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Surface landmarks of the lungs.

Each lung is conical; the apex is rounded and extends anteriorly about 4 cm above the first rib into the base of the neck in adults.  Posteriorly, the apices of the lungs rise to about the level of T1.  The lower borders descend on deep inspiration to about T12 and rise on forced expiration to about T9.  The base of each lung is broad and concave, resting on the convex surface of the diaphragm.  The medial surfaces of the lung are to some extent concave, providing a cradle for the heart.  The tracheobronchial tree is a tubular system that provides a pathway for air to move from the upper airway to the farthest alveolar reaches.  The trachea is 10 to 11 cm long and about 2 cm in diameter.  It lies anterior to the esophagus and posterior to the isthmus of the thyroid.  The trachea divides into the right and left main bronchi at about the level of T4 or T5 and just below the manubriosternal joint.

 

Major landmarks of the thorax.

Anatomic landmarks

·   The nipples

·   The manubriosternal junction (angle of Louis):  a visible and palpable angulation of the sternum and the point at which the second rib articulates with the sternum.  One can count the ribs and intercostal spaces from this point.  The number of each intercostal space corresponds to that of the rib immediately above it.

·   The suprasternal notch:  a depression, easily palpable and most often visible at the base of the ventral aspect of the neck, just superior to the manubriosternal junction.

·   Costal angle:  the angle formed by the blending together of the costal margins at the sternum.  It is usually no more than 90 degrees, with the ribs inserted at approximately 45-degree angles.

·   Vertebra prominens:  the spinous process of C7.  It can be more readily seen and felt with the patient’s head bent forward.  If two prominences are felt, the upper is that of the spinous process of C7, and the lower is that of T1.  It is difficult to use this as a guide to counting ribs posteriorly, because the spinous processes from T4 down project obliquely, thus overlying the rib below the number of its vertebra.

·   The clavicles

 

 

Landmark lines

·   Midsternal line: vertical line down the midline of the sternum

·   Right and left midclavicular lines:  parallel to the midsternal line, beginning at midclavicle; the inferior borders of the lungs generally cross the sixth rib at the midclavicular line

·   Right and left anterior axillary lines:  parallel to the midsternal line, beginning at the anterior axillary folds

·   Right and left midaxillary lines:  parallel to the midsternal line, beginning at the midaxilla

·   Right and left posterior axillary lines:  parallel to the midsternal line, beginning at the posterior axillary folds

·   Vertebral line:  vertically down the spinal processes

·   Right and left scapular lines:  parallel to the vertebral line, through the inferior angle of the scapula when the patient is erect

 

  Major symptoms of pulmonary disease in children, adults, pregnant women and older adults.

Adults

·   Coughing

·   Shortness of breath

·   Chest pain

Infants and Children

·   Coughing or difficulty breathing of sudden onset

·   Difficulty feeding:  increased perspiration, cyanosis, tiring quickly, disinterest in feeding, inadequate weight gain

·   Apneic episodes

Pregnant Women

·   Coughing

·   Shortness of breath

Elderly adults

·   Difficulty swallowing

·   Cough, dyspnea on exertion, shortness of breath

·   Fatigue, fever, night sweats

·   Significant weight changes 

 

The four basic components of the thorax and lung examination.

INSPECTION

Inspect the chest, front and back, noting thoracic landmarks, for the following:

­ Size and shape (anteroposterior diameter compared with transverse diameter)

­ Symmetry

­ Color

­ Superficial venous patterns

­ Prominence of ribs

Evaluate respirations for the following:

­ Rate

­ Rhythm and pattern

Inspect chest movement with breathing for the following:

­ Symmetry

­ Bulging

­ Use of accessory muscles

Note any audible sounds with respiration

PALPATION

Palpate the chest for the following:

­ Symmetry

­ Thoracic expansion

­ Pulsations

­ Sensations such as crepitus, grating vibrations

­ Tactile fremitus

PERCUSSION

Perform direct or indirect percussion on the chest, comparing sides, for the following:

­ Diaphragmatic excursion

­ Percussion tone intensity, pitch, duration, and quality

AUSCULTATION

Auscultate the chest with the stethoscope diaphragm, from apex to base, comparing sides for the following:

­ Intensity, pitch, duration, and quality of expected breath sounds

­ Unexpected breath sounds (crackles, wheezes, rhonchi, friction rubs)

­ Vocal resonance

 

Barrel chest and its significance.

The barrel chest results from loss of muscle strength in the thorax and diaphragm, coupled with the loss of lung resiliency.  The ribs are more horizontal, the spine is somewhat kyphotic, and the sternal angle more prominent.  The trachea may be posteriorly displaced.  The barrel chest results from compromised respiration due to chronic asthma, emphysema, or cystic fibrosis.

 

Pectus carinatum and pectus excavatum.

Pectus carinatum (pigeon chest) is a prominent sternal protrusion

Pectus excavatum (funnel chest) is an indentation of the lower sternum above the xiphoid process.

 

Symptoms of abnormal breathing including dyspnea, orthopnea, paroxysmal nocturnal dyspnea, and tachypnea and describe their potential significance.

• Dyspnea:  difficult and labored breathing with shortness of breath, commonly observed with pulmonary or cardiac compromise

• Orthopnea:  shortness of breath that begins or increases when the patient lies down

• Paroxysmal nocturnal dyspnea:  a sudden onset of shortness of breath after a period of sleep

• Tachypnea:  a persistent respiratory rate approaching 25 respirations per minute, is often a symptom of protective splinting from pain of a broken rib or pleurisy.  Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern.

 

Abnormal patterns of breathing including bradypnea, Kussmaul, hyperpnea, Cheyne-Stokes, Biot respiration and their potential significance.

·         Bradypnea:  a rate slower than 12 respirations per minute, may indicate neurologic or electrolyte disturbance, infection, or a sensible response to protect against the pain of pleurisy or other irritative phenomena.  It may also indicate a splendid level of cardiovascular fitness

·         Kussmaul breathing:  always deep and most often rapid, indicates respiratory effort associated with metabolic acidosis

·         Hyperpnea:  laborious, rapid, and deep breathing, may be caused by exercise and anxiety. May also be caused by central nervous system and metabolic disease

·         Cheyne-Stokes breathing:  a regular pattern of breathing, with intervals of apnea followed by a crescendo/decrescendo sequence of respiration.  Occurs in children and older adults during sleep. Otherwise it occurs in patients who are seriously ill, particularly those with brain damage at the cerebral level or with drug-caused respiratory compromise.

·         Biot respiration:  somewhat irregular respirations varying in depth and interrupted by intervals of apnea, but lacking the repetitive pattern of Cheyne-Stokes. Usually associated with severe and persistent increased intracranial pressure, respiratory compromise resulting from drug poisoning, or brain damage at the level of the medulla.

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Retractions and their significance.

Retractions suggest an obstruction to inspiration at any point in the respiratory tract.  As intrapleural pressure becomes increasingly negative, the musculature “pulls back” in an effort to overcome blockage.  Any significant obstruction makes the retraction observable with each inspiratory effort.

 

Stridor and its significance.

Stridor is a high-pitched, noisy respiration.  A sign of obstruction that is high in the respiratory tree, especially in the trachea or larynx.  Breathing is characterized by stridor, and the chest wall seems to cave in at the sternum, between the ribs, at the suprasternal notch, above the clavicles, and at the lowest costal margins.

 

Crepitus and its potential significance.

In palpation, crepitus is a crackly or crinkly sensation that can be both palpated and heard.  It indicates air in the subcutaneous tissue from a rupture somewhere in the respiratory system or by infection with a gas-producing organism.  It may be localized or cover a wider area of the thorax, usually anteriorly and toward the axilla.  Crepitus is always a sign requiring attention.

 

The significance of decreased or increased fremitus.

Decreased or absent fremitus may be caused by excess air in the lungs or may indicate emphysema, pleural thickening or effusion, massive pulmonary edema, or bronchial obstruction.

Increased fremitus occurs in the presence of fluids or a solid mass within the lungs and may be caused by lung consolidation, heavy but non-obstructive bronchial secretions, compressed lung, or tumor.

 

The significance of tracheal deviation.

The trachea may be deviated because of problems within the chest and may, on occasion, seem to pulsate.  It may be displaced by atelectasis, thyroid enlargement, significant parenchymal and /or pleural fibrosis, or pleural effusion, and may be pushed to one side by tension pneumothorax, a tumor, or nodal enlargements on the contralateral side, or pulled by a tumor on the side to which it deviates.  Anterior mediastinal tumors may push it posteriorly; with mediastinitis, the trachea may be pushed forward.

 

 

The significance of hyperresonance and dullness to percussion.

Hyperresonance associated with hyperinflation may indicate emphysema, pneumothorax, or asthma.

Dullness or flatness suggests atelectasis, pleural effusion, pneumothorax, or asthma. 

 

Examination for diaphragmatic excursion and the normal results.

·   Ask the patient to inhale deeply and hold

·   Percuss along the scapular line until you locate the lower border, the point marked by change in note from resonance to dullness

·   Mark the point.  Allow the patient to breathe, and then repeat the procedure on the other side.

·   Ask the patient to take several breaths and then to exhale as much as possible and hold.

·   Percuss up from the marked point and make a mark at the change from dullness to resonance.  Remind the patient to start breathing.  Repeat on other side.

·   Measure and record the distance in centimeters between the marks on each side.  The excursion distance is usually 3 to 5 cm.

 

The three normal breath sounds and their normal locations.

·   Vesicular:  Heard over most of lung fields; low pitch; soft and short expirations; will be accentuated in a thin person or a child, and diminished in the overweight or very muscular patient.

·   Bronchovesicular:  Heard over main bronchus area and over upper right posterior lung field; medium pitch; expiration equals inspiration.

·   Bronchial/tracheal:  Heard only over trachea; high pitch; loud and long expirations, often somewhat longer than inspiration.

 

Amphoric and cavernous breathing and the potential significance of these breath sounds.

·   Amphoric breathing:  resembles the noise made by blowing across the mouth of a bottle, is most often heard with a large, relatively stiff-walled pulmonary cavity or a tension pneumothorax with bronchopleural fistula.

·   Cavernous breathing:  sounds as if it were coming from a cavern, is commonly heard over a pulmonary cavity in which the wall is rigid.

 

Abnormal breath sounds, wheezes, crackles, rhonchi and pleural friction rub and their potential significance.

·   Wheeze:  a continuous, high-pitched, musical sound, almost a whistle, heard during inspiration or expiration.  It is caused by high-velocity air flow through a narrowed airway.  A bilateral wheeze may be caused by asthma or bronchitis.  A unilateral or sharply localized wheeze or stridor may indicate a foreign body.  A tumor can create a consistent wheeze of single pitch at the site of compression.

·   Crackles:  discrete discontinuous sounds, each lasting just a few milliseconds.  May be fine, high-pitched, and relatively short in duration or may be coarse, low-pitched and long in duration.  Are caused by disruptive passage of air through the small airways in the respiratory tree.

·   Rhonchi:  (sonorous wheezes) deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles.  Are caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure.  Rhonchi tend to disappear after coughing, whereas crackles do not.

·   Pleural friction rub:  occurs outside the respiratory tree, has a dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration.  May have a machine-like quality.  Has no significance if heard over the liver or spleen.  A friction rub heard over the heart or lungs is caused by inflamed, roughened surfaces rubbing together.  Over the pericardium, this sound suggests pericarditis; over the lungs, pleurisy.  The respiratory rub will disappear when breath is held.  The cardiac rub will not.

 

Bronchophony, whispered pectoriloquy, egophony and their potential significance.

(These auditory changes may be present in any condition that consolidates lung tissue.)

·   Bronchophony:  during auscultation, spoken sounds are heard with greater clarity and increased loudness

·   Whispered pectoriloquy:  extreme bronchophony in the presence of consolidation of the lungs, even whisper can be heard clearly through the stethoscope

·   Egophony:  when the intensity of the spoken voice is increased and there is a nasal quality (e’s sound like stuffy broad a’s)

 

The respiratory examination of the newborn infant.

The approach to examination of the chest and lungs of the newborn follows a sequence similar to that for adults.  Percussion, however, is usually unreliable.  Use Apgar score.   

 

Physical findings associated with common abnormalities to include asthma, atelectasis, chronic obstructive pulmonary disease, emphysema, pleural effusion, pneumonia, and pneumothorax.

Condition	Inspection	Palpation	Percussion	Auscultation
Asthma	Tachypnea, Dyspnea	Tachycardia, diminished fremitus	Occasional hyperresonance, occasional limited diaphragmatic descent	Prolonged expiration,  wheezes, diminished lung sounds
Atelectasis	Delayed or diminished chest wall movement, narrowed intercostals spaces on affected side Tachypnea	Diminished fremitus, apical cardiac impulse is deviated ipsilaterally, trachea is deviated ipsilaterally	Dullness over affected lung	In upper lobe: bronchial breathing, egophony, whispered pectoriloquy In lower lobe:  diminished or absent breath sounds
COPD	Respiratory distress, audible wheezing, cyanosis, distention of neck veins, peripheral edema, and finger clubbing (rarely)	Limited mobility of diaphragm, diminished vocal fremitus	Occasional hyperresonance	Post-pertussive rhonchi, sibilant wheezing, inspirational crackles, breath sounds somewhat diminished
Emphysema	Tachypnea, deep breathing, pursed lips, barrel chest, thin, underweight	Apical impulse may not be felt, liver edge displaced down, diminished fremitus	Hyperresonance, limited descent of diaphragm on inspiration, upper border of liver dullness pushed down	Diminished breath and voice sounds with occasional prolonged expiration, diminished audibility of heart sounds, occasional adventitious sounds
Pleural effusion	Diminished and delayed respiratory movement on affected side	Diminished respiratory movement on affected side, cardiac apical impulse is shifted contralaterally, trachea shifted contralaterally, diminished fremitus, tachycardia	Dullness, hyperresonant note in area superior to effusion	Diminished to absent breath sounds, bronchophony, whispered pectoriloquy, egophony in area superior to effusion, occasional friction rub
Pneumonia	Tachypnea, shallow breathing, flaring of alae nasi, occasionally cyanosis, limited movement at times on involved side, splinting	Increased fremitus in presence of consolidation,  decreased fremitus in presence of a concomitant empyema or pleural effusion	Dullness of consolidation is great	Various crackles and occasional rhonchi, bronchial breath sounds, egophony, bronchophony, whispered pectoriloquy
Pneumothorax	Tachypnea, cyanosis, respiratory distress, bulging intercostals spaces, respiratory lag on affected side, tracheal deviation	Diminished to absent fremitus, Cardiac apical impulse, trachea, and mediastinum shifted contralaterally Diminished tactile fremitus, tachycardia	Hyperresonance	Diminished to absent breath sounds, succusion splash audible if air and fluid mix, sternal and precordial clicks and crackling if air underlies that area, diminished to absent whispered voice sounds

 

Clinical presentation of croup vs. epiglottitis.

Croup:

It occurs most often in very young children, generally from about 1.5 to 3 years of age.  Boys are more frequently affected than girls and some children are prone to recurrent episodes.  Episodes often occur in the evening.  The child awakens suddenly, often very frightened, with a harsh stridorous cough, somewhat like the bark of a seal.  Labored breathing, retraction, and inspiratory stridor are characteristic.  Fever does not always accompany croup.  Children with croup may be frightened, but they do not have the toxic, drooling facies of persons with epiglottitis.

Epiglottitis:

An acute, life-threatening disease almost always caused by Haemophilus influenzae type B.  It begins suddenly and progresses rapidly, often to full obstruction of the airway resulting in death.  It may occur at any age, but occurs most often in children between the ages of 3 and 7.  The child sits straight up with neck extended and head held forward, appears, very anxious and ill, is unable to swallow, and is drooling from an open mouth; cough is not common.  The fever may be high.  The epiglottis appears beefy red.  It is vital not to attempt to visualize the epiglottis.  Any suspicion of epiglottitis should be treated as medical emergency.

 

Empyema

Empyema is defined as fluid collected in the pleural spaces that is a purulent exudate, arising most commonly from adjacent infected, sometimes traumatized tissues.  It may be complicated by pneumonia, a penetrating injury, simultaneous pneumothorax, or bronchopleural fistulae.  Breath sounds are distant or absent in the affected area, the percussion note is dull, vocal fremitus is absent, and the patient is often febrile and tachypneic and appears ill.

 

The presentation of a lung abscess.

A lung abscess is a well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis.  It may at first appear to be a localized pneumonia, and it may elude diagnosis for a long time unless it invades a bronchus so that resulting drainage will allow detection of an air-fluid level.  The percussion note is dull and the breath sounds distant or absent over the affected area.  There may be a pleural friction rub, and cough may produce a purulent, foul-smelling sputum.  The patient is usually obviously ill and febrile, sometimes tachypneic.  The breath commonly has a foul odor.

 

The clinical presentation of cystic fibrosis.

Salt loss in sweat is distinctive.  Heavy secretions of abnormally thick mucus cause progressive clogging of the bronchi and bronchioles, leading to frequent and progressive pulmonary infections.  Initially, areas of hyperinflation and atelectasis are evident.  As pulmonary dysfunction progresses, the tolerance for exercise diminishes and pulmonary hypertension and cor pulmonale often occur.