Respiratory System Physical Diagnosis Course I

History…

Daniel Eshetu

Learning Objectives

• Revise basic anatomic landmark of the

respiratory system

• Know how to assess respiratory

symptoms

• Follow the cardinal steps in physical

Examination of respiratory system

examination

• Identify Normal finding of chest

• Appreciate the abnormal findings and their

clinical relevance

Outline

• Anatomic landmark of Chest wall

• Respiratory symptoms

• Respiratory Physical Examination

• Normal Findings

• Overview of abnormal finding and their

clinical correlation

Anatomy ...Lungs,Lobes,Fissures

• Anterior: apex of each lung rises

about 2 -4 cm above clavicle

• The lower border:crosses 6th rib

at midclavicular line & 8th rib at

the midaxillary line

• Posterior: lower border of the

lung lies at the level of the T10

spinous process

Anatomy ...Lungs,Lobes,Fissures

• Each lung is divided roughly in half by an

oblique (major) fissure

• Approximated by a string that runs from the

T3 spinous process obliquely down and

around the chest to the 6th rib at the

midclavicular line

• The right lung is further divided by the

horizontal (minor) fissure. Anteriorly, this

fissure runs close to the 4th rib and meets

the oblique fissure in the midaxillary line

near the 5th rib

Rt Lung has 3 lobes & lt lung has 2 lobes

Locations on the Chest- External terms

• Supraclavicular—above the clavicles

• Infraclavicular—below the clavicles

• Interscapular—between the scapulae

• Infrascapular—below the scapula

• Bases of the lungs—the lowermost portions

• Upper, middle, and lower lung fields or

zones

Anatomy…Trachea & main

bronchus

• The trachea

bifurcates into its

mainstem bronchi

at the levels of the

sternal angle

anteriorly and the

T4 spinous process

posteriorly

History taking in patients with

lung disease

Symptoms: onset, duration, triggers, and

severity

Underlying illnesses

Family history

Environmental exposures

Smoking history

Cough

Mechanism of Cough

• Cough is a protective mechanism for

removing irritants from the airways.

• The cough reflex arc includes the following

components:

– Cough receptors

– Afferent pathway (glossopharyngeal nerve)

– Cough center (medulla)

– Efferent pathway (abdominal muscles,

intercostals, diaphragm, glottis, and vocal cords

Cough…Ask

• Is dry or productive of sputum?

• Duration of cough? Acute Vs Chronic

• Is the cough worse at any time of day or

night?

• Is the cough aggravated by anything, for

example dust, pollen or cold air?

• Associated symptoms?

Common Causes of Acute Cough

• Infectious causes of acute cough include:

– Viral upper respiratory infections

– Pertussis

– Sinus infections

– Acute bronchitis

– Pneumonia

Common Causes of Cough

• Noninfectious causes of acute cough

include:

– Flare-ups of chronic conditions such as chronic

bronchitis, emphysema, and asthma

– Environmental allergies and irritants

Common Causes of Chronic

Cough• Infectious causes of chronic cough include:

– Tuberculosis

– Fungal disease

• Noninfectious causes of chronic cough include:

– Airway disease (Asthma/COPD/bronchiectasis)

– Post nasal drainage

– Gastroesophageal reflux

– Ace inhibitors

Phlegm or sputum

Mechanism of Mucus Production• Benefits of mucus

– ability to trap and eliminate inhaled particles and to

prevent desiccation of airway surfaces

• Mucins are high–molecular-weight glycoproteins that

are the chief components that render viscoelastic and

gel-forming properties to mucus

• Known stimuli include:

– exposure to inhaled allergens

– parainfluenza virus

– bacterial lipopolysaccharide

– neutrophil elastase

– various cytokines

Sputum…

• Characterize:

Colour – green or yellow(purulent)

Consistency

Odor

Volume

Hemoptysis

Hemoptysis

• Hemoptysis is the coughing up of blood

from the lungs; it may vary from blood-

streaked phlegm to frank blood

• Assess Volume of blood (Massive> 200-

600 ml of blood > 24hr)

• Differentiate it from Hematemesis: Color,

associated symptoms

Mehanisms of Hemoptysis

• Bleeding from:

– congenital or acquired abnormal bronchial or

pulmonary blood flow, venous obstruction, or

vascular abnormalities

– immune-mediated endothelial damage

– infectious or traumatic erosion of tracheal,

bronchial, or bronchiolar epithelium.

Common Causes of Hemoptysis

• Hemoptysis can be caused by a range of disorders.

• Acute bronchitis is the most common cause, especially

in smokers.

• Other common causes (“Battle Camp”):

– bronchiectasis, aspergilloma, tumor, tuberculosis,

lung abscess, emboli, coagulopathy, autoimmune

disorders, AVM, alveolar hemorrhage, mitral

stenosis, pneumonia

Wheeze

Mechanism of Wheeze

• The American Thoracic Society Committee on

pulmonary nomenclature defined wheezes as high-

pitched continuous sounds with a dominant

frequency of 400 Hz or more

• In contrast, rhonchi are characterized as low-

pitched continuous sounds with a dominant

frequency of about 200 Hz or less

Common Causes of Wheeze

• Not all that wheezes is asthma:

– CHF

– COPD

– Aspiration

– Pulmonary Embolism

– Bronchogenic Carcinoma

Dyspnea

Dyspnea

• Dyspnea is a non painful but uncomfortable

awareness of breathing that is

inappropriate to the level of exertion

• Determine its severity based on the

patient’s daily activities

• Assess timing and setting of dyspnea, any

associated symptoms, and relieving or

aggravating factors

Mechanism of Dyspnea

• Increased neural output to the respiratory

muscles

• A limited ventilatory response due to

weakness, paralysis, or increased

mechanical load generates afferent

information from vagal receptors in the

lungs (and possibly mechanoreceptors in the

respiratory muscles) to the sensorimotor

cortex and results in the sensation of

dyspnea

Common Causes of Dyspnea

• Acute Dyspnea (PPOPPA)

– Pulmonary Embolism

– Pulmonary Edema

• Pulmonary: Noxious gas inhalation, HAPE

• Cardiogenic: Congestive Heart Failure

– Obstructed Airway (foreign body, epiglottis)

– Pneumothorax (spontaneous)

– Pneumonia

– Asthma or COPD

Common Causes of Dyspnea

• Chronic Dyspnea > 1 Month

– COPD and Asthma

– Restrictive Lung Disease

• Interstitial lung disease

• Kyphoscoliosis

• Neuromuscular disease (e.g. Myasthenia Gravis)

– Congestive heart failure

– Anemia

– Obesity/Deconditioning

Environmental Exposures

Household Air Pollution

Environmental Exposure

Cigarette Smoking

Comparison of Smoking In Ethiopia and

the USA

• Ethiopia (2010: World Bank)

– 8.1% of men smoke

– 0.5% of women smoke

– Overall prevalence is increasing

• USA (2007: CDC)

– 22.3% of men smoke

– 17.4% of women smoke

– Overall prevalence is decreasing

Smoking

• Smoking is assessed as pack years

• Smoking causes lung cancer

• Smoking causes airways diseases (e.g.,

emphysema, bronchitis, chronic airway

obstruction

Smoking Cessation

Five A’s To Help Patients Quit Smoking

• Ask

• Advise

• Assess

• Assist

• Arrange

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