Respiratory Flashcards
Interpret:
Reduced chest wall movement
Bilateral or focal coarse inspiratory crackles, through inspiration and expiration, may clear temporarily after coughing
Sputum container with purulent or blood stained sputum
Finger clubbing
Percussion normal
+/- cor pulmonale symptoms
Dx and ddx?
Bronchiectasis
Ddx:
Pulmonary fibrosis: fine crackles at late inspiratory phase, reduced lung volume
COPD with chronic bronchitis: less coarse crackles and more hyperinflation
Asthma: crackles +/- wheezing, copious tenacious sputum production
Post-TB lung destruction: bronchiectasis, fibrosis and cavitation, focal/ unilateral bronchiectasis
Causes of bronchiectasis
Idiopathic (most) Post- tuberculosis Post-pneumonia Childhood measles or pertussis Rheumatoid arthritis, SLE Pulmonary fibrosis causing traction bronchiectasis
Kartagener’s syndrome
Allergic bronchopneumonia aspergillosis (ABPA)
Interpret:
Bilateral pitting LL edema Tachypnea Reduced gap between suprasternal notch and cricoid cartilage Barrel chest Hyper-resonant on percussion Decreased breath sounds with long expiratory phase +/- inspiratory crackles Low vocal resonance Pursed lip breathing
Dx and ddx?
COPD
Ddx:
Chronic asthma: shows greater variation in symptoms + reversible airflow obstruction on spirometry
Overlapping asthma and COPD: ACOS
Bronchiectasis: lung crackles across insp. and expiration
Risk factors of COPD
Cigarette smoking
Heavy exposure to indoor air pollution
Alpha-1 antitrypsin deficiency
Occupational exposure to dusts or fumes
Interpret:
Tachypnea
Decreased chest movement on affected side
Tracheal deviation +/- apex shift to affected side
Dull percussion to affected sides
Decreased breath sounds on affected areas
Dx?
Causes?
How to distinguish upper or lower lung lobe pathology?
Lung collapse
Causes:
- Endobronchial obstruction or extrinsic compression by neoplasm
- Foreign body aspiration
- Infections: endobronchial TB
Tracheal deviation in upper lobe, Apex deviation in lower lobe
How to distinguish pleural effusion and lung collapse in PE?
Tracheal or mediastinal shift towards collapse side; shift away from effusion
Dull on percussion for collapse, stony dull for effusion
Decreased breath sounds/ vocal resonance for BOTH
Interpret:
Tachypnea Decreased chest movement on left side Tracheal deviation to right side Stony dull on percussion on left side Decreased breath sounds on left side Decreased bronchial breath sounds on left side Distinct small scar in the back
Dx?
Causes?
Pleural effusion
Infection: bacterial, TB or fungal pleurisy, suppurative aspiration pneumonia
Cancer: Malignant effusion or mesothelioma
Bilateral: Hepatic hydrothorax, heart failure, kidney failure
Ddx of pleural effusion
Lung collapse/ consolidation
Raised hemidiaphragm
Large lung mass
Interpret:
Tachypneic with O2 supply
Finger clubbing
Normal palpation and percussion
Fine, end-inspiratory crackles at lower zones, bilateral in posterior and lateral aspects
Dx?
Idiopathic pulmonary fibrosis
What diseases give clubbing and inspiratory crackles
Bronchiectasis if bilateral
Obstructive pneumonia due to lung cancer if localized
Most useful test for diagnosis of idiopathic pulmonary fibrosis?
High resolution CT thorax
Conditions that may be mistaken for asthma?
Upper airway obstruction: laryngeal stenosis, tumor, vocal cord dysfunction
Lower airway obstructive diseases: bronchiectasis, COPD, bronchiolitis aspergillosis, eosinophilic granulomatous pulmonary angiitis (EPGA)
Left heart failure
Interpret:
Cough with sputum + hemoptysis
History of recurrent lung infections
Dyspnea
Coarse inspiratory crackle over bilateral lower zones
Mild finger clubbing with no cervical lymphadenopathy
Loud P2
Dx?
Tests?
Bronchiectasis
High resolution CT thorax
Lung function test
24 hour sputum volume
Find etiologies by:
Gastric reflux study
Sputum for AFB
Serum immunoglobulin levels
Appearance of bronchiectasis on HRCT
Signet ring appearance:
internal lumen of affected airways are larger than accompanying arteries
Lack of normal bronchial tapering
Presence of peripheral airways within 1cm of costal pleura
Air-fluid levels in dilated bronchi
Linear clusters of cysts
Causes of hoarseness of voice?
→ Common: laryngitis, inhaled corticosteroid
→ Other respiratory: RLN palsy (in Lt CA lung), CA larynx
→ Non-respiratory: hypothyroidism (myxedema of vocal cord)
Causes of dry cough
chest infection, asthma, CA lung, LVF, ILD, ACEI side effects
Causes of bovine and whooping cough
Bovine cough: lack of usual explosive beginning
→ Indicates vocal cord paralysis
Whooping cough: violent and rapid coughing preceded by a loud ‘whooping’ inhalation
→ Indicates pertussis
Respiratory hand signs
- Clubbing: 80% due to respiratory diseases
- Hypertrophic pulmonary osteoarthropathy (HPO):
Paraneoplastic periosteal inflammation at distal ends of bones
swelling and tenderness over the wrists
D/dx: primary CA lung, pleural fibromas, idiopathic - Tar stains at fingers
- Wasting and weakness:
□ Look for wasting of small muscles of hand and finger
abduction weakness
□ May be caused by compression and infiltration of T1 lower trunk by Pancoast tumour - Asterixis (flapping tremor)
3 causes of asterixis
D/dx:
→ Severe CO2 retention
→ Hepatic encephalopathy
→ Azotaemia due to kidney failure
Respiratory neck signs
Cervical lymphadenopathy
JVP for cor pulmonale signs
List 4 abnormal chest wall shapes and associated pathologies
1) Barrel chest: ↑AP diameter due to hyperinflation of lungs
D/dx:
→ Severe asthmas, emphysema
→ Normal in elderly, thin people (∵small abdomen)
2) Funnel chest (pectus excavatum): □ Localized depression at lower end of sternum □ May occur in congenital syndromes eg. Marfan syndrome
3) Pigeon chest (pectus carinatum):
□ Outward bowing of sternum and costal cartilage
□ D/dx:
→ Chronic childhood respiratory illness
→ Bony malformation, eg. rickets
→ Congenital syndromes, eg. Marfan syndrome
4) Kyphoscoliosis: exaggerated forward curvature of spine and lateral bowing of spine D/dx: → Idiopathic (80%) → Secondary to poliomyelitis → Marfan’s syndrome-associated
Surgeries associated with midline sternotomy
Midline sternotomy: midline
along sternum
→ CABG
→ Lung transplant
Surgeries associated with thoracotomy scar
Thoracotomy: long diagonal posterior scar on thorax → Pneumonectomy → Lobectomy → Lung transplant → Thoracoplasty
Surgeries associated with VAT scars
Video-assisted thoracoscopy (VATs): three 2-3cm scars
→ Bx of lymph nodes
→ Lung reduction surgery
→ Pleurodesis
Location of chest drain scars
At posterior lung base
Define normal and abnormal rates of breathing
□ Normal = 16 – 25/min (classically quote 12-16/min)
□ Tachypnoea = >25/min
□ Bradypnoea = <8/min
2 signs of dyspnea
Use of accessory respiratory muscles: sternocleidomastoids, platysma, strap muscles of neck
→ Inspiration: elevation of shoulders
→ Expiration: contraction of abdominal muscles
In-sucking: in-drawing of intercostal and supraclavicular spaces during inspiration
Cause of paradoxical breathing
- Abdomen sucks inwards with inspiration
- Cf normally pouching outward due to
diaphragmatic descent
> > Diaphragmatic paralysis
5 characteristics signs of COPD
□ Use of accessory muscles
→ Indicating ↑work of breathing
□ In-drawing of intercostal and supraclavicular spaces
→ Indicating a more negative intrathoracic pressure
□ Pursed-lip breathing
→ Provides positive airway pressure
→ prevent airway collapse during expiration
□ Lean forward with arms on knees
→ Compresses abdomen + pushes diaphragm upward
→ restore dome shape of diaphragm
→ Improve effectiveness during inspiration
□ Tracheal tug
Causes of unilateral decrease chest wall movement
Unilateral:
- Localized lung fibrosis
- Consolidation
- Collapse
- Pleural effusion
- Pneumothorax
- Pain (pleuritic, trauma)
Causes of bilateral reduced chest wall movement
COPD
ILD
Describe Hoover’s sign for COPD
Hoover’s sign for COPD
□ Hands placed along costal margin with thumbs close to xiphisternum
□ Normal = separation of thumbs
□ COPD = thumbs become closer
In COPD, the lungs become hyperinflated, pressing the diaphragm downward. Therefore, normal inspiratory contraction of diaphragm actually draws the rib cage inward.
Differentiate mediastinal deviation causes
→ Volume loss lesion if towards side of lesion
- Lobar collapse
- Lobar fibrosis
- Pnuemonectomy
→ Space-occupying lesion if away from side of lesion
- Pleural effusion
- Tension pneumothorax
- Other masses, eg. retrosternal goitre
Sites of percussion in respiratory exam
□ Bilateral supraclavicular fossa at apex
□ Bilateral clavicle (direct tapping)
□ Bilateral anterior chest for 3 times
→ Move laterally at Lt inferior chest to avoid cardiac dullness
□ Bilateral axilla for 2 times
□ Bilateral posterior chest for 4 times
→ Percuss at apex from behind
→ Percuss between medial border of scapula and spine
→ Ask pt to cross arms in front to hold contralateral shoulder
→ protracts scapula to further expose upper lobe
→ Also percuss at posterior axillae
Percussion findings and implications in respiratory exam
□ Resonant over normal lung
□ Hyperresonant over hollow structure, eg. bowels,
pneumothorax
□ Dull over solid structure, eg. consolidation, liver, lung
collapse
□ Stony dull over fluid-filled structure eg. pleural effusion
Implications of lack of liver and cardiac dullness
Hyperinflation of lungs
Emphysema or asthma
Sites of auscultation in respiratory exam
Ask pt to take deep breaths in and out through the mouth
Auscultate bilaterally at the following sites:
□ Supraclavicular fossa (B)
□ Anterior chest for 3 times (D/B)
→ Move laterally at Lt inferior chest to avoid heart
□ Axilla for 2 times (D/B)
□ Posterior chest for 4 times (D/B)
Define causes of vesicular vs bronchial breath sounds
Vesicular (normal) sounds:
□ Origin: flow vortices in small airway (inspiration),
large airway (expiration)
Bronchial breath sounds:
□ Origin: turbulent flow in large airways
Define difference in characteristics between vesicular vs bronchial breath sounds
Vesicular (normal) sounds: faint, low-pitched rushing sound
→ Gentle beginning and end
→ Inspiratory phase longer and louder12 (E:I ≈ 1:3)
→ No gap between inspiratory and expiratory phases
Bronchial sounds:
higher-pitched, hollow, blowing quality
→ Inspiratory phase shorter/equal and softer (E:I ≈ 1-3:1)
→ Expiratory phase louder and higher pitch
→ Audible gap between inspiratory and expiratory phases
All bronchial breath sounds are abnormal.
T or F
→ Normal when heard over manubrium or posterior central chest, Normally muffled by alveoli (high pitch)
→ NOT heard over peripheral chest
→ Abnormal when heard over peripheral chest
Indicates ↑sound transmission in alveoli
Causes of bronchial breath sounds
Common
- Lung consolidation
Uncommon
- Localized pulmonary fibrosis
- Above pleural effusion
- Collapsed lung
Causes of unilateral decreased breath sounds
Unilateral ↓breath sounds indicate bronchial obstruction □ COPD, esp emphysema □ Pleural effusion □ Pneumothorax □ Pneumonia □ Large neoplasm □ Collapsed lungs
Wheezing
- Timing
- Characteristic
- Pitch
- D/dx
Timing:
Most commonly expiratory
Inspiratory or biphasic wheezes indicate severe narrowing
Characteristics:
musical quality due to continuous oscillation of airway walls
Pitch:
Higher pitch from smaller bronchi
Lower pitch (aka rhonchi) from larger bronchi
D/dx:
□ Asthma (often high-pitched)
□ COPD (often low-pitched)
Define different timings of crackles and implied underlying conditions
□ Early inspiratory indicates small airway obstructive diseases (eg. COPD)
□ Mid-inspiratory indicates pulmonary oedema
□ Late or pan-inspiratory indicates alveolar diseases
→ Pulmonary fibrosis (fine)
→ Pulmonary oedema (medium)
→ Pneumonia, lung abscess, TB, COPD secretions (coarse)
□ Biphasic indicates bronchiectasis (coarse)
Explain physiology of fine crackles
Fine crackles indicates airway instability
→ Expiration → small airways collapse
→ Inspiration → air rapidly enters distal airways → pops open
D/dx: pulmonary fibrosis
Physiology of medium crackles
Medium crackles indicates disruption of surfactant function
→ D/dx: pulmonary oedema (due to LV failure)
Physiology of coarse crackles
Coarse crackles indicates excess bronchial secretions
→ Inspiration → air bubbles through secretions → gurgling sounds
→ Disappear upon coughing
D/dx: bronchiectasis, other causes of retained bronchial secretions
Causes of pleural friction rub
pleurisy □ Pulmonary embolism □ Pneumonia □ Pleural malignancy □ Spontaneous pneumothorax □ Pleurodynia: pain due to rib cage/diaphragm pathologies
Define different vocal resonance and underlying pathologies
1) Normal lung:
→ Transmits low-pitched sound with a booming quality
→ High-pitched sound becomes attenuated
2) Consolidated lung:
→ Transmit high frequency with a bleating quality
→ Aegophony: ‘ee’ becomes ‘aa’
□ Normal areas: sound inaudible and muffled
□ Consolidation: clearly audible (pectoriloquy)
□ Pleural effusion: even more muffled
D/dx for cor pulmonale
- Idiopathic
- COPD
- ILD
- Pulmonary thromboembolism
- Marked obesity
- Sleep apnoea
- Severe kyphoscoliosis
Signs of cor pulmonale
□ JVP for RH failure → may indicate cor pulmonale
□ Auscultation for P2 > A2 → suspect pulmonary hypertension
Cause of Pemberton’s sign
Pemberton’s sign:
□ Ask pt to lift arms over head and wait for 1min
□ Development of facial plethora, cyanosis, inspiratory stridor, non-pulsatile ↑JVP
→ indicates SVC obstruction
Interpret:
Flattened chest and deep supraclavicular fossa on left side
Reduced chest wall movement on left side
Tracheal deviation to the left side
Dull percussion over clavicles
Decreased breath sounds on left side with localized fine crackles
Dx?
3 causes?
Apical fibrosis
Old pulmonary TB
Ankylosing spondylitis
Post-radiation pulmonary fibrosis (e.g. lung cancer)
Conditions that give clubbing with inspiratory crackles
Bronchiectasis - bibasilar
Obstructive pneumonia e.g. due to lung cancer - localized
What systemic features would you look for in pulmonary fibrosis
Autoimmune diseases such as RA
Interpret:
Cachexic Tachypnea Central trachea Decreased chest movement on right side Dull percussion on right lower chest Decreased breath sounds on right lower zone Vocal resonance reduced over lower zone
dx?
ddx?
Pleural effusion
RLL collapse/ consolidation
Raised hemidiaphragm
Large lung mass
4 different types of sputum and associated pulmonary conditions
Very tenacious in asthma
Purulent (creamy or yellow) in URTI or pneumonia
Brown/ Red for intra-alveolar haemorrhage
True mucoid with greyish fragments +/- blood stains- Bronchiectasis
Characteristic signs of COPD
□ Use of accessory muscles □ In-drawing of intercostal and supraclavicular spaces □ Pursed-lip breathing □ Lean forward with arms on knees □ Tracheal tug
Unilateral decrease chest wall movement
Unilateral:
- Localized lung fibrosis
- Consolidation
- Collapse
- Pleural effusion
- Pneumothorax
Bilateral decrease chest wall movement
Bilateral:
- COPD
- ILD
Explain Hoover’s sign for COPD
Hoover’s sign for COPD □ Hands placed along costal margin with thumbs close to xiphisternum □ Normal = separation of thumbs □ COPD = thumbs become closer
List volume loss lesions and space-occupying lesions
→ Volume loss lesion if towards side of lesion
- Lobar collapse
- Lobar fibrosis
- Pnuemonectomy
→ Space-occupying lesion if away from side of lesion
- Pleural effusion
- Tension pneumothorax
- Other masses, eg. retrosternal goitre
Test for use of accessory respiratory muscles
Use of accessory respiratory muscles:
□ Place fingers in supraclavicular fossa → feel for contraction of scalene muscles
□ Place fingers on SCM muscle → feel for contraction of SCM
4 different percussion qualities and underlying causes
□ Resonant over normal lung
□ Hyperresonant over hollow structure, eg. bowels,
pneumothorax
□ Dull over solid structure, eg. consolidation, liver, lung
collapse
□ Stony dull over fluid-filled structure eg. pleural effusion
What causes loss of liver and cardiac dullness
Emphysema or Asthma can cause hyperinflation»_space; decrease liver and cardiac dullness
Causes of bronchial breath sounds
Common - Lung consolidation Uncommon - Localized pulmonary fibrosis - Above pleural effusion - Collapsed lung
Differences between bronchial and vesicular breath sounds
Vesicular (normal) sounds:
Characteristics: faint, low-pitched rushing sound
→ Gentle beginning and end
→ Inspiratory phase longer and louder12 (E:I ≈ 1:3)
→ No gap between inspiratory and expiratory phases
Bronchial breath sounds:
Characteristics: higher-pitched, hollow, blowing quality
→ Inspiratory phase shorter/equal and softer (E:I ≈ 1-3:1)
→ Expiratory phase louder and higher pitch
→ Audible gap between inspiratory and expiratory phases
Causes of unilateral decrease in breath sounds
Unilateral ↓breath sounds indicate bronchial obstruction □ COPD, esp emphysema □ Pleural effusion □ Pneumothorax □ Pneumonia □ Large neoplasm □ Collapsed lungs
Causes of wheezing
→ Polyphonic wheeze indicates diffuse airway narrowing (asthma, COPD)
→ Monophonic wheeze (that is not cleared by coughing) indicates fixed bronchial obstruction
D/dx: acute or chronic airway obstruction (bronchospasm + mucosal oedema + excessive secretions)
□ Asthma (often high-pitched)
□ COPD (often low-pitched)
Difference between stridor, rhonchi, rales, crepitations
- Stridor = inspiratory wheezing sound
- Rhonchi = low-pitched wheezes
- Rales = low-pitched crackles
- Crepitations = high-pitched crackles
Causes of early inspiratory crackles
small airway obstructive diseases (eg. COPD)
Causes of mid inspiratory crackles
pulmonary oedema
Causes of pan/ late inspiratory crackles
→ Pulmonary fibrosis (fine)
→ Pulmonary oedema (medium)
→ Pneumonia, lung abscess, TB, COPD secretions (coarse)
Cause of biphasic crackles
Biphasic indicates bronchiectasis (coarse)
Cause of fine, medium and coarse crackles
Fine = pulmonary fibrosis Medium = pulmonary edema Coarse = Bronchiectasis
Causes of increased or decreased vocal resonance
Consolidation = increase vocal resonance
Pleural effusion = decrease vocal resonance
D/dx of cor pulmonale
- Idiopathic
- COPD
- ILD
- Pulmonary thromboembolism
- Marked obesity
- Sleep apnoea
- Severe kyphoscoliosis
5 additional exams after respiratory exam
Heart:
□ JVP for RH failure → may indicate cor pulmonale
□ Auscultation for loud P2 → suspect pulmonary hypertension
Liver:
□ Drooping due to emphysema
□ Enlargement due to CA lung metastasis
Pemberton’s sign: SVC obstruction due to CA compression
