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

2. 2Diagnosis Interrogatory Physical Examination ComplementaryExamination

3. 3DiagnosisInterrogatory Antecedents Familial Personnel Symptoms Main Secondary

4. 4 Diagnosis Physical Examination Signs Vital Main

5. 5DiagnosisComplementaryExamination Laboratory Radiology Procedures

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

7. 7 Diagnosis Physical Examination Signs Vital Main

8. Inspection 8

9. Observe the patient from the end of the bed 9

10. Normal Breathing The respiratory rate is about 14- 20 per min in normal adults The respiratory rate is about 14- 20 per min in normal adults Up to 44 per min in infants Up to 44 per min in infants10

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

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

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

14. 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

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

16. 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

17. 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

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

19. 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

20. Signs And Symptoms Of Respiratory Distress 20

21. Inspect the patient's hands 21

22. Clubbing 22 Patient's Hands

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

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

26. 26 Thoracic Bronchial cancer usually not small cell cancer

27. 27Thoracic Empyema, abscess Chronic lung suppuration Bronchiectasis Cystic fibrosis

28. 28Thoracic Fibrosing alveolitis Mesothelioma TB

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

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

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

32. 32 Rare Familial Thyroid acropachy

33. 33

34. 34

35. 35

36. Cyanosis 36

37. 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

38. Cyanosis CentralPeripheral38

39. 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

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

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

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

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

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

45. Causes of Peripheral Cyanosis 45

46. All causes of Central Cyanosis   cause Peripheral Cyanosis 46

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

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

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

50. 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. 51 Peripheral Cyanosis

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

53. 53 PeripheralCyanosisPeripheralCyanosis

54. Palpation 54

55. Palpate the trachea 55

56. Pneumothorax / Pleural effusion 56

57. 57

58. Palpation of the nodes 58

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

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

62. 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)

63. 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)

64. Percussion 64

65. Percuss the lung fields 65

66. Normal lung sounds resonant Normal lung sounds resonant66

67. 67

68. 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. 69

70. Auscultation 70

71. Auscultation 71

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

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

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

75. 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) http://www.mayoclinic.org/symptoms/wheezing/basics/causes/sym-20050764

76. Causes 76

77. http://www.mayoclinic.org/symptoms/wheezing/basics/causes/sym-20050764

78. 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 http://www.mayoclinic.org/symptoms/wheezing/basics/causes/sym-20050764

79. The most common cause of recurrent wheezing is Asthma 79

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

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

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

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

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

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

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