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The thoracic cage consists of the sternum, 12 pairs of ribs, 12 thoracic vertebrae, and
the diaphragm, which forms the floor.
On the anterior thorax, surface landmarks include:
Anteriorly, the apex (or highest point) of the lungs lies 3 or 4 cm above the inner
third of the clavicles. The base (or lower border) rests on the diaphragm at about the
fifth intercostal space in the right midclavicular line and at the sixth rib in the left
midclavicular line.
Laterally, the lungs extend from the apex of the axilla to the seventh or
eighth rib.
Posteriorly, C7 marks the apex, and T10 usually corresponds to the base.
On deep inspiration, the base descends to T12.
Although the right lung is shorter than the left lung, it has three lobes while the
left lung has two. The lobes are stacked in diagonal sloping segments and are
separated by fissures that run obliquely.
The pleurae form an envelope between the lungs and the chest. The pleural cavity
is a potential space that contains a few millilitres of lubricating fluid. The cavity
normally has a vacuum (or negative pressure) that holds the lungs tightly against the
chest. The lubricating fluid prevents friction as the lungs move during respiration.
The trachea lies anterior to the esophagus. It bifurcates just below the sternal
angle anteriorly, and at the level of T4 or T5 posteriorly. The right bronchus is shorter,
wider, and more vertical than the left. The bronchial tree protects the alveoli from
small particulate matter by using mucus and cilia, which sweep particles upward for
swallowing or expulsion. The functional unit of the respiratory tract is the acinus.
The respiratory system has four major functions:
The respiratory system develops in utero, but does not function until birth.
It continues to develop during childhood and reaches adult size by
adolescence.
During pregnancy, the growing uterus elevates the diaphragm 4 cm. This
decrease in the vertical diameter of the thoracic cage is offset by an
increase in the horizontal diameter. The fetus increases maternal oxygen
demands, which are met by an increased tidal volume.
In older adults, the costal cartilages become calcified. Respiratory muscle
strength declines after age 50. Lung elasticity decreases, making the lungs
less distensible and lessening their tendency to collapse and recoil. These
changes lead to decreased vital capacity and increased residual volume.
Also percuss to map out the lower lung border and measure diaphragmatic
excursion.
If indicated, also measure forced expiratory time and assess arterial oxygen
saturation with a pulse oximeter.
Many provincial and territorial governments have smoke-free legislation. As part
of the assessment, include health promotion. For example, discuss exposure to secondhand smoke (or environmental tobacco smoke), which increases the patients risk of
adverse health effects.