GOOD MORNING GOOD MORNING

TO TO

YOU ALL YOU ALL

ANTERIOR/ANTERIOR/POSTERIOR CHESTPOSTERIOR CHEST

PREPARED BY ESTHER N. RIVERAPREPARED BY ESTHER N. RIVERA

Thoracic Cage – is the entire/outer structure Thoracic Cage – is the entire/outer structure of the thorax.of the thorax.

= is a bony structure with a conical shape = is a bony structure with a conical shape which is narrower at the top.which is narrower at the top.

= it provides support and protection for = it provides support and protection for many important organsmany important organs

= is constructed of the = is constructed of the SternumSternum 12 pairs of ribs12 pairs of ribs 12 thoracic vertebrae12 thoracic vertebrae MusclesMuscles CartilageCartilage= it is narrower at its superior end and = it is narrower at its superior end and

broader at its inferior end and is flattened broader at its inferior end and is flattened from front to backfrom front to back

(Tortora: 222)(Tortora: 222)

ANTERIOR THORACIC ANTERIOR THORACIC LANDMARKLANDMARK

1. Suprasternal notch – is an important 1. Suprasternal notch – is an important landmarklandmark

= a U-shaped indentation located on the = a U-shaped indentation located on the superior border of the manubrium or superior border of the manubrium or joint just above the sternum in joint just above the sternum in between the clavicles.between the clavicles.

2. Sternum – “breastbone”2. Sternum – “breastbone”= flat bone which lies in the center of the = flat bone which lies in the center of the

chest anteriorlychest anteriorly= measures about 15 cm (6 inches) in = measures about 15 cm (6 inches) in

lengthlength= it is attached to the first 7 ribs= it is attached to the first 7 ribs

3 parts:3 parts:a. Manubrium – the superior part a. Manubrium – the superior part =articulates with the costal cartilage of the 1st and =articulates with the costal cartilage of the 1st and

the 2the 2ndnd ribs ribsb. The body – the middle and the largest partb. The body – the middle and the largest part=articulates directly or indirectly with the costal =articulates directly or indirectly with the costal

cartilage of the 2cartilage of the 2ndnd through the 10 through the 10thth ribs ribsc. Xiphoid process – the inferior and the smallest partc. Xiphoid process – the inferior and the smallest part= no ribs are attached to it the xiphoid process = no ribs are attached to it the xiphoid process

provides attachment for some abdominal musclesprovides attachment for some abdominal muscles

3. Costal Angle - the right and left costal margins form 3. Costal Angle - the right and left costal margins form an angle where they meet at the xiphoid processan angle where they meet at the xiphoid process

= usually 90 degrees or less, this angle increases = usually 90 degrees or less, this angle increases when the rib cage is chronically over inflated as when the rib cage is chronically over inflated as its emphysemaits emphysema

4. Manusbriosternal angle or sternal angle4. Manusbriosternal angle or sternal angle= also called the “angle of Louis”= also called the “angle of Louis”= this is the articulation of the manubrium and the = this is the articulation of the manubrium and the

body of the sternum and it is continuous with the body of the sternum and it is continuous with the 22ndnd rib and becomes a reference point for counting rib and becomes a reference point for counting ribs and intercostal spaces (Jarvis, 448)ribs and intercostal spaces (Jarvis, 448)

5. Intercostal spaces – are the spaces in between the 5. Intercostal spaces – are the spaces in between the ribsribs

6. Ribs – the 12 pairs of ribs give the structural 6. Ribs – the 12 pairs of ribs give the structural support to the sides of the thoracic cavitysupport to the sides of the thoracic cavity

= constitute the main structures of the thoracic cage= constitute the main structures of the thoracic cage= they are numbered superiorly to inferiorly, the = they are numbered superiorly to inferiorly, the

uppermost pair is number oneuppermost pair is number one= each pair of ribs has a corresponding pair of ICS = each pair of ribs has a corresponding pair of ICS

located immediately inferior to itlocated immediately inferior to it

= anteriorly, the first 7 pairs articulate with = anteriorly, the first 7 pairs articulate with the sternum by way of costal cartilagesthe sternum by way of costal cartilages

= the first pair of ribs curves up immediately = the first pair of ribs curves up immediately under the clavicle, so only a small portion of under the clavicle, so only a small portion of these ribs and 1these ribs and 1stst interspaces are palpable interspaces are palpable

= ribs 2 to 6 are easy to count anteriorly= ribs 2 to 6 are easy to count anteriorly= ribs 7 to 10 connect to the cartilages of the = ribs 7 to 10 connect to the cartilages of the

pair lying superior to them rather than to pair lying superior to them rather than to the sternumthe sternum

= 11= 11thth and 12 and 12thth ribs are floating ribs” because ribs are floating ribs” because they do not connect to either the sternum they do not connect to either the sternum or another pair anteriorly, they are attached or another pair anteriorly, they are attached posteriorly to the vertebra and their posteriorly to the vertebra and their anterior tips are free and palpableanterior tips are free and palpable

= posteriorly, each pair of ribs articulates = posteriorly, each pair of ribs articulates with the respective thoracic vertebrawith the respective thoracic vertebra

= the ribs are more difficult to palpate = the ribs are more difficult to palpate posteriorly posteriorly

( :297)( :297)

7. Clavicle – or the collar bone7. Clavicle – or the collar bone

= a slender, doubly curved bone= a slender, doubly curved bone

= it attaches to the manubrium of the = it attaches to the manubrium of the sternum to the acromion of the scapulasternum to the acromion of the scapula

= it acts as a brace to hold the arm away = it acts as a brace to hold the arm away from the top of the thorax and helps from the top of the thorax and helps prevent shoulder disclocationprevent shoulder disclocation

POSTERIOR THORACIC POSTERIOR THORACIC LANDMARKLANDMARK

1. C 7 or vertebra prominens1. C 7 or vertebra prominens= the most prominent bony spur = the most prominent bony spur

protruding at the base of the neck protruding at the base of the neck when the head is flexedwhen the head is flexed

2. Spinous process2. Spinous process= single projection arising from the = single projection arising from the

posterior aspect of the vertebral archposterior aspect of the vertebral arch= it alligns with their same numbered ribs = it alligns with their same numbered ribs

only down to T4only down to T4= after T4, the spinous processes angle = after T4, the spinous processes angle

downward from their vertebral body downward from their vertebral body and overlies the vertebral body and rib and overlies the vertebral body and rib belowbelow

3. Scapula – or the shoulder blades3. Scapula – or the shoulder blades= they are triangular and are commonly = they are triangular and are commonly

called “wings”called “wings”= it is not directly attached to the axial = it is not directly attached to the axial

skeletonskeleton 2 important processes:2 important processes:a.a. Acromion - connects with the clavicle Acromion - connects with the clavicle

laterally at the acromioclavicular laterally at the acromioclavicular jointjoint

b.b. Coracoid – the beaklikeCoracoid – the beaklike= points over the top of the shoulder = points over the top of the shoulder

and anchors some of the muscles of and anchors some of the muscles of the joints (Jarvis:449)the joints (Jarvis:449)

REFERENCE LINEREFERENCE LINEANTERIOR CHESTANTERIOR CHEST

1.Midsternal line1.Midsternal line

= passes through= passes through

the center of the the center of the

sternumsternum

2. Midclavicular line2. Midclavicular line

=an imaginary line =an imaginary line

that descends from that descends from

the middle of the the middle of the

clavicle(Smeltzer:447)clavicle(Smeltzer:447)

POSTERIOR CHESTPOSTERIOR CHEST

1. Vertebral line1. Vertebral line

= also called spinal= also called spinal

lineline

= overlies the = overlies the

spinous processesspinous processes

of the vertebraeof the vertebrae

2. Scapular line2. Scapular line

= drops from the = drops from the

inferior angle of the inferior angle of the

scapula (Bickley:212)scapula (Bickley:212)

LATERAL CHESTLATERAL CHEST1. Anterior axillary line1. Anterior axillary line= line extends from= line extends fromthe anterior axillarythe anterior axillaryfold where the pectoralisfold where the pectoralismajor muscle insertsmajor muscle inserts2. Posterior axillary line2. Posterior axillary line= continues down from= continues down fromthe posterior axillary foldthe posterior axillary foldwhere latissimus dorsiwhere latissimus dorsimuscle inserts(Smeltzer:477)muscle inserts(Smeltzer:477)3. Midaxillary line3. Midaxillary line= runs down from the apex= runs down from the apexof the axilla and lies between of the axilla and lies between and parallel to the other and parallel to the other two(Jarvis:450)two(Jarvis:450)

THE THORACIC CAVITYTHE THORACIC CAVITY

Mediastinum – is the middle section of the Mediastinum – is the middle section of the thoracic cavity containing the thoracic cavity containing the esophagus, trachea, heart and the great esophagus, trachea, heart and the great vesselsvessels

= the right and the left pleural cavities, on = the right and the left pleural cavities, on either side of the mediastinum contains either side of the mediastinum contains the lungsthe lungs

Lungs – are two coned-shaped, elastic Lungs – are two coned-shaped, elastic structure suspended within the thoracic structure suspended within the thoracic cavity (Jarvis:457)cavity (Jarvis:457)

= are paired but not precisely symmetric = are paired but not precisely symmetric structuresstructures

= the right lung is shorter than the left = the right lung is shorter than the left lung because of the underlying liverlung because of the underlying liver

= the left lung is narrower than the right = the left lung is narrower than the right lung because the heart bulges to the leftlung because the heart bulges to the left

= at the point of the midclavicular line on = at the point of the midclavicular line on the anterior surface of the thorax, the the anterior surface of the thorax, the lung extends approximately to the 6lung extends approximately to the 6thth rib rib

= laterally, lung tissue reaches the level = laterally, lung tissue reaches the level of the 8of the 8thth rib rib

= posteriorly, the lung base lies at about the = posteriorly, the lung base lies at about the 1010thth rib rib

= the right lung has 3 lobes= the right lung has 3 lobes

= the left lung has 2 lobes (Jarvis:452)= the left lung has 2 lobes (Jarvis:452)

IN A HEALTHY ADULTS, DURING DEEP IN A HEALTHY ADULTS, DURING DEEP INSPIRATION, THE LUNGS EXTEND DOWN INSPIRATION, THE LUNGS EXTEND DOWN TO THE 8TO THE 8THTH ICS ANTERIORLY AND 12 ICS ANTERIORLY AND 12THTH POSTERIORLYPOSTERIORLY

DURING EXPIRATION, LUNGS RISE TO THE DURING EXPIRATION, LUNGS RISE TO THE 55THTH OR 6 OR 6THTH ICS ANTERIORLY AND 10 ICS ANTERIORLY AND 10THTH ICS ICS POSTERIORLY ( :300)POSTERIORLY ( :300)

TRACHEATRACHEA

= is a flexible structure that lies anterior = is a flexible structure that lies anterior to the esophagusto the esophagus

= begins at the level of the cricoid = begins at the level of the cricoid cartilage in the neckcartilage in the neck

= is approximately 10 to 12 cm long = is approximately 10 to 12 cm long (adult)(adult)

= help to maintain the shape and prevent = help to maintain the shape and prevent its collapse during respiration its collapse during respiration ( :301)( :301)

BRONCHIBRONCHI

= both bronchi are at an oblique position in = both bronchi are at an oblique position in the mediastinum and enter the lungs at the the mediastinum and enter the lungs at the hilumhilum

= the right main bronchus is shorter and = the right main bronchus is shorter and more vertical than the leftmore vertical than the left

= the left bronchus is narrower and extends = the left bronchus is narrower and extends at more of right angle of the tracheaat more of right angle of the trachea

The trachea and the bronchi represent The trachea and the bronchi represent “dead space” in the respiratory system“dead space” in the respiratory system

= they function primarily as a passageway = they function primarily as a passageway for both inspired and expired air ( Phipps: for both inspired and expired air ( Phipps: 979)979)

LUNGS BORDERSLUNGS BORDERSANTERIORANTERIOR

1. Apex – extends slightly above the clvicle1. Apex – extends slightly above the clvicle

= highest point of lung tissue is 3- 4 cm above the = highest point of lung tissue is 3- 4 cm above the inner third of the clavicleinner third of the clavicle

2. Base – the broad lung area resting on the 2. Base – the broad lung area resting on the diaphragm at the 6diaphragm at the 6thth rib in the midclavicular line rib in the midclavicular line (Jarvis: 452)(Jarvis: 452)

POSTERIORPOSTERIOR

1.1. C 7 – marks the apex of lung tissueC 7 – marks the apex of lung tissue

2.2. T 10 – usually corresponds to the baseT 10 – usually corresponds to the base

= deep inspiration expands the lungs and their = deep inspiration expands the lungs and their lower border drops to the level of T12 lower border drops to the level of T12 (Jarvis:450)(Jarvis:450)

PREPARATIONPREPARATIONINSTRUCTIONS FOR THE PATIENT INSTRUCTIONS FOR THE PATIENT

MUST BE CLEAR AND WITH COURTESYMUST BE CLEAR AND WITH COURTESY1. Draping1. Draping2. Position2. Position3. Other provisions to ensure further comfort3. Other provisions to ensure further comfort• Provide warm room and conducive for Provide warm room and conducive for

examinationexamination = well lighted= well lighted = well ventilated= well ventilated• Provide privacyProvide privacy• Wash your hands but be sure hands are not coldWash your hands but be sure hands are not cold• The diaphragm of your stethoscope must warmThe diaphragm of your stethoscope must warm• Request your client to empty his/her bladderRequest your client to empty his/her bladder• Examination must not be interruptedExamination must not be interrupted

II. Observe for Chest II. Observe for Chest ConfigurationConfiguration Does the chest move equally on the Does the chest move equally on the

two sides?two sides?

Does breathing appear distressing?Does breathing appear distressing?

Is it noisy?Is it noisy?

Is breathing regular?Is breathing regular?

Is there any prolongation of Is there any prolongation of expiration?expiration?

INSPECTIONINSPECTION=Thorax provides information about the =Thorax provides information about the

musculoskeletal structure, patients nutritional musculoskeletal structure, patients nutritional status, and respiratory systemstatus, and respiratory system

= the nurse must observe the skin over the thorax for = the nurse must observe the skin over the thorax for color and turgor and for the evidence of loss of color and turgor and for the evidence of loss of subcutaneous tissuesubcutaneous tissue

= it is important to note symmetry, if present= it is important to note symmetry, if present= when findings are recorded, anatomic landmarks are = when findings are recorded, anatomic landmarks are

used as point of reference (Smeltzer:476)used as point of reference (Smeltzer:476)I. observe respirationI. observe respiration1.1. Rate: normal, above normal. Below normalRate: normal, above normal. Below normal2.2. Rhythm: regular, irregularRhythm: regular, irregular3.3. Depth: normal, deep, shallowDepth: normal, deep, shallow4.4. Effort: use of accessory musclesEffort: use of accessory muscles

II. Observe for Chest II. Observe for Chest ConfigurationConfiguration Does the chest move equally on the Does the chest move equally on the

two sides?two sides?

Does breathing appear distressing?Does breathing appear distressing?

Is it noisy?Is it noisy?

Is breathing regular?Is breathing regular?

Is there any prolongation of Is there any prolongation of expiration?expiration?

1. Barrel chest – results as a result of 1. Barrel chest – results as a result of ossification of the lungsossification of the lungs

= increase in the anteroposterior diameter of = increase in the anteroposterior diameter of the thoraxthe thorax

= patient with emphysema, the ribs are more = patient with emphysema, the ribs are more widely space and the ICS tend to buldge on widely space and the ICS tend to buldge on expirationexpiration

2. Funnel chest (Pectus Excavatum) – occurs 2. Funnel chest (Pectus Excavatum) – occurs when there is a depression in the lower when there is a depression in the lower portion of the sternumportion of the sternum

= this may compress the heart and the great = this may compress the heart and the great vessels resulting in murmursvessels resulting in murmurs

= may occur with rickets or Marfan’s syndrome= may occur with rickets or Marfan’s syndrome

3. Pigeon chest (Pectus Carinatum) – may occur 3. Pigeon chest (Pectus Carinatum) – may occur as a result of displacement of the sternumas a result of displacement of the sternum

= there is an increase in the anteroposterior = there is an increase in the anteroposterior diameterdiameter

= may occur with rickets, Marfan’s syndrome or = may occur with rickets, Marfan’s syndrome or severe kyphoscoliosissevere kyphoscoliosis

4. Kyphoscoliosis – characterized by elevation of 4. Kyphoscoliosis – characterized by elevation of the scapula and the corresponding S-shaped the scapula and the corresponding S-shaped spinespine

= this deformity limits lung expansion within the = this deformity limits lung expansion within the thoraxthorax

= may occur with osteoporosis and other skeletal = may occur with osteoporosis and other skeletal disorders that affect the thorax (Smeltzer:476)disorders that affect the thorax (Smeltzer:476)

BREATHING PATTERNS AND RESPIRATORY RATEBREATHING PATTERNS AND RESPIRATORY RATENormal adult – 12-19 breaths per minute (rate)Normal adult – 12-19 breaths per minute (rate)

500-500 ml (depth) air moving in and 500-500 ml (depth) air moving in and out/respirationout/respiration

even (pattern)even (pattern)Ratio of pulse to respiration = 4:1Ratio of pulse to respiration = 4:1

1. Eupnea – normal breathing at 12-19 breaths/min1. Eupnea – normal breathing at 12-19 breaths/min

2. Bradypnea – slower than normal, less than 2. Bradypnea – slower than normal, less than breaths/min with normal depth and regular rhythmbreaths/min with normal depth and regular rhythm

= associated with increase ICP, brain injury, and drug = associated with increase ICP, brain injury, and drug overdoseoverdose

3. Tachypnea – rapid, shallow breathing, more than 24 3. Tachypnea – rapid, shallow breathing, more than 24 breaths/minbreaths/min

= commonly seen in patient with pneumonia, = commonly seen in patient with pneumonia, pulmonary edema. Metabolic acidosis, septicemia, pulmonary edema. Metabolic acidosis, septicemia, severe pain and rib fracture severe pain and rib fracture

4. Hyporventilation – shallow, irregular breathing 4. Hyporventilation – shallow, irregular breathing

5. Hyperventilation – increased rate and depth of 5. Hyperventilation – increased rate and depth of breathingbreathing

= associated with severe acidosis of diabetic, = associated with severe acidosis of diabetic, renal origin (Kausmaul breathing)renal origin (Kausmaul breathing)

6. Apnea – period of cessation of breathing6. Apnea – period of cessation of breathing

= time of duration varies= time of duration varies

= may occur briefly during other breathing = may occur briefly during other breathing disorders such as sleep apneadisorders such as sleep apnea

= if sustained, apnea is life-threatening= if sustained, apnea is life-threatening

7. Cheyne stokes – characterized by alternating 7. Cheyne stokes – characterized by alternating episodes of apnea and periods of deep breathingepisodes of apnea and periods of deep breathing

= deep respirations become increasingly shallow, = deep respirations become increasingly shallow, followed by apnea that may last approx. 20 followed by apnea that may last approx. 20 secondsseconds

= the cycle repeats after each apneic period= the cycle repeats after each apneic period

= associated with heart failure and damage of the = associated with heart failure and damage of the respiratory center (drug-induced, tumor, trauma)respiratory center (drug-induced, tumor, trauma)

8. Biot’s respiration – or cluster breathing8. Biot’s respiration – or cluster breathing

= periods of normal breathing (3-4 breaths) = periods of normal breathing (3-4 breaths) followed by varying period of apnea (usually 10 followed by varying period of apnea (usually 10 seconds to 1 min)seconds to 1 min)

= CNS disorder (Kozier:1297)= CNS disorder (Kozier:1297)

TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATION

OBSERVE NORMAL ABNORMAL

General Appearance Quiet respiration Lips puckered when exhaling

Sitting or reclining without difficulty Restless and apprehensive

Skin translucent, appears dry Leans forward with hands or elbows on knees

Nailbeds pink Skin: diaphoretic, dull pale or ruddy

Mucous membranes pink and moist* Cyanosis: skin or mucous membranes have bluish cast

Cyanosis or pallor assessed by establishing an early individual baseline

Central cyanosis: results from decreased oxygenation of blood +

Peripheral cyanosis: result of local vasoconstriction or decreased cardiac output

Nail clubbing: painless enlargement of terminal phalanges related to chronic tissue hypoxia

Trachea Midline in neck Tracheal deviation; displacement either lateral, anterior, posterior

Jugular venous distension

Cough: strong or weak, dry or wet, productive or non-productive

Sputum production: amount, color, odor, consistency

* Dark-skinned people might have normal bluish-pigmentation mucous membranes.+ Central cyanosis is relevant to respiratory status. Observe nailbeds, mucous membrane and lips.

TABLE 35-3 POSSIBLE FINDINGS BY INSPECTION IN A PULMONARY EXAMINATION

OBSERVE NORMAL ABNORMAL

Rate Eupnea: 12 to 20 Tachypnea: rate> 20 breaths/minute

Bradypnea: rate < 12 breaths/minute

Breathing pattern Minimal effort with inspiration: passive, quiet expiration

Hyperpnea: increased breathing depth

Inspiration/expiration ratio: 1:2 Accessory muscle breathing

Male: diaphragmatic breathing Apnea: total absence of breathing

Female: thoracic breathing Biots: irregular rhythm with periods of apnea

Cheyne-Stokes: cyclical deeper and shallower breaths, followed by periods of apnea

Kussmaul’s: deep, rapid, and regular breathing

Paradoxical: portion of chest wall moves in during inhalation and out during exhalation

Stridorous: audible, loud, low-pitched sound with inhalation and exhalation

Thoracic configuration

Symmetric appearance Chest expands unevenly

Muscular development asymmetric

Anteroposterior diameter (AP) less than transverse diameter

Barrel chest: AP diameter increased in relation to transverse diameter

Spine straight Kyphosis: increased thoracic curvature

Scoliosis: increased lateral curvature

Scapulae on same horizontal plane Scapular placement asymmetric

PALPATIONPALPATION= Start palpation by feeling for the position = Start palpation by feeling for the position

of the trachea.of the trachea.= facing to the patient, place two fingers = facing to the patient, place two fingers

either side of the trachea (note whether either side of the trachea (note whether the distance between the trachea and the the distance between the trachea and the sternomastoid tendons are equalsternomastoid tendons are equal

= at the back of the patient, hook your = at the back of the patient, hook your finger round the tendon to meet the finger round the tendon to meet the trachea (maybe displaced- mass in the trachea (maybe displaced- mass in the neckneck

= palpates the thorax for tenderness, = palpates the thorax for tenderness, masses, lesions, respiratory excursion masses, lesions, respiratory excursion and vocal fremitus (Smeltzer:478)and vocal fremitus (Smeltzer:478)

Purposes (Bickley:230)Purposes (Bickley:230)1.1. Identification of tender areasIdentification of tender areas2.2. Assessment of observed abnormalitiesAssessment of observed abnormalities3.3. Further assessment of chest Further assessment of chest

expansionexpansion4.4. Assessment of tactile fremitusAssessment of tactile fremitus

Identify tender massIdentify tender mass= palpate an area of pain or lesions are = palpate an area of pain or lesions are

apparent – perform direct palpation apparent – perform direct palpation with the fingertips (for the lesion and with the fingertips (for the lesion and subcutaneous masses) subcutaneous masses)

= use the ball of the hand for deeper masses = use the ball of the hand for deeper masses or generalized flank or rib discomfortor generalized flank or rib discomfort

Assess any abnormalitiesAssess any abnormalities= observe for any masses or sinus tract = observe for any masses or sinus tract

(inflammatory, tube-like opening onto the (inflammatory, tube-like opening onto the skinskin

Respiratory ExcursionRespiratory Excursion= an examination of the thoracic expansion = an examination of the thoracic expansion

and may disclose significant information and may disclose significant information about thoracic movement during breathingabout thoracic movement during breathing

= assess the patient for range and symmetry = assess the patient for range and symmetry of excursionof excursion

= instruct patient to inhale deeply= instruct patient to inhale deeply while moving the thumbs fromwhile moving the thumbs from the 10the 10thth rib with the fingers rib with the fingers loosely grasping and parallel to loosely grasping and parallel to the lateral rib cage.the lateral rib cage.

= slide them medially about 2-2.5 cm= slide them medially about 2-2.5 cm(1 inch) just enough to raise fold (1 inch) just enough to raise fold of skin on each side bet. theof skin on each side bet. the thumb and the spinethumb and the spine

= watch the distance bet. the thumb= watch the distance bet. the thumb as they move apart during inspiration.as they move apart during inspiration.

= feel for the range and symmetry= feel for the range and symmetryof the rib cage as it expands andof the rib cage as it expands andcontractscontracts

TACTILE FREMITUSTACTILE FREMITUSFremitus – refers toFremitus – refers topalpable vibrationspalpable vibrationstransmitted throughtransmitted throughthe bronchopulmonary the bronchopulmonary tree to the chest wall tree to the chest wall when the patient speakswhen the patient speaks= is the detection of the = is the detection of the resulting vibration onresulting vibration onthe chest wall by touchthe chest wall by touch= normal fremitus varies= normal fremitus varies= lower pitched sounds = lower pitched sounds

traveltravelbetter through the better through the

normalnormaland produce greater and produce greater

vibrationvibrationof the chest wallof the chest wall

= the patient is asked = the patient is asked to repeat “99”, “1 2 3”, to repeat “99”, “1 2 3”, or “eee,eee,eee” as you or “eee,eee,eee” as you move your hands down move your hands down the thoraxthe thorax= the vibrations are = the vibrations are detected with the palmar detected with the palmar surfaces of the fingers and surfaces of the fingers and hands or the ulnar aspect hands or the ulnar aspect of the extended hands of the extended hands = hands are moved in sequence down to the = hands are moved in sequence down to the

thoraxthorax= corresponding areas of the thorax are = corresponding areas of the thorax are

comparedcompared= BONY AREAS ARE NOT TESTED= BONY AREAS ARE NOT TESTED= if fremitus is faint, ask patient to say it again = if fremitus is faint, ask patient to say it again

more loudly or in deeper voice (Smeltzer:479)more loudly or in deeper voice (Smeltzer:479)

PERCUSSIONPERCUSSION

= is one of the most important technique of = is one of the most important technique of physical examinationphysical examination

=percussion of the chest sets and the chest wall =percussion of the chest sets and the chest wall and underlying tissues into motion, producing and underlying tissues into motion, producing audible sound and palpable vibrationsaudible sound and palpable vibrations

Purposes: 1. to detect the resonance or hollowness Purposes: 1. to detect the resonance or hollowness of the chest (underlying tissues are air-filled, of the chest (underlying tissues are air-filled, fluid-filled or solid)fluid-filled or solid)

2. Used to estimate the size and location of certain 2. Used to estimate the size and location of certain structure within the thorax (diaphragm, heart, structure within the thorax (diaphragm, heart, liver)liver)

= it penetrates only about 5-7cm into the chest = it penetrates only about 5-7cm into the chest therefore it will not help to detect deep-seated therefore it will not help to detect deep-seated lesions (Epstein:627)lesions (Epstein:627)

PosteriorPosterior

= percussion usually begins with the = percussion usually begins with the posterior thoraxposterior thorax

= ideally, the patient is in a sitting = ideally, the patient is in a sitting position with the head flexed forward position with the head flexed forward and the arm crossed on the lap – the and the arm crossed on the lap – the position separates the scapulae widely position separates the scapulae widely and exposes more lung areaand exposes more lung area

= proceeds down the posterior thorax, = proceeds down the posterior thorax, percussing symmetry areas at 5-6cm percussing symmetry areas at 5-6cm (2-2.5 inch) interval (Smeltzer:480)(2-2.5 inch) interval (Smeltzer:480)

= hyperextend the middle = hyperextend the middle finger of your left hand finger of your left hand (pleximeter)(pleximeter)= press its distal interphalangeal = press its distal interphalangeal joint firmly on the surface joint firmly on the surface to be percussedto be percussed= avoid surface contact by= avoid surface contact by any part of the hand becauseany part of the hand because this dampens our vibrationsthis dampens our vibrationsNote: thumb, 2Note: thumb, 2ndnd, 4, 4thth, 5, 5thth fingers fingers are not touching the chestare not touching the chest= position your right forearm= position your right forearm quite close to the surface, with the hand cocked quite close to the surface, with the hand cocked

upwardupward= the middle finger should be partially flexed, related, = the middle finger should be partially flexed, related,

and poised to strikeand poised to strike

= with a quick sharp = with a quick sharp

but relaxed wrist but relaxed wrist

movement, strike the movement, strike the

pleximeter finger pleximeter finger

with the right middlewith the right middle

finger or plexor fingerfinger or plexor finger

= aim at your distal = aim at your distal

interphalangeal jointinterphalangeal joint

= strike using the tip = strike using the tip

of your plexor finger,of your plexor finger,

not the finger padnot the finger pad

= your finger should = your finger should

be almost at right anglesbe almost at right angles

to the pleximeterto the pleximeter

A SHORT FINGERNAIL IS RECOMMENDED TO A SHORT FINGERNAIL IS RECOMMENDED TO AVOID SELF-INJURYAVOID SELF-INJURY

WITHDRAW YOUR STRIKING FINGER QUICKLY WITHDRAW YOUR STRIKING FINGER QUICKLY TO AVOID DAMPING THE VIBRATIONS YOU TO AVOID DAMPING THE VIBRATIONS YOU HAVE CREATED (Bickley:224)HAVE CREATED (Bickley:224)

PERCUSSION SOUNDSPERCUSSION SOUNDS1.1. Resonance – low-pitched sound heard Resonance – low-pitched sound heard

over normal lungsover normal lungs2.2. Hyperresonance – loud, lower-pitched Hyperresonance – loud, lower-pitched

sound than normal resonance heard over sound than normal resonance heard over hyperinflated lung such as in chronic hyperinflated lung such as in chronic obstructive lung disease, acute asthmaobstructive lung disease, acute asthma

3.3. Tympany – drumlike, loud, empty quality Tympany – drumlike, loud, empty quality heard over gas-filled stomach or heard over gas-filled stomach or intestine or pneumothoraxintestine or pneumothorax

4.4. Dull – medium intensity pitch and Dull – medium intensity pitch and duration, heard over areas “mixed” solid duration, heard over areas “mixed” solid and lung tissue (pneumonia)and lung tissue (pneumonia)

5.5. Flat – soft, high pitched sound of short Flat – soft, high pitched sound of short duration heard over very dense tissue duration heard over very dense tissue where air is not present (Lewis:555)where air is not present (Lewis:555)

= percuss one side of = percuss one side of

the chest and then the the chest and then the

other at each levelother at each level

= omit the areas over= omit the areas over

the scapulae – the the scapulae – the

thickness of muscle and thickness of muscle and

bone alters the percussion bone alters the percussion

notes over the lungsnotes over the lungs

(Bickley:225)(Bickley:225)

AnteriorAnterior

= patient is an upright = patient is an upright position with shoulders position with shoulders arched backward andarched backward and arms at the tablearms at the table= begin in the supra-= begin in the supra-clavicular area and clavicular area and proceeds downward, proceeds downward, from one intercostal space to the next from one intercostal space to the next = for female patient, it maybe necessary to displace the = for female patient, it maybe necessary to displace the

breasts with the left hand while percussing with the breasts with the left hand while percussing with the rightright

= using both hands, place finger of one on the chest = using both hands, place finger of one on the chest with fingers separated (Bickley:232)with fingers separated (Bickley:232)

YOU MAY ASK THE PATIENT TO MOVE HER BREAST FOR YOU MAY ASK THE PATIENT TO MOVE HER BREAST FOR YOUYOU

= strike one of them with the terminal phalynx = strike one of them with the terminal phalynx of the middle finger of the of the other handof the middle finger of the of the other hand

= it must be removed again immediately, = it must be removed again immediately, otherwise the resultant sound will be dampedotherwise the resultant sound will be damped

= the striking movement should be a flick of = the striking movement should be a flick of the wrist and the striking finger should be at the wrist and the striking finger should be at right angle to the other fingerright angle to the other finger

= each side is compared with the equivalent = each side is compared with the equivalent area from top to bottomarea from top to bottom

= DO NOT FORGET THE SIDES= DO NOT FORGET THE SIDES= the anterior and lateral thorax is examined = the anterior and lateral thorax is examined

with the patient in supine positionwith the patient in supine position= if patient cannot sit, percussion of the = if patient cannot sit, percussion of the

posterior thorax is performed with the patient posterior thorax is performed with the patient positioned on the sidepositioned on the side

AUSCULTATIONAUSCULTATION

= prefers to use the diaphragm of the = prefers to use the diaphragm of the stethoscope stethoscope

= in thin bony chest, the bell may give a = in thin bony chest, the bell may give a more airtight fit and is less likely to trap more airtight fit and is less likely to trap hairs underneath which produces a hairs underneath which produces a crackling sound (Epstein:628)crackling sound (Epstein:628)

= the most important examining = the most important examining technique for assessing air flow through technique for assessing air flow through the tracheobronchial treethe tracheobronchial tree

= it involves:= it involves:

1.1. Listening to the sounds generated Listening to the sounds generated by breathingby breathing

2.2. Listening for any adventitious Listening for any adventitious (added) sound(added) sound

3.3. If abnormalities are suspected, If abnormalities are suspected, listening to the sounds of the listening to the sounds of the patient’s whispered voice as they patient’s whispered voice as they are transmitted through the chest are transmitted through the chest wallwall

= ask patient to take deep breath through = ask patient to take deep breath through the mouththe mouth

= listen to the breath sounds using the same = listen to the breath sounds using the same pattern for percussion, moving from one pattern for percussion, moving from one side to the other and comparing side to the other and comparing symmetric areas of the lungs (Bickley:226)symmetric areas of the lungs (Bickley:226)

= listen at least 1 full breath on each = listen at least 1 full breath on each locationlocation

BE ALERT FOR PATIENT DISCOMFORT DUE BE ALERT FOR PATIENT DISCOMFORT DUE TO HYPERVENTILATION (light-headedness, TO HYPERVENTILATION (light-headedness, faintness)faintness)

ALLOW PATIENT TO REST AS NEEDED ALLOW PATIENT TO REST AS NEEDED (Smeltzer:480)(Smeltzer:480)

BREATH SOUNDSBREATH SOUNDS

= evaluate the presence and quality of normal breath = evaluate the presence and quality of normal breath soundssounds

= are usually louder in the upper anterior lung fields= are usually louder in the upper anterior lung fields

1. Vesicular – soft and low-pitched 1. Vesicular – soft and low-pitched = they are heard through inspiration, continue = they are heard through inspiration, continue

without pause through expirationwithout pause through expiration= have 3:1 ratio with inspiration longer than = have 3:1 ratio with inspiration longer than

expirationexpiration= can be heard over most of both lungs= can be heard over most of both lungs

2. Bronchovesicular – with inspiratory and expiratory 2. Bronchovesicular – with inspiratory and expiratory sounds about equal in length, at times separated sounds about equal in length, at times separated by a silent interval differences in pitch and by a silent interval differences in pitch and intensity are often easily detected during intensity are often easily detected during expirationexpiration

= often can be heard in the 1= often can be heard in the 1stst and 2 and 2ndnd interspaces anteriorly and between the interspaces anteriorly and between the scapulaescapulae

= can be heard over the large airways esp. = can be heard over the large airways esp. on the righton the right

3. Bronchial – louder and higher in pitch3. Bronchial – louder and higher in pitch= with a short silence between inspiratory = with a short silence between inspiratory

and expiratory soundsand expiratory sounds= expiratory sound last longer than = expiratory sound last longer than

inspiratory soundsinspiratory sounds= can be heard over the manubrium, if = can be heard over the manubrium, if

heard at all (Bickley:227)heard at all (Bickley:227)

ADVENTITIOUS SOUNDADVENTITIOUS SOUND

1.1. Wheezes – rhonchiWheezes – rhonchi= a high-pitched, musical sound = a high-pitched, musical sound

similar to a squeaksimilar to a squeak= it is heard most commonly during = it is heard most commonly during

expiration, but also can be heard expiration, but also can be heard during inspirationduring inspiration

= low-pitched, coarse, loud, low = low-pitched, coarse, loud, low snoring or moaning soundsnoring or moaning sound

=it is heard in narrowed airway =it is heard in narrowed airway diseases such as asthma, chronic diseases such as asthma, chronic emphysemaemphysema

2.2.

www.umshp.org/rt/sounds/sounds.html

education.vetmed.vt.edu/Curriculum/VM8754/respir/sdf/sounds/sounds.htm

www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm