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 cough Infection sinuses 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 sputum Cause Appearance Type Acute pulm edema Clear, watery Serous Chronic Bronchitis,COPD Asthma Clear, gray White, viscid Mucoid Broncho-pulmon infection Yellow-green Purulent Pneumococcal inf Golden-yellow Rusty

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 cough Infection sinuses 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 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 cancer Tumor Endobronchial metastasis Bronchial carcinoid Bronciectasis Infection Pulmonary TB Lung abscess, Mycetoma Pulmonary Infarction vascular Wegner Granulomatosis Goodpasteur`s syndrome Vasculitis

Causes of hemoptysis/2 Inhaled foreign body Trauma Chest trauma Iatrogenic; Bronchoscopic biopsy Transthoracic lung biopsy Mitral valve disease cardiac Acute left ventricular failure Blood dyscrasia hematological Anticoagulation

Non central causes of chest pain Infection Malignancy Pneumothorax Pulmonary Infarction Connective tissue disease Rheumatoid arthritis, SLE) PLEURAL Pesistant cough, breathlessness Muscle sprain /tears Bronholm`s disease Rib fracture Intercostal nerve compression Chest wall

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 Dissection Great 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 , Obesity Noncardio-respiratory Metabolic acidosis psychogenic Neurogenic Left ventricular failure cardiac Mitral valve disease cardiomyopathy Constrictive pericarditis Pericardial effusion

Respiratory Laryngeal tumors Airways Foreign body Asthma COPD Bronchiectasis Lung cancer Bronchiolitis Cystic fibrosis Pulmonary fibrosis,alveolitis Parynchima Tuberculosis, pneumonia, diffuse infection sarcoidosis

Causes of breathlessness/2 Pulmonary Embolism Pulmonary circulation Pulmonary vasculitis Primary pulmonary HTN Pneumothorax pleura effusion Diffuse pleural fibrosis kyphosis chest wall Ankylosing spondylitis Myasthenia gravies,Muscle dystrophies Neuromuscular

Breathlessness, mode of onset,duration and progression Pulmonary thromboembolism Minutes Pneumothorax Acute left ventricular failure Asthma, inhaled foreign body pneumonia Hours 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