1 Tracheobronchial Tree Anatomic Landmarks Tubular system that - PDF document

Chest and Lungs ¤ The chest and lungs allow for respiration Chapter 13 ¤ Purpose of respiration is to keep the body adequately supplied with oxygen and protected from excess accumulation of carbon dioxide Thorax and Respiratory System ¤ Respiration involves: ¤ Movement of air back and forth from the alveoli to the outside environment ¤ Gas exchange across the alveolar-pulmonary capillary membranes ¤ Circulatory system transport of oxygen to, and carbon dioxide from, the peripheral tissues Tracey A. Littrell, BA, DC, DACBR, DACO, CCSP 1 2 Chest ¤ Chest or thorax, a cage of bone, cartilage, and muscle ¤ Sternum ¤ Manubrium ¤ Xiphoid process ¤ Twelve pairs of ribs connected to the thoracic vertebrae and to the sternum by the costal cartilages ¤ Primary muscles of respiration Anatomy and Physiology ¤ Diaphragm ¤ Primary muscle ¤ Contracts during inspiration ¤ External intercostal muscles ¤ Increase the anteroposterior chest diameter during inspiration ¤ Primary muscles of respiration ¤ Interior intercostal muscles ¤ Decrease the transverse chest diameter during expiration ¤ Sternocleidomastoid and trapezius accessory muscles ¤ Brought into play when there are pulmonary problems and compromise 3 4 Chest (Cont.) Lungs ¤ Highly elastic lungs paired but not symmetric ¤ Interior divided into three spaces ¤ Right lung: three lobes ¤ Mediastinum ¤ Left lung: two lobes and a lingula ¤ Situated between lungs ¤ Lobes contain ¤ Contains all thoracic viscera except the lungs ¤ Blood vessels ¤ Right and left pleural cavities ¤ Lymphatics ¤ Lined with parietal and visceral pleurae ¤ Nerves ¤ Lungs enclosed by serous membrane ¤ Alveolar ducts connecting with alveoli ¤ Alveoli, as many as 300 million in adult 5 6 1

Tracheobronchial Tree Anatomic Landmarks ¤ Tubular system that provides a pathway along which air is filtered, humidified, and warmed ¤ Trachea lies anterior to the esophagus and posterior to the isthmus of the thyroid ¤ Divides into the right and left main bronchi at about the level of T4 or T5 and just below the manubriosternal joint ¤ Topographic markers ¤ The main bronchi are divided into three branches on the right and two on the ¤ Nipples (usually 4 th intercostal space for males; more variable for left females) ¤ Right bronchus wider, shorter, and more vertically placed than the left bronchus ¤ Manubriosternal junction (2 nd intercostal space) (and therefore more susceptible to aspiration of foreign bodies) ¤ Suprasternal notch ¤ The branches then begin to subdivide into terminal bronchioles and ultimately into ¤ Costal angles respiratory bronchioles where gas exchange takes place ¤ Vertebra prominens ¤ The bronchial arteries branch from the anterior thoracic aorta and the intercostal arteries, supplying blood to the lung parenchyma and stroma ¤ Spinous process of C7 or T1 ¤ Bronchial vein is formed at the hilum of the lung ¤ Clavicles (apex of the lung partially above the clavicles) ¤ Most of the blood supplied by the bronchial arteries is returned by the pulmonary veins 7 8 Infants and Children Infants and Children (Cont.) ¤ Fetal lungs contain no air; gas exchange is through placenta ¤ At birth, lungs adapt to postnatal function ¤ Chest of the newborn is generally round ¤ Relative decrease in pulmonary pressure most often leads to closure of the foramen ovale within minutes after birth ¤ Chest circumference is same as head circumference until about 2 years of age—why would a child have a barrel chest? ¤ Increased oxygen tension in the arterial blood usually stimulates contraction and closure of the ductus arteriosus ¤ With growth, the chest assumes adult proportions, with the ¤ Reminder: The foramen ovale and the ductus arteriosus do not lateral diameter exceeding the anteroposterior diameter always close so readily ¤ Chest wall is thinner and bony structures more prominent and yielding than in adults 9 10 Pregnant Women Older Adult ¤ Mechanical and biochemical factors lead to changes in respiratory function ¤ Barrel chest from loss of muscle strength in thorax and ¤ Enlarging uterus diaphragm and loss of lung resiliency ¤ Increased progesterone ¤ Skeletal changes emphasizing dorsal curve of thoracic spine ¤ Anatomic changes in chest ¤ Alveoli less elastic, causing fatigue and dyspnea on exertion ¤ Lower ribs flare ¤ Diaphragm rises above usual position ¤ Decrease in vital capacity/increase in residual volume ¤ Diaphragm movement increases so that major work of breathing is done by diaphragm ¤ Mucous membranes drier ¤ Minute ventilation increases due to increased tidal volume ¤ Respiratory rate usually remains unchanged, unless pain alters 11 12 2

Review of Related History Coughs History of Present Illness ¤ Coughing ¤ Describe ¤ Onset ¤ Dry or moist ¤ Nature of cough ¤ Onset (Gradual or sudden? How long? Precipitating event(s)? ¤ Sputum production ¤ Frequency of occurrence ¤ Sputum characteristics ¤ Regularity ¤ Pattern ¤ Pitch and loudness ¤ Severity ¤ Postural influences ¤ Associated symptoms ¤ Quality ¤ Efforts to treat 13 14 Sputum History of Present Illness (Cont.) ¤ The production of sputum is generally associated with cough ¤ Shortness of breath ¤ Onset ¤ Describe ¤ Pattern ¤ Color (Spectrum from ________ to ________) ¤ Position most comfortable, number of pillows used ¤ Consistency (Spectrum from thin to thick) ¤ Related to extent of exercise, certain activities, time of day, eating ¤ Odor ¤ Harder to inhale or exhale ¤ Severity ¤ Associated symptoms ¤ Efforts to treat 15 16 History of Present Illness (Cont.) Past Health History ¤ Thoracic trauma or surgery, dates of hospitalization for ¤ Chest pain pulmonary disorders ¤ Onset and duration ¤ Associated symptoms ¤ Use of oxygen and ventilation-assisting devices ¤ Efforts to treat ¤ CPAP or BiPAP ¤ Other medications ¤ Chronic pulmonary diseases ¤ Illicit drugs (e.g., cocaine) ¤ Other chronic disorders ¤ Testing ¤ Immunization against Streptococcus pneumoniae , influenza 17 18 3

Personal and Social History Family History ¤ Employment ¤ Home environment ¤ Tobacco use ¤ Tuberculosis (TB) ¤ Exposure to respiratory infections, influenza, TB ¤ Cystic fibrosis ¤ Emphysema ¤ Nutritional status ¤ Allergy, asthma, atopic dermatitis ¤ Use of complementary and alternative therapies ¤ Malignancy ¤ Regional/travel exposures ¤ Bronchiectasis ¤ Hobbies ¤ Bronchitis ¤ Use of alcohol/drugs ¤ Clotting disorders (risk of pulmonary embolism and ________) ¤ Exercise tolerance 19 20 Infants and Children Pregnant Women ¤ Low birth weight and prematurity ¤ Weeks of gestation ¤ Coughing and sudden-onset shortness of breath ¤ Presence of multiple fetuses, polyhydramnios, other conditions in which uterus displaces diaphragm ¤ Possible ingestion of kerosene, antifreeze, or hydrocarbons in household cleaners ¤ Exercise type and energy expenditure ¤ Apneic episodes; use of apnea monitor ¤ Exposure to and frequency of respiratory infections ¤ Swallowing dysfunction ¤ Gastroesophageal reflux ¤ History of pneumococcal and influenza vaccination 21 22 Older Adults ¤ Exposure and frequency of respiratory infections ¤ History of pneumococcal and flu vaccine ¤ Need for supplemental oxygen ¤ Effects of weather on respiratory efforts and infection occurrence ¤ Immobilization and sedentary habits ¤ Difficulty swallowing Examination and Findings ¤ Altered activities from respiratory symptoms ¤ Emphasize ¤ Smoking history ¤ Cough ¤ Dyspnea on exertion or breathlessness ¤ Fatigue ¤ Weight changes ¤ Fever and night sweats 23 24 4

Order of the Examination Equipment ¤ None of the following examinations are invasive—so why is the ¤ Marking pen order important? ¤ Centimeter ruler and tape measure ¤ 1. Inspection ¤ Stethoscope with bell and diaphragm (for infants, you will need ¤ 2. Palpation a smaller stethoscope) ¤ 3. Percussion ¤ Drapes ¤ Diaphragmatic excursion ¤ 4. Auscultation ¤ NO EXAM SHOULD BE INTERPRETED IN ISOLATION OF THE HISTORY AND OTHER EXAM FINDINGS 25 26 Inspection Inspection (Cont.) ¤ Chest ¤ Peripheral clues may suggest pulmonary or cardiac difficulties ¤ Shape and symmetry ¤ Fingers: clubbing ¤ Chest wall movement ¤ Breath: odor ¤ Superficial venous patterns ¤ Skin, nails, and lips: cyanosis or pallor ¤ Prominence of ribs ¤ Lips: pursing ¤ Anteroposterior vs. transverse diameter ¤ Nostrils: flaring ¤ Barrel chest ¤ Sternal protrusion ¤ Spinal deviation 27 28 29 30 5