1. LUNGS AND RESPIRATORY SYSTEM

2. Lung Physical exam: 1- Inspection 2- Palpation 3- Percussion

3. 4-Auscultation 5- Egophony

4. INSPECTION
Deformities or asymetry
Abnormal retraction of the interpaces
Impairment in respiratory movement

5. Tactile Fremitus
Performed by : 1- placing ulnar side of hand or palm against the patient posterior chest wall.
2 – Have the patient say ninety-nine
Increased tactile fremitus =increased density of the lungs (consolidation).
Decreased tactile fremitus =excess subcutaneous tissue on the chest ,air or fluid

6. Percussion
Dull =increased density such as fluid in the lungs , or lung cavity or consolidation
Tympanic = hollow air-containing structure
Resonant = structure of air within tissue
Hyperresonant = decreased density and more air , such as in emphysema

7. Auscultation
Crackles :short discontinuous nonmusical sounds heard mostly during inspiration
Wheezes :continuous , musical , high-pitched heard mostly during expiration.
Rhonchi:lower-pitched lung sounds
Pleural rub :Sound produced by motion pleura, heard best at end of inspiration /beginning of expiration

8. Lung auscultation

9. Egophony
Spoken words by the patient are increased in intensity and take on different quality during auscultation.Patient says eeee”and will heard as “aaaa”in area of consolidation and in areas of compressed lung above a pleural effusion

10. PLEURAL EFFUSION Definition Transudate : 1- increased hydrostatic pressure 2- decreased oncotic pressure 3- CHF, Cirrhosis, Nephrosis

11. Oxidative pleural effusion
Increased capillary permeability
Tumors, Trauma, Infection

12. Diagnosis criteria of exudate
Ratio of pleural to serum protein >0.5
Ratio of pleural to serum LDH >0.6
Pleural fluid LDH >2/3 upper normal limit

13. Para pneumonic effusion :
Pleural fluid leukocyte count >10,000/mm
Always exudates
WBC >100,000 =empyema
Empyema =pus in pleural space , positive cultures, require chest tube

14. Gross blood in pleural fluid:
Tumor (breast ,lung cancer, lymphoma)
Trauma
Pulmonary infarction
Aortic dissection

15. Low glucose in pleural fluid is associated :
Empyema
Rheumatoid arthritis
Tumor
tuberculosis

16. High amylase in pleural fluid is associated :
Pancreatitis
Renal failure
Tumor
Esophageal rupture

17. PULMONARY FUNCTION TEST
Spirometry measures the rate at which the lung changes during forced breathing
Forced vital capacity (FVC) :
Fev1 :the volume of air exhaled in the first second of the FVC
Normal FEV1/FVC ratio=>0.7

18. Spirometry1

19. Normal spirogram

21. Obstructive defect and restrictive defect

24. Lung Infections
Pneumonia: infection of the lung parenchyma by any microorganism.
Etiology:
A- community acquired pneumonia
1-S-Pneumonia
2- H. influenzae

25. B- community acquired atypical
1- chlamydia pneumoniae
2- Legionella pneumophila
3- Mycoplasma pneumonia

26. C- Hospital acquired
1- pseudomonas aeruginosa
2 S.Aureus
3- Enteric organisms

27. Signs and Symptoms
A- Typical Symptoms
1- Fever
2- cough
3- pleuritic chest pain

28. B- Atypical Symptoms
1- Dry cough
2-headache
3- malaise
4- Gastrointestinal symptoms

29. Physical exam
1- Dullness to percussion
2-Rales
3- Tactiles fremitus
4- Egophony (E to A changes ) with stethoscope

30. Diagnosis
A – Chest Xray
1- upper lobe infiltrate or consolidation
2- small cavities w/o air-fluid levels( M.tb
3- larges cavities with air-fluid levels (staph)
4- diffuse bilateral infiltrate (PCP, Mycoplasma)

31. Criteria for admission
1- Age >50
2-Nursing home residents
3- underlying chronic disease
4- change in mental status
5- Tachypnea, tachycardia, or hypotension
6- Pleural effusion

32. Scenario 1
A 19 y/o college student male c/o malaise, dry cough for the last 10 days, denied fever and pleuritic chest pain .Physical unremarkable , CXR showed diffuse bilateral infiltrate.

33. Scenario2
A patient comes to the ER with consolidation and pleural effusion on CXR. What is the most important test to determine admission/treatment.

34. Scenario 3
A 27 y/o White male brought to the ER c/o productive cough, fever and pleuritic chest pain.Physical exam elicited tachypnea and crackles on R upper lobe .What other physical finding suggestive of typical pneumonia?

35. Chronic Obstructive pulmonary Disease:
Obstructive Disorders
Chronic Obstructive pulmonary Disease:
A-Chronic bronchitis :chronic expiratory airflow obstruction accompanied by chronic productive cough for 3 or more months in each of 2 successive years

36. Emphysema :chronic expiratory airflow obstruction accompanied by permanent enlargement of the airspace distal to the terminal bronchioles due destruction of alveolar septa.

37. Pathophysiology of Emphysema
Centrilobular emphysema affects the respiratory bronchioles.
Panlobular emphysema occurs in patients with alpha-1 antitrypsin deficiency.
Distal acinar emphysema is associated with spontaneous pneumothorax.

38. Epidemiology
1- Higher prevalence in men
2- Mortality rates are higher in whites
3- Only 15 % of smokers develop COPD

39. Risk Factors
Smoking
Alpha-1-antitrypsin deficiency

40. Diagnosis /Findings
Chest xray: hyperinflated lungs, flattened diaphragm.
Physical exam: Barrel chest
Pulmonary function tests: irreversible obstructive pattern (low FEV1)
Computed tomography: loss of alveolar walls

41. Symptoms
Cough
Dyspnea on exertion
CO2 retention (chronic bronchitis)
Weight loss (emphysema)
tachypnea

42. treatment
Smoking cessation
Oxygen
Maintain vaccination against influenza and S.pneumoniae
Beta agonist and ipratropium
Steroid

43. Asthma
A chronic condition characterized by:
1- airway inflammation
2- brochoconstriction
3- hypersecretion

44. PATHOPHYSIOLOGY
IgE mediated ,associated with histamine release from mast cells(early phase)
The late phase is associated with cytokine release

45. TRIGGERS
Exposure to pets, dust ,smoke ,carpets
Aggravation by exercise ,hot or cold weather
Seasonal changes

46. Signs and symptoms
Chest tightness
Wheezing
Shortness of breath
cough

47. Differential diagnosis of wheezing
Reactive airway disease
Congestive heart failure
Foreign body aspiration (most often in children)
Asthma

48. Physical Exam
Wheezing on exhalation
Decreased air entry , increased expiratory phase
Decreased peak flow and FEV1
Retractions of sternocleidomastoids

49. Intercostal muscle use for breathing
Oxygen saturation <95%
Inability to speak full sentences

50. asthma classification and treatment