Chest expansion, asymmetrical
Asymmetrical chest expansion is the uneven extension of portions of the chest wall during inspiration. During normal respiration, the thorax uniformly expands upward and outward, and then contracts downward and inward. When this process is disrupted, breathing becomes uncoordinated, resulting in asymmetrical chest expansion.
The onset may be sudden or gradual and may affect one or both sides of the chest wall. It may occur as delayed expiration (chest lag), abnormal movement during inspiration (for example, intercostal retractions, paradoxical movement, or chest-abdomen asynchrony), or unilateral absence of movement. Asymmetrical chest expansion usually results from pleural disorders, such as life-threatening hemothorax or tension pneumothorax. (See Recognizing life-threatening causes of asymmetrical chest expansion.) It can also result from a musculoskeletal or urologic disorder, airway obstruction, or trauma. Regardless of its underlying cause, asymmetrical chest expansion produces rapid and shallow or deep respirations that increase the work of breathing.
Act Now: If you detect asymmetrical chest expansion, first consider traumatic injury to the patient’s ribs or sternum, which can cause flail chest, a life-threatening emergency characterized by paradoxical chest movement. Quickly take the patient’s vital signs and look for signs of acute respiratory distress — rapid and shallow respirations, tachycardia, and cyanosis. Provide pain management and pulmonary toilet. Don’t tape or use sandbags to temporarily splint the unstable flair segment because these actions will impede chest expansion and decrease oxygenation and clearance of secretions.
Depending on the severity of respiratory distress, administer oxygen by nasal cannula, mask, or mechanical ventilator. Prepare the patient for emergency intubation, if indicated. Insert an I.V. line to allow fluid replacement and administration of pain medication. Obtain a blood sample for arterial blood gas analysis, and connect the patient to a cardiac monitor.
Although asymmetrical chest expansion may result from hemothorax, tension pneumothorax, bronchial obstruction, and other life-threatening causes, it isn’t a cardinal sign of these disorders. Because any form of asymmetrical chest expansion can compromise the patient’s respiratory status, don’t leave the patient unattended, and stay alert for signs of respiratory distress.
Assessment
History
Ask the patient whether he experiences dyspnea or pain during breathing. If he reports shortness of breath, ask whether it’s constant or intermittent. If the patient reports that the pain worsens with inspiration or expiration, ask him if there are precipitating or aggravating factors or factors that alleviate the pain.
Ask the patient whether he has a history of pulmonary or systemic illness, such as frequent upper respiratory tract infections, asthma, tuberculosis, pneumonia, or cancer, or if he has had thoracic surgery. Any of these findings can produce asymmetrical chest expansion on the affected side. Ask about a history of blunt or penetrating chest trauma, which may have caused pulmonary injury. Ask the patient whether he may have inhaled toxic fumes or aspirated a toxic substance, perhaps at his place of employment.
Physical examination
Examine the posterior chest wall for areas of tenderness or deformity. To evaluate the extent of asymmetrical chest expansion, place your hands — fingers together and thumbs abducted toward the spine — flat on both sections of the lower posterior chest wall. Position your thumbs at the 10th rib, and grasp the lateral rib cage with your hands. As the patient inhales, note the uneven separation of your thumbs, and gauge the distance between them. Then repeat this technique on the upper posterior chest wall. Next, use the ulnar surface of your hand to palpate for vocal or tactile fremitus on both sides of the chest. To check for vocal fremitus, ask the patient to repeat “99” as you proceed. Note asymmetrical vibrations and areas of enhanced, diminished, or absent fremitus. Gently palpate the trachea for midline positioning. Then percuss and auscultate to detect air and fluid in the lungs and pleural spaces. Finally, auscultate all lung fields for normal and adventitious breath sounds. Examine the patient’s anterior chest wall, using the same assessment techniques.
ALERT: Be prepared for immediate intervention if your examination of the patient reveals deviation of the trachea, which typically indicates an acute problem. Prepare the patient for emergency intubation and possible mechanical ventilation. Plan for emergency X-rays or a computed tomography scan to identify the problem.
Pediatric pointers
Children have a greater risk than adults of mainstem bronchi (especially left bronchus) intubation. However, because children’s breath sounds are usually referred from one lung to the other because of the small size of the thoracic cage, use chest wall expansion as an indicator of correct tube position. Children also develop asymmetrical chest expansion, paradoxical breathing, and retractions with acute respiratory illnesses, such as bronchiolitis, asthma, and croup.
Congenital abnormalities, such as cerebral palsy and diaphragmatic hernia, can also cause asymmetrical chest expansion. With cerebral palsy, asymmetrical facial muscles usually accompany chest-abdomen asynchrony. With a life-threatening diaphragmatic hernia, asymmetrical expansion usually occurs on the left side of the chest.
Geriatric pointers
Asymmetrical chest expansion may be more difficult to identify in elderly patients due to the structural changes associated with aging.
Medical causes
Bronchial obstruction.
With bronchial obstruction, life-threatening loss of airway patency may occur gradually or suddenly. Typically, lack of chest movement indicates complete obstruction; chest lag signals partial obstruction. If air is trapped in the chest, you may detect intercostal bulging during expiration and hyperresonance on percussion. You may also note dyspnea, accessory muscle use, decreased or absent breath sounds, and suprasternal, substernal, or intercostal retractions.
With flail chest — a life-threatening injury to the ribs or ster-
num — the unstable portion of the chest
wall collapses inward during inspiration and balloons outward during expiration (paradoxical movement). The patient may have ecchymoses, severe localized pain, or other signs of traumatic injury to the chest wall. He may also exhibit rapid, shallow respirations, tachycardia, and cyanosis.
Bleeding into the pleural space causes chest lag during inspiration in hemothorax, a life-threatening condition. Other findings include signs of traumatic chest injury, stabbing pain at the injury site, anxiety, dullness on percussion, tachypnea, tachycardia, and hypoxemia. If hypovolemia occurs, you’ll note signs of shock, such as hypotension and a rapid, weak pulse.
Kyphoscoliosis.
Abnormal curvature of the thoracic spine in the anteroposterior direction (kyphosis) and the lateral direction (scoliosis) gradually compresses one lung and distends the other. This produces decreased chest wall movement on the compressed-lung side and expands the intercostal muscles during inspiration on the opposite side. It can also produce ineffective coughing, dyspnea, back pain, and fatigue.
Myasthenia gravis.
Progressive loss of ventilatory muscle function produces asynchrony of the chest and abdomen during inspiration (“abdominal paradox”), which can lead to the onset of acute respiratory distress. Typically, the patient’s shallow respirations and increased muscle weakness cause severe dyspnea, tachypnea and, possibly, apnea.
With phrenic nerve dysfunction, the paralyzed hemidiaphragm fails to contract downward, causing asynchrony of the thorax and upper abdomen on the affected side during inspiration (“abdominal paradox”). Its onset may be sudden, as in trauma, or gradual, as in infection or spinal cord disease. If the patient has underlying pulmonary dysfunction that contributes to hyperventilation, his inability to breathe deeply or to cough effectively may cause atelectasis of the affected lung.
Pleural effusion.
Chest lag at end-inspiration occurs gradually in pleural effusion — a life-threatening accumulation of fluid, blood, or pus in the pleural space. Usually, some combination of dyspnea, tachypnea, and tachycardia precedes chest lag; the patient may also have pleuritic pain that worsens with coughing or deep breathing. The area of the effusion is delineated by dullness on percussion and by egophony, bronchophony, whispered pectoriloquy, decreased or absent breath sounds, and decreased tactile fremitus. Fever appears if infection causes the effusion.
Depending on whether fluid consolidation in the lungs develops unilaterally or bilaterally, asymmetrical chest expansion occurs as inspiratory chest lag or as chest-abdomen asynchrony. The patient typically has fever, chills, tachycardia, tachypnea, and dyspnea along with crackles, rhonchi, and chest pain that worsens during deep breathing. He may also be fatigued and anorexic and have a productive cough with green or yellow mucus or rust-colored sputum.
Entrapment of air in the pleural space can cause chest lag at end-inspiration. Pneumothorax is a life-threatening condition that also causes sudden, stabbing chest pain that may radiate to the arms, face, back, or abdomen and dyspnea unrelated to the chest pain’s severity. Other findings include tachypnea, decreased tactile fremitus, tympany on percussion, decreased or absent breath sounds over the trapped air, tachycardia, restlessness, and anxiety.
With tension pneumothorax, the same signs and symptoms occur as in pneumothorax, but they’re much more severe. A tension pneumothorax rapidly compresses the heart and great vessels, causing cyanosis, hypotension, tachycardia, restlessness, and anxiety. The patient may also develop subcutaneous crepitation of the upper trunk, neck, and face and mediastinal and tracheal deviation away from the affected side. You may auscultate a crunching sound over the precordium with each heartbeat; this indicates pneumomediastinum.
Poliomyelitis.
With poliomyelitis — a rare disorder — paralysis of the chest wall muscles and diaphragm produces chest-abdomen asynchrony (“abdominal paradox”), fever, muscle pain, and weakness. Other findings include decreased reflex response in the affected muscles and impaired swallowing and speaking.
Pulmonary embolism is an acute, life-threatening disorder that causes chest lag; sudden, stabbing chest pain; and tachycardia. The patient usually has severe dyspnea, blood-tinged sputum, pleural friction rub, and acute anxiety.
Other causes
Medical treatments.
Asymmetrical chest expansion can result from pneumonectomy and surgical removal of several ribs. Chest lag or the absence of chest movement may also result from intubation of a mainstem bronchus, a serious complication typically due to incorrect insertion of an endotracheal tube or tube movement while it’s in the trachea.
Nursing considerations
Because asymmetrical chest expansion increases the work of breathing, supplemental oxygen is usually given during acute events. Assess the patient’s respiratory status frequently.
If the patient is intubated, regularly auscultate breath sounds in the lung peripheries to ensure equal ventilation. Maintain the ventilator settings and alarms, as ordered.
Patient teaching
Explain all procedures and tests, especially if the patient is intubated. Teach the patient and his family early signs of infection.
Pictures
Book Source Details
- Book Title: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2007 Lippincott Williams & Wilkins.
Other Book Chapters Related to Chest symptoms
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- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
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Copyright Details: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest symptoms
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Chest pain (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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