Respiratory System

Examination

By Dr.Khalil Alsoutary

Asst professor

Balqa Applied university

June 15,2019

Surface markings of the lung, pleura and trachea

the bifurcation of the trachea at sternal angle

Surface

anatomy of the

Thorax

Lobes of the

lung

Anterior view

And lateral view

Common Symptoms

➢ Cough

➢ Spurum Production

➢ Hemoptysis

➢ Chest pain

➢ Breathlessness

➢ Wheezing

Causes of coughInfectionsinuses

Infection ,tumors (benign

,malignant), Aspiration

Gastro-esophageal reflux

Foreign body, irritant Dust

Larynx, trachea

Large airways

Asthma

Post-viral airway reactivity

Chronic Bronchitis

Bronchiectasis ,Bronchiolitis

Small airways

Characters of cough➢ A nocturnal cough causing sleep

disturbance is a common symptom of

asthma. Occult gastro-esophageal reflux is

a common cause of daytime cough, as is

chronic sinus disease with associated

postnasal drip.

Character of cough

➢ Angiotensin-converting enzyme inhibitors

used to treat left ventricular failure and

hypertension may cause a dry cough,

particularly in women. This is caused by

peptides, e.g. bradykinin and substance P,

that would normally be degraded by

angiotensin-converting enzyme.

cough

➢ Coughing during and after swallowing

liquids suggests neuromuscular disease of

the oropharynx. Occupational asthma and

exposure to dusts and fumes are a

recognized cause of chronic cough that

typically lessens during weekends and

holidays.

Sputum production

➢ SPUTUM PRODUCTION

➢ Expectorated respiratory secretions are

known as sputum or phlegm and need to

be specifically asked about. Patients may

find it difficult to discuss sputum

production because of a natural

reluctance, and it may be regularly

swallowed.

main types of sputumCauseAppearanceType

Acute pulm edemaClear, waterySerous

Chronic

Bronchitis,COPD

Asthma

Clear, gray

White, viscid

Mucoid

Broncho-pulmon

infection

Yellow-greenPurulent

Pneumococcal infGolden-yellowRusty

Common Symptoms➢ All of these can also occur in the absence of

respiratory disease. For example, breathlessness, wheeze and central chest pain may be the presenting feature of an acute myocardial infarction complicated by pulmonary edema. Diabetic ketoacidosis may present with breathlessness and weight loss.

➢ Although many respiratory conditions share the same combination of symptoms (e.g. cough, sputum production and breathlessness are features of pneumonia, asthma, COPD, cystic fibrosis and bronchiectasis),

➢ the mode of onset, duration, progression and severity of each symptom characteristically differ.Therefore , each symptom needs careful exploration of mode of onset, duration, progression, aggravating/relieving factors and relationships with other symptoms.

Causes of coughInfectionsinuses

Infection,tumors

(benign,malignant), Aspiration

Gastroesophageal reflux

Foreign body,irritant Dust

Larynx, trachea

Large airways

Asthma

Post-viral airway

reactivityChronic Bronchitis

Bronchiectasis,Broncolitis

Small airways

Cough-character

➢ A feeble non-explosive 'bovine' cough with hoarseness may occur with respiratory muscle weakness but is more usually associated with lung cancer invading the left recurrent laryngeal nerve with resultant paralysis of the left vocal cord. A rare cause is thoracic aortic aneurysm that also damages the left recurrent laryngeal nerve.

cough

➢ Patients with severe airflow obstruction (asthma or COPD) often have prolonged wheezy coughing, and sometimes the sustained increase in intrathoracic pressure is sufficient to impair venous return to the heart, resulting in reduced cardiac output and cough syncope or near-syncope.

➢ The cough of laryngeal inflammation, infection and tumour tends to be harsh, barking or painful and may be associated with hoarseness and stridor.

Cough-character

➢ moist cough usually indicates secretions in the upper and larger airways and occurs in bronchial infection and bronchiectasis. A persistent moist 'smoker's' cough first thing in the morning is typical of chronic bronchitis. Smokers often do not mention it because it is so common they assume it is normal. Any change in the pattern of this cough may indicate the development of lung cancer.

➢ A dry centrally painful and non-productive cough is a feature of tracheitis and pneumonia. A paroxysmal dry cough in patients with asthma may follow a viral respiratory infection and last several months.

➢ A chronic dry cough is common in interstitial disease, e.g. cryptogenic fibrosing alveolitis.

Sputum production➢ SPUTUM PRODUCTION : Expectorated

respiratory secretions are known as sputum or phlegm and need to be specifically asked about. Patients may find it difficult to discuss sputum production because of a natural reluctance, and it may be regularly swallowed. There are four main types of sputum

➢

Sputum production

➢ Amount : Ask how many teaspoons of sputum are coughed up each day. Statements by patients that they cough up small (a teaspoonful) or large (a teacupful) amounts of sputum are usually helpful. Regular coughing up of large volumes of purulent sputum influenced by posture is characteristic of bronchiectasis.

➢

Sputum production➢ The sudden production of large amounts

of purulent sputum on a single occasion

suggests the rupture of a lung abscess

or empyema into the bronchial tree.

➢ Large volumes of watery sputum with a

pink tinge in an acutely breathless

patient suggests pulmonary oedema,

whereas large volumes of watery sputum

for weeks (bronchorrhoea) is a symptom

of alveolar cell cancer.

➢

Different colours of sputum. (A) White. (B) Yellow. (C) Green. (D) Rusty red

General Examination

➢ Respiratory Rate

Count the number of respiration per minute,

tachypnea is resprate>15 caused by

fever,asthma and COPD,reduced ventilatory

capacity as in B.Asthma and

pneumonia,pulmonary edema and interstitial

lung disease

HEMOPTYSIS

➢ Hemoptysis induce anxiety in many

patients, bwcause of lung cancer

➢ It is important to determine if the blood

has been coughed up,or vomited from

the upper resp tract or suddenly

appear in the mouth without coughing

hemoptysis

➢ Amount and appearance—streaking of clear sputum with blood, or the presence of blood clots in sputum for 1wk or more suggest lung cancer

➢ Duration and frequency—coughing up of large amounts of blood is rare, life threatening condition that occur in bronchiectasis ,TB, lung cancer,

➢ pulmonary infarction, lung abscess, mycetoma(rare)

Causes of Hemoptysis

Lung cancerTumor

Endobronchial metastasis

Bronchial carcinoid

BronciectasisInfection

Pulmonary TB

Lung abscess, Mycetoma

Pulmonary Infarctionvascular

Wegner Granulomatosis

Goodpasteur`s syndrome

Vasculitis

Causes of hemoptysis/2

Inhaled foreign bodyTrauma

Chest trauma

Iatrogenic; Bronchoscopic

biopsy

Transthoracic lung biopsy

Mitral valve diseasecardiac

Acute left ventricular failure

Blood dyscrasiahematological

Anticoagulation

Infection

Malignancy

Pneumothorax

Pulmonary Infarction

Connective tissue disease

Rheumatoid arthritis, SLE)

PLEURAL

Malignancy

Pesistant cough,

breathlessness

Muscle sprain /tears

Bronholm`s disease

Rib fracture

Intercostal nerve compression

Chest wall

Non central causes of chest pain

Chest pain

➢ Chest pain can originate from the

pleura, the chest wall and mediastinal

structures

➢ History should include- site,

radiation,mode of onset,

duration,severity, aggravating and

releiving factors including relation to

breathing

Central causes of chest pain

Infections

Irritant Dust

Tracheal

Massive pulmonary embolism

Acute M. infarction/ischemia

cardiac

Oesophagitis

Rupture

Esophageal

Aortic DissectionGreat

vessels

Lung cancer, Thymoma,

lymphadenopathy, metastasis,

mediastininitis

Mediastinal

Pleural pain

➢ Typicall sharp, stabbing and always

increased by inspiration and coughing

➢ Irritation of the parietal pleura of upper 6

ribs is perceived as a localized pain

➢ Irritation of the parietal pleura overlying the

central diaphragm is referred yo the neck

or shoulder tip

➢ The lower 6 intercoatal nerves innervate

the parital pleura and outer diaphragm,pain

may be referred to the upper abdomen

Chest wall pain➢ Chest wall pain Pain originating from the

chest wall may indicate respiratory or musculoskeletal disease. Or develop a generalized feeling of chest tightness or diffuse pain.

➢ Patients with asthma or COPD often mention this form of pain if asked but it is rarely a presenting complaint.

➢ The sudden onset of localized pain after vigorous coughing or direct trauma is characteristic of rib fractures or intercostal muscle injury.

Chest wall pain

➢ Prevesicular herpes zoster and intercostal nerve root compression can cause chest pain in a thoracic dermatomal distribution.

➢ Malignant chest wall pain due to lung cancer, mesothelioma or rib metastases is typically dull, aching, or gnawing in nature, unrelated to respiration, progressively worsening and eventually disrupting sleep.

➢ The pain of Pancoast's tumour of the lung apex is due to erosion of the first rib and is often referred down the medial aspect of the arm because of invasion of the lower roots of the brachial plexus

Breathlessness

➢ Breathlessness (dyspnoea) is an undue

awareness of breathing. It is a natural

consequence of strenuous physical exercise.

Patients may use terms such as 'shortness of

breath', 'difficulty getting enough air in',

'feeling puffed', or 'tiredness'. These terms

indicate that the patient is getting breathless

but are usually unhelpful in elucidating

possible causes (Table 4.5).

Breathlessness

➢ A careful history of breathlessness covers

➢Mode of onset,

➢duration,

➢progression,

➢ variation,

➢ aggravating/relieving factors

➢severity and associated symptoms.

Causes of breathlessness

Anemia , ObesityNoncardio-respiratory

Metabolic acidosis

psychogenic

Neurogenic

Left ventricular failurecardiac

Mitral valve disease

cardiomyopathy

Constrictive pericarditis

Pericardial effusion

RespiratoryLaryngeal tumorsAirways

Foreign body

Asthma

COPD

Bronchiectasis

Lung cancer

Bronchiolitis

Cystic fibrosis

Pulmonary fibrosis,alveolitisParynchima

Tuberculosis, pneumonia, diffuse

infection

sarcoidosis

Causes of breathlessness/2

Pulmonary EmbolismPulmonary

circulation

Pulmonary vasculitis

Primary pulmonary HTN

Pneumothoraxpleura

effusion

Diffuse pleural fibrosis

kyphosischest wall

Ankylosing spondylitis

Breathlessness, mode of

onset,duration and progression

Pulmonary thromboembolismMinutes

Pneumothorax

Acute left ventricular failure

Asthma, inhaled foreign body

pneumoniaHours to days

Asthma

COPD exacerbation

Breathlessnes,mode of action,

duration, and progression

Weeks to months Anemia

Pleural effusion

Respiratory N-Muscular

disease

Months-Years COPD

Pulmobnary fibrosis

Pulmonary tuberculosis

Severity of Breathlessness

➢ Grade 1 breathless when hurrying on level

➢ Grade 2 Breathless when walking with people of own age on level ground

➢ Grade 3 has to stop because of breathlessness when walking on ground level at own pace

wheeze

➢ A high-pitched whistling sound produced by air passing through small vessel

➢ Typically wheeze is limited to and louder during expiration

➢ Wheeze on exercise is a common symptom of asthma and COPD

➢ A common mistake is failure to distinguish a wheeze from inspiratory stridor caused by partial occlusion of a large airway by a tumour or foreign body