial PaO2
An elevated arterial PaO2
Question 3
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A client has been admitted with chest trauma
after a motor vehicle accident and has
undergone subsequent intubation. A nurse
checks the client when the ventilator’s highpressure alarm sounds, and notes that the
client has absence of breath sounds in the
right upper lobe of the lung. The nurse
immediately assesses for other signs of :
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2.
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4.
Displaced endotracheal tube
Acute respiratory distress syndrome (ARDS)
Pulmonary embolism
Right pneumothorax
Question 4
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A nurse working on a medical respiratory
nursing unit is caring for several clients
with respiratory disorders. The nurse
would determine that which of the following
clients on the nursing unit is at the least
risk for infection with tuberculosis?
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2.
3.
4.
A newly immigrated woman from Korea
An uninsured man who is homeless
An elderly woman admitted from a longterm care facility
A man who is an inspector for the U.S.
Postal Service
Question 5
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A nurse is caring for a patient after a
bronchoscopy and biopsy. Which of
the following signs if noted in the
client should be reported
immediately to the physician?
1.
2.
3.
4.
Blood-streaked sputum
Dry cough
Hematuria
Stridor