Chest - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

7/31/2019 Chest - Dr Abo-ElAsrar - By El Azhar Medical Students 2012

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( BETA EDITION)

With

Prof. Dr Mohammed Abo El-Asrar

Edited By

El-Azhar Medical students 2012


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Chest - Dr. Abo-Asrar

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Total pages = 55

Total time = about 6.5 hours

1- lecture 56 4 - 1

introduction to chest ( page 4 )

2- lecture 57 19 29

Bronchial asthma ( page 19 )

3- lecture 58 29 3

cont. BA (types of asthma) ( page 29 ) Pneumonia ( intro ) ( page 31 )

Pneumococci ( page 33 )

staph pneumonia ( page 34 )

streptococci + gram -ve ( page 35 )

viral ( page 36 )

4- lecture 59 38 - 5

mycoplasma ( page 38 )

Acute bronchiolitis ( page 38 )

Bronchiectasis ( page 43 )

Croup ( page 50 )

Dry pleurisy ( page 53 )

Pleural effusion ( page 54 )


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Chest - Dr. Abo-Asrar

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Chest - Dr. Abo El-Asrar

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symptomschest

,,chest

,,,

..

1- cough

,,,dry coughproductive cough

2- expectoration

3- Dyspnea

,,,dyspnea,,Hypoxia

dyspneagradegrades of respiratory distress

:

4- Noisy respiration

,,naked ear(,,

),,,,

,,noisy respiration

,,,respiratory tract:

Nosenaso pharynxLarynx

- Medium sized airway

-small bronchus

-small bronchusterminal bronchiole

-terminal bronchiolealveoli

tracheamajor bronchus

tracheaMajor bronchusconnectorsUpperlower

connectors,,ringcartilageringcartilage

chest


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- during respiration

diameterlowerupper

Lower respiratory tractinspiration,,,

-Upper respiratory tract,,,

Uppper respiratory tractInspiration

,,,,,

lower respiratory tract

expiration

-upper respiratory tractlower respiratory tract..,,

alveolialveoli..alveoli,,elastic

Inspiration,,,recoilalveoli..

,,

bronchusconstrictiondiameter

upper respiratory tractexpirationdiameter

diameterUpper respiratory tractinspiration

diameterlower respiratory tractexpiration

,,partialcomplete

partial obstruction,,partial obstruction

..diameterdiameter

-,,,,Inspirationexpiration


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Noisy respiration

,,,timinginspirationexpiration

,,,upperlower

,,noisy respiration

a -nose due to partial obstruction

-nasal polyprhinitisnasal congestion

-,,,inspiration,,Inspiration

expiration

b -Naso pharynx

-adenoidpartial obstructionInspiration

:,,,

,,

,,parasympatheticairway

chest

c -Larynx stridor ( charactarstic )

Upper,,,Inspiratory...Stridor

:,,,,

,,Inspiratory sound

d -medium sized and small bronchus as in bronchospasm Wheeze

- during expiration ( as the disease in lower respiratory tract called wheeze ( )

e -alveoli grunting

- Expiratory sound = pneumonia

gruntingalveolar pathologyalveolar pathology

pneumonia

:gruntingpneumonialarynx

-alveolicells:

Type one alveolar cell & Type two alveolar cell


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1- type one alveolar cell ,,

Mucous secretionair way..

airway

-alveoliinspirationexpiration

-()expiration2 surfacesalveoli

fluid..(alveoli,,,)

two layers

)

,,..

2- type two alveolar cell

surfactant(which prevent alveolar collapse during full expiration)

,,InfectionalveoliMucous secretion(rhinitisNasal discharge)

surfactant

..

-pneumonia(collapse)full expiration

spasm of adductors of the vocal cordsVC..alveoli

two layersalveolicollapse

grunting

F - connectors Trachea & large bronchus

-secretionbronchitistacheitis

-secretions(Inspiratoryexpiratory)

-()rackling sound..

5- chest pain

..chest pain

a-dry pleurisy stitching pain .

,,:

b-Muscle strain Diffuse dull aching pain

,,,,

-Muscle strainabdominal wallchest wall

6- hemoptysis

-malignancy,,tuberculosis,,


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-bronchitisInfection

7- cyanosis

:..respiratory failure

chest

fever,,Infection,,

signsexamination..chest

4

,,

chestinspection

A Signs of respiratory distress :

-respiratory distress

-distressedWhich degree1- 1st degree of respiaratory distress :

respiratory distress

-respiratory problemretentionCarbon dioxideoxygen saturation

..,,

-brainchemo receptorsrespiratory center

blood gases,,respiratory

rate

sayadultrespiratory ratesay 1830

so, tachypnea

working ala nasai..,,

2- 2nd degree respiratory distress :

-respiratory systemwithin limits

respiratory rate

compensation

-accessory muscles of respiration

accessory muscle of respiration

-negative pressure inside the thorax

LunghypoxiaHyper capnia

hyper inflation of the lung-:

antero posterior diameter of the chestvertical diameter of the chest

a- either antero posterior diameter : HOW ?? contraction of intercostal & subcostal ms.


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Intercostal and subcostal retraction

ribsObliqueIntercostal muscleribs

Horizontalantero posterior diameter

Intercostal muscles

-indrawinginter costal spacesubcostal spaces

intercostal retractionsubcostal &..grade

b- or vertical diameter : HOW ?? contraction of sternomastoid ms. one of the major accessory muscle

suprasternal & supraclavicular retraction

-clavicle,,,sternomastoid

supraclavicular & suprasternal indrowing

1- if upper respiratory tract obstruction (as stridor)

sternamastoid acts as accessory ms. (not intercostal ms. ) suprasternal & supraclavicular retractio

-..tachypnea..working ala nasaisupra sternal and supra clavicular retraction

2- but if lower respiratory tract obstruction (as pnumonia or BA )

intercostal ms act as accessory ms. (not sternomastoid ms. ) intercostal & subcostal retraction

-..tachy pnea..working ala nasai

intercostalsubcostal retraction

anatomy

:embryologycommon dermatome

embryology,,

refered painembryology

common dermatome..,,,

-:upper respiratory systemsterno mastoiddermatome

upper respiratory tractaccessory muscledermatome

sterno mastoid

-,,,Lower respiratory tractInter costal

-NB,,,,,

chest

inter costasubcostalsupra sternalsupra clavicular,,,Mental retarded

..ENT,,,!!

3- 3rd degree respiratory distress :

= Grunting in pneumonia only .

4- 4th degree cyanosis if respiratory failure .


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B chest movement :

Inspection,,,commentMovement of the chest)

-chest walllimitation of movement

(limitation of movementpathology)

pathologyBilaterallimitation,,,

Unilateral

-confirmpalpationfold of skin..

-where is the lesion nothing else

-Limitation of movement bilateralbilateral pathology

-,,,,,Normal,,

diseased

C - Bulge or retraction :

,,,bulgeretraction

||,movement

- if bulge at one side ( means massive pleural effusion,tension pneumothorax or unilatera

emphysema )

if bulged side is bulged ( diseased ) or normal & the other side is retracted ??- if retraction at one side ( means fibrosis or collapse )

if retracted side is retracted ( diseased ) or normal & the other side is bulged ??

bulgeretraction

movement

affectedaffected

unilateral retraction

fibrosiscollapse

,,,,,,,,

bulge

bulge


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massive pleural effusion

massivebulge

,,bulgetension pneumothorax

tension pneumothoraxPleura

LungUnilateral emphysema

Unilateral bulge

tension pneumothorax

unilateral emphysema

massive pleural effusion

clinical:Unilateral retraction

trasnverse diameter of the chestanteroposterior diameter

,,transverseanteroposterior()

Transverse : anteroposterior = 3 : 2

,,,antero posterior diametertransverse diameter

antero posterior diameter

-,,limitation of movement bilateralbilateral bulge

Barrel shaped chest

bilateral bulge

,,,..lung

bronchial asthmaattack

bronchiolitis,,

Lung,,emphysema

-bilateral pleural effusionMassivegeneralized edemaNephrotic,,

lung

3

A Trachea :

-Index fingersupra sternal notch

-,,,resistance


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tracheatracheaMiddle lineslightly to the right..

,,resistance

-sternomastoid muscleresistance

trachea

NBtrachea is shifted to the left..Shifted

tracheaexaminer!!!,,,trachea

-,,..

right side

1- trache is retracted( pulled ) to Lt side

-pushed

-Inspection..:

- limitation of mov. In lt side & retraction in lt side

tracheaLt....

trachea..

2- trache is pushed( from Rt. side ) to Lt side

-retracted

-Inspection..:

- limitation of mov. In Rt side & bulge in Rt. side

tracheaLt....

trachea..

NB,,,pathologybilateraltracheacentral

B palpable sounds :

-Intercostal space

supra mammary

mammary area

Infra mammary

,,,Mid clavicular line..,,anterior axillaryMid axillary


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-,,,

1- may wheeze :

-palpable wheezebroncho spasm

2- may pleural rub :-friction rub

,,actually

C Tacitile vocal fremitus :

-TVFco operative

,,,ninity nine,,

-,,palpable sounds

NBTVFcompartive,,TVF bilaterally diminishedTVF

bilaterally

TVF,,TVF

NB . Any pathology decrease TVF except : 3 Cs

- Pneumonia ( consolidation ) .

- lobe Collapse with patent bronchus .

- Cavity (superficial ) .

-Normal percussion of the chestLight percussion

-light percussionpercussionwrist

-Heavy percussionmental retardedelbow!!

more heavyshoulder!!!!!!!!!!!!

NBPercussionwrist

-Percussionmid clavicular linecompartive

-anterior axillarycompartivemid axillaryinter scapularinfra scapular

-percussionlungNormally resonant

,,,abnormal

1- dullness or impaired note :

Dullness,,,pathologydullness

,,stony dullnessstony dullnessdiagnosticpleural effusion

2- hyper resonant :

Percussion of the chest..Hyper resonant chest


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hyper resonance

bilateral

bilateral

-emphysemabronchial asthma during the attackbronchiolitis

,,,Unilateral hyper resonant chest..

Pleura,,,Unilateral pnumo thorax

lung,,Unilateral emphysema

auscultation of the chestcomment3

1- air entry :

respiratory distress(chestrespiratory distressbronchitis)

diminished air entry

- bilateral diminished air entry or unilateral diminished air entry

2- breath sound :

A Normal vesicular breath sound

-Normallayalveoli

-alveoli

Lung

,,,,,

,,....)

-,,,..

alvoli..inspiration()expiration()

Normal vesicular breathing

B Harsh vesicular breath sound or prolonged expiratory time

:

a- obstruction of air outlet

Outletalveoliobstructionairway

b- or not recoil alveoli ( inelastic alveoli )

alveoliIn elasticrecoilrecoil

NBharsh vesicular breathingnormal breathing

-air way


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-,,,,,normal breathing

-pathologylungharsh vesicular breathing

NB. No gap

C Bronchial breathing :

-Pneumonia..alveoliInflammatory secretionalveolus..alveoli(masscollapse)

-,,alveoli..

During inspiration

-alveolitracheanearby bronchus

Gap

-inspiration..Nearby bronchusalveoli,,,

alveoli..,,,,gap

Expiration

,,alveoli

expiration

-bronchial breathing

bronchial breathing,,,,Inspirationexpirationgap

-NBalveoli..tubetubular sound

tubehollow breathing

NBbronchial breathingTVF

TVFbronchus

3- advential sound :

rhonchi..creptitation

A Rhonchi : 2 types

a- sibilant rhonchi = wheeze :

,,,,siblent rhonchibroncho spasmbroncho stenosis

-siblent rhonchi

bronchial asthma..bronchiolitis..viral pneumonia

-unilateral obstruction


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1-

,,foreign body inhalationunilateral obstruction

2-(bronchus)

3-wall of the bronchus,,

-bronchusbronchus

,,,

b- sonorous rhonchi :

-sonorous rhonchicoarse crepititation

-..secretionbronchussonorous rhonchicoarse

crepitus

sonorous rhonchi

snoring

coarse crepititation

B Crepitations :

a- Coarse :

b- Fine crepitations :

wall of the alveoliIn elastic

-alveoli..

-,,fine crepititation

-pneumonia

-congestive heart failure

-bronchiectasis

complicationschest

complications of respiratory diseases,,,:

1- Respiratory failure

respiratory failurecentral cyanosis

,,,central cyanosisrespiratory failure(respiratory

failureblood gases),,respiratory diseaserespiratory

failure

2- Heart failure :


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a- toxic myocarditis

bacterial infection,,toxinsbacteriatoxic myocarditis

b- viral infection

viral myocarditisHeart failure

c- may be due to cor pulmonale right sided failure

cor pulmonaleLung pathologyfibrosisPulmonary arterypulmonary

artery vessel..Pulmonary artery pressure..

-Pulmonary artery pressureback pressureright ventricle

d- also, severe hypoxia may cause cardiomyopathy .

,,

1- chest X ray :

chestchest X - ray..chest X - raydiagnostic2- CBC :

-CBC

-chesttotal leucocytic countinfection

differential countInfection

Lympho cytosis..viraltuberculus

Neutrophilsbacterial

esinophilsvisceral larva migrans..parastic infection..allergicasthma

3- Blood gases for dignosis of respiratory failure.

a- PH < 7.1 b- PCO2 > 60 mmHg c- PO2 < 50 mmHg

PH7.17.2

CO260 mm Hg50

PO2

4- specific investigations according to the pathologyspecific investigations

skeleton

treatmentrespiratory distress


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1- Hospitalization

-respiratory distress

complete bed rest,,,,

,,,,Intra venous fluids

maintenance fluids

maintenance fluids900

-600

,,9006002/3

hypoxiahypoxiaADH

full maintenancepulmonary edema3Oxygenoxygen therapyoxygen therapy

2- ttt of underlying etiology .

distress

PneumoniaPneumoina

3- ttt of complications .

-Heart failure,,diuretics,,digoxinrespiratory

distress

-respiratory failure,,,mechanical ventilator

4- symptomatic ttt never give cough sedatives in pediatrics .

-feverish,,anti pyretics

-broncho spasm,,broncho dilator

-,,mucolyticexpectorant,,,,cough

therapy

(cough therapy)

-,,respiratory distresshospitalization

-distressedrespiratory failureHeart failure

complications

Underlying etiologysymptomatic treatment


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pathogenesisC / P

-bronchial asthmaso common,,,,,,,,,,,,

asthma

-stressmost common type of asthmaallergic asthma

allergic induced asthmaextrinsic asthma

......

....:

Item:

,,, ,,,allergenallergens

-most common allergen,,,viral infection

-allergendustfumes..pollens

-,,

,,,,,,,,,,

allergenssurfaceMucosaskin

..branched cellsdendritic cells

dendritic cellsallergens..dendritic cellsInterlukin one

activationT helper cell


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stimulationB lymphocytes

T helper cells..OnceactivatedactivationB lymphocyte

Direct activationInterlukin onedendritic cellsallergen

activationactivated T helper cells

-B lymphocytesOnce activatedPlasma cells

-Plasma cellsimmune globulinsallergen()Ig E

Ig G4

-allergensimmune globulin EImmune globulin G4

-,,atopic..atopic,,,,

""feedback inhibitionImmune globulins Eimmune globulin G4

-activationT suppressor cells

T suppressor cells,,OnceactivatedsuppressionT helpersuppression

B lymphocytes

Immune globulin Eimmune globulin G4 production

,,,viral infection..allergens

dustdustdust mites

dust mites,,

123

-autosomal dominant gene..

geneautosomal

malefemale

,,,,,,Incidencepre adolescence

Malefemale..adolescent period..gene factor

exposuremalefemales

out of control

dominant genepathological gene


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positive family history..is diseased

bronchial asthmaatopic diseases

genechromosome11

-asthmagenechromosome11

colonyT suppressorT helper cells

allergenimmune globulin EImmune globulin G4

-blockT suppressor

-activationcycleT helper

allergensImmune globulins Eimmune globulins G4allergic

-allergic

-allergic

-allergicpollens

-virus Infectionvirus induced asthma

""defectcolonyallergen

management,,,,..asthma

Immune globulin EYspecific receptorspecific cells

cellsMast cells

,,esinophils,,,basiophils""

:esinophilsmast cells

-Immune globulins E

surfacemast cellsesinophils

-,,sensitized cells,,,

antibodycell membrane

Is an inert antibody


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allergen

-allergen,,antibodymast cells

esinophils

-antibody..direct antigen antibody reaction

-antibodytwo ends

cell membrane

back endantibody bindingallergen

-Y,,allergens..allergens

two armsallergens

,,allergen

-two limbs..

antibody()

-antibodyallergenstwo limbs(Y shaped end)

(

antibodyY

mast cellsesinophils

Yallergen

two ends

allergen

cell membrane

Calcium channels

Calcium channelCalcium channel)

two armscalcium channelsCalcium channels

calciumInfluxmast cellsesinophils

-..esinophilsMast cellsesinophilsMast cellsvesicles

,,,light microscopevesicle

,,,,,,vesicleLight microscope

,,granulesvesiclesvesiclesInflammatory mediators

allergic inflammatory mediatorsvesicles

""

histamine

Prostaglandin E2


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thromboxane E2

prostacyclin

Platelets activating factorsPAF

bradykinine

slow releasing substance of anaphylaxisLeukotrines

vesicle,,,electron microscopevesiclecell

membranemyo epithelial fibersMuscle fibersactin and myosine

calciumcytoplasm

-actinmyosintroponine C and troponine Ssliding of actin over

myosin

vesiclecell membraneContraction

-vesiclecell membranecell membrane

cell membrane

-membranes..adhesion,,vesicle..allergic Mediators

....vesicle

-vesiclemembranevesiclemembrane

-vesicleallergic mediators

vesicle..

-Microscopevesicle

degranulationreduction of the number of the vesicle inside the cell

-,,first 6 hoursjust broncho spasm

broncho spasmcontractionsmooth muscle of the bronchus

broncho dilatordramatic response

,,,:

broncho spasm,,,broncho spasmLumenbronchus

edemaMucosabronchusbronchus

-,,,Mucous secretion,,secretionLumen

,,,broncho dilatortwo factors

air wayedemasecretion


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..

bronchospasm , secretions & odema

wall of the bronchusmucous membranemusclemediators

6bronchospasmlumen..Dry cough

prolonged expirationHarshlower

Expirati

Wheeze....palpable

6mucosal odemaecretions

Dyspnea..coughproductive..:

sonorus rhonchi & coarse crepitations due to secretions

bronchusalveolihyperinflated

bilateral bulgebarrel shaped chesthyperresonant percussion (

bilatera

alveoliwalldegenerationalveoli

emphysematous bullae

lungpleura..bullae....

pneumothorax

-pleurapneumomediastinal()

surgical emphysema..lunglung

collapse

1. Cough dry (6 hours) then productive2. Expectoration3. respiratory distress --Dyspnea4. Wheeze5. () chest pain mostly dull aching pain due to ms strain6. respiratory failure central cyanosis

History of repeated attacks of6


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1- Signs of respiratory distress

Tachypnea Working ala nasai Suprasternal and supra clavicular retractionintercostal and subcostal retraction & central cyanosis2- Bilateral limitation of movement of the chest

air entry

3- bilateral bulge Barrel shaped chest

Disease here is bilateral

tracheacentral

Palpable ronchiPalpable wheeze

TVF

bilateral hyper resonant chest

1- Air entry bilateral diminished air entry

2- breath sounds harsh vesicular breathing

3- advential sound - siblent rhonchi

then may sonorous rhonchi & coarse crepitaions

1) May HF 3

1- Hypoxia (if severe asthma)

2- Cor pulmonale

If marked emphysema >> alveoli >> wall of alveoli >>

compress the capillaries of the pulm a. >> pulm. HTN >> RSHF (cor pulmonale )

3- If precepitating factor is viral infection >> may viral myocarditis and HF

2) Respiratory Failure.

3) Specific complications

1- Emphysema2- Pneumothorax , pneumomediastinum ( ) may lead to massive lung collapse


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(d.t. severe pneumothorax.)

3- Surgical emphysema.

1) Chest X-ray Hyperinflated lung

-Not diagnostic in BA (only to exclude other causes of wheezy chest)

>> Leucocytosis

- In all allergic asthma >>>>> Eosinophilia

3) Blood gases : for Resp. Failure (cyanosis )

4) Specific investigations :

1- Sputum analysis

- in Allergic asthma >>>> Eosinophils

If PPFs is infection >>>> Lymphocytes or others

2- IgE & IgG4 >>> in Extrensic asthma

3- In Extrensic asthma >> so, skin brick test

3

a- But not goodve >>> antihistaminic

b- means

+ve

c- (skin brick test)

Invitro test ( )

4- Pulmonary functions:

(asthma grade of asthma )

asthma>> (dehydration )


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((oral intake

3- Oxygen therapy.B - ttt of underlying aetiology ( )

1- ()

2-3-4- Psychological factors :5- > odema & secretions ()

2- selective B2 agonist as salbutamol

-B2((selective B2 agonist as Salbutamol

inhalationnebulizer(saline)

mucosal decongestionVCmucolytic effectsecretion

nebulizer.

3

3- Parasympatholytic

-parasympatholyticnebulizeripratropium

ampulenebulizerbronchodil,secretion & odema

B2atrovent


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4- Aminophyllin

-cAMPphosphodiesterase enztheophillineenz

-cAMPgive initial dose then maintainance > 1st 24 Hrs6Give 1 mg/kg/dose

ICUcomplications

- for fever, expectoration,infection give symptomatic

D In between attacks

3In between attacks

1- Avoid :

triggering factors ( .- )

also avoid psychological factors >>>psychological support

2- Pharmacotherapy >>> (attacks )

a- give single bronchodilator (B2)

b- theophylline

c- inhaler corticosteroids Or leukotrien receptor antagonist :

-..

inhaler corticosteroids Or leukotrien receptor antagonist


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d- short course corticosteroids or mast cell stabilizer if frequent attcks.

- attack may give short course corticosteroids

maymast cell stabilizer prevent Ca influx to inside ofmast cell .

1- Extrensic autosomal dominant gene ...

2- Intrinsic

A in adult ( )

due chronic irritaion with smoking

B in childern :post viral repeated viral infection" >>> irritate parasymp. Ns >>> vagus >>> Asthma

So, it as a neurogenic not an allergic asthma

- ( triggering factor viral infection ) + -ve family history + -ve skin test + normal IgE & IgG4

Grades according to :

1- Frequency of the attacks :

:

1-attack()

2-nebulizer

3-..

2- Frequency of nocturnal symptoms

3- according to Pulmonary function test ( FEV 1 Sec. )

Mild, Moderate, Sever

-prognosis..:

a mild & moderate asthma50 % releaved ) complete improve ( at 10 years max. at 20 yrs

-recurrence

b - sever asthma >> only 5%

& 95 % develop adult asthma ( )


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1- Aspirin induced asthma

allergic asthma

: 2 pathways Arachidonic acid -

A - by PG, Thromboxane, Prostacycline

B - or by Leukotriens (slow releasing substance of anaphylaxis)

Mast cells & Esinophils Arachidonic acid -

Allergic mediators

slow releasing substance (Leukotreins) arachidonic acid Cyclooxygenase Aspirin

Mast cells & Esinophils Vesicles Aspirin Fever

Leukotriens as allergic mediator + long acting >> So, cause sever attack

of asthma & may Status Asthmaticus >> anti leukotriens >>

asthma2- Exercise induced asthma

-attacks

exercisedryness of secretions..

hyperosmoler statedegranulationmast cell

3- Nocturnal asthma

..

1- parasymp. Bronchospasm2- cortisone level (circadian rhythm)3- Weak cardiac sphincter asthma >> asthma GER aspiration asthma

Asthma

1 - Over crowding & Poverty ""

Chronic irritation asthma

Intrinsic asthma


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3 - Maternal Smoking chronic irritation

- Also if father is smoker

NBguide lineasthma

..asthma.

4 - Maternal age if20 years oldincidence of having asthmatic child

... asthma 2.5

5 - Psychological factors

Asthma

Inflamation in lung parynchma = alveoli

A - Anatomically x-ray

1- Alveoli in one lobe is affected

2- or in X ray inflammation around the alveoli around the bronchus called bronchopneumonia

Inflamation Bronchus Alveoli

broncho pneumonia>> Patchy

3- Hilar or Interstitial pneumonia

-main bronchushilum of the lung.

Bilateral & around hiluBilateral & patchyUnilateral (one lobe

only)

ViralViral OR bacterialBacterial only ( )

virus

B - Etiological classification :

1- bacterial

as pneumococci, staph, H. infl., psuedomonas, klebs, TB

2- Viral :

Rsv

3- Fungal : as aspergellus , candida only in immunocompromized


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4- Paraseticas pneumocystic carnii

5- Physical Pnuemonia due to sudden change of body temp.

signs of distress

6- Orthostatic or hypostatic pnuemonia

Stagnation of lung secretions >> infection

7- Chemical pneumonia:

Very irritant to alvehydrocarbons

8- May due to Radiotherapy >>

: Pneumonia ..

....

pneumonia..

..

A - Complaint:

1) Fever >> high grade in bact. & low in viral() Infection

2) Cough >> dry then productive3) Expectoration4) Dyspnea5) Grunting6) Chest pain >> d.t. pluerisyPluera Surface of the lung Pneumonic patches

Pleurisy

7) If RF >> CyanosisB - Examination

1- Inspection

I. Respiratory diseress syndrome (Tachypnea_Working ala nasi_intercostal & subcostal retraction &grunting or cyanosis)

II. Movement >> Limitation- lobar >> uni - Broncho & Interstitial >> Bi


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2- Palpation

I. Tarachea >> centerII. Palpaple sound >> rub if pleurisyIII. TVF >>

- lobar >> on affected lobe

- broncho >> patchy

- interstitial >> parasternal

3- percussion >> dulness

as TVF ()

-sometimes tender >> if pleurisy ()

4- Auscultation

I. Air entry >> diminished on affected areasII. Breath sound >> bronchial breathingIII. Adventitial >> fine and medium sized crepitations C - Complications

1- RF

2- HF if bact. > HF due to Toxic myocarditis & if viral > HF due to viral myocarditis

3- Plural effusion >>

4- May paralytic illeus (Toxic or Hypoxic)

D - Investigations

1) Chest x-ray: -type -complicated or not2) CBC >> total leukocytic count infection

Lemphocytes for diagnosis of RF " 4) Isolation of the organism >>culture >>

-sputum or blood sample or pleural tab if pleural effusion

E - TTT

1) Hospitalization : -Rest O2 therapy -IV fluid maintainance2)

TTT of eitiology: -antibiotics acc. to culture

-G +ve >> penecilline (if resistant >> give cephalosporine)

-Gve >> 3rd generation cephalosporine

3) symptomatic ttt :

i. Fever >> not aspirin if viableii. If productive couph >> expectorant4) ttt of complication


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Prevention :

pneumococcal vaccine

Staph infection ...

Fruncle or breast abscess in mother >> lequifaction & localization of infection

(lobar (

C/P

1) Complaint : high grade fever2) ExaminationI. Inspection>> unilat limitation of movement >> mostly on right sideII. Palpation >> rub + TVF ( unilat & patchy )III. Percussion : as TVFIV. Auscultation : as TVF

Investigations

X-ray

Complications :

- Pl. eff : >> pus=emphysema- Lung abscess

) Abscess ) Encysted plneumatocele Cloxacilline

Brocho or lobar

Complication :

-post streptococcal GN or Rh. Fever - may septic focus in bone or joint

Investigations : ASO

gram positive,,,penicillin,,,

,,,third generation cephalosporin


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A H. influenza pneumonia

Pneumo coccal pneumonia,,,

Complications

complicationsmeningismMeningitis

The same

,,,Lumbar puncturemeningismmeningitis

third generation cephalosporingram negative

prevention

preventionH. Influenza vaccine

pneumo coccal pneumonia

Influenza vaccine

B - klebsiel la pneumoina

Klebsiellagram negative bacteria..

- cause broncho or lobar .

,,,

1- if cause lobar in immunocompromised not take triangular shape

LobarImmune compromisedLobar pnuemoniatringular

shap

loberoundedrounded shadow(tringular shadow)

X raytumor mass

2- extensive inflam. Reaction friable lung may Hge Hgic effusion

extensive inflammatory reactionsurface of the lungfriable

,,effusion..effusion,,,hemorrhagic effusion..Malignanc

Klebsiellalung malignancy

-gram negativethird generation cephalosporin

-,,,respiratory syncytial virus..influenzaPara influenzavirus


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-:broncho pneumoniainterstitial pneumonia

A Symptoms :

- Symptoms of upper respiratory tract ( catarrhal symptoms 2or 3 days befor pneumonia )

- low grade fever

- Wheeze

-wheeze..virus,,irritationvagus

para sympathetic over tonebroncho spasm

viral pneumonia,,,wheezy chest

-chest painviral myositisMuscle strain

-cyanosis,,,viral pneumonia

1-signs of respiratory disterss2-Limitation of movement bilaterally

bronchointerstitial

3-Trachea central

4-palpable sounds Palpable rhonchi

5-TVF increased

6- percussion dullness

7-auscultation,,,

*air entry diminished

*bronchial breathing

*fine Medium sized consenanting crepitation

*siblent ronchi due to broncho spasm

1-Respiratory failure

2-Heart failure)viral myocarditis)

3- post viral immune disease,,,complications..,,post viral auto immune disease

auto immune diseaseviral infection

1-hospitlization

2- ttt of cause

,,,Ribavirinpara influenza virusrespiratory syncytial virus


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P a g e |38"":,,:"" " 2012

3-symptomatic treatment

broncho dilator

4- ttt of complications

MycoplasmaOrganism..shcool childrenclosed contacts,

Over crowding

Mycoplasma pneumoniaPenumonia

1-cold antibodies

cold antibody,,,anti bodyactivated37

,,,Hypothermia

-cold antibody,,auto immune hemolytic anemia

Pneumoniaauto immune hemolytic anemiaPneumonia

mycoplasma

,,,viral pneumonia

viral pneumoniaauto immune disorderauto immune hemolytic

anemia

2-specific drug therapy

3rd generation cephalosporinanti viral

specific drug therapygeneration

,,,,,

acute bronchiolitis

Is the mose distressing disease

severe respiratory distress

small bronchus

serosaMucosaIn between,,,Musclosa

small bronchusembryologybudding..


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P a g e |39"":,,:"" " 2012

budding:

a- alveoli

-,,alveoli

b- terminal bronchiole

small bronchusterminal bronchiole

alveoligas exchange mechanism(5 %

)

,,,terminal bronchiole90 %gas exchange mechanism

at birth terminal bronchioles

:terminal bronchioles,,,

,,,,,

-95 %gas exchange mechanismalveoli

-5 %terminal bronchiole

- So, bronchiolitis Means inflammation in terminal bronchiles-inflammationmucosaedematous,,

,,,

1- at birth ( < 2 years )

-90 %gas exchange,

-..terminal bronchiolesedematous

alveoli,,gas exchangealveoli

gas exchange

2- after 2 years

,,,Pathology..Inflammationterminal bronchioles

5 %gas exchange

Lumen..edemaalveoli

alveoli(95% of gas exchange at this age)


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P a g e |40"":,,:"" " 2012

bronchiolitis,,,

asthmatic bronchitis

,,,,respiratory distress

respiratory distressMore severe

,,bronchiolitis

....

1st 2 years of life

-inflammation..

-...even so early

virus..RSVvirusdroplet infection

()

virusairwayirritation of parasympathaticbronchospasm

small & medium sized bronchus..

-

-..hyperinflation

-tracheainspection

-percussion

virusrapid spreading...alveoliinflammation in adjacent

alveoli

alveolar reaction that leading to pneumonitis & inelastic alveolar wall so, may .

Etiology

Inflammation in terminal broncheoles caused mainle by viral infection

( mostly RSV .. & may influnza , parainf. Viruses ,measles & mycoplasma )

1- History of upper respiratory tract catarrhal symptoms


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P a g e |41"":,,:"" " 2012

-,,rhinitissneezing,,,low grade fever

,,maximum39

-

2- Severe cough

expectoration

3- dyspnea

4- wheeze

5- & may central cyanosis

And very rapidlycentral cyanosis

*signs of respiratory distress

Tachypne Working ala nasai Intercostal and subcostal retratction If alveolar pathology grunting cyanosis*limitation of movement of the chest bilateral

*bulge bilateral ( Hyper inflated chest )or (barrel chest)

*trachea central

*palpable wheeze or palpable rhonchi dueto broncospasm

TVF ,,, bilaterally diminished

comperative signs

*bilateral hyper resonant chest

air entry diminished,,bilateral


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P a g e |42"":,,:"" " 2012

breath sounds ,,, harsh vesicular addventious sounds broncho spasm siblent ronchi pneumonic reaction fine crepititation

:bronchiolitisviral pneumonia

,,,viral pneumoniaacute bronchiolitis

-viral pneumoniadullness

-,,,Hyper resonant

1-respiratory failure

2-heart failure dueto

viral myocarditis severe hypoxia

,,,cor pulmonale..

severe acute,,,,,,,

Cor pulmonale

3-emphysematous bullae )due to hyperinflated chest ) may rupture

pneumo thoraxPneumo mediastinumsurgical emphysema

1- Chest X - ray hyper inflated lung

2-CBC

total leucocytic count + Lymphocytosis

3-Blood gases

respiratory failure

PH7.2-PO250-CO2respiratoryfailure

4-viral marker virus,,,

5-sputum cultures

secondary bacterial infection


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P a g e |43"":,,:"" " 2012

1- Hospitalization :

-

bronchiolitis,,

-oxygen therapy

-IV fluids2/3

2- ttt of virus :

-,,Ribavirinanti viralMost common

3- Symptomatic treatment

feverishanti pyretics

mucolytics and expectorant,,,

broncho spasmbroncho dilators

,,,:edemacortico steroid

cortico steroids:viral infection..,,controversal

,,,..cortico steroids

Some of the authors recommendcortico steroids

severe distressedematerminal bronchioles

4- ttt of complications :

-,,,Heart failure,,heart failure

-respiratory failure,,mechanicalventilators

Persistent cystic dilatation of the bronchi (small or medium sized bronchus )

medium sized bronchusdilatationsecretionsstagnant.

stagnant secretionsuper added infectioninfected secretion

small bronchusMedium sized bronchusmicro abscessesInfected sputum

bilateralbasalLower lobes

unilateral

Upper lobe,,,upper lobeLocalized

Upper lobelocal cause

:


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A - congenital

congenital:

1- isolated :

isolated,,,,,small bronchusMedium sized bronchus

dilate..stagnant secretion2ry infection

Unilateralbilateral..Lobe

2- as a part of immotile cilia syndrome

-syndrome:

a- Bronchiectasis :

-immotile cilia syndromeKartagnar syndrome

-Cilia,,,Immotile cilia,,,stagnant secretion

dominant lobes(lower lobes)+super added infection

Bronchiectatic changes

b- chronic sinusitis :-Bronchiectasis,,,,chronic sinusitis

-chronic sinusitisfrontalfrontal sinus

ciliagooddrainage

-cilia,,,good drainagesinus

stagnant secretionsinus

infection

-sinusitissinusesair

inflammatory secretions

Skull X - rayabsent frontal air sinus

c- Dextrocardia :

Heartcardiology

-heartapex of the heart

-apex..cardic tubecilia

cilia,,cardic tube..apex

-cilia,,,heart

isolated DextrocardiaB - acquired causes

1- any chronic infection in respiratory tract :

chronic infectionrespiratory tractbronchiectatic changes

-chronic infectionbronchus,,healing by fibrosis


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P a g e |45"":,,:"" " 2012

bronchusfibrous tissuewall,,,stagnantionsecretion

wall..wall,,,bronchus,,secretion

2-Obstruction

obstruction,,

a- in lumen as FB or dried secretions :

Lumenchest,,,Lumenbronchus

,,,

foreign bodyinspissated secretion

-prolonged coughanti histaminicdrynesssecretion

airwayforeign body,,,

b- outside lumen tumors or LNs

,,,Lymph nodestumors

bronchus,,,lymph nodestumor

c- from the wall granuloma of TB-wall,,,Obstruction

-T.B.granulomaT.B.wallbronchus

obstruction

-obstructionbroncheactasispartialcomplete

bronchectasis

C/P..C/P

pathology,,,lower lobes..bronchibronchusdilatedinspissated

pusinfected sputum

..fever,,,

-Hectic fever

,,,,,:..

-Inflammationair waycoughProductive cough

-,,,Huge amount of sputumexpectoration

:..yellowishgreenish

organismsecondary infection

Infected sputum,,,

-,,,

,,:,,


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P a g e |46"":,,:"" " 2012

,,,Lower lobe of the lung,,,sputum

Pus..,,,,,

- symptoms in winter

:,,,Infectionrespiratorysystem

sputum.. ,,,secretionNormal air way

..

-broncho spasmUpper lobe(Upper lobe)

:dyspneaMild dyspnea))

-Wheeze..,,,

-broncho spasm..alveoliUpper lobehyper inflated

Upper lobelimitation of movement

,,,bulgepercussionhyper resonantUpper lobe

Lower lobe,,,

-chronic infection,,,Inflammationalveoli

pneumoniaPneumonia,,,healing by

fibrosis..lower partretractiondullness

-Pneumonic reactionbronchial breathing..fine creptitation

-rhonchi,,,Lower lobessecretion

secretionsnorous rhonchicoarse creptitation,,,secretion

-broncho spasmrhonchisiblent rhonchi

-,,,Chronic infection

very toxicchronic toxemia..chronic toxemia,,,proliferation

nail bed..clubbing


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P a g e |47"":,,:"" " 2012

-chronic toxemiaamyloidosiskidney..Nephrotic Syndrome

,,generalized edema..,,,

puffinessamyloidosisKidney

-,,amyloidosis,,

Hypo proteinemia

:chronic toxemia

,,,..,,hypo proteinemia..edema

-,,Infectionwall of the bronchus..,,ulcer

ulcer,,,

,,,,,,hemoptysis

hemoptysis,,first signLocalized bronchiectasisupper

lobe

upper lobe,,,bronchectatic changesgood drainage

,,,,..hemoptysisfirst sign

Localized bronchiectasisUpper lobe

..

1-fever

2-cough

3-expectoration

expectoration,,,

-huge amountcolored

Related to certain postureon leaning forward

-winter timeearly morning

4-hemoptysis

Ulcerationair way

5-wheeze

broncho spasmUpper lobe

6-chest pain

pleurisy(dry pleurisy)Muscle strainchronic cough


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P a g e |48"":,,:"" " 2012

1-fever 2-very toxic 3-may pallor 4-may clubbing

5-Puffiness of the eyelids

puffiness of eyelids

chronic cough

,,,Hypo proteinemiaproductive cough

,,,renal amyloidosis

fibrosischronic infection

fibrosisPulmonary artery

Hyper inflated alveolicapillaries of the pulmonary artery

Pulmonary artery pressurePulmonary hypertension))

6-Lower limb edema

chronic cough

1-Inspection

*Mild respiratory distress

tachypnea

working ala nasai

Inter costal and subcostal retraction

,,,Pneumonic reactiongrunting

*limitation of movement (bilateral)

*bulge in the upper part retraction in the lower part

2-Palpation

*trachea central

*palpable sounds

-Upper lobepalpable wheeze

-pleural rubPleurisy


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P a g e |49"":,,:"" " 2012

*TVF

diminished..,,

3-percussion

,,,hyper resonance..Impaireddullness

4-auscultation

*air entry

bilaterally diminished

*breath sounds

-,,,Harsh vesicular

-,,,bronchialPneumonia

*adventious sounds

-,,,siblent rhonchi

-,,sonorous rhonchicoarse crepititationsecretionfine crepititation

pleural rubsurroundingPneumonia

1-renal amyloidosis

2-Lung

*Lung abscess , empyema ,Pleural effusion , cor pulmonale & Pyopneumothorax

1-Chest X - ray

-bilateral basal honey comb appearance

-upper lobehyper inflated

2-CBC

-total leucocytic count( ,,,infection)

Neutrophilsbacterial infection

3-blood gases NO NEED

-respiratory failurecomplications

blood gases4-sputum analysis and culture

Organism

5-broncho scopic examination

broncho graphy,,broncho scope

Obstructioninfection


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P a g e |50"":,,:"" " 2012

aspirationsecretion

Local antibiotic therapy

broncho scope

-cilia,,,bronchial tree

Immotile ciliaelectron microscope

1-Postural drainage

2-mucolytic and expectorant

3-broncho dilators

4-antibiotics

5-resistant cases

-,,Hemoptysis..surgical treatment

-lobe,,,Croupstridor

-croupy cough..larynx

LarynxIrritative cough

croupy cough

-vocal cord,,hoarseness of voice

-larynxstridor

respiratory distress

clinical condition, characterized by croupy cough, hoarseness of voice, stridor with or without respirator

distress .

with or without respiratory distressdegree ofOf obstruction of the airway

A - mechanical obstruction :

.. very common

1- foreign body

coins

2- congenital anomaly in Larynx as :

a-laryngeal web


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P a g e |51"":,,:"" " 2012

:,,,,,

b-larngeo malacia

:,,

,,collapselarynx

c-Mechanical compression as

goiter

retro pharyngeal abscesspara pharyngeal abscess

angioneurotic edemalarynxlarynx

B - Inflammatory conditions :

a- viral infection

Respiratory Syncytial Virus..para influenzaInfluenzaMeaslesvirusviral larngitis

laryngeo trachitis

acute laryngeo tracheo bronchitis

b- H influenza acute epiglotitis

-epiglotisacute epiglotitis..larynx,,,stridor

severe respiratory distress

40

,,drolling of saliva

Prone position,,,,,

-throat examination(Is absolutely contraindicated)

,,throat examinationcardic arrest..epiglotis

Highly innervated by vagus

c- Diphtheria

laryngeal diphtheria,,,Larynx.. ,,stridor

C - tetany :

spasm of the adductors of the vocal cords

laryngismus stridulus

D - papilloma :

,,,hemorrhagic polypvocal cordpapillomavocal cord


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P a g e |52"":,,:"" " 2012

1-croupy cough

2-hoarsness of voice

3-stridor

4-respiratory distress

Here on examination surasternal & supraclvicular retraction ( as the problem in upper not lowe

)

-upper,,Lower is free

Inspection,,palpation,,Percussion,,,auscultationnormal

-,,medical emergency..

1-plain X - ray

-

-anteroPosteriorlateral

-radio opaque foreign bodycoin

- radio opaque foreign body

- epi glotis ,, edematous- Narrowing below epiglotis

acute laryngeo tracheo bronchitis

1-hospitlization

a- bed rest

b- oxygen

-Oxygen,,cold modified

,,laryngeal edema

-vaso constriction of the capillaries..laryngeal edema

c- IV fluids


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P a g e |53"":,,:"" " 2012

2- TTT of the cause

foreign body..viral infectionribavirin

3- If no improvement give supportive ttt

a- give Epinephrin-larygeal edemaRacemic epinephrineInhaler epinephrine

nebulizerinhalation..epinephrinevaso constriction

capillaries

laryngeal edema

b- if not present give cortisone IV

c- If no improvement do tracheostomy

,,,,

irritative cough..allergic in nature

Diseases of the pleura

dry pleurisy..

dry fibrinous inflammation of the pleura

Primary pathologypleura

a- viral infection

viral infection,,virusviremiaPleura

dry pleurisy

b- renal failure

ureadepositpleuradry pleurisy

c- rheumatic fever

dry pericardititisdry pleurisydry peritonitisdry pleurisy

d- T.B.

Primarypleura..dry pleurisy


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P a g e |54"":,,:"" " 2012

a- lung as

Pneumonia ,, bronchiectasis,, abscess,, infarction

b- Mediastinum as

mediastinitis

c- chest wall

Osteomyelitis fracture rib

d- Infra diaphragmatic as

Liver abscess

-mainlyprimary cause

- chest pain stiching in character

coughrespirationholding of breathing

1- inespection

- limitation of movement

- tachypnea

2- palpation

pleural rub

3- PercussionPleurisy..tender percussion

4- auscultation

pleural rub

-Chest X ray to know the underlying cause

other pathology

chest X -rayrib

Chest X - raylung abscess

Lobar pneumonia

bronchiectasis

,,

analgesicspain


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P a g e |55"":,,:"" " 2012

pleural effusionX - ray()

fluid collectedpleural sac

fluid:

1- transudate :

,,transudate),, )generalized edematransudatebilateral effusion

2- Exudate :

-exudate,,surrounding pathologyLung,,Mediastinum,,pleura,,

diaphragmatic,,,infra diaphragmatic

3- Pus :

-Pus,,,staph pneumonia,,Lung abscess

4- Hemorrhagic effusion :klebsiellaT.B.,,traumachest wall..cancer

5- chylus : ( Lymph )

lymphatic system obstructiontraumathoracic duct

6- idiopathic exuadate :

Primary pleurisy..primary pleurisyexudates

1-Symptoms of the cause

2-Respiratory distress

signs of respiratory distress

Limitation of movement of the chestaffected side

bulge

*trachea ,,, pushed to the opposite side

*TVF diminished

stony dullnessdiagnostic

*air entry diminished in the affected side

breath sounds *adventious soundsunderlying pathology


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A - Chest X - ray

B - CBC

empyemamarked neutrophiliatuberculusmarked lymphocytosis

C - blood gases

respiratory failure

D - Pleural tap

,,transudate

exudate

hemorrhagichemorrhagic

chylus

LDH

Chloridechemistry

mesenchymal cellstransudate

pus cellsempyema

caseous materialLymphocytesTuberculosis

malignant cellsmalignant effusion

1-TTT OF CAUSE

2-Inter costal tube IF :

massive effusion*respiratory distress

Pus*,,

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Documents

Chest - Dr Abo-ElAsrar - By El Azhar Medical Students 2012