Thorax and Lungs Anatomy PDF

THORA X AND LUNGS M I K H A I L N E S S M. B U H AY, M D STUDY THE CHEST WALL ANATOMY. Thorax is the part of the body between the neck and the abdomen STUDY THE CHEST WALL ANATOMY. Palpate your ste...

THORA X AND LUNGS M I K H A I L N E S S M. B U H AY, M D STUDY THE CHEST WALL ANATOMY. Thorax is the part of the body between the neck and the abdomen STUDY THE CHEST WALL ANATOMY. Palpate your sternal angle (Angle of Louis). Then slowly move to its lateral sides and feel for the 2nd costal cartilage(2nd rib). This is important later for locating the different intercostal spaces (ICS). LOCATING FINDINGS ON THE CHEST Describe chest findings in two dimensions: – Along the vertical axis (Eleven ICS) It’s like you’re using a map for – Around the circumference of the chest (Vertical Lines) your findings. Along the vertical axis, you will use the intercostal spaces Around the chest circumference, you will use the vertical lines. We will talk about these in a while.  The first 7 ribs are your TRUE RIBS. Ribs 8, 9 and 10 are your FALSE RIBS. While your Ribs 11 and 12 are your RED = ICS # FLOATING RIBS BLACK = RIB #  This is the posterior thorax The inferior angle of the scapula is usually at the level of the 7th rib or 7th ICS. RED = ICS # BLACK = RIB #  CIRCUMFERENCE OF THE CHEST: VISUALIZE A SERIES OF VERTICAL LINES This is the At the middle of the supraclavicular sternum area At the middle of the clavicle Vertical line from the anterior axillary fold  Vertical line from the anterior axillary fold Vertical line from the apex of the axilla Vertical line from the posterior axillary fold  Vertical line along the inferior angle of the scapula Vertical line along the vertebral column ANTERIOR LANDMARKS POSTERIOR LANDMARKS LATERAL LANDMARKS  NOTE SPECIAL LANDMARKS: 2nd intercostal space for needle insertion (thoracentesis) for tension pneumothorax. 4th intercostal space for chest tube insertion. T4 for the lower margin of an endotracheal tube on a chest x-ray.  Let’s practice again what you have learned. Palpate your sternal angle (Angle of Louis). Then slowly move to its lateral sides and feel for the 2nd costal cartilage(2nd rib).  The 2nd ICS at the midclavicular line (MCL) is for needle insertion for tension pneumothorax (air inside your pleural space). Needle is inserted at the upper portion of the rib so as to prevent hitting the intercostal VAN (vein, artery and nerve) Treatment for a pneumothorax usually involves inserting a needle or chest tube between the ribs to remove the excess air. However, a small pneumothorax may heal on its own.  The needle should only reach the pleural space to release the trapped air in the pleural space (pneumothorax). BRONCHOSCOPY A bronchoscopy is a procedure that allows a doctor to examine the inside of the lungs, including the bronchi. During a bronchoscopy, a doctor inserts a thin tube containing a light and camera into the lungs through the nose or mouth THORACENTESIS Thoracentesis is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, or air from the pleural space to help you breathe easier. THORACENTESIS  CTT: CHEST TUBE THORACOSTOMY CTT, commonly referred to as “putting in a chest tube”, is a procedure that is done to drain fluid, blood, or air from the space around the lungs.  TRIANGLE OF SAFETY for Chest Tube Thoracostomy (CTT) These are the different borders ENDOTRACHEAL TUBE INSERTION  This is an Endotracheal (ET) tube. An ET tube is a flexible plastic tube that is placed through the mouth into the trachea to help a patient breathe. The ET tube is then connected to a ventilator, which delivers oxygen to the lungs. T4 is for the lower margin of an endotracheal tube on a chest x-ray. ANTERIOR AND POSTERIOR LUNGS Apex of the lungs found at the supraclavicular area  LUNG FISSURES The right lung has the horizontal and oblique fissures dividing the right The left lung only has the oblique lung into 3 lobes (Right upper, fissure dividing the left lung into 2 middle and lower lobes) lobes (Left upper and lower lobes) Oblique fissure Horizontal fissure SURFACE MARKINGS This is very important for us to localize the lesion in lung. ANATOMIC DESCRIPTORS OF THE CHEST Supraclavicular—above the clavicles Infraclavicular—below the clavicles Interscapular—between the scapulae Infrascapular—below the scapulae Bases of the lungs—the lowermost portions  THE TRACHEOBRONCHIAL TREE The right main bronchus is shorter, wider and more vertical compared to your left main bronchus. This is the main reason why foreign objects lodge more frequently at the right main bronchus. THE PLEURAE Two continuous pleural surfaces, or serous membranes, separate the lungs from the chest wall. –The visceral pleura Covers the outer surface of the lungs Lack sensory nerves –The parietal pleura Lines the pleural cavity along the inner rib cage and the upper surface of the diaphragm Intercostal and phrenic nerves  Transudative VS Exudative type of pleural effusion. MUSCLES FOR RESPIRATION THE HEALTH HISTORY Common or Concerning Symptoms Chest pain Shortness of breath (dyspnea) Wheezing Cough Blood-streaked sputum (hemoptysis) Daytime sleepiness or snoring and disordered sleep SOURCES OF CHEST PAIN AND RELATED CAUSES Now we’re reminded that not all chest pains are caused by a cardiac pathology. CHEST PAIN Chest pain is reported in one in four patients with panic and anxiety disorders Angina pectoris Some call this your Levine’s sign – clenched fist over the sternum Musculoskeletal pain – finger pointing to a tender spot on the chest wall Heartburn – hand moving from the neck to the epigastrium COUGH A cough is a reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi. Duration: – Acute: Less than 3 weeks – Subacute: 3-8 weeks – Chronic: More than 8 weeks ADVERSE EFFECTS OF SMOKING ON HEALTH AND DISEASE ASSESSING READINESS TO QUIT SMOKING: BRIEF INTERVENTIONS MODELS Always assess and advise your patient to quit smoking.  PHYSICAL EX AMINATION INSPECTION Position the patient Drape appropriately Carefully observe the rate, rhythm, depth, and effort of breathing OBSERVE THE SHAPE OF THE CHEST Observe the shape of the chest Barrel Chest AP Diameter = Transverse Diameter Observe the shape of the chest OBSERVE THE SHAPE OF THE CHEST OBSERVE THE SHAPE OF THE CHEST INSPECTION Symmetrical? Lag/delay? Signs of respiratory distress? – Tachypnea – Cyanosis or pallor – Audible sounds of breathing – Retractions/Use of accessory muscles Skin and soft tissue sink in DIFFERENT RETRACTIONS PALPATION Identify tender areas Crepitus? Crepitus is a crackling or popping sound that occurs as a result of Masses? tissues rubbing together abnormally. The sound results from an abnormal interaction between air, fluid or Sinus tracts? bone. – Tunneling wounds  TEST CHEST EXPANSION Place thumbs at about the level of T10. During inspiration, you should be able to note the symmetric lateral movement of your thumb and hands.  TEST CHEST EXPANSION Place your thumbs along each costal margin, your hands along the lateral rib cage. Slide them medially a bit to raise loose skin folds between your thumbs. During inspiration, you should be able to note the symmetric lateral movement of your thumb and hands. PALPATE BOTH LUNGS FOR SYMMETRIC TACTILE FREMITUS (POSTERIOR) Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetric. Use the ball or ulnar surface of your hand to feel for the tactile fremitus. Let the patient say “99”. Note the symmetric palpable vibrations. LOCATIONS FOR Fremitus is difficult to feel through PALPATING FREMITUS the breast tissue of women; in such cases, gently displace the breast (ANTERIOR) Use the ball or ulnar surface of your hand to feel for the tactile fremitus. Let the patient say “99”. Note the symmetric palpable vibrations. PERCUSSION Please practice how to do percussion. Pleximeter finger Plexor Finger/Striking finger PERCUSSION Percussion sets the chest wall and underlying tissues in motion, producing audible sound and palpable vibrations. Percussion helps you establish whether the underlying tissues are air-filled, fluid-filled, or consolidated. So through percussion, we want to establish what is the underlying tissue especially in different pathologies. Eg. Air = pneumothorax Fluid-filled = pleural effusion Consolidation = Severe pneumonia (swelling or hardening of lung tissue) PERCUSSION Your goal is to transmit vibrations through the bones of this joint to the underlying chest wall Percussion Notes and Their Characteristics  PERCUSS ONE SIDE OF THE CHEST AND THEN THE OTHER AT EACH LEVEL IN A LADDER-LIKE PATTERN Follow this ladder- like pattern in doing your percussion. Note for the percussion note.  PALPATE AND PERCUSS IN A “LADDER” PATTERN Follow this ladder-like pattern in doing your percussion. Note for the percussion note. PERCUSSION Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples: – Lobar pneumonia (alveoli are filled with fluid and blood cells) – Pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. IDENTIFY THE EXTENT OF DIAPHRAGMATIC EXCURSION Absent descent of the diaphragm can indicate pleural effusion. An abnormally high level suggests a pleural effusion or an elevated hemidiaphragm from atelectasis or phrenic nerve paralysis AUSCULTATION Auscultation involves: (1) listening to the sounds generated by breathing (2) listening for any adventitious (added) sounds, and (3) if abnormalities are suspected, listening to the sounds of the patient’s spoken or whispered voice as they are transmitted through the chest wall (transmitted voice sounds). AUSCULTATION Listen to the breath sounds with the diaphragm of your stethoscope. Always place the stethoscope directly on the skin. Use the ladder pattern. Listen to at least one full breath in each location. Follow this ladder-like pattern in doing your auscultation. Listen carefully for the breath sounds during INHALATION and EXHALATION AUSCULTATION Note the intensity of the breath sounds. –Breath sounds may be decreased when air flow is decreased (obstructive lung disease or respiratory muscle weakness) transmission of sound is poor (pleural effusion, pneumothorax, or COPD). Silent gap? (bronchial breath sounds) AUSCULTATION Breath sounds are classified by intensity, pitch, and duration during inspiration and expiration. CHARACTERISTICS OF BREATH SOUNDS All over the chest CHARACTERISTICS OF BREATH SOUNDS PATTERNS OF BREATHING WHEEZES AND RHONCHI Wheezes and rhonchi last much longer and sound more musical than crackles.  Relatively high-pitched Hissing quality Often suggests asthma WHEEZES AND RHONCHI Rhonchi –considered by some to be a variant of wheezes, arising from a narrowed airway, but lower in pitch, snoring quality. –Unlike wheezes, rhonchi may disappear with coughing, so secretions may be involved.  Picture to help you differentiate CRACKLES, WHEEZING AND RHONCHI TRANSMITTED VOICE SOUNDS If you hear abnormally located bronchovesicular or bronchial breath sounds, assess transmitted voice sounds: –Egophony –Bronchophony –Whispered pectoriloquy TRANSMITTED VOICE SOUNDS Egophony. –Ask the patient to say “ee.” –You will normally hear a muffled long E sound. – If “ee” sounds like “A” and has a nasal bleating quality, an E-to- A change, or egophony, is present. TRANSMITTED VOICE SOUNDS Bronchophony. – Ask the patient to say “ninety-nine.” – Normally the sounds transmitted through the chest wall are muffled and indistinct. – Louder voice sounds are called bronchophony. – Localized bronchophony and egophony are seen in lobar consolidation from pneumonia. TRANSMITTED VOICE SOUNDS Whispered pectoriloquy. – Ask the patient to whisper “ninety-nine” or “one-two- three.” – The whispered voice is normally heard faintly and indistinctly, if at all. – Louder, clearer whispered sounds are called whispered pectoriloquy TRANSMITTED VOICE SOUNDS These changes in voice sound suggest the air-filled lung has become airless.  Notice the opacity here as compared to the normal lung. Lung consolidation occurs when the air that usually fills the small airways in your lungs is replaced by pus, blood, or water. DESCRIBING YOUR FINDINGS Normal Chest and Lungs: –Equal chest expansion with clear breath sounds. OR Thorax – Symmetric with good expansion Lungs – Resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi. Diaphragm descends 4 cm bilaterally.  Consolidation Pleural Pneumothora Effusion x Tactile/Vocal Increased Decreased Decreased Fremitus /Absent /Absent Breath sounds Bronchial Decreased Decreased Crackles Absent over fluid Percussion Dull Dull Hyperresonant THANK YOU!