Main Symptoms and Signs of Respiratory Diseases

Prof. Marianna Tovt-Korshynska

PULMONARY PATIENT EXAMINATION

Case History:- COMPLAINS; - ANAMNESIS MORBI (HISTORY OF THE PRESENT and PAST ILLNESS);

- ANAMNESIS VITAE (FAMILY.

DRUG AND SOCIAL HISTORY); - EXAMINATION.

History Taking (Case History)

• Chief complaints

• History of present illness

• Past medical history

• Systemic enquiry

• Family history

• Drug history

• Social history

Main symptoms

SOB/Dyspnoea

Cough(productive/dry)

Sputum (colour, amount, smell)

Haemoptysis

Chest pain

Hoarseness

Wheezing

Main symptoms (1)

Dyspnea (breathlessness, shortness of breath) – the subjective sensation of difficulty in breathing – maybe the most common respiratory complain and cannot be differentiated at first glance from dyspnea due to cardiac disease, neuromuscular weakness, or obesity.

Dyspnea should always be quantified as to how much exertion is necessary to produce the sensation of breathlessness. A variety of scaling methods have been designed to quantify dyspnea.

.

Normal respiration rate for an adult at rest is 12 to 20 (16-18) breaths per minute

Abnormal respiratory patterns (2)

• Orthopnea is shortness of breath (dyspnea) that occurs when lying flat (heart failure, pulmonary

edema, abdominal obesity…)

• Platypnea is shortness of breath that is relieved when lying down, and worsens when sitting or standing (hepatopulmonary syndrome /venous blood from the liver does not pass

through the lungs/ or an anatomical cardiovascular defect).

American Thoracic Society Shortness of Breath Scale

Grade 0 (none) - Not troubled by shortness ofbreath when hurrying on the level or walking up a slight hill.

Grade 1 (mild) - Troubled by shortness of breathwhen hurrying on the level or walking up a slight hill.

Grade 2 (moderate) - Walks more slowly than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level.

Grade 3 (severe) - stops for breath after walking about 100 yards (96 meters) or a few minutes on the level.

Grade 4 (very severe) - Too breathless to leave the house;breathless when dressing or underdressing.

Common Tests in the Evaluation of Dyspnea

CXRCardiac enlargementVascular enlargement Abnormal interstitial markingsPleural effusions Hyperinflation InfiltrationNodules/masses…

Pulmonary function testsSpirometry - Obstructive and Restrictive changes. Diffusing capacity …

Computed tomography Abnormal interstitial markings. Lymphadenopathy Atelectasis Vascular filling defects. Ground-glass opacities .Neoplastic disease…

Blood tests Elevated white blood cell count Anemia…

Dyspnea may be acute, chronic, or paroxysmal (recurrent)

AcutePulmonary edema

Asthma

Injury to chest wall and intrathoracic structures

Spontaneous pneumothorax

Pulmonary embolism

Pneumonia

Adult respiratory distress syndrome

Pleural effusion

Pulmonary hemorrhage

Chronic, progressiveCOPD

Left ventricular failure

Diffuse interstitial fibrosis

Asthma

Pleural effusions

Pulmonary thromboembolia Pulmonary vascular disease

Psychogenic dyspnea

Anemia, severe

Hypersensitivity disorders

Dispnea together with wheezing mostly point to the presence of an obstructive airway process but may be seen in heart failure as well.

Wheezing – may result from airway hyperreactivity, airway narrowing, airway obstruction, compression, tumors, aspirated foreign bodies...

Coughcommon to obstructive, inflammatory, infectious, and neoplastic pulmonary processes, as well as cardiac diseases and disorders of the ears, nose, and throat. Cough is a normal defense mechanism of the respiratory tract, but when increased in severity or frequency, cough can be a cause of disease as well as an indicator of disease.

• Onset?• Duration?• Character? • Nocturnal?• Precipitating factors?• Relieving factors?• Sputum?• Haemoptysis?• Association?

Acute cough (<3 weeks)

• The most common cause - viral infection (sinusitis, nasopharygnitis). Mostly transient and self-limited, at the beginning, nonproductive and quite annoying; later it becomes productive of mucous or mucopurulent sputum before it begins to subside.

• In acute viral respiratory tract infection, post-nasal drip may be another cause for triggering the cough.

• Acute infections of lungs – tracheobronchitis, lobar pneumonia, bronchopneumonia, exacerbation of chronic bronchitis

• The mechanical irritation of different origin; coughing itself can cause more coughing. Inflammation, in addition, increases the secretion.

Sub acute cough (between 3 and 8 weeks)

• Is commonly post-infectious, resulting from persistent airway inflammation and/or postnasal drip following viral infection, pertussis, or infection with Mycoplasma or Chlamydia

CHRONIC COUGH (persisting for >8 weeks)

Chronic infections of lungsBronchitis Bronchiectasis Tuberculosis or fungusParenchymal inflammatory processesInterstitial fibrosis and infiltrationsSmoking TumorsAortic aneurysm (Brassy cough)Gastrointestinal causesGastrioesophageal reflux (GERD)Foreign bodyCardiovascular causesLeft ventricular failurePulmonary infarctionMedication-induced causesAngiotensin-converting enzyme (ACE) inhibitors (following soon after drug initiation or with years of use)

Sputum production

Sputum production reflects the presence of inflammatory, infectious or neoplastic disease in the airways or pulmonary parenchyma. The amount and character of sputum provide helpful clues to distinguish among possible etiologies (mucoid, mucopurulent, purulent;copious, foul, blood-tinged…).

• Cough with increasing intensity that lasting above week • Cough accompanied by long steading (weeks)

hyperthermia 38 °C• Cough accompanied by hyperthermia above 38 °C

during 3 days or more• Cough accompanied by dyspnea and thorasic pain on

breathing• Cough of pus• Blood spitting • Cough with pronounced dyspnea• Cough and weakness and weight loss• Excessive sweating, shivering• Sudden attack of severe cough• Severe cough during an hour without any interval• Abundant expectoration of sputum

Threatening symptoms Threatening symptoms Cough with increasing intensity that lasting above week Cough with increasing intensity that lasting above week Cough accompanied by long steading (weeks) Cough accompanied by long steading (weeks)

hyperthermia 38 hyperthermia 38 °C°C Cough accompanied by hyperthermia Cough accompanied by hyperthermia aboveabove 38 38 °C °C

during 3 days or moreduring 3 days or more Cough accompanied by dyspnea and thorasic pain on Cough accompanied by dyspnea and thorasic pain on

breathingbreathing Cough of pusCough of pus Blood spitting Blood spitting Cough with pronounced dyspneaCough with pronounced dyspnea Cough and weakness and weight lossCough and weakness and weight loss Excessive sweating,Excessive sweating, shiveringshivering Sudden attack of severe coughSudden attack of severe cough Severe cough during an hour without any intervalSevere cough during an hour without any interval Abundant expectoration of sputumAbundant expectoration of sputum

Hemoptysis - is never normal and can be a warning of a serious or even life-threatening respiratory disorder. Hemoptysis must be differentiated from hematemesis and from simple epistaxis, and must be quantified in terms of volume per 24 hours for adequate assessment.

Source?Source? Onset?Onset? Duration?Duration? Character?Character? Amount?Amount?

HEMOPTYSIS HEMATEMESIS

History

Absence of nausea and vomiting Presence of nausea and vomiting

Lung disease Gastric or hepatic disease

Asphyxia possible Asphyxia unusual

Sputum examination

Frothy Rarely frothy

Liquid or clotted appearance Coffee ground appearance

Bright red or pink Brown to black

Laboratory

Alkaline pH Acidic pH

Mixed with macrophages and neutrophils

Mixed with food particles

Differentiating Features of Hemoptysis and Hematemesis

Haemoptysis

Mild hemoptysis: loss of 200-300ml/day.

Moderate: loss of 300-600ml/day.

Severe: loss of > 600ml/day.

Non Major <100-200 ml

Major

200-500 ml in 24h

Massive

≥ 500 ml in 24h

Some Common Causes of Hemoptysis

Infections•Bronchitis•Tuberculosis•Fungal infections•Pneumonia•Lung abscess•Bronchiectasis

Neoplasms•Bronchogenic carcinoma•Bronchial adenoma

Cardiovascular disorders•Pulmonary infarction from thromboembolism•Mitral stenosis

TraumaForeign bodyHematologic -

immunologic•Goodpasture’s syndrome

CYANOSIS -

bluish discoloration of the skin that is caused by increased amounts of reduced hemoglobin in the sub capillary venous plexus; most apparent in the lobes of the ears, cutaneous surfaces of the lips, nail beds. In patients with dark skin - mucous membranes and retina.

Unless flow through the skin is slowed, as in heart

failure, cyanosis implies arterial hypoxemia.

Cyanosis does not appear in carbonmonoxide poisoning or in severe anemia with hypoxemia, because of insufficient amount of reduced hemoglobin.

CYANOSIS -

•chronic bronchitis, emphysema, severe pneumonia - derangements in ventilation-perfusion relationships - arterial hypoxemia.

•diffuse interstitial fibrosis - normal arterial oxygenation at rest is succeeded by arterial hypoxemia, and sometimes by cyanosis, during exercise•syndrome of alveolar hypoventilation in patients with normal lungs (arterial hypoxemia) (centr alv hyp-n, obesity, COPD…)

•diminished cardiac output (severe heart failure - not only the hands and feet but also the tip of the nose becomes blue)

•peripheral vasoconstriction (Raynaud’s disease - cyanosis of the nail beds)

•intracardiac right-to-left shunts - congenital heart diseases, severe heart failure

CYANOSIS

INXPECTION: Pathological chest

Emphysematous (barrel-like) chest

Pathological chest Paralytic chest

CLUBBING -selective bulbous enlargement of the distal segments of the digits due to an increase in soft tissue.Is generally acquired, but may be hereditary (constitution). Acquired clubbing is seen in a wide variety of disorders, both extrathoracic and thoracic

Clinical Disorders Commonly Associatedwith Clubbing of Digits

Pulmonary and thoracicPrimary lung cancerMetastatic lung cancerBronchiectasisCystic fibrosisLung abscessPulmonary fibrosisPulmonary arteriovenous malformationsEmpyemaMesotheliomaNeurogenic diaphragmatic tumors

CardiacCongenitalSubacute bacterial endocarditis

Gastrointestinal and hepaticHepatic cirrhosisChronic ulcerative colitisRegional enteritis (Crohn’s disease)

CLUBBING

RESPIRATORY CHEST PAINExtracardiac painful sensations mostly can arise from the pleura, the lungs, and the chest wall.

• Pleuritic Pain –during deep breathing (predominantly inspiration), coughing or

laughing; usually local.

- as a rule is part of a syndrome of pleural inflammation and malignancy (except pulmonary infarction - often unassociated with any premonitory signs).

- pneumothorax.

• Pulmonary Pain – - tracheitis, tracheobronchitis - the pain is searing, most pronounced

after cough.

- pulmonary hypertension - the pain appears during exertion, is substernal, invariably is associated with dyspnea

• Chest Wall Pain – musculoskeletal injury, trauma

Physical examination (1)

• Inspection-Respirator rate, depth…

-Cyanosis, clubbing

• Palpation-Tenderness over a rib

-Increased or diminished

vocal fremitus (transmission of sound)…

Physical examination (2)

Percussion of the Chest

•Tympanic - over the abdomen.

• Resonance - over normal lung tissue,

•Hyper-resonance - over overinflated lungs (as in emphysema).

•Dullness - pneumonia, Flatness - over pleural effusion.

Physical examination (3)

Auscultation of Lungs

•Changes in the Intensity and Duration of Lung Sounds (LS)Vesicular - normal. Abnormal decrease or increase in the intensity of LS. Harsh or bronchial LS

•Changes in the Quality of LSAdventitious Lung Sounds•Continuous: wheezes (rhonchi sibilantes), rhonchi (rhonchi sonori), stridor•discontinuous (crackles – coarse and fine)

AUSCULTATIONTerm Definition

Rales Adventitious lung sounds (ALS) that are generated in bronchi and bronchioles

Dry rales Continuous musical sounds, persist throughout the respiratory cycle and vary greatly in their character, pitch, and intensity, formed due to narrowing airways

Moist or wet rales

Are generated in bronchi and cavities in the lungs in presence of liquid secretions

Crepitation (fine rales)

Is generated in alveoli when they contain small amount of liquid secretion due to separating alveolar walls at the end of inspiration with slight cracking sound

Pleural friction rub

Appears when pleural layers lost their smoothness and produce non-musical creaking sound during breathing movements of the lungs

Rales are ALS occurring in the trachea, bronchi, and lung cavities. They can be moist and dry.Dry rales occur only in the bronchi at narrowing of the lumina. This narrowing can be caused by:1. Swelling of the bronchial mucosa due to inflammation.2. Spasm of the smooth muscles of small bronchi.3. Accumulation of viscous sputum, which can adhere to the bronchial walls and narrow the lumen.4. Formation of fibrous tissue in the walls of separate bronchi.5. Vibration of the viscous sputum at moving along the large and medium-sized bronchi during expiration and inspiration.

Dry rales are divided into wheezes (high pitched – in small bronchi) and couse (sonorous, buzzing – in larger bronchi) rales

Moist rales

Moist rales are formed as a result of accumulation of fluid secretion (sputum, blood, pus) in the bronchi or in the pathological cavity when the air is passing through this secretion. Moist rales are heard both at the phase of inspiration and the phase of expiration, but at inspiration they are louder.

Moist rales may be fine bubbling, medium bubbling, and coarse bubbling according to the size of the bronchi or cavity where they develop.

CHEST RADIOLOGY

• Important component in assessment of the patient with known or suspected pulmonary disease

• May provide the earliest or only clue to the presence of clinically significant respiratory disease

• Evaluation invariably begins with routine chest XR, supplemented, by more specialized techniques

Routine CXR examination

• A posteroanterior (PA) chest radiograph may be used as the sole routine and/or screening procedure, since most pathological respiratory conditions are demonstrable in this view.

• Preferably, a lateral view should also be part of the routine examination. The lateral view adds valuable information about areas that are not well seen in the PA projection (anterior portion of the lung, adjacent to the mediastinum—an area that may be obscured by the overlying heart and aortic shadows). The vertebral column and a small pleural effusion are also best seen on lateral view.

1 . Trachea. 2. Sternum. 3. Right atrium . 4. Right hemidiaphragm. 5 . Aorticknob. 6. Left hilum. 7. Left ventricle. 8. Left hemidiaphragm (with stomach bubble). 9. Retrosternal clear space. 10. Right ventricle. 11 . Left hemidiaphragm (with stomach bubble). 12. Left upper lobe bronchus.

Normal Chest X-RayNormal Chest X-Ray

Compartments of the mediastinum

Review of Lung AnatomyReview of Lung Anatomy

RUL

RML

RLL

LUL

LLL

Lingula

SegmentsSegment of the right lung: 1-upical RUL, 2-posterior, 3-anterior, 4-lateral RML, 5-medial, 6-superior RLL, 7-medial basal, 8-anterior basal, 9-lateral basal, 10-posterior basal.

Segments of the left lung: 1-upical LUL, 2-posterior, 3-anterior, 4-superior lingular, 5-inferior lingular, 6-superior LLL, 7-(medial basal, 8-anterior basal), 9-lateral basal, 10-posterior basal

Pulmonary nodules can be classified according to size and morphology.

Size•miliary nodules: <2 mm•pulmonary micronodule: 2-7 mm•pulmonary nodule: 7-30 mm•pulmonary mass: >30 mm

Morphologysolid pulmonary nodules•calcified pulmonary nodulespartly solid pulmonary nodulesground glass pulmonary nodules

ATELECTASIS

.

The lateral view in uncovering a solitary nodule

The lateral view in uncovering a small pleural effusion.

hyper-radiolucency is associated with a flat diaphragm, a wide anteroposterior diameter of the chest, increase in the retrosternal space

Increased markings pattern. The vascular markings are prominent throughout the lung fields. The patient has chronic bronchitis and emphysema.

Specialized techniques

• Computed tomography (CT) is a radiologic technique for scanning cross-sections of the entire body. The increased resolution of CT permits identification of many findings of the lungs, mediastinum, and chest wall, that are not visible on the plain radiograph.

• Pulmonary angiography - the use of intravenous contrast material, permits separation of vascular from nonvascular mediastinal lesions.

• High-resolution CT (HRCT) is based on generation of images of very thin anatomic slices (1mm vs. 7 to 10 mm for the usual CT slice), is primarily useful in identifying interstitial lung disease and bronchiectasis. In most instances, a routine CT study is performed prior to the HRCT study to better evaluate the mediastinum, bones, and small pulmonary nodules that can be overlooked on the high-resolution images (since only some samples of the lung are imaged on HRCT).

CT: peripheral pleural fibrosis and adjacent honeycombing (ILF)

High-resolution CT of interstitial lung disease

•Spiral (helical) CT is a CT technology in which the source and detector travel along a helical path relative to the object while moving the patient couch through the bore of the scanner. Spiral CT can achieve improved image resolution while scanning more quickly for a reduced radiation dose.

•CT angiography is an application of helical CT. Axial, multiplanar, and three-dimensional images of the vascular system are possible using this technique. CT angiography is an excellent tool for identifying pulmonary embolism and has largely supplanted pulmonary angiography

• Magnetic resonance imaging (MRI) or nuclear

magnetic resonance is a technique that uses radio waves modified by a strong magnetic field. Unlike CT, vascular structures are usually well seen without the use of contrast material (although intravenous gadolinium can be administered for

better vascular evaluation). MRI may also have a major role in the investigation of pulmonary embolism, either acute or chronic.

PULMONARY FUNCTION TESTING

• The most commonly used is spirometry.

Spirometry

is a method of assessing lung function by measuring the total volume of air the patient can expel from the lungs after a maximal inhalation.

Volume Measuring Spirometer

Small Hand-held Spirometers

Standard Spirometric Indicies

• FEV1 - Forced expiratory volume in one second:

The volume of air expired in the first second of the blow

• FVC - Forced vital capacity:

The total volume of air that can be forcibly exhaled in one breath

• FEV1/FVC ratio:

The fraction of air exhaled in the first second relative to the total volume exhaled

Totallung

capacity

Tidal volume

Inspiratory reservevolume

Expiratory reservevolume

Residual volume

Inspiratory capacity

Vital capacity

Lung Volume Terminology

Spirogram Patterns

• Normal

• Obstructive

• Restrictive

• Mixed Obstructive and Restrictive

Predicted Normal Values

Age

Height

Sex

Ethnic Origin

Affected by:

Normal Trace Showing FEV1 and FVC

1 2 3 4 5 6

1

2

3

4

Volu

me, lit

ers

Time, sec

FVC5

1

FEV1 = 4L

FVC = 5L

FEV1/FVC = 0.8

Spirometry: Obstructive DiseaseVolu

me, lit

ers

Time, seconds

5

4

3

2

1

1 2 3 4 5 6

FEV1 = 1.8L

FVC = 3.2L

FEV1/FVC = 0.56

Normal

Obstructive

Volu

me, lit

ers

Time, seconds

FEV1 = 1.9L

FVC = 2.0L

FEV1/FVC = 0.95

1 2 3 4 5 6

5

4

3

2

1

Spirometry: Restrictive Disease

Normal

Restrictive

Mixed Obstructive and Restrictive

Volu

me, lit

ers

Time, seconds

Restrictive and mixed obstructive-restrictive are difficult to diagnose by spirometry alone; full respiratory function tests are

usually required(e.g., body plethysmography, etc)

FEV1 = 0.5L

FVC = 1.5L

FEV1/FVC = 0.30

Normal

Obstructive - Restrictive