Chest and chest wall problems

Chapter 4 Chest and chest wall problems



Julian Smith



4.1 Introduction


Assessment of the cardiovascular and respiratory systems is usually done sequentially. The best general measure of cardiorespiratory function and of anaesthetic risk is the patient’s exercise tolerance.


Exercise tolerance can be assessed initially from the history and by simple office or bedside tests. An inability to climb two flights of stairs indicates a significant reduction in cardiorespiratory function. Postoperative complications are likely. Exercise tolerance can also be graded to give an assessment of diminishing reserve related to pain or breathlessness:








To assess respiratory reserve (Box 4.1), it is important to determine how well the patient can move air, assessed at the bedside or by spirometry with forced vital capacity testing. A forced expiration time (FET) of less than three seconds is normal. A time of more than five seconds is abnormal and indicates significant obstructive airways disease, as does inability to blow out a match held at 15 cm from the mouth. Obstructive airways disease is by far the most common type of lung disease seen. It occurs as part of the degenerative effects of ageing and is exacerbated by smoking.



The other main type of lung disease is restrictive disease, resulting from conditions that restrict or destroy lung tissue. Pulmonary atelectasis, oedema, effusions and infections are the most common causes seen in post-surgical patients. Counting while breath-holding should be possible for at least 20 seconds. Inability to do so suggests significant restrictive lung disease.


Pulmonary function tests (PFTs) augment the bedside tests and are used to define the degree of respiratory dysfunction on presentation, the amount of functional respiratory reserve and hence the ability to tolerate lung surgery and, at follow-up, the response to therapy. There are two major types of PFT:




When considering surgical therapy for a given patient, it may be evident that the patient has insufficient ventilatory reserve to cope with a chest wall incision or a major pulmonary resection and alternative non-operative therapies will need to be offered.


Arterial blood gas analysis is also an important investigation in patients with acute and chronic thoracic conditions. Parameters measured include PaO2, pCO2, pH, bicarbonate level and arterial oxygen saturation.



History


Breathlessness, chest pain, palpitations and cough are cardinal symptoms of cardiorespiratory disease.


Breathlessness on exertion is a feature of both cardiac and respiratory disease and is also seen in the severely anaemic patient. Dyspnoea at rest is more characteristic of heart failure (‘cardiac asthma’) than of chronic pulmonary disease. With cardiac disease, dyspnoea is of variable severity, not usually associated with wheeze or productive cough and may be nocturnal as well as exertional. The heart will usually be enlarged. Ankle oedema also strongly suggests heart failure.


Breathlessness on sudden awakening is called paroxysmal nocturnal dyspnoea, which is sometimes the initial symptom of congestive cardiac failure. By contrast, obstructive lung disease presents with exertional dyspnoea of insidious onset, a wheeze associated with prolonged expiration and an ineffective and productive cough. Paroxysmal nocturnal dyspnoea can simulate bronchial asthma first appearing in adult life or the symptoms of regurgitation and nocturnal aspiration of gastric juice in patients with reflux oesophagitis.


Marked fatigue relieved by rest is common in heart failure and in some instances may be the main complaint. Fatigue and lethargy due to chronic depression are not relieved by rest.


Any chest pain must be assessed carefully. In ischaemic heart disease, anginal pain is due to coronary artery narrowing or occlusion. Non-cardiac causes of chest pain are also common.


Cardiac pain is retrosternal, described as constricting or crushing, and may radiate to the neck or shoulders and arm. The pain may be brought on by exertion (angina of effort) or be continuous, suggesting myocardial infarction. Patients with angina can be classified using the New York Heart Association (NYHA) classification, as shown in Table 4.1.


Table 4.1 New York Heart Association classification of angina


















Class Description
I Angina with strenuous exercise
II Angina with moderate exercise
III Angina after climbing one flight of stairs or walking one or two blocks
IV Angina with any activity

Elective surgery is permitted in patients with Class I and Class II angina but is usually contraindicated with Class III or IV angina. In these latter cases, coronary angiography and percutaneous coronary intervention (PCI) or coronary bypass grafting may be considered before major elective surgery.


Pleuritic pain arises from inflamed pleura, is described as sharp or stabbing and is made worse by deep breathing and coughing.


Awareness of the action of the heart (palpitations) suggests cardiac disease. This symptom must be defined as accurately as possible. The patient may be aware of a fast or slow pounding of the heart, a sensation of a missed or irregular beat or a fluttering in the chest. The symptom can occur in normal individuals after exertion or from anxiety. Syncope may occur. If the symptom has not been precipitated by such obvious causes, an arrhythmia should be excluded.


Cough is the most common and prominent symptom of respiratory disease. Paroxysmal coughing suggests bronchial obstruction. The integrity of the cough reflex is essential if sputum retention is to be prevented in the perioperative period.


Wheezing is a characteristic symptom of bronchial narrowing, occurring during expiration in chronic obstructive airways disease and paroxysmally and throughout the breathing cycle in bronchial asthma.


Haemoptysis can occur in many bronchopulmonary diseases, including bronchitis, tuberculosis, carcinoma and bronchiectasis. Haemoptysis associated with acute pleuritic chest pain suggests pulmonary embolus and infarction.


A careful enquiry should always be made about past and present medications taken by the patient and any allergy to such medications. This should include drugs prescribed, bought over the counter and ‘alternative’ medicines. Of particular importance are cardiac drugs and those with effects that might influence the safety of surgery, including insulin and oral hypoglycaemic drugs, oral contraceptives, diuretics, digitalis, beta-blocking agents and other antihypertensives, uricosuric drugs, anti-anxiety (phenothiazine) drugs, antidepressants, sedatives and aperients. The past history may reveal relevant illnesses such as asthma, tuberculosis, bronchiectasis, rheumatic fever or occupations of significance and allergies. Smoking habits and alcohol intake must be noted. Actions to diminish intake during preoperative preparation (which can minimise and reverse cardiorespiratory damage) must commence as soon as possible.



Physical examination






Examination of the head and neck


Central cyanosis implies increased deoxygenated haemoglobin in arterial blood leaving the heart. The bluish tinge is best observed in the tongue and buccal mucosa. When cyanosis is due to veno-arterial shunting, peripheral cyanosis is also present but the skin is warm — in contrast to the peripheral cyanosis of peripheral vascular disease or low cardiac output states. Central plethora with cyanosis is also seen in respiratory failure or polycythaemia. When cyanosis is associated with swelling of the head and neck, fullness of the central veins and loss of the normal venous pressure wave, superior vena caval obstruction must be considered as a possible diagnosis.


Examination of the eyes may reveal the pallor of anaemia. A greyish yellow nodule or plaque of the eyelids (xanthoma) suggests hyperlipidaemia. A white ring (arcus) at the junction of iris and sclera can suggest advanced atherosclerosis and hyperlipoproteinaemia but can occur in older patients without these stigmata (arcus senilis). Sometimes Horner’s syndrome is detected, with eye changes of meiosis, ptosis, enophthalmos and anhidrosis secondary to sympathetic nerve paresis from an apical lung malignancy. Brachial plexus symptoms (T1 compression) may coexist (Pancoast’s syndrome). Examination of the neck may reveal the diffuse goitre of Graves’ disease. Tracheal deviation may be due to displacement of a goitre or to mediastinal shift. Enlarged cervical lymph nodes may be the only sign of carcinoma of the lung or may be part of a systemic disorder such as sarcoidosis, in which pulmonary involvement is common.



Jugular venous pressure and pulse


The height of jugular venous filling (right atrial pressure) above the manubriosternal joint (right atrial level) is measured with the patient reclining with the neck at 45° inclination above the horizontal. The neck is examined in an oblique light with the head turned slightly away and the pulse wave of the internal jugular vein (running from the manubriosternal joint to the angle of mandible) observed. Filling of the external jugular vein is also noted. A raised jugular venous pressure is the cardinal sign of heart failure. The form or shape of the venous pressure wave may also help in the diagnosis of valvular and other structural cardiac disorders.


Differentiation between venous and arterial pulsations in the neck can sometimes be difficult. Venous pulsations are more easily seen than felt, arterial pulsations more readily felt than seen. Venous pulsation is characterised by two distinct waves in each cycle (‘double flicker’). The venous pulse will normally rise during expiration or the valsalva manoeuvre or on pressure over the liver and will fall on sitting upright. Compressing the internal jugular vein just above the clavicle eliminates the venous pulse wave. Arterial pulsation does not change with any of these (Table 4.3).


Table 4.3 Venous and arterial pulses and pressures in the neck































  Venous Arterial
Easily palpable No Yes
Visible but not palpable Yes No
Waves per cycle Two One
Changes with respiration and valsalva *Yes No
Changes with compression of neck and abdomen *Yes No
Changes with posture *Yes No

* If vena cava unobstructed


If there is elevation without a venous pulse wave and no fall on sitting to 90°, superior vena caval obstruction is probably present.



Examination of the heart


After inspection of the chest wall the strength of the cardiac impulse is assessed and the apex beat located by palpation. The apex beat is normally in the left fifth intercostal space in the mid-clavicular line, 7–12 cm from the left sternal edge. The apex beat may not be felt in the obese or emphysematous patient. Lateral displacement of the apex beat indicates left ventricular hypertrophy, especially when vigorous and sharply localised. An enlarged right ventricle causes little displacement of the apex beat; its pulsation is felt best at the left sternal edge. Vibrations or thrills may be felt corresponding to audible heart murmurs.


Auscultation is performed over the precordium, examining each phase of the cardiac cycle and using different positions to assist in interpretation. Starting at the apex, auscultation may reveal additional heart sounds, extracardiac sounds or clicks and murmurs due to turbulent flow within the heart. Murmurs are graded according to intensity. A soft short systolic murmur at any valve area may be innocent if there are no other abnormalities, especially if the murmur disappears during respiration or with a change in posture. Anaemia may cause a flow murmur related to an increased cardiac output consequent upon a decrease in oxygen-carrying capacity of the blood. Diastolic murmurs are not found in healthy subjects. The areas where murmur are best heard are: the aortic area at the right second costochondral junction and down the left side of the sternum — especially on leaning forward and in expiration; the pulmonary area at the left second interspace; the tricuspid area at the left fourth interspace; and the mitral area at the apex — especially when the patient is turned on to the left side.


Systolic murmurs are produced by valvular diseases, mitral incompetence and aortic sclerosis/stenosis or by ventricular septal defects. Fever, anxiety and pregnancy may sometimes induce benign systolic murmurs. The louder a systolic murmur, especially one associated with a thrill and cardiomegaly, the more likely it is to be of organic origin. An early systolic murmur that replaces the first sound and is transmitted into the left axilla is organic and is due to mitral incompetence and regurgitation. The aortic systolic murmur of aortic stenosis is ejection in type, midsystolic and is transmitted into the neck. Diastolic murmurs are caused by aortic incompetence, mitral stenosis or dilatation of the aortic ring in patients with marked hypertension and intracardiac shunt. The mitral stenotic murmur is diastolic with a presystolic crescendo component (unless there is atrial fibrillation) and is preceded by an opening snap, often best heard with the patient lying on the left side. The aortic incompetent murmur is in early diastole and is best heard with the patient leaning forward and holding the breath in expiration.


Finally the abdomen and legs are examined.


Congestive cardiac failure (CCF) is a very common medical problem encountered in surgical patients and includes left and right ventricular failure.


Left ventricular failure (Table 4.4) is characterised predominantly by symptoms such as exertional dyspnoea, cough, fatigue orthopnoea and paroxysmal nocturnal dyspnoea. Fatigue may be the chief complaint in patients with heart failure from mitral valve disease. The signs include cardiomegaly, basal crepitations in the lungs, gallop rhythm (a cadence found with tachycardia plus triple rhythm due to a loud, easily heard, third heart sound) and evidence of pulmonary venous congestion on X-ray (Kerley B lines).


Table 4.4 Clinical manifestations of heart failure







































  Left Right
Symptoms Dyspnoea Dyspnoea
  Cough  
  Orthopnoea  
  Paroxysmal
nocturnal
dyspnoea
 
Signs Cardiomegaly Elevated venous
pressure
  Gallop rhythm  
  Basal crepitations Oedema
    Hepatomegaly

Right ventricular failure is characterised predominantly by signs — elevated venous pressure (the major sign of CCF), hepatomegaly and dependent oedema.



Examination of the chest and lungs


A knowledge of lung surface anatomy is important in the diagnosis and treatment of pulmonary disease. Both lungs are divided into two by the oblique fissure that follows a line extending around the chest from the fourth thoracic vertebra to the sixth costal cartilage, crossing the fifth rib in the midclavicular line. On the right side the middle lobe is mainly sited anteriorly and is separated from the upper lobe by the transverse fissure. The transverse fissure is transposed to the body surface as a line from the fourth right costal cartilage anteriorly and extends posteriorly to the fifth rib in the mid-axillary line where it joins the oblique fissure.


The chest is inspected for deformity and asymmetry, pulsations and scars. The rate, regularity, depth and ease of breathing is noted. Alterations in shape, such as the barrel chest of emphysema, are noted. The severity of breathlessness is graded. Laboured breathing with nasal flaring, accessory muscle hypertrophy, tracheal tug and intercostal retraction are the features of acute respiratory failure in children. Laboured breathing at rest with accessory muscle hypertrophy and pursed lips on expiration is diagnostic of emphysematous respiratory failure in adults.


Chest expansion is measured on palpation at the level of the fourth costal cartilage, after examination of the neck for tracheal position. A chest expansion of 5–7 cm is normal in adults under 40 years of age. Both lungs are compared for expansion, placing the hands over the areas to be examined and thumbs in the midline. Asymmetry of expansion may be due to pleural effusion, collapse or pneumothorax.


Percussion is performed with a uniform technique. The examiner should concentrate more on the note than the method, percuss from resonant to dull areas and compare sides. What constitutes a normal note can only be learnt with practice. Three notes of varying shades are detectable — dull, resonant and hyperresonant. Dullness over lung areas indicates the presence of definite pathology; its absence does not necessarily mean the absence of pathology. Dullness is profound over fluid and only slightly impaired over pleural or pulmonary fibrosis and consolidation. The hyperresonant note of emphysema is generalised and of low pitch; that of pneumothorax is of similar quality. The tympanitic note of percussion over a hollow viscus is different, being of higher pitch with a ringing quality. Distinguishing between these two notes is not easy.


Systematic auscultation is performed. Three types of sound are heard on auscultation: voice, breath and adventitial sounds.


Vocal resonance (transmission of voice — say ‘99’) is listened for systematically over all areas of the lungs. Vocal sounds are increased over consolidation and cavities. Marked increase in voice transmission is called whispering pectoriloquy. Diminution or absence of vocal resonance correlates with the degree of impairment of the percussion note. Vocal resonance is most diminished over an effusion.


Breath sounds are assessed. Normal breath sounds are produced in the larynx and consist of an inspiratory sound followed immediately by a shorter, softer expiratory sound, a pattern known as vesicular breathing. Vesicular breathing may be harsher in patients with prolongation of expiration from mild airways obstruction. Breath sounds are reduced or absent over effusion or pneumothorax, which poorly conduct sound from the underlying lung. Bronchial breathing is the main sign of consolidation. It has a blowing quality with an extended expiration similar to the tracheal sound, as this large tube sound is transmitted freely to the chest wall through solid lung. The sound may be soft or loud, high- or low-pitched. High-pitched (tubular) bronchial breathing is heard over pneumonic consolidation. Bronchial breathing may also be heard over fibrosed lung, a large cavity or just above an effusion.


Adventitious sounds occurring separate from the breath sounds are listened for. There is no generally agreed convention for the classification of adventitious sounds. One description divides adventitious sounds into three types.


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Jul 18, 2017 | Posted by in GENERAL SURGERY | Comments Off on Chest and chest wall problems

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