Barrel chest
In barrel chest, the normal elliptical configuration of the chest is replaced by a rounded one in which the anteroposterior diameter enlarges to approximate the transverse diameter. The diaphragm is depressed and the sternum pushed forward with the ribs attached in a horizontal, not angular, fashion. As a result, the chest appears continuously in the inspiratory position. (See Recognizing barrel chest, page 96.)
Typically a late sign of chronic obstructive pulmonary disease (COPD), barrel chest results from augmented lung volumes due to chronic airflow obstruction. The patient may not notice it because it develops gradually.
History and physical examination
Begin by asking about a history of pulmonary disease. Note chronic exposure to environmental irritants such as asbestos. Also ask about the patient’s smoking habits.
Then explore other signs and symptoms of pulmonary disease. Does the patient have a cough? Is it productive or nonproductive? If it’s productive, have him describe the sputum’s color and consistency. Does the patient experience shortness of breath? Is it related to activity? Although dyspnea is common with COPD, many patients fail to associate it with the disease. Instead, they blame “old age” or “getting out of shape” for causing dyspnea.
Auscultate for abnormal breath sounds, such as crackles and wheezing. Then percuss the chest. Hyperresonant sounds indicate trapped air; dull or flat sounds indicate mucus buildup. Be alert for accessory muscle use, intercostal retractions, and tachypnea, which may signal respiratory distress.
Finally, observe the patient’s general appearance. Look for central cyanosis in the cheeks, nose, and mucosa inside the lips. In addition, look for peripheral cyanosis in the nail beds. Also note clubbing, a late sign of COPD.
Medical causes
Asthma
Typically, barrel chest develops only in chronic asthma. An acute asthma attack causes severe dyspnea, wheezing, and a productive cough. It can also cause prolonged expiratory time, accessory muscle use, tachycardia, tachypnea, perspiration, and flushing.
Chronic bronchitis
A late sign in chronic bronchitis, barrel chest is characteristically preceded by a productive cough and exertional dyspnea. This form of COPD may also cause cyanosis, tachypnea, wheezing, prolonged expiratory time, and accessory muscle use.
Emphysema
Barrel chest is a late sign in this form of COPD. Typically, emphysema begins insidiously, with dyspnea the predominant symptom. Eventually, it may also cause chronic cough, anorexia, weight loss, malaise, accessory muscle use, pursed-lip breathing, tachypnea, peripheral cyanosis, and clubbing.
Special considerations
To ease breathing, have the patient sit and lean forward, resting his hands on his knees to support the upper torso (tripod position). This position allows maximum diaphragmatic excursion, facilitating chest expansion.
Pediatric pointers
In infants, the ratio of anteroposterior to transverse diameter is normally 1:1. As the child grows, this ratio gradually changes to 1:2 by age 5 to 6. Cystic fibrosis and chronic asthma may cause barrel chest in children.
Geriatric pointers
In elderly patients, senile kyphosis of the thoracic spine may be mistaken for barrel chest. However, patients with senile kyphosis lack signs of pulmonary disease.
Patient counseling
Advise the patient to avoid bronchial irritants, especially smoking, which may exacerbate COPD. Tell him to report purulent sputum production, which may indicate upper respiratory tract infection. Instruct him to space his activities to help minimize exertional dyspnea.
Pictures
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
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» Next page:
Chest Pain, Atypical (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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