BATES CHAPTER 15
Intercostal space number = rib number above it
Sternal angle (Angle of Louis) - horizontal bony ridge where manubrium joins body of sternum
o Directly adjacent to 2nd rib and costal cartilage
2nd intercostal space for needle insertion to decompress tension pneumothorax
Intercostal space between 4th and 5th ribs = chest tube insertion
Level of 4th rib = lower margin of well-placed ET tube
Costal cartilage of 1-7 ribs articulate with sternum
Cartilage of 8-10 articulate with costal cartilage above them
11 and 12 rib have no anterior attachment = “floating rib”
Posteriorly, 12th rib is starting point for counting ribs and intercostal spaces
o Inferior scapula tip usually at 7th rib or intercostal space
o When neck is flexed forward, most protruding process usually C7 vertebra, ribs
coincide with thoracic vertebrae
Intercostal space between 7 and 8 = thoracentesis needle immediately superior to 8th rib
Midsternal line – along sternum
Midclavicular line – clavicular midpoint
Anterior axillary line – anterior axillary fold
Midaxillary line – axilla apex
Posterior axillary line – posterior axillary fold
Scapular line – inferior angle of scapula
Vertebral line – overlies thoracic spinous processes
“Triangle of Safety” – in midaxillary line formed by lateral border pectoralis major anteriorly,
lateral border latissimus dorsi posteriorly, nipple line (4th and 5th intercostal space) inferiorly
– “safe position” for chest tube insertion
Apex of each lung about 2-4 cm above inner 1/3 of clavicle
Anterior lung lower border crosses 6th rib at midclavicular line and 8th rib at midaxillary line
Posterior lung border at T10
Inspiration descends d/t constriction and descension of diaphragm
Oblique (major) fissure – divides lung in half
o T3 obliquely down and around chest to 6th rib at midclavicular line
Horizontal (minor) fissure – further divides R lung
o Runs anteriorly close to 4th rib and meets oblique fissure in midaxillary line near 5th
rib
R lung – upper, middle, lower lobe
L lung – upper and lower lobe
Supraclavicular – above clavicles
Infraclavicular – below clavicles
Interscapular – between scapulae
Infrascapular – below scapulae
Apex of lung – uppermost portion
Base of lung – lowermost portion
Trachea bifurcates into mainstem bronchi at sternal angle and T4
o R main bronchus wider, shorter, more vertical than L main and directly enters lung
hilum
Aspiration PNA more common in R middle and lower lobes
, o L main bronchus extends inferolaterally from below aortic arch and anterior to
esophagus and thoracic aorta and then enters lung hilum
Each main bronchus divides into lobar then segmental bronchi and bronchioles and
terminated into sac-like alveoli where gas exchange occurs
Two continuous pleural surfaces, or serous membranes, separate lungs from chest wall
o Visceral pleura covers outer surface of lung
o Parietal pleura lines pleural cavity along inner rib cage and upper diaphragm surface
o Pleural space between visceral and parietal contains serous fluid
Pleural effusion - accumulation of pleural fluid
Parietal pleura inflammation causes pleuritic pain
Diaphragm – primary muscle of inspiration
o Inspiration – contraction – descends
o Scalenes – run from cervical vertebrae to 1st 2 ribs
o Parasternals – parasternal intercostal muscles cross obliquely from sternum to ribs
o Intrathoracic pressure decreases as thorax expands drawing air through
tracheobronchial tree into alveoli
o Expiration – relaxes – ascends
Abd muscles assist
o Accessory muscles – SCM and scalenes
History
o Symptoms that warrant medical interventions
Inability to speak in full sentences, use of accessory muscles, cyanosis, evidence
of low O2 sat, pulsus paradoxicus
o Thorough past medical hx, complete medical and allergy list
o Social hx – tobacco and recreational drugs, occupational and environmental exposures,
travel hx
Dyspnea (shortness of breath) - painless but uncomfortable awareness of breathing that’s
inappropriate to level of exertion
o Anxious patient present different
Difficulty taking deep breath, smothering sensation with ability to get enough
air, parathesis (sensation fo tingling or “pins and needles” around lips and
extremities)
Wheezes – musical respiratory sound may be audible to pt and others
Cough – reflex response to stimuli irritates receptors
o Acute = < 3 week
o Subacute = 3-8 week
o Chronic = > 8 week
o Dry/productive, volume of sputum with color consistency odor
Mucoid – translucent white or gray in viral infection of cystic fibrosis
Purulent – yellow or green in bacterial
Foul smelling – anaerobic lung abscess
Thick and tenacious – cystic fibrosis
o Associated symptoms often lead to cause
Hemoptysis – blood coughed up from lower respiratory tract
o Vary from blood streaked to frank blood
o Confirm source – lungs, pharynx, nose, mouth, GI tract
Chest pain – lung tissues have no pain receptors
, Physical exam should begin during interview by observing pt speak
o Inability to speak full sentences without stopping = increased respiratory drive or
impairment of ventilation with reduced vital capacity
o Increased work of breathing (supraclavicular retractions, use of accessory muscles of
ventilation, tripod position) = increased airway resistance or stiff lung/chest wall
Signs of respiratory distress
o Tachypnea – > 25 breaths/min
o Cyanosis or pallor
o Audible breathing sounds
o Accessory muscle use
Posterior chest
o Arms folded across chest with hands on shoulders – allows increased access to lung
fields
o Note shape and how chest moves
o Focus palpation on tender or bruising areas
o Sinus tracts – blind inflammatory tube-like structures opening onto skin
o Test chest expansion – lung excursion
o Tactile fremitus – palpable vibrations transmitted through bronchopulmonary tree to
chest wall as speaking “ninety-nine” or “one-one-one"
o Percussion helps establish underlying tissues filled with air, fluid, or consolidation
BOX 15-3
Pleximeter finger – stable middle finger
Plexor finger – striking middle finger
Flat, dull, resonant, hyper resonant, tympanic
Diaphragmatic excursion
o Auscultation – assessing airflow BOX 15-4
Cough once or twice to clear mild atelectasis or mucus
Diaphragm of stethoscope with ladder pattern
Silent gap suggests bronchial breath sound
Vesicular – soft and light pitched without pause
Bronchovesicular – inspiration and expiration equal length separated by slight
interval
Bronchial – louder, harsher, and higher pitch with short silent gap, expiration >
inspiration
Tracheal – loud harsh sound
Adventitious lung sounds – added sounds superimposed on usual breath sound
Crackles/rales
Wheezes
Rhonchi
Silent chest = minimal air movement = CLINICAL EMERGENCY
Pleural friction rub – coarse grating biphasic usually on exp
Egophony - “ee” sounds like “a” with nasal quality
Bronchophony - “ninety-nine”, not muffled, distinct louder voice
Pectoriloquy – whisper “ninety-nine” or “one-two-three", louder clearer whisper
sound
Should be faint and indistinct if heard at all
Anterior chest – same as posterior
, 2002 American Thoracic Society – 6-minute walk test to predict clinical outcome of COPD
patient
o Tests pulmonary function
o Require 100 ft hallway
o Measures distance patient can quickly walk on flat hard surface in 6 minutes
Forces expiratory time
o Slowed in obstructive pulmonary disease
o Take deep breath in then out as quickly and completely as possible with mouth open
o Listen over trachea and time audible expiration
o Try to get 3 consistent reading with short rest between
Fractured rib – local pain and tenderness in 1 or more ribs
o Compress chest on AP plane (sternum and thoracic spine) to distinguish fracture from
soft tissue injury
o “This painful? Where?”
Lung cancer
o 2nd most frequently diagnoses cancer in US and leading cause of cancer death in men
and women
o Risk factors – cigarette smoking, radon, familial risk
o Longer smoking hx and greater amount smoked associated with higher risk
o Only 16% diagnosed at early stage
o USPSTF grade B – low-dose-computed tomography (LDCT) lung cancer screening
Annual screening recommended for current smoker (or quit within last 15 years)
if smoked average 1 pack for 30 yr and age 55-80
Counsel smoking cessation and offer smoking cessation interventions
Latent tuberculosis
o Tuberculin skin test (TST)
Placement of purified protein derivative and 48-72 hr interpretation
Measured in mm of induration – palpable raised hardened area of swelling
Presence of induration = positive test
o Interferon-gamma release assay (IGRA) blood test
Single venous blood draw and lab processing within 8-30 hour
o USPSTF grade B rec for screening latent TB in asymptomatic adult at increased risk for
TB
o USPSTF – moderately beneficial to treat latent TB in preventing progression to active
disease
Primary harm = hepatotoxicity
Obstructive sleep apnea (OSA) – repeated episodes of upper airway collapse during rapid eye
movement (REM) sleep leading to hypoxemia and disrupted sleep
o Definitive diagnosis with polysomnography in sleep lab
Measures brainwaves, air flow, respiratory effort, oxygenation, and heart rhythm
Severity based on hourly number of apnea episodes (breathing cessation ≥ 10
seconds) and hypopnea (breathing reduction ≥ 10 seconds accompanied by O2
desaturation or sleep arousal)
o Primary treatment – positive airway pressure
Continuous (CPAP)
Bilevel (BiPAP)
Auto titrating (APAP)
Intercostal space number = rib number above it
Sternal angle (Angle of Louis) - horizontal bony ridge where manubrium joins body of sternum
o Directly adjacent to 2nd rib and costal cartilage
2nd intercostal space for needle insertion to decompress tension pneumothorax
Intercostal space between 4th and 5th ribs = chest tube insertion
Level of 4th rib = lower margin of well-placed ET tube
Costal cartilage of 1-7 ribs articulate with sternum
Cartilage of 8-10 articulate with costal cartilage above them
11 and 12 rib have no anterior attachment = “floating rib”
Posteriorly, 12th rib is starting point for counting ribs and intercostal spaces
o Inferior scapula tip usually at 7th rib or intercostal space
o When neck is flexed forward, most protruding process usually C7 vertebra, ribs
coincide with thoracic vertebrae
Intercostal space between 7 and 8 = thoracentesis needle immediately superior to 8th rib
Midsternal line – along sternum
Midclavicular line – clavicular midpoint
Anterior axillary line – anterior axillary fold
Midaxillary line – axilla apex
Posterior axillary line – posterior axillary fold
Scapular line – inferior angle of scapula
Vertebral line – overlies thoracic spinous processes
“Triangle of Safety” – in midaxillary line formed by lateral border pectoralis major anteriorly,
lateral border latissimus dorsi posteriorly, nipple line (4th and 5th intercostal space) inferiorly
– “safe position” for chest tube insertion
Apex of each lung about 2-4 cm above inner 1/3 of clavicle
Anterior lung lower border crosses 6th rib at midclavicular line and 8th rib at midaxillary line
Posterior lung border at T10
Inspiration descends d/t constriction and descension of diaphragm
Oblique (major) fissure – divides lung in half
o T3 obliquely down and around chest to 6th rib at midclavicular line
Horizontal (minor) fissure – further divides R lung
o Runs anteriorly close to 4th rib and meets oblique fissure in midaxillary line near 5th
rib
R lung – upper, middle, lower lobe
L lung – upper and lower lobe
Supraclavicular – above clavicles
Infraclavicular – below clavicles
Interscapular – between scapulae
Infrascapular – below scapulae
Apex of lung – uppermost portion
Base of lung – lowermost portion
Trachea bifurcates into mainstem bronchi at sternal angle and T4
o R main bronchus wider, shorter, more vertical than L main and directly enters lung
hilum
Aspiration PNA more common in R middle and lower lobes
, o L main bronchus extends inferolaterally from below aortic arch and anterior to
esophagus and thoracic aorta and then enters lung hilum
Each main bronchus divides into lobar then segmental bronchi and bronchioles and
terminated into sac-like alveoli where gas exchange occurs
Two continuous pleural surfaces, or serous membranes, separate lungs from chest wall
o Visceral pleura covers outer surface of lung
o Parietal pleura lines pleural cavity along inner rib cage and upper diaphragm surface
o Pleural space between visceral and parietal contains serous fluid
Pleural effusion - accumulation of pleural fluid
Parietal pleura inflammation causes pleuritic pain
Diaphragm – primary muscle of inspiration
o Inspiration – contraction – descends
o Scalenes – run from cervical vertebrae to 1st 2 ribs
o Parasternals – parasternal intercostal muscles cross obliquely from sternum to ribs
o Intrathoracic pressure decreases as thorax expands drawing air through
tracheobronchial tree into alveoli
o Expiration – relaxes – ascends
Abd muscles assist
o Accessory muscles – SCM and scalenes
History
o Symptoms that warrant medical interventions
Inability to speak in full sentences, use of accessory muscles, cyanosis, evidence
of low O2 sat, pulsus paradoxicus
o Thorough past medical hx, complete medical and allergy list
o Social hx – tobacco and recreational drugs, occupational and environmental exposures,
travel hx
Dyspnea (shortness of breath) - painless but uncomfortable awareness of breathing that’s
inappropriate to level of exertion
o Anxious patient present different
Difficulty taking deep breath, smothering sensation with ability to get enough
air, parathesis (sensation fo tingling or “pins and needles” around lips and
extremities)
Wheezes – musical respiratory sound may be audible to pt and others
Cough – reflex response to stimuli irritates receptors
o Acute = < 3 week
o Subacute = 3-8 week
o Chronic = > 8 week
o Dry/productive, volume of sputum with color consistency odor
Mucoid – translucent white or gray in viral infection of cystic fibrosis
Purulent – yellow or green in bacterial
Foul smelling – anaerobic lung abscess
Thick and tenacious – cystic fibrosis
o Associated symptoms often lead to cause
Hemoptysis – blood coughed up from lower respiratory tract
o Vary from blood streaked to frank blood
o Confirm source – lungs, pharynx, nose, mouth, GI tract
Chest pain – lung tissues have no pain receptors
, Physical exam should begin during interview by observing pt speak
o Inability to speak full sentences without stopping = increased respiratory drive or
impairment of ventilation with reduced vital capacity
o Increased work of breathing (supraclavicular retractions, use of accessory muscles of
ventilation, tripod position) = increased airway resistance or stiff lung/chest wall
Signs of respiratory distress
o Tachypnea – > 25 breaths/min
o Cyanosis or pallor
o Audible breathing sounds
o Accessory muscle use
Posterior chest
o Arms folded across chest with hands on shoulders – allows increased access to lung
fields
o Note shape and how chest moves
o Focus palpation on tender or bruising areas
o Sinus tracts – blind inflammatory tube-like structures opening onto skin
o Test chest expansion – lung excursion
o Tactile fremitus – palpable vibrations transmitted through bronchopulmonary tree to
chest wall as speaking “ninety-nine” or “one-one-one"
o Percussion helps establish underlying tissues filled with air, fluid, or consolidation
BOX 15-3
Pleximeter finger – stable middle finger
Plexor finger – striking middle finger
Flat, dull, resonant, hyper resonant, tympanic
Diaphragmatic excursion
o Auscultation – assessing airflow BOX 15-4
Cough once or twice to clear mild atelectasis or mucus
Diaphragm of stethoscope with ladder pattern
Silent gap suggests bronchial breath sound
Vesicular – soft and light pitched without pause
Bronchovesicular – inspiration and expiration equal length separated by slight
interval
Bronchial – louder, harsher, and higher pitch with short silent gap, expiration >
inspiration
Tracheal – loud harsh sound
Adventitious lung sounds – added sounds superimposed on usual breath sound
Crackles/rales
Wheezes
Rhonchi
Silent chest = minimal air movement = CLINICAL EMERGENCY
Pleural friction rub – coarse grating biphasic usually on exp
Egophony - “ee” sounds like “a” with nasal quality
Bronchophony - “ninety-nine”, not muffled, distinct louder voice
Pectoriloquy – whisper “ninety-nine” or “one-two-three", louder clearer whisper
sound
Should be faint and indistinct if heard at all
Anterior chest – same as posterior
, 2002 American Thoracic Society – 6-minute walk test to predict clinical outcome of COPD
patient
o Tests pulmonary function
o Require 100 ft hallway
o Measures distance patient can quickly walk on flat hard surface in 6 minutes
Forces expiratory time
o Slowed in obstructive pulmonary disease
o Take deep breath in then out as quickly and completely as possible with mouth open
o Listen over trachea and time audible expiration
o Try to get 3 consistent reading with short rest between
Fractured rib – local pain and tenderness in 1 or more ribs
o Compress chest on AP plane (sternum and thoracic spine) to distinguish fracture from
soft tissue injury
o “This painful? Where?”
Lung cancer
o 2nd most frequently diagnoses cancer in US and leading cause of cancer death in men
and women
o Risk factors – cigarette smoking, radon, familial risk
o Longer smoking hx and greater amount smoked associated with higher risk
o Only 16% diagnosed at early stage
o USPSTF grade B – low-dose-computed tomography (LDCT) lung cancer screening
Annual screening recommended for current smoker (or quit within last 15 years)
if smoked average 1 pack for 30 yr and age 55-80
Counsel smoking cessation and offer smoking cessation interventions
Latent tuberculosis
o Tuberculin skin test (TST)
Placement of purified protein derivative and 48-72 hr interpretation
Measured in mm of induration – palpable raised hardened area of swelling
Presence of induration = positive test
o Interferon-gamma release assay (IGRA) blood test
Single venous blood draw and lab processing within 8-30 hour
o USPSTF grade B rec for screening latent TB in asymptomatic adult at increased risk for
TB
o USPSTF – moderately beneficial to treat latent TB in preventing progression to active
disease
Primary harm = hepatotoxicity
Obstructive sleep apnea (OSA) – repeated episodes of upper airway collapse during rapid eye
movement (REM) sleep leading to hypoxemia and disrupted sleep
o Definitive diagnosis with polysomnography in sleep lab
Measures brainwaves, air flow, respiratory effort, oxygenation, and heart rhythm
Severity based on hourly number of apnea episodes (breathing cessation ≥ 10
seconds) and hypopnea (breathing reduction ≥ 10 seconds accompanied by O2
desaturation or sleep arousal)
o Primary treatment – positive airway pressure
Continuous (CPAP)
Bilevel (BiPAP)
Auto titrating (APAP)
