SURFACE ANATOMY (THORAX) PHYSIOTHERAPY.pptx

Surface anatomy of the thorax with relevance to Physiotherapy

1. Surface anatomy of the thorax Application techniques

2. Assessment SUBJECTIVE ASSESSMENT Subjective assessment is based on an interview with the patient. It should generally start with open-ended questions
What is the main problem?
What troubles you most?
Allowing the patient to discuss the problems that are most important to him at that time.

3. Assessment OBJECTIVE ASSESSMENT Objective assessment is based on examination of the patient, together with the use of tests such as spirometry, arterial blood gases and chest radiographs. A good examination will provide an objective baseline for the future measurement of the patient’s progress. By developing a standard method of examination, the findings are quickly assimilated, and the physiotherapist remains confident that nothing has been omitted.

4. Assessment GENERAL EXAMINATION Examination starts by observing the patient from the end of the bed. Is the patient short of breath, sitting on the edge of the bed, distressed? Is he obviously cyanosed? Is he on supplemental oxygen? If so, how much? What is his speech pattern – long fluent paragraphs without discernible pauses for breath, quick sentences, just a few words, or is he too breathless to speak? When he moves around or undresses, does he become distressed? The patient’s level of consciousness should also be noted. Any patient with a decreased level of consciousness is at risk of aspiration and retention of pulmonary secretions.

5. Inspection OBSERVATION OF THE CHEST When examining the chest fit is important to remember the surface landmarks of the thoracic contents, some important points are: • The oblique fissure, dividing the upper and middle lobes from the lower lobes, runs underneath a line drawn from the spinous process of T2 around the chest to the 6 th costochondral junction anteriorly.
•The horizontal fissure on the right dividing the upper lobe from the middle lobe, runs from the 4 th intercostal space at the right sternal edge horizontally to the midaxillary line, where it joins the oblique fissure.
• The diaphragm sits at approximately the 6 th rib anteriorly, the 8 th rib in the midaxillary line, and the 10 th rib posteriorly.
• The trachea bifurcates just below the level of the manubriosternal junction.
• The apical segment of both upper lobes extends 2.5 cm above the clavicles.

6. Inspection CHEST SHAPE The chest should be symmetrical with, the ribs, in adults, descending at approximately 45° from the spine. The transverse diameter should be greater than the anteroposterior (AP) diameter. The thoracic spine should have slight kyphosis. Important common abnormalities include: • Kyphosis • Kyphoscoliosis • Pectus excavatum and pectus carinatum

7. INSPECTION BREATHING PATTERNS Observation of the breathing pattern gives further information concerning the type and severity of respiratory disease. Normal.breathing should be regular with a rate of 12-16 breaths/min, as mentioned previously. Inspiration is active and expiration passive. The approximate ratio of inspiratory to expiratory time (I:E ratio) is 1:1.5 to 1:2.
Prolonged expiration may be seen in patients with obstructive lung disease, where expiratory airflow is severely limited by dynamic closure of the smaller airways. In severe obstruction the I:E ratio may increase to 1:3 or 1:4.

8. Palpation Palpation is a vital medical technique used by physiotherapist to assess the body by applying gentle pressure with the hands and fingers. It provides valuable information about underlying tissues and structures, helping healthcare professionals diagnose and manage various conditions.

9. When palpating the thorax, follow this step-by-step guide:
• Initial Contact
• Superficial Palpation
• Bony Landmarks • Soft Tissue Palpation • Comparison and documentation

10. Auscultation Auscultation involves listening to the sounds produced within the thorax, particularly the lungs and heart, using a stethoscope. Knowledge of thoracic surface anatomy is essential for placing the stethoscope correctly to hear specific sounds. Surface landmarks for Lung Auscultation: SUPERIOR LOBE
• Apical segment: 2cm superior to medial 1/3 of clavicle
• Anterior segment: 2 nd  intercostal space mid clavicular line
• Posterior segment: Between C7 & T3
MIDDLE LOBE
• Right anterior only: 4 th  intercostal space mid-clavicular line

11. Auscultation INFERIOR LOBE
• Anterior: 6 th  intercostal space, mid-axillary line
• Posteriorly: between T3 & T10
During auscultation, different types of breath sounds can be heard, which provide critical information about the condition of the lungs and airways. Here are the main types of breath sounds and their points of auscultation:

12. Auscultation BREATH SOUNDS 1. Vesicular Breath Sounds
Description: Soft, low-pitched sounds heard during inspiration, with a shorter, softer expiratory phase.
2. Bronchial Breath Sounds
  Description: Louder, higher-pitched sounds with a distinct pause between inspiration and expiration, and a longer expiratory phase.
3. Bronchovesicular Breath Sounds:
  Description: Intermediate in intensity and pitch between vesicular and bronchial sounds, with no pause between inspiration and expiration.

13. Auscultation 4. Adventitious Breath Sounds:
  Description: Abnormal sounds heard in addition to normal breath sounds.
  Types:
•  Crackles ( Rales ): Discontinuous, brief, popping sounds heard primarily during inspiration. Indicative of fluid in the alveoli and smaller airways (e.g., pulmonary edema, pneumonia).
•  Wheezes : Continuous, high-pitched, musical sounds heard during expiration (and sometimes inspiration), indicating narrowed airways (e.g., asthma, COPD).
•  Rhonchi : Continuous, low-pitched, snoring sounds indicating secretions in the larger airways (e.g., bronchitis).
•  Stridor : A high-pitched, inspiratory sound indicating upper airway obstruction (e.g., croup, foreign body).

14. Auscultation Surface landmarks for heart auscultation •  Aortic valve:  The aortic point is located on the right side of the sternum in the second intercostal space.
•  Plumonary valve : The pulmonic point is left to the sternum in the second intercostal space
•  Mitral valve : The mitral point is located at the left side of the sternum in the fifth intercostal space.
•  Tricuspid valve : The tricuspid point is left of the sternum in the fourth intercostal space.
•  Erb ’ point: Erb’s point is located to the left of the sternum in the third intercostal space and is the approximate center of the heart.

15. Percussion Percussion involves tapping on the surface of the thorax to evaluate the underlying structures based on the sound produced. This helps in determining the density of tissues, detecting fluid accumulation, air pockets, and other anomalies. Key Areas for Lung Percussion: 1. Clavicles: Percuss above and below the clavicle to assess the apices of the lungs.
2. Intercostal Spaces: Percuss along the intercostal spaces from the top of the thorax to the base, avoiding the ribs.
3. Scapular Borders: Percuss medial to the scapulae posteriorly to assess the upper and lower lobes.

16. Percussion Key Areas for Heart Percussion 1. Left Sternal Border: 3 rd to 5 th Intercostal Spaces: Percussion is performed along the left sternal border to identify the left border of the heart.
2. Right Sternal Border:
  3 rd to 5 th Intercostal Spaces: This area is percussed to identify the right border of the heart, although this is less commonly done since the right heart border is often less distinct.
3. Apex of the Heart:
  5 th Intercostal Space, Midclavicular Line: Percussion in this area helps to locate the apex of the heart, which can give an idea about left ventricular size and position.

17. Percussion Clinical Relevance :
• Cardiac Enlargement: An enlarged heart may extend the area of dullness further laterally and inferiorly, indicating conditions such as cardiomegaly or left ventricular hypertrophy.
• Pericardial Effusion: A larger area of dullness may indicate the presence of fluid in the pericardial sac.
• Pulmonary Conditions: Conditions such as left lower lobe consolidation can alter the expected percussion notes.

18. CLINICAL APPLICATION CLINICAL APPLICATION IN ASTHMA: Thoracic surface anatomy plays a significant role in understanding and managing asthma, a chronic respiratory condition characterized by inflammation and narrowing of the airways. It’s clinical applications include:
 - Physical examination - Localization of respiratory sounds - Assessment of respiratory function - Identification of trigger points for asthma attacks

19. Clinical application CLINICAL APPLICATION IN COPD COPD will typically present in adulthood and often during the winter months. Patients usually present with complaints of chronic and progressive dyspnea, cough, and sputum production. Patients may also have wheezing and chest tightness. While a smoking history is present in most cases, there are many without such a history. They should be questioned on exposure to second-hand smoke, occupational and environmental exposures, and family history.

20. CLINICAL APPLICATION CLINICAL APPLICATION IN PNEUMONIA Pneumonia is an acute inflammation of the lung tissue; the alveoli and adjacent airways. • Radiograph.
Consolidation can be seen as an opacity, especially in lobar pneumonia. There may also be evidence of a pleural effusion
• Auscultation.
Bronchial breathing can be heard (especially in lobar pneumonia) because the consolidated lung tissue conducts the sounds of air movement in the trachea. Whispering  pectoriloquy and increased vocal resonance can be heard. Wheeze may be evident if bronchospasm is present.

21. Clinical application CLINICAL APPLICATION IN BRONCHIECTASIS Bronchiectasis is a chronic respiratory condition characterized by irreversible and abnormal widening or dilatation of the bronchi, the airways that carry air to the lungs. Diagnosis
  A. Clinical Evaluation: Including medical history and physical examination.
  B. Imaging Studies: Such as chest X-ray or high-resolution computed tomography scan.
  C. Pulmonary Function Tests (PFTs)
  D. Sputum Culture and Analysis
  E. Bronchoscopy (if needed)

22. Clinical APPLICATION CLINICAL APPLICATION IN THORACIC OUTLET SYNDROME (TOS) Signs and Symptoms
Symptoms can include pain in the neck, upper chest, shoulder, and arm, numbness, tingling, weakness, discoloration, and coldness in the affected limb. Different
Diagnosis
Healthcare providers diagnose TOS through physical exams, medical history reviews, and various tests like electromyography, CT angiogram, MRI, and nerve conduction velocity studies. These tests help confirm TOS and rule out other potential causes of symptoms like carpal tunnel syndrome.

23. POSTURAL Dysfunctions Postural dysfunction of the thorax refers to abnormal alignment and positioning of the thoracic spine and rib cage, often resulting from poor posture, muscle imbalances, or structural abnormalities.
Here are some common postural dysfunctions of the thorax: • Thoracic kyphosis • Forward head posture • Rounded Shoulders • Scoliosis • Rib flare • Pectus excavatum and Pectus carinatum

24. References Bickley LS, Szilagyi PG. The thorax and lungs. Bates’ Guide to Physical Examination. 9 th ed. Philadelphia: Lippincott Williams & Wilkins; 2005. 241-77. https://my.clevelandclinic.org/health/diseases/17553-thoracic-outlet-syndrome-tosHo T, Cusack RP, Chaudhary N, Satia I, Kurmi OP. Under- and over-diagnosis of COPD: a global perspective. Breathe ( Sheff ). 2019 Mar;15(1):24-35. [PMC free article] [PubMed] Ferri S, Crimi C, Heffler E, Campisi R, Noto A, Crimi N. Vitamin D and disease severity in bronchiectasis.  Respir Med. 2019 Mar;148:1-5. [PubMed]
Guan WJ, Han XR, de la Rosa-Carrillo D, Martinez-Garcia MA. The significant global economic burden of bronchiectasis: a pending matter.  Eur Respir J. 2019 Feb;53(2)[PubMed]

25. THANK YOU!!!!!