Chest And Lungs

CHEST

AND

LUNGS

ANATOMIC LANDMARKS: - nipples - manubriosternal junction (sternum and point at which 2nd rib articulates with sternum) - suprasternal notch - costal angle - vertebra prominence (seen and felt best with patient’s head bent forward – C7) - clavicles INFANTS AND CHILDREN - at about 4 wks gestation, lung is groove on ventral wall of gut - evolves ultimately from simple sac to involuted structured of tubules and spaces - lungs contain no air, alveoli are collapsed - passive respiratory movements do not open alveoli or move the lung fields - at birth, after cord is cut, lungs fill with air for 1st time - decrease in pulmonary pressure leads to closure of foramen ovale - increased oxygen tension in arterial blood stimulates contraction and closure of ductus arteriosus - chest of newborn is generally round (AP Transverse 1:1) - relatively thin chest wall of infant and young child makes bony structure more prominent PREGNANT WOMEN - as lower ribs flare, an increase in transverse diameter - at rest, diaphragm rises above usual resting position - major work of breathing is done by diaphragm - ventilation (minute and alveolar) increases - respiratory rate is unchanged OLDER ADULTS - barrel chest is characteristic of most, due to loss of muscle strength in thorax and diaphragm - skeletal changes emphasize dorsal curve of thoracic spine, may have stiffening and decreased expansion of chest wall - alveoli become less elastic and relatively more fibrous - underventilation in lower lung fields and decreased tolerance for exertion - mucous membranes become drier and less able to rid mucus

I. A.

REVIEW

OF

RELATED HISTORY

HISTORY OF PRESENT ILLNESS 1. Cough – onset, nature (wet, hacking, productive, nonproductive, etc.), sputum, pattern, severity, efforts to treat

2. Shortness of Breath – onset, pattern (most comfortable, number of pillows used), severity 3. Chest Pain – onset, duration, efforts to treat, other meds B.

PAST MEDICAL HISTORY - thoracic, nasal, and/or pharyngotracheal trauma or surgery, use of oxygen, chronic pulmonary diseases, other chronic disorders, testing, immunizations C.

FAMILY HISTORY - when, what kind: tuberculosis (qualify – date of occurrence or exposure), cystic fibrosis, emphysema, allergy, asthma, atopic dermatitis, malignancy, bronchiectasis, bronchitis, lung cancer D. PERSONAL AND SOCIAL HISTORY - nature of employment, home environment, tobacco use, exposure to respiratory infections, nutritional status, use of herbal or other remedies, regional or travel exposures (when and where), hobbies, use of alcohol and/or illegal drugs, exercise tolerance

II.

EXAMINATION

AND

FINDINGS

A.

INSPECTION - have patient sit upright, if possible - position patient so that light source comes at different angles - if patient is in bed and mobility is limited, ensure access to both sides of bed - raise and lower bed as needed - note shape and symmetry of chest from both back and front - chest will not be absolutely symmetric - anteroposterior (AP) diameter of chest is ordinarily less than transverse diameter, often by as much as half (2:1) barrel chest – results from compromised respiration as in chronic asthmas, emphysema, or cystic fibrous - ribs are horizontal, spine at least somewhat kyphotic (hunchback), sternal angle more prominent, trachea may be posteriorly displaced - spine may be deviated either posteriorly (kyphosis) or laterally (scoliosis) - common structural problems include pigeon chest (pectus carinatum – prominent sternal protrusion) and funnel chest (pectus excavatum – indentation of lower sternum above xiphoid process) - inspect skin, nails, lips, and nipples, noting whether cyanosis or pallor is present

- smell breath - note supernumerary nipples - look for superficial venous patterns over chest, which may be a sign of heart disorders or vascular obstruction or disease - underlying fat and relative prominence of ribs give some clue to general nutrition 1. Respiration – determine rate (12 – 20/min) – ratio of respiration to heartbeats is approximately 1:4 - rates vary in different waking and sleep states - note pattern (rhythm) and the way the chest moves - expansion of chest should be bilaterally symmetric - find bottom of ribcage, use hands to cinch in waist and feel expansion - pattern of breathing should be even, neither too shallow nor too deep a.

Descriptors dyspnea – difficult and labored breathing with SOB - sedentary lifestyle and obesity are common causes - increases with severity of underlying condition apnea – absence of spontaneous respiration orthopnea – SOB that begins or increases when patient lies down - ask if more than one pillow helps paroxysmal nocturnal dyspnea – sudden onset of SOB after

period of sleep - sitting upright is helpful platypnea – dyspnea increases in upright posture tachypnea – persistent respiratory rate approaching 25/min bradypnea – rate slower than 12/min - may indicate neurologic or electrolyte disturbance, infection or sensible response to protect against pain of pleurisy or other irritative phenomena hyperpnea – breathing laboriously, as if forced and deeply Kussmaul breathing – always deep and most often rapid - eopnymic description applied to respiratory effort associated with metabolic acidosis hypopnea – abnormally shallow respirations (pleuritic pain limits excursion)

Cheyne-Stokes respiration (periodic breathing) – regular periodic pattern of breathing with intervals of apnea followed by crescendo/decrescendo sequence of respiration - children and older adults may breathe in this pattern during sleep, otherwise it occurs in patients who are seriously ill, particularly with brain damage at cerebral level or drug-caused respiratory compromise - occasional deep, audible sigh that punctuates otherwise regular respiratory pattern is associated with emotional distress air trapping – result of prolonged by inefficient expiratory effort - rate increases - effort becomes more shallow, amt of trapped air increases, and lungs inflate biot respiration – irregular respirations varying in depth and interrupted by intervals of apnea, but lacking repetitive pattern of periodic respirations - usually associated with severe and persistent increased intracranial pressure, respiratory compromise resulting from drug poisoning, or brain damage at level of medulla - when breathing is labored or respirations are deeper than usual, accessory muscles of respiration (sternocleidomastoid, trapezius muscles) may be used - expansion should be symmetric without apparent use of accessory muscles - not unusual to see abdominal respiration, particularly in very young infants - thoracic respiration is the rule at most ages unless intercostal and other thoracic muscles are compromised - men are more likely to use diaphragmatic respiration and women, particularly when pregnant, thoracic - chest asymmetry can be associated with unequal expansion and respiratory compromise caused by collapsed lung or limitation of expansion by extra pleural air, fluid or a mass

- unilateral or bilateral bulging can be reaction of ribs and interspaces to respiratory obstruction - prolonged expiration and bulging on expiration probably caused by outflow obstruction or valvelike action of compression by tumor, aneurysm, or enlarged heart - retractions suggest obstruction to inspiration at any point - when obstruction is high in respiratory tree, breathing is stridor (harsh) and chest wall seems to cave in - paradoxic breathing occurs when negative intrathoracic pressure is transmitted to abdomen by weakened, poorly functioning diaphragm; obstructive airway disease; or during sleep, in the event of upper airway obstruction - lower thorax is drawn in and abdomen protrudes, opposite occurs on expiration - foreign body in one or the other bronchi causes unilateral retraction, but suprasternal notch is not involved - occurs with asthma and bronchiolitis - observe lips and nails for cyanosis, lips for pursing, fingers for clubbing and alae nasi for flaring - - suggests pulmonary or cardiac difficulty B.

PALPATION - feeling for pulsations, areas of tenderness, bulges, depressions, unusual movement, and unusual positions - during respiration, stand behind patient, place thumbs along spinal processes at level of 10th rib, with palmar or ulnar side of hand lightly in contact, watch thumbs diverge during quiet and deep breathing (symmetry) - note quality of tactile fremitus (palpable vibration of chest wall resulting from speech or other verbalizations) - use a firm, light touch, establishing even contact as patient speaks (counts) - vibration should decrease as you palpate down the back - decreased or absent fremitus may be caused by excess air in lungs or may indicate emphysema, pleural thickening, or effusion, massive

pulmonary edema, or bronchial obstruction - increased fremitus, often coarser or rougher in feel, occurs in presence of fluids or a solid mass - should be bilateral symmetry and some elasticity of ribcage, but sternum and xiphoid should be relatively inflexible and thoracic spine rigid crepitus – crackly or crinkly sensation - can be both palpated and heard (gentle bubbly feeling) - air in subcutaneous tissue from rupture in respiratory system or infection with gas-producing organism - may be localized or cover a wide area - requires attention pleural friction rub – palpable, coarse, grating vibration, usually on inspiration - caused by inflammation of pleural surfaces - note position of trachea - place index finger in suprasternal notch and move it gently, side to side - space above to the inner borders of sternocleidomastoid muscles should be equal on both sides - slight, barely noticeable deviation to right is not unusual C.

PERCUSSION - compare all areas bilaterally - suggested sequence: examine back with patient sitting with head bent forward, arms folded in front have patient raise arms overhead for all positions percuss at 4- to 5-cm intervals resonant – loud intensity, low pitch, hollow qlty hi pitch, very dull qlty - heard over the lungs

flat – soft intensity, - heard over bone

dull – med. intensity, med./hi pitch, dull thud qlty tympanic – loud intensity, hi pitch, drumlike - heard over bone - heard over stomach D.

AUSCULTATION - characterized by intensity, pitch, quality and duration - with patient sitting upright, if possible, have him/her breathe slowly and deeply through the mouth, exaggerating normal respiration - be careful of hyperventilation

- diaphragm is usually preferred to bell for listening to high-pitched sounds and it provides broader area of sound - should be no movement of patient or stethoscope except for respiratory excursion - listen systematically at each position throughout inspiration and expiration 1.

Breath Sounds – made by flow of air through respiratory tree - characterized by pitch, intensity, and quality and relative duration of inspiratory and expiratory phases - relatively more difficult to hear or are absent if fluid or pus has accumulated in pleural space, if secretions or a foreign body obstructs bronchi, if lungs are hyperinflated, or if breathing is shallow from splinting for pain - easier to hear when lungs are consolidated a.

Vesicular – low-pitched, low-intensity sound heard over healthy lung

tissue - heard over lung fields (sides and back) b. Bronchovesicular – heard over major bronchi and are typically moderate in pitch and intensity - abnormal if heard over peripheral lung tissue - heard right over sternum in the middle c. Bronchial - ordinarily heard only over trachea - abnormal if heard over peripheral lung tissue - heard right under collarbone at neck amphoric – breathing that resembles the noise made by blowing across the mouth of a bottle - heard with a large, relatively stiff-walled pulmonary cavity or tension pneumothorax with bronchopleural fistula cavernous breathing – sounding as if it were coming from a cavern - commonly heard over pulmonary cavity in which wall is rigid 2.

Adventitious Sounds a. Crackles – abnormal respiratory sound heard more often during

inspiration - characterized by discrete discontinuous sounds - individual noise tends to be brief and interval is similarly brief - fine, high pitched and relatively short in duration (sibilant) - coarse, low pitched, and relatively longer in duration (sonorous)

- caused by disruptive passage of air through small airways in respiratory tree - dry quality, more crisp than gurgling, apt to occur high in respiratory tree b. Rhonci – sonorous wheezes – deeper, more rumbling, more pronounced during expiration - prolonged and continuous, less discrete than crackles - caused by passage of air through airway obstructed by thick secretions, muscular spasm, new growth, or external pressure - may be palpable at times - tends to disappear after coughing c.

Wheezes – sibilant wheeze – thought of as a form of rhonchus - continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration - caused by relatively high-velocity air flow through narrowed airway - composed of complex combination of variety of pitches or of a single pitch - may vary from area to area and minute to minute - if heard bilaterally, may be caused by bronchospasm of asthma or acute or chronic bronchitis - unilateral or more sharply localized wheezing or stridor may occur with foreign body d.

Friction Rub – occurs outside respiratory tree - dry, crackly, grating, low-pitched sound (machine-like

quality) - heard both in expiration and inspiration, over the heart or lungs - caused by inflamed, roughened surfaces rubbing together e. gurgling sounds

Mediatinal Crunch (Hamman Sign) – loud crackles and clicking and - more pronounced toward end of expiration - easiest to hear when patient leans to left or lies down on left

side 3.

Coughs – common symptom of respiratory problems - preceded by deep inspiration, followed by closure of glottis and contraction of chest, abdominal and even pelvic muscles, then a sudden spasmodic expiration, forcing sudden opening of glottis - may be voluntary, but are usually reflexive response

- described according to moisture, frequency, regularity, pitch and loudness, and quality

III. A.

DEVELOPMENTAL VARIATIONS

INFANTS discharge uncommon -

- percussion may be unreliable inspect thoracic cage, noting size and shape observe nipples for symmetry in size and presence of swelling and patterns of respirations vary with room temperature, feeding and sleep cyanosis of hands and feet is common expected rates vary from 40 – 60/min, although 80/min is not

note regularity, nasal flaring is common coughing is rare and should be considered a problem sneezing is frequent and expected hiccups are frequent, though silent - frequent hiccupping, may suggest seizures, drug withdrawal, or encephalopathy - palpate ribcage and sternum, noting loss of symmetry, unusual masses or crepitus - listen to chest, if baby is crying and restless, wait for quieter time - not uncommon to hear crackles and rhonchi immediately after birth - stridor (high-pitched, piercing sound most often heard during inspiration) is result of obstruction high in respiratory tree - respiratory grunting is a mechanism infant uses to expel trapped air or fetal lung fluid while trying to retain air and increase oxygen levels B.

CHILDREN – use thoracic muscles for respiration by age 6 or 7 - respiratory rates decrease with age and without significant gender difference newborn = 30 – 80 rpm 1 year = 20 – 40 rpm 3 years = 20 – 30 rpm 6 years = 16 – 22 rpm 10 years = 16 – 20 rpm 17 years = 12 – 20 rpm - if roundness of chest persists past 2nd year of life, be concerned about possibility of chronic obstructive pulmonary problem such as cystic fibrosis - children younger than 5 or 6 may not be able to give enough of expiration to satisfy, particularly when subtle wheezing is suspected - ask child to “blow out” flashlight or blow away tissue C.

PREGNANT WOMEN – dyspnea is common - decrease in functional residual capacity (resting position of lungs after normal expiration)

- increase in vital capacity (amt of air that can be expelled at normal rate of exhalation after max. inspiration) - increased tidal volume (amt of air inhaled and exhaled during normal breathing) - increased ventilation by breathing more deeply, not more frequently D.

OLDER ADULTS – chest expansion is often decreased - may be less able to use respiratory muscles because of muscle weakness, general physical disability, or sedentary lifestyle - bony prominences are marked and loss of subcutaneous tissue - dorsal curve of thoracic spine is pronounced (kyphosis – hunchback) with flattening of lumbar curve - AP diameter increases in relation to lateral diameter - more difficulty breathing deeply and holding breath - tire more quickly even when well

IV.

COMMON ABNORMALITIES

A. ASTHMA (REACTIVE AIRWAY DISEASE) – chronic obstructive pulmonary disease (COPD) - characterized by airway inflammation and generally resulting from airway hyperreactivity triggered by allergens, anxiety, upper respiratory infections, cigarette smoke or other environmental poisons, or exercise - paroxysmal dyspnea, tachypnea, cough, wheezing on expiration and inspiration, chest pain - may last for minutes, hours or prolonged over days - varies in intensity B. age

ATELECTASIS – incomplete expansion of lung at birth or collapse of lung at any - affected area of lung is airless - overall effect is to dampen or mute the sounds in the involved area

C.

BRONCHITIS – inflammation of mucous membranes of bronchial tubes - may be accompanied by fever and chest pain - initial stimulus is irritation by an internal or external noxious influence

D. PLEURISY – inflammatory process involving visceral and parietal pleura, often the result of pulmonary infections, bacterial or viral, and sometimes associated with neoplasm or asbestosis - onset is usually sudden and typical pleuritic pain is acute - becomes “dry making breathing difficult - rubbing can be felt and heard - respirations are rapid and shallow, with diminished breath sounds

- accompanied by fever, tachypnea, and malaise E. PLEURAL EFFUSION – excessive nonpurulent fluid in pleural space resulting in permanent fibrotic thickening - findings vary with severity and position of patient - fluid is mobile and will gravitate to most dependent position - breath sounds are muted F. EMPYEMA – occurs when fluid collected in pleural spaces is purulent exudate, arising most commonly from adjacent infected, sometimes traumatized, tissues - may be complicated by pneumonia, penetrating injury, or bronchopleural fistulae - breath sounds are distant or absent in affected area, percussion is dull, vocal fremitus is absent - patient is febrile, tachypneic and appears ill G. LUNG ABSCESS – well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis - may at first appear to be localized pneumonia - percussion is dull, breath sounds distant or absent over affected area - may have pleural friction rub - cough may produce purulent, foul-smelling sputum - patient is obviously ill and febrile, sometimes tachypneic - breath has foul odor H. PNEUMONIA – inflammatory response of bronchioles and alveolar spaces to infective agent (bacterial, fungal, or viral) - dyspnea, tachypnea, crackles - diminished breath sounds, percussion is dull I.

INFLUENZA – host of viruses cause this acute, generalized, febrile illness - characterized by cough, fever, malaise, headache, coryza and mild sore throat typical of common cold - elderly, very young and chronically ill are particularly susceptible (may prove fatal) - yearly immunization is often preventive - crackles, rhonchi, tachypnea, generally nonproductive cough and substernal pain J. TUBERCULOSIS – chronic infectious disease that most often begins in the lung but may then have widespread manifestations in many organs and systems - inhaled from airborne moisture of coughs and sneezes of infected person and given the opportunity to settle in furthest reaches of lung

K. PNEUMOTHORAX – presence of air or gas in pleural cavity may be result of trauma or may occur spontaneously - air becomes trapped on expiration and results in increased pressure in pleural space - breath sounds are distant, percussion may boom - “coin click” = place coin over suspicious area in chest (posteriorly), while listening on opposite side (anteriorly), have someone strike coin with edge of another - clear click will be heard only in event of pronounced pneumothorax L. HEMOTHORAX – presence of blood in pleural cavity may be result of trauma or invasive medical procedures - air may be present with blood - breath sounds are distant or absent, percussion is dull and “coin click” is absent M. LUNG CANCER – generally refers to bronchogenic carcinoma, malignant tumor that evolves from bronchial epithelial structures - etiologic agents include tobacco smoke, asbestos, ionizing radiation, and other inhaled chemicals and noxious agents - may cause cough, wheezing, variety of patterns of emphysema and atelectasis, pneumonitis, and hemoptysis CHILDREN / ADOLESCENTS A. CYSTIC FIBROSIS – autosomal recessive disorder of exocrine glands involving lungs, pancreas, and sweat glands - cough with sputum is hallmark in children younger than 5 yrs - salt loss in sweat is distinctive - tolerance for exercise diminishes and pulmonary hypertension and cor pulmonale often occur B. EPIGLOTTITIS – acute, life-threatening disease almost always caused by type B influenzae - begins suddenly and progresses rapidly, often to full obstruction of airway and resulting in death - may occur at any age but occurs most often in children between 3 and 7 - 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 - fever may be high - epiglottis appears beefy red, immediate attention is required with help of anesthesiologist and/or otolaryngologist and radiologist

- direct examination of throat with or without tongue blade is to be avoided - immunization has greatly reduced incidence, gravity mandates attention C. CROUP – syndrome that generally results from infection with a variety of viral agents particularly parainfluenza viruses - occurs most often in very young, generally around 1½ - 3 - boys are more commonly affected, and some children are prone to recurrent episodes - harsh, bark-like cough, labored breathing, retraction, hoarseness, and inspiratory stridor - fever does not always accompany OLDER ADULTS A. CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) – nonspecific designation that includes a group of respiratory problems in which coughs, chronic and often excessive sputum production, and dyspnea are prominent features - irreversible expiratory airflow obstruction occurs - most patients have been smokers - chest may be barrel shaped, scattered crackles or wheezes may be heard - obstruction can be evaluated during forced maximal expiration - listen over trachea with diaphragm of stethoscope as patient inhales to the limit and then breathes out as quickly as possible through an open mouth - if forced expiration time is longer than 4 to 5 seconds, suspect airway obstruction B. Emphysema – perhaps the most severe COPD, a condition in which air may take over and dominate a space in a way that disrupts function - air spaces beyond terminal bronchioles dilate, rupturing alveolar walls, permanently destroying them, reducing their number, and permanently hyperinflating lung - alveolar gas is trapped, essentially in expiration, and gas exchange is seriously compromised - chronic bronchitis is common precursor - loss of elasticity because of aging, smoking, or impairment of defenses are also contributors - percussion tends to be hyperresonant, occasionally prolonged expiratory effort to expel air - dyspnea even at rest - cough is infrequent without much production of sputum - patient is thin, barrel chested, and even cachectic