BIOE221 Session 5 Examination of Thorax- Respiratory system Bioscience Department
Session Objectives Understand the structure of the thorax and the organs contained in this cavity Understand the importance and rationale for the techniques used in a respiratory system examination. Make relations between this section and the previous sessions
Position & Surface Anatomy of the Thorax Thoracic cage defined by: sternum 12 pairs ribs 1-7 attach directly to sternum 8-10 attach to costal cartilage above 11-12 floating free palpable tips 12 thoracic vertebrae inferior border diaphragm separates thoracic cavity from abdominal cavity
Thoracic Landmarks Anterior suprasternal notch sternum manubrium/ body/ xiphoid process manubrosternal angle (angle of Louis) ribs costal angle Posterior vertebra prominens (spinous process of C7) spinous processes alignment with ribs before & after T4 inferior border of scapulae 12 th rib
Anterior Thoracic Cage (Jarvis 2016, p.413)
Reference Lines - Thorax Anterior chest mid sternal line mid clavicular line Anterior axillary line (Jarvis 2012)
Reference Lines - Thorax Posterior chest vertebral (mid spinal) line scapular line (Jarvis 2012)
Reference Lines - Thorax Lateral chest mid axillary line anterior axillary line posterior axillary line (Jarvis 2012)
Thoracic Cavity Contents (Tortora & Derrickson 2012)
Lung Fields Anterior View Posterior View (Jarvis 2016, p.415-416)
Lung Fields Right Lateral View Left Lateral View (Jarvis 2016, p.415-416)
Muscles for Breathing (Jarvis 2016, p.418)
Case History Questions Subjective data of the case history should include: Cough Duration, production of sputum Shortness of breath With level of activity Chest pain with breathing Past Hx respiratory infections Bronchitis, pneumonia, asthma, emphysema, TB Smoking hx No. Of cigs per day/ years smoked Environmental exposure Self care behaviours
Anterior Chest Inspection of anterior chest Appropriate draping will be required for respiratory examination Assessment of respiratory function by palpation, percussion and auscultation is performed on the posterior thorax.
Inspection Anterior Thorax Facial expression& demeanour relaxed unconscious breathing effort Level of consciousness alert/ cooperative Skin colour & condition no cyanosis of lips/ no unusual pallor / no plethora Quality of respiration normal, relaxed, quiet, regular, effortless breathing Use of accessory muscles of respiration Respiratory rate
Inspection Thorax Shape & configuration Spinous processes in straight line Thorax symmetric/ downward sloping ribs Scapulae placed symmetrically AP diameter < transverse diameter (approx. 0.75) Neck & trapezius muscles developed normally for age & occupation Position Relaxed posture/ arms comfortably at sides Skin colour & condition Note any lesions/ scars
Inspection Shape & Configuration (Jarvis 2016, p.442-443) Barrel Chest Normal Scoliosis Kyphosis
Palpation Posterior Thorax Palpation of the posterior thorax involves: General Palpation Temperature, tenderness, pain, structures and masses Symmetric expansion Normally the thoracic cage will expand equally on both sides as the patient breathes in. Tactile Fremitus Vocally induced vibrations that can be felt evenly on left to right comparison, and decreases in intensity as you move from the scapulae to the lung bases.
Symmetric Expansion (Jarvis 2012)
Palpation Symmetric Expansion Symmetric expansion refers to the equal movement of the right and left chest wall during inhalation. Possible abnormality Unequal chest expansion Marked atelectasis/ pneumonia/ trauma/ pneumothorax Pain on deep inspiration inflamed pleura
Tactile (Vocal) Fremitus (Jarvis 2012)
Palpation Tactile (Vocal) Fremitus Findings normally most prominent between scapulae decreases as you progress down due to more tissue impeding sound transmission Abnormal decreased obstruction to transmission of vibrations e.g. in bronchus/ emphysema/ pleural effusions increased compression or consolidation of lung tissue e.g lobar pneumonia
Percussion Posterior Thorax Lung fields Start at apices/ percuss intercostal spaces Compare side to side all the way down lung region Percuss at 5cm intervals, avoid scapulae & ribs Resonance low pitched, clear, hollow sound altered with heavy musculature/ obese Abnormal Hyperresonance too much air (lower pitched booming sound) e.g. emphysema/ pneumothorax (NB- hyperresonance normal in young children) Dull note abnormal density (soft muffled thud) e.g. pneumonia/ pleural effusion/ atelectasis/ tumour
Percussion Posterior Thorax (Jarvis 2012)
Auscultation Extraneous Noises Don t confuse background noises (extraneous noises) with lung sounds Causes Own breathing on stethoscope tubing Stethoscope tubing bumping on itself/ objects Patient shivering Patient s hairy chest Rustling of clothing/ paper
Auscultation Posterior Thorax Breath sounds Instruct person to breathe in and out through their mouth Listen to following lung areas bilaterally Posterior from apices at C7 to bases (T10) Laterally from axillae down to 7 th -8 th ribs Three types of normal breath sounds (adult/ older child) Bronchial breath sounds(tracheal) Bronchovesicular breath sounds Vesicular breath sounds See table 18-1 p. 430 in Jarvis (2016)
Auscultation Posterior Thorax (Jarvis 2012)
Adventitious Breath Sounds Adventitious sounds Added sounds superimposed on normal breath sounds, NOT normally heard in lungs Caused by Collision of moving air with secretions in the airway Popping open of previously deflated airway Narrowing of the airway causing whistling sound Called (Table 18-6: Jarvis 2016, p.446-447) Crackles (rales) Wheeze (rhonchi) Atelectatic crackles (not pathological)
Auscultation Posterior Thorax Abnormal findings Decreased/ absent breath sounds Bronchial tree obstructed Emphysema Pleurisy/ pleural thickening/ effusion/ pneumothorax Increased breath sounds E.G. Bronchial over peripheral lung fields Bronchopneumonia/ pleural effusion Crackles (rales) Consolidation/ pulmonary oedema (fluid in the alveoly) Wheezes (rhonchi) Asthma/ emphysema (airway narrowing)
Websites for lung Auscultation sounds Adventitious breath sounds http://www.youtube.com/watch?v=5ja6d1mguh0 Stridor http://www.youtube.com/watch?v=obr9y3srplg&feature=related Whooping cough http://www.youtube.com/watch?v=kzv4iahbc48&feature=related Normal and abnormal breath sounds bronchial, vesicular etc http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm
Resources Jarvis, C, 2016, Physical Examination & Health Assessment, 7 th edn, Elsevier, Sydney Tortora GJ & Derrickson B, 2014, Principles of Anatomy & Physiology, 14 th edn, John Wiley & Sons, USA
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