Accessory muscle use
Accessory muscle use: Excerpt from Signs & Symptoms: A 2-in-1 Reference for Nurses
When breathing requires extra effort, the accessory muscles — the sternocleidomastoid, scalene, pectoralis major, trapezius, internal intercostal, and abdominal muscles — stabilize the thorax during respiration. Some accessory muscle use normally takes place during such activities as singing, talking, coughing, defecating, and exercising. (See Accessory muscles: Locations and functions.) However, more pronounced use of these muscles might signal acute respiratory distress, diaphragmatic weakness, or fatigue. It may also result from chronic respiratory disease. Typically, the extent of accessory muscle use reflects the severity of the underlying cause.
Emergency Actions
If the patient displays increased accessory muscle use, immediately look for signs of acute respiratory distress, including decreased level of consciousness, shortness of breath when speaking, tachypnea, intercostal and sternal retractions, cyanosis, external breath sounds (such as wheezing or stridor), diaphoresis, nasal flaring, and extreme apprehension or agitation. Quickly auscultate for abnormal, diminished, or absent breath sounds. Check for airway obstruction and, if detected, attempt to restore airway patency. Insert an airway or intubate the patient. Then begin suctioning and manual or mechanical ventilation. Assess oxygen saturation using pulse oximetry if available. Then administer oxygen. You may need to use a high flow rate initially, but be attentive to the patient’s respiratory drive (too much oxygen may decrease respiratory drive). If the patient has chronic obstructive pulmonary disease (COPD), use only a low flow rate for mild COPD exacerbations. An I.V. line also may be required.
History
If the patient’s condition allows, question him thoroughly. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, or fever.
Explore his medical history, focusing on respiratory disorders, such as infection or COPD. Ask about cardiac disorders such as heart failure, which may lead to pulmonary edema; also inquire about neuromuscular disorders such as amyotrophic lateral sclerosis, which may affect respiratory muscle function. Note a history of allergies or asthma. Because collagen vascular diseases can cause diffuse infiltrative lung disease, ask about such conditions as rheumatoid arthritis and lupus erythematosus.
Ask about recent trauma, especially to the spine or chest. Find out if the patient has recently undergone pulmonary function testing or received respiratory therapy. Ask about smoking and occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the patient’s family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.
Physical assessment
Perform a detailed chest assessment, noting abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing.
Medical causes
Acute respiratory distress syndrome
In acute respiratory distress syndrome (ARDS), accessory muscle use increases in response to hypoxia. It’s accompanied by intercostal, supracostal, and sternal retractions on inspiration and by grunting on expiration. Other characteristics of this life-threatening disorder include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.
Airway obstruction
Acute upper airway obstruction can be life-threatening — fortunately, most obstructions are subacute or chronic. Typically, this disorder increases accessory muscle use. Its most telling sign, however, is inspiratory stridor. Associated signs and symptoms include dyspnea, tachypnea, gasping, wheezing, coughing, drooling, intercostal retractions, cyanosis, and tachycardia.
Amyotrophic lateral sclerosis
Typically, amyotrophic lateral sclerosis (ALS) affects the diaphragm more than the accessory muscles. As a result, increased accessory muscle use is characteristic. Other signs and symptoms of this progressive motor neuron disorder include fasciculations, muscle atrophy and weakness, spasticity, bilateral Babinski’s reflex, and hyperactive deep tendon reflexes. Incoordination makes carrying out routine activities difficult for the patient. Associated signs and symptoms include impaired speech; difficulty chewing or swallowing and breathing; urinary frequency and urgency; and, occasionally, choking and excessive drooling. ( Note: Other neuromuscular disorders may produce similar signs and symptoms.) Although the patient’s mental status remains intact, his poor prognosis may cause periodic depression.
Asthma
During acute asthma attacks, the patient usually displays increased accessory muscle use. Accompanying it are severe dyspnea, tachypnea, wheezing, productive cough, nasal flaring, and cyanosis. Auscultation reveals faint or possibly absent breath sounds, musical crackles, and rhonchi. Other signs and symptoms include tachycardia, diaphoresis, and apprehension caused by air hunger. Chronic asthma may also cause barrel chest.
Chronic bronchitis
With chronic bronchitis, a form of COPD, increased accessory muscle use may be chronic and is preceded by a productive cough and exertional dyspnea. Chronic bronchitis is accompanied by wheezing, basal crackles, tachypnea, jugular vein distention, prolonged expiration, barrel chest, and clubbing. Cyanosis and weight gain from edema account for the characteristic label of “blue bloater.” Low-grade fever may occur with secondary infection.
Emphysema
With emphysema, a form of COPD, increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough. Sometimes called a “pink puffer,” the patient will display pursed-lip breathing and tachypnea. Associated signs and symptoms include peripheral cyanosis, anorexia, weight loss, malaise, barrel chest, and clubbing. Auscultation reveals distant heart sounds; percussion detects hyperresonance.
Pneumonia
Bacterial pneumonia usually produces increasedaccessory muscle use. Initially, this infection produces sudden high fever with chills. Its associated signs and symptoms include chest pain, productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.
Pulmonary edema
With acute pulmonary edema, increased accessory muscle use is accompanied by dyspnea, tachypnea, orthopnea, crepitant crackles, wheezing, and a cough with pink, frothy sputum. Other findings include restlessness, tachycardia, ventricular gallop, and cool, clammy, cyanotic skin.
Pulmonary embolism
Although signs and symptoms vary with the size, number, and location of the emboli, this life-threatening disorder may cause increased accessory muscle use. Commonly, it produces dyspnea and tachypnea that may be accompanied by pleuritic or substernal chest pain. Other signs and symptoms include restlessness, anxiety, tachycardia, productive cough, low-grade fever and, with a large embolus, hemoptysis, cyanosis, syncope, jugular vein distention, scattered crackles, and focal wheezing.
Spinal cord injury
Depending on the location and severity of a spinal cord injury, increased accessory muscle use may occur. An injury below Ll typically doesn’t affect the diaphragm or accessory muscles, whereas an injury between C3 and C5 affects the upper respiratory muscles and diaphragm, causing increased accessory muscle use.
Associated signs and symptoms of spinal cord injury include unilateral or bilateral Babinski’s reflex; hyperactive deep tendon reflexes; spasticity; and variable or total loss of pain and temperature sensation, proprioception, and motor function. Horner’s syndrome (unilateral ptosis, pupillary constriction, facial anhidrosis) may occur with lower cervical cord injury.
Thoracic injury
With thoracic injury, increased accessory muscle use may occur, depending on the type and extent of injury. Associated signs and symptoms of this potentially life-threatening injury include an obvious chest wound or bruising, chest pain, dyspnea, cyanosis, and agitation. Signs of shock, such as tachycardia and hypotension, occur with significant blood loss.
Special considerations
If the patient is alert, elevate the head of the bed to make his breathing as easy as possible. Encourage him to get plenty of rest and to drink plenty of fluids to liquefy secretions. Administer oxygen. Prepare him for such tests as pulmonary function studies, chest X-rays, lung scans, arterial blood gas analysis, complete blood count, and sputum culture.
Pediatric pointers
Because an infant’s or a child’s accessory muscles tire sooner than an adult’s muscles, these patients are more likely to encounter respiratory distress that can rapidly precipitate respiratory failure. Upper airway obstruction — caused by edema, bronchospasm, or a foreign object — usually produces respiratory distress and increased accessory muscle use. Disorders associated with airway obstruction include acute epiglottitis, croup, pertussis, cystic fibrosis, and asthma. Supraventricular, intercostal, or abdominal retractions indicate accessory muscle use.
Geriatric pointers
Because of age-related loss of elasticity in the rib cage, accessory muscle use may be part of an older person’s normal breathing pattern.
Patient counseling
Because labored breathing can make the patient apprehensive, provide a calm environment and encourage him to perform relaxation techniques while you provide interventions to reduce the work of breathing.
If appropriate, stress how smoking endangers the patient’s health, and refer him to an organized program to stop smoking. Also, teach him how to prevent infection. Explain the purpose of prescribed drugs, such as bronchodilators and mucolytics, and make sure he knows their dosage and schedule.
Show the patient with a chronic lung disorder how to perform pursed-lip, diaphragmatic breathing and coughing and deep-breathing exercises.
Pictures
Book Source Details
- Book Title: Signs & Symptoms: A 2-in-1 Reference for Nurses
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Signs & Symptoms: A 2-in-1 Reference for Nurses, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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