Guidelinesfor Third-year Students of the Medical Department

Subgect Propedeutics of the internal medicineModul № 1Enclosure module № 2Topic Syndromes of lobar and focal consolidations of lung tissue, pleural

effusion, pneumothorax, atelectasisCourse 3Faculty Medical № 1

1. Importance of the topic Syndromic diagnostics is one of the important components at the diagnostic process. Revealing pathogenic relation between different symptoms and signs forms integral estimate about patient’s condition. It is indispensable to correct diagnosis and treatment.

2. Concrete aims: ─ Study main symptoms and signs of the syndromes of focal and lobar consolidation of the

lung tissue─ Learn main instrumental methods that can help to establish consolidation of the lung tissue─ Study main symptoms and signs of the syndrome of pleural effusion─ Learn basic investigations that should be performed for confirming pleural effusion and

laboratory examinations of the pleural fluid─ Study main symptoms, signs of pneumothorax, its instrumental diagnostics─ Master causes, symptoms and signs of the different types of atelectasis, their instrumental

diagnostics

3. Basic training level

Previous subject Obtained skillNormal anatomy Anatomy of the airways and lungs, their blood supply and

innervationNormal physiology Mechanics of breathing, gas exchange in the lung and tissues of

system organsHistology Ontogenesis of the respiratory tract, histological structure of the

respiratory tract and alveoliPropedeutics to internal medicine

Subjective, objective and instrumental examinations of the respiratory patients

4. Task for self-depending preparation to practical training4.1. List of the main terms that should know student preparing practical training

Term Definition

Consolidation of the lung tissue

Pathologic process when alveoli are felt with inflammatory exudates, transudates, blood tumor cells or others

Pleural effusion Accumulation of fluid in the pleural cavityTransudates Non-inflammatory fluid that can accumulate in pleural cavity, alveoli,

bronchus and othersExudates Inflammatory fluid that can accumulate in pleural cavity, alveoli, bronchus

and othersPneumothorax Accumulation of air in the pleural cavityAtelectasis Collapse of lung tissue

4.2. Theoretical questions:1. What is definition and causes of syndromes of lobar and focal consolidation of lung tissue?2. What are symptoms and signs of the lobar and focal consolidation of the lung tissue?3. How can consolidation of the lung tissue be confirmed by instrumental examination?4. What is definition and causes of the pleural effusion?5. What are symptoms and signs of the pleural effusion?6. How pleural effusion can be confirmed by instrumental examination?7. How pleural fluid should be investigated with laboratory methods8. What is definition and causes of the pneumothorax?9. What are symptoms and signs of the pneumothorax?10. What is definition and causes of the atelectasis?11. Which types of atelectasis do you know; their distinguishing symptoms and signs?

4.3. Practical task that should be performed during practical training1. Revealing and assessment of symptoms and signs of focal and lobar consolidation of the lung

tissue2. Revealing and assessment of symptoms and signs of pleural effusion3. Revealing and assessment of symptoms and signs of pneumothorax4. Revealing and assessment of symptoms and signs of atelectasis5. Assessment of the pleural fluid analysis

Topic contentLobar and focal consolidation of lung tissue is the complex of symptoms that appears after effect on the lung different pathogenic mechanisms resulting to pulmonary infiltrate or proliferation. The lobar consolidation involves some segments or whole lobe of lung. The focal consolidation involves small site of lung tissue.Causes of the lobar consolidation of lung tissue:

1. Community-acquired and nosocomial pneumonia – infiltration of lung by inflammatory cells due to non specific inflammation

2. Lobar tuberculosis - infiltration of lung by inflammatory cells due to specific inflammation3. Lobar pneumofibrosis – proliferation at lung by connective tissue4. Lung cancer and tumor - proliferation at lung by tumorous tissue5. Infarction-pneumonia at patients with sub-massive pulmonary embolism - infiltration of lung by

blood and inflammatory cellsCauses of the focal consolidation of lung tissue

1. Community-acquired, nosocomial, aspiration pneumonia2. Focal tuberculosis3. Focal pneumofibrosis4. Lung tumor

Symptoms of the focal consolidation of lung tissue: Sometimes there is breathlessness because small part of lung is involved, lung function and gas exchange is not limited.Cough can be dry or with purulent sputum. It is depended from stage of disease.Signs of the focal consolidation of lung tissue:Visual examination of the chestSometimes there is limitation of the chest moving at the affected side.

Palpation of the chestMay be, there is a tenderness of the pleural points, positive Potendzher symptom, amplifying of voice resonance if the site of consolidation is near surface of chest.Percussion of the chestComparative percussion: If site of consolidation is near of the chest surface it can be dullness of percussion sound. Because account of solid components of lung tissue increase due to infiltration but air presents in alveoli which haven’t been involved to pathological process and they get to percussion sphere. If site of consolidation is deeply in lung percussion sound is clear without change.Topographic percussion: Some change can be if site of consolidation is near of chest surface. There is dimension of lower lung border excursion.Auscultation of the lungThere is diminished vesicular breathing because less alveoli involve to act of breathing. There are sonorous bubbling (moist) rales. They are formed in bronchus which around by consolidated lung tissue. Such tissue conduct sounds from bronchus better then healthy and we can hear them as sonorous. Sometimes if site of consolidation is near chest surface crepitations can be heard.X-ray signs of the focal pulmonary consolidation: There is peribronchial and perivascular and/or focal infiltration of lung tissue.Symptoms of the lobar consolidation of lung tissue:

o Breathlessness occurs due to large injury of lung that result to diminution of it function and changing of gas content of blood.

o Chest pain happens due to involving of pleura in inflammatory process.o Cough can be dry or with purulent bloody sputum. It is depended from stage or form of disease.

Signs of the lobar consolidation of lung tissueVisual examination: It is severe condition of the patient. He has redness in cheek at the affected side, herpes on his lips, sometimes prefers to lie on the affected side. There is tachypnea, cyanosis.Visual examination of the chest: There is limitation of the chest moving at the affected side. Auxiliary muscles take part in breathing.Palpation of the chestThere is a tenderness of the pleural points, positive Potendzher symptom, because large part of lung with pleura is involved to inflammatory process and surrounded tissues react to this. It is obtained amplifying of voice resonance according to the affected lobe or segments, because consolidated lung tissue conducts acoustic waves better than normal one.Percussion of the chestComparative percussion: Over the consolidated lobe the percussion sound is dull because only solid components of infiltrated lung tissue get to percussion sphere.Topographic percussion: The lower border of the affected lung lifts up if pathological process localizes in lower lobe. The height of lung apex pulls down. But size of the lung doesn’t change. It is obtaining due to increasing of solidity of lung tissue. There is dimension of lower lung border excursion.Auscultation of the lungThere is pathological bronchial breathing because all alveoli are filled up with inflammatory exudates, whispering pectoriloquy. There is pleural rub due to inflamed pleura rubbing against each other. You can hear depressed vesicular or bronchial breathing and crepitations in the beginning or end of pathological process. X-ray signs of lobar pulmonary consolidation: There is intensive and homogeneous infiltration of lobe or segments.A pleural effusion results from the accumulation of abnormal volumes (>10-20 ml) of fluid in the pleural space. According to causes of pleural effusion and content of pleural fluid there are two types – exudates and transudates.Causes of the pleural effusion:

1. Cardiac failure2. Pneumonia3. Tuberculosis 4. Malignancy5. Pulmonary embolism

6. Chest injury7. Liver cirrhosis, pancreatitis and other

Symptoms of the pleural effusion:It may be asymptomatic if little quantity of fluid accumulates in pleural space.It is associated with breathlessness, dry cough, chest pain (suggesting pleural inflammation), chest “heaviness”, palpitation, if quantity of fluid is large (more than 400-500 ml).Signs of the pleural effusion:Visual examinationIt is a severe condition of the patient. There is tachypnea, cyanosis and limitation of the chest moving at the affected side. Patient prefers to lie on the affected side because it facilitates his breathing.Palpation of the chestIt is obtained reduced or absent tactile vocal fremitus, because fluid damps acoustic waves, and increased chest resistance. Sometimes, may be positive Potendzher symptom.Percussion of the chestComparative percussion: It is dullness over fluid.Topographic percussion: Lower lung border has shape named Ellis-Damuazo line which begins near column and rises to scapular then descends to axillary region and continues horizontally. This shape of line makes conditional upon different property of lung tissue to be squeezed. Auscultation of the lungThere are no any sounds over the fluid. But sometimes may be diminished vesicular breathing if it is little quantity of fluid. You can hear diminished bronchial breathing if quantity of fluid much and squeezed lung has similar density as fluid. Above the fluid it is diminished vesicular breathing and, sometimes, pleural rub.X-ray signs of the pleural effusion: It is usually detected effusion volumes of 200 ml or more by posterior-anterior position. Lateral chest X-ray is more sensitive and may detect as little as 50 ml pleural fluid. Classical chest X-ray appearance is of basal opacity obscuring hemidiaphragm, with concave upper border. Massive effusion may result in a ‘white-out’ of the hemithorax, with mediastinal displacement away from the effusion. Lack of the mediastinal shift in such cases raises the possibility of associated volume loss due to bronchial obstruction from a primary lung cancer.Ultrasound is extremely sensitive at detecting fluid volumes of 100 ml or more, and is useful for distinguishing pleural fluid from pleural masses or thickening, and for demonstrating loculation.Laboratory assessment of pleural fluid:1. Common – visual assessment, comparative density, Rivalt test 2. Biochemistry for measurement of protein, LDH, glucose, cholesterol, triglycerides, amylase, depending on the clinical circumstances.3. Cytology for examination for malignant cells and differential cell count4. Microbiology for Gram stain and microscopy, culture, MBT examinationIs the pleural effusion a transudates or exudates?Sign transudates exudatescomparative density < 1,015-1,018 >1,018Rivalt test negative positiveprotein <30 g/l >30 g/lPleural fluid protein/serum protein ratio <0,5 >0,5LDH <1,6 mMol/l >1,6 mMol/lPleural fluid LDG/serum LDG ratio <0,6 >0,6erythrocytes <10*109/l >100*109/lleucocytes <1*109/l >1*109/lpH >7,3 <7,3glucose 3,3-5,5 mMol/l <3,3 mMol/lA pneumothorax is an air in the pleural space; may occur with apparently normal lungs (primary pneumothorax) or in the presence of underlying lung disease (secondary pneumothorax); may occur spontaneously or following trauma.Causes of pneumothorax:

1. It occurs following an air leak from apical bullae.2. Underlying diseases: COPD, asthma, interstitial lung disease, necrotizing pneumonia,

tuberculosis, Pneumocystis carinii pneumonia, cystic fibrosis, Langerhans’cell histiocytosis, lymphangioleiomyomatosis, Marfan’s syndrome, oesophageal rupture, lung cancer, catamenial pneumothorax, pulmonary infarction.

Spontaneous – due to rupture of blebs, usually in thin tall young males with history of smokingTraumatic – iatragenic (i.e. subclavian central line insertion, excessive PPV, thoracic surgery, transbronchial lung biopsy) or penetrating chest trauma (knife, bullet).Tension – most serious: air enters on inspiration but cannot escape on expiration = pneumothorax size increases with each breath. Lung eventually collapses under increasing pressures.

Symptoms of pneumothorax:o Acute pleuritic chest pain due to rupture of pleurao Acute breathlessness. It is often minimal in young patients and is more severe in secondary

pneumothorax and if it is tension pneumothorax/o Sometimes can be dry cough.

Signs of pneumothoraxVisual examination: It is severe condition of the patient. He has tachypnea, cyanosis, tachycardia. May be feel “bubbles” and “crackles” under the skin of the torso and neck if there is subcutaneous emphysema.Visual examination of the chest: Chest is asymmetric – affected side is increased. There is diminished chest excursion on the affected side. Auxiliary muscles take part in breathing.Palpation of the chestIt is obtained absent tactile vocal fremitus, because air in pleural space damps acoustic waves. Chest resistance is increased. Sometimes there is a tenderness of the pleural points, positive Potendzher symptom; because pleura is involved to pathology process and surrounded tissues react to this. Percussion of the chestComparative percussion: Over affected lung the percussion sound is hyper-resonant.Topographic percussion: Erroneously the lower border of the affected lung descends down and apex of lung lifts up when you make percussion but in reality lung collapses. Lower lung border excursion is absent.Auscultation of the lungThere is quiet or absent breath sounds on the pneumothorax side.X-ray signs of pneumothorax: no lung markings on affected side peripheral to edge of collapsed lung and depressed diaphragm, tracheal/mediastinal shift to unaffected side.Atelectasis is complex of symptoms and signs when part of lung or whole lung doesn’t content air or content less air than normal and it collapses.Classification:Obstructive – due to occlusion of the airwaysCompressive – due to pressure of lung by fluid or air in pleural space.Causes of obstructive atelectasis:

1. Central lung cancer2. Characinoid of bronchus3. Foreign body of bronchus4. Tumor of mediastinum5. Enlarged lymphonodules of mediastinum or tracheal-bronchial, bronchial-pulmonary ones due

to tuberculosis or metastasis.Causes of compressive atelectasis:

1. Pleural effusion2. Pneumothorax3. Tumor of pleura4. Deformation of chest.

Sign and symptoms of obstructive atelectasisBreathlessnessVisual examination

If atelectasis large, there is severe condition o patient, tachypnea, cyanosis. Chest is asymmetric – affected side and chest excursion is diminished.Palpation of the chestIt is obtained diminished or absent tactile vocal fremitus, because collapsed lung tissue damps acoustic waves. Chest resistance is increased.Comparative percussion: It is dullness over atelectasis.Topographic percussion: Lower lung border is lifted up by collapsed segments.Auscultation of the lungThere are no any sounds over the atelectasis because air doesn’t come into alveoli. Sign and symptoms of compressive atelectasis

. BreathlessnessVisual examination

If atelectasis large, there is severe condition o patient, tachypnea, cyanosis. Chest is asymmetric – affected side is bigger than normal and chest excursion is diminished.Palpation of the chestIt is obtained diminished or absent tactile vocal fremitus, because collapsed lung tissue damps acoustic waves. Chest resistance is increased.Comparative percussion: It is dullness over atelectasis.Topographic percussion: Lower lung border is lifted up by collapsed segments.Auscultation of the lungThere is diminished bronchial sound over the atelectasis because collapsed lung tissue conducts acoustic waves from bronchusX-ray signs of atelectasis and addicted methods of diagnostics of atelectasis.Diminished volume and elevated hemidiaphragm on affected side; mediastinal shift to affected side; increased opacity; scattered densities.

Materials for self-control (added)

7. Reference source

o Handbook of diseases.-.2nd ed.- Springhouse Corporation, 2000 – P.85-86, 658-659, 668-669.

Lecturer Demchuk H.V.

Test for self-control1. Syndrome of the focal consolidation of the lung tissue can be if patient has:

a. focal pneumonia;b. focal pneumofibrosis;c. focal tuberculosis;d. lung cancer;e. all mentioned above.

2. Syndrome of the lobar consolidation of the lung does not reveal at patient with…a. Lobar pneumoniab. Infiltrative tuberculosisc. Pulmonary embolism with infarction-pneumoniad. COPDe. Lung cancer

3.At the patient with lobar consolidation at palpation of the chest can be obtaineda. Amplifying vocal fremitus on the affected sideb. Weakened vocal fremitus on the affected sidec. Vocal fremitus does not changed. Vocal fremitus is absente. Amplifying vocal fremitus on the health side

4.At the patient with focal consolidation near the root of lung at palpation of the chest can be obtained

a. Amplifying vocal fremitus on the affected sideb. Weakened vocal fremitus on the affected sidec. Vocal fremitus does not changed. Vocal fremitus is absente. Amplifying vocal fremitus on the health side

5.Pathological bronchial breathing is heard at patients with:a. focal consolidationb. lobar consolidationc. pleural effusiond. emphysemae. acute bronchitis

6.Percussion sound of the lobar consolidation of lung tissue is:a. tympanicb. clearc. resonanced. dulle. small dull

7.Auscultation signs of the focal consolidation is:a. Vesicular breathing with prorogated exhalation and wheezeb. Absent of the any breath soundc. Diminished vesicular breathing and sonorous bubbling (moist) ralesd. Unchanged vesicular breathinge. Pathological bronchial breathing

8.Auscultation signs of the lobar consolidation is:f. Vesicular breathing with prorogated exhalation and wheezeg. Absent of the any breath soundh. Diminished vesicular breathing and sonorous bubbling (moist) ralesi. Unchanged vesicular breathingj. Pathological bronchial breathing

9. Obstructive atelectasis can be if patient has:a. Lung cancer;b. Metastasis into pulmonary lymphonodes;c. Foreign body of bronchus;

d. Tuberculosis of the pulmonary lymphonodes;e. all mentioned above.

10. Compressive atelectasis can be if patient has:a. Pleural tumor (mesotelioma);b. Massive pleural effesion;c. Pneumothorax;d. Deformation of the chest;e. all mentioned above.

11. Percussion sound over massive pleural effusion:a. tympanicb. clearc. resonanced. dulle. small dull

12. Percussion sound over pneumothorax:a. tympanicb. clearc. resonanced. dulle. small dull

13. Auscultation signs of pneumothorax:a. Diminished vesicular breathing and wheezeb. Diminished vesicular breathing and cracklesc. absent of breath soundsd. unchanged breath sounde. Pathological bronchial breathing

14. Auscultation signs of massive pleural effusion:a. Diminished vesicular breathing and wheezeb. Diminished vesicular breathing and cracklesc. absent of breath soundsd. unchanged breath sounde. Pathological bronchial breathing

15. If patient has massive pleural effusion vocal fremitus is:a. Absent on the affected sideb. Increased on the affected sidec. Diminished on the affected sided. Normale. Increased on the health side

16. Percussion sound over small pleural effusion:a. tympanicb. clearc. resonanced. dulle. small dull

17.If patient has small pleural effusion vocal fremitus is:a. Absent on the affected sideb. Increased on the affected sidec. Diminished on the affected sided. Normale. Increased on the health side

18. Which properties does transudate have?a. Light yellow colorb. Protein < 30 g/lc. Negative Rivalt test

d. 1-5 leucocytes and 2-6 mezoteliocytese. All mentioned above

19. Which properties does not exudate have?a. Comparative density < 1,018b. Protein > 30 g/lc. Positive Rivalt testd. 10-25 leucocytes and 2-6 mezoteliocytese. Yellow color

20. Percussion sound of the focal consolidation of lung tissue is:a. tympanicb. clearc. resonanced. dulle. small dull

Control questions1. What is definition and causes of syndromes of lobar and focal consolidation of lung tissue?2. What are symptoms and signs of the lobar and focal consolidation of the lung tissue?3. How can consolidation of the lung tissue be confirmed by instrumental examination?4. What is definition and causes of the pleural effusion?5. What are symptoms and signs of the pleural effusion?6. How pleural effusion can be confirmed by instrumental examination?7. How pleural fluid should be investigated with laboratory methods8. What is definition and causes of the pneumothorax?9. What are symptoms and signs of the pneumothorax?10. What is definition and causes of the atelectasis?11. Which types of atelectasis do you know; their distinguishing symptoms and signs?

4.3. Practical task that should be performed during practical training1. Revealing and assessment of symptoms and signs of focal and lobar consolidation of the lung

tissue2. Revealing and assessment of symptoms and signs of pleural effusion3. Revealing and assessment of symptoms and signs of pneumothorax4. Revealing and assessment of symptoms and signs of atelectasis5. Assessment of the pleural fluid analysis

Situation tasksTask 140-year-old male patient, height 180 sm, long time smoked, suddenly feels knife-like pain in the chest and breathlessness after physical extension. At visual examination left part of the chest enlarged and is left behind from right in breathing, at percussion – resonant sound, at auscultation – breathing is absent.1. What syndrome has developed at the patient?2. Which investigation should be performed to confirm it?3. How is respiratory rate changed at the patient?Task 219-year-old female patient complains of dyspnea, cough with purulent sputum and left side chest pain. The symptoms appeared after hard work and overcooling 3 days before. At the visual inspection skin is pale and cyanotic, respiratory rate is 32 and left part of the chest is left behind from right. At auscultation you hear pathological bronchial breathing.1. What syndrome has developed at the patient?2. What signs of the syndrome can be obtained by percussion?

3. What investigation should be used for confirming syndrome?Task 379-year-old male was admitted to pulmonology department with hemoptysis and breathlessness. During examination patient’s general condition is moderate severe, skin is pale and cyanotic; at auscultation – weakened vesicular breath sound over lower right lobe. You suppose a central lung cancer.1. What syndrome has developed at the patient?2. What signs of the syndrome can be obtained by percussion?3. Which method can help you to confirm diagnosis?Task 455-year-old female patient notes dry cough, breathlessness and palpitation. Patient condition is severe, diffuse cyanosis; right part of the chest is left behind from left. At percussion – dull sound over lower right lobe.1. What syndrome has developed at the patient?2. What signs of the syndrome can be obtained by auscultation?3. What investigations are mandatory for establishing diagnosis?