Signs and Symptoms in Pulmonary Disease פרופ' נוויל ברקמן מכון הריאה ביה"ח האוניברסיטאי הדסה עין-כרם

Dyspnea Subjective feeling of air hunger / abnormally uncomfortable awareness of breathing. When does it occur? (rest or exercise). Associated symptoms – pain etc. Quantitation - effort tolerance – level, incline, steps, 6-minute walk. New York Heart Association I - IV

Dyspnea – cont. Dyspnea at rest. Duration Changes over time: sudden onset: pneumothorax, pulmonary emboli, anxiety. Changes over time:

Dyspnea- differential diagnosis Respiratory – Airways obstruction – large, small Parenchymal disease Vascular disease Chest wall Heart disease Anemia Anxiety

Dyspnea- cont. Orthopnea – dyspnea when lying down (heart failure, COPD, diaphragmatic paralysis). Paroxysmal nocturnal dyspnea. Platypnea Sleep apnea

Cough Acute or chronic Dry or productive Intermittent or continuous Is it worse at night? Change in nature of chronic cough Associated symptoms, medications

Cough – cont. Acute infections – bronchitis, pneumonia, pertussis Chronic infections – bronchiectasis, TB, CF Airway disease – asthma, chronic bronchitis, post nasal drip Parenchymal disease – interstitial fibrosis, sarcoidosis, emphysema Tumours Foreign body Cardiovascular – CHF, PE, aortic aneurysm Drugs- ACE inhibitors Other- reflux, aspirations, middle ear pathology

Chest Pain Pleuritic pain- sharp, stabbing in nature, worsened by cough, deep breathing. Usually indicates inflammation or tumour. “Mediastinal” pain- cardiac, esophageal, aneurysm. Musculoskeletal Neuralgia

Wheezing High-pitched continuous whistling sound. Inspiratory or expiratory or both. Indicated airway obstruction. Should be differentiated from stridor.

Hemoptysis Coughing up of blood. Always significant! R/O hematemesis, nose bleeding. Bronchitis, bronchiectasis, pneumonia, cancer; seldom tuberculosis, PE, vasculitis.

Other Smoking- including passive, time since cessation. Travel 1 pack year = 20 cigarettes/day for 1yr. Travel Family history Drugs, hobbies Sexual habits

Occupation What work do you do? Are your symptoms better at weekends? Does anyone else at work have similar symptoms? Pneumoconioses, moulds, bakers etc.

Physical examination The respiratory system cannot be viewed in isolation: respiratory disease often presents with extrapulmonary signs or symptoms and extrapulmonary disease may present with respiratory findings!!

Vital signs in ALL patients pulse Blood pressure, pulsus paradoxus respiratory rate! temperature conciousness (hypercapnia cause sedation, hypoxemia causes restlessness) Respiratory pattern Cheyne-Stokes respiration Kussmaul’s respiration

Physical examination Inspection Cough – sputum. Cyanosis – central, peripheral. Clubbing Flapping tremor Chest- deformation, scars, symmetry (pectus excavatum, carinatum). Barrel-shaped chest in emphysema. Chest movement (including abdominal movement). Use of accessory muscles.

(כחלון) - Cyanosis Blue skin colour Indicates the presence of >5g/100ml of deoxygenated hemoglobin. Central cyanosis - seen on the tongue. Indicates hypoxemia. Peripheral cyanosis – indicates poor perfusion.

Clubbing - differential diagnosis Malignancy - lung cancer, mesothelioma. Pulmonary fibrosis. Chronic suppurative lung disease: bronchiectasis, lung abscess, empyema. Cyanotic congenital heart disease. Subacute bacterial endocarditis. Cirrhosis, inflammatory bowel disease, hyperthyroidism (acropachy).

Physical examination Inspection Cough – sputum. Cyanosis – central, peripheral. Clubbing Flapping tremor Chest- deformation, scars, symmetry (pectus excavatum, carinatum). Barrel-shaped chest in emphysema. Chest movement (including abdominal movement). Use of accessory muscles.

Physical examination Palpation Trachea Cardiac apex Chest excursion Lymphadenopathy Signs of right-sided (and left-sided) cardiac disease/ failure.

Physical examination Percussion Cardiac dullness, liver, diaphragms Dull - indicates consolidation or atelectasis. Stony dull – indicates fluid. Hyperresonance – pneumothorax, emphysema or bullae. Vocal fremitus – “44”

Vocal fremitus Increased - consolidation. Decreased – pleural effusion or thickening, emphysema, pneumothorax, atelectasis

Physical examination Auscultation NATURE of breath sounds: vesicular or bronchial. INTENSITY of breath sounds/ air entry. DURATION of breath sounds.

Vesicular breath sounds Heard over normal lung. Expiration softer and longer than inspiration Pause between inspiration and expiration. lung sounds lung sounds

Bronchial breathing “Tracheal” sounding: inspiration and expiration are of equal intensity. Normal over right anterior superior chest. Present in consolidation, atelectasis, above pleural effusion.

Adventitious sounds WHEEZE (צפצופים) - sibilant or high pitched continuous sound arising from medium or small airways, indicate obstruction. RHONCUS- sonorous or low-pitched rhoncus arising from large airways. FRICTION RUB – continuous creaking noise, indicates pleural inflammation.

Adventitious sounds- Crackles (rales, crepitations) (חרחורים) Discontinuous sound. Caused by secretions or small airspace opening / closure. Fine - pneumonia, cardiac failure, fibrosis. Coarse – bronchiectasis. (Wet or dry) Inspiratory, expiratory or both.

Auscultation Bronchophony (vocal resonance) Egophony “e” to “a” Whispering pectoriloquy

Findings in common lung conditions Bronchial breathing Breath sounds קולות נשימה Fremitus פרמיטוס Percussion ניקוש Pneumothorax Pleural effusion Consolidation

Emphysema Accessory muscles, “pursed-lip” breathing. Barrel chest, reduced excursion, reduced crico-sternal distance. Loss of cardiac dullness, low liver, low diaphragms. REDUCED AIR ENTRY “Faulty stethoscope sign” Prolonged expiration, wheeze.

Asthma Respiratory rate. Talking dyspnea Accessory muscles Pulsus paradoxus Air entry Wheezing

Pulmonary fibrosis Clubbing End- inspiratory crackles. Small lungs, reduced excursion.