Ribs 1-7: Attached directly to the sternum

Ribs 8-10: Attach to the costal cartilage above

Ribls 11-12: Floating

Anterior Thoracic Landmarks:

Suprasternal Notch

Anterior Thoracic Landmarks:

Sternum

Anterior Thoracic Landmarks:

Manubriosternal Angle/ Angle of Louis

Marks site of tracheal bifurcation ito right and left main bronchi

Corresponds with upper border of the atria of the heart

Lies above the 3th vertebra on the back

Anterior Thoracic Landmarks:

Costal Angle

Posterior Thoracic Landmarks:

Vertebra Prominens

Posterior Thoracic Landmarks:

Spinous Process

Posterior Thoracic Landmarks:

12th Rib

* Shorter

* 3 Lobes: Upper (Apex to the 5th rib), Middle (Horizontal fissure to the 6th rib), and the Lower (5th to the 8th

* Narrower

* Only 2 Lobes - no middle lobe

* Posterior chest contains almost all lower lobe

Shorter Anteriorly

Extend further down posteriorly

Visceral: Lines the outside of the lungs and into the fissures

Parietal: Lines the inside of the chest wall and diphragm

Contains lubricating fluid - Acts as a vacuum and normally has negative pressure, which holds the lungs tightly against the chest wall

Causes noise during respiration

Trachea lies in front of the esophagus

* Right main bronchus is shoter, wider and more vertical then the left main bronchus

1. Supply oxygen to the body for energy production

2. Remove CO2 as a waste product

3. Maintain Homeostasis

4. Maintain Heat Exchange

Vertical Diameter Lengthens or Shortens (downward/upward movement of diaphragm)

Anteroposterior diamter Increases or Decreases (elevation or depression of ribs)

 Forced Breathing: Demand the use of accessory neck muscles to heave up the sternum and rib cage; Forced expiration cause the abdominal muscles to contract forcefully against the diaphragm, making it dome upwards and squeeze against the lungs

Inspiration causes the diaphragm to ....

Does this increase or decrease the anteroposterior diameter?

Descend and Flatten

Increases the anteroposterior diameter

Developmental Care

Infants

What is Surfactant?

Developmental Care

Infants

Foramen Ovale

Since the respiratory system is not at work in the placenta, there is no point in pumping all the oxgenated blood through the lungs

2/3 of it is shunted through an opening in the atrial septum (Foramen Ovale) in to the left side of the heart where it is pumped out through the aorta

Closes just after birth

Developmental Care

Infants

Ductus Arteriosus

Since the respiratory system is not at work in the placenta, there is no point in pumping all the oxgenated blood through the lungs - Blood is pumped b the right side of the heart out through the pulmonary artery but is detoured through the ducts arteriosus to the aorta

Closes hours after birth

Developmental Care

Pregnant Female

Increased Tidal Volume

Developmental Care

Aging Adult

Characteristics of an Aging Lung

* Costal cartilages become calcified (less mobile)

* Respiratory msucle strength declines after age 50

* Elastic properties change- larger possibiltiy to collapse

* Loss of intra-alveolar septa and decreased number of alveoli - less surface for gas exchange)

* Increased risk for dyspnea (difficult or labored breathing)

* Risk for postoperative pulmonary complications

Developmental Care

Aging Adult

Vital Capacity vs. Residual Volume

DECREASED Vital Capacity (Max amt of air that a person can expel from the lungs after first filling the lungs to max)

INCREASED Residual Volume (Amt of air remaining in the lungs even after the most forceful expiration)

Difficulty breathing when supine - state number of pillows in discreption:

Ex: 2 pillow orthopnea

Scoliosis (S-Shaped Vertebrae)

Kyphosis (Humpback)

Anteroposterior = Transverse diameter

Results in emphysema

(Ribs are horizontal, chest appears as if held in continuous inspiration)

* Atelectasis: Lungs are not fully inflated

* Pneumonia: Inflammation of Lungs

* Thoracic Trauma

Place hands on the posterolateral chest with thumbs at the level of T9 or T10; Pinch up a small fold of skin between your thumbs; tell person to take deep breath; hands serve as mechanical amplifiers;

When the person inhales, the thumbs should move apart symmetrically

Fremitus is a palpable vibration; sounds are generated from the larynx to the bronchi and through the lung tissue to the chest wall - where you can feel vibrations

Have the patient say 99 and assess for equal vibrations

Palpable with thick bronchial secretions;

A palpable vibration produced during breathing caused by partial airway obstruction. The obstruction can be due to mucus or other secretions in the airway, bronchial hyperreactivity, or tumors.

* Pleural Effusion (Fluid in the space between the visceral and parietal pleura)

* Actelectasis (in the lower lobes)

1. Bronchial

2. Bronchovesicular

3. Vesicular

Expiration > Inspiration

Tracheal: Heard over trachea; Harsh sounds like air being blown through a pipe

Bronchial: Heard over large airways in the anterior chest near 2^nd and 3^rd intercostals; Tubular and hollow-sounding; Loud and high pitch with short pauses between inspiration and expiration; Expiration sound last longer (Expiration > Inspiration)

INSPIRATION = EXPIRATION

1.      Posterior chest between scapulae and center anterior chest; Soft sound with tubular quality (mixed); Sounds are equal during inspiration and expiration (Inspiration = Expiration); Pitch and intensity are more easily detected during expiration

Expiration < Inspiration

Sounds are soft, blowing, or rustling heard in most lung fields (sounds like the wind in trees); heard throughout inspiration and continue with no pause in expiration; fade about one way through expiration (Expiration < Inspiration)

Obstructs

Pleural thickening

1. Bronchial tree is obstructed (by secritions, mucus or foreign object)

2. Emphysema (loss of elasticity)

3. Obstruction of the transmission of ound between the lung and the stethoscope (usually involving the pleural cavity)

Consolidation (ex: Pneumonia) or compression (ex: Fluid in intrapleural space) yields a dense lung area that enhances the transmission of sound from the bronchi;

When inspired air reaches the alveoli, it hits solid lung tissue that conducts sound mroe efficiently to the surface

Fluids in small airways (atelectasis); Crackles are a discountinous of sounds; intermittent; nonmusical; brief; heard on inspiration or expiration; popping sounds are created when air is forced through respiratory passages that are narrowed by fluid, mucus or pus; Crackles are associated with inflammation or infection of small bronchi, bronchioles and alveoli; Crackles that don’t produce a cough indicate pulmonary edema or fluid in the alveoli due to heart failure or adult respiratory distress syndrome

Wheezes

High vs. Low Pitched

Wheezes: Heard throughout inspiration or expiration or both; caused by air moving through airways narrowed by constriction or swelling of airway or partial airway obstruction

 High Pitched: Squeaking quality referred to as silibiant rhonchi; heard continuously through inspiration and expiration; musical quality; occur when airways are narrowed during an acute asthmatic attack

 Low Pitched: Snoring or moaning quality may be referred to as sonorous rhonchi; secretion in large airways such as bronchitis; clear when coughing

1.      Low pitched, grating, creaking sound; Occur when pleural surfaces rub together during respiration; more often heard on inspiration then expiration; easily confused with pericardial friction rub;

a.      Distinguish between pleural or pericardial friction rub, ask patient to hold his breath briefly – if the rubbing sound continues, its pericardial friction rub because the inflamed pericardial layers continue rubbing together with each heart beat; pleural rub stops when breathing stops

Canbe ausculatated over the chest wall just as it can be felt in tactile fremitus; ask the person to repeat the phase 99 - Listen for the presence of bronchophony (abnormal transmission of sound from lungs), egophony (due to enhanced transmission of high-frequency noise across fluid, such as in abnormal lung tissue, with lower frequencies filtered out) and whispered pectoriloquy (an increased loudness of whispering while the physician is listening using a stethoscope on the lung fields on a patient's back.^[1]

Usually sounds of this volume would not be heard when whispered)

What will enhance the voice sounds making the words more distinct?

Consolidation or compression of lung tissue; solidification in a firm dense mass; may contain fluid instead of air

Configurations of the Thorax:

Normal Adult

Configurations of the Thorax:

Barrel Chest

Equal anteroposterior-to-transverse diameter; ribs are horizontal instead of normal downward slope;

Associated with aging and chronic emphysema and asthma (hyperinflation of lungs)

Configurations of the Thorax:

Pectus Excavatum

Configurations of the Thorax:

Pectus Carinatum

Configurations of the Thorax:

Scoliosis

Respiration Patterns:

Purpose of a Sigh

Respiration Patterns:

Tachypnea

Respiration Patterns:

Bradypnea

Respiration Patterns:

Hyperventilation

Increase in rate ad depth; occurs with extreme exertion, fear or anxiety; Could also occur with diabetic ketoacidosis, hepatic coma, salicylate overdose, lesions of the midbrain, alteration in blood gas concentration;

Hyperventilation blows off CO2, causing a decreasedl level in the blood (alkalosis)

Respiration Patterns:

Hypoventilation

Respiration Patterns:

Cheyne-Stokes Respiration

Cycle in which respirations increase in rate and depth and then decrease; breathing periods last 30-45 seconds; Periods of apnea (20 seconds); Common cause is severe heart failure or renal failure, meningitis, drug overdose and increased intracranial pressure;

Occurs normally in infants and elderly while sleeping

Respiration Patterns:

Biot's Respiration

Excessive Drowsiness or by anxiety, restlessness and irritability

(Cerebral Hypoxia is deprivation of oxygen to the brain)

Cutaneous angiomas are ... ?

What are they associated with?

Can they be evident on the chest?

1. Cutaneous angiomas are benign tumors on the skin (made of blood vessels)

2. Are associated with liver disease or portal hypertension

3. Yes, they can be evident on the chest

1. Part of the lung is Obstructed

2. Part of the lung collapsed (Pneumonia)

1. Ideally, have a tech or another RN supporting the person in an upright position

2. If no one is available, role the patient from side to side (this limits the ability to compare symmetry)

*Decreased chest expansion

*Increased anteroposterior diameter (creating a barre chest appearance)

*Kyphosis: Outward curvature of the spine (observation: Person may be holding their head backwards)

*Fatigue during auscultation - allow brief rest periods to prevent hyperventilation

Infant & Children

Normal Chest Diameters

Under 6: Barrel Chest

Over 6: Normal 1:2 Anterioposterior:Transverse diameter

Infant & Children

Harrison Groove

Infant & Children

Apgar Scoring System

What is the Apgar Scoring System?

When is it tested?

What does it measure?

1st Respiratory Assessment: It measures the succcessful transition to extrauterine life.

Performed at 1 and 5 minutes of life.

1-Minute Apgar Test indicates a newborn isin good condition if the baby only needs suctioning of the nose and mouth

Apgar Scoring System Assess:

1. Heart Rate

2. Respiratory Effort

3. Muscle Tone

4. Reflex Irritability (response to cathater nares)

5. Color

Infant & Children

Apgar Scoring System

Immeidate newborn depressed respirations are due to ...

1. Maternal drugs

2. Interruption of the uterine blood supply

3. Obstruction of the tracheobronchial tree with mucus or fluid

Infant & Children

Apgar Scoring System

Apgar Score of 0-2 Requires ...

Infant & Children

A newborn breaths through their _____ .

What is the major Respiratory Muscle involved in newborn Respiration?

1. Nose (no flaring of nostrils, normal)

2. Diaphgragm (intercostal muscles are not well develop; the newborn abdomen moves with every breath)

Infant & Children

Retractions of the sternum and intercostal muscles indicate ...

Increased Inspiratory effort

(atelectasis, pneumonia, asthma, acute airway obstruction)

Infant & Children

Infant Breath Rates

What is normal?

What is abnormal?

What is a normal respiratory rate per minute for an infant with early signs of heart failure?

1. Normal: 30-40 Breaths per Minutes

2. Abnormal: 60+ breaths per minute (may accompany pneumonia, fever, pain, heart disease, anemia)

3. An infant with tachypnea of 50100 per minutes while sleeping may have early stages of Heart Failure

Infant & Children

When will crepitus be palpable in a newborn?

Infant & Children

What is Rachitic Rosary?

Infant & Children

True or False

Percussion is useful in the newborn Respiratory Assessment.

False. Percussion is useless in the newborn because the adult's fingers are too large

The only thing that can be percussed is HYPERRESONANCE in infants with thin chest walls.

Infant & Children

What is the normal breath sound of child?

Bronchovesicular

Deminished breath sounds occur with Pneumonia, atelectasis, pleural effusion or pneumothorax

Infant & Children

Why do crackles occur in newborns?

Opening of the airways and clearing of the fluid.

Crackling can be heard loud in the stethescope because of thin chest walls - makes it difficult to hear actual respiration

Infant & Children

Crackles in upper lung field occur with ....

Infant & Children

Crackles in lower lung field occur with ....

Infant & Children

What sounds are heard with pneumonia, bronchiolitis, or atelectasis?

Infant & Children

Wheezing occurs with ...

Infant & Children

Persistnent Peristalic sounds with diminished breath sounds indicated ....

Left Sided heart failure: Tachypnea (increased rate of breathing) and increased work of breathing; Rales or crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli); Cyanosis which suggests severe hypoxemia, is a late sign of extremely severe pulmonary edema

Bioventricular Failure: Dullnesss of lung fields during percussion and reduced breathing sounds due to pleural effusion (fluid collection in between the lung and the chest wall).

Dr. Davenport, Lecture Question

Active vs. Passive

Inspiration: Active

Expiration: Passive

* Emphyzema patients have problems with expiration

Dr. Davenport, Lecture Question

What blood vessels nourish the lungs?

Dr. Davenport, Lecture Question

What blood vessels remove blood from the tissue?

Dr. Davenport, Lecture Question

What Point do the Lobes Come Together (T#)?

Where do the lungs end (T#)?

Where does lung excursion occur (T#-T#)?

T3 Thoraic Vertebrae – Point where the Lobes come together

T10 – End of lungs

T12 – Lung excursion is from T10 to T12

Dr. Davenport, Lecture Question

What is Hypoventilation?

Why is Hypocapnia?

Hypoventilation – not getting rid of enough CO2

  Fast Rate – breathing so fast – not allowing for adequate gas exchange

  Or lungs are ineffective organs – unable to give gas exchange

Hypoventilation = Hypocapnia

Dr. Davenport, Lecture Question

What is Crepitus?

What does it feel like?

What is different crepitus feature on men?

What is crepitus? – Popping sound – May be a punctured Lung (Called Anumothorax) – Air that gets out of the lung and rest in skin tissue – will feel crunchy during palpating – Its SubQ Air or SubQ Emphazema

  Note where the crepitus – men get incredibly large testicles and penis – because of escaped air

  Feels – like bubble wrap that is easy to pop

  Patient will need something to fix the hole in their lungs

Dr. Davenport, Lecture Question

Notes from lecture of Adventitious Sounds

Rhonchi are both inspiratory and expiratory but predominate during expiration

Crackles = Pulmanary Edema – Fluid flowing back into lungs

Rhonchi – Mucusy – Ammonia – cleared with coughing, because it can be cleared with coughing

  Someone with emphazema or bronchitis – often sound they will have is Rhonchi

Wheezing – Asthma – Narrowing of the air ways

Stridor – upper airway obstruction – EMERGENCY

  Baby inhales an M&M

Dr. Davenport, Lecture Question

When to use Bronchophony?