RESPIRATORY SYSTEM

Dr Saneesh P JSultan Qaboos University Hospital, Muscat

Introduction

Acute Shortness of BreathChest pain

Cardinal symptoms of respiratory disease

coughsputum productionhaemoptysischest painbreathlessnesswheeze

History taking

LocationQualityQuantity or severityTimingSetting in which it occursAggravating or relieving factorsAssoc manifestations; addl relevant features of each symptom

SACRED SEVEN

BREATHLESSNESS

Breathlessness (dyspnoea) is an undue awareness of breathing

Shortness of breath

How fast did it happen?Do you have chest pain?Does the pain change with respiration (pleuritic) ?Does your SOB gets better or worse with walking?Does your breathing pattern improve when you sit up?

Shortness of breath

Do you have a history of asthma or emphysema (COPD)?Have you had clots in your legs?Have you been hit in the chest?Are you sleepy during the day?

Causes of SOB?

Breathlessness when lying flat Orthopnoea Usually associated with left ventricular failure. It can also be a feature of respiratory muscle weakness, large pleural effusion, massive ascites, morbid obesity or any severe lung disease.

Breathlessness that wakes the patient from sleep

Paroxysmal nocturnal dyspnoeatypical of asthma and left ventricular failure

Patients with asthma typically wake between 3 and 5 a.m. and have associated wheezing. Breathlessness worse on waking is more typical of COPD and may improve after coughing up sputum.

Patients with exercise-induced asthma may notice that the breathlessness continues to worsen for 5–10 minutes after stopping activity.

If you suspect asthma, ask about exposure to allergens, smoke, perfumes, fumes, cold air or drugs, e.g. aspirin, non-steroidal anti-inflammatory drugs. Common allergens are house dust mite (shaking bedding, hoovering), animals (cats, dogs, horses) and grass pollens (mowing the lawn, the ‘hayfever season’) and tree pollens.

Breathlessness improving at weekends or holidays

Occupational asthma

Breathlessness on sitting up with relief on lying down

Platypnoea Right-to-left shunting through a patent foramen ovale, atrial septal defect or a large intrapulmonary shunt.

Breathlessness when lying on one side Trepopnoeadue to unilateral lung disease (patient prefers the healthy lung down), dilated cardiomyopathy (patient prefers right side down) or tumours compressing central airways and major blood vessels.

Etiology of Dyspnoea

SOB grading

COPD is characterised by airflow obstruction that is usually progressive and not fully reversible. It is defined as a reduced post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio of <70%. Asthma is reversible airways obstruction

Chest pain

Chest pain - History

SiteRadiationmode of onsetdurationseverityaggravating/relieving factors including the effects of breathing and movement

Pleural pain

SharpStabbing Intensified by inspiration or coughingIrritation of the parietal pleura of the upper six ribs causes localised pain. Irritation of the parietal pleura overlying the central diaphragm innervated by the phrenic nerve is referred to the neck or shoulder tip.

Pleural pain

The lower six intercostal nerves innervate the parietal pleura of the lower ribs and the outer diaphragm, and pain from these sites may be referred to the upper abdomen. Common causes of pleuritic chest pain are

pulmonary embolismpneumoniapneumothorax fractured ribs

Chest wall pain

Sudden and localised after vigorous coughing or direct trauma is characteristic of rib fractures or intercostal muscle injury. Prevesicular herpes zoster and intercostal nerve root compression can cause chest pain in a thoracic dermatomal distribution.

Chest wall pain

Chest wall pain due to direct invasion by lung cancer, mesothelioma or rib metastasis is typically dull, aching or gnawing, unrelated to respiration, progressively worsens and disrupts sleep. Pancoast’s tumour of the lung apex may involve the first rib and the brachial plexus, causing referred pain down the medial side of the ipsilateral arm.

Mediastinal pain

Central, retrosternal and unrelated to respiration or cough. Irritant dusts or infection of the tracheobronchial tree produce a raw, burning retrosternal pain worse on coughing. A dull, aching retrosternal pain that disturbs sleep is a feature of cancer invading mediastinal lymph nodes or an enlarging thymoma.

Chest pain

Massive pulmonary thromboembolism acutely increasing right ventricular pressure may produce central chest pain similar to myocardial ischaemia

Physical Examination

Respiratory System

Wash your handsIntroduce yourself

Patient detailsExplain/consent

Scene survey

WIPES

Gene

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Respiratory RateTachypnoeaBradypnoeaHyperpnoea

Breathing patternsHyperventilation

Kussmaul’s breathingHypoventilationPeriodic breathing (Cheyne–Stokes respiration)

Obstructive sleep apnoea/ hypopnoea syndrome (OSAHS)

combination of excessive daytime sleepiness and recurrent upper airway obstruction with sleep fragmentation caused by upper airway obstruction from collapse of the retropharynx

A) Hyperinflated chest with intercostal indrawing. (B) Kyphoscoliosis.

(C) Pectus carinatum with prominent Harrison’s sulcus (arrow). (D) Pectus excavatum.

Trail sign: Sternomastoid prominence on the side of tracheal shift

Chest expansion

Reduced expansion On one side

pleural effusionlung or lobar collapsepneumothorax anunilateral fibrosis

Paradoxical inward movement

diaphragmatic paralysis severe COPD

Flail chest

Bilateralsevere COPD diffuse pulmonary fibrosis

Subcutaneous emphysema Mediastinal emphysema occurs if air tracks into the mediastinum and is associated with a characteristic systolic ‘crunching’ sound on auscultating the precordium (Hamman’s sign). Tenderness over the costal cartilages is found in the costochondritis of Tietze’s syndrome.Localised rib tenderness can be found over areas of pulmonary infarction or fracture.

Percussion

Kronig’s isthmus & Grocco’s triangle

Ewart’s signDullness below the left scapula – large pericardial effusion

Conner’s signDullness to percussion below the right scapula – large pericardial effusion

Kellock’s signFeeling increased rib vibration in the anterior chest to percussion posteriorly – pleural effusion

D’Amato’s signChange in percussible dullness with change in position – pleural effusion

Skodaic hyper-resonanceHyper-resonance just above an area of dullness – a useful sign of pleural effusion

Auscultation

Auscultation

Auscultation

Auscultation

D’Espine’s sign

D’Espine’s signImportant sign of a posterior mediastinal massAt the level of mid-scapula (about T5) – listen over the vertebral spinous process and on either side of the vertebral column. Normally the lateral sounds are louder and more distinct.When the upper airway sounds are of greater intensity than the corresponding lateral lung sounds – implies a continuity (a mass) between a mainstem bronchus and vertebra

Special tests

Post-tussive RalesLung abscess

Egophony (Goat sound)“E” to “A” – pulmonary consolidation

Whisper pectoriloquy“sixty-six whiskeys, please”Consolidation

BronchophonyConsolidation/compressed lung

Coin test for Pneumothorax

PUTTING IT ALL TOGETHER

Note the patient’s general appearance and demeanour. Look for central cyanosis of the lips and tongue.Examine the skin for rashes and nodules.Listen for hoarseness and stridor. Examine the hands for finger clubbing, peripheral cyanosis and tremor.

Measure the blood pressure.Examine the neck for raised JVP and cervical lymphadenopathy. Record the respiratory rate.Observe the breathing pattern, and look for use of accessory muscles.

Auscultation

Bedside Clinics

Lab Investigations

Peak Flow Meter

Chest X ray

Chest X ray

Normal Chest x ray

Chest X ray

Pleural effusion (Left)

Chest X ray

Pneumothrorax

Chest X ray

Pneumonia - consolidation

Pleural Effusion Consolidation

Tracheal deviation Contralateral None

Fremitus Decreased Increased

Percussion Dull Dull

Breath sounds Decreased Decreased

Emphysema Pneumothorax

Tracheal deviation None Contralateral

Fremitus Decreased Decreased

Percussion Hyper-resonant Hyper-resonant

Breath sounds Crackles Decreased

Thank you