Eyes

The pupillary reflexes are evaluated as part of the neurologic examination. Cranial nerves II and III must be intact for normal pupillary reflexes to be present. If the pupils are equal in size, round, and reactive to light and accommodation, the physician may simply write PERRLA (pupils equal, round, reactive to light and accommodation) in the patient’s chart. Head trauma, tumors, central nervous system disease, and certain medications can cause abnormal findings. Brain death, catecholamines, and atropine can cause the pupils to become dilated and fixed (mydriasis). Atropine is a common medication used during cardiopulmonary resuscitation, and its administration minimizes the use of assessing pupillary reflexes as a measure of the patient’s neurologic status. Parasympathetic stimulants and opiates can cause pinpoint pupils (miosis). Examination of the pupillary reflexes is also discussed in Chapter 6.

Examination of the eyelids is useful when the RT or other clinician suspects disease of the cranial nerves. Drooping of the upper lid (ptosis) may be an early sign of disease involving the third cranial nerve. Congenital defects, cranial tumors, and neuromuscular diseases, such as myasthenia gravis, may cause ptosis. Ptosis may be an early warning sign of respiratory failure when a descending neuromuscular disease, such as myasthenia gravis, is occurring. Neuromuscular diseases affecting the cranial nerves also may result in blurred or double vision (diplopia) and involuntary, cyclic movement of the eyeballs known as nystagmus.

Neck

Inspection and palpation of the neck are of value in determining the tracheal position, estimating the jugular venous pressure (JVP), and identifying whether the patient’s accessory muscles are in use. Normally, the trachea is located centrally in the neck when the patient is facing forward. The midline of the neck can be identified by palpation of the suprasternal notch at the base of the anterior neck. The midline of the trachea should be directly below the center of the suprasternal notch.

The trachea may be shifted from midline with atelectasis, pneumothorax, pleural effusion, or lung tumors. In instances of atelectasis or lung resection (removal of one part of a lung), the trachea shifts toward the affected side as it moves toward the side with reduced lung volumes. Conversely, the trachea often shifts (deviates) away from a tension pneumothorax, pleural effusion, or lung tumor because of the effect that excessive air, fluid, or tissue outside of the lung has on pushing the trachea away from the affected side toward the unaffected side. It should also be noted that abnormalities in the lower lung fields may not shift the trachea unless the defect is severe.

The JVP is estimated by examining the level of the column of blood in the jugular veins. JVP reflects the volume and pressure of the venous blood in the right side of the heart. Both the internal and external jugular veins can be assessed, although the internal jugular is most reliable. Persons with an obese or muscular neck may not have visible neck veins, even with distention.

In the supine position, the neck veins of a healthy person are full. When the head of the bed is elevated gradually to a 45-degree angle from horizontal, the level of the column of blood descends to a point no more than a few centimeters above the clavicle with normal venous pressure. With elevated venous pressure, the neck veins may be distended as high as the angle of the jaw, even when the patient is sitting upright (Fig. 5-1). The degree of venous distention can be estimated by measuring the distance the veins are distended above the sternal angle. The sternal angle has been chosen universally because its distance above the right atrium remains nearly constant (approximately 5 cm) in all positions. With the head of the bed elevated to a 45-degree angle, venous distention greater than 3 to 4 cm above the sternal angle is abnormal (Fig. 5-2).

Exact quantification of the jugular pressure in terms of centimeters above the sternal angle is difficult and probably exceeds the accuracy needed for most observers. A simple grading scale of normal, increased, and markedly increased is acceptable.

The level of jugular venous distention may vary with breathing. During inhalation, the level of the column of blood may descend toward the thorax and return to the previous position with exhalation. For this reason, JVP should always be estimated at the end of exhalation.

The most common cause of jugular venous distention is right-sided heart failure. Right-sided heart failure may occur secondary to left-sided heart failure or chronic hypoxemia. Hypoxemia initiates pulmonary vasoconstriction and increases the resistance to blood flow through the pulmonary vasculature, increasing the workload of the right ventricle. Persistent lung disease with hypoxemia may result in right-sided heart failure and jugular venous distention. Jugular venous distention also may occur with hypervolemia and when the venous return to the right atrium is obstructed by tumors in the mediastinum.

Contraction of the sternocleidomastoid muscle in the neck is an indication that the patient’s work of breathing is increased. It is a common finding in patients with airway obstruction and is discussed in the section on chest inspection.

The attending physician often examines the patient’s neck for enlarged lymph nodes (lymphadenopathy) during the initial examination. Lymphadenopathy is a common finding in patients with respiratory infections, and the lymph nodes usually are tender to palpation in this situation. Nontender lymphadenopathy may be caused by malignancy or HIV.

The carotid pulse in the neck is palpated to evaluate the strength of the left ventricular contraction and the condition of the aortic valve. Heart disease that results in poor left ventricular contraction causes the carotid pulse to become weak. Stenosis of the aortic valve also causes a weak carotid pulse along with a systolic murmur (see Examination of the Precordium). An incompetent aortic valve that causes regurgitation of blood back into the left ventricle results in a pulse that rises and descends sharply. This is called a water-hammer pulse. The left and right carotid pulses must not be palpated simultaneously because this may significantly reduce blood flow to the brain.

The strength of the pulse at any location is described on a scale of 0 to 4, as follows:

Imaginary Lines

On the anterior chest, the midsternal line divides the chest into two equal halves. The left and right midclavicular lines parallel the midsternal line and are drawn through the midpoints of the left and right clavicles, respectively (Fig. 5-3).

The midaxillary line divides the lateral chest into two equal halves. The anterior axillary line parallels the midaxillary line and is situated along the anterolateral chest. The posterior axillary line is also parallel to the midaxillary line and is located in the posterolateral chest (Fig. 5-4).

Three imaginary vertical lines are drawn on the posterior chest. The midspinal line divides the posterior chest into two equal halves. The left and right midscapular lines parallel the midspinal line and pass through the inferior angles of the scapulae in the relaxed upright patient (Fig. 5-5).

Thoracic Cage Landmarks

On the anterior chest, the suprasternal notch is located at the top of the manubrium and can be located by palpation of the depression at the base of the neck. Directly below this notch is the sternal angle, which is also called the angle of Louis. The sternal angle can be identified by palpating down from the suprasternal notch until the ridge between the gladiolus and the manubrium is identified. This important landmark is visible in most persons. The second rib articulates with the top of the gladiolus at this point (Fig. 5-6). Rib identification on the anterior chest can now be accomplished with this as a reference point. It is recommended that ribs be counted to the side of the sternum because individual costal cartilages that attach the ribs to the sternum are not identified as easily near the sternum.

On the posterior chest, the spinous processes of the vertebrae are useful landmarks (Fig. 5-7). The spinous process of the seventh cervical vertebra (C7) usually can be identified by having the patient extend the head and neck forward and slightly down. At the base of the neck, the most prominent spinous process that can be visualized and palpated is C7. The spinous process just below C7 belongs to the first thoracic vertebra (T1). The scapular borders also can be useful landmarks on the posterior chest. With the patient’s arms raised above the head, the inferior border of the scapula lies almost directly over the oblique fissure that separates the upper from the lower lobes on the posterior chest.

Lung Fissures

Between the lobes of the lungs are the interlobar fissures. Both lungs have an oblique fissure that begins on the anterior chest at approximately the sixth rib at the midclavicular line. This fissure extends laterally and upward until it crosses the fifth rib on the lateral chest in the midaxillary line and continues on the posterior chest to approximately T3 (Figs. 5-8 and 5-9).

The right lung also has a horizontal fissure that separates the right upper lobe from the right middle lobe. The horizontal fissure extends from the fourth rib at the sternal border around to the fifth rib at the midaxillary line. The left lung rarely has a horizontal fissure.

Tracheal Bifurcation

On the anterior chest, the carina (tracheal bifurcation) is located approximately beneath the sternal angle (angle of Louis) and on the posterior chest at approximately T4.

Diaphragm

The diaphragm is a dome-shaped muscle that lies between the thoracic and abdominal cavities and moves up and down during normal ventilation. At the end of a tidal expiration, the right dome of the diaphragm is located at the level of T9 posteriorly and the fifth rib anteriorly. On the left, the diaphragm comes to rest at the end of expiration at T10 posteriorly and the sixth rib anteriorly. The right hemidiaphragm is usually a little higher anatomically than the left hemidiaphragm because of the placement of the liver.

Lung Borders

Superiorly on the anterior chest, the lungs extend 2 to 4 cm above the medial third of the clavicles. The inferior borders on the anterior chest extend to approximately the sixth rib at the midclavicular line and to the eighth rib on the lateral chest wall. On the posterior chest, the superior border extends to T1, and the inferior border varies with ventilation between approximately T9 and T12 (see Fig. 5-9).

Thoracic Configuration

The normal adult thorax has an anteroposterior diameter less than the transverse (side-to-side) diameter. The anteroposterior diameter normally increases gradually with age and prematurely increases in patients with COPD. This abnormal increase in anteroposterior diameter is called a barrel chest and is commonly seen in patients with emphysema due to hypertrophy of the accessory muscles of breathing and chronic hyperinflation of the lungs. When the anteroposterior diameter increases, the ribs lose their normal 45-degree angle of slope in relation to the spine and become horizontal (Fig. 5-10). Other abnormalities of the thoracic configuration include the following:

Pectus carinatum: outward sternal protrusion anteriorly

Pectus excavatum: depression of part or all of the sternum

Kyphosis: spinal deformity in which the spine has an abnormal anteroposterior curvature (Fig. 5-11)

Scoliosis: spinal deformity in which the spine has a lateral curvature (see Fig. 5-11)

Kyphoscoliosis: combination of kyphosis and scoliosis (see Fig. 5-11)

It should be noted that several of the above abnormalities, depending on their severity, can result in a restrictive lung defect. In particular, the abnormalities of pectus excavatum and kyphoscoliosis may produce such a restriction. Severe trauma to the chest cage can result in fractures of the ribs and sternum. Abnormal configuration of the thoracic cage may result, especially if multiple ribs are broken. A section of the rib cage may move paradoxically with breathing when multiple ribs are fractured at more than one site. The paradoxical motion is seen as a sinking inward of the affected region with each spontaneous inspiratory effort and an outward movement with subsequent exhalation. This paradoxical motion of the affected rib cage is called flail chest.

Breathing Pattern and Effort

The healthy adult at rest has a consistent rate and rhythm of ventilation. The diaphragm and the intercostal muscles are the primary muscles of ventilation, actively working to increase the thoracic cavity dimension during normal inspiratory effort. During normal breathing at rest, the diaphragm performs the majority of the work of breathing. The effort of breathing is minimum on inhalation and passive on exhalation. Men typically breathe with the diaphragm, causing the stomach to move slightly outward during inhalation. Women tend to use a combination of intercostal muscles and the diaphragm, producing more chest wall movement than men. Table 5-1 describes the abnormal patterns of breathing. See Chapter 4, Table 4-4 for further descriptions of terms commonly used to describe breathing rates associated with patterns of breathing.

Additional muscles of ventilation, called accessory muscles, are also slightly active during normal, resting breathing. When ventilatory demands increase, these accessory muscles become more active in assisting the primary muscles of ventilation in the work of breathing. The predominant accessory muscles include the intercostal, scalene, sternocleidomastoid, pectoral, trapezius, and abdominal wall muscles. The accessory muscles of inspiration specifically include the external intercostals, scalene, sternocleidomastoids, trapezius, pectoralis minor, and pectoralis major. Changes in the patient’s breathing pattern can provide important clues to the type of respiratory problem present. Patients with restrictive lung disease (reduced lung volumes) typically breathe with a rapid (tachypnea) and shallow (hypopnea) pattern (see Chapter 4, Table 4-4 for further discussion of breathing rate and pattern terminology). The more lung volume lost, the greater increase in the respiratory rate. Acute obstruction of intrathoracic airways, as occurs with asthma, results in a prolonged exhalation time. The approximate I:E ratio can be determined by timing the two phases of breathing. Normal I:E ratio is approximately 1:2. With more severe cases of airway obstruction, the I:E ratio may be 1:3, 1:4, or even longer at 1:5 or greater. Acute upper airway obstruction, as occurs with croup or epiglottitis, often results in a prolonged inspiratory time.

Any respiratory abnormalities that increase the work of breathing may cause the accessory muscles of breathing (most visibly the scalenes and sternocleidomastoids) to become active during breathing at rest. This is common in acute and chronic diffuse airway obstruction, acute upper airway obstruction, and disorders that reduce lung compliance such as pneumonia or acute respiratory distress syndrome.

Significant increases in the effort of breathing cause large swings in pleural pressure. As a result, the skin overlying the chest cage may sink inward between the ribs during inspiration and bulge outward during exhalation, when the work of breathing is increased. Inward depression of the skin during inspiration is known as retractions. Retractions may be seen between ribs (intercostal), below the ribs (subcostal), or above the clavicles (supraclavicular).

The opposite movement of the skin during exhalation is known as bulging. Obesity and muscular chest walls prevent retractions and bulging from occurring unless the abnormality is severe.

The diaphragm may be nonfunctional in patients with spinal injuries or neuromuscular disease and severely limited in patients with COPD. When this occurs, the accessory muscles of breathing become active, even at rest. The respiratory accessory muscles may also become active during acute airway obstruction. However, its absence does not rule out the possibility that severe airway obstruction is present.