01201452554P_2014.10.02 MSII Respiratory Symptoms and Signs.pptx

Respiratory Symptoms and SignsMatthew C. Miles, MDAssistant Professor of Internal Medicine,Pulmonary Diseases, and Critical Care Medicine

Wake Forest Baptist Medical Center

Objectives

• Understand the language of the respiratory examination• Explain possible causes of respiratory symptoms• Describe normal and abnormal auscultation of the chest• Describe normal and abnormal percussion of the chest• Correctly identify disease states based on respiratory

signs and symptoms


From “Look and Hear” to “See and Listen”

• “the most important part of an art is to be able to observe properly” – René Laennec

• “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” – Sir William Osler


Symptoms vs. Signs

Symptoms are perceived by the patient

Dyspnea

Cough

Pain

Signs are observed by the clinician

Wheeze

Crackles

Clubbing


Respiratory SymptomsDyspnea, Cough, Chest PainAsking the right questions, listening to the answers


Dyspnea

A psycho-physiologic

sensation with many possible

causes

Latin dyspnoea,

Greek dyspnoia

“Shortness of breath”

Perception of difficult or

painful breathing

If worsens with physical activity:

dyspnea on exertion


Cardiopulmonary Sites Causing Dyspnea


Dyspnea

• Triggered by receptors in chest wall, respiratory muscles, lung parenchyma, carotid body, and brain stem

• Adaptation can occuro Chronic severe lung disease patients who report minimal

dyspneao Trained athletes with dyspnea despite no measurable

physiologic abnormality

• NOT coupled to respiratory efforto ↑work of breathing ≠ ↑amount of dyspnea


Taking a Dyspnea History

Onset and course over

time• Specific & sudden, or vague & gradual?

Impact on daily

activities• “decreased activity phenomenon”

Aggravating factors

• Car exhaust, dusts, molds, perfumes, pets

Position • orthopnea, platypnea


Respiratory DDx for Dyspnea

Pulmonary embolism

Pulmonary arteriovenous malformations

Asthma

COPD

Tracheomalacia, bronchomalacia

Pneumonia

Lung cancer

Pneumothorax


Cough

• Occurs seldom in healthy individuals• A normal protective mechanism• Unimportant vs. Heralding severe disease• Phaseso Inhalation o Glottis closure, Compressiono Expulsion – glottis openso Relaxation


Taking a Cough History

Duration • Acute, or Subacute/Chronic

Sputum • Quality, quantity

Timing • Morning, evening, no variation?

Aggravating factors

• Air temp, location, exposures

Associated symptoms

• Fever, chest pain, hoarseness


Respiratory DDx for Cough

Irritant inhalation

Upper respiratory infection

Upper airway cough syndrome

ACE inhibitors

Gastroesophageal reflux disease

Asthma

Chronic bronchitis

Acute

Subacute&

Chronic


Hemoptysis: Coughing of Blood

• Always requires thorough evaluationo CXR (often CT), +/- bronchoscopy

• Massive (~200ml/24h) vs submassive• DDx: hematemesis, epistaxiso Bronchitiso Lung cancero Tuberculosiso Bronchiectasis


Chest Pain

• Extremely common, many causes• Always a symptom to be carefully consideredo Intensity ≠ Importance


Taking a Chest Pain History

Onset • Specific and Rapid, Vague and Slow

Duration • Seconds vs. Minutes vs. Hours

Location • Specific, pinpoint vs. vague

Quality • sharp, burning, pressure, tight, heavy

Aggravating factors

• exertion, inspiration

Alleviating factors

• rest, medications


Respiratory DDx for Chest Pain

Pleuritis – acute inflammation of parietal pleura

• Localized, “sharp”, “a catch”• Worsened by deep inspiration• Many conditions could underlie:

• Infectious pleuritic• Pneumothorax• Pulmonary embolism• Pneumonia• Pleural malignancy


Respiratory Examination & Signs$0.00 additional charge∞ additional information


René Laennec

• “father of modern knowledge of pulmonary disease”• introduced auscultationo 1819: De l’auscultation médiate

• invented the stethoscopeo modeled after an observation of children playing by tapping on

a cylinder


Stethoscope: “Chest examiner”

1800s

2000s


Normal Respiratory Effort

• Unlabored• Mouth closed• Allows for normal speech• Diaphragm alone


Abnormal Respiratory Effort

• Visibly Labored• Mouth open• Cannot speak normally • Diaphragm not aloneo Sternocleidomastoid hypertrophyo Intercostal retractionso Abdominal muscle contractionso “Tripod” arm support

• Hyperinflation may be seeno “Barrel-chest”


Normal breath sounds

• Sounds over the lung lobeso “vesicular” sounds

• Sounds over the tracheao “bronchial” sounds

o Bronchial sounds are abnormal if heard over the lobes

inh

exh

inh

exh



• Sounds over the lung lobeso “vesicular” sounds

• Sounds over the tracheao “bronchial” sounds

inh

exh

inh

exh




Abnormal breath sounds

• Continuouso Wheezeso Rhonchi

• Discontinuouso Fine Crackleso Coarse Crackles


Abnormal continuous sounds

• Wheezes• High pitched (>400Hz), longer than 250msec

• Produced by fluttering of airway walls

• Rhonchi• Low pitched (<200Hz), longer than 250msec

• Produced by flutter or rupture of fluid films

http://www.youtube.com/watch?v=33qV3d3U0q4

http://www.youtube.com/watch?v=YOnBu8CClmQ



• Wheezes• Classically present in asthma

• Many other conditions (VCD, foreign body)

• Rhonchi• Excessive large airway secretions

• Mechanical ventilation, poor pulmonary toilet

• Often clear with cough or suctioning



• Wheezes and Rhonchi: Describingo Location (focal, diffuse)o Quiet or forced expirationo Clearance with coughing (rhonchi)


Abnormal discontinuous sounds

• Fine Crackles• Coarse Crackleso Short explosive nonmusical

soundso Reflect explosive opening of

small airways



• Crackleso Early-inspiratory

• Heart failureo Late-inspiratory

• Pulmonary fibrosis



• Crackles: describingo Location: Bibasilar, diffuseo Fine or coarseo Early- or Late-inspiratory


Stridor

• An important extra-thoracic soundo Differs from wheezing:

• Stridor is predominantly inspiratoryo Caused by turbulent flow in extrathoracic airwayo Most commonly due to vocal cord dysfunction, tracheal

stenosis, or foreign bodyo May be a medical emergency!


Percussion

• Coordinated tapping on a finger held against the patient’s chest

• The percussion “note” is heard, but predominantly it is felt


Percussion

plexorpleximeter


Percussion

• resonant• dull• flat• tympanic• hyperresonant

• Normal lung• Normal liver• Normal thigh• Normal bowel• Abnormal


Percussion

• resonant• dull• flat• tympanic• hyperresonant

• Normal lung• pleural effusion, consolidation• massive effusion• tension pneumo• pneumothorax


Percussion

• Describing:o Location: unilateral or bilateralo Note: resonant, dull, flat, or hyperresonant

http://www.physicalexam.med.ualberta.ca/physical_exam/ASCM1/Physical_Examination/ascm1/Respiratory/index.htm


Palpation - Fremitus

boy oh boy. . .toy boat. . .

blue balloon. . .

any low frequency phrase



• Bilateral comparison is key• Increased fremitus:o Consolidated lung (pneumonia)

• Decreased fremitus:o Pleural space filling (effusion or pneumothorax)

• This is sound transmission – travels best through solids and poorly through air

• What happens if there is consolidation with a small pleural effusion?



• Describing:o Location: which side, which lobeso Intensity: Increased or Decreased


Digital Clubbing

• An important but uncommon manifestation in some pulmonary diseases

• NOT present in: COPD• PRESENT (maybe) in: lung cancer, pulmonary fibrosis,

chronic pulmonary infection


Digital Clubbing

Mason: Murray and Nadel’s Textbook of Respiratory Medicine, 5th ed.Rutherford J D Circulation 2013;127:1997-1999


Digital Clubbing

• Describing:o Presence (or absence)o Unilateral or bilateralo Timing of onset – 2 weeks is enough


Putting it all togetherDisorder Inspection Palpation Percussion Auscultation

Bronchial asthma (acute attack)

Hyperinflation; use of accessory muscles

Impaired expansion; decreased fremitus

Hyperresonance; low diaphragm

Prolonged expiration: inspiratory and expiratory wheezes

Pneumothorax (complete) Lag on affected side Absent fremitus Hyperresonant or

tympanicAbsent breath sounds

Pleural effusion (large) Lag on affected side

Decreased fremitus; trachea and heart shifted away from affected side

Dullness or flatness Absent breath sounds

Atelectasis(lobar obstruction) Lag on affected side

Decreased fremitus; trachea and heart shifted toward affected side

Dullness or flatness Absent breath sounds

Consolidation (pneumonia)

Possible lag or splinting

Increased fremitus on affected side Dullness Bronchial breath

sounds

Fibrosis(End-stage)

Often normal; frequently nonproductive cough

Fremitus symmetric ResonantShallow breathing; late-inspiratory crackles

Documents

01201452554P_2014.10.02 MSII Respiratory Symptoms and Signs.pptx