15. pulmonary consolidation syndromes

7/25/2019 15. Pulmonary Consolidation Syndromes

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PULMONARY CONSOLIDATIONPULMONARY CONSOLIDATION

SYNDROMESSYNDROMES


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PULMONARY CONSOLIDATION SYNDROMESPULMONARY CONSOLIDATION SYNDROMESClassificationClassification

Not retractileNot retractile1.1.Well delimitatedWell delimitated

PNEUMONIASPNEUMONIAS

PULMONARY INFARCTIONPULMONARY INFARCTION

2.2.Not well delimitatedNot well delimitated lunglung cancer

OrOr

InflamatoryInflamatory / Not/ Not inflamatoryinflamatory

RetractileRetractile


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I.I.

PULMONARY CONSOLIDATIONPULMONARY CONSOLIDATION

SYNDROMESYNDROME

CAUSED BY INFLAMMATORY PROCESSCAUSED BY INFLAMMATORY PROCESS


BRONCHOPNEUMONIASBRONCHOPNEUMONIAS


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PNEUMONIAS:PNEUMONIAS:

--bacterialbacterial

--viralviral

--with atypical microorganismswith atypical microorganisms

CLASSIFICATION:


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BACTERIAL PNEUMONIASBACTERIAL PNEUMONIAS


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PHYSICAL SIGNS IN PULMONARYPHYSICAL SIGNS IN PULMONARY

CONSOLIDATIONCONSOLIDATION

Increased tactileIncreased tactile fremitusfremitus

DulnessDulness to percussionto percussion

egophonyegophony and whisperedand whispered pectoriloquypectoriloquyBronchial breath soundsBronchial breath sounds

RalesRales or cracklesor crackles

/absent intensity of breath sounds/absent intensity of breath sounds


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Bacterial PneumoniasBacterial PneumoniasThe most common etiologies :The most common etiologies :

Pn. with S.pneumoniae (pneumococcus)(Lobar Pn.)=typical lobar pneumonia

& The most common pneumoniaPn. with Staphylococcus

Pn. withStreptococcus

Pn. with Klebsiela(Friendlander bacillus)

Pn. with Haemophilus influenzae


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TYPICAL LOBAR PNEUMONIATYPICAL LOBAR PNEUMONIA


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TYPICAL LOBAR PNEUMONIATYPICAL LOBAR PNEUMONIA

Etiology: Streptococcus pneumoniae

= G+ diplo coccus

Involves 1 segment / pulmonary lobe

Evolution in 3 stages1.Onset2.Evolution

3.Resolution


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ONSET-1

CHILLSCHILLS suddensuddenSingle rigorSingle rigor

Duration 15Duration 15 30 minutes30 minutes

followed by

high FEVERFEVER390

400

, constantpyrexia


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ONSET-2

Chest aching/Chest aching/pleuriticpleuritic painpain

1. Severe

2. Sharp/knifelike

3.Aggravated by each breath/by coughing/by coughing4. The patient is immobilized on the sick side

5. Localization: submammary area/basalbasal

6.6. Results from inflamed parietal pleuraResults from inflamed parietal pleura((e.g.: diaphragmatic pl.e.g.: diaphragmatic pl. shoulder painshoulder painchildrenchildren abdominal pain)abdominal pain)


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ONSETONSET--33

COUGH irritativeirritative,, hollow coughhollow cough, at first, at first

11 3 day3 day

-- Productive ofProductive of

pinkish or adherentpinkish or adherent rusty sputumrusty sputum

containing fibrin and red cellscontaining fibrin and red cells


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ONSET-4

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Warm teguments (febrile)Warm teguments (febrile)Severe state of healthSevere state of health

Redness of faceRedness of face

herpesherpes labialislabialis((whole face)whole face)


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ONSET-5

RESPIRATORY SYSTEM EXAMINATIONINSPECTION - superficial respiration ( caused by chest( caused by chest

aching/aching/pleuriticpleuritic pain)pain)

-- polypneapolypnea

PALPATION normally transmitted tactilenormally transmitted tactile fremitusfremitus

PERCUSSION:: discreet dullnessdiscreet dullness

AUSCULTATION ::

Initially:Initially: tonality and intensity oftonality and intensity of breathbreathsounds = bronchial breath soundssounds = bronchial breath sounds

timber changes = hardening of breath soundstimber changes = hardening of breath sounds

== fremitusfremitus, breath and voice sounds are transmitted as if, breath and voice sounds are transmitted as if

they came directly from the larynx and tracheathey came directly from the larynx and trachea


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EVOLUTION

After 24After 24 48 hours48 hours

Duration 7Duration 7 10 days10 days

Clinical presentation ofClinical presentation of consolidation syndromeconsolidation syndromeSustainedSustainedFeverFever

Dyspnea withDyspnea with inspiratoryinspiratorypolypneapolypnea

CyanosisCyanosisSustainedSustained pleuriticpleuriticpainpain ofof intensityintensity

CoughingCoughing withwith rusty sputumrusty sputum yellowishyellowish (afterwards)(afterwards)

Redness of face (plethora of the cheek of affected side))

JaundiceJaundice (( hemolysishemolysis, impaired liver function), impaired liver function)


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EVOLUTION

THORAX EXAMINATION

Inspection : chest expansion

restricted motion of the affectedhemithorax

Palpation : tactile fremitus

Percussion : Dullness

Auscultation : bronchial breath sounds

surrounded by fine crepitant rales, instead of

vesicular breath sounds

(initially, fine crepitant rales dominate, being replaced

by tubular or bronchial breath sounds)


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Resolution

Less well defined dullnessLess well defined dullness

/ tubular breath sounds disappear/ tubular breath sounds disappear

CrepitantCrepitant ralesrales reappearreappear

= other characters= other characters

coarse, unequal, mucouscoarse, unequal, mucous


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Recovery inRecovery incrisiscrisis

= sudden= sudden

Before AB /Before AB / pt. diedpt. diedin crisisin crisis

The patient state of health is aggravated suddenlyThe patient state of health is aggravated suddenly

Rapid temperature rise at 40Rapid temperature rise at 4000

deliriumdelirium

Abundant sweatingAbundant sweating FeFeverver normalnormal

Normal pulseNormal pulse


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RecoveryRecoveryinin lisislisis

Without particular clinical signsWithout particular clinical signs

Apparent state of health is improvingApparent state of health is improvingBody temperature begins to fallBody temperature begins to fall

Cough diminishes, then disappearsCough diminishes, then disappears


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LABORATORY FINDINGSLABORATORY FINDINGS

INFLAMATIONINFLAMATION:: leukocytosisleukocytosis withwith

neutrophilsneutrophils,, VSH,VSH, fibrinogen,fibrinogen, CRPCRP

BIOCHIMIEBIOCHIMIE:: indirectindirect bilbil.,.,

creatininecreatinine,, urea (urea (oliguriaoliguria))

SPUTUM:SPUTUM:

--Bacteriological examination: Grams method, culture=pneumococci

-Cellularity: red cells, alveolar cells, leucocytes


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CONFIRMATIONCONFIRMATIONXX--ray of the chestray of the chest

= triangular density= triangular density1.1. The base towards the pleuraThe base towards the pleura

2.2. The tip towards theThe tip towards the hilhil3.3. SubcostalSubcostal intensity, homogenousintensity, homogenous

4.4. May occupy an entireMay occupy an entire segment / lobesegment / lobe


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Strep. pneumoniaeStrep. pneumoniae

pneumonia.pneumonia.

Right upperRight upper--lobelobeconsolidationconsolidation

demonstrating ademonstrating a

pronounced airpronounced air

bronchogram and absencebronchogram and absenceofof

volume change.volume change.


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Bacterial pneumonia. Pneumococci on sputum Gram stain.


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Bacterial pneumonia.

A posteroanterior chest radiograph shows left lower pneumonia.

Sputum Gram stain showed gram-positive diplococci.


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PARTICULAR FORMSPARTICULAR FORMSABORTIVE FORMSABORTIVE FORMS

spontaneous healing without ABspontaneous healing without AB

THE ELDER PNEMUMONIATHE ELDER PNEMUMONIA

discreet presentation, severe evolutiondiscreet presentation, severe evolution

CHILD PNEUMONIACHILD PNEUMONIA

abdominal pain, vomiting,abdominal pain, vomiting, meningealmeningeal signssigns

ALCHOOLICSALCHOOLICS mental disorders, psychomotor agitationmental disorders, psychomotor agitation


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EVOLUTION

NATURAL

-Death in crisis

-Complication

UNDER TREATMENT

-ImmunocompetentYoungers

= healing in 5-6 days-Complications at

elders,

immunosuppressed

COMPLICATIONS

Sepsis bacteriemia:

pericarditis, endocarditis,meningitis, brain abscess,

parotitis, nephritis,

Circulatory collapse

Abscess

Pleural effusion

- Early -parapneumonic

= sterile serocitrine effusion

-Late: metapneumonic

=usually, purulent fluid


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STAPHYLOCOCCAL PNEUMONIASTAPHYLOCOCCAL PNEUMONIA

May begin insidiouslyMay begin insidiously

Grave state of healthGrave state of health

Clinical =Clinical = dyspneadyspnea and cyanosis are the chiefand cyanosis are the chiefsymptomssymptoms

RemitentRemitent feverfever

Sputum may be bloody or frankly purulentSputum may be bloody or frankly purulent

Physical signs:Physical signs: consolidated foci, dull areas,consolidated foci, dull areas,bronchial respiration, fine crackles and coarsebronchial respiration, fine crackles and coarsecracklescrackles

XX--rayray = Multiple foci of patchy consolidation= Multiple foci of patchy consolidationpneumatocelespneumatoceles pneumotoraxpneumotorax

= in fact, bronchopneumonia= in fact, bronchopneumonia


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PNEUMONIA WITH KLEBSIELLA PNEUMONIAEPNEUMONIA WITH KLEBSIELLA PNEUMONIAE(Friedlander(Friedlander))

Most frequently found in pts. with increasedMost frequently found in pts. with increasedsusceptibility (chronic diseases, underfed persons)susceptibility (chronic diseases, underfed persons)

Characteristic = severe state of health withCharacteristic = severe state of health withprostration, often with collapse septicprostration, often with collapse septicpatientspatients

Intense cyanosis andIntense cyanosis and dyspneadyspnea

Sputum is thick, gelatinous, brick red, andSputum is thick, gelatinous, brick red, andlaced with puslaced with pus

Consolidation syndrome is not often presentConsolidation syndrome is not often present

XX--ray: densities that occupy more than one lobe,ray: densities that occupy more than one lobe,often, an entire lungoften, an entire lung

Tendency to form abscess and to be a chronic formTendency to form abscess and to be a chronic form


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TREATMENTTREATMENT--GENERAL PRINCIPLESGENERAL PRINCIPLES

OxygenOxygen

HydrationHydrationSymptomatic (Symptomatic (antipyretics,anticoughing, drugs that fluidly sputum)

Complications treatmentComplications treatment

ETIOLOGIC = ANTIBIOTICSETIOLOGIC = ANTIBIOTICS


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ETIOLOGICAL SPECIFIC treatmentETIOLOGICAL SPECIFIC treatmentif the etiological agent is identified +if the etiological agent is identified + antibiogramantibiogram

Strep.pneumoniaeStrep.pneumoniae

Penicillin sensitive =Penicillin sensitive =AMP iv,AMP iv, amoxamox popo, M, pen G iv,, M, pen G iv, doxidoxi, O, O CephCeph

P resistant :P resistant : FQ (FQ (moximoxi) / P) / P cephceph 33

HH influenzaeinfluenzae

--lactamaselactamase + :+ :AM/CL, OAM/CL, O CephCeph 2/3, P2/3, P CephCeph 33

--LactamaseLactamase ::AMP iv,AMP iv, amoxamox popo, TMP/SMX, M, TMP/SMX, M

Amp- ampicilineAM/CL- augmentin

P Ceph 3- 3rd generation cephalosporin

FQ- fluoroquinolone ( Moxi- moxifloxacine)Tmp/smx- trimetoprim/sulfametoxaxol


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ATYPICAL INTERSTITIALATYPICAL INTERSTITIAL


((NON BACTERIALNON BACTERIAL))


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ETIOLOGIESETIOLOGIES commonly,commonly, viral,,

Also with:Also with: chlamydiachlamydia,, mycoplasmaemycoplasmae

CLINICAL MANIFESTIONS:CLINICAL MANIFESTIONS:

FeverFeverCough with mucous expectoration orCough with mucous expectoration or

mucopurulentmucopurulent

Bronchitis syndromeBronchitis syndromeAsthenia, nocturne diaphoresisAsthenia, nocturne diaphoresis


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The pulmonary infiltrative processesThe pulmonary infiltrative processes

dondont realizet realize

parenchymatousparenchymatous consolidationconsolidation

syndromesyndrome


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CLINICAL DIAGNOSTICCLINICAL DIAGNOSTIC

Significantepidemiologicalelement

Suggested by the association of:Rinitis

Erythematous angina

Bronchitis

There is a poor correlation betweenclinical signs and X-ray chest


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XX--ray chestray chest

Accentuated patternAccentuated pattern

Linear and reticular densitiesLinear and reticular densities

HilarHilar--basal,basal,

uniuni or bilateralor bilateral

Sometimes, the densities are microSometimes, the densities are micro-- oror

macronodularmacronodular with transitory characterwith transitory character


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A 38-year-old patient with Mycoplasma pneumonia.Chest radiograph shows a vague, ill-defined opacity


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Measles pneumonia.Measles pneumonia.An example of a widespread primary viralAn example of a widespread primary viralpneumonia with extensive bilateral confluent consolidation.pneumonia with extensive bilateral confluent consolidation.


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BRONCHOPNEUMONIABRONCHOPNEUMONIA


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Anatomic and clinical syndrome caused by various diseases,Anatomic and clinical syndrome caused by various diseases,

with unpredictable evolution, reserved prognosiswith unpredictable evolution, reserved prognosis

Affect extreme ages orAffect extreme ages or immunodepressedimmunodepressed personspersons

May be: primary / secondaryMay be: primary / secondary

PRIMARY:PRIMARY:

Children, elders,Children, elders, immunodepressedimmunodepressed ((microbial associationsmicrobial associations))

SecondarySecondary

--more commonlymore commonly

--predisposing causes:predisposing causes:

various pulmonary infections (microbial, viral)various pulmonary infections (microbial, viral)

AspirationAspiration

Toxic substances inhalationToxic substances inhalation



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SYMPTOMSSYMPTOMS discreet/ absentdiscreet/ absent

with severe state of healthwith severe state of health

Untypical, insidiousUntypical, insidious ONSETONSET

Grave, severeGrave, severe STATE OF HEALTHSTATE OF HEALTH

CHILLS,CHILLS,pleuriticpleuriticpainpain may missmay miss

Gradually increase ofGradually increase ofFEVERFEVER, it is, it is

irregular, it increases each time a new, it increases each time a newfocus reappears, decreases at the end offocus reappears, decreases at the end ofthe diseasethe disease


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COUGHCOUGH withwith mucopurulentmucopurulent sputum withsputum withhemorrhagichemorrhagic striaestriae

Intense centralIntense central CYANOSISCYANOSIS (lips and(lips and

extremities)extremities)DYSPNEADYSPNEA

withwith

Severe POLYPNEASevere POLYPNEA (> 35respirations/min)(> 35respirations/min)

== on the first plane +on the first plane + suprasternalsuprasternal andandintercostalintercostal retraction and grunting (newborn)retraction and grunting (newborn)

// or permanentor permanent dyspneadyspnea withwith

exacerbationsexacerbations


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BRONCHOPNEUMONIAS

PHYSICAL SIGNS

There is no correlation

between the gravity of

general signs+dyspnea

and physical signs

Varying with time and

location, changing the

characters from day to

day, sometimes in hours

Fluctuating

They vary with thedegree of process

extension


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PERCUSSIONPERCUSSION

Only in confluentOnly in confluent bronchopneumoniasbronchopneumonias,,

there arethere are dulldull areas that mimic lobarareas that mimic lobarpneumoniapneumonia

Usually, foci are localized in inferiorUsually, foci are localized in inferior

lobes (exceptions: scarlet rash, barkinglobes (exceptions: scarlet rash, barking

cough)cough)


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AUSCULTATIONAUSCULTATION ::Bronchial breath soundsBronchial breath sounds

= the expression of bronchitis= the expression of bronchitis

-- Crackles surrounding the territory ofCrackles surrounding the territory of

lobular focuslobular focus

Fine and CoarseFine and Coarse CRACKLESCRACKLES


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ConclusionConclusion

Disparate zones of congestionDisparate zones of congestion

Bronchial vesicular soundsBronchial vesicular sounds,,

Fine bubblingFine bubbling ralesrales, coarse, coarse

crepitantscrepitants,,

andand dull areasdull areas


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Chest XChest X--rayray

There is no correlation between clinicalThere is no correlation between clinical

presentation andpresentation and XrayXrayXrayXray chest: multiple patchy opacities,chest: multiple patchy opacities,

with irregular outlines and less wellwith irregular outlines and less well

limitedlimited

Sometimes, there are opacities moreSometimes, there are opacities more

densedense


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COMPLICATIONS

EARLY ONSET : LOCAL / GENERALEARLY ONSET : LOCAL / GENERAL

LATE ONSET :LATE ONSET : bronchiectasisbronchiectasisE.g.:E.g.:

Septic shock with tachycardia, hypotension,Septic shock with tachycardia, hypotension,

collapse, renal failurecollapse, renal failure, heart failure Hypoxemia withHypoxemia with hypercapniahypercapnia

Children: acuteChildren: acute corcor pulmonalepulmonale

Prognosis was severe before antibiotics use improvedwith etiological and complications treatment (supportive)


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INFLAMATIONINFLAMATION:: leukocytosisleukocytosis withwith

polymorphonuclearspolymorphonuclears,, VSH,VSH, fibrinogen,fibrinogen, CRPCRP

BIOCHIMIEBIOCHIMIE:: indirectindirect bilbil.,., creatininecreatinine,, urea (urea (oliguriaoliguria))

SPUTUM:SPUTUM:--Bacteriological examination: Gram method, culture

=pneumococ

-Celullarity: red cells, alveolar cells, leukocytes


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Consolidation syndrome caused byConsolidation syndrome caused byalveolar airalveolar air

replacement with bloodreplacement with blood

Sudden occlusion of a part of pulmonary arterial treeSudden occlusion of a part of pulmonary arterial tree

Predisposing factors (diseases that favor thrombosisPredisposing factors (diseases that favor thrombosis

deep venous thrombosis)deep venous thrombosis)


Classification CSClassification CS

Not retractileNot retractileWell delimitatedWell delimitated

Not well delimitatedNot well delimitated




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CLINICALCLINICAL

CHEST PAINCHEST PAIN

PleuriticPleuritic chest pain aggravated by cough/respirationchest pain aggravated by cough/respirationLateralLateral decubitusdecubitus on the healthy side)on the healthy side)

DYSPNEADYSPNEA

ANXIETYANXIETY

HEMOPTOSYSHEMOPTOSYS after a few hours of chest painafter a few hours of chest pain

onset /onset /Or dry cough with pleural characterOr dry cough with pleural character




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ConjunctivalConjunctivaljaundicejaundice

Lips cyanosisLips cyanosis

TachycardiaTachycardia

FeverFever

Sometimes, right heart failure signsSometimes, right heart failure signs




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SMALLSMALLINFARCTINFARCT

Sub dullnessSub dullness

tactiletactile fremitusfremitus

Coarse respirationCoarse respiration

Pleural rubPleural rub




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LARGELARGEINFARCTINFARCT

Sub dullnessSub dullness

tactiletactile fremitusfremitus

Tubular breath soundsTubular breath sounds

RalesRales, fine, fine crepitantscrepitantsPleural rubPleural rub

Pleural effusion syndromePleural effusion syndrome




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DIAGNOSTICDIAGNOSTIC

The clinical manifestations of underlyingThe clinical manifestations of underlyingdiseasedisease

X ray chestX ray chest

Triangular density with the base towardsTriangular density with the base towards

the pleurathe pleura dilated pulmonary arterydilated pulmonary artery




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TREATMENTTREATMENT

Of underlying diseaseOf underlying diseaseANTICOAGULANTANTICOAGULANT

HEPARINS (UFH, LMWH)HEPARINS (UFH, LMWH)

ORAL ANTICOAGULANTSORAL ANTICOAGULANTS



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II.II.PULMONARYPULMONARY

CONSOLIDATIONS CAUSED BYCONSOLIDATIONS CAUSED BYTUMORAL PROCESSESTUMORAL PROCESSES

ClassificationClassificationNot retractileNot retractile

Well delimitatedWell delimitatedNot well delimitatedNot well delimitated



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BRONCHOPULMONAR NEOPLASMBRONCHOPULMONAR NEOPLASM

Association of syndromesAssociation of syndromes

Retractile consolidation syndrome / nonRetractile consolidation syndrome / nonretractileretractile

Pleural effusion syndromePleural effusion syndrome

MediastinalMediastinal pulmonary syndromepulmonary syndromeCavity syndromeCavity syndrome


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According to localizationAccording to localization neoneo. are. are::Hilar

Peripheral noduleLobar

Segmental

Consolidation pulmonary syndrome = RareConsolidation pulmonary syndrome = Rare


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CHIEF COMPLAINTSCHIEF COMPLAINTS

COUGHCOUGH

Irritation of X nerveIrritation of X nerve

PAINPAIN

Appears tardilyAppears tardily

permanent, not related to the respirationpermanent, not related to the respirationHEMOPTISYSHEMOPTISYS

currant jellycurrant jellyaspectaspect

DYSPNEADYSPNEA If there is an involvement of principal bronchiaIf there is an involvement of principal bronchia

Physical signsPhysical signs


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Physical signsPhysical signs

LOCALIZED BRONCHIC OBSTRUCTION SYNDROMELOCALIZED BRONCHIC OBSTRUCTION SYNDROME

PARTIAL OBSTRUCTIONPARTIAL OBSTRUCTION

Localized wheezingLocalized wheezing

LocalLocal hyperresonancehyperresonance

Sibilants + localized bronchial breath soundsSibilants + localized bronchial breath sounds

tactiletactile fremitusfremitus,, vesicular breath soundsvesicular breath sounds localizedlocalized

TOTAL OBSTRUCTIONTOTAL OBSTRUCTION

==AtelectasisAtelectasis Dullness or flatness, withoutDullness or flatness, without fremitusfremitus, absent breath sounds, absent breath sounds

COMPLICATION OF THE OBSTRUCTIONCOMPLICATION OF THE OBSTRUCTION

Repeated pneumonias in the same placeRepeated pneumonias in the same place

AbscessesAbscesses

O OSDR CAUSED BY LOCAL INVASION


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SDR. CAUSED BY LOCAL INVASIONSDR. CAUSED BY LOCAL INVASIONTHE INVASION OF MEDIASTINUMTHE INVASION OF MEDIASTINUM RecurentRecurentN.N. = vocal cords palsy, hoarseness= vocal cords palsy, hoarseness

PhrenicPhrenic= diaphragm palsy, pain irradiated to neck= diaphragm palsy, pain irradiated to neck

EsophagusEsophagus= deglutition disorders= deglutition disorders X nerveX nerve = Dyspnea, constipation= Dyspnea, constipation

CervicalCervical sympaticsympatic= Claude= Claude--BernardBernard-- HornerHorner sdrsdr..

TracheaTrachea== stridorstridor,, dyspneadyspnea

Superior cave veinSuperior cave vein= turgescent jugulars, pelerine= turgescent jugulars, pelerineedemaedema

PleuraPleura= pleural effusion syndrome= pleural effusion syndrome

PericardiumPericardium= pericardial effusion/= pericardial effusion/ tamponadetamponade

MyocardiumMyocardium = arrhythmias= arrhythmias Towards the superior thoracic outlet =Towards the superior thoracic outlet = sdr.Pancoastsdr.Pancoast

( the 1( the 1stst--22ndnd ribrib lysislysis))

S G S OSIGNS FROM


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SIGNS FROMSIGNS FROM

LYMPHATIC SPREADLYMPHATIC SPREAD

Ganglions:Ganglions:

hilarhilar,,

mediastinalmediastinal,,

supraclavicularsupraclavicularCarcinomatousCarcinomatous lymphangitislymphangitis

((dyspneadyspnea, Respiratory failure, Respiratory failure))

HEMATOGENOUS SPREADHEMATOGENOUS SPREADliver, brain, SR, boneliver, brain, SR, bone

SYSTEMIC SYNDROMESSYSTEMIC SYNDROMES


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weightweight

FeverFever

EndrocrineEndrocrine syndromessyndromes

NeurologicNeurologic paraneoplasticparaneoplastic syndromes= peripheral neuropathysyndromes= peripheral neuropathy

MyasthenicMyasthenic EatonEaton--Lambert syndrome,Lambert syndrome, polymyositispolymyositis

Rheumatic syndromesRheumatic syndromes

Pierre MariePierre Marie hypertrophichypertrophic osteoarthropathyosteoarthropathy

DermatologicalDermatological syndrsyndr.:.: dermatomyositisdermatomyositis,, achantosisachantosis nigricansnigricans

Migratory venousMigratory venous thromboplebitisthromboplebitis ((TrouseauTrouseau))

NonbacterialNonbacterial thromboticthrombotic ((maranticmarantic)) endocarditisendocarditis

HematologicHematologic manifestations: anemia, thrombocytopenia,manifestations: anemia, thrombocytopenia,disseminated intravascular coagulationdisseminated intravascular coagulation

MembranousMembranous glomerulopathyglomerulopathy



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Clinical suspicionClinical suspicion confirmedconfirmed Rx, CT,Rx, CT,

bronchoscopybronchoscopy (( sputum),sputum), mediastinoscopymediastinoscopy

TREATMENTTREATMENT

ChemotherapyChemotherapy

SurgerySurgery

Radiotherapy preRadiotherapy pre--surgery / palliativesurgery / palliative


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RETRACTILE PULMONARYRETRACTILE PULMONARYCONSOLIDATIONSCONSOLIDATIONS

ATELECTASISATELECTASIS

ClassificationClassificationNot retractileNot retractile

Well delimitatedWell delimitated

Not well delimitatedNot well delimitatedRetractileRetractile

PULMONARY ATELECTASISPULMONARY ATELECTASIS


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Alveolar airAlveolar air resorptionresorption due to mechanicaldue to mechanical

causes (commonly bronchial obstruction)causes (commonly bronchial obstruction)

Consolidation syndrome with the tractionConsolidation syndrome with the traction

of surrounding tissues/organs towards theof surrounding tissues/organs towards the

involved sideinvolved side

Most symptoms are related to onsetMost symptoms are related to onset

rapidityrapidity



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Lobar, segmental ATELECTASISLobar, segmental ATELECTASIS

PainPain

Dry coughDry cough

CyanosisCyanosis

Small ATELECTASISSmall ATELECTASIS

=asymptomatic, occasional=asymptomatic, occasional

finding on Xfinding on X--rayray



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AffectedAffected hemithoraxhemithorax smaller in volumesmaller in volume

SupraclavicularSupraclavicular area depression on the involved sidearea depression on the involved side

Retraction ofRetraction of intercostalintercostal spacesspaces

thorax expansionthorax expansion

Palpation:Palpation: tactiletactile fremitusfremitus/ absent/ absent

Percussion : dullnessPercussion : dullnessAscultationAscultation:: / absent breath sounds/ absent breath sounds



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XX--RAYRAY

Homogenous density with concavity towards theHomogenous density with concavity towards the

exteriorexterior involves 1 segment, / one lobe,/ the entire lunginvolves 1 segment, / one lobe,/ the entire lung

With a smaller extension than the respective regionWith a smaller extension than the respective region(in normal conditions)(in normal conditions)

Narrow and obliqueNarrow and oblique intercostalintercostal spacesspaces

MediastinMediastin shifted toward involved sideshifted toward involved side

Ascended diaphragmAscended diaphragm

InspiratoryInspiratory movement ofmovement of mediastinmediastin toward thetoward theinvolved sideinvolved side


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Atelectasis. Left lower lobe collapse.

The opacity is in the posterior inferior location.


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Atelectasis. Loss of volume on the left side; an elevated and silhouetted left

diaphragm; and an opacity behind the heart, called a sail sign,

are present.


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Atelectasis. Left upper lobe collapse showing opacity contiguous

to the aortic knob, a smaller left hemithorax, and a mediastinal shift.


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Complete atelectasis of the left lung. Mediastinal displacement,

opacification, and loss of volume are present in the left hemithorax.


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Complete right lung atelectasis.


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Atelectasis. Right upper lobe collapse.


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DISORDERS OF THE PLEURADISORDERS OF THE PLEURADISORDERS OF THE PLEURA


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CLASSIFICATIONCLASSIFICATION

1.Pleuritic syndrome (dry)

2.Pleural effusion

3.Pleural fibrosis4.Pneumothorax

AnatomyAnatomy


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1.Parietal pleura

2.Visceral pleura

Both parietal and visceral membranes are smooth, glistening, and

semitransparent. Despite these similarities, the two membranes have

unique differences in anatomic architecture, innervation, pain fibers, blood

supply, lymphatic drainage, and function. For example, the visceral pleurae

contain no pain fibers and have a dual blood supply (bronchial and

pulmonary).

Parietal pleurae cover the inner surface of the thoracic cavity, including the

mediastinum, diaphragm, and ribs.

Visceral pleurae envelop all surfaces of the lungs, including the interlobar

fissures.

This lining is absent at the hilus, where pulmonary vessels, bronchi, and

nerves enter the lung tissue.

The mediastinum completely separates the right and left pleural spaces.

- pleural space- pleural fluid: 5 -20 ml

FUNCTION OF PLEURAL FLUIDFUNCTION OF PLEURAL FLUID


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is to provide a frictionless surface betweenthe two pleurae in response to changes in

lung volume with respiration.

Normally, pleural fluid:Normally, pleural fluid:

spreads thinly over visceral and parietal pleuraespreads thinly over visceral and parietal pleurae

enters the pleural space from systemicenters the pleural space from systemic

capillaries in the parietal pleuraecapillaries in the parietal pleurae exits via parietal pleural stomas andexits via parietal pleural stomas and lymphaticslymphatics

facilitate movement between the lung and chestfacilitate movement between the lung and chest

wallwall compositioncomposition plasma but lower in protein (< 1.5plasma but lower in protein (< 1.5 g/dLg/dL))

Characteristics ofCharacteristics of


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clear ultrafiltrate of plasma

pH 7.60-7.64

protein content less than 2% (1-2 g/dL)

fewer than 1000 WBCs per cubic millimeter glucose content similar to that of plasma

LDH level less than 50% of plasma

Na, K, Ca concentration similar to interstitial fluid

Normal pleural fluidNormal pleural fluid


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ymptoms

ymptoms

-- Pleuritic chest painPleuritic chest pain

-- Dry coughDry cough

-- DyspneaDyspnea

Signs:Signs:

-- Pleural friction rubPleural friction rub

-- Particular signsParticular signs -- Pleural effusionPleural effusion syndromesyndrome-- Pleural fibrosisPleural fibrosis syndromesyndrome

PLEURITIC CHEST PAINPLEURITIC CHEST PAIN


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CharacterCharacter : a vague discomfort OR sharp pain

WorsensWorsens by deep inhalation, chest expansion

Location:Location: depending on affected pleura

indicates inflammation of the parietal pleura usually felt over the inflamed site E.g.

Diaphragmatic pleura shoulder

Central pleura radiates back, neck, shoulder

intra-abdominal referred from irritation of lower 6 ic nerves

Special situations:Special situations:

MissMiss in interlobar effusion

ContinuousContinuous, not influenced by respiration in: Pleural tumor

Empyema

Massive Pleural effusion

PLEURITIC CHEST PAINPLEURITIC CHEST PAIN


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Differential diagnosisDifferential diagnosis

rib fracture = Fixed point location+ bone crepitation Costochondritis local inflammation

Herpes zoster = pain on nerves + vesicles

Tracheobronchitis - burning over trachea + sputum

Angor pectoris

Pericarditis

PLEURITIC COUGHPLEURITIC COUGH


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dry, without sputum production

Irritative

Associated usually with pleuritic chest pain

DETERMINED by: Pleural irritation

DYSPNEA in pleural syndromesDYSPNEA in pleural syndromes


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Progressive

Generated by pain

Associated tachypnea Associated with large effusion installed rapidly

It indicates a large effusion (usually not


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Pleural friction rubPleural friction rub Corresponding to the pain location

Intensity maximum on posterior axillary line

Present throughout respiratory cycle Loudest at end inspiration and early expiration

Great variability

Seldom present

When present, best heard over the area of pleural

inflammation, over posterior inferior aspect

of thoracic cage, or over inferior lateral anterior

surface of thoracic cage Described as a rubbing or grating (eg, leather rubbing

on leather), harsh, dry, and scratchy sound that

disappears with breath holding

Pleural effusionsPleural effusions


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Pleural effusion is defined as an abnormalPleural effusion is defined as an abnormal

accumulation of fluid in the pleural space.accumulation of fluid in the pleural space.

Excess fluid results from the disruption ofExcess fluid results from the disruption ofthe equilibrium that exists across pleuralthe equilibrium that exists across pleural

membranes.membranes.

DEFINITIONDEFINITION

F


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Frequency annual incidence: 320 per 100,000 people

Mortality/Morbidity directly related to cause, stage of disease, andbiochemical findings in the pleural fluid.

Sex M = F (incidence equal between the sexes)

Exception: some causes with sex predilection

Age Pleural effusions usually occur in adults.

1 Altered permeabilit of the ple ral membranes

MECHANISMS OF PLEURAL EFFUSION:MECHANISMS OF PLEURAL EFFUSION:


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1. Altered permeability of the pleural membranes2. Reduction in intravascular oncotic pressure

3. Increased capillary permeability or vascular disruption

4. Increased capillary hydrostatic pressure in the systemic

and/or pulmonary circulation5. Reduction of pressure in pleural space; lung unable to expand

6. Inability of the lung to expand (e.g., extensive atelectasis, mesothelioma)

7. Decreased lymphatic drainage or complete blockage, including thoracic

duct obstruction or rupture

8. Increased fluid in peritoneal cavity, with migration across the diaphragm

via the lymphatics

9. Movement of fluid from pulmonary edema across the visceral pleura

10.Persistent increase in pleural fluid oncotic pressure from an existing pleural

effusion, causing accumulation of further fluid

11.Iatrogenic causes



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CausesCauses multiple

Classification:Classification:

1.Transudates

2. Exudates

11 Manifestations related to the underlying disease processManifestations related to the underlying disease process

CLINICAL ASPECT -

CLINICAL ASPECTCLINICAL ASPECT --


HistoryHistory


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1.1. Manifestations related to the underlying disease processManifestations related to the underlying disease process

2.2. DyspneaDyspnea

Most common clinical symptom at presentation

Can be determined by other underlying lung disease3.3. Chest painChest pain

Intensity:Intensity: May be mild or severe

Character:Character: Typically sharp or stabbing LocalizedLocalizedto the chest wall or referred to the ipsilateral

shoulder or upper abdomen because of diaphragmatic involvement

ExacerbatedExacerbatedby deep inspiration DiminishesDiminishes in intensity as the effusion increases in size

Offers etiological clue:

transudates do not cause direct pleural irritation

CLINICAL ASPECT -

CLINICAL ASPECTCLINICAL ASPECT --


Physical findingsPhysical findings


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are variable

depend on the volume of the pleural effusion

undetectable for effusions smaller than 300 mL

EFFUSION LARGER THAN 300 MLEFFUSION LARGER THAN 300 ML

1. Dullness or decreased resonance to percussion

2. Diminished or inaudible breath sounds

3. Decreased tactile fremitus

4. Egophony

5. Pleural friction rub

6. Asymmetric expansion of thoracic cage,

with lagging expansion on the affected side (i.e., Hoover sign)

7. Mediastinum shift

Egophony


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Egophony

("e" to "a" changes) at the most superior aspect of the pleural effusion

(This finding signifies atelectasis and consolidation caused by

compression of lung parenchyma with subsequent decrease in gascontent per unit volume.)

Pleural friction rub

Present throughout respiratory cycle Loudest at end inspiration and early expiration

Seldom present

Best heard over the area of pleural inflammation, over posterior inferior

aspect of thoracic cage, or over inferior lateral anterior surface ofthoracic cage

Physical findings

For small medium and large effusion


For small medium and large effusionFor small medium and large effusion



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For small, medium and large effusionFor small, medium and large effusionFor small, medium and large effusion

Small pleural effusion (under 500 ml)Small pleural effusion (under 500 ml)

DULL AREADULL AREA Posterior only (usual)Posterior only (usual)

BasalBasal

33-- 4 cm high4 cm high dullness upper limit = Horizontal linedullness upper limit = Horizontal line

Not mobile with respirationNot mobile with respiration

DiferentialDiferential diagnosis with:diagnosis with: Ascended diaphragm ( performAscended diaphragm ( perform HirtzHirtz maneuver)maneuver)

AtelectasisAtelectasis (dullness with increased tactile(dullness with increased tactile fremitusfremitus))


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Posteroanterior upright chest radiograph showsisolated left sided pleural effusion

and loss of left lateral costophrenic angle.

Small effusionSmall effusion


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Small pleural effusionSmall pleural effusion


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PseudotumorPseudotumor

Pseudotumors represent an accumulation of

fluid between interlobar fissures or fluid encapsulated

by adhesions.

Physical findings

For small, medium and large effusion


For small, medium and large effusionFor small, medium and large effusion



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Medium pleural effusion (800Medium pleural effusion (800-- 1200 ml)1200 ml)DULL AREADULL AREA

PosteriorPosterior Upper limit :Upper limit :

the tip ofthe tip ofscapula,scapula, DamoiseauDamoiseau lineline = parabolic line of which the= parabolic line of which the

highest point is on the middlehighest point is on the middle axillaryaxillary lineline Anterior:Anterior:

Dullness up to the 5th ribDullness up to the 5th rib With every 500 ml accumulationWith every 500 ml accumulation dullnessdullness

increases with oneincreases with one intercostalintercostal spacespace When dullness is up to the 1st rib = 3000 ml fluidWhen dullness is up to the 1st rib = 3000 ml fluid

TraubeTraube area disappears when fluid reaches 800 mlarea disappears when fluid reaches 800 ml MediastinalMediastinal shift (usually >1000shift (usually >1000 mLmL))

Damoiseau-Ellis line

Also known as:

Damoiseaus curve


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Ellis sign

Ellis-Damoiseau line

Ellis-Damoiseaus parabolic curve

Garlands curve

Associated persons:

Louis Hyacinthe Cleste Damoiseau

Calvin Ellis

George Minott Garland

Description:

The upper limit of the percutatory demonstrable upper limit of a

pleuritic exudate. A characteristic parabolic line of which the

highest point is in the middle axillary line.

Garlands curve is entered as Garlands triangle under George Minott Garland,

American internist, 1848-1926.

Bibliography:* L. H. C. Damoiseau:

Recherches cliniques sur plusieurs points du diagnostic

des panchements.

Extrait des Archives gnrales de mdecine, Paris, 1844.

Du diagnostic et du traitement de la plresie. Paris, 1845.

* C. Ellis:

The line of dulness in pleurite effusion.

Boston Medical and Surgical Journal, 1874, 90: 13-14.

The curved line of pleuritic effusion.

Boston Medical and Surgical Journal, 1876, 95: 689-697


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PA chest radiography shows an opacity (E) in the lower left hemithorax

with obliteration of the left hemidiaphragm and curvilinear upper margin

consistent with effusion.

Note the extension of the fluid into the left major fissure (arrow)

and mediastinal shift to the right.

CLINICAL ASPECT - Physical findings

CLINICAL ASPECTCLINICAL ASPECT -- Physical findingsPhysical findings


L l l ff i (2000 l)L l l ff i (2000 l)


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Large pleural effusion (2000 ml)Large pleural effusion (2000 ml)

Dull area greater then previous

Infraclavicular tympanitic Subclavicular tympanitic

Mediastinal shift

Seen only with massive effusions (usually >1000 mL) Chest radiographies displacement of trachea and

mediastinum to the contralateral side of the pleural

effusion

(In contrast with complete atelectasis of the ipsilateral lung,when the trachea deviates toward the affected side and is

most commonly seen with complete obstruction of ipsilateral

mainstem bronchus caused by bronchogenic carcinoma.)

L l l ff iL l l ff i


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Large pleural effusionLarge pleural effusion

Loculated collections


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Parietal collection

Diminished respiratory movement

Diminished tactile fremitus

Interlobar collection

Suspended dullness in medium part of axilaWithout pain

Diaphragmatic collection

Pain by phrenic nerve irritation


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Dry pleuritic syndrome

Pleuritic chest pain Cough not productive, irritative

Pleural friction rub

RX: + / - diminished diaphragmatic movement

DetectionDetection



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DetectionDetection

1.Physical examination2.Chest x-ray

3.Ultrasonography can be used to detect as little as 5-50 mL

of pleural fluid, with 100% sensitivity for effusions of 100 mL or

more.

4.Chest CT scanning

5.Thoracentesis

6.Evaluation of pleural fluid to determine cause

blunting of the costophrenic angle and/or sulci(sharp angle between the diaphragm and rib cage)

Chest xChest x--rayray


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(sharp angle between the diaphragm and rib cage)

blunting becomes more pronounced as fluid accumulates

an upwardly concave meniscus seems to ascend the

lateral chest wall; this is called the meniscus sign. Clues indicating pleural effusion include

generalized homogenous opacity

diffuse haziness as the fluid forms layers posteriorly

visibility of pulmonary vessels through the haziness,

absence of air bronchogram.

Diaphragmatic inversion because of the weight of the

pleural effusion on the left side. The superior border of thediaphragm become upwardly concave, and paradoxical movement

occurs with respiration; the diaphragm rises with respiration and falls

with expiration. When the pleural fluid is removed, the diaphragm

assumes its normal shape.

Upright posteroanterior or anteroposterior rg may not show lateral

Chest xChest x--rayray


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p g p p g y

costophrenic angle blunting until 250-500 mL of fluid is present.

Haziness is less apparent as it progresses cephalad.

Lateral radiographs show blunting of the posterior costophrenic angleand the posterior gutter when as little as 175-200 mL of fluid is present.

Bilateral decubitus rg. are recommended, with larger effusions.

They provide clues to exclude a loculated effusion and underlying

pulmonary lesion or pulmonary thickening and can depict as little as 5-

10 mL of fluid.

Recumbent (supine views) usually are obtained in critically ill patients.

Findings may include costophrenic angle blunting (earliest finding),

generalized homogenous opacity, obliteration of the diaphragmatic

silhouette, decreased visibility of the lower-lobe vasculature, widened

minor fissure, apical capping, and hemidiaphragmatic elevation.

Posteroanterior radiographs may depict the following:

Flattening of the medial diaphragmatic aspect, with gradual upward

and lateral inclination from the cardiac shadow; lateral displacement


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; p

of the diaphragmatic dome apex (middle or inner hemithoracic third

to lateral third)

Change of the normal, domelike diaphragmatic curve to a

hockey-stick shape

Sharp diaphragmatic sloping toward the lateral costophrenic angle

Hemidiaphragm elevation

Increased distance (>2.0 cm) between the gastric fundus air bubble

and superior right hemidiaphragmatic margin

Absence of lower-lobe vessels normally present below the diaphragm

Lateral radiographs may depict sharp angulation of the anterior

diaphragmatic portion (ie, Rock of Gibraltar or middle-lobe step sign).

ThoracentesisThoracentesis


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http://picasaweb.google.com/clinicalcases/ThoracentesisAStepByStepProcedureGuide#

Thoracentesis (also known as thoracocentesis or pleural tap)

is an invasive procedure to remove fluid or air from the pleural space for diagnostic

or therapeutic purposes. A cannula, or hollow needle, is carefully introduced into

the thorax, generally after administration of local anesthesia.The procedure was first described in 1852.

The recommended location varies depending upon the source.

Some sources recommend the midaxillary line, in the sixth, seventh, or eighth

intercostal space.

EmpyemaEmpyema


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= purulent pleural effusions= purulent pleural effusions

present on Xpresent on X--ray of 20ray of 20--60% of patients60% of patientswith bacterial pneumoniawith bacterial pneumonia

often solves with antibiotic therapyoften solves with antibiotic therapy

Risk factors: aspiration,Risk factors: aspiration,

immunocompromisedimmunocompromised patientspatients

ExudativeExudative stagestage: free flowing pleural fluid, very: free flowing pleural fluid, very

EmpyemaEmpyema


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amenable to treatment with closed tube drainageamenable to treatment with closed tube drainage

FibrinopurulentFibrinopurulent stagestage: formation of fibrin strands: formation of fibrin strandsthrough the pleural fluid resulting inthrough the pleural fluid resulting in loculationsloculations, makes, makes

adequate drainage with single chest tube unlikelyadequate drainage with single chest tube unlikely

Organizational stage:Organizational stage: fibrosis is much more extensivefibrosis is much more extensive

forming a pleural peel that restricts expansion even ifforming a pleural peel that restricts expansion even if

fluid can be evacuatedfluid can be evacuated

EmpyemaEmpyema


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DecubitusDecubitus films will be helpful in determiningfilms will be helpful in determining

if fluid is freely flowing orif fluid is freely flowing or loculatedloculated

Pleural fluid that is gross pus with positivePleural fluid that is gross pus with positive

cultures or gram stain is consideredcultures or gram stain is consideredempyemaempyema along with other findings: pH


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Treatment:Treatment:

-- drainage of pus by chest tubedrainage of pus by chest tube reexpansionreexpansion

of lungof lung

-- eradication of the infection.eradication of the infection.

Treatment of organizational stage requiresTreatment of organizational stage requiressurgical intervention with removal of thesurgical intervention with removal of the

fibrous peelfibrous peel

DEFINITION

PneumothoraxPneumothorax


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= the presence of air within the pleural space resulting

in collapse of the lung on the affected side

- it is considered one of the most common forms of

thoracic disease.

DEFINITION

Classification



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1. Spontaneous pneumothorax

Primary

Secondary

2. Traumatic pneumothorax

Resulting from direct (blunt) chest trauma

Resulting from penetrating chest trauma3. Iatrogenic pneumothorax

Resulting from biopsy procedure

Resulting from therapeutic procedures4. Catamenial pneumothorax

5. Pneumothorax in AIDS


HistoryHistory


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Acute onset of chest painAcute onset of chest pain

- Severe and/or stabbing pain, radiating to ipsilateral

shoulder and increasing with inspiration (pleuritic)

Sudden shortness of breathSudden shortness of breath

# Anxiety, cough, and vague presenting symptoms (e.g.,

general malaise, fatigue) are less commonly observed.

# Dyspnea tends to be more severe with secondary

spontaneous pneumothoraces because of decreased lung

reserve.

General appearanceGeneral appearance

Diaphoretic

Splinting chest wall to relieve pleuritic pain

PneumothoraxPneumothoraxPhysicalPhysical


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Splinting chest wall to relieve pleuritic pain

Cyanotic (with tension pneumothoraces)

Vital signsVital signs

Tachypnea

Tachycardia (most common finding) - If faster than 135 (bpm),

tension pneumothorax is likely.

Pulsus paradoxus

Hypotension (often with tension pneumothorax) Asymmetric lung expansion - Mediastinal and tracheal shift to the

contralateral side with a large tension pneumothorax

Distant or absent breath sounds

Hyperresonance on percussion Decreased tactile fremitus

CardiovascularCardiovascular- Jugular venous distension (tension pneumothorax)

NeurologicNeurologic - Altered mental status

Pulmonary SignsPulmonary SignsMildMild pneumothotaxpneumothotax no obvious signs

PneumothoraxPneumothoraxPhysicalPhysical


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MildMild pneumothotaxpneumothotax no obvious signs

VoluminousVoluminous on the affected side appear Fullness of the chest

Wide intercostal spaces

Diminished respiratory movement

Diminished or no vocal fremitus or resonance Trachea and heart displace toward the healthy side

Tympanic sound on percussion

Liver dullness edge displaces downward when pneumothorax

is on the right side.

Breath sound is diminished or disappeared on the affected side

Coin sign is positive.


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Small spontaneous primary pneumothorax.



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large right-sided pneumothorax has occurred from a rupture of a subpleural bleb.



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A true pneumothorax line. Note that the visceral pleural line is observed clearly,

with the absence of vascular marking beyond the pleural line.



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Pneumomediastinum from barotrauma may

result in tension pneumothorax and obstructive shock.


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Table and pictures


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A dull sound due to pleural effusion is usually located atits highest point at the axillar line. On chest radiograph,

the dull sound represents the highest point of the Ellis-

Damoiseau line. At the paravertebral line, just at the

border of the lung, an area with lesser dullness at the

side of the effusion may be heard (Figure). This has been

named the Garlands triangle. On the contralateral side,

an area of dullness over the normal lung (Groccos

triangle) may be detected.


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inspection

Chest appearance Respiratory movement


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Consolidation Symmetrical Diminished on the

affected side

Emphysema Barrel-shaped Diminished on both

sides

Atelectasis Denting of the affected side Diminished on the

affected side

Pleural effusion Fullness of the affected side Diminished ordisappeared on the

affected side

Thickened

pleura

Denting of the affected side Diminished on the

affected sidepneumothorax Fullness of the affected side Diminished or

disappeared on the

affected side

palpation

Trachea location Vocal fremitus


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Consolidation Central Increased on theaffected side

Emphysema Central Diminished on both

sides

Atelectasis Deviate toward theaffected side

Diminished ordisappeared

Pleural effusion Deviate toward the

normal side

Diminished or

disappeared

Thickenedpleura

Deviate toward theaffected side

Diminished

pneumothorax Deviate toward the

normal side

Diminish or disappeared

Percussion Auscultation

Note Breath sound rale Vocal resonance


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Consolidation Dullness or

flatness

Bronchial

breath sound

Moist rale Strengthened

Emphysema Hyper

resonance

Diminished Always

without

Diminished

Atelectasis Dullness Disappeared or

diminished

Without Disappeared or

diminished

Pleural

effusion

Flatness Diminished or

disappeared

Without Diminished or

disappeared

Thickened

pleura

Dullness Diminished Without Diminished

pneumothorax Tympany Diminished ordisappeared

Without Diminished ordisappeared

Inspection Palpation Percussion Auscultation

Chest

appearance

Respiratory

movement

Trachea

location

Vocal fremitus Note Breath sound rale Vocal

resonance

Consolidation Symmetrical Diminished on

the affected side

Central Increased on

the affected

side

Dullness or

flatness

Bronchial breath

sound

Moist

rale

Strengthened


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Emphysema Barrel-shaped Diminished on

both sides

Central Diminished on

both sides

Hyper

resonance

Diminished Always

without

Diminished

Atelectasis Denting of the

affected side

Diminished on

the affected side

Deviate

toward the

affected side

Diminished or

disappeared

Dullness Disappeared or

diminished

Without Disappeared or

diminished

Pleural

effusion

Fullness of the

affected side

Diminished or

disappeared on

the affected side

Deviate

toward the

normal side

Diminished or

disappeared

Flatness Diminished or

disappeared


disappeared

Thickened

pleura

Denting of the

affected side

Diminished on

the affected side

Deviate

toward the

affected side

Diminished Dullness Diminished Without Diminished

pneumothorax Fullness of the

affected side

Diminished or

disappeared on

the affected side

Deviate

toward the

normal side

Diminish or

disappeared

Tympany Diminished or

disappeared


disappeared

Right middleRight middle--lobe atelectasislobe atelectasis

in a 70in a 70--yearyear--old female withold female with


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in a 70in a 70 yearyear old female withold female with

chronic obstructive lungchronic obstructive lung

disease. (A) The frontal chestdisease. (A) The frontal chest

radiograph shows minimalradiograph shows minimalblurring of the right heartblurring of the right heart

border. (B) The lateral chestborder. (B) The lateral chest

radiograph shows that theradiograph shows that the

right middle lobe isright middle lobe is

completely collapsed. Thecompletely collapsed. Thedepressed minor fissuredepressed minor fissure

(arrows), and the anteriorly(arrows), and the anteriorly

displaced major fissuredisplaced major fissure

(arrowheads) are almost(arrowheads) are almost

apposed.apposed.


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45-year-old man with left upper-lobe collapse due to endobronchial sarcoidosis.

(A) The chest radiograph shows hazy opacity over the left chest, with obscuration of the

left heart border. The apex of the left lung appears lucent because it is occupied by the s

uperior segment of the hyperinflated left lower lobe. The aortic arch is sharply outlined

by the hyperinflated left lower lobe. (B) The lateral view shows the hyperinflated leftlower lobe interfacing anteriorly with the collapsed left upper lobe along the major fissure

(arrows). (C) An axial CT scan shows the complete left lower-lobe collapse, and

endobronchial obstruction of the left upper-lobe bronchus (arrow). No extrinsic

component is shown.

Bilateral lowerBilateral lower--lobe collapselobe collapse,,

presumed due to mucoid impaction,presumed due to mucoid impaction,

in a 63in a 63--yearyear--old man followingold man following

abdominal surgery. (A) The frontalabdominal surgery. (A) The frontal

chest radiograph shows thechest radiograph shows the

triangular outlines of the collapsedtriangular outlines of the collapsed


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triangular outlines of the collapsedtriangular outlines of the collapsed

lower lobes (lower lobes (sail signsail sign) (arrows).) (arrows).

Both hila are depressed. The medialBoth hila are depressed. The medialportions of the diaphragm areportions of the diaphragm are

obscured. The collapsed left lowerobscured. The collapsed left lower

lobe is almost exactly superimposedlobe is almost exactly superimposed

on the heart. (B) A lateral cheston the heart. (B) A lateral chest

radiograph shows the collapsedradiograph shows the collapsed

lobes overlying the spine (arrows).lobes overlying the spine (arrows).

The posterior portions of bothThe posterior portions of both

hemidiaphragms are obscured.hemidiaphragms are obscured.

Combined right middle and right lowerCombined right middle and right lower--

lobe collapselobe collapse in a 66in a 66--yearyear--old womanold woman

with breathlessness followingwith breathlessness followingabdominal surgery. The frontal chestabdominal surgery. The frontal chest

radiograph shows combined rightradiograph shows combined right


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middle lobe and right lowermiddle lobe and right lower--lobelobe

collapse. Arrows indicate the minorcollapse. Arrows indicate the minorfissure. Arrowheads indicate the majorfissure. Arrowheads indicate the major

fissure. The multilobar collapsefissure. The multilobar collapse

simulates a right pleural effusion, butsimulates a right pleural effusion, but

the marked inferior hilar displacement,the marked inferior hilar displacement,

the marked depression of the rightthe marked depression of the right

major fissure, and the ipsilateralmajor fissure, and the ipsilateral

mediastinal shift are important cluesmediastinal shift are important clues

that this is a volumethat this is a volume--losing process. Alosing process. A

decubitus view showed only minimaldecubitus view showed only minimal

right pleural fluidright pleural fluid


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Strep. pneumoniaeStrep. pneumoniae pneumonia.pneumonia.

Bilateral lowerBilateral lower--zonezone consolidation (arrows).consolidation (arrows). AlthoughAlthough

pneumococcalpneumococcal pneumonia is typicallypneumonia is typically unifocal, multifocalunifocal, multifocal

involvement is not uncommon.involvement is not uncommon.

Strep. pneumoniaeStrep. pneumoniae

pneumonia.pneumonia.

Very extensiveVery extensive

consolidation affectingconsolidation affecting


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consolidation affectingconsolidation affecting

more than one lobe inmore than one lobe in

the right lung. Thethe right lung. The

central lucency is due tocentral lucency is due to

cavitationcavitation an unusualan unusual

feature in pneumococcalfeature in pneumococcalpneumonia.pneumonia.

Staph. aureusStaph. aureus pneumonia.pneumonia.

This cavitary pneumoniaThis cavitary pneumonia


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This cavitary pneumoniaThis cavitary pneumonia

waswas

a communitya community--acquiredacquiredinfection occurring twoinfection occurring two

weeks after an influenzaweeks after an influenza

A infection.A infection.

Staph. aureusStaph. aureus pneumoniapneumonia

pneumatoceles.pneumatoceles.


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pp

Appearances followingAppearances following

incomplete resolution of aincomplete resolution of astaphylococcal pneumonia.staphylococcal pneumonia.

There are several thinThere are several thin--walledwalled

cysts consistent withcysts consistent with

pneumatoceles. Suchpneumatoceles. Such

pneumatoceles are common inpneumatoceles are common in

children but unusual in adults.children but unusual in adults.

Staph. aureusStaph. aureus

infectioninfection in a drugin a drugabuser.abuser.

Multiple disseminatedMultiple disseminated

nodularnodular


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nodularnodular

consolidations,consolidations,

confluent in the rightconfluent in the rightlower zone; severallower zone; several

have cavitated. Thehave cavitated. The

appearances areappearances are

typical oftypical ofhaematogenoushaematogenous

dissemination.dissemination.

GramGram--negativenegative

pneumoniapneumonia


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pneumoniap

((HaemophilusHaemophilus

influenzaeinfluenzae))showing a typicalshowing a typical

bronchopneumonicbronchopneumonic

pattern ofpattern of

heterogeneous localizedheterogeneous localizedconsolidation. Suchconsolidation. Such

infections are commonlyinfections are commonlybasal.basal.

Legionella pneumophila pneumoniaLegionella pneumophila pneumonia. While the unilateral lower. While the unilateral lower--zone peripheral consolidation is a typical appearance, it complezone peripheral consolidation is a typical appearance, it completelytely

lacks specificity. Apparent cavitation was spurious.lacks specificity. Apparent cavitation was spurious.


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15. pulmonary consolidation syndromes

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