Chapter 15
Thorax and Lungs
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Competencies
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Identify the anatomic landmarks of
the thorax.
Describe the characteristics of the
most common respiratory chief
complaints.
Perform inspection, palpation,
percussion, and auscultation on a
healthy adult and on a patient with
pulmonary pathology.
(continues)
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Competencies
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Explain the pathophysiology for
abnormal findings.
Document respiratory assessment
findings.
Describe the changes that occur in
the lungs with the aging process.
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Anatomy—Anterior
Thorax
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Sternum
Clavicles
Nipples
Suprasternal notch
Angle of Louis
Costal angle
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Anatomy—Posterior
Thorax
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Vertebra prominens
Spine
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Anatomy—Lungs
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Right lung—three lobes
Left lung—two lobes
Apex
Base
Midclavicular line (MCL)
Midaxillary line (MAL)
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Anatomy—Lungs
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Pleura
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Parietal
Visceral
Mediastinum or interpleural space
Bronchi
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Right
Left
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Anatomy—Lungs
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Alveoli
Diaphragm
External intercostal muscles
Accessory muscles
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Thoracic Anatomic
Topography
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Anterior axillary line
Midspinal (vertebral) line
Midsternal line
Posterior axillary line
Scapular line
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Physiology
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Ventilation
External respiration
Internal respiration
Control of breathing
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Health History
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Patient profile
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Age
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Children and young adults: bronchiectasis,
cystic fibrosis
Adults and older adults: chronic bronchitis,
emphysema, pneumonia, lung cancer
Gender
Race
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African American: sarcoidosis
Caucasian: cystic fibrosis
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Common Chief
Complaints
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Dyspnea
Cough
Sputum
Chest pain
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Characteristics of Chief
Complaint
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Quantity
Quality
Associated manifestations
Aggravating factors
Alleviating factors
Timing
Setting
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Past Health History
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Medical
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Respiratory specific
Nonrespiratory specific
Surgical
Medications
Communicable diseases
Allergies
Special needs
Childhood illnesses
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Family Health History
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Allergies?
Asthma?
Cystic Fibrosis?
Emphysema?
Cancer?
Bronchiectasis?
TB?
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Social History
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Alcohol, drug, or tobacco use
Travel history
Work and home environment
Hobbies and leisure activities
Stress
Economic status
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Health Maintenance
Activities
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Sleep
Diet
Exercise
Use of safety devices
Health check-ups
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Assessment of
the Thorax and Lungs
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Equipment
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Stethoscope
Centimeter ruler and measuring tape
Washable marker
Watch with second hand
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Inspection
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Shape of thorax
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Transverse diameter
Anteroposterior (AP) diameter
Symmetry of chest wall
Presence of superficial veins
Costal angle
Angle of the ribs
Intercostal spaces
Muscles of respiration
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Respirations
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Rate
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Eupnea 12 – 20 bpm
Tachypnea > 20 bpm
Bradypnea < 12 bpm
Apnea: no respiration for 10 or more
seconds
(continues)
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Respirations
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Pattern
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Cheyne-Stokes
Biot’s or Ataxisic
Apneustic
Agonal
(continues)
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Respirations
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Depth
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Shallow
Hyperpnea
Air trapping
Kussmaul’s
Sighing
(continues)
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Respirations
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Symmetry
Audibility
Patient position
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Upright
Supine
Orthopnea
Mode of breathing
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Sputum
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Color
Odor
Amount
Consistency
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Assessing Patients with
Respiratory Assistive
Devices
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Oxygen therapy
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Mode of delivery
Percentage of oxygen
Flow rate
Humidification
Pulse oximeter
(continues)
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Assessing Patients with
Respiratory Assistive
Devices
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Incentive spirometer
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Frequency of use; volume achieved;
number of repetitions
Endotracheal tube
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Size
Nasal or oral insertion
(continues)
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Assessing Patients sith
Respiratory Assistive
Devices
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Length of tube as it exits mouth or
nose
Cuff inflated or deflated
Tracheostomy tube
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Size
Cuffed or cuffless
How tube is secured to neck
(continues)
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Assessing Patients with
Respiratory Assistive
Devices
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Mechanical ventilation
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Type of ventilator
Fio2
Mode
Peep
Rate
Tidal volume
Alarms
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Palpation
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Anterior
Posterior
Lateral
Pulsations
Masses
(continues)
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Palpation
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Thoracic tenderness
Crepitus
Thoracic expansion
Tactile or vocal fremitus
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Percussion
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Anterior
Posterior
Lateral
Diaphragmatic excursion
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Auscultation—Fields
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Anterior
Posterior
Lateral
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Auscultation—Breath
Sounds
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Pitch
Intensity
Quality
Duration
Location
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Normal Breath Sounds
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Bronchial
Bronchovesicular
Vesicular
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Adventitious Breath
Sounds
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Crackle or Rale
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Wheeze
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Fine
Coarse
Sonorous (Rhonchi)
Sibilant
Pleural friction rub
Stridor
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Voice Sounds
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Bronchophony
Egophony
Whispered pectoriloquy
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Normal Findings
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AP to transverse diameter is 1:2
Elliptical-shaped thorax
Shoulders and scapula at same
height bilaterally
(continues)
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Normal Findings
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No masses or superficial veins
Costal angle < 90 degrees during
exhalation and at rest
Ribs articulate at a 45-degree angle
with the sternum
Absence of intercostal retractions
(continues)
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Normal Findings
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No accessory muscle use
Respiratory rate 12–20 breaths per
minute
Eupnea
Respiratory pattern is regular and
even
Respiratory depth is nonexaggerated
and effortless
(continues)
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Normal Findings
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Symmetrical rise and fall of thorax
Respirations are quiet, unless a few
centimeters from patient’s nose or
mouth
Able to breath comfortably in
supine, prone, or upright position
Usually breathe through nose
(continues)
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Normal Findings
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Small amount of sputum may be present
Sputum should be odorless and light
yellow to clear in color
No pulsations, masses, thoracic
tenderness, crepitus present
Thoracic expansion is 3 to 5 cm
Normal fremitus present on ulnar aspect
of hand
Trachea is midline
(continues)
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Normal Findings
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Resonant sound on percussion over
lung tissue
Dull sounds over diaphragm and
cardiac silhouette
Rib sounds are flat
Hyperresonance present if adult is
thin
(continues)
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Normal Findings
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Diaphragmatic excursion is 3 to 5
cm
Bronchial breath sounds over
trachea
Bronchovesicular breath sounds
over scapular area
Vesicular breath sounds over
peripheral lung
(continues)
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Normal Findings
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Whispered pectoriloquy,
bronchophony, egophony are
muffled
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Age-Related Changes
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Anatomic changes
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Increased work of breathing
Limited chest wall expansion
Muscle atrophy
Alveolar gas exchange
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Decreased surface area for diffusion
(continues)
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Age-Related Changes
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Regulation of ventilation
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Decreased sensitivity to changes in
carbon dioxide and oxygen
Lung defense mechanisms
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Decreased ciliary action
Diminished cough reflex
Increased susceptibility for infection
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