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COUGH, PRODUCTIVE
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181
noticed an increase in sputum production since
his coughing began. This may result from external stimuli or from such internal causes as
chronic bronchial infection or a lung abscess.
Also ask about the color, odor, and consistency
of the sputum. Blood-tinged or rust-colored
sputum may result from trauma due to coughing or from an underlying condition, such as a
pulmonary infection or a tumor. Foul-smelling
sputum may result from an anaerobic infection,
such as bronchitis or a lung abscess.
How does the cough sound? A hacking cough
results from laryngeal involvement, whereas a
“brassy” cough indicates major airway involvement. Does the patient feel any pain associated
with his productive cough? If so, ask about its
location and severity and whether it radiates to
other areas. Does coughing, changing body position, or inspiration increase or help relieve his
pain?
Next, ask the patient about his cigarette,
drug, and alcohol use and whether his weight or
appetite has changed. Find out if he has a history of asthma, allergies, or respiratory disorders,
and ask about recent illnesses, surgery, or trauma. What medications is he taking? Does he
work around chemicals or respiratory irritants
such as silicone?
Examine the patient’s mouth and nose for
congestion, drainage, or inflammation. Note his
breath odor: Halitosis can be a sign of pulmonary infection. Inspect his neck for distended
veins, and palpate it for tenderness, masses,
and enlarged lymph nodes. Observe his chest
for accessory muscle use, retractions, and uneven chest expansion, and percuss it for dullness, tympany, or flatness. Finally, auscultate for
pleural friction rub and abnormal breath
sounds, including rhonchi, crackles, or wheezing. (See Productive cough: Causes and associat-
ed findings, pages 182 and 183.)
M
EDICAL CAUSES
◆ Actinomycosis. This disorder begins with a
cough that produces purulent sputum. Fever,
weight loss, fatigue, weakness, dyspnea, night
sweats, pleuritic chest pain, and hemoptysis
may also occur.
◆ Aspiration pneumonitis. This disorder
causes coughing that produces pink, frothy,
possibly purulent sputum. The patient also has
marked dyspnea, fever, tachypnea, tachycardia,
wheezing, and cyanosis.
◆ Asthma (acute). A severe asthma attack,
which can be life-threatening, may produce
tenacious mucoid sputum and mucus plugs.
Such an attack typically starts with a dry cough
and mild wheezing, then progresses to severe
dyspnea, audible wheezing, chest tightness, and
a productive cough. Other findings include apprehension, prolonged expiration, intercostal
and supraclavicular retraction on inspiration,
accessory muscle use, rhonchi, crackles, flaring
nostrils, tachypnea, tachycardia, diaphoresis,
and flushing or cyanosis. Attacks commonly occur at night or during sleep.
◆ Bronchiectasis. The chronic cough of this
disorder produces copious mucopurulent sputum that has characteristic layering (top, frothy;
middle, clear; bottom, dense with purulent particles). The patient has halitosis: His sputum
may smell foul or sickeningly sweet. Other
characteristic findings include hemoptysis, persistent coarse crackles over the affected lung
area, occasional wheezing, rhonchi, exertional
dyspnea, weight loss, fatigue, malaise, weakness, recurrent fever, and late-stage finger
clubbing.
◆ Bronchitis (chronic). The cough associated
with chronic bronchitis may be nonproductive
initially; eventually, however, it produces mucoid sputum that becomes purulent. Secondary
infection can also cause mucopurulent sputum,
which may become blood tinged and foul
smelling. The cough, which may be paroxysmal
during exercise, usually occurs when the patient
is recumbent or rises from sleep.
The patient also exhibits prolonged expiration, accessory muscle use, barrel chest, tachypnea, cyanosis, wheezing, exertional dyspnea,
scattered rhonchi, coarse crackles (which can
be precipitated by coughing), and late-stage
clubbing.
◆ Chemical pneumonitis. This disorder caus-
es a cough with purulent sputum. It may also
cause dyspnea, wheezing, orthopnea, fever,
malaise, crackles, laryngitis, rhinitis, and mucous membrane irritation of the conjunctivae,
throat, and nose. Signs and symptoms may increase for 24 to 48 hours after exposure, then
resolve; in severe pneumonitis, however, they
may recur 2 to 5 weeks later.
◆ Common cold. The common cold may cause
a productive cough with mucoid or mucopurulent sputum, but it usually starts with a dry,
hacking cough, sore throat, sneezing, rhinorrhea, and nasal congestion. Headache, malaise,
fatigue, myalgia, and arthralgia may also occur.
◆ Emphysema. This disorder causes a chronic
productive cough with scant mucoid, translucent,
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SIGNS & SYMPTOMS
Productive cough: Causes and associated findings
Major associated signs and symptoms
Common
causes
Chest pain
Crackles
Cyanosis
Decreased breath
sounds
Dyspnea
Fatigue
Fever
Rhonchi
Sore throat
Tachycardia
Tachypnea
Weight loss
Wheezing
Actinomycosis
Aspiration
pneumonitis
Asthma (acute)
Bronchiectasis
Bronchitis (chronic)
Chemical
pneumonitis
Common cold
Legionnaires’
disease
Lung abscess
(ruptured)
Lung cancer
Nocardiosis
North American
blastomycosis
Plague
Pneumonia
(bacterial)
•••• •
•• •••• •• •
••• • • •• •
••••• ••
•• • • • •
••••••
•• •
•• ••• ••
•• ••• •
•••• ••
•••• •
•
•
•••
•• •
•
••
•••• ••
Pneumonia
(mycoplasmal)
Psittacosis
Pulmonary
coccidioidomycosis
Pulmonary edema
•• •• •
•• • •
•••••
•• ••• ••
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Productive cough: Causes and associated
findings
Common
causes
(continued)
Major associated signs and symptoms
Chest pain
Crackles
Cyanosis
Decreased breath
sounds
Dyspnea
Fatigue
Fever
Rhonchi
Sore throat
Tachycardia
Tachypnea
183
Weight loss
Wheezing
Pulmonary
emphysema
Pulmonary
embolism
Pulmonary
tuberculosis
Silicosis
Tracheobronchitis
grayish white sputum that can become mucopurulent. Patients with emphysema are typically
thin and have the characteristic pink or red
complexion (“pink puffer” appearance). They
may also exhibit increased accessory muscle
use, tachypnea, grunting expirations through
pursed lips, diminished breath sounds, exertional dyspnea, rhonchi, barrel chest, anorexia, and
weight loss. Clubbing is a late sign.
◆ Legionnaires’ disease. This disorder causes
a cough that produces scant mucoid, nonpurulent and, possibly, blood-streaked sputum. Prodromal signs and symptoms typically include
malaise, fatigue, weakness, anorexia, diffuse
myalgia, and possibly diarrhea. Within 12 to
48 hours, the patient develops a dry cough and
a sudden high fever with chills. Many patients
also have pleuritic chest pain, headache,
tachypnea, tachycardia, nausea, vomiting, dyspnea, crackles, mild temporary amnesia, disorientation, confusion, flushing, mild diaphoresis,
and prostration.
◆ Lung abscess (ruptured). The cardinal sign
of a ruptured lung abscess is a cough that produces copious amounts of purulent, foulsmelling and, possibly, blood-tinged sputum. A
ruptured abscess can also cause diaphoresis,
anorexia, clubbing, weight loss, weakness,
••• • • •• •
•• ••••
•
••
•• • ••
•
•• ••
••• •
fatigue, fever with chills, dyspnea, headache,
malaise, pleuritic chest pain, halitosis, inspiratory crackles, and tubular or amphoric breath
sounds. The patient’s chest is dull on percussion
on the affected side.
◆ Lung cancer. One of the earliest signs of
bronchogenic carcinoma is a chronic cough that
produces small amounts of purulent (or mucopurulent), blood-streaked sputum. In a patient
with bronchoalveolar cancer, however, coughing produces large amounts of frothy sputum.
Other signs and symptoms of lung cancer include dyspnea, anorexia, fatigue, weight loss,
chest pain, fever, diaphoresis, wheezing, and
clubbing.
◆ Nocardiosis. This disorder causes a produc-
tive cough (with purulent, thick, tenacious, and
possibly blood-tinged sputum) and fever that
may last several months. Other findings include
night sweats, pleuritic pain, anorexia, weight
loss, malaise, fatigue, and diminished or absent
breath sounds. The patient’s chest is dull on
percussion.
◆ North American blastomycosis. This
chronic disorder may produce a dry hacking
cough or a productive cough with bloody or purulent sputum. Other findings include pleuritic
chest pain, fever, chills, anorexia, weight loss,
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malaise, fatigue, night sweats, cutaneous lesions (small, painless, nonpruritic macules or
papules), and prostration.
◆ Plague. Caused by Yersinia pestis, plague is
one of the most virulent and, if untreated, most
lethal bacterial infections known. Most cases
are sporadic, but the potential for epidemic
spread still exists. Clinical forms include bubonic (the most common), septicemic, and pneumonic plagues. The bubonic form is transmitted
to man from the bite of infected fleas. Signs and
symptoms include fever, chills, and swollen, inflamed, and tender lymph nodes near the site of
the fleabite. Septicemic plague may develop as a
complication of untreated bubonic or pneumonic plague and occurs when plague bacteria enter the bloodstream and multiply. The pneumonic form can be contracted by inhaling
respiratory droplets from an infected person or
inhaling the organism that has been dispersed
in the air through biological warfare. The onset
is usually sudden with chills, fever, headache,
and myalgia. Pulmonary signs and symptoms
include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, increasing respiratory distress, and cardiopulmonary insufficiency.
◆ Pneumonia. Bacterial pneumonia initially
produces a dry cough that becomes productive.
Associated signs and symptoms develop suddenly and include shaking chills, high fever,
myalgia, headache, pleuritic chest pain that increases with chest movement, tachypnea,
tachycardia, dyspnea, cyanosis, diaphoresis, decreased breath sounds, fine crackles, and
rhonchi.
Mycoplasmal pneumonia may cause a cough
that produces scant blood-flecked sputum. In
most cases, however, a nonproductive cough
starts 2 to 3 days after the onset of malaise,
headache, fever, and sore throat. Paroxysmal
coughing causes substernal chest pain. Patients
may develop crackles but generally don’t appear
seriously ill.
◆ Psittacosis. As this disorder progresses, the
characteristic hacking cough, nonproductive at
first, may later produce a small amount of mucoid, blood-streaked sputum. The infection
may begin abruptly with chills, fever,
headache, myalgia, and prostration. Other
signs and symptoms include tachypnea, fine
crackles, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness,
nausea, vomiting, and a faint macular rash.
Severe psittacosis may produce stupor, delirium, and coma.
◆ Pulmonary coccidioidomycosis. This disor-
der causes a nonproductive or slightly productive cough with fever, occasional chills, pleuritic
chest pain, sore throat, headache, backache,
malaise, marked weakness, anorexia, hemoptysis, and an itchy macular rash. Rhonchi and
wheezing may be heard. The disease may
spread to other areas, causing arthralgia,
swelling of the knees and ankles, and erythema
nodosum or erythema multiforme.
◆ Pulmonary edema. When severe, this life-
threatening disorder causes a cough that produces frothy, blood-tinged sputum. Early signs
and symptoms include exertional dyspnea,
paroxysmal nocturnal dyspnea followed by orthopnea, and a cough that may be nonproductive initially. Fever, fatigue, tachycardia, tachypnea, dependent crackles, and ventricular gallop
may also occur. As the patient’s respirations become increasingly rapid and labored, he develops more diffuse crackles and the productive
cough, worsening tachycardia, and possibly arrhythmias. His skin becomes cold, clammy, and
cyanotic; his blood pressure falls; and his pulse
becomes thready.
◆ Pulmonary embolism. This life-threatening
disorder causes a cough that may be nonproductive or may produce blood-tinged sputum.
Usually, the first symptom of a pulmonary embolism is severe dyspnea, which may be accompanied by angina or pleuritic chest pain. The patient experiences marked anxiety, a low-grade
fever, tachycardia, tachypnea, and diaphoresis.
Less common signs include massive hemoptysis, chest splinting, leg edema and, in a large
embolus, cyanosis, syncope, and distended
jugular veins. The patient may also have a
pleural friction rub, diffuse wheezing, crackles,
chest dullness on percussion, decreased breath
sounds, and signs of circulatory collapse.
◆ Pulmonary tuberculosis. This disorder
causes a mild to severe productive cough along
with some combination of hemoptysis, malaise,
dyspnea, and pleuritic chest pain. Sputum may
be scant and mucoid or copious and purulent.
Typically, the patient experiences night sweats,
easy fatigability, and weight loss. His breath
sounds are amphoric. He may exhibit chest dullness on percussion and, after coughing,
increased tactile fremitus with crackles.
◆ Silicosis. A productive cough with mucopu-
rulent sputum is the earliest sign of this disorder. The patient also has exertional dyspnea,
tachypnea, weight loss, fatigue, general weakness, and recurrent respiratory infections.
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185
Auscultation reveals end-inspiratory, fine crackles at the lung bases.
◆ Tracheobronchitis. Inflammation initially
causes a nonproductive cough followed by
chills, sore throat, slight fever, muscle and back
pain, and substernal tightness. As secretions increase, the cough produces mucoid, mucopurulent, or purulent sputum. The patient typically
has rhonchi and wheezing; he may also develop
crackles. Severe tracheobronchitis may cause a
fever of 101° to 102° F (38.3° to 38.9° C) and
bronchospasm.
O
THER CAUSES
◆ Diagnostic tests. Bronchoscopy and pul-
monary function tests may increase productive
coughing.
◆ Drugs. Expectorants, such as ammonium
chloride, guaifenesin, potassium iodide, and terpin hydrate, increase productive coughing.
◆ Respiratory therapy. Intermittent positive-
pressure breathing, nebulizer therapy, and incentive spirometry can help loosen secretions
and cause or increase productive coughing.
S
PECIAL CONSIDERATIONS
Avoid taking measures to suppress a productive
cough because retention of sputum may interfere with alveolar aeration or impair pulmonary
resistance to infection. Expect to give a mucolytic and an expectorant, and increase the patient’s intake of oral fluids to thin his secretions
and increase their flow. In addition, you may
give a bronchodilator to relieve bronchospasms
and open airways. An antibiotic may be ordered
to treat underlying infection.
Humidify the air around the patient; this will
relieve mucous membrane inflammation and
help loosen dried secretions. Provide pulmonary
physiotherapy, such as postural drainage with
vibration and percussion, to loosen secretions.
Aerosol therapy may be necessary.
Provide the patient with uninterrupted rest
periods. Keep him from using respiratory irritants. If he’s confined to bed rest, change his position often to promote the drainage of secretions.
Prepare the patient for diagnostic tests, such
as chest X-rays, bronchoscopy, a lung scan, and
pulmonary function tests. Collect sputum specimens for culture and sensitivity testing.
P
EDIATRIC POINTERS
Because his airway is narrow, a child with a
productive cough can quickly develop airway
occlusion and respiratory distress from thick or
excessive secretions. Causes of a productive
cough in children include asthma, bronchiectasis, bronchitis, acute bronchiolitis, cystic fibrosis, and pertussis.
When caring for a child with a productive
cough, expect to administer an expectorant, but
not a cough suppressant. To soothe inflamed
mucous membranes and prevent drying of secretions, provide humidified air or oxygen. Remember, high humidity can induce bronchospasm in a hyperactive child or produce
overhydration in an infant.
G
ERIATRIC POINTERS
Always ask elderly patients about a productive
cough because this sign may indicate a serious
acute or chronic illness.
P
ATIENT COUNSELING
Encourage the patient not to smoke because
doing so can aggravate his condition. Explain
that quitting even after decades of smoking is
helpful. Teach him how to breathe deeply, to
cough effectively and, if appropriate, to splint
his incision when he coughs. Tell him to sit or
stand upright when coughing, if possible, to
maximize chest expansion. Teach the patient
and his family how to use chest percussion to
loosen secretions.
Tell the patient to cover his mouth and nose
with a tissue when he coughs and to dispose of
contaminated tissues properly, to protect himself and others from the cough and secretions.
Be sure to provide a container for tissues and
sputum.
Crackles
[Rales, crepitations]
A common finding in patients with certain cardiovascular and pulmonary disorders, crackles
are nonmusical clicking or rattling noises heard
during auscultation of breath sounds. They usually occur during inspiration and recur constantly from one respiratory cycle to the next.
They can be unilateral or bilateral and moist or
dry. They’re characterized by their pitch, loudness, location, persistence, and occurrence during the respiratory cycle.
Crackles indicate abnormal movement of air
through fluid-filled airways. They can be irregularly dispersed, as in pneumonia, or localized,
as in bronchiectasis. (A few basilar crackles can
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be heard in normal lungs after prolonged shallow breathing. These normal crackles clear with
a few deep breaths.) Crackles usually indicate
the degree of an underlying illness. When crackles result from a generalized disorder, they usually occur in the less distended and more dependent areas of the lungs, such as the lung
bases, when the patient is standing. Crackles
caused by air passing through inflammatory exudate may not be audible if the involved portion
of the lung isn’t being ventilated because of
shallow respirations. (See How crackles occur.)
EMERGENCY INTERVENTIONS Quickly
take the patient’s vital signs, and examine
him for signs of respiratory distress or airway obstruction. Check the depth and rhythm of respirations. Is he struggling to breathe? Check for increased accessory muscle use and chest wall
motion, retractions, stridor, or nasal flaring. Provide supplemental oxygen. Endotracheal intubation may be necessary.
H
ISTORY AND PHYSICAL
EXAMINATION
If the patient also has a cough, ask when it began and if it’s constant or intermittent. Find out
what the cough sounds like and whether he’s
coughing up sputum or blood. If the cough is
productive, determine the sputum’s consistency,
amount, odor, and color.
Ask the patient if he has any pain. If so,
where is it located? When did he first notice it?
Does it radiate to other areas? Also, ask the patient if movement, coughing, or breathing worsens or helps relieve his pain. Note the patient’s
position: Is he lying still or moving about restlessly?
Obtain a brief medical history. Does the patient have cancer or any known respiratory or
cardiovascular problems? Ask about recent
surgery, trauma, or illness. Does he smoke or
drink alcohol? Is he experiencing hoarseness or
difficulty swallowing? Find out which medications he’s taking. Also, ask about recent weight
loss, anorexia, nausea, vomiting, fatigue, weakness, vertigo, and syncope. Has the patient been
exposed to irritants, such as vapors, fumes, or
smoke?
Next, perform a physical examination. Examine the patient’s nose and mouth for signs of infection, such as inflammation or increased secretions. Note his breath odor: Halitosis could
indicate pulmonary infection. Check his neck for
masses, tenderness, swelling, lymphadenopathy, or venous distention.
Inspect the patient’s chest for abnormal configuration or uneven expansion. Percuss for
dullness, tympany, or flatness. Auscultate his
lungs for abnormal, diminished, or absent
breath sounds. Listen to his heart for abnormal
sounds, and check his hands and feet for edema
or clubbing. (See Crackles: Causes and associated
findings, page 188.)
M
EDICAL CAUSES
◆ Acute respiratory distress syndrome. This
life-threatening disorder causes diffuse fine to
coarse crackles that are usually heard in the dependent portions of the lungs. It also produces
cyanosis, nasal flaring, tachypnea, tachycardia,
grunting respirations, rhonchi, dyspnea, anxiety,
and decreased level of consciousness.
◆ Asthma (acute). A severe attack usually oc-
curs at night or during sleep, causing dry,
whistling crackles. An attack typically starts
with a dry cough and mild wheezing and progresses to severe dyspnea, audible wheezing,
chest tightness, and a productive cough. Other
findings include apprehension, prolonged expirations, rhonchi, intercostal and supraclavicular
retractions on inspiration, accessory muscle
use, flaring nostrils, tachypnea, tachycardia, diaphoresis, and flushing or cyanosis.
◆ Bronchiectasis. In this disorder, persistent
coarse crackles are heard over the affected area
of the lung. They’re accompanied by a chronic
cough that produces copious amounts of mucopurulent sputum. Other characteristics include halitosis, occasional wheezing, exertional
dyspnea, rhonchi, weight loss, fatigue, malaise,
weakness, recurrent fever, and late-stage
clubbing.
◆ Bronchitis (chronic). This disorder causes
coarse crackles that are usually heard at the
lung bases as well as prolonged expirations,
wheezing, rhonchi, exertional dyspnea, tachypnea, and a persistent productive cough from increased bronchial secretions. Clubbing and cyanosis may also occur.
◆ Chemical pneumonitis. In acute chemical
pneumonitis, diffuse fine to coarse, moist crackles accompany a productive cough with purulent sputum, dyspnea, wheezing, orthopnea,
fever, malaise, and mucous membrane irritation. Signs and symptoms may worsen for 24 to
48 hours after exposure, then resolve; if severe,
however, they may recur 2 to 5 weeks later.
◆ Interstitial fibrosis of the lungs. Cello-
phane-like crackles can be heard over all lobes
in this disorder. As the disease progresses, a
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How crackles occur
Crackles occur when air passes through fluid-filled airways, causing collapsed alveoli to pop open
as the airway pressure equalizes. They can also occur when membranes lining the chest cavity
and the lungs become inflamed. The illustrations below show a normal alveolus and two pathologic alveolar changes that cause crackles.
NORMAL ALVEOLUS
Bronchiole
Alveolus
CO
2
ALVEOLUS IN PULMONARY EDEMA
CO
2
ALVEOLUS IN INFLAMMATION
Arterial blood
O
2
Mixed venous blood
Bronchiole
O
2
Alveolus
Arterial blood
Fluid
Interstitial congestion
Mixed venous blood
Bronchiole
Inflammation with exudate
CO
Alveolus
2
O
2
Arterial blood
Edema of alveolar wall
Secretions
Mixed venous blood
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SIGNS & SYMPTOMS
Crackles: Causes and associated findings
Common
causes
Acute respiratory
distress syndrome
Major associated signs and symptoms
Chest pain
Cough
Cyanosis
Dyspnea
Fatigue
Fever
Hemoptysis
Rhonchi
•• •••
Tachycardia
Tachypnea
Vomiting
Weakness
Weight loss
Asthma (acute)
Bronchiectasis
Bronchitis (chronic)
Chemical
pneumonitis
Interstitial fibrosis
of the lungs
Legionnaires’
disease
Lung abscess
Pneumonia
(bacterial)
Pneumonia
(mycoplasmal)
Pneumonia (viral)
Psittacosis
Pulmonary edema
Pulmonary
embolism
•••• •••
••••• ••
••• •• •
•••••
••••• • •
•• •••• ••••
•• •••• ••
•••••• •••
••••
•••
•• • ••
••• • ••
•••• •• ••
Pulmonary
tuberculosis
Sarcoidosis
Silicosis
Tracheobronchitis
•• •••• ••
•• • •
••• •••
••• •••
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nonproductive cough, dyspnea, fatigue, weight
loss, cyanosis, and pleuritic chest pain develop.
◆ Legionnaires’ disease. This disorder causes
diffuse moist crackles and a cough producing
scant mucoid, nonpurulent and, possibly, bloodstreaked sputum. Prodromal signs and symptoms usually include malaise, fatigue, weakness, anorexia, diffuse myalgia and, possibly,
diarrhea. Within 12 to 48 hours, the patient develops a dry cough and a sudden high fever
with chills. He may also have pleuritic chest
pain, headache, dyspnea, tachypnea, tachycardia, nausea, vomiting, mild temporary amnesia,
confusion, flushing, mild diaphoresis, and prostration.
◆ Lung abscess. This disorder produces fine to
medium, moist inspiratory crackles. The onset
is insidious; signs and symptoms include
sweats, anorexia, weight loss, fever, fatigue,
weakness, dyspnea, clubbing, pleuritic chest
pain, pleural friction rub, and a cough producing
copious amounts of foul-smelling, purulent and,
possibly, blood-tinged sputum. The patient’s
breath sounds are hollow and tubular or amphoric; the affected side of his chest is dull on
percussion.
◆ Pneumonia. Bacterial pneumonia produces
diffuse fine crackles, sudden shaking chills, high
fever, tachypnea, pleuritic chest pain, cyanosis,
grunting respirations, nasal flaring, decreased
breath sounds, myalgia, headache, tachycardia,
dyspnea, cyanosis, diaphoresis, and rhonchi.
The patient also has a dry cough that later becomes productive.
Mycoplasmal pneumonia produces medium
to fine crackles with a nonproductive cough,
malaise, sore throat, headache, and fever. The
patient may have blood-flecked sputum. In viral
pneumonia, diffuse crackles develop gradually
and may be accompanied by a nonproductive
cough, malaise, headache, anorexia, low-grade
fever, and decreased breath sounds.
◆ Psittacosis. Diffuse fine crackles may be
heard as this disorder progresses. Accompanying findings include a characteristic hacking,
productive cough, chills, fever, headache, myalgia, and prostration. Other features include
tachypnea, chest pain (rare), epistaxis, photophobia, abdominal distention and tenderness,
nausea, vomiting, and a faint macular rash.
◆ Pulmonary edema. Moist, bubbling crackles
on inspiration are one of the first signs of lifethreatening pulmonary edema. Other early findings include exertional dyspnea; paroxysmal
nocturnal dyspnea, then orthopnea; and cough-
ing, which may be initially nonproductive but
later produces frothy, bloody sputum. Related
clinical effects include tachycardia, tachypnea,
and a ventricular gallop (a third heart sound
[S
]). As the patient’s respirations become in-
3
creasingly rapid and labored, he develops more
diffuse crackles, worsening tachycardia, hypotension, a rapid and thready pulse, cyanosis,
and cold, clammy skin.
◆ Pulmonary embolism. This life-threatening
disorder can cause fine to coarse crackles and a
cough that may be dry or may produce bloodtinged sputum. Usually, the first sign of pulmonary embolism is severe dyspnea, which
may be accompanied by angina or pleuritic
chest pain. The patient has marked anxiety, a
low-grade fever, tachycardia, tachypnea, and diaphoresis. Less-common signs include massive
hemoptysis, chest splinting, leg edema and,
with a large embolus, cyanosis, syncope, and
distended jugular veins. The patient may also
have a pleural friction rub, diffuse wheezing,
chest dullness on percussion, decreased breath
sounds, and signs of circulatory collapse.
◆ Pulmonary tuberculosis. In this disorder,
fine crackles occur after coughing along with
some combination of hemoptysis, malaise, dyspnea, and pleuritic chest pain. Sputum may be
scant and mucoid or copious and purulent. Typically, the patient is easily fatigued and experiences night sweats, weakness, and weight loss.
His breath sounds are amphoric.
◆ Sarcoidosis. This disorder produces fine,
bibasilar, end-inspiratory crackles and, rarely,
wheezing. The patient doesn’t have a fever but
does have malaise, fatigue, weakness, weight
loss, a cough, dyspnea, and tachypnea.
◆ Silicosis. This disorder produces fine end-in-
spiratory crackles heard at the lung bases. The
earliest sign of silicosis is a productive cough
with mucopurulent sputum. The patient also exhibits exertional dyspnea, tachypnea, weight
loss, fatigue, general weakness, and recurrent
respiratory tract infections.
◆ Tracheobronchitis. In its acute form, this
disorder produces moist or coarse crackles
along with a productive cough, rhonchi, wheezing, chills, sore throat, a slight fever, muscle and
back pain, and substernal tightness. Severe tracheobronchitis may cause a moderate fever and
bronchospasm.
S
PECIAL CONSIDERATIONS
To keep the patient’s airway patent and facilitate his breathing, elevate the head of his bed.
190 CREPITATION, BONY
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To liquefy thick secretions and relieve mucous
membrane inflammation, administer fluids, humidified air, or oxygen. Diuretics may be needed
if crackles result from cardiogenic pulmonary
edema. Turn the patient every 1 to 2 hours, and
encourage him to breathe deeply.
Plan daily uninterrupted rest periods to help
the patient relax and sleep. Prepare the patient
for diagnostic tests, such as chest X-rays, a lung
scan, and sputum analysis.
P
EDIATRIC POINTERS
Crackles in an infant or a child may indicate a
serious cardiovascular or respiratory disorder.
Pneumonias produce sudden diffuse crackles in
children. Esophageal atresia and tracheoesophageal fistula can cause bubbling, moist
crackles due to aspiration of food or secretions
into the lungs—especially in neonates. Pulmonary edema causes fine crackles at the base
of the lungs, and bronchiectasis produces moist
crackles. Cystic fibrosis produces widespread
fine to coarse inspiratory crackles and wheezing
in infants. Sickle cell anemia may produce
crackles when it causes pulmonary infarction or
infection.
G
ERIATRIC POINTERS
Crackles that clear after deep breathing may indicate mild basilar atelectasis. In elderly patients, auscultate lung bases before and after
auscultating apices.
P
ATIENT COUNSELING
Teach the patient how to cough effectively and
splint incision areas if appropriate. Encourage
him to avoid smoking and using aerosols, powders, or other products that might irritate his
airways.
Crepitation, bony
[Bony crepitus]
Bony crepitation is a palpable vibration or an
audible crunching sound that results when one
bone grates against another. This sign commonly results from a fracture, but it can also occur when bones that have been stripped of their
protective articular cartilage grind against each
other as they articulate—for example, in patients with advanced arthritic or degenerative
joint disorders.
Eliciting bony crepitation can help confirm
the diagnosis of a fracture, but it can also cause
further soft tissue, nerve, or vessel injury. Always evaluate distal pulses and perform neurologic checks distal to the suspected fracture site
before manipulating an extremity. In addition,
rubbing fractured bone ends together can convert a closed fracture into an open one if a bone
end penetrates the skin. Therefore, after the initial detection of crepitation in a patient with a
fracture, avoid subsequent elicitation of this
sign.
H
ISTORY AND PHYSICAL
EXAMINATION
If you detect bony crepitation in a patient with a
suspected fracture, ask him if he feels any pain
and if he can point to the painful area. To prevent lacerating nerves, blood vessels, or other
structures, immobilize the affected area by applying a splint that includes the joints above and
below the affected area. Elevate the affected
area, if possible, and apply cold packs. Inspect
for abrasions or lacerations. Find out how and
when the injury occurred. Palpate pulses distal
to the injury site, and check the skin for pallor
or coolness. Test motor and sensory function
distal to the injury site.
If the patient doesn’t have a suspected fracture, ask about a history of osteoarthritis or
rheumatoid arthritis. Do any medications help
ease arthritic discomfort? Take the patient’s vital signs and test joint range of motion.
M
EDICAL CAUSES
◆ Fracture. In addition to bony crepitation, a
fracture causes acute local pain, hematoma,
edema, and decreased range of motion. Other
findings may include deformity, point tenderness, discoloration of the limb, and loss of limb
function. Neurovascular damage may cause increased capillary refill time, diminished or absent pulses, mottled cyanosis, paresthesia, and
decreased sensation (all distal to the fracture
site). An open fracture produces an obvious
skin wound.
◆ Osteoarthritis. Joint crepitation may be
elicited during range-of-motion testing in advanced osteoarthritis. Soft fine crepitus on palpation may indicate roughening of the articular
cartilage; coarse grating may indicate badly
damaged cartilage. The cardinal symptom of osteoarthritis is joint pain, especially during motion and weight bearing. Other findings include
joint stiffness that typically occurs after resting
and subsides within a few minutes after the patient begins moving.
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