Respiratory system Flashcards
Demonstrate how you would investigate symmetrical inflation of the lung and describe the anatomical basis
The chest expands symmetrically on both sides during inspiration (when lungs inflate)
It is easier to detect a unilateral decrease in expansion of the chest (common causes are pneumothorax, pleural effusion, collapsed lung, etc.), whilst a bilateral decrease in expansion (seen in asthma) is difficult to detect
Ask subject to sit over the edge of the couch
Look for any asymmetry in movements of the chest wall anteriorly and posteriorly
Stand in front of the subject and place hands firmly on the anterior chest wall (just below 5th or 6th ribs, beneath the breast in female subject) with fingers extended around the sides of the chest
The thumbs should just meet in the anterior midline (mid-sternal line), resting lightly on the chest wall, to allow its movement during respiration
Ask subject to take a deep breath in and observe how far the tips of the thumbs move apart- should be at least 5cm
Repeat this examination on the posterior chest wall, with thumbs meeting in the posterior midline T10 (T7 is at the level of inferior angle of the scapula)
Movement of the anterior chest wall gives some idea of expansion of upper and middle lobes, while movement in the posterior chest wall indicates expansion of lower lobe of lung
Observe and describe the breathing pattern and breathing rate
Pretend to take the patient’s radial pulse whilst observing the movements of their chest as they breathe
Count breaths per minute- 12-18 is normal
How would you demonstrate percussion of upper/middle/lower lobe(s) of right/left lungs?
Percussion should be performed symmetrically and systematically on the anterior, posterior and axillary regions of the chest wall
In the anterior view:
Areas 1 and 2 for lung apex
Areas 3, 4, 6 and 10 for upper lobes
Areas 5 or 9 are for middle lobe (difficult in females)
Areas 7 and 8 for lower lobes
Areas 9 and 10 are just below the axilla on the anterior chest wall
In the posterior view:
Areas 1 and 2 for apex
Areas 3, 4, 5 and 6 for lower lobes
Ask patient to cross their arms in front of their chest to move the scapula laterally (protraction) for posterior wall percussion
Describe and demonstrate where you would auscultate upper/middle/lower lobe(s) of right/left lungs
Ask the subject to take deep breaths through the open mouth
Use the diaphragm of the stethoscope to examine all areas except for 1 and 2, for which the bell is used
Bronchial breathing: listen over the trachea, manubrium and sternal angle
Examine the rest of the area as marked on the diagram
Examine the apex (1 and 2) and also below axilla (9 and 10), and don’t forget the posterior chest wall
Area 9 is specifically for the middle lobe in females
In females the lower lobes on the anterior chest wall are below the base of the breast (6th rib)
Do both lungs sound the same?
Do upper and lower lobes sound the same?
Describe and demonstrate the surface markings of the oblique fissure of the right/left lung
The oblique fissure closely follows the medial border of the scapula when the arm is raised above the head of the subject. Extrapolate this line anteriorly to meet the lower border of the lung.
Posteriorly, the oblique fissure of both lungs (lung border) is marked at the level of spine of T3
Anteriorly, the lower border of the lung at the 6th costal cartilage is marked.
The connection between these two points by a smooth curved line running around the lateral thoracic wall represents the oblique fissure.
Describe and demonstrate the surface markings of the horizontal fissure of the right lung
Palpate the 4th costal cartilage on the right side and draw a line along the 4th cartilage and rib backwards to meet the oblique fissure in the mid-axillary line.
This marks the horizontal fissure separating the upper and middle lobes of the right lung.
It passes above the nipple in the male.
Describe and demonstrate the surface marking of the inferior margin of parietal pleura of right/left lung
Connecting the following points on the chest wall outlines the right parietal pleura:
1) The apex of the pleura (in the root of the neck above the medial 1/3 of the clavicle)
2) Just over the sternoclavicular joint
3) Just right of anterior median line at centre of sternal angle- level 2nd costal cartilage
4) Just right of anterior median line at level of 4th costal cartilage
5) Just right of anterior median line at level of 6th costal cartilage (xiphoid process)
6) Mid-clavicular line at level of 8th rib (just above costal margin)
7) Mid-axillary line at level of 10th rib (lowest point of costal margin)
8) Scapular line (lateral margin of erector spinae muscles) crossing the 12th rib
9) Transverse process of L1 vertebra (subcostal pleura below 12th rib)
10) Transverse process T1 vertebra (first palpate spine of T1)
To mark out the left parietal pleura, mark all points similarly to the right side, with the following exceptions: at 4) and 5), the pleura deflect sharply to the left to allow for the cardiac notch. The pleural deflection is shallower than the cardiac notch of the left lung.
From the midclavicular line to the vertebral column, the inferior boundary of the parietal pleura can be approximated by a line that runs between rib VIII, rib X, and vertebra TXII.
Describe the right and left lung in terms of fissures and lobes
The right lung has 3 lobes. The oblique fissure divides the upper and middle lobe from the lower lobe. The transverse fissure (right lung only) divides the upper from the middle lobe.
The left lung has only two lobes divided by an oblique fissure.
Describe and demonstrate the inferior margin of the visceral pleura of the right/left lung
The visceral pleura is continuous with the parietal pleura at the hilum of each lung, where structures enter and leave the organ. The visceral pleura is firmly attached to the surface of the lung, including both opposed surfaces of the fissures that divide the lungs into lobes.
The inferior margin of the lung is therefore the same as the inferior margin of the visceral pleura: midclavicular line at 6th rib (anteriorly), mid-axillary line at 8th rib (laterally), and scapular line at 10th rib (posteriorly).
Where is the triangle of safety for insertion of a chest drain?
The most common position for chest drain insertion is anterior to the mid-axillary line avoiding the long thoracic nerve lying behind, in the ‘safe triangle’.
This is the triangle bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major muscle, a horizontal line at the 5th intercostal space at the mid-axillary line (superior to the horizontal level of the male nipple), and an apex below the axilla
Describe and demonstrate the surface marking of mediastinal pleura of right and left lung on anterior surface of chest wall
Mediastinal pleura covers the mediastinum.
In the region of vertebra TV to TVII, the mediastinal pleura reflects off the mediastinum as a tubular, sleeve-like covering for its structures (i.e. airway, vessels, nerves, lymphatics) that pass between the lung and mediastinum.
This sleeve-like covering, and the structures it contains, forms the root of the lung.
The root joins the medial surface of the lung at the hilum, where the mediastinal pleura is continuous with the visceral pleura.
