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Questions and Answers
What happens to breath sounds when there is decreased air flow?
Which characteristic of wheezes distinguishes them from crackles?
What does egophony indicate when the letter 'E' sounds like 'A'?
What is the expected sound when the patient whispers 'ninety-nine' in a case of whispered pectoriloquy?
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Which condition may cause transmitted voice sounds to be louder than normal?
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What might suggest that secretions are involved when assessing breath sounds?
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What anatomical region is defined as the part of the body between the neck and the abdomen?
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Which ribs are classified as true ribs?
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What is the location of the inferior angle of the scapula?
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Where is the 2nd intercostal space primarily used for medical procedures?
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Which ribs are categorized as false ribs?
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How many intercostal spaces (ICS) are there along the vertical axis?
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Which vertical line runs from the anterior axillary fold?
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What is the duration classification for chronic conditions?
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What is the purpose of palpating the sternal angle (Angle of Louis)?
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Which ribs are known as floating ribs?
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What sign indicates respiratory distress during inspection?
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What is a barrel chest characterized by?
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How is tactile fremitus assessed?
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What is crepitus during a physical examination?
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What should be observed for during chest inspection?
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What position should the thumbs be placed in for testing chest expansion?
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Which of the following is NOT a sign observed during chest inspection?
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What action should be taken with breast tissue when assessing tactile fremitus in women?
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What is indicated by the use of accessory muscles during breathing?
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What is the primary purpose of inserting a needle into the pleural space during a tension pneumothorax?
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Which rib's costal cartilage corresponds to the 2nd intercostal space for needle insertion?
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What is the purpose of a bronchoscopy?
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What is the common term for chest tube thoracostomy?
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What does the T4 mark on a chest x-ray indicate?
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What is thoracentesis primarily used for?
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Which anatomical landmark is used to locate the 2nd intercostal space?
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What is the optimal technique for needle insertion during tension pneumothorax?
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In which procedure is a thin tube with a light and camera used to inspect the lungs?
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What complication is addressed with a chest tube thoracostomy?
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What is the primary purpose of percussion in a clinical setting?
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Which of the following conditions is indicated by dullness in percussion notes?
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What pattern should be followed during percussion of the chest?
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What does absent descent of the diaphragm suggest during examination?
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What are the three main components of auscultation?
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Which finger is commonly used as the pleximeter in percussion?
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In which condition might the alveoli be filled with fluid and blood cells?
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What should be done with the stethoscope prior to auscultation?
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Which of these is NOT an indication of percussion?
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What should be noted during percussion regarding the percussion note?
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Study Notes
Chest Wall Anatomy
- Identify the sternal angle, or angle of Louis, as a key landmark for locating intercostal spaces
- The first 7 ribs are true ribs, ribs 8, 9, and 10 are false ribs, and ribs 11 and 12 are floating ribs
- The inferior angle of the scapula is typically located at the level of the 7th rib or 7th intercostal space
- Chest findings are described in two dimensions: along the vertical axis (intercostal spaces) and around the chest circumference (vertical lines)
Chest Wall Landmarks
- Anterior landmarks include the supraclavicular area, the middle of the sternum, the middle of the clavicle, the anterior axillary fold, and the midclavicular line
- Posterior landmarks include the vertebral column, the inferior angle of the scapula, and the posterior axillary fold
- Lateral landmarks include the apex of the axilla and the posterior axillary fold
Clinical Procedures on the Chest
- The 2nd intercostal space at the midclavicular line is the needle insertion site for tension pneumothorax, inserting the needle at the upper portion of the rib to avoid the intercostal vein, artery, and nerve
- The 4th intercostal space is the site for chest tube insertion
- The T4 level is the lower margin location for an endotracheal tube on a chest x-ray
Bronchoscopy
- A bronchoscopy is a procedure used to examine the lungs, including the bronchi, using a thin tube with a light and camera inserted through the nose or mouth
Thoracentesis
- A procedure where a needle is inserted into the pleural space to remove excess fluid, such as a pleural effusion, or air
Chest Tube Thoracostomy (CTT)
- CTT, or "putting in a chest tube," is a procedure used to drain fluid, blood, or air from the space around the lungs
- The triangle of safety for chest tube thoracostomy includes the following borders: inferior border of the rib, superior border of the rib, and the lateral border of the pectoralis major muscle
Endotracheal Tube Insertion
- An endotracheal (ET) tube is a flexible plastic tube inserted through the mouth into the trachea to assist with breathing
- The ET tube is connected to a ventilator to deliver oxygen to the lungs
Assessing Readiness to Quit Smoking (BRIEFS)
- Always assess and advise patients to quit smoking
Physical Examination
- Ensure proper draping for patient comfort
- Observe the rate, rhythm, depth, and effort of breathing
- Note if there are any signs of respiratory distress, such as tachypnea, cyanosis or pallor, audible sounds of breathing, retractions, or use of accessory muscles
Inspection of Chest Shape
- Observe the shape of the chest for abnormalities, such as:
- Barrel chest: anteroposterior (AP) diameter is equal to transverse diameter
- Pectus excavatum: sunken sternum
- Pectus carinatum (pigeon breast): protrusion of the sternum
- Kyphosis: abnormally rounded upper back
- Scoliosis: lateral curvature of the spine
Palpation
- Identify any areas of tenderness
- Check for crepitus, masses, and sinus tracts
Testing Chest Expansion
- Place thumbs at the level of T10 and observe symmetric lateral movement with inspiration
Palpating Tactile Fremitus
- Use the ball or ulnar surface of the hand to feel for tactile fremitus, the vibrations transmitted through the bronchopulmonary tree to the chest wall, while the patient says "99"
- Palpate both lungs for symmetric tactile fremitus in both anterior and posterior positions, displacing breast tissue if necessary
Percussion
- Percussion is used to establish whether underlying tissues are air-filled, fluid-filled, or consolidated
- Percuss one side of the chest then the other at each level in a ladder-like pattern
- Percussion notes and their characteristics:
- Resonance: normal sound over healthy lung tissue
- Hyperresonance: louder, booming sound over air-filled lungs, such as in emphysema
- Dullness: muffled sound over fluid or solid tissue, such as in pneumonia, pleural effusion, or atelectasis
- Flatness: very quiet, thudding sound over dense tissue, such as in muscle or bone
Identifying Diaphragmatic Excursion
- Percuss over the lower lung fields to identify the diaphragmatic excursion, or the range of movement of the diaphragm
- Absent descent of the diaphragm may indicate pleural effusion, and an abnormally high level suggests a pleural effusion or elevated hemidiaphragm due to atelectasis or phrenic nerve paralysis
Auscultation
- Listen to breath sounds with the diaphragm of the stethoscope, placing it directly on the skin
- Always listen to at least one full breath in each location, following a ladder-like pattern
- Auscultate during both inhalation and exhalation
Auscultation of Breath Sounds
- Note the intensity of breath sounds; decreased intensity may be due to decreased airflow or poor transmission of sound
- Identify silent gaps, which may indicate bronchial breath sounds
Characteristics of Breath Sounds
- Breath sounds are classified by intensity, pitch, and duration during inspiration and expiration
- Normal breath sounds include:
- Vesicular: soft, low-pitched, breezy sounds heard over most of the lung fields
- Bronchovesicular: medium-pitched, blowing sounds heard over the major bronchi
- Bronchial: loud, high-pitched, hollow sounds heard over the trachea and main bronchi
Patterns of Breathing
- Observe for different breathing patterns, including:
- Eupnea: normal, relaxed breathing
- Tachypnea: rapid, shallow breathing
- Bradypnea: slow, shallow breathing
- Hyperpnea: deep, rapid breathing
- Apnea: absence of breathing
Wheezes and Rhonchi
- Wheezes and rhonchi are both musical sounds produced by airflow obstruction
- Wheezes: relatively high-pitched, hissing quality, often associated with asthma
- Rhonchi: lower-pitched, snoring quality, may disappear with coughing, suggesting secretions
Transmitted Voice Sounds
- Assess transmitted voice sounds if abnormalities are suspected:
- Egophony: "ee" sounds like "A" with a nasal bleating quality, indicating consolidation
- Bronchophony: louder voice sounds, suggesting consolidation
- Whispered pectoriloquy: louder, clearer whispered sounds, suggesting consolidation
Importance of Transmitted Voice Sounds
- Changes in voice sound suggest that the air-filled lung has become airless, indicating consolidation or atelectasis
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Description
Explore the intricacies of chest wall anatomy, including key landmarks such as the sternal angle and rib classifications. Gain a comprehensive understanding of both anterior and posterior landmarks, along with their clinical significance in procedures. Perfect for medical students and professionals needing to refine their knowledge of thoracic anatomy.
