Respiratory Flashcards
Causes of tracheal deviation
- Towards the side of the lung lesion
a. Upper lobe collapse
b. Upper lobe fibrosis
c. Pneumonectomy - Away from the side of the lung lesion (uncommon)
a. Massive pleural effusion
b. Tension pneumothorax - Upper mediastinal masses, such as retrosternal goitre
Signs of consolidation
● Expansion: reduced on the affected side
● Vocal fremitus: increased on the affected side
● Percussion: dull but not stony dull
● Breath sounds: bronchial
● Additional sounds: medium, late or pan-inspiratory crackles as the pneumonia resolves
● Vocal resonance: increased
● Pleural rub: may be present
Signs of atelectasis
● Trachea: displaced towards the affected side
● Expansion: reduced on the affected side with flattening of the chest wall on the same side
● Percussion: dull over the collapsed area
● Breath sounds: reduced, nil added sounds
Signs of pleural effusion
● Trachea and apex beat: displaced away from a massive effusion
● Expansion: reduced on the affected side
● Percussion: stony dullness over the fluid
● Breath sounds: reduced or absent. May be an area of bronchial breathing audible above the effusion due to compression of overlying lung
● Vocal resonance: reduced
Causes of a pleural effusion
● Transudate
o Cardiac failure
o Hypoalbuminaemia from nephrotic syndrome or chronic liver disease
o Hypothyroidism
o Meigs syndrome (ovarian fibroma causing pleural effusion and ascites)
● Exudate
o Pneumonia
o Neoplasm – bronchial carcinoma, metastatic carcinoma, mesothelioma
o Tuberculosis
o Pulmonary infarction
o Subphrenic abcess
o Acute pancreatitis
o Connective tissue disease (e.g. rheumatoid arthritis, SLE)
o Drugs such as methysergide, cytotoxics
o Irradiation
o Trauma
● Haemothorax
o Severe trauma to the chest
o Rupture of a pleural adhesion containing a blood vessel
● Chylothorax
o Trauma or surgery to the thoracic duct
o Carcinoma or lymphoma involving the thoracic duct
● Empyema
o Pneumonia
o Lung abscess
o Bronchiectasis
o Tuberculosis
Lights criteria
The formal definition of an exudate is that the fluid has at least one of the following Light’s criteria:
- Fluid protein/serum protein >0.5
- Pleural fluid LDH/serum LDH >0.6
- Pleural fluid LDH >2/3 of normal upper limit of LDH in serum
Signs of a lobectomy
● Thoracotomy scar
● Tracheal deviation (in upper lobectomy or pneumonectomy)
● Ribs may be pulled in
● Reduced chest expansion
● Dull percussion note
● Reduced breath sounds with possible overlying bronchial breathing
● Possible displaced apex beat
Signs of a pneumothorax
● Expansion: reduced on the affected side
● Percussion: hyperresonnace if the pneumothorax is large
● Breath sounds: greatly reduced or absent
● There may be subcutaneous emphysema
Signs of bronchiectasis
● Systemic signs: fever, cachexia, sinusitis
● Clubbing and cyanosis
● Sputum: voluminous, purulent, foul-smelling sometimes blood-stained
● Course pan-inspiratory or late inspiratory crackles over the affected lobe
● Signs of severe bronchiectasis
o Very copious sputum and bronchiectasis
o Clubbing
o Widespread crackles
o Signs of airway obstruction
o Signs of respiratory failure and cor pulmonale
Signs of COPD
● Barrel-shaped chest with increased anteroposterior diameter
● Pursed-lip breathing
● Use of accessory muscles of respiration and drawing in of the lower intercostal muscles with inspiration
● Palpation: reduced expansion and a hyperinflated chest, tracheal tug
● Percussion: hyperresonant with decreased liver dullness
● Breath sounds: decreased, early inspiratory crackles
● Signs of right heart failure
Signs of ILD
● General: dyspnoea, cyanosis and clubbing
● Palpation: expansion is slightly reduced
● Auscultation: fine (Velcro-like) late inspiratory or pan-inspiratory crackles heard over the affected lobes
● Signs of associated connective tissue disease: rheumatoid arthritis, systemic lupus erythematosus, scleroderma, Sjogren’s syndrome, polymyositis and dermatomyositis
Causes of interstitial fibrosis
Upper lobe predominant (SCHART) ● S = silicosis, sarcoidosis ● C = coal worker’s pneumoconiosis ● H = histiocytosis ● A = ankylosing spondylitis, allergic bronchopulmonary aspergillosis ● R = radiation ● T = tuberculosis
Lower lobe predominant (ARSIO) ● A = asbestosis ● R = rheumatoid arthritis ● S = scleroderma ● I = idiopathic interstitial fibrosis ● O = other (drugs e.g. busulfan, bleomycin, nitrofurantoin, hydralazine, methotrexate, amiodarone), other collagen vascular diseases, acute allergic alveolitis, acute eosinophilic pneumonitis
Difference between UIP and NSIP
UIP - Usual interstitial pneumonia
- associated with IPF and RA
- Honeycombing
- normal lung alternating with interstitial fibrosis and honeycombing.
- apicobasal gradient
- sub pleural involvement
- reticular opacities
- traction bronchiectasis
NSIP - Nonspecific interstitial pneumonia
- ground glass opacities
- reticular opacities
- traction bronchiectasis
- subpleural sparing
Extra-pulmonary signs of sarcoidosis
● Skin: lupus pernio (violaceous patches on the face), pink nodules and plaques in old scars, erythema nodosum on the shins
● Eyes: ciliary injection, anterior uveitis
● Lymph nodes: generalised lymphadenopathy
● Liver and spleen: enlarged (uncommon)
● Parotids: gland enlargement (uncommon)
● Central nervous system: cranial nerve lesions, peripheral neuropathy (uncommon)
● Musculoskeletal system: arthralgia, swollen fingers, bone cysts (rare)
● Heart: heart block presenting as syncope, cor pulmonale (rare)
● Signs of hypercalcaemia
Causes of bronchial breath sounds
- lobar pneumonia
- localised fibrosis or collapse
- above a pleural effusion
- large lung cavity
