Resp CCE

Question 1

What are four red flag symptoms in the respiratory history and their possible causes?

Answer 1

I. Haemoptysis
• Most common causes are URTI, bronchitis, pneumonia,
bronchiectasis, and bronchial carcinoma (pulmonary embolism may
also cause).
II. Sudden onset dyspnoea
• Consider pneumothorax or pulmonary embolism.
III. Sudden onset stridor
• Consider anaphylaxis, inhaled foreign body, acute epiglottitis, toxic gas inhalation.
IV. Chronic cough and sputum
• In patient from endemic countries consider TB.

Question 2

Describe the surface anatomy landmarks that overlie the inferior border of the pleurae?

Answer 2

The inferior border of the pleurae extends from the lowest point of the anterior border around the side of the chest, deep to the eighth rib at the midclavicular line, 10th rib at the midaxillary line, and reaching the 12th rib in the scapular line.

Question 3

Describe the surface anatomy landmarks that overlie the inferior borders of the lungs?

Answer 3

The inferior border of the lungs continues deep to the sixth rib in the midclavicular line,
the eighth rib in the midaxillary line, and the 10th rib in the scapular line.

Question 4

What sort of environmental cues might you notice around the bed in the general observation part of the respiratory exam?

Answer 4

Look for the presence of sputum mug O2 mask or prongs, O2 cylinders, intravenous cannula, asthma inhalers, CPAP pump for OSA, BiPAP pump for non-invasive ventilation, or chest tube and drainage for pneumothorax or pleural effusion.

Question 5

Describe the “classic dyspnoeic posture”?

Answer 5

Tripod - leaning forward, using arms to fix shoulders, using accessory muscles, i.e., sternocleidomastoids and scalenes on inspiration, and abdominal oblique muscles on expiration with pursed lips.

Question 6

What is cyanosis? Name two respiratory causes?

Answer 6

Cyanosis (blue): absolute quantity of deoxyhaemoglobin. The cause in the respiratory system is usually a ventilation-perfusion (V/Q) mismatch, which can be caused by a number of different pathologies, including:
• Hypoventilation
• Pulmonary embolism
• Lung malignancy
• COPD
• Pneumonia
• Asthma

Question 7

What are two respiratory causes of clubbing?

Answer 7

• Suppurative lung disease: bronchiectasis, lung abscess, lung empyema
• Lung Malignancy (rare in small cell carcinoma)
• Pulmonary Fibrosis
• Rare: cystic fibrosis, asbestosis and mesothelioma

Question 8

Why might you see wasting of the intrinsic muscles of the hands in the respiratory exam?

Answer 8

The interossei, thenar and hypothenar muscles can all waste away due to interruption of the lower trunk of the Brachial Plexus. In the respiratory system, this would be associated with any tumour of the apex of the lung, on the same side of the body, called a Pancoast Tumour. Note that the term Pancoast tumour is non-specific and does not denote a histological type. You can further test the intrinsic muscles of the hand for weakness (this will be covered later in the year in Neuro).

Question 9

What is a flapping tremor (asterixis) a sign of in the respiratory exam?

Answer 9

It is a sign of severe CO2 retention.

Question 10

Can you describe Cheyne-Stokes breathing?

Answer 10

Alternating periods of deep breathing and then apnoea, due to injury to the respiratory centres of the brain – it is seen in severe heart failure, stroke, hyponatraemia, brain injury and brain tumours, as well as caused by drugs and carbon monoxide poisoning.

Question 11

Can you describe Kussmaul’s breathing?

Answer 11

Deep, rapid, sighing breathing associated with acidosis, the classical example of which is Diabetic Ketoacidosis (DKA) and kidney failure. Other causes of tachypnoea (heart and lung disease) reduce vital capacity and cause rapid, shallow breathing, rather than deep breathing.

Question 12

What is pulsus paradoxus, and what is it associated with in the respiratory system?

Answer 12

• This is an exaggeration of the normal fall in systolic BP during inspiration
• The definition of pulsus paradoxus is a drop in systolic blood pressure of >10
mmHg during inspiration, however, in some patients this is still normal.
• A difference of greater than >15-30 mm Hg is much more likely to be
pathological and may be evident as a palpable drop in the pulse volume during
inspiration.
• In the respiratory system, this would be associated with severe asthma.l

Question 13

Describe Horner’s Syndrome and explain what causes it in the respiratory system?

Answer 13

• In the respiratory system, this is associated with an apical lung tumour (a Pancoast Tumour), invading the ipsilateral sympathetic trunk as it travels to the face. There are many other causes in different body systems.
• Inspect the face and eyes for the following triad (which rhymes):
o Ptosis–in Horner Syndrome there is partial ptosis (drooping) of the upper
eyelid, as well as rising of the lower eyelid. The eye can also appear sunken
due to this effect, which is called apparent enophthalmos.
o Miosis – a constricted pupil.
o Anhidrosis–the forehead is matt in colour due to the loss of sweating.

Question 14

Describe some differences between leukoplakia and candidiasis?

Answer 14

You can differentiate leukoplakia from candidiasis, in that the latter can be scraped off with the tongue depressor. It is often painful and red around lesions. Leukoplakia is not usually painful and cannot be scraped off. It frequently requires biopsy to differentiate dysplasia, carcinoma in situ or oral cancer.

Question 15

Describe a bovine cough. What pathology is it associated with?

Answer 15

A longer, non-explosive cough, with the quality of a voiceless “ha” may be a bovine cough. In the respiratory system, a bovine cough could be associated with unilateral paralysis of the vocal cords, especially from a left Pancoast tumour, invading the left recurrent laryngeal nerve.

Question 16

Describe a barrel chest deformity and give an example of a lung disease it may be associated with.

Answer 16

Barrel chest is a deformity created by an increased in the AP diameter of the chest as a result of lung disease such as COPD or chronic, severe asthma.

Question 17

List the groups of cervical lymph nodes while you palpate them.

Answer 17

• Submental – under the chin.
• Submandibular – under the mandible.
• Pre‐auricular and Post‐auricular – in front of and behind the ears.
• Occipital – at the back of the head, under the occipital protuberance.
• Jugular chain – this contains multiple groups, roughly following the internal
jugular vein, deep to sternocleidomastoid and lateral to the trachea.
• Posterior triangle (this group follows the accessory nerve).
• Supraclavicular.

Question 18

Give two examples of pathologies that deviate the trachea TOWARDS the side of the pathology?

Answer 18

• Atelectasis/collapse
• Pneumonectomy (surgical removal of lung tissue)
• Pulmonary fibrosis

Question 19

Give two examples of pathologies that deviate the trachea AWAY from the side of the pathology?

Answer 19

• Large pleural effusion
• Large lung malignancy
• Tension pneumothorax (especially traumatic)

Question 20

Give an example of when you might hear these different percussion notes?

Answer 20

I. Stony dull – over bone or fluid (e.g. over pleural effusion or ascites)
II. Dull – over dense tissue e.g. over the liver or spleen
III. Resonant – over air-filled organs (e.g. normal lungs)
IV. Hyper-resonant – More air content than normal lung (e.g. sometimes bowel,
pneumothorax)

Question 21

Describe the differences between vesicular breathing and bronchial breathing. Which of these is usually pathological?

Answer 21

Vesicular breath sounds are “normal” breath sounds, associated with air movement towards the periphery of the airways. They are soft, low pitched, and are louder and longer in inspiration. They continue without any audible gap from inspiration into expiration, before the sounds fade a third of the way through expiration.
Bronchial breath sounds have a hollow, blowing quality. They exhibit a gap between inspiration and expiration, with a harsher expiratory component. They can be a normal finding over the manubrium and between the scapulae near the level of the scapular spine. When the bronchial tree leading to the lung tissue is open, but it is surrounded by consolidated tissue, these sounds are produced. This is because sound is transmitted better through the surrounding consolidated tissue than it is through normally ventilated lung tissue.

Question 22

What are the four types of adventitious (added) sounds you might hear in auscultation? Choose one of these four to describe in more depth.

Answer 22

Stridor:
• These sounds are loud, course, rattly or musical, and are usually inspiratory.
• Stridor is associated with upper airway obstruction (larynx or trachea), such as from
an inhaled foreign body or epiglottitis in children.

Wheeze:
• The sound quality is described as being “musical”, with a varied pitch. It can be likened to a whistle, whereby a note is produced by airflow through a narrow aperture.
• They are more common in expiration (expiratory wheeze) than in inspiration (inspiratory wheeze) but can be present in both phases of respiration. Wheeze may be exaggerated by forced expiration.
• Wheeze is associated with asthma, chronic bronchitis COPD, and pulmonary oedema.
• Persistent localised wheeze (which is not present elsewhere in the lung fields) may conversely suggest partial airway obstruction from a tumour or foreign body

Crackles:
• Theoretically these are caused by the “popping” open of small airways, during inspiration, or air bubbles passing through in secretions, from expiration.
• These are usually described as “interrupted” and “non-musical”.
• Crackles can be heard in pneumonia & pulmonary oedema.

Pleural rub:
• Caused by friction of inflamed pleural surfaces rubbing against each other. It is usually a biphasic, often localised, creaking sound, heard in pneumonia and pulmonary infarction.

Question 23

When doing bronchophony what does it indicate if the “99” is:

a. Muffled?
b. Clearly distinguishable?
c. Quieter or absent?

Answer 23

Muffled?
This is usually what is heard over normal lung. The “99” is quite indistinct from hearing the number spoken through the air.

Clearly distinguishable?
If the number “99” is clearly distinguishable, this suggests that the lung tissue beneath your stethoscope is consolidated and hence, the sound waves are conducted more efficiently.

Quieter or absent?
If the “99” sound is quieter or absent, the sound waves are being blocked by another medium between your stethoscope and the lung tissue – usually either air (pneumothorax) or water (pleural effusion).

Question 24

In consolidation, what findings might you expect when examining the lungs by EPAR (expansion, percussion, auscultation and resonance)?

Answer 24

Expansion: Reduced on affected side.
Percussion: Dull.
Auscultation: Bronchial breathing over the area of consolidation +/- a rub and you may hear some late inspiratory crackles
Resonance: Increased.

Question 25

In asthma, what findings might you expect when examining the lungs by EPAR (expansion, percussion, auscultation and resonance)?

Answer 25

Expansion: Hyper-inflated.
Percussion: Resonant or hyper-resonant (generalised).
Auscultation: Vesicular obscured by wheeze. May be silent if severe. There may also be added wheezes and crackles.
Resonance: Decreased

Question 26

In pleural effusion, what findings might you expect when examining the lungs by EPAR (expansion, percussion, auscultation and resonance)?

Answer 26

Expansion: Reduced on affected side.
Percussion: Dull/ stony dull.
Auscultation: Decreased or absent breath sounds (bronchial breathing may be heard at the top of a large effusion.) Might hear a friction rub.
Resonance: Decreased or absent (may have increased vocal resonance at the top of a large effusion.)

Question 27

In pneumothorax, what findings might you expect when examining the lungs by EPAR (expansion, percussion, auscultation and resonance)?

Answer 27

Expansion: Reduced on affected side.
Percussion: Unilaterally hyper-resonant (i.e. over the affected side).
Auscultation: Absent or decreased breath sounds. Might hear a friction rub.
Resonance: Decreased or absent