Question

Topic Chest and Thorax Assessment.

Differentiate the normal and abnormal findings for chest and thoracic.

Answer 1

DETAILS OF NORMAL AND ABNORMAL FINDINGS OF CHEST AND THORAX

It includes four stages

1 - Inspection.

The respiratory rate may increase with the presence of an interstitial pulmonary process or chest wall restriction, but tidal volume typically remains unchanged. The presence of slow, gasping ventilatory maneuvers is an ominous sign suggesting cerebral hypoxemia.

Dysrhythmic breathing is typified by Cheyne–Stokes respiration. This eponym refers to a periodic pattern of alternating hyperpnea and apnea. Though at times, it is a normal phenomenon seen in infants, the elderly, and during ascent to altitude, more often it is a reflection of significant cardiac and/or pleural nervous system dysfunction.

Breath volumes are increased without substantial modification of rate as a compensatory mechanism to blunt the effects of metabolic acidosis such as occurs with uncontrolled diabetes. When this occurs, the effort associated with this Kussmaul breathing seems to be minimal.

The configuration of the chest may aid in the diagnostic process. Typically, pectus excavatum (funnel chest) or its counterpart pectus carinatum (pigeon breast) are associated with unequivocal physical findings but rarely have an adverse impact on pulmonary function. Scars identify previous surgery or trauma and alert the clinician to the need for a complete history of the event. The so-called barrel chest deformity, sometimes referred to as increased A–P diameter, often erroneously is interpreted as associated with the presence of pulmonary emphysema. Several studies have proved that this description is not necessarily associated with underlying pulmonary disease but regularly is a function of weight loss and mild kyphosis, a function of the aging process.

During breathing, the assessment of changing chest shape can be more helpful. The presence of intercostal retraction, pursued-lip breathing, and use of accessory muscles suggest airways obstruction. Paradoxical movement of the chest and abdominal muscles should alert the clinician to the possible usefulness of pulmonary physiotherapy to improve ventilatory efficiency. Grimaces or other expressions of discomfort occurring at the same point in each ventilatory cycle should influence the examiner to identify the origin of that discomfort more precisely. Finally, wheezing heard by the examiner during tidal volume breathing or exaggerated breathing may be a reflection of upper airway obstruction (stridor) or severe lower airway narrowing. The search for dermatologic abnormalities also may lead to the identification of other systemic or pulmonary processes.

2 - Palpation

Palpation is used both as a screening technique and as a means to confirm a specific diagnosis. Light palpation over the entire thorax posteriorly, laterally, and anteriorly will aid in the identification of cutaneous and subcutaneous nodules and the site of previously unsuspected tenderness. Nodules that are firm and freely moveable suggest a focal benign inflammatory or clinically insignificant problem. Those that are hard, fixed and multiple suggest metastatic malignancy. Fleshy nodules may be indicative of a systemic disease such as neurofibromatosis.

Tenderness may be elicited during this same maneuver. At times, it is unsuspected by both the patient and the examiner. Under other circumstances, it is used to aid in a diagnosis of the complaint of chest pain. Localizing a rib fracture, either traumatic or pathologic, or reproducing the chest pain of costochondritis by firm palpation of an inflamed costochondral junction may be most helpful in planning further management. Tenderness over an inflamed or infarcted area of the lung may also aid in the localization of the disease process.

Assessment of ventilatory excursion includes evaluation of the synchrony of expansion and the degree of chest expansion associated with a deep forceful inspiration from residual volume. Asymmetrical expansion invariably implies decreased ventilation to one side. This may be due to thoracic wall abnormalities, particularly those that are either associated with structural immobility or defect (thoracoplasty) or pain (rib fracture). Similarly, the problem may be caused by an inflamed, fibrosis, or malignantly infiltrated pleura, a unilateral pleural effusion, and interstitial pulmonary process, or complete obstruction of an airway or airways on the ipsilateral side. The functional severing of the phrenic nerve or intraabdominal process causing paralysis of the ipsilateral hemidiaphragm may be responsible for asymmetrical expansion. Asynchronous expansion may occur secondary to these processes but usually occurs with functional diaphragmatic impairment or pain.

Palpation is used to assess further abnormalities; gynecomastia suspected because of observed breast enlargement is confirmed by the palpation of breast tissue. Similarly, spider hemangiomas are confirmed when the central arterial supply is seen to feed the spider's radicals following manual occlusion.

Finally, deviation of the trachea to one side can mean that a process is either pulling the trachea to one side, such as occurs with lung volume loss (lobar collapse, atelectasis, pneumothorax), or pushing the trachea away, such as might occur with either a tumor or an inflammatory mass. The spontaneous movement of the trachea in synchrony with the pulse suggests the presence of an aortic aneurysm.

3 - Percussion

Percussion is a major aid in the assessment of ventilatory exertion, the assessment of hyperinflation, and the presence of focal thoracic disease.

The general percussion over a hemithorax can give a clue as to the presence or absence of a pulmonary process. When the percussion note is hyper resonant, one can postulate that the lungs are hyperinflated, such as may occur with emphysema or during so-called air trapping seen in patients with acute asthma. This may also occur in patients with an acute spontaneous pneumothorax. Dullness to percussion, particularly associated with the presence of a high, poorly moving diaphragm, is likely to be associated with a restrictive ventilatory defect if the findings are bilaterally symmetrical. Usually, this is associated with an interstitial pulmonary process that can be further evaluated by the presence or absence of late inspiratory crackles on auscultation. Flatness to percussion suggests the virtual absence of air directly beneath the percussed finger and may reflect either fluid in the pleural space (pleural effusion, empyema), solid material in the pleural space (fibrothorax, mesothelioma), or atelectasis.

4 - Auscultation

Bronchial breath sounds may be either normal or abnormal. When they are heard on the periphery, where vesicular breath sounds are normally heard, one can imply that the airways to the lung units are open but that the lung units themselves are filled with liquid-like material. When this occurs without pleural fluid, the bronchial breath sounds are loud; when consolidation is associated with a pleural effusion, the bronchial breath sounds are present but often quite decreased in intensity. Confirmation of the presence of bronchial breath sounds can be obtained by listening for egophony ("E to A" sound). This sound is elicited by asking the patient to say the letter "E" as one listens over the suspicious area with the stethoscope. When consolidation is present, the spoken "E" sound is converted to an auscultated "A" sound, similar to that produced by a bleating goat.

In addition to assessing the quality of breath sounds, it is also important to assess the duration of the expiratory phase. Timing the duration of an expiratory sound while listening with the diaphragm over the trachea during a forced expiratory volume maneuver is used to identify airways obstruction. The expiratory sound should terminate within 6 seconds. If the sound is prolonged, airways obstruction manifested by an FEV1 of fewer than 1.5 liters can be assumed.

Auscultatory wheezes imply the presence of slitlike openings through which a critical velocity of the gas is passing. When wheezes are local, one must consider external compression of an airway. Enlarged lymph nodes and tumors do this. A lesion within the airway, such as an endobronchial malignancy or foreign body, also can produce a localized wheeze. Diffuse wheezing is present in inflammatory processes such as bronchitis (both acute or chronic), contraction of hypertrophied bronchial smooth muscle as seen in asthma, inspissated thick secretions of pneumonia, and airway collapse associated with the dynamic compression of pulmonary emphysema.

Crackles imply the snapping open of airways or alveoli. Since larger airways open first as inhalation progresses from the residual volume, early inspiratory crackles imply large airways disease while late inspiratory crackles either mean small airways problems (less than 2 mm) or poorly compliant alveoli walls such as seen in congestive heart failure, pulmonary fibrosis, or other interstitial pulmonary processes.

Gurgles suggest fluid in the airways. This may be produced by excessive serous secretion in alveolar cell carcinoma, infected purulent secretion of acute or chronic bronchitis or bronchiectasis, or transudate fluid entering the airways from the alveoli as occurs in pulmonary edema.