Post on 19-Jul-2016
Respiratory Symptoms and SignsMatthew C. Miles, MDAssistant Professor of Internal Medicine,Pulmonary Diseases, and Critical Care Medicine
Wake Forest Baptist Medical Center
Objectives
• Understand the language of the respiratory examination• Explain possible causes of respiratory symptoms• Describe normal and abnormal auscultation of the chest• Describe normal and abnormal percussion of the chest• Correctly identify disease states based on respiratory
signs and symptoms
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From “Look and Hear” to “See and Listen”
• “the most important part of an art is to be able to observe properly” – René Laennec
• “There is no more difficult art to acquire than the art of observation, and for some men it is quite as difficult to record an observation in brief and plain language.” – Sir William Osler
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Symptoms vs. Signs
Symptoms are perceived by the patient
Dyspnea
Cough
Pain
Signs are observed by the clinician
Wheeze
Crackles
Clubbing
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Respiratory SymptomsDyspnea, Cough, Chest PainAsking the right questions, listening to the answers
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Dyspnea
A psycho-physiologic
sensation with many possible
causes
Latin dyspnoea,
Greek dyspnoia
“Shortness of breath”
Perception of difficult or
painful breathing
If worsens with physical activity:
dyspnea on exertion
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Cardiopulmonary Sites Causing Dyspnea
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Dyspnea
• Triggered by receptors in chest wall, respiratory muscles, lung parenchyma, carotid body, and brain stem
• Adaptation can occuro Chronic severe lung disease patients who report minimal
dyspneao Trained athletes with dyspnea despite no measurable
physiologic abnormality
• NOT coupled to respiratory efforto ↑work of breathing ≠ ↑amount of dyspnea
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Taking a Dyspnea History
Onset and course over
time• Specific & sudden, or vague & gradual?
Impact on daily
activities• “decreased activity phenomenon”
Aggravating factors
• Car exhaust, dusts, molds, perfumes, pets
Position • orthopnea, platypnea
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Respiratory DDx for Dyspnea
Pulmonary embolism
Pulmonary arteriovenous malformations
Asthma
COPD
Tracheomalacia, bronchomalacia
Pneumonia
Lung cancer
Pneumothorax
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Cough
• Occurs seldom in healthy individuals• A normal protective mechanism• Unimportant vs. Heralding severe disease• Phaseso Inhalation o Glottis closure, Compressiono Expulsion – glottis openso Relaxation
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Taking a Cough History
Duration • Acute, or Subacute/Chronic
Sputum • Quality, quantity
Timing • Morning, evening, no variation?
Aggravating factors
• Air temp, location, exposures
Associated symptoms
• Fever, chest pain, hoarseness
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Respiratory DDx for Cough
Irritant inhalation
Upper respiratory infection
Upper airway cough syndrome
ACE inhibitors
Gastroesophageal reflux disease
Asthma
Chronic bronchitis
Acute
Subacute&
Chronic
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Hemoptysis: Coughing of Blood
• Always requires thorough evaluationo CXR (often CT), +/- bronchoscopy
• Massive (~200ml/24h) vs submassive• DDx: hematemesis, epistaxiso Bronchitiso Lung cancero Tuberculosiso Bronchiectasis
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Chest Pain
• Extremely common, many causes• Always a symptom to be carefully consideredo Intensity ≠ Importance
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Taking a Chest Pain History
Onset • Specific and Rapid, Vague and Slow
Duration • Seconds vs. Minutes vs. Hours
Location • Specific, pinpoint vs. vague
Quality • sharp, burning, pressure, tight, heavy
Aggravating factors
• exertion, inspiration
Alleviating factors
• rest, medications
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Respiratory DDx for Chest Pain
Pleuritis – acute inflammation of parietal pleura
• Localized, “sharp”, “a catch”• Worsened by deep inspiration• Many conditions could underlie:
• Infectious pleuritic• Pneumothorax• Pulmonary embolism• Pneumonia• Pleural malignancy
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Respiratory Examination & Signs$0.00 additional charge∞ additional information
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René Laennec
• “father of modern knowledge of pulmonary disease”• introduced auscultationo 1819: De l’auscultation médiate
• invented the stethoscopeo modeled after an observation of children playing by tapping on
a cylinder
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Stethoscope: “Chest examiner”
1800s
2000s
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Normal Respiratory Effort
• Unlabored• Mouth closed• Allows for normal speech• Diaphragm alone
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Abnormal Respiratory Effort
• Visibly Labored• Mouth open• Cannot speak normally • Diaphragm not aloneo Sternocleidomastoid hypertrophyo Intercostal retractionso Abdominal muscle contractionso “Tripod” arm support
• Hyperinflation may be seeno “Barrel-chest”
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Normal breath sounds
• Sounds over the lung lobeso “vesicular” sounds
• Sounds over the tracheao “bronchial” sounds
o Bronchial sounds are abnormal if heard over the lobes
inh
exh
inh
exh
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Normal breath sounds
• Sounds over the lung lobeso “vesicular” sounds
• Sounds over the tracheao “bronchial” sounds
inh
exh
inh
exh
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Normal breath sounds
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Abnormal breath sounds
• Continuouso Wheezeso Rhonchi
• Discontinuouso Fine Crackleso Coarse Crackles
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Abnormal continuous sounds
• Wheezes• High pitched (>400Hz), longer than 250msec
• Produced by fluttering of airway walls
• Rhonchi• Low pitched (<200Hz), longer than 250msec
• Produced by flutter or rupture of fluid films
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Abnormal continuous sounds
• Wheezes• Classically present in asthma
• Many other conditions (VCD, foreign body)
• Rhonchi• Excessive large airway secretions
• Mechanical ventilation, poor pulmonary toilet
• Often clear with cough or suctioning
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Abnormal continuous sounds
• Wheezes and Rhonchi: Describingo Location (focal, diffuse)o Quiet or forced expirationo Clearance with coughing (rhonchi)
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Abnormal discontinuous sounds
• Fine Crackles• Coarse Crackleso Short explosive nonmusical
soundso Reflect explosive opening of
small airways
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Abnormal discontinuous sounds
• Crackleso Early-inspiratory
• Heart failureo Late-inspiratory
• Pulmonary fibrosis
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Abnormal discontinuous sounds
• Crackles: describingo Location: Bibasilar, diffuseo Fine or coarseo Early- or Late-inspiratory
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Stridor
• An important extra-thoracic soundo Differs from wheezing:
• Stridor is predominantly inspiratoryo Caused by turbulent flow in extrathoracic airwayo Most commonly due to vocal cord dysfunction, tracheal
stenosis, or foreign bodyo May be a medical emergency!
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Percussion
• Coordinated tapping on a finger held against the patient’s chest
• The percussion “note” is heard, but predominantly it is felt
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Percussion
plexorpleximeter
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Percussion
• resonant• dull• flat• tympanic• hyperresonant
• Normal lung• Normal liver• Normal thigh• Normal bowel• Abnormal
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Percussion
• resonant• dull• flat• tympanic• hyperresonant
• Normal lung• pleural effusion, consolidation• massive effusion• tension pneumo• pneumothorax
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Percussion
• Describing:o Location: unilateral or bilateralo Note: resonant, dull, flat, or hyperresonant
http://www.physicalexam.med.ualberta.ca/physical_exam/ASCM1/Physical_Examination/ascm1/Respiratory/index.htm
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Palpation - Fremitus
boy oh boy. . .toy boat. . .
blue balloon. . .
any low frequency phrase
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Palpation - Fremitus
• Bilateral comparison is key• Increased fremitus:o Consolidated lung (pneumonia)
• Decreased fremitus:o Pleural space filling (effusion or pneumothorax)
• This is sound transmission – travels best through solids and poorly through air
• What happens if there is consolidation with a small pleural effusion?
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Palpation - Fremitus
• Describing:o Location: which side, which lobeso Intensity: Increased or Decreased
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Digital Clubbing
• An important but uncommon manifestation in some pulmonary diseases
• NOT present in: COPD• PRESENT (maybe) in: lung cancer, pulmonary fibrosis,
chronic pulmonary infection
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Digital Clubbing
Mason: Murray and Nadel’s Textbook of Respiratory Medicine, 5th ed.Rutherford J D Circulation 2013;127:1997-1999
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Digital Clubbing
• Describing:o Presence (or absence)o Unilateral or bilateralo Timing of onset – 2 weeks is enough
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Putting it all togetherDisorder Inspection Palpation Percussion Auscultation
Bronchial asthma (acute attack)
Hyperinflation; use of accessory muscles
Impaired expansion; decreased fremitus
Hyperresonance; low diaphragm
Prolonged expiration: inspiratory and expiratory wheezes
Pneumothorax (complete) Lag on affected side Absent fremitus Hyperresonant or
tympanicAbsent breath sounds
Pleural effusion (large) Lag on affected side
Decreased fremitus; trachea and heart shifted away from affected side
Dullness or flatness Absent breath sounds
Atelectasis(lobar obstruction) Lag on affected side
Decreased fremitus; trachea and heart shifted toward affected side
Dullness or flatness Absent breath sounds
Consolidation (pneumonia)
Possible lag or splinting
Increased fremitus on affected side Dullness Bronchial breath
sounds
Fibrosis(End-stage)
Often normal; frequently nonproductive cough
Fremitus symmetric ResonantShallow breathing; late-inspiratory crackles