Lecture 22- Symptoms and signs of respiratory disease

Question 1

many diseases involvinf different parts of the respiratory system

Answer 1

airways

lung parenchma

pulmonary circulation

pleura

chrst wall and neuromusculat

Question 2

Airways (intrathoracic)

Answer 2

• Asthma
• COPD
• Bronchiectasis
• Cystic Fibrosis

Question 3

Lung parenchyma

Answer 3

• Pulmonary fibrosis
• Pneumonia
• TB

Question 4

Pulmonary circulation

Answer 4

• Pulmonary embolism

Question 5

Pleura (between)

Answer 5

• Pneumothorax
• Pleural effusion

Question 6

Chest wall shape and neuromuscular

Answer 6

• e.g. kyphoscoliosis, myasthenia gravis

Question 7

when trying to diagnose a resp condition

Answer 7

• history
• clinical exam
• +- furthrr investigations

Question 8

Cardinal* Signs and Symptoms of Respiratory Disease

Answer 8

• SoB
• chest pain
• cough
• sputum
• Wheeze/ stridor
• Haemoptysis

Question 9

dyspnoea is a

Answer 9

subjective awareness of icnrease effort breathing

• Symptom rather than a sign…
• But may be objective evidence i.e. raised RR, accessory muscle use

Question 10

SoB is very common and variably described

Answer 10

Common to all respiratory conditions

But not specific..e.g. anaemia, heart failure, obesity

Question 11

further questions to ask if someone is breathless

Answer 11

• onset, duration, timing
• progression
• precipitating factors
• severity
  
  • e.g. when speaking or when walking

Question 12

chest pain…..

Answer 12

many potential causes

• pleura
• chest wall
• mediastinal structures

Question 13

chest pain associated with the pleura

Answer 13

• Infection (causing pleurisy)
• Pneumothorax
• Pulmonary embolism (causing infarct)

Question 14

chest pain associated with the chest wall

Answer 14

• Rib fracture
• Costochondritis
• Shingles (varicella zoster)

Question 15

chest pain associated with mediastinal structures

Answer 15

• ACS (acute coronary syndrome)
• Pericarditis
• Oesophagitis/GORD

• Aortic dissection

Question 16

Pleuritic chest pain

Answer 16

irriation of the parietal pleura

• thoracic or shoulder tip - referred- intercosta nerve/phrenic nerve
• Pleuritic pain
• Sharp
• Often well localised
• Worsens with inspiration, coughing, positional movement

Question 17

cardiac pain

Question 18

outline coughing

Answer 18

a short explosive expulsion of air- importantn protective mechanism

–> tirggered by stimulation of mechano and or chemoreceptors within airway e.g. by irriation e.g. inflammation or foregin body

1. adduction of VCs
2. contraction of itnernal intercostals and abdominal muscles= increased intrthoracic pressure
3. abduction of VCs

Question 19

cough characteristics to think about

Answer 19

Productive cough = sputum

Character e.g.

Timing

Commonest cause is URTI

But…can be a sign of more serious and/or chronic disease

Question 20

producitve cough can mean

Answer 20

sputum and haemoptysis

Question 21

chronic bronhcitis and COPD sputum

Answer 21

clear sputum- no active infection

Question 22

Yellow/green sputum (live/dead neutrophils)

Answer 22

infection

Question 23

Large volumes (yellow/green)could suggest

Answer 23

bronchiectasis

Question 24

Haemoptysis (blood in sputum)…

Answer 24

potential red flag

Question 25

cough can be caused by

Answer 25

respiratory causes non-resp cause

Question 26

respiratory cause of cough

Answer 26

Any irritation of airways (upper and lower respiratory tract!), lung parenchyma or pleura (acute or chronic)

Question 27

non-respiratory causes of cough

Answer 27

• LV heart failure (“pink frothy sputum”) * GORD * Drugs e.g. ACE-inhibitors

Question 28

Wheeze and Stridor

Answer 28

Abnormal breath sounds indicating narrowing within the airway causing turbulent air flow

Question 29

describe what a wheeze sounds like and when it occurs

Answer 29

* **high pitched, “musical”** * Mostly on **expiration** * Narrowing in intrathoracic airways * E.g. from bronchial smooth muscle * contraction, oedema, mucous * Narrowing exacerbated during expiration * May only be audible with stethoscope

Question 30

describe what stridor sounds like and what will cause it

Answer 30

* High pitch, constant, loud * Mostly on inspiration * Indicates narrowing in extrathoracic airway (upper airway) * Supraglottis, glottis, infraglottis or trachea * Narrowing exacerbated during inspiration * Often audible without stethoscope!

Question 31

A 38 year old woman with a history of smoking presents with acute onset of dyspnoea and chest pain... Oxygen saturations are 90% on air, respiratory rate 28, pulse rate 90, temperature 36.6°C and BP 120/87 A. Pneumonia B. Acute coronary syndrome C. Pulmonary embolism D. Pneumothorax

Answer 31

D

Question 32

clinical exam

Answer 32

* **inspection** * face * chest * hands * **palpation** * tracheal position * chest expansion- symmetrical? * **percussion** * resonant * hyper-resonant * dull * stony-dull * **auscultation** * normal (vesicular) * bronchial * reduced or absent * added sounds

Question 33

inspection looking for

Answer 33

- raised RR - central or peripheral cyanosis - clubbing - use of accessory muscles to breath - pursed lip breathing - barrel shaped chest

Question 34

peripheral cyanosis

Answer 34

* Cold exposure and decreased cardiac output * Slowing of blood to peripheries (due to vasoconstriction) * Increased oxygen extraction * More deoxygenated blood present in that area

Question 36

Central cyanosis

Answer 36

lips and tongue (mucous membranes) • Significant cardiac or respiratory cause • Caused by increase in amount of deoxygenated Hb in blood arriving at tissues [deoxygenated blood is leaving the heart]

Question 38

clubbing

Answer 38

is a symptom of disease, often of the heart or lungs which cause chronically low blood levels of oxygen.

Question 39

use of accesory muscles to breath

Answer 39

The diaphragm muscle is of the skeletal or striated type and is the major muscle of ventilation. Accessory muscles of ventilation include the scalene, the sternocleidomastoid, the pectoralis major, the trapezius, and the external intercostals.

Question 40

pursed lip breathing

Answer 40

Breathing out slowly through mouth with pursed lip Commonly seen in COPD

Question 41

how does Pursed lip breathing help

Answer 41

Pursing lips increases resistance to outflow on expiration Maintains intrathoracic airway pressures allowing for small airways to remain open for longer- * prolonging period for gas exchange to occur * and to allowing more air to empty (rather than trap)

Question 42

Barrel Shaped Chest Increased.....

Answer 42

increased ...A-P diameter * Associated with lung hyperinflation * Seen in severe COPD (especially emphysema) * AP diameter \> lateral diameter * Chronic over-inflation of lungs (due to air trapping) * Hyperexpands the chest wall over time

Question 43

tracheal position in pleural effsion

Answer 43

pushes the trachea to the opposite side

Question 44

tracheal position in pneumothroax

Answer 44

possible if tension - will push away

Question 45

how to check symmetry of chest expansion

Answer 45

using both hands on the chest

Question 46

normal percussion?

Answer 46

resonant

Question 47

hyper resonant on percussion

Answer 47

increased air e.g. pneumothorax

Question 48

dull sound on percussion

Answer 48

cosolidation e.g. pneumonia

Question 49

stony dull sound on percusion

Answer 49

pleural effusion

Question 50

normal auscultation called

Answer 50

vesicular - rusting leaves - inpriation and first part of expiration - no gap between inspiratory and expiratory components

Question 51

bronchial sound on auscultation

Answer 51

* ‘Blowing’ harsh sound * Inspiration and expiration • Gap between

Question 54

reduced or absent sound on auscultation

Answer 54

pleural effusion- absent over fluid asthma- normal or reduced pneumothorax- absent

Question 55

added sounds heard on auscultation

Answer 55

* wheeze or stridor * crackles * pleural rub

Question 56

what causes crackles and how can they sound

Answer 56

Snapping open of alveoli/small bronchi 1. Fine --\> pulmonary fibrosis 2. Course --\> COPD, bronchiectasis (air bubbling through mucous secretions)

Question 57

Pleural rub

Question 58

summary of clinical exam of diff lung conditions

Answer 58