The respiratory system

Presenting symptoms: Couph , sputum , heamoptysis , dyspnoea , wheez , chest pain , fever, hoarseness and nihgt sweats.

Cough & sputumCough occurs when deep inspiration is followed by explosive expiration.Duration of cough is important: -1) Cough of recent origin associated with fever & other symptoms of respiratory tract infection as:

a) Acute bronchitis b) pneumonia.2) Chronic cough with wheezing as Asthma (or it can be without wheezing).3) Cough, which is worse at night, is suggestive..

a)Asthma or b) Heart failure.4) Irritant chronic dry cough is suggestive..

a) esophageal reflux. b) acid irritation.5) Cough immediately after eating or drinking is due to Tracheo- esophageal fistula or Esophageal reflux.6) Chronic productive cough of large volumes of purulent sputum is suggestive.. Bronchiectasis.7) ACE inhibitor drugs can cause dry cough.

Some types of cough:1) Cough associated with inflammation of epiglottis may have Barking quality.2) Cough caused by tracheal compression by tumor may be Loud and Brassy.3) Cough associated with recurrent laryngeal nerve palsy has Bovine cough (hollow sound) because vocal cord is unable to close completely.

Foul smelling , dark color sputum due to 1-Large abscess. 2-anaerobic organisms.

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Pink frothy secretions from the trachea occure in pulmonary edema.

Haemoptysis (coughing up of the blood) due to Lung disease.

Breathlessness (Dyspnoea): Dyspnoea : subjective awareness of breathing. Causes: (Table 4.3. p102) Classes of dyspnoea : I- Dyspnoea on heavy exertion.II- Dyspnoea on moderate exertion.III- Dyspnoea on minimal exertion.IV- Dyspnoea at rest.

Dyspnoea and Wheeze suggests airways disease,which may be Asthma or chronic airflow limitation .

The duration of dyspnoea is important like:A) Dyspnoea progressively worse over weeks, months, years due to Pulmonary fibrosis.B) Dyspnoea of more rapid onset due to : 1) Respiratory infection : a - Bronco pneumonia. b - Labor pneumonia. 2) Pneumonitis.C) Dyspnoea that varies from day to day or hour to hour due to Asthma.D) Dyspnoea on moderate exertion due to Obesity. Lack of physical fitness.

Wheeze: Definition : Continuous whistling rise during breathing. Caused by :

1) Asthma.2) Chronic airflow limitation.3) Airways obstructions (by foreign bodies or tumor).

Wheeze is maximum during expiration & accompanied by prolong expiration.

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Chest pain:Characteristics1) It is characteristically Pleuritic in nature, i.e.

1- Sharp. 2- Worse by deep inspiration. 3- Worse by coughing.

2) Localized to one area of the chest.3) Associated with dyspnoea.

Other presenting symptom :Fever at night

Causes :1) TB (also with sweating at night).2) Pneumonia.3)Mesothelioma.

Hoarseness Causes :

1) Inflammation of vocal cord (Laryngitis).2) Vocal cord tumor.3) Recurrent laryngeal nerve palsy.

Sleep apnea: Abnormal increase in periodic cessation of breathing

during sleep. Obstructive sleep apnea (airflow stop despite persistence of

respiratory effort). Present with daytime somnolence due to: 1- Chronic fatigue. 2- Morning headache. 3- Personality disturbance.

Central sleep apnea (cessation of inspiration muscle activity) present with somnolence but don’t snore excessively.

Hyperventilation: Occurs in some patient that response to anxiety by the

rate & depth of their breathing. This result in ↑ CO2 excretion development of Alkalosis PH of the blood. It results in: 1- Paresthesia of the fingers & around the mouth.

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2 2- Lightheadedness. 3- Chest pain. 4- Feeling of impending collapse.

Past History: Should ask about previous respiratory illness.

Treatment: You must know if the patient take any medication because

it is helpful in diagnosis the disease such as:1) Bronchodilator in case .. a) Asthma. b) COPD. c)Bronchiectasis.2) Steroids including…a) Sarcoidosis. b) Hypersensitivity pneumonia. c) Asthma.3) Physiotherapy including … a) Cystic fibrosis b) Bronchiectasis- almost every class of drug can produce lung toxicity e.g…4) Pulmonary embolism from oral contraceptive pill.5) Interstitial lung disease from cytotoxic agents e.g. (Methotrexate, Cyclophosphamide, Bleomycine).6) Bronchospasm from B-blocker and NSAIDs.7) Cough from ACE Inhibitor.

Occupational History:-Expose to dust from industries or factories (asbestos / silica / cotton...etc).-Asbestos exposure e.g. (asbestosis , mesothelioma, carcinoma of the lung ).-Working with animals like birds e.g. (fever , psittacosis). -Expose to A.C. e.g. allergic alveolitis.

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Social History: Ask about Smoking. the risk of lung cancer when the patient smokes & work

in asbestoses factory. Passive smoking also is important. Drinking alcohol case …

1) Aspiration pneumonia. 2) Alcoholitics. 3) Klebsilla pneumonia.

IV drug users at : 1) Lung abscess. 2) Pulmonary edema.

Family History: Ask about any family history of asthma, cystic fibrosis,

Emphysema and α- Antitrypsin deficiency. Family history of infection of Tuberculosis is important.

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Begging a physical examination

(1) introduction ,privacy & positioning: (alwys tell the PT what you are doing).

)2 (General inspection ł (appearance): - appearance: well or ill (face, foot, hand, eye ,mouth, Higden, dental care). - body built: obese, thin, cachexic - color : pale, cyanotic, jaundice. - Distreast: respiratory And cardic (stridulous , tachypnoic , upset, comfortable) - environment: IV line ,BP, catheter, and ECG.

NOTE: the general inspection ∏-which is related to the ill system- could be done here also.

(3) Vital singes: BP, Temp, respiratory rate, pulse ( regulatory, rate.

)4 (exposure of the needed area: this could be done after the general inspection .∏

)5(on the ill system :general inspection ∏ (related to the ill system), inspection, palpation, precaution auscultation.

Respiratory Examination

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Positioning the patient If the patient is not acutely ill, the examination is easier

with the patient sitting ver the edge of the bed or on a chair.

General appearance…A) Dyspnea ..

Examination :1- Watch for signs of dyspnea.2- Count respiratory rate (should not exceed 14 breaths per min).3- Check if the accessory muscles of respiration are being used (sternomastoids, platysma and strap muscles of the neck). They cause elevation of the shoulders with inspiration.

B) Central Cyanosis .. It is a late sign of hypoxemia. Examination : by inspecting the tongue in good light. Cause: Lung diseases that result in significant ventilation-

perfusion imbalance (such as pneumonia, chronic airflow limitation and pulmonary embolism) cause arterial oxygen saturation and central cyanosis1.

C) Character of the cough and sputum.. Discussed before.

D) Stridor..Definition : a rasping or croaking noise loudest on inspiration due to obstruction of the larynx, trachea or large airways.Cause: Foreign body, a tumour, infection (e.g. epiglottitis) or inflammation (Table 4.5 p107).E) Hoarseness

Causes include :1- Laryngitis (commonest cause).

1 If the deoxygenated hemoglobin is 5g/100mL.

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2- Recurrent laryngeal nerve palsy.3- Laryngeal carcinoma.

The hand :A) Clubbing

Refer to CVS H & P.

B) Staining of the fingers It is a sign of cigarette smoking. Caused by the tar (as nicotine is colourless).

C) Wasting and weakness Cause : compression by a peripheral lung tumour of a

lower trunk of the brachial plexus may result in wasting of the small muscles of the hand.

D) Pulse rate Tachycardia and pulsus paradoxus are important signs of

severe asthma.

E) Flapping tremor (asterixis) Refer to GIT H & P. Cause: Severe carbon dioxide retention, usually due to

severe chronic airflow limitation.

The face :Horner’s syndrome

Inspect the eyes (a constricted pupil, partial ptosis and loss of sweating) which can be due to an apical lung tumour compressing the sympathetic nerves in the neck.

Nose : Look for any :

1) Polyps (associated with asthma).

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2) Engorged turbinates (various allergic conditions).3) Deviated septum ( nasal obstruction).

Mouth : Look for evidence of an upper respiratory tract infection (a

reddened pharynx and tonsillar enlargement with or without a coating of pus).

Feet : Look for swelling (edema) , cyanosis (may be a clue for

cor pulmonale) and DVT.

The Chest (from the front and from the back)

Inspection:A) Shape & symmetry of the chest :1) Barrel chest :

It is an in the anteroposterior (AP) diameter compared to the lateral diameter. It indicates hyperinflammation as in patients with Asthma or Emphysema.

2) Pigeon chest (Pectus Carinatum): A localized prominence (an outward bowing of the sternum & costal cartilage). It may be a manifestation of chronic childhood respiratory illness. It results from repeated strong contraction of diaphragm while the thorax is still pliable. It occurs also in Rickets.

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3) Funnel chest (Pectus Excavatum): A localized depression of the lower end of the sternum. In sever cases, lung capacity may be restricted.

Harrison’s sulcus: It is a linear depression of the lower ribs just above the costal margins at the side of attachment of the diaphragm. It can result in sever asthma in childhood or rickets.

4) Kyphosis : An exaggerated forward curvature of the spine. Scoliosis: An exaggerated lateral curvature of the spine. Causes of kyphoscoliosis : may be idiopathic, secondary to poliomyelitis or associated with Marfan’s syndrome. Severe thoracic Kyphoscoliosis may reduces the lung capacity & ↑ the work of breathing.

Lesion of the chest wall:1) Scars from previous thoracic operation or from chest

drains from previous pneumothorax or pleural effusion.2) Thoracoplasty causes sever chest deformity. This operation

for tuberculosis & done by removal of the large number of ribs on one side of the chest to achieve permanent collapse of the affected lung.

3) Subcutaneous emphysema is a cracking sensation felt on palpating the skin of the chest or neck. On inspection, there is often diffuse swelling of the chest wall & neck. It is caused by air tracking from the lungs & is usually due to pneumothorax.

4) Prominent veins may be seen in patient with superior vena cava obstruction.

5) Sige of radiotherpy erythema and thiking of the skin over irredated area.

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Movement of chest wall: Look for asymmetry of chest wall movement anteriorly &

posteriorly. Assessment of the expansion of the upper lobes is best

achieved by inspection from behinds the patient.- Unilateral reduction of chest movement may be due to : 1) localized pulmonary fibrosis. 2)consolidation.

4)collapse. 3)pleural effusion. 4)pneumothorax.- Bilateral reduction of chest movement indicates a diffuse abnormality such a s: chronic airflow limitation or diffuse pulmonary fibrosis.

- Accessory muscles using.

Palpation : (alwys ask about point of tenderness)

Chest expansion : Examination :

* Place the hand on chest wall.* The fingers extend around the sides of chest.* The thumbs should meet in the middle line. * The thumbs should be lifted slightly off the chest so they are free to move with respiration.* As the patient takes a big breath, the thumbs should move symmetrically at least 5 cm.

Apex beat: Displacement of apex beat toward the side of lesion when:

1- Collapse of lower lobe. 2- Localized pulmonary fibrosis. Movement of the apex beat away from the side of lesion

when:1- Pleural effusion. 2- Tension pneumothorax.

Tactile vocal fremitus: Examination : Palpate the chest wall with palm of hand

while patient repeats ((Ninety Nine))…(( أربعين و .((أربعة The cause of change in vocal fremitus is same as these for

vocal resonance (will be taken later).

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Ribs: Localized pain suggests ribs fracture. It might be secondary to trauma or spontaneous as a result

of tumor deposition or bone disease.

The Trachea : Examination :

From in front of the patient the forefinger of the right hand is pushed up & backwards from suprasternal notch until the trachea is felt (figure 4.2 P109).- If the trachea is displaced to one side its edge rather than its middle will be felt & large space will be present on one side than the other.

Causes : (Table 4.6 P110) Tracheal tug : is demonstrated when the finger resting on

trachea feels it moves inferiorly with each inspiration , this is a sign of overexpansion due to airflow obstruction.

Percussion :

Examination :* The left hand on the chest wall & the fingers are separated.* The left middle finger is pressed firmly against the chest.* The pad of the right middle finger is used to streak the middle phalanx of the middle finger of the left hand.* On percussion of the back, the scapula should be rotate anteriorly by asking the patient to move the elbow forward across the front of the chest.

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Notes on examination :* The percussing finger is quickly removed so the note generated is not demand.* The percussing finger should be partly flexed.* The loose swinging movement should come from the wrist not from the forearm.* Percuss the clavicle directly.

* The percussion should be done in 6 plases with the last 2 on the lateral wall of the chest, the movement between the positons should be by a zigczag movement.On the back, a paravertibral percussion must be done.* percssion of the lung apex and 2nd itrcostal space is important.

Sounds of percussion : 1) Dull sound : percussion over the solid structures as liver or consolidated area of the lung.2) Stony dull sound : percussion over fluid filled area such as pleural effusion.3) Resonant sound : percussion of normal lung.4) Hyper-resonant sound : percussion over hollow structure such as bowel or pneumothorax.

Liver dullness :* Upper level of liver dullness is determined by percussing down anterior chest wall on mid clavicular line.* Normally it is in sixth rib in right-mid clavicular line.* If it is resonant below this level it is sign of hyperinflation due to emphysema or asthma.

Cardiac dullness :* Present on the left side of the chest.* It may ↓ due to emphysema or asthma.

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Auscultation:

1) Breath sounds :

Quality of breath sounds :1-Vasicular sounds : normal breathe sounds.* Produced by airways rather than alveoli.* Louder & longer on inspiration rather than expiration.* No gab between inspiration & expiration sounds.* They like the sound of wind resulting in leaves.* Cause : transmission of air turbulence in large airways filtered through normal lung to chest wall.

2- Bronchial sounds:* Turbulence is heard in large airways without being filtered by alveoli.* Hollow, blowing quality.* Audible through expiration.* There is gab between inspiration & expiration.* Expiration sound has higher intensity & pitch than the inspiration sound.* Causes of bronchial sound:1) Common IS lung consolidation.2) Uncommon are : 1)pulmonary fibrosis. 2)pleural effusion. 3) collapsed lung.

Intensity of breathing sound : Causes of reduced breath sounds include :1)chronic airflow inflation (emphysema),2) pleural effusion.3) pneumothorax.4)pneumoni. 5)neoplasm .6) pulmonary collapse.

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Added (adventitious) sounds (2 types):1) Wheeze:

Definition: Continuous, musical quality sound.- It can be heard in inspiration or expiration or both.- It is louder during expiration due to airway dilated during inspiration & narrowed during expiration.-High pitched produced in large airways, low pitched in small ones.

Cause: Continuous oscillation of opposing air wall which imply a significant airway narrowing.

Occur in:1) Asthma (high pitch).2) Chronic airflow limitation (low pitch). There is bronchial muscle spasm, mucosal edema & excessive secretions.

Note : It is a poor guide of severity because it might be absent in sever airway obstruction because of velocity of air get to reduced below a critical level necessary to produce the sound.

2) Crackles :Definition: Interrupted non-musical sounds.

Cause: loss of stability of peripheral airways, which collapse on expiration.

Timing of crackles:A) Early inspiration crackles : disease of small airways (chronic air flow limitation).B) Late paninspiratory crackles : disease of alveoli. They are fine-medium coarse in quality.

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Quality of the crackles:1) Fine crackles like sound of hair between fingers. Typically caused by pulmonary fibrosis.2) Medium crackles Caused by LV failure (which produces increased alveolar fluids).3) Coarse has a gurgling quality. Occur in any case that causes pools of retained secretions. Such as Bronchiectasis.4)Pleural friction rub: Check CVS

3) Vocal resonance : Definition: Auscultation of the chest while the patient

speaks. Ask the patient to say (ninety-nine) while listing to chest.

In normal lung: Low pitch speech : booming quality. High pitch speech : attenuated.

Consolidated lung transmit high frequencies so that speech heard through the stethoscope takes on bleating quality called (aegophony).

In over consolidated lung number become clear audible. In normal lung sound is muffled number. Some times vocal resonance ↑ that whispered speech is

heard called (whispering pectoriloquy).

The heart : See CVS.

The abdomen : Palpable the liver to check if :

A) it is displaced downword due to emphysema, or.B) for enlargement due to deposit of tumor in case of lung carcinoma.

Other :Pemberton’s sign :

Ask the patient to lift his arms over the head. Look for development facial plethora, inspiratory stridor & elevation of JVP.

This occurs in superior vena cava obstruction.

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