The Clinical Respiratory Signs 1 Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health – Dr Mazen Qusaibaty MD, DIS / Head Pulmonary and Internist Department Ibnalnafisse Hospital Ministry of Syrian health –

2Diagnosis Interrogatory Physical Examination ComplementaryExamination

3DiagnosisInterrogatory Antecedents Familial Personnel Symptoms Main Secondary

4 Diagnosis Physical Examination Signs Vital Main

5DiagnosisComplementaryExamination Laboratory Radiology Procedures

6Diagnosis Interrogatory Antecedents Familial Personnel Symptoms Main Secondary Physical examination Signs Vital Main Complementaryexamination Laboratory Radiology Procedures

7 Diagnosis Physical Examination Signs Vital Main

Inspection 8

Observe the patient from the end of the bed 9

Normal Breathing The respiratory rate is about per min in normal adults The respiratory rate is about per min in normal adults Up to 44 per min in infants Up to 44 per min in infants10

Rapid superficial breathing (Tachypnea) The causes: The causes:  Restrictive lung disease  Pleuritic chest pain  An elevated diaphragm 11

Rapid Deep Breathing (Hyperpnea, Hyperventilation) The causes: The causes:  Exercise  Anxiety  Metabolic Acidosis 12

Rapid Deep Breathing (Hyperpnea, Hyperventilation) In the comatose patient In the comatose patient  Infarction  Hypoxia  Hypoglycemia affecting the midbrain or pons. 13

Kussmaul Breathing Kussmaul Breathing Deep breathing due to Metabolic Acidosis. Deep breathing due to Metabolic Acidosis.  It may be: Normal Normal Fast Fast rate Slow Slow rate 14

Slow Breathing (Bradypnea) The causes: The causes:  Diabetic coma  Drug-induced respiratory depression  Increased intracranial pressure 15

Cheyne - Stokes Breathing Periods of deep breathing alternate with periods of apnea (no breathing) Periods of deep breathing alternate with periods of apnea (no breathing)16

Cheyne - Stokes Breathing Children and aging people normally may show this pattern in sleep Children and aging people normally may show this pattern in sleep17

Cheyne - Stokes Breathing Other causes include Other causes include  Heart failure  Uremia  Drug-induced respiratory depression  Brain damage 18

Ataxic Breathing (Biot`s breathing) Is characterized by unpredictable irregularity. Is characterized by unpredictable irregularity. Breaths may be shallow or deep, and stop for short periods. Breaths may be shallow or deep, and stop for short periods. Causes include Causes include  Respiratory depression  Brain damage, typically at the medullary level. 19

Signs And Symptoms Of Respiratory Distress 20

Inspect the patient's hands 21

Clubbing 22 Patient's Hands

The exact mechanism of clubbing is unclear The exact mechanism of clubbing is unclear23

25 Megakaryocyte Platelets PDGF (platelet-derived growth factor + VEGF (Vascular Endothelial Growth Factor (

26 Thoracic Bronchial cancer usually not small cell cancer

27Thoracic Empyema, abscess Chronic lung suppuration Bronchiectasis Cystic fibrosis

28Thoracic Fibrosing alveolitis Mesothelioma TB

29 Thoracic Bronchial cancer usually not small cell cancer Empyema, abscess Chronic lung suppuration Bronchiectasis Cystic fibrosis Fibrosing alveolitis Mesothelioma TB

30 Cardiovascular: Cyanotic congenital heart disease Endocarditis Atrial myxoma Aneurysms Infected grafts

31 GI Inflammatory bowel disease (especially Crohn’s) Cirrhosis GI Lymphoma Malabsorption

32 Rare Familial Thyroid acropachy

33

34

35

Cyanosis 36

Is the abnormal Blue Discoloration of the skin and mucous membranes Is the abnormal Blue Discoloration of the skin and mucous membranes  Increasing in the deoxygenated haemoglobin level to above 5 g/dL 37

Cyanosis CentralPeripheral38

Any severe respiratory disease Any severe respiratory disease 1.Pulmonary oedema 2.Pulmonary embolism 3.Decreased PO 2 of inspired air (eg high altitude) 4.Severe pneumonia 39

5.COPD 6.Acute severe asthma, 7.Acute adult respiratory distress syndrome 40

  Cyanotic congenital heart disease   Eisenmenger's syndrome   Pulmonary arteriovenous fistluas.41

Abnormal Haemoglobins Do not allow adequate oxygen uptake Central cyanosis in adults 42 Central Cyanosis

Methaemoglobinaemia Genetic Associated with certain drugs Quinones Primaquine Sulfonamides 43 Central Cyanosis

Polycythaemia rubra vera Polycythaemia rubra vera Any other cause of polycythaemia Any other cause of polycythaemia44

Causes of Peripheral Cyanosis 45

All causes of Central Cyanosis   cause Peripheral Cyanosis 46

Reduced cardiac output: Reduced cardiac output:  Heart failure  Shock 47

Peripheral vascular disease: Peripheral vascular disease:  Thrombosis + - Embolism  Atheroma 48

Causes of peripheral cyanosis Vasoconstriction:   Cold exposure   Raynaud's phenomenon.   Betablocker drugs 49

Vasoconstriction   Acrocyanosis: benign, caused by spasm of smaller skin arteries and arterioles, causing hands and feet to be cold and mottled.50 Peripheral Cyanosis

51 Peripheral Cyanosis

Venous obstruction: Venous obstruction:  Lower limb deep vein thrombosis can occasionally produce a painful blue leg (phlegmasia cerulea dolens). 52PeripheralCyanosisPeripheralCyanosis

53 PeripheralCyanosisPeripheralCyanosis

Palpation 54

Palpate the trachea 55

Pneumothorax / Pleural effusion 56

57

Palpation of the nodes 58

Some causes of generalized lymphadenopathy Hematological malignancies (e.g., lymphoma, acute, and chronic lymphatic leukemia)

Some causes of generalized lymphadenopathy Infections Viral (e.g., HIV, infectious mononucleosis, cytomegalovirus [CMV]) Bacterial (e.g., tuberculosis, syphilis, brucellosis)

Some causes of generalized lymphadenopathy Infiltrative diseases (e.g., sarcoidosis, amyloidosis) Autoimmune diseases (e.g., systemic lupus erythematosus [SLE], rheumatoid arthritis) Drugs (e.g., phenytoin causes a pseudolymphoma)

Some causes of generalized lymphadenopathy Hematological malignancies (e.g., lymphoma, acute, and chronic lymphatic leukemia) Infections Viral (e.g., HIV, infectious mononucleosis, cytomegalovirus [CMV]) Bacterial (e.g., tuberculosis, syphilis, brucellosis) Infiltrative diseases (e.g., sarcoidosis, amyloidosis) Autoimmune diseases (e.g., systemic lupus erythematosus [SLE], rheumatoid arthritis) Drugs (e.g., phenytoin causes a pseudolymphoma)

Percussion 64

Percuss the lung fields 65

Normal lung sounds resonant Normal lung sounds resonant66

67

Dullness: Dullness:  Heard over areas of density Consolidation Consolidation Collapse Collapse Alveolar fluid Alveolar fluid Pleural thickening Pleural thickening Peripheral abscess Peripheral abscess Neoplasm Neoplasm68

69

Auscultation 70

Auscultation 71

Adventitious Lung Sounds Discontinuous Sounds   Crackles: Pneumonia CHF ARDS Fibrosis 72

Adventitious Lung Sounds Continuous Sounds   Wheezes   Rhonchi 73

74 W H E Z I NG W H E Z I NG

Wheezing Wheezing is a high-pitched whistling sound made while breathing.   Most commonly wheezing occurs during breathing out (expiration)   But it can sometimes be related to breathing in (inspiration)

Causes 76

The narrowing of the airways can be caused by: The narrowing of the airways can be caused by:  Inflammation (Asthma or COPD)  Infection (Viruses, atypical bacteria)  Physical obstruction: A tumor A tumor Foreign object that's been inhaled Foreign object that's been inhaled

The most common cause of recurrent wheezing is Asthma 79

Possible causes of wheezing include: Possible causes of wheezing include:  Post Nasal drip   Epiglottitis   Bronchitis   Bronchiolitis (especially in young children) (RSV)   Bronchitis   Pneumonia 80

Possible causes of wheezing include:   Smoking   COPD   Emphysema   Sleep apnea, obstructive 81

Possible causes of wheezing include:   Medications (particularly aspirin)   Childhood asthma 82

Possible causes of wheezing include:  Anaphylaxis  Anaphylaxis  Bronchiectasis 83

Possible causes of wheezing include:   Foreign object inhaled   GERD — Gastroesophageal reflux disease   Heart failure   Lung cancer 84

Possible causes of wheezing include:   Vocal cord dysfunction (a condition that affects vocal cord movement) 85

Diagnosis Interrogatory Antecedents Familial Personnel Symptoms Main Secondary Physical examination Signs Vital Main Complementary examination Laboratory Radiology Procedures