Common causes are reduced pulmonary or chest wall compliance, COPD, respiratory muscle fatigue or neuromuscular diseases. Patients with barely visible expansions of the (lower) chest typically have (very) low tidal volumes and are at high risk of respiratory failure. The range of chest wall expansion during inspiration is a good clinical marker of tidal volume. “stove-in chest”) are rare, but, if present, they are associated with life-threatening/fatal lung and/or mediastinal injuries. Significant deformities of the chest due to trauma (e.g. Enlarged intercostal spaces with bulging lung tissue are less frequently noted over the lateral chest wall during acute exacerbation in asthenic patients. In patients with COPD, lung apices may be seen and palpated in the supraclavicular region. Scars of previous thoracic surgeries indicate that the patient may have reduced lung capacities (e.g. Similarly, centripetal (abdominal) obesity may be associated with a reduction in chest wall compliance and lung capacities. A barrel-shaped chest is suggestive of the presence of underlying COPD and/or lung hyperinflation. Chest wall deformities such as kyphosis, scoliosis, kyphoscoliosis, severe funnel (pectus excavatum) or pigeon-shaped (pectus carinatum) chests are associated with reduced lung capacities and resultant restrictive lung disease. Visual inspection of the chest can reveal important clues about lung function. Patients with COPD who regularly take this position may develop hyperkeratosis of the skin over the knees and distal thighs (Dahl sign).Ĭhest Form, Chest Wall Expansion and Symmetry This position allows maximizing respiratory muscle contraction. Patients with acute asthma or an exacerbation of chronic obstructive pulmonary disease (COPD) feel most relief from dyspnoea when sitting and leaning forward with their arms stemmed on their knees or the bed (Fig. In clinical practice, this effect can also be used therapeutically (“place the good lung down!” to improve oxygenation). As gravity causes blood to be redistributed in the chest, dyspnoea develops in the lateral position with the more diseased side of the lung placed downwards. It describes the occurrence of dyspnoea in one lateral position as opposed to the other. in those with right-sided pleural effusion), asymmetrical pulmonary disease (large atelectasis or total lung collapse, pleural effusion, pneumonia, patients post pneumonectomy) or mediastinal/endobronchial tumours. Trepopnea is a phenomenon encountered in patients with heart failure (e.g. Furthermore, note the tanned appearance of the patient (obviously from sunbathing) indicating the patient has been active until before this episode of acute illness Note the sitting position and the pillows placed under the back of the patient to relieve dyspnoea. A history of paroxysmal nocturnal dyspnoea characterized by repeated awakening due to breathlessness while sleeping in the recumbent position is a typical symptom of heart failure.Ĭritically ill patient with acute heart failure and respiratory distress at admission to the intensive care. Conversely, placing the patient into a supine position may be used as a stress test to exclude respiratory distress due to heart failure or (pulmonary) fluid overload. supporting their back with pillows to achieve a maximum upright position) (Fig. Accordingly, patients with heart failure prefer to sit upright (e.g. While increased venous return in the supine patient is well tolerated in individuals with a preserved heart function, this leads to pulmonary venous congestion, an increase in interstitial lung water and a subsequent reduction of lung capacities with resultant shortness of breath in patients with impaired heart function. Relief of breathlessness in a sitting or standing position compared to the recumbent position is referred to as orthopnoea. Extremely useful and relevant information can be obtained when analysing the position assumed by patients with dyspnoea.
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