The authors would like to acknowledge David A. Miller for his contributions that remain unchanged from the first edition.
DISORDERS OF THE CHEST WALL
I. Components of the chest that may contribute to respiratory dysfunction
A. Spine
B. Rib cage
C. Costosternal margins
D. Pleura
II. Disorders of the spine
A. Congenital scoliosis
1. The spine assumes an S-shaped curvature.
2. May induce a restrictive ventilatory defect
3. Most often, scoliosis remains an insignificant variable, unless one of the following occurs:
a. The curvature is severe.
b. Superimposed chest disease makes the work of breathing difficult.
4. In these instances, the risk of respiratory failure may increase.
B. Kyphosis of the spine
1. The spine has an accentuated dorsal curve.
2. May induce a restrictive ventilatory defect
4. Can increase the risk of breathing problems in the presence of other chest diseases
5. Acquired kyphosis
a. Results from osteoporosis
b. Common clinical problem resulting from vertebral collapse with pain
c. Treatment of the pain may introduce the additional risk of ventilatory compromise.
III. Rib and sternal fracture and sternal dehiscence after cardiac surgery
A. Fracture of the ribs, or even of the sternum, can occur spontaneously or as the result of trauma or surgery.
B. Instability of the chest wall, with flailing of the wall outward during inspiration and associated chest pain resulting from fractures, limits chest wall movement, especially if multiple fractures are present.
C. Abnormal movement of the chest wall can result in hypoventilation and in poor secretion clearance.
D. Pain medication may facilitate breathing, but it can also lead to hypoventilation and ventilatory failure.
E. Milder problems theoretically can be helped with chest wall binders; however, with significant impairment of ventilation, positive pressure ventilation to stabilize the chest wall may be necessary.
F. Sternal dehiscence following open-heart surgery or surgical procedures involving the mediastinum similarly can result in respiratory embarrassment.
IV. Costochondral junctions
A. Costosternal junctions may become inflamed owing to the following:
1. Arthritis (autoimmune in origin)
a. Rheumatoid disease
b. Systemic lupus erythematosus
2. Costochondritis (Tietze’s syndrome)
B. Although typically not serious, costochondritis may be confused with other, more serious, conditions within the chest.
C. Costochondritis is more common in young women.
D. Tenderness over the affected area is common.
E. NSAIDs (e.g., naproxen sodium [Aleve], 200-400 mg PO every 8 hours) and heat are helpful in relieving the pain.
PLEURAL DISORDERS
I. Pleurisy
A. Pleural pain is typically associated only with inspiration and expiration.
B. Pleurisy, painful breathing, usually is the result of inflammation of the parietal or visceral pleura, or both.
C. Causes for pleurisy are the same as for pleural effusion, listed in Section II. A.
