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Differential Diagnosis
Pulmonary Disorders
Pulmonary Disorders Pulmonary pain is usually localized to the
anterior chest, side or back Can radiate to the neck, upper trap muscles,
costal margins, thoracic region, scapulae or shoulder
Usually increased with inspiratory movements such as laughing, coughing, sneezing or deep breathing
Associated symptoms include dyspnea (exertional or rest), persistent cough, fever and chills
Pulmonary Anatomy
Pulmonary Disorders
The most common pulmonary conditions that mimic musculoskeletal dysfunction include:• Pulmonary artery hypertension
• Pulmonary embolism
• Pleurisy
• Pneumothorax
• Pneumonia
Pulmonary Disorders
Any of the following symptoms are associated with lung cancer and requires physician referral for assessment:• CNS symptoms
• Muscle weakness
• Muscle atrophy
• Headache
• Loss of LE sensation
• Localized or radicular back pain
Pulmonary Pain Parietal pleura is sensitive to painful stimuli,
but visceral pleura is not Trachea and large bronchi are innervated by
the vagus trunk Finer bronchi and lung parenchyma have no
innervation Trachebronchial pain is referred to sites in the
neck or anterior chest at the same level as the irritation• Caused by inflammatory lesions, foreign materials or
cancerous tumors
Pulmonary Pain
Disease may be extensive prior to onset of pain
Pain does not occur until it reaches the parietal pleura• Pain is described as sharp and localized
• Aggravated with inspiratory movements
• Relieved by lying on the affected side (autosplinting)
Pulmonary Pain
Pleural pain occurs with:• Pleurisy
• Pneumonia
• Pulmonary infarct
• Tumor
• Pneumothorax
Pulmonary Pain
Diaphragmatic pleural pain• Peripheral – Sharp pain referred to costal
margins or lumbar region
• Central – Sharp pain referred to the upper trap or shoulder on the ipsilateral side
• Cardiac and diaphragmatic pain are often experienced in the shoulder because both are supplied by the C5-C6 spinal segment
Diaphragmatic Pleurisy
Refers pain to the costal margins or upper trap muscles
Aggravated by diaphragmatic motions (coughing, laughing, or deep breathing)
Change in position does not reproduce the symptoms• If a true intercostal lesion or tear, bending or
rotation of the trunk would cause or reproduce the pain
Pulmonary Physiology
Primary function of the respiratory system is to provide oxygen to and remove carbon dioxide from cells in the body
Effectiveness of ventilation is most often measured by arterial blood gas testing
Arterial Blood Gases
pH * =pKa [HCO3] + log[HCO3] / 0.03 x pCO2 * Arterial pH * 7.35 – 7.45 PaCO2 * 35 – 45 mmHg
• * Measured
HCO3 22 – 26 mEq/L• Calculated not measured
• Obtained with CMP
PaO2 80 – 100 mm Hg Sat O2 > 95%
Oxygen
Determination of Oxygen content in blood• PaO2
• Sat O2
• Hb (14-18 gm/dl) from CBC
PaO2
• Dissolved oxygen in plasma
Sat O2
• Reflects oxygen saturation of hemoglobin
• = [Hb-O2 / (Hb-O2 + reduced-Hb)]*100%
Porth, 29-22, 2005
Oxygen Decrease
Manifestations• Angina
• Tachycardia
• Arrhythmias
• MI
• Confusion and Stupor
• Decreased aerobic capacity
• Cyanosis
Carbon Dioxide and Bicarbonate
Bicarbonate (HCO3), extracellular anion Regulation
• Metabolic activity
• Loss
• HCO3: Renal
• CO2: Respiratory
Physiologic effects• Maintain pH
• Osmotic pressure regulation
Porth 34-2, 2005
Porth 34-1, 2005
pH Calculation
Normal pH = 7.35 – 7.45 pH = pKa HCO3
- +log([HCO3-]/[0.03 x pCO2]
• H2CO3 pKa = 6.1
([HCO3-]/[CO2] = 20/1 for pH = 7.4
• < 20/1 = acidosis
• > 20/1 = alkalosis
• Numerator [HCO3 -]: kidney
• Denominator [CO2]: lungs
Porth, 34-1, 2005H2CO3 mEq/L = 0.03* CO2 mm Hg
Respiratory Acidosis Decreased pulmonary ventilation leads to
retention and concentration of carbon dioxide, hydrogen and carbonic acid
May result in hypoxia Hyperkalemia and cardiac changes result and
could cause cardiac arrest Advancing symptoms may include diaphoresis,
shallow rapid breathing, restlessness, and cyanosis
These symptoms need immediate medical referral
Respiratory Alkalosis Increased respiration decreases the amount of carbon
dioxide and hydrogen available increased pH Usually due to hyperventilation
• Causes may be neurogenic or psychogenic Muscular tetany and convulsions can occur Cardiac arrhythmias caused by serum potassium loss
may occur Respiratory alkalosis is more commonly seen in PT
clinics than respiratory acidosis Initially treat with reassurance, facilitate relaxation and
slow breathing If hyperventilation continues in the absence of pain or
anxiety, immediate physician referral is needed
Chronic Obstructive Pulmonary Disease COPD – Considering changing name to CAL
(Chronic airflow limitation) Leading cause of morbidity and mortality
among cigarette smokers Narrowing of the airways obstructs airflow to
and from the lungs Trapped air hinders normal gas exchange and
causes alveoli distention Includes disorders of obstructive bronchitis,
emphysema and asthma
Emphysema Elasticity of the lungs is reduced Marked dyspnea is common Cough is uncommon Uses accessory muscles for respiration Often leans forward with arms braced on the
knees to support the shoulder and chest for breathing
Barrel chest develops Pursed-lip breathing should be encouraged Routine progressive walking is the most
common form of exercise
Tuberculosis Bacterial infectious disease Most often affects the lungs
• Fatigue• Dyspnea• Dull chest pain, tightness or discomfort• Frequent productive cough
Can affect the hip joints and vertebrae resulting in arthritic-like damage and possibly avascular necrosis of the hip
Pott’s disease (TB of the spine) – Rare but can cause compression fractures of the vertebrae
Apical (Pancoast’s) Tumors
Tumor of the apex of the lung Frequently extend to C8-T1 nerves within the
brachial plexus
Apical (Pancoast’s) Tumors
Produces sharp, pleuritic pain in the axilla, shoulder and subscapular area on the affected side
UE pain in an ulnar nerve distribution Subsequent atrophy of UE muscles Sometime mistaken for subacromial bursitis Also mimics serratus anterior trigger points –
Rule out by palpation and lack of neurological deficits
Cystic Fibrosis Inherited disorder of the exocrine glands Primarily affects the digestive and respiratory systems Salt accumulates in the cells lining the lungs and digestive
tissues. The surrounding mucus is abnormally thick and sticky Bronchioles are obstructed by mucus plugs and trapped air
predisposes the patient to infections Persistent coughing and wheezing Excessive appetite but poor weight gain Salty skin/sweat Barrel chest develops Dyspnea is prominent Uses accessory muscles with respiration Cyanosis and digital clubbing present
Pulmonary Embolism
Signs and symptoms are nonspecific and vary greatly
Most common symptoms are dyspnea, pleuritic chest pain and cough
Pleuritic chest pain is usually sudden onset and aggravated by breathing
May also report hemoptysis, apprehension, tachypnea and fever
Pleurisy Inflammation of the pleura Caused by infection, injury or tumor May be wet or dry Symptoms include chest pain, cough, dyspnea, fever,
chills and tachypnea Chest pain is sudden and varies in description from
vague discomfort to intense stabbing or knifelike Aggravated by breathing, coughing, laughing or other
deep inspiratory movements Pain may be referred to the lower chest wall, abdomen,
neck, upper trap muscles and shoulder
References Arnall D, Ryan M.1995. Screening for Pulmonary System
Disease. In: Boissonnault editor: Examination in Physical Therapy Practice Screening for Medical Disease. 2nd edition. Philadelphia, PA: Churchill Livingstone, p69-100.
Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p332-365.
Jarvis C. 2000. Physical Examination and Assessment, 3rd edition. Philadelphia, PA: WB Saunders. In: Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p333.
Porth, Carol M, Pathophysiology: Concept of Altered Health States, 7th ed., J.B. Lippincott Co., Philadelphia, 2005.