Abnormalities in the shape of the chest

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Those of clinical importance are as follows.

Increase in anteroposterior diameter. In some patients with emphysema, the posterior AP diameter is increased and the two measurements may approximate (barrel chest). The degree of chest deformity in emphysema is not a reliable guide to the severity of the functional defect. An increase in anteroposterior diameter may also be due to thoracic kyphosis unrelated to respiratory disease (Fig. 4.12).

Thoracic kyphoscoliosis. This ranges in degree from the minor changes in spinal curvature seen in many otherwise healthy subjects to grossly disfiguring and disabling deformities I Fig. 4.12). Thoracic scoliosis may alter the position of the mediastinum in relation to the anterior chest wall, with the result that abnormalities in ihe position of the trachea and the apex beat may be mistakenly attributed to heart or pulmonary disease. Severe kyphoscoliosis may have profound effects on pulmonary function, as the chest deformity reduces the ventilatory capacity of the lungs and increases the work of breathing (p. 120). Such patients may develop hypoxaemia, hypercapnia and heart failure at an early age.

Pectus carinatum (pigeon chest). This is a common sequel of chronic respiratory disease, usually asthma, in childhood (Fig. 4.13). it consists of a localised prominence of the sternum and adjacent costal cartilages, often accompanied by indrawing of ihe ribs to form symmetrical horizontal grooves (Harrison's sulci) above the costal margins, which are themselves usually everted. These deformities are thought to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state. Pectus carinatum deformity may also be caused by rickets or be present for no obvious reason.

Pectus excavatum (funnel chest). In this developmental defect there is either a localised depression of the lower end of the sternum (Fig. 4.14). or. less commonly, depression of the whole length of the body of the sternum and of the costal cartilages attached to it. Pectus excavatum is usually

Rickets Chest
Fig. 4.12 Kyphoscoliosis.
Pigeon Chest
Fig. 4.13 Pigeon chest deformity (pectus carinatum).

asymptomatic, but, when there is a very marked degree of depression of the sternum, the heart may be displaced to the left, and the ventilatory capacity of the lungs restricted.

Naturally Cure Pectus Excavatum
Fig. 4.14 Funnel chest deformity (pectus excavatum).

Thoracic operations. Surgery may result in varying degrees of chest deformity as may severe chest trauma.

Lesions of the chest wall

Abnormalities which may be detected by combined inspection and palpation of the chest wall are listed in Table 4.16. The nature of skin and subcutaneous nodules may have to be determined by aspiration or biopsy.

Subcutaneous emphysema (air in subcutaneous tissues) is recognised by the characteristic crackling sensation elicited by palpation of the air-containing tissues. It may cause diffuse swelling of the chest wall, neck and face. Subcutaneous emphysema is a common complication of intercostal tube drainage of a pneumothorax. In severe asthma, air may track into the mediastinum (mediastinal emphysema) via ruptured alveoli or broncbioli. The air usually escapes innocuously into the neck, and even when there is marked mediastinal and subcutaneous emphysema it is not in itself dangerous. When air is present in the mediastinum, the heart sounds may be obscured by a churning noise accentuated during cardiac systole.

Abnormalities of respiratory movements

Respiratory frequency. Respiratory rate is increased in a variety of pathological states, including pyrexia, acute pul

TABLE 4.16 Lesions of the chest wa II

Cutaneous lesions

Skin eruptions, sarcoid nodules, purpuric spots (Fig. 2.1 D), bruises, scars, discharging sinuses

Subcutaneous lesions

Inflammatory swellings, metastatic tumour nodules, sebaceous cysts, sarcoid nodules, neurofibromas (Fig. 2.41), lipomas

Subcutaneous emphysema

Pneumothorax, severe asthma

Vascular anomalies

Spider naevi, enlarged vascular channels (arterial in coarctation ol the aorta; venous in superior vena caval obstruction)

Localised prominences and deformities

Clavicles, scapulae, sternum, ribs, costochondral junctions, spinous processes

Localised tenderness

Fractured rib, tumour involving chest wall, spinal nerve root disorders

Lesions ol breast (p. 67)

Enlargement of axillary lymph nodes (p, 59)

monary infections, chest wall and pleural pain, and conditions in which there is an increase in the work of breathing, e.g. bronchial asthma and acute pulmonary oedema.

Respiratory depth. Although difficult to assess accurately, it is usually possible to recognise marked degrees of overventilation and undervenlilation. The latter may be of considerable importance in the recognition of type 11 respiratory failure.

In massive pulmonary embolism and in metabolic acidosis, usually due to diabetic ketoacidosis or uraemia, pulmonary ventilation at rest may be considerably raised. This can be recognised by an increase in the depth of respiration (air hunger) which may give rise to the subjective sensation of breathlessness. In periodic or Cheyne-Stokes breathing there is a cyclical variation in the depth of respiration, with overventilation alternating with periods during which breathing ceases (apnoea). This occurs in certain neurological conditions, particularly those involving the medulla, and in some patients with cardiac failure.

Chest expansion. A measured maximum chest expansion of 2 cm or less is definitely abnormal. Chest expansion is diminished in almost every type of diffuse bronchopulmonary disease, e.g. bronchial asthma, emphysema and pulmonary fibrosis, and in conditions which restrict movement of the ribs, such as ankylosing spondylitis.

Mode of breathing. If respiratory movements are exclusively thoracic, this may be because diaphragmatic movement is inhibited by abdominal pain or restricted by increased intra abdominal pressure caused by ascites, gaseous distension of the bowel, a large ovarian cyst or pregnancy. If respiratory movements are exclusively abdominal, ankylosing spondylitis, intercostal paralysis or pleural pain may be responsible for the lack of chest expansion.

Reduced expansion. Unilateral reduction of chest wall expansion occurs in many types of respiratory disease. In pleural effusion (see Fig. 4.20) and empyema, expansion may be absent If the condition is chronic and has resulted in pleural thickening and fibrosis, rctraction of the ribs and intercostal spaces may produce flattening of the affected side of the chest. This is sometimes described as a 'frozen chest', Less marked reduction of expansion occurs in pulmonary consolidation and collapse. In pneumothorax (see Fig. 4.22D) the limitation of expansion is related to the amount of air in the pleural space; in tension pneumothorax, the affccted side of the chest may be immobilised in a position of almost full inspiration. In pulmonary tuberculosis, even extensive lesions may have little effect on chest wall expansion during the early stages of the disease, but when fibrosis develops there may be severe restriction of expansion, with flattening of the affected side of the chest.

In bronchial asthma, emphysema and diffuse pulmonary fibrosis, expansion of the chest wall is symmetrically rcduced. In the first two conditions this results from overinflation of the lungs. In diffuse pulmonary fibrosis, on the other hand, inspiratory movement is restricted by the reduced distensibility of the lungs. In severe cases, this may bring each inspiration to an abrupt halt and produce the phenomenon of 'doorstep' breathing.

Increased movements. Although breathlessness is a subjective sensation, il is usually accompanied by objective evidence of respiratory difficulty or distress. There is often an increase in respiratory frequency, which may be accompanied by dilatation of the alae nasi during inspiration. This may be observed in the absencc of breathlessness and is not reliable evidence of respiratory distress. A much more useful clinical guide is the presence of abnormal increase of respiratory movements of the following types:

• Abnormal inspiratory movements produced by contraction of the cervical muscles (principally the sternomastoids, scalcni and trapezii), by which the whole thoracic cage is, in effect, lifted off the diaphragm with every inspiration. Patients breathe in this way if adequate pulmonary ventilation cannot be achieved by normal inspiratory efforts, for example when there is gross overdistension of the lungs in advanced emphysema and severe bronchial asthma. More violent inspiratory movements of a similar character arc observed in patients with obstruction of the larynx or trachea. Indrawing of the suprasternal and supraclavicular fossae, the intercostal spaces and the epigastrium with each inspiration invariably accompanies airways obstruction of this type, which is also seen, although usually less conspicuously, in COPD and severe asthma.

A much more striking degree of localised indrawing of the chest wall is seen in patients who have sustained double fractures of a series of ribs or of the sternum. The portion of the thoracic cage between the fractures become mobile and is sucketl in with every inspiration. Paradoxical movement of this type interferes seriously with pulmonary ventilation and may cause grave respiratory distress and hypoxaemia.

• Abnormal expiratory movements are produced by powerful contractions of the abdominal muscles and latissimus dorsi. These are observed if the elastic recoil of the lungs is insufficient to complete the expulsion of air from the alveoli, as in emphysema, or when severe expiratory airflow obstruction is present as in bronchial asthma and some cases of COPD. Patients with a severe degree of expiratory obstruction prefer to be upright, grasping a bed table or the back of a chair. This enables them to fix the shoulder girdle so that the latissimus dorsi can be used to augment the expiratory efforts. Many patients, especially those with emphysema and with acute

Pursed Lip Breathing Physiology

exacerbations of COPD, exhale through their mouths with pursed lips (Fig. 4.15). This manoeuvre helps to keep Ihe intrabronchial pressure above that within the surrounding alveoli and rcduccs or prevents collapse of the bronchial wall which would otherwise result from the unopposed pressure of air trapped in the alveoli.


• Chest deformity in emphysema is not a reliable guide to the severity ot the functional disability.

• Severe kyphoscoliosis may have a profound effect on pulmonary function.

• Much more reliance should be given to inspection than palpation in detecting differences in the range of expansion on the two sides of the chest.

• Localised impairment of respiratory expansion is usually caused by underlying lung or pleural disease.

■ Chest expansion is often much diminished in patients with increased vertical chest movements, e.g. exacerbation of severe COPD.

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  • ren
    What might cause abnormal chest expansion?
    8 years ago
  • sanni
    How to measure pectus excavatum?
    8 years ago
  • leena
    Have Pectus Carinatum?
    8 years ago
  • christine slack
    Is pigeon chest dangerous?
    8 years ago
  • patrick
    What is barrel chest deformity?
    8 years ago
  • gundabald
    Is there any danger with pigeon chest?
    8 years ago
  • haddas aman
    How to cure a chest malformation?
    8 years ago
  • steffen
    Are chest deformities dangerous?
    8 years ago
  • mantissa
    Does weight lifting help pectus carinatum?
    7 years ago
    Has anyone had fractured ribs to pigeon chest?
    5 years ago
  • Lemlem
    What happen to the lung during barrel chest deformity?
    4 years ago
    Are pigeon chests typically very strong?
    4 years ago
  • Hannele Kyll
    Does a person with emphysema has a pigeon, barrel, kyphoscoliosis or funnel chest?
    4 years ago
  • juliane
    How can cure the rickets pigeon shaped?
    4 years ago
  • miley
    What is a pigeon shape thoracic?
    4 years ago
  • peter
    What is a barrel chest with respect to chronic obstructive pulmonary disease?
    4 years ago
  • Oskar
    Is barrel chest wall abnormality?
    4 years ago
  • justiina tiisanoja
    What are the abnormal shapes of chest?
    4 years ago
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    How to assess pigeon shaped chest?
    4 years ago
  • franziska
    Can Pneumothorax cause chest shape change?
    4 years ago
  • jonatan sainio
    How chest deformities can affect respiratory examination?
    4 years ago
  • zahra
    What r the reason for irregular shape chest?
    3 years ago
    Is it normal chang in shape of chest?
    3 years ago
  • grace
    Does chest deformities increases?
    3 years ago
  • Gary
    How to differentiate pigeon chest with funnel chest in rickets?
    3 years ago
  • Lea
    What is the shape of a normal chest wall?
    3 years ago
  • veronica
    What is the shape of the chest in human?
    3 years ago
  • hiwet
    Does pigeon and barrel chest and scoliosis cause tracheal deformity?
    3 years ago
  • sophie
    What does mile pectus excavatum deformity artery chest wall look like?
    3 years ago
  • justiina
    Why patients with asthama have pigeon chest?
    3 years ago
  • Muhammed Muhammed
    How to identify abnormal chest shape?
    3 years ago
  • Sebastian Faber
    How COPD cause sternal depression?
    3 years ago
  • May
    Why patients with emphysema have indrawing of his lower chest in inspiration?
    3 years ago
  • Sirkka
    Does a pigeon chest limit chest expansion?
    3 years ago
  • John
    What is barrel chest diameter shape?
    3 years ago
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    Is pigeon chest a dangerous disease?
    3 years ago
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    What is normwl shape of chest?
    3 years ago
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    3 years ago
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    How to measure barrel shaped chest using cardboard?
    3 years ago
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    How can we identified abnormal chest ?
    3 years ago
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    How to measure a barral shape chest?
    3 years ago
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    Why is my chest goin barrel shaped?
    3 years ago
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    How to reduce pigeon neck deformity?
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    What is the shape of chest of pneumothorax patient?
    3 years ago
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    3 years ago
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    What is meant by pigeon chest?
    3 years ago
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    Where do we find the funnel, barrel and pigeon chest?
    3 years ago
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    How to cure chest depression deformity?
    3 years ago
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    How to access for barrel shaped thorax?
    3 years ago
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    How chest wall indrawing occurs?
    3 years ago
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    What is the shape of the chest in tuberculosis?
    3 years ago
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    Which condition of disease the chest can become pigeon like shaped?
    3 years ago
  • uta
    How to correct abnormal chest?
    2 years ago
  • marino
    What are the abnormality of chest shape?
    2 years ago
  • INES
    What are the types of chest shape?
    2 years ago
  • hilda
    Which deformity results from asthma?
    2 years ago
  • caelan
    How the The abnomarity of chest affect the respiration?
    2 years ago
  • sheryl
    What is harrisons sulci deformity of the chest and how long does it last?
    2 years ago
  • Maria
    How to avoid abnormal chest shape?
    2 years ago
  • jens
    How to indetify chest abnormality?
    2 years ago
  • rowan jones
    Why barrel shaped chest in emphysema?
    2 years ago
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    What is cheast shape abnormalities?
    2 years ago
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    What does posterior chest wall deformities look like as in quizlet?
    2 years ago
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    Is a base ball shaped heart abnormal?
    1 year ago
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    1 year ago
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    How does shape and abnormalies affect breathing?
    1 year ago
  • Caramella
    What is the name for abnormal chest bones that gives you a diaonnosis for pulmonary embolism?
    1 year ago
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    How to treat chest rib deformity?
    1 year ago
  • Dieter Frei
    What conditions can cause an abnormal anteroposrerior diameter?
    12 months ago
  • Edward
    What are the abnormalities when examining of the chest?
    11 months ago
  • amaranto
    How many different chest shapes impact respiratory function?
    9 months ago
  • Mackenzie
    Does asthma limit chest expansion?
    6 months ago
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    3 months ago
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    How to observe chest symmetry and shape?
    2 months ago
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    How to assess ap chest diameter?
    1 month ago
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    What is biatrial prominence noting pectus deformity?
    12 days ago

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