The document provides detailed information about the anatomy and landmarks of the chest, including the thoracic cage, ribs, sternum, and vertebrae. It describes the internal structures such as the lungs, heart, blood vessels, and pleura. Key points include that the left lung has two lobes instead of three, and the distribution of the different lung lobes in the anterior and posterior chest. The document also covers respiratory mechanics, auscultation locations and notes, palpation techniques, and abnormal chest findings.

1. Chest (Thorax
and Lungs)

2. Thoracic Cage/Cavity
� Is a bony structure with a conical shape which is
narrower at top
� It defined by
sternum – 3 parts: manubrium, body and xiphoid process
Ribs – 12 pairs, 1st seven attach to the sternum (costal
cartilages)
Ribs 8,9,10 attach to the costal cartilage above and ribs
11, 12 are floating ribs

3. Anterior thoracic landmarks
� Suprasternal notch – U shaped depression
� Sternum – breastbone
3 parts: Manubrium, body, Xiphoid process
� Angle of Louis – manubriosternal angle continuous with
2nd rib
� Costal angle usually 90 degree or less than (increases
when rib cage is chronically overinflated)

5. Posterior Thoracic Landmarks
� Veterbra prominens – flex head, feel most prominent
bony projection at base of neck = c7 next lower one is
T1
� Spinous processes – spinal column
� Scapula –symmetrical, lower tip at the 7-8th rib
� 12th rib midway b/t spine and side

7. Reference Lines
- Anterior axillary line
- Midsternal line
- Midclavicular line

8. References Lines
- Posterior Chest
- Vertebral line – midspinal
- Scapular Line

9. Reference Lines
� Lateral Chest
- Anterior Axillary line
- Posterior axillary line
- Mid- axillary line

10. Thoracic Cavity
� Mediastinum middle of the thoracic cavity and contain
• Esophagus
• Trachea
• Heart
• Great Vessels
� Pleural cavities on either side of the mediastinum
contain the lungs

11. Lobes of Lung
� Right Lung
- 3 lobes, upper, middle, lower
- Shorter due to liver
� Left lung
- LUL = Left Upper and Lower (2 lobes)
- Narrower due heart

16. Take special note of three points
that commonly confuse beginning
examiners
� Left lung has no middle lobe
� Anterior chest contains mostly upper and middle lobe
with very little lower lobe
� Posterior chest contains almost all lower lobe

17. Pleurae
� The pleurae form an envelope between the lungs and
chest wall
� Visceral pleura – lines outside of lungs
� Parietal pleura – lines inside of chest wall and diaphragm
� Pleural cavity – the inside of the envelope- space
between visceral and parietal pleura, lubrication.
Normally has a vacuum or neg. pressure

18. Tracheal and Bronchial Tree
� Trachea – anterior to esophagus
- 10-11 cm. long begins at cricoid cartilage
- Bifurcates just below the sternal angle (AKA angle of Louis,
manubriosternal angle) into the
- Right main stem – shorter, wider, more than Left Main Bronchus
The Trachea and Bronchi provide the passage for air to get into the lungs
from the environment = Dead Space (no air exchange takes place here)
� Bronchi
- Secrete mucus- captures particles
- Cilia-moves the trapped particles up to be expelled or swallowed

20. Mechanic of Respiration
� 4 major functions of the respiratory system
1. Supply oxygen for energy production
2. Remove carbon dioxide, waste product of energy reactions
3. Homeostasis, acid-base balance of arterial blood
4. Heat exchange
� Respiration maintain pH (acid-base balance) of the blood by
supplying oxygen and eliminating carbon dioxide
� Lungs help to maintain the pH balance by adjusting the amount of
Carbon dioxide through:
- Hypoventilation causes carbon dioxide to build up in blood
- Hyperventilation causes carbon dioxide to be blown off

21. Respiration = breathing
� Inspiration
� Expiration
� Control of Respiration
- Involuntary control by respiratory center in the brain
stem consisting of the pons and medulla
- Hyercapnia is an increase of carbon dioxide in the
blood and provides
- Hypoxemia also increases respirations but less effective

23. Subjective Data
� Cough
� SOB
� Chest Pain
� Respiratory infections
� Smoking
� Environmental exposure
� Self-care behaviors

24. Objective Data
� Inspect
� Palpate
� Percuss
� Auscultate
After Posterior Thyroid Exam
Posterior Chest, Lateral chest then anterior chest

25. Equipment for Exam
� Stethoscope
� Ruler – 15cm
� Tape measure
� Washable marker
� Alcohol swabs
Remember to clean stethoscope end piece and warm
prior to use on client
Quiet environment conducive to hearing lung sounds

26. Posterior chest
� Inspect Thoracic Cage
- Shape and configuration
- Anteroposterior diameter should be less than transverse
diameter ratio 1:2 to 5:7
- Note position of person to breathe

27. Posterior Chest
� Palpate
- Symmetric expansion-warmed hands-thumbs at T9-T10
pinch up small fold of skin
- Ask the client to tale a deep breath

29. Posterior Chest
� Tactile fremitus – palpable vibration of sound from the
larynx- use palmer ase of fingers- “99” or blue moon
� Symmetry important –vibration should feel the same
bilaterally
� Avoid palpating over scapulae because bone dampens
out sound
� ↓ fremitus = obstructed bronchi, pleural effusion,
pneumothorax or emphysema
� Note any barrier that is b/t the sound and your hand will
↓ fremitus
� ↑ fremitus occurs only with gross changes (Lobar
pneumonia).

31. � Entire Chest wall – gently palpate.
- Note ; tenderness, skin temperature, moisture
lumps, lesions
- Crepitus = coarse crackling sensation palpable
over skin surface (subcutaneous emphysema
when air escapes from lung into subcutaneous
tssiue)

32. Posterior Chest
� Percuss start at the apices, across shoulders, then
interspaces side to side (5cm. Intervals). Avoid scapulae
and ribs
- Resonance predominates in healthy lung
- Hyperresonance – too much air, emphysema,
pneumothorax
- Dull= abnormal density, pneumonia, tumor, atelectasis

34. Diaphragmatic expansion
� Lower lung borders in expiration and inspiration
� 1st exhale and hold-percuss down the scapulae line until sound
chanes from resonant to dull. Mark with marker
� Estimates the level of the diaphragm separating the
abdominal cavity. May be higher on right due to liver
� Now take deep breath and hold (of the client)
� Percuss from mark to dull sound and mark
� Measure the difference. It should be equal bilaterally and 3-5
cm in adult may be 7-8 cm in well conditioned person
� Note hold your own breath when conducting this test

36. Posterior Chest
�Auscultate
- Position client
- Instruct to breath through mouth, little deeper than usual
- Tell you if becomes light headed
- Use flat diaphragm and hold firmly on chest
- Must listen to at least 1 full respiration before moving
stethoscope side to side
- Compare both sides (lung fields)

38. Normal breath sounds
� Bronchial – anterior chest only = over trachea and larynx
- quality =harsh, hollow, tubular
- Inspiration< expiration
- Amplitude =loud
� Bronchovesicular both anterior and posterior
- Over major bronchi, posterior between scapulae, anterior upper
sternum, 1st and 2nd ICS
- Pitch = high
- Inspiration = Expiration
- Moderate amplitude
� Vesicular – anterior and posterior

40. Adventitious Sounds
� Not normally heard in the lungs.
� Caused by moving air colliding with secretions or by popping open of previously
deflated airways
� Crackels (Rales)
- Fine –high pitched popping-not cleared by coughing. Simulate sound by rolling
strand of hair between fingers near ear or moisten thumb and index finger and
separate then near your ear
- Course crackles – (opening a Velcro fastener)
� Pleural Friction Rub – coarse and low pitched, 2 pieces of leather rubbed
together close to ear
� Wheeze (Rhonchi)
- High pitched, musical squeaking = air squeezes-asthma

41. Coarse
Crackles

42. Fine Crackles

43. Voice sounds
� Quality of voice or vocal resonance
� Ausculated over chest wall
� Ask the person/client to repeat a phrase such as “ninety-
nine” while you listen
� Normal voice is soft, muffled and indistinct;
� Pathology that increase lung density enhances
transmission of voice sounds
� When they formed, testing for possible presence of
bronchophony, egophony, and whispered pectoriloquy

44. Anterior Chest
�Inspect
- Shape and configuration
- Facial expression – relaxed
- Level of conscious – should be alert and cooperative
- Skin color and condition
- Quality of respiration – regular and een, no retraction or use
of accessory muscles

45. Anterior chest
�Palpate
- Symmetric chest expansion
- Assess the tactile(vocal) fremitus (compare the vibration
from one side to another by repeating “ninety-nine”
- Note any tenderness, skin mobility, turgor, temperature
and moisture

46. Symmetric
Expansion

47. Tactile fremitus

48. Sequence for
percussion and
auscultation

49. Anterior Chest
�Percussion
- Begin at apices in supraclavicular areas
• Interspaces – resonance
• Female breast tissue
- Note borders of cardiac dullness normally found on
anterior chest

50. Expected
percussion notes

51. Anterior chest
Auscultate
� Breath Sounds
- Apices (supraclavicular) to 6th rib
- Use sequence indicated for percussion
- Evaluate normal breath sound, noting any abnormal breath
sounds and any adventitious sounds
� Measurement of pulmonary status

52. Location of breath
sounds

53. Abnormal Findings :
Configurations of the Thorax
� Barrel chest
� Pectus excavatum
� Pectus carinatum
� Scoliosis
� Kyphosis