NRS 6421 The Respiratory System|Thoracic and Pulmonary
Examination: Landmarks, Intercostal Spaces, Triangle of Safety,
Rib Anatomy, Lung Lobes, Fissures, Tracheobronchial Tree,
Pleurae, Transudate and Exudate Effusions, Breathing Mechanics,
Accessory Muscles, Dyspnea, Cough, Hemoptysis, Chest Pain, Past
and Family History, Lifestyle Assessment, Respiratory Rate and
Pattern, Chest Expansion, Fremitus, Percussion, Breath Sounds,
Adventitious Sounds, Bronchophony, Egophony, Whispered
Pectoriloquy, Pulse Oximetry, Peak Flow Assessment, Rib
Fractures, Vaccinations, Tobacco Cessation, Obstructive Sleep
Apnea Screening Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
Landmarks
suprasternal notch - 5 cm below is the sternal angle (angle of Louis) which is attached to the second rib.
Costal cartilage - intercostal spaces, and ribs
Special landmarks - 2nd ICS - for needle placement for decompression of tension pneumothorax
Between 4th and 5th ICS is for chest tube insertion
On chest Xray - ET tube should be placed at the 4th rib
Avoid needle insertion on the inferior margin of each rib as neurovascular structures are located there.
ICS between 7th and 8th space is landmark for thoracentesis.
anterior surface of the thorax
The first seven ribs are all joined to the sternum , 8, 9 , 10 join with the ribs above them and 11 and 12
are posterior ribs known as floating ribs - do not attach anteriorly.
post. thorax cavity landmarks
Useful landmark -Inferior tip of scapula lies at 7th rib or intercostal space
,C7 and T1 - can palpate when neck is flexed forward Posterior side - you start with the 12 rib and count
upwards -
triangle of safety
4th - 5th ICS, anterior axillary line
Formed by the lateral board of the pectoralis major muxcle (anterior), lateral border of the latissimus
dorsi posteriorly and nipple line - safe spot for chest tube insertion
Lungs, lobes, fissures anatomy
apex is located approximately 2 - 4 cm above midclavicular line
The lower borders of both lungs cross at the 6th rib at mid clavicular line and 8th rib at mid axillary line.
Posteriorly base of lung lies at T 10
R lung is divided into three lobes left - two
Each lung is divided in half by oblique major fissure
Horizontal and oblique fissures
lateral view of lungs
Usually physical exam findings correlate with lobe anteriorly- however signs that are found laterally can
originate from all three lobes.
Trachea and bronchus tubes
Trachea bifurcates into bronchus - breath sounds over this area are a lot harsher- bifurcation takes place
at the sternal angle anteriorly and T4 spinous process posteriorly
R bronchus is wider shorter and more vertical than the left main bronchus that is why aspiration takes
place more frequently in R middle and lower lung lobes
Bronchus then divides into bronchi and bronchioles terminating in alveoli
, Pleurae
Pleural linings - visceral covers outer lining of the lungs, parietal lines the pleural cavity -- only the
parietal pleural are innervates by intercostal and phrenic nerves - which results in parietal pain
with infectious or inflammatory processes ie. Pneumonia, PE, pericarditis, collagen vascular disease
Between these two lines you have pleural space -
which contains serous pleural fluid.
transudate effusion causes
CHF
Cirrhosis
Nephrotic syndrome
PE
Pericardial disease
Most common: HF, cirrhosis with ascites, hypoalbuminemia (from nephrotic syndrome)
Exudate effusion causes
Infectious (pneumonia, TB)
Malignancy
Connective tissue disease
Abdominal disorder (pancreatitis, esophageal rupture)
Chylothorax
Most common: pneumonia, cancer, PE, TB
Examination: Landmarks, Intercostal Spaces, Triangle of Safety,
Rib Anatomy, Lung Lobes, Fissures, Tracheobronchial Tree,
Pleurae, Transudate and Exudate Effusions, Breathing Mechanics,
Accessory Muscles, Dyspnea, Cough, Hemoptysis, Chest Pain, Past
and Family History, Lifestyle Assessment, Respiratory Rate and
Pattern, Chest Expansion, Fremitus, Percussion, Breath Sounds,
Adventitious Sounds, Bronchophony, Egophony, Whispered
Pectoriloquy, Pulse Oximetry, Peak Flow Assessment, Rib
Fractures, Vaccinations, Tobacco Cessation, Obstructive Sleep
Apnea Screening Exam Questions Verified and Provided with
Complete A+ Graded Rationales Latest Updated 2026
Landmarks
suprasternal notch - 5 cm below is the sternal angle (angle of Louis) which is attached to the second rib.
Costal cartilage - intercostal spaces, and ribs
Special landmarks - 2nd ICS - for needle placement for decompression of tension pneumothorax
Between 4th and 5th ICS is for chest tube insertion
On chest Xray - ET tube should be placed at the 4th rib
Avoid needle insertion on the inferior margin of each rib as neurovascular structures are located there.
ICS between 7th and 8th space is landmark for thoracentesis.
anterior surface of the thorax
The first seven ribs are all joined to the sternum , 8, 9 , 10 join with the ribs above them and 11 and 12
are posterior ribs known as floating ribs - do not attach anteriorly.
post. thorax cavity landmarks
Useful landmark -Inferior tip of scapula lies at 7th rib or intercostal space
,C7 and T1 - can palpate when neck is flexed forward Posterior side - you start with the 12 rib and count
upwards -
triangle of safety
4th - 5th ICS, anterior axillary line
Formed by the lateral board of the pectoralis major muxcle (anterior), lateral border of the latissimus
dorsi posteriorly and nipple line - safe spot for chest tube insertion
Lungs, lobes, fissures anatomy
apex is located approximately 2 - 4 cm above midclavicular line
The lower borders of both lungs cross at the 6th rib at mid clavicular line and 8th rib at mid axillary line.
Posteriorly base of lung lies at T 10
R lung is divided into three lobes left - two
Each lung is divided in half by oblique major fissure
Horizontal and oblique fissures
lateral view of lungs
Usually physical exam findings correlate with lobe anteriorly- however signs that are found laterally can
originate from all three lobes.
Trachea and bronchus tubes
Trachea bifurcates into bronchus - breath sounds over this area are a lot harsher- bifurcation takes place
at the sternal angle anteriorly and T4 spinous process posteriorly
R bronchus is wider shorter and more vertical than the left main bronchus that is why aspiration takes
place more frequently in R middle and lower lung lobes
Bronchus then divides into bronchi and bronchioles terminating in alveoli
, Pleurae
Pleural linings - visceral covers outer lining of the lungs, parietal lines the pleural cavity -- only the
parietal pleural are innervates by intercostal and phrenic nerves - which results in parietal pain
with infectious or inflammatory processes ie. Pneumonia, PE, pericarditis, collagen vascular disease
Between these two lines you have pleural space -
which contains serous pleural fluid.
transudate effusion causes
CHF
Cirrhosis
Nephrotic syndrome
PE
Pericardial disease
Most common: HF, cirrhosis with ascites, hypoalbuminemia (from nephrotic syndrome)
Exudate effusion causes
Infectious (pneumonia, TB)
Malignancy
Connective tissue disease
Abdominal disorder (pancreatitis, esophageal rupture)
Chylothorax
Most common: pneumonia, cancer, PE, TB
