Randa M. Albusoul

Respiratory System

Anatomy

Chest assessment can be done in two dimensions:

vertical axis and circumference of the chest.

Thoracic cage is bony structure, conical shape, narrower at the top Defined by: sternum, 12 pairs of ribs, & 12 thoracic vertebrae

1-7 ribs: attach to sternum. 8,9 &10 ribs: attach to costal cartilage above. 11 & 12 ribs: are floating ribs.

The tip of 11th rib can

be felt laterally, and the

tip of 12th rib

posteriorly.

The intercostal space is

named after the rib

above it.

Posterior thoracic

landmarks:

•Vertebral prominens (C7): flex head & feel most prominent vertebrae at base of the neck; If 2 vertebraes seem prominent, upper is C-7 & lower is T-1. •Spinous process: count down these knobs on the vertebrae, which stack together to form the spinal column.

•Inferior border of scapula: lower tip is usually at 7th or 8th rib. •12th Rib: palpate midway between the spine & the person’s side to identify its free tip.

Anterior thoracic landmarks:

•The right and left costal margins form an angle

where they meet at the xiphoid process.

•Usually 90 degree or less.

•Sternal angle (angle of Louis): between the

manubrium and body of the sternum,

approximatly 5 cm under suprasternal notch, it is

continuous with the 2nd rib.

•The angle of Louis also marks the site of

tracheal bifurcation, it corresponds with the upper

border of the atria of the heart.

2nd intercostal

space for

Tension

pneumothorax

4th intercostal

space

For chest tube

T7-T8

intercostal

space for

Thoracentesis

Reference lines: for locating abnormalities on

the chest.

•The apex of lung extend above clavicle. •The base at the level of diaphragm. •At the midclavicular line anteriorly the lung extend to the 6th rib. •Midaxillary extend to the 8th rib. •Posteriorly the lung base lie at the 10th rib. •On inspiration the lung descends farther.

6 8

6 8 10

•Forms an thin envelope between the lungs and the chest wall. •Visceral pleura- lines the outside of the lungs, dipping down into the fissures; It is continuous with the parietal pleura lining the inside of the chest wall and diaphragm. •The inside of the envelope is a potential space filled with a few milliliters of lubricating fluid; It normally has a negative pressure, which holds the lungs tightly against the chest wall. •The lungs slide smoothly & noiselessly up & down during respiration. •The pleurae extend about 3 cm below the level of the lungs forming the costodiaphragmatic recess.

Lung fissures are a double fold of

visceral pleura that either completely or

incompletely invaginate lung parenchyma to

form the lung lobes. Each lung has

an oblique fissure separating the upper lobes

from the lower lobes and the right lung has

a horizontal fissure that separates the right

upper lobe from the right middle lobe.

•Trachea-Lies anterior to the esophagus; is 10-11 cm long in adult •Begins at cricoid cartilage & bifurcates just below the sternal angle into the R & L main bronchi; and T4 posteriorly; R bronchus shorter, wider, & more vertical. •Trachea & Bronchi transport gases between the environment and the lung parenchyma; They constitute the dead space that is filled with air but is not available for gaseous exchange-150 ml in adult.

• Breathing is controlled in

the brain stem and

mediated by muscles of

respiration.

•Diaphragm is the primary

muscle of inspiration;

when descends it enlarges

the thoracic cavity and

push the abdominal wall

outward.

•Muscles of the rib cage

and neck extend the thorax

during inspiration.

•Normal breathing is quiet and easy; barely audible.

• When a healthy person lies supine, the breathing

movements of the thorax are relatively slight. In

contrast, the abdominal movements are usually easy to

see.

• In the sitting position, movements of the thorax

become more prominent.

•During exercise and in certain diseases, extra work is

required to breathe, and accessory muscles join the

inspiratory effort. The sternomastoids are the most

important of these, and the scalenes may become

visible.

•Abdominal muscles assist in expiration.

Subjective Data

Concerning symptoms of the respiratory system are:

Shortness of breath (SOB) (Dyspnea)

Wheezing

Cough

Hemoptysis or purulent sputum

Chest pain

Dyspnea: may be sudden RT infection,

pulmonary embolism, anxiety,

pneumothorax….

Or may be gradual RT pulmonary fibrosis,

lung cancer….

Abnormality:

* Orthopnea: ( difficult breathing when supine R/T

heart failure.

* Paroxysmal nocturnal dyspnea ( sever dyspnea

that awaken the pt from sleep R/T heart failure.

Cough: is typically a reflex response to stimuli that

irritate receptors in the larynx, trachea, or large

bronchi. These stimuli include mucus, pus, blood,

dust, foreign bodies, and even extremely hot or cold

air.

An acute cough lasts ˂ 3 weeks,

Subacute 3 to 8 weeks,

and Chronic ˃ 8 weeks.

Wheezing is a high-pitched sound made while you

breathe. It is heard most clearly when you exhale, but

in severe cases, it can be heard when you inhale. It is

caused by narrowed airways (airway obstraction) from

secretions, tissue inflammation, or a foreign body.

-If the patient has cough; when and how often does it occur??

*Continuous cough RT acute infection. * Cough only in the morning RT chronic bronchitis, smoking.

*Cough in the evening RT exposure to irritant during

day.

*cough at night RT sinusitis.

-If there is any sputum. Color , amount with odor,

increase or decrease?

*Non productive cough RT URTI or early CHF .

* White sputum RT common cold , viral infection

*Yellow or green RT bacterial infection.

*Bloody sputum (hemoptysis).

*Pink frothy RT pulmonary edema.

Remember that

lung tissue itself has no pain fibers.

Pain in lung conditions such as

pneumonia or pulmonary infarction may

be RT inflammation of the parietal

pleura.

Chest pain: may be RT cardiac, respiratory,

gastrointestinal, or musculoskeletal causes.

Past History

•Have you had any prior respiratory problems,

such as respiratory infections, asthma, bronchitis,

emphysema, pneumonia, tuberculosis, collapsed

lung (pneumothorax), or cystic fibrosis?

●Have you had thoracic surgery, biopsy, or trauma

to your chest?

●Do you have any allergies that affect your

breathing or respiratory system?

Family History

●Does anyone in your family currently have a

respiratory infection disease?

●Has anyone had lung cancer, asthma, or

cystic fibrosis?

●Did anyone smoke in your home when you

were growing up? Who?

Lifestyle and Personal Habits

●Do you smoke or have you ever smoked? How

many? When start?

●Are you exposed to second-hand smoke? Where?

How many hours per day? For how many years?

●Are you exposed to any environmental conditions

at home or work that affect your breathing?

●Are you taking any prescription, herbal, or over-

the-counter (OTC) medications for breathing or

respiratory problems?

●Do you use oxygen or other treatments for

breathing problems (e.g., nebulizer treatments)?

Objective Data

•The chest can be examined in the supine, sitting,

and if necessary lateral positions.

•When examining posterior chest while patient is

sitting the patient’s arms should be folded across

the chest with hands resting, if possible, on the

opposite shoulders. This position moves the

scapulae partly out of the way and increases your

access to the lung fields.

Inspect for any signs of respiratory difficulty.

•Observe the patient’s facial expression; it should be

relaxed and calm.

●Observe level of consciousness.

●Assess the patient’s color for cyanosis, especially the

face, mucous membranes, and nail beds.

•Inspect the neck. During inspiration, is there

contraction of the accessory muscles, namely, the

sternomastoid and scalene muscles, or supraclavicular

retraction? Is the trachea midline?

Atelectasis

Pulmonary edema

Pleural effusion Clubbing nails

Inspect position of client :

*Normally sitting up relaxed, breath easily with arm

at side or in lap.

*Abnormal:

Tripod position RT COPD

•Observe the shape of the chest.

Normal Barrel

chest scoloisis

Kyphosis Pectus

Excavatum Pectus

Carinatum

•Impaired respiratory movement on one or both

sides, such as flail chest.

Flail chest or paradoxical

breathing is a life-threatening

medical condition that occurs

when a segment of the rib cage

breaks under extreme stress and

becomes detached from the rest

of the chest wall.

Inspect nasal flaring, pursed lip breathing.

** Normally not observed .

- Flaring nose seen in hypoxic child.

- Pursed lip RT asthma, CHF, or physiologic response

to slow down respiration

•Listen to the patient breathing; normally breathes

are quiet and regular “12-20” times per minute,

without any effort.

•Are there any audible sounds? Wheezing,

stridor…

Stridor: airway obstruction in the larynx, thorax.

Wheezing: severe asthma.

•Inspect posterior thorax;

-Let patient sit with arms at side.

-Stand behind the patient

-Observe the scapula and the shape and

configuration of chest wall

-Normally the scapula are symmetric and

non-protruding

*Shoulders and scapula are at equal

horizontal line

*The ratio of anteroposterior to the

transverse diameter is 1:2

Spinous process appear straight , thoracic appears

symmetric with rib sloping downward ar 45 degree

from spine.

•Identify tender or warm areas; palpate where

pain has been reported, or the area of lesions or

bruises.

•Assess any abnormalities such as masses.

•Test chest expansion: Place your hand on the posterior

chest wall with your thumb at the

level of T9 or T 10.

Press together to form small fold

Ask client take deep breath

Observe movement of the thumbs Normally the thumb should move 5-10

cm apart symmetrically.

•Feel for tactile fremitus:

Fremitus is vibration

of air in the bronchial

tubes transmitted to

the chest wall as the

patient is speaking.

use the ball or ulnar

edge of one hand.

•Ask patient to say ninety-nine, or one-one-one.

•Assess symmetry and intensity of vibration.

•Normally the fremitus is symmetric for bilateral

position, however, more prominent in the

intrascapular area and on the right side.

If not palpable ask pt to talk loudly.

RESONANCE- Predominates in healthy lung

tissue

HYPERRESONANCE- Too much air present as

in emphysema or pneumothorax.

DULLNESS- Abnormal density in lungs due to

possible pneumonia, pleural effusion, or tumor

Lung fields: the predominant note is resonance

in healthy lung tissue. percussion can detect

lesions in 5-6 cm deep.

•Percuss to map out the lower lung border in expiration and inspiration. •Ask pt to exhale & hold it. •Percuss down the scapular line until the sound changes from resonant to dull on each side. •Next, have pt take deep breath & hold it; continue percussing down scapular line & mark the level where the sound changes to dull. •Measure the difference; should be equal bilaterally & measure 3-5 cm in adults

•USE DIAPHRAGM

•HAVE PERSON BREATHE THRU

MOUTH

•WET CHEST HAIR IF NEEDED

•COMPARE ONE SIDE TO THE OTHER

•LISTEN TO FRONT & BACK

•LISTEN TO AT LEAST ONE FULL

RESPIRATION IN EACH LOCATION

Breath sounds:

•Vesicular are soft and low pitched. They are heard

through inspiration, continue without pause through

expiration, and then fade away about one third of the

way through expiration.

●Bronchovesicular, with inspiratory and expiratory

sounds about equal in length, at times separated by a

silent interval. Detecting differences in pitch and

intensity is often easier during expiration.

●Bronchial are louder and higher in pitch, with a short

silence between inspiratory and expiratory sounds.

Expiratory sounds last longer than inspiratory sounds.

•Listen to adventitious (extra sounds):

•Transmitted voice sounds:

•If you heard abnormal bronchov. Or bronchial

sounds, or adventitious sounds use this

technique.

•Ask the pt to say 99; normally muffled and

indistinct if clear bronchophony.

•Ask the pt to say ee; you should hear ee, if aa

lobal consolidation from pneumonia

•Ask the patient to whisper 99; heard faintly

and indistinctly.