Topic 6

Assessing the Thorax

and Lungs
Anatomy and Physiology of
the Thorax and Lungs
Monsale, Wenjolyn Mae D.
Thorax –  The area of the body between the Lower respiratory system – it
neck and the abdomen. constitutes the lungs, the distal portion of the

It provides a base for the muscle attachment of trachea, and the bronchi that are located in the

the upper extremities. The thorax also provides thorax.

protection for the heart, lungs, and viscera.

Thoracic cage - outer structure of the
thorax

Thoracic cavity – contains the respiratory

components.
 Thoracic Cage Sternum and Clavicles
The sternum, or breastbone, lies in the center of the
Is constructed of the sternum, 12 pairs of chest anteriorly and is divided into three parts: the
manubrium, the body, and the xiphoid process.
ribs, 12 thoracic vertebrae, muscles, and
cartilage. It provides support and
protection for many important organs
including those of the lower respiratory manubrium

system. The body

Xiphoid process
Suprasternal notch – U-shaped indentation
located on the superior border of the
manubrium. An important landmark.
Sternal angle/Angle of Louis – bony ridge that
can be palpated at the point where manubrium
articulates with the body of the sternum.
Ribs and Thoracic Vertebrae
The 12 pairs of ribs constitute the main structure of
the thoracic cage. Each pair of ribs has a
corresponding pair of intercostal spaces located
immediately inferior to it.
Costal angle – an important landmark for assessment.
An angle between the right and left costal margins.
It is normally less than 90 degrees but may be
increased in instances of emphysema.
Costal angle
Costal margin
Vertical Reference Lines
To describe a location around the
circumference of the chest wall,
the examiner uses imaginary lines
running vertically on the chest
wall.
On the anterior chest:
midsternal line and the right
and left mid-clavicular lines.

Posterior thorax: vertebral or

spinal line and the right and left
scapular lines.

Lateral aspect of the thorax: mid-

axillary line, anterior axillary
line, and posterior axillary line.
 Trachea and Bronchi
Thoracic Cavity Trachea – flexible structure that
It consists of the mediastinum and the lungs, lies anterior to the esophagus. 10-
and is lined by the pleural membranes. 12 cm long in an adult.
C-shaped rings of hyaline cartilage
Mediastinum – central area in the thoracic compose the trachea; maintain its shape
cavity. Contains trachea, bronchi, esophagus, and prevent its collapse during
heart, and great vessels. Lungs lie on each side respiration.
of this area. Right main bronchus is Bronchi and trachea: “dead
shorter and more vertical space”—air is transported
than the left main bronchus. but no gas exchange takes
place. Passageway for
inspired and expired air.
Bronchioles: oxygen and
smaller carbon dioxide Lined with cilia—sweep dust,
passageways. during foreign bodies, and bacteria
Alveoli: tiny air
respiration. toward the mouth.
sac at the end of Alveolar sacs:
the bronchioles; cluster of alveoli
where the blood (resembling
and lungs grapes)
exchange
Lungs
Two cone-shaped, elastic structures
suspended within the thoracic cavity.

The lungs are not symmetric. The right lung is

larger and weighs more than the left lung. It
has three borders- anterior, posterior and Each lung is divided into lobes by fissures.
inferior and two surfaces- medial and costal.
•Both lungs have oblique fissure and the right is further divided
by a transverse fissure. The oblique fissure in the left lung
separates the superior and the inferior lobe. The oblique and
horizontal fissure divides the lungs into superior, middle and
inferior lobes. Thus the right lung has three lobes while the left
has two.
Pleural Membranes
Pleura – a thin, double-layered serous
membrane that lines the thoracic cavity.
Parietal pleura – lines the chest cavity
Visceral pleura – invest the lungs and covers the
external surfaces of the lungs.
Pleural space – lies between the two pleural
layers.
The function of the pleura is to allow optimal
expansion and contraction of the lungs during
breathing. The pleural fluid acts as a lubricant,
allowing the parietal and visceral pleura to
glide over each other friction free.
Mechanics of Breathing
When you breath in, the external intercostal
muscles contract, moving the ribcage up and out and
the diaphragm moves down at the same time, creating
negative pressure within the thorax.
The lungs are held to the thoracic wall by the pleural
membranes, and so expand outwards as well.
Expiration is mainly due to the natural elasticity of the
lungs, which tend to collapse if they are not held against
the thoracic wall.
HEALTH HISTORY
Lacorte, Yla
DYSPNEA
• Shortness of breath induced by excessive physical activity, an
allergic reaction, asthma, and other serious conditions is known as
dyspnea. Learn how to define dyspnea before diving into its causes
and remedies.
• Dyspnea, which some refer to as shortness of breath, is a feeling that
you cannot breathe enough air into your lungs. During this, you may
also experience tightness in your chest.
 Common Causes
Shortness of breath is not always related to an
underlying condition. It may be caused by:

Aerobic exercise
Intense physical activity
High altitude with lower oxygen levels
Poor cardiovascular fitness
Anxiety
Related Conditions
Asthma
Chronic Obstructive Pulmonary Disease
Heart Failure
Panic Attack
Pulmonary Edema
CHEST PAIN
• Between 44 and 88 percent of people with chronic obstructive pulmonary disease (COPD)
experience some sort of chest pain. Being in pain can affect your quality of life and take a toll on
your mental health. When you live with COPD, there are many reasons why you may experience
pain in your chest. Chest pain in COPD has several potential

• Chest pain is common in people living with COPD. Changes in lung structure and function can
contribute to pain. Muscles in the chest can also be strained and cause pain. There are many
strategies that may help you better manage your pain. Medications to treat COPD are an
important part of preventing and managing pain.
COUGH
• A chronic cough is one of the primary symptoms of COPD.1 Other symptoms can include:

• Breathlessness, especially with activity

• Wheezing
• Chest tightness
• However, many people have COPD and don't realize it for a time, because the symptoms
tend to show themselves only as the disease worsens.1 It's not uncommon for a cough to be
one of the first symptoms to be noticed.

• With COPD, the cough tends to be one we call "productive." That means it produces mucus,
or phlegm, in your airways that a cough tries to clear. At times, the COPD cough may be
more of a dry, hacking cough, but the productive, or wet, cough is more common.
EQUIPMENT NEEDED

• GLOVES
• EXAMINATION GOWN AND DRAPE
• STETHOSCOPE
• LIGHT SOURCE
• MASK
• SKIN MARKER
• METRIC RULER
General Consideration
Belton Llanda Jr. BSN 1-A
1. The patient must be properly undressed and
gowned for this examination.
Includes:
• Accessories
• Watch
• Jewelry
2. Ideally the patient should be sitting on the end of
an exam table.
• Sitting Position

• Assessment Techniques:
• Percussion
• Inspection
• Auscultation
• Palpation
3. The examination room must be quiet to perform
adequate percussion and auscultation.
4. Observe the patient for general signs of respiratory
disease (finger clubbing, cyanosis, air hunger, etc.).
5. Try to visualize the underlying anatomy as you
examine the patient.
6. Complaints of chest pain or chest discomfort raise the specter
of heart disease but often arise from conditions in the thorax
and lungs.
7. For patients who are short of breath, focus on such
pulmonary complaints.
Inspection
Overencio, Lianne Casey
 General
Inspect for nasal flaring and pursed lip breathing
Normal: Nasal flaring is not observed. Diaphragm and the external intercostal muscles do most of the work
of breathing.
Abnormal findings: Nasal flaring is seen with labored respiration and is indicative of hypoxia. Pursed lip
breathing may be seen in asthma, emphysema, or CHF.

Hypoxia Asthma Emphysema CHF

Observe color of face, lips, and chest:
Normal: Evenly colored skin tone, without unusual or prominent discoloration.
Abnormal findings: Ruddy to purple complexion may be seen in clients with COPD or CHF as result of polycythemia. Cyanosis
may be seen if client is cold or hypoxic.

COPD CHF Cyanosis

Inspect color and shape of nails:

Normal: Pink tones seen in nailbeds and 160 degree angle between nail base and skin.
Abnormal findings: Pale or cyanotic nails may indicate hypoxia. Early clubbing (180 degree angle) and late clubbing (Greater
than 180 degree angle) can occur from hypoxia.

Pail or Cyanotic nails Clubbing

 Posterior thorax
Inspection configuration: Position of scapulae and the shape and configuration of the chest wall.
Normal: Scapulae are symmetric and non-protruding. Spinous processes appear straight, and thorax appears
symmetric, with ribs sloping downward at approximately a 45 degree angle in relation to the spine.

Kyphosis increased curve of thoracic spine.

Abnormal findings:

Scoliosis Barrel chest

Observe use of accessory muscles: Watch as the client breathes and note of muscles.
Normal: The client does not use accessory (trapezius/shoulder) muscles to assist breathing.
Abnormal findings:

Tripod position

Inspect the client’s positioning: Posture and ability to support weight while breathing comfortably.
Normal: Sitting up and relaxed, breathing easily with arms at sides or in lap.
Abnormal finding: Tender or painful areas may indicate inflamed fibrous connective tissue . Pain over
the intercostal spaces may be from inflamed pleurae. Pain over the ribs, especially at the costal
chondral junctions, is a symptoms of fractured ribs.

Inflamed fibrous connective tissue Inflamed pleurae Fractured ribs

 Anterior thorax
Inspect shape and configuration
Normal: The anteroposterior is less than the transverse diameter and the ratio is 1:2
Abnormal findings: Anteroposterior equals transverse diameter, resulting in a barrel chest.

Barrel chest

Inspect position of the sternum:

Normal: Sternum positioned at midline and straight.
Abnormal findings:

Pectus excavatum Pectus carinatum

Watch for sternal retractions:
Normal: Retractions not observed
Abnormal finding: Sternal retractions are noted, with severely labored breathing.

Inspect slope of the ribs:

Normal: Ribs slope downward with symmetric intercostal spaces. Costal angle is within 90 degrees.
Abnormal findings: Barrel chest configuration results in a more horizontal position of the ribs and costal
angle of more than 90 degrees.

Barrel chest
Observe quality and pattern of respiration:
Normal: Respirations are relaxed, effortless and quiet.
Abnormal findings: Labored and noisy breathing is often seen with severe asthma or chronic bronchitis.

Asthma Chronic Bronchitis

Abnormal breathing patterns includes:

Tachypnea Bradypnea Hyperventilation

Hypoventilation Cheyne-Stokes respiration Biot respiration

Inspect intercostal spaces:
Normal: No retractions or bulging of intercostal are noted.
Abnormal findings: Retractions of the intercostal spaces indicates an increased inspiratory effort. Bulging of the intercostal
spaces indicates trapped air such as in emphysema and asthma.

Asthma Emphysema

Observe for use of accessory muscles:

Normal: Use of accessory muscles (sternomastoid and rectus abdominis) is not seen with normal respiratory effort. And use
neck muscles for a short time to enhance breathing.
Abnormal findings: Neck muscles (sternomastoid, scalene and trapezius) are used to t facilitate inspiration in cases of acute
or chronic airway obstructions or atelectasis. The abdominal muscles and the intercostal muscles are use to facilitate
expiration in COPD.
Palpation
Lacson, King Manuel
 PALPATION- Posterior thorax
Palpate for tenderness and sensation- Palpation may be performed with one or both
hands, but the sequence of palpation is established.

Normal: No tenderness, pain, or unusual

sensations. Temperature should be equal
bilaterally.

Abnormal findings: Muscle soreness from

exercise or the excessive work breathing may
be palpated as tenderness. Increased warmth
may be related to local infection.
Palpate for crepitus- Normal: Abnormal Findings:
also called
subcutaneous The examiner finds Crepitus can be palpated
emphysema, a no palpable if air escapes from the
crackling sensation crepitus. Lung or other airways into
that occurs when air the subcutaneous tissue,
passes through fluid as occurs after an open
or exudate. thoracic injury around a
chest tube, or tracheostomy.

Palpate surface Normal: Abnormal Findings:

characteristics
Skin and A physician or other appropriate professional
subcutaneous should evaluate any unusual palpable mass.
tissue are free of
lesions and masses
Palpate for fremitus- Use Normal: Abnormal Findings:
the ball or ulnar edge of
one hand to assess for A decrease in the Unequal fremitus is usually the result of
fremitus (vibrations of intensity of fremitus consolidation (which increases fremitus) or
air in the bronchial tubes is normal as the bronchial obstruction, air trapping in
transmitted to the chest examiner moves emphysema, pleural effusion, or
wall). toward the base of pneumothorax (which all decrease fremitus).
the lungs.

Assess chest expansion- Normal: Abnormal Findings:

When the client Unequal chest expansion can occur with

takes a deep breath, severe atelectalsis (collapse or incomplete
the examiner’s expansion), pneumonia, chest trauma, or
thumb should move pneumothorax (air in the pleural space).
5 to 10 cm apart
symmetrically.
 PALPATION- Anterior thorax
Palpate for tenderness, sensation and surface masses – Use your fingers to palpate
for tenderness and sensation.

Normal: No tenderness or pain is palpated

over the lung area with respirations.

Abnormal findings: Tenderness over thoracic

muscles can result from exercising (e.g.,
pushups) especially in previously sedentary
client.
Palpate for tenderness at Normal: Abnormal Findings:
costochondral junctions of ribs
Palpation does not elicit
tenderness.

Palpate for crepitus Normal: Abnormal Findings:

No crepitus is palpated. Crepitus can be palpated if air escapes from

the lung or other airways into the
subcutaneous tissue, as occurs after an open
thoracic injury around a chest tube, or
tracheostomy.

Palpate for any surface masses or Normal: Abnormal Findings:

lesions
No unusual surface masses or Surface masses or lesions may indicate cysts
lesions are palpated. or tumors.
Palpate for fremitus- Normal: Abnormal Findings:
A decreased Diminished vibrations, even with a loud spoken
intensity of voice, may indicate an obstruction of the
fremitus is tracheobronchial tree. Clients with emphysema
expected toward may have considerably decreased fremitus as a
the base of the result of air trapping.
lungs.

Palpate anterior chest Normal: Abnormal Findings:

expansion.
Thumbs move Unequal chest expansion can occur with severe
outward in a atelectasis, pneumonia, chest trauma, pleural
symmetric fashion effusion, or pneumothorax. Decreased chest
from the midline excursion at the bases of the lungs is seen with
COPD.
PERCUSSION
Jurquina, Arlo
TO PERCUSS FOR TONE.
POSTERIOR THORAX - PERCUSSION
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Start at the apices of the scapulae Resonance is the percussion tone Hyperresonance is elicited in cases
and percuss across the tops of elicited over normal lung tissue. of trapped air such as in
both shoulders. Then percuss the Percussion elicits flat tones over emphysema or pneumothorax.
intercostal spaces across and the scapula.
down, comparing sides. Percuss
the lateral aspects at the bases of
the lungs, comparing sides. The
picture below depicts the
sequence for percussion.
POSTERIOR THORAX - PERCUSSION
ASSESSMENT PROCEDURE NORMAL FINDINGS ABNORMAL FINDINGS

Percuss for diaphragmatic Excursion should be equal Dullness is present when fluid or
excursion. Ask the client to exhale bilaterally and measure 3-5cm in solid tissue replaces air in the lung
forcefully and hold the breath. adults. or occupies the pleural effusion, or
Beginning at the scapular line (T7), tumor.
percuss the intercostal spaces of
the right posterior chest wall.
POSTERIOR THORAX - PERCUSSION
ASSESSMENT PROCEDURE
Percuss downward until tone
changes from resonance to
dullness. Mark this level and allow
the client to breath. Next ask the
client to inhale deeply and hold it.
Percuss the intercostal spaces
from the mark downward until
resonance change to dullness.
Mark the level and allow the client
to breath. Measure the distance
between the two marks. Perform
this on both sides of the posterior
thorax.
NORMAL FINDINGS ABNORMAL FINDINGS
The level of the diaphragm may be Diaphragmatic descent may be
higher on the right because of the limited by atelectasis of the lower
position of the liver. lobes or by emphysema, in which
diaphragmatic movement and air
In well-conditioned clients, trapping are minimal. The
excursion can measure up to 7 or diaphragm remains in a low
8 cm. position on inspiration and
expiration.
Other possible causes for limited
descent can be pain or abdominal
changes such as extreme ascites,
tumors, or pregnancy.
Uneven excursion may be seen
with inflammation from unilateral
pneumonia, damage to the
phrenic nerve, or splenomegaly.
ANTERIOR THORAX - PERCUSSION
ASSESSMENT PROCEDURE
Percuss the apices above the
clavicles. Then percuss the
intercostal spaces across and
down, comparing sides.
NORMAL FINDINGS
Resonance is the percussion tone
elicited over normal lung tissue.
Percussion elicits dullness over
breast tissue, the heart and the
liver. Tympany is detected over
the stomach and flatness is
detected over the muscles and
bones.
ABNORMAL FINDINGS
Hyperresonance is elicited in cases
of trapped air such as in
emphysema or pneumothorax.
Dullness may characterize areas of
increased density such as
consolidation, pleural effusion, or
tumor.
 INTERPRETATION
PERCUSSION NOTES AND THEIR MEANING.
Normal
Percussion over normal, healthy lung tissue should produce a
resonant note.

Flat or Dull
Dull percussive sounds are indicative of abnormal lung density.
Likely indicating: atelectasis, tumour, plural effusion, lobar
pneumonia.

Hyperresonant
Hyperresonance on percussion indicates too much air is present
within the lung tissue.
Likely indicating: Emphysema or pneumothorax.
Auscultation
Mayoni, Cyrah Dana
1. POSTERIOR THORAX
AUSCULTATION
To auscultate for breath sounds.
NORMAL: Vesicular breath sounds are low
pitched and normally heard over most
lung fields. 
Tracheal breath sounds are heard over the
trachea.
Bronchovesicular and bronchial sounds
are heard in between.
2. ANTERIOR THORAX
AUSCULTATION
To auscultate for breath sounds.
NORMAL: Vesicular breath sounds are low
pitched and normally heard over most
lung fields. 
Tracheal breath sounds are heard over the
trachea.
Bronchovesicular and bronchial sounds
are heard in between.
 AbN: EMPHYSEMA
The alveoli and lung tissue are
destroyed. The alveoli cannot
support the bronchial tubes. The
tubes collapse and cause an a
blockage, which traps air inside the
lungs. Too much air trapped in the
lungs can give some patients a
barrel-chested appearance. 
You will hear wheezing when
auscultating
AbN: PNEUMOTHORAX
A pneumothorax occurs when air
leaks into the space between
your lung and chest wall. This air
pushes on the outside of your
lung and makes it collapse. A
pneumothorax can be a complete
lung collapse or a collapse of
only a portion of the lung.

There is no sounds present when

auscultating.
 AbN:
PLEURAL EFFUSION
Pleural effusion is the build-up
of excess fluid (water or pus)
between the layers of the
pleura outside the lungs.

When auscultating, you will

hear pleural rub.
 AbN: PNEUMONIA
Pneumonia is an infection that
inflames your lungs' air sacs
(alveoli). The air sacs may fill up
with fluid or such as a cough,
fever, chills pus, causing
symptoms and trouble
breathing.

You will hear rhonchi and

crackles.
 Adventitious (Extra)
Lung Sounds
PREPARED BY: JOFERLYNN HILAJOS
 Adventitious (Extra) Lung Sounds

Adventitious Breath Sounds or Abnormal Sounds

Are the medical term for respiratory noises beyond that of
normal breaths sounds. These sounds may occur continuously or
intermittently and this includes crackles, rhonchi, and wheezes.
 Adventitious (Extra) Lung Sounds
Discontinuous Sounds

Crackles or Rales
Crackles are described as course or fine and it is discontinuous, interrupted
explosive sounds. These can occur if the small air sacs in the lungs fill with
fluid and there's any air movement in the sacs, such as when you're
breathing.
 Adventitious (Extra) Lung Sounds
Fine Crackles
 Are soft, very short, and high pitched lung sounds.
 Adventitious (Extra) Lung Sounds
Coarse Crackles Sound
 Are louder, rather long, more low pitched ling sounds
 Adventitious (Extra) Lung Sounds
Continuous Sounds

Wheezes
 Inflammation and narrowing of the airway in any location, from your throat out
into your lungs.
 Adventitious (Extra) Lung Sounds
Continuous Sounds

Rhonchi
 These are low-pitched wheezing sounds sound like snoring and usually happen
when you breathe out.
 Adventitious (Extra) Lung Sounds
Continuous Sounds

Pleural Friction rub

 It is a raspy breathing sound caused by inflammation of the tissues around your
lungs . The sound is usually “grating” or “creaky.”
 Normal Breaths Sounds

Normal Breath Sounds

 Normal breath sounds are classified as bronchial, bronchovesicular, and vesicular

sounds. The patterns of normal breath sounds are created by the effect of body
structures on air moving through airways.
 Normal Breaths Sounds
Normal Breath Sounds

Bronchial
 Are loud, harsh breathing sounds with a midrange pitch.
 Normal Breaths Sounds
Normal Breath Sounds

Bronchovesicular
 Are softer than bronchial sounds, but have a tubular quality.
 Normal Breaths Sounds
Normal Breath Sounds

Vesicular
 Are soft, low-pitched sounds that doctors can hear throughout the lungs, primarily
when a person breathes in.