Respiratory system

Symptoms / Chief complaint• Cough

• Sputum

• Hemoptysis

• Dyspnea

• Chest pain (chest tightness / discomfort)

• Wheezing

Symptoms / Chief complaint• Cough

• Sputum

• Hemoptysis

• Dyspnea

• Chest pain (chest tightness / discomfort)

• Wheezing

Cough

• Type – Dry, Productive , Short, Brassy, Bovine ,Barking , whooping,

Cough syncope, Nocturnal, Drug induced

• Onset & Duration

• Pattern : activities, time of day, weather

• Severity

• Timing and associated features

Causes of cough:

Normal chest X-ray Abnormal chestX-ray

Acute cough(<3 weeks)

Viral respiratory tract infection, Bacterial infection (acute bronchitis), Inhaled foreign body, Inhalation of irritant, dusts/fumes

Pneumonia, Inhaled foreign body, Acute hypersensitivityPneumonitis

Chronic cough(>8 weeks)

GERD, Asthma, Post viral bronchial hyper reactivity, Rhinitis/sinusitis, Cigarette smokingDrugs (ACE inhibitors, Irritant dusts/fumes)

Lung tumor, TB, Interstitial lung disease, Bronchiectasis

Sputum• Sputum is mucus produced from the respiratory tract. The

normal lung produces about 100 ml of clear sputum each day, which is transported to the oropharynx and swallowed

• Amount

• Color

• Presence of blood  (hemoptysis)

• Odor

• Consistency

Color & Consistency:Type Appearance CauseSerous Clear, watery,

Frothy, pinkAlveolar cell cancer, Acute pulmonary oedema

Mucoid Clear, grey

White, viscid

Chronic bronchitis/COPD

Asthma

Purulent Yellow

Green

Acute bronchopulmonary infectionAsthma (eosinophils) Longer-standing infection, PneumoniaBronchiectasis, Cystic fibrosis, Lung abscess

Rusty Rusty red Pneumococcal pneumonia

Haemoptysis• coughing up blood from the respiratory tract

• Types

– Frank

– Haemoptysis in suppurative lung disease

– Spurious

– Pseudohaemoptysis

– Endemic

Causes

Malignant• Lung cancer• Endobronchial metastasesBenign• Bronchial carcinoid

Infection• Bronchiectasis • Tuberculosis• Lung abscess• Mycetoma• Cystic fibrosis

Vascular• Pulmonary infarction • Arteriovenous malformation• Vasculitis • Goodpasture’s syndrome• Iatrogenic • Bronchoscopic biopsy • Transthoracic lung biopsy • Bronchoscopic diathermy • Acute left ventricular failure • Anticoagulation• Polyangiitis • Trauma• Inhaled foreign body • Chest trauma• Mitral valve disease • Haematological• Blood dyscrasias

Dyspnoea

• Dyspnoea (breathlessness) is undue awareness of breathing and is normal with strenuous physical exercise.

• Patients use terms such as ‘shortness of breath’,‘difficulty getting enough air in’, or ‘tiredness

Grades: M R C classification:

– Grade I: Breathless when hurrying on the level or walking up a slight hill

– Grade II: Breathlessness when walking with people of own age or on level ground

– Grade III: Walks slower than peers, or stops when walking on the flat at own pace

– Grade IV: Stops after walking 100 metres, or a few minutes, on the level

– Grade V: Too breathless to leave the house (Too breathless to wash or dress Sherwood )

Modes of onset, duration and progression

Minutes• Pulmonary thromboembolism• Pneumothorax, Asthma, Inhaled foreign body• Acute left ventricular failure

Hours to days• Pneumonia, Asthma , Exacerbation of COPD, LHF

Weeks to months• Anaemia, Pleural effusion, Respiratory neuromuscular

disorders

Months to years• COPD, Pulmonary fibrosis, TB, Muscle weakness

Variability

• Orthopnoea :Breathlessness when lying flat (LVF)

• Platypnoea: Breathlessness on sitting up with relief on lying down right-to-left shunting

• Trepopnoea : Breathlessness when lying on one side is due to unilateral lung disease dilated Cardiomyopathy

• Paroxysmal nocturnal dyspnoea : wakes the patient from sleep

• Breathlessness improving at weekends or holidays occupational asthma.

Causes of Breathlessness • Cardiorespiratory

– Anaemia– Metabolic acidosis– Obesity– Psychogenic– Neurogenic

• Cardiac– Left ventricular failure– Mitral valve disease– Cardiomyopathy– Constrictive pericarditis– Pericardial effusion

Respiratory

Airways• Laryngeal tumour• Foreign body• Asthma• COPD• Bronchiectasis• Lung cancer• Bronchiolitis• Cystic fibrosis

Pulmonary circulation• Pulmonarythromboembolism• Pulmonary vasculitis• Primary pulmonaryhypertension

Parenchyma• Pulmonary fibrosis• Alveolitis• Sarcoidosis• Tuberculosis• Pneumonia• Diffuse infections, e.g.Pneumocystis jirovecipneumonia• Tumour (metastatic,lymphangitis)

Pleural• Pneumothorax• Effusion• Diffuse pleural fibrosis

Chest wall• Kyphoscoliosis• Ankylosing spondylitis

Neuromuscular• Myasthenia gravis• Neuropathies• Muscular dystrophies• Guillain–Barré syndrome

Chest pain

• Chest pain can originate from the parietal pleura, the chest wall and mediastinal structures .

• Pleural pain

• Chest wall pain

• Mediastinal pain

• Retrosternal pain– Upper– Lower

Causes of Chest painNon- Central

Pleural• Infection: pneumonia,bronchiectasis, tuberculosis• Malignancy: lung cancer,mesothelioma, metastatic• Pneumothorax• Pulmonary infarction• Connective tissue disease:rheumatoid arthritis, SLE

Chest wall• Malignancy: lung cancer, mesothelioma, bony metastases• Persistent cough/breathlessness• Muscle sprains/tears• Bornholm’s disease (Coxsackie B infection)• Tietze’s syndrome (costochondritis)• Rib fracture, • Intercostal nerve compression, • Thoracic shingles (herpes zoster)

Central

CentralTracheal• Infection• Irritant dusts

Cardiac• Massive pulmonarythromboembolism• Acute MI/ischaemia

Oesophageal• Oesophagitis• Rupture

Great vessels• Aortic dissection

Mediastinal• Lung cancer• Thymoma• Lymphadenopathy• Metastases• Mediastinitis

• Past History– Similar illness– TB, Asthma, IHD, DM– Childhood illness- measles, inflenza, whooping

cough– Recent travel

• Family history– Similar illness– DM,TB, HT, IHD,– Parents marriage: consanguineous– Asthma, Eczema

• Personal history– Appetite– Veg/non-veg– Bowel & bladder – Alcohol- amount & duration– Smoking-No., duration (smoking index)

• Menstrual history– Menarche, LMP– Regular, amount– Associated pain

• Treatment History

General examination• Built• Nourishment• Dyspnoea• Cyanosis• Anemias• Jaundice • Clubbing• Lymphadenopathy• Eye• Pedal edema

Cyanosis

Grades and Examination of Clubbing

Lymphatic and Veins

• Lymph node: – Parietal pleura axillary lymph node– Whole right lung& left lower lobe right

supraclavicular lymph node– Left upper lobe left supraclavicular lymph

node

• Veins: – Superior vena caval syndrome

Examination of the neck

• Scalene Lymph Node– Large and fixed : Primary lung malignancy– Hard, craggy, matted, with/out sinus

formation: calicified TB lymphadenopathy

• Other significant nodes:– Supraclavicular – Cervical– Axillary

External manifestations

• Asterixis• Halitosis• Gynaecomastia• Horner’s syndrome• Small muscle wasting• External markers of TB• External markers of cor pulmonale

Examination

What is the most important start to any exam ??

Introduce yourself to the patient and let them know what you are about to do …

Systemic Examination of Respiratory system

Inspection/Observation• Upper Respiratory Tract

– Oral - Tonsils– Nosecavity -Throat– Pharynx

• Lower Respiratory Tract– Supraclavicular area - Suparscapular region– Infraclavicular area -Interscapular region– Mammary region - Infrascapular

region– Axillary region– Infra axillary region

• Shape

• Bilateral movement

• Subcoastal angle

• Dyspnea

• Accessory muscles

• Trachea position

• Apex beat

• Shoulder drooping

• Spine position

• Visible scars/ dilated veins/ sinuses

• Position of Trachea:– Trail’s sign

• Position of the apex beat

Chest Deformities

• Flat chest

• Barrel chest

• Pectus Carinatum

• Pectus excavatum: It’s the exaggeration of the normal hollowness over the lower end of the sternem.

• Harrison’s sulcus:

• Rickety rosary:

• Scorbutic rosary:

Spine Abmormalites• Kyphosis: Causes the patient to be bent forward.

• Ankylosing spondylitis: Diminished volume of lung & capacity of the chest

• Scoliosis: spine is curved to either the left or right.

Movement of the chest

• Rate

• Rhythm

• Equality

• Type of breathing

Rate• Normal: 14-18 breaths/min• Type of breathing• Pulse : Respiratory rate (4:1)• Tachyponea:

– Nervousness, fever, hypoxia, exertion– APE, Pneumonia, Pul. Emobolism, ARDS, Metabolic

acidosis

• Bradypnoea: – Alkalosis, Hypothyroidism, raised ICT

• Hyperpnoea:– Acidosis, brainstem lesion, Hysteria

Rhythem

Inspiration: by the contraction Of the external intercostal muscles and the diaphragm

Expiration: Depends upon the elastic recoil of the lungs

Abnormal breathing patterns

• Cheyne-Stokes respirations

– Hyperpnoea followed by apnoea– periods of respirations during which the tidal volume

starts shallow and gets progressively deeper, and then gets progressively shallower.

– Causes: strokes, traumatic brain injuries, brain tumors, CO poisoning, and metabolic encephalopathy, normal side-effect of morphine administration.

• Kussmaul's Breathing:

– Labored hyperventilation characterized by a deep and rapid respiratory pattern.

– Causes: late stages of a severe metabolic acidosis (DKA).

• Apneustic Breathing:

– prolonged inspiratory phases with each breathe, followed by a prolonged expiratory phase

– causes: lesion to the upper part of the pons

• Ataxic Breathing:

– A completely irregular breathing pattern with irregular pauses and unpredictable periods of apnea.

– Cause: lesion to the medulla oblongata secondary to trauma or stroke.

– very poor prognosis.

• Biot's Breathing

• Apnoea between several shallow or few deep inspirations

• It is very similar to Cheyen-Stokes except the spontaneous tidal volume is equal throughout the period of respiration.

• Causes: Lesions to the medulla oblongata by CVA or trauma, or pressure on the medulla due to uncal or tenorial herniation, prolonged opioid abuse.

Palpation• Position of the trachea• Apex position• Rib crowding• Bony tenderness• Lymphnode

– Axillary– Cervical– Supraclavicular

• Measurement of chest expansion

Assessment of chest expansion• Anterior Thoracic Movement:

• Posterior Thoracic Movement:

Tactile Fremitus

Location:

Assessing Fremitus:

PercussionPercussion Areas:

Anterior & Lateral

Posterior

Methods of Percussion

Auscultation

Vesicular Inspiratory sounds lasts longer than expiratory sounds

Soft Over most of lungs

Bronchovesicular

Inspiration and expiration sounds are equal.

Intermediate Angle of louis/between scapulae.

Bronchial Expiratory sounds last longer than expiratory ones.

Loud Over manubrium sternum.

Tracheal Inspiratory and expiratory are about equal

Very loud Over trachea in neck.

Breath sounds to the bases

Equal breath sounds

Inspiration

Expiration

Abnormal breath sounds Absent or diminished breath sounds Displaced bronchial breath sounds Adventitious breath sounds

Listen with intent for

Most common cause air passing through fluid (other?)

Fine = Smaller airways

Coarse = Larger airways

Predominantly heard on inspiration

Can be equal both lungs

Can be isolated to one area

Crackles

Produced by air forcing its way through narrowed airways (bronchoconstricted)

High pitched musical sounds heard on expiration

Can be heard on inspiration

Smooth Muscles Irritation = Bronchoconstriction

Wheezes

High pitched continuous crowing sound that is heard over the trachea and larynx

Stethoscope not normally needed

Best heard over neck

Partial airway obstruction from: foreign objects, swelling

Stridor

Constant grating sound that is heard on inspiration and expiration

Caused from parietal and visceral pleura rubbing together

Pleura inflamed (loss of serous fluid)

Usually localized

Pleural Rub

Attempt to place patient in sitting position

Attempt to minimize as much outside noise as possible

Encourage patient not to make any moaning and groaning noises

Proper Auscultation Procedure

Where should I listen?

Anterior Chest

Posterior Chest