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