Accessory muscle use
When breathing requires extra effort, the accessory muscles—the sternocleidomastoid, scalene, pectoralis major, trapezius, internal intercostals, 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 may 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 interventions
If the patient displays increased accessory muscle use, immediately look for signs of acute respiratory distress. These include 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. Administer oxygen; if the patient has chronic obstructive pulmonary disease (COPD), use only a low flow rate for mild COPD exacerbations. You may need to use a high flow rate initially, but be attentive to the patient’s respiratory drive. Giving too much oxygen may decrease the patient’s respiratory drive. An I.V. line may be required.
History and physical examination
If the patient’s condition allows, examine him more closely. Ask him about the onset, duration, and severity of associated signs and symptoms, such as dyspnea, chest pain, cough, and 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 tests or received respiratory therapy. Ask about smoking and about occupational exposure to chemical fumes or mineral dusts such as asbestos. Explore the family history for such disorders as cystic fibrosis and neurofibromatosis, which can cause diffuse infiltrative lung disease.
Perform a detailed chest examination, noting abnormal respiratory rate, pattern, or depth. Assess the color, temperature, and turgor of the patient’s skin, and check for clubbing. (See Accessory muscle use: Causes and associated findings, page 30.)
Medical causes
Acute respiratory distress syndrome (ARDS)
In ARDS—a life-threatening disorder—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 include tachypnea, dyspnea, diaphoresis, diffuse crackles, and a cough with pink, frothy sputum. Worsening hypoxia produces anxiety, tachycardia, and mental sluggishness.
Airway obstruction
An 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 (ALS)
Because ALS affects the diaphragm more than the accessory muscles, increased accessory muscle use is characteristic of this disorder. Other signs and symptoms 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 accompanied by 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
In this 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. Patients with chronic bronchitis are sometimes called “blue bloaters” because of the cyanosis and weight gain from edema that commonly occur. Low-grade fever may occur with secondary infection.
Diffuse infiltrative (or fibrotic) lung disease
In diffuse infiltrative lung disease, progressive pulmonary degeneration eventually increases accessory muscle use. Typically, though, the patient reports progressive dyspnea on exertion as his chief complaint. He may also have a cough, anorexia, weakness, fatigue, vague chest pain, tachypnea, and crackles at the base of the lungs.
Emphysema
Increased accessory muscle use occurs with progressive exertional dyspnea and a minimally productive cough in this form of COPD. These patients are sometimes called “pink puffers” because of their characteristic pursed-lip breathing, tachypnea, and a pink or red complexion. 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 initially produces sudden high fever with chills. Associated signs and symptoms include increased accessory muscle use, chest pain, productive cough, dyspnea, tachypnea, tachycardia, expiratory grunting, cyanosis, diaphoresis, and fine crackles.
Pulmonary edema
In 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. Common findings include 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
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 in lower cervical cord injury.
Thoracic injury
Increased accessory muscle use may occur, depending on the type and extent of the 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.
Other causes
Diagnostic tests and treatments
Pulmonary function tests, incentive spirometry, and intermittent positive-pressure breathing can increase accessory muscle use.
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.
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.
Pediatric pointers
Because infants and children tire sooner than adults, they can develop respiratory failure from respiratory distress more quickly than adults. 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 elderly 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.
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.
Other Book Chapters Related to Muscle symptoms
Read excerpts from these other book chapters related to Muscle symptoms:
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- Muscle spasms
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
- [ read ]
Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Muscle symptoms
» Next page: Muscle atrophy [Muscle wasting] (Professional Guide to Signs & Symptoms (Fifth Edition))
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