THE CHEST – PART IIPHYSICAL DIAGNOSIS

Dr Sham A. CaderDepartment Of Internal Medicine and Rheumatology

PHYSIOLOGY OF RESPIRATION

o The medulla (located in the brain stem just above the spinal cord) is the respiratory center. It is stimulated by the increased concentration of carbon dioxide and increased hydrogen ions.

o The lungs and circulation act together to bring gases to body tissues for gas exchange.

o Movement of oxygen into the lungs (inspiration) and removing carbon dioxide (exhalation) is called ventilation.

o Respiration occurs in the alveoli capillary system where there is an actual exchange of gases between the air and blood

Normal respiratory functioning-Depends on four essential factors

o The integrity of the airway system o Properly functioning alveolar system o Properly functioning cardiovascular

system o Muscle movements which provide the force

for ventilation. The diaphragm and the intercostal muscles are responsible for normal breathing

o The diaphragm is innervated by the phrenic nerve. If the phrenic nerve is damaged, the diaphragm on the affected side will be paralyzed. Accessory muscles of the abdomen, neck and back are used when the patient is having difficulty breathing.

o Adequate fluid intake is needed to produced thin watery mucous

o Respiration depends on perfusion. Greater activity leads to increased cellular oxygen need, greater cardiac output, and increased blood return to the lungs.

o Oxygen and carbon dioxide move through the alveoli. Most oxygen and carbon dioxide is carried by the heme part of hemoglobin. It binds with the molecule to create oxyhemoglobin.

o When the oxygenated blood reaches the body cells, there is an exchange of oxygen and carbon dioxide. This is called cellular respiration.

SYMPTOMS OF ACUTE HYPOXIA

o Dyspnea

o Elevated blood pressure with a small pulse pressure

o Increased respiratory and pulse rates

o Paleness

o Cyanosis

o Anxiety and restlessnes

SYMPTOMS OF CHRONIC HYPOXIA

o Altered thought processes o Headaches o Chest pain o Enlarged heart o Polycythemia -clubbed fingers - secondary to

polycythemia o Anorexia o Constipation o Decreased urinary output

o Weakness of extremity muscles

FACTORS AFFECTING RESPIRATORY FUNCTIONING

o HEALTH -Persons with renal or cardiac problems often have respiratory problems related to fluid overload

o DEVELOPMENT- Scoliosis- Obesity and pregnancy

o NARCOTICS AND ANALGESICS

Versed and Valium can cause respiratory arrest particularly if given IV push at too fast a rate.

o LIFE-STYLE

Smoking decreases lung ciliary action, decreases production of surfactant, and increases blood pressure due to nicotine absorption.

Smoking is measured in pack-years. To calculate, take how many packs a day the person smokes, times the number of years the person has smoked

o ENVIRONMENT

Smoke, and irritating fumes (butane, paint thinner, glue) can lead to upper respiratory irritation such as laryngitis

o PSYCHOLOGIC HEALTH

Stress can lead to excessive sighing or hyperventilation.

Anxiety has be linked to bronchospasm and bronchial asthma.

Hyperventilation

o SUDDEN anxiety or "panic attacks" can be accompanied by hyperventilation.

o Common symptoms of anxiety attacks with hyperventilation include: nervousness, palpitations, increased respiratory rate, numbness, and tingling around mouth, tip of nose, and finger tips.

o Continued hyperventilation will result in respiratory alkalosis, nausea, lightheadedness, fainting, and cramping of the hands.

ASSESSING RESPIRATORY FUNCTIONING

• INSPECTION The anterior-posterior diameter should be less

than the transverse diameter Movement of the chest should be symmetrical Skin should be warm and dry No cyanosis or pallor Respiratory rate 16 to 24 per min for adult Flaring nostrils, intercostal retractions,

tachypena, or bradypnea needs evaluation.

PALPATION

• Trachea equidistant from each clavicle • Vocal fremitus - bilateral equal mild fremitus • Increased fremitus is seen with pneumonia. • Decreased or absent fremitus is noted in

COPD. • The presence or absence of crepitations, masses,

edema, or tenderness should be noted

PERCUSSION

• Resonance is heard over the normal lung • Emphysematous lungs have loud low, booming

sound (hyperresonance). • Dull sound over liver is normal. Dullness over the

lung field occurs when fluid or solid tissue replaces normal lung tissue and requires investigation.

• Dullness over the lung field is indicative of the following conditions: pneumonia, hemothorax, and lung tumors

AUSCULTATION

• The client should breath through his open mouth slowly.

• If abnormal sound is heard, have the client cough and listen again.

• Location, change in breath sounds after coughing, and heard of inspiration or expiration should be noted

Adventitious Breath Sounds

• Crackles (Rales)

Crackling sounds caused by air passing through moisture in the alveoli or bronchioles. Heard in Bronchitis, Pneumonia, Pulmonary edema, CHF, Interstitial fibrosis

• Rattles (Rhonchi)

o Coarse rattling/bubbling sounds from fluid or obstructions in large airways. Sounds tend to change with coughing

o Heard in Chronic bronchitis, Tumors, Pneumonia and COPD

• Squeaks or Wheezes

o Squeaky, musical sounds associated with air squeezing through narrowed airways

o Bronchospasm (asthma) Edema, Tumors, RSV

• Rubs (Pleural friction rubs)

o Rough, grating, scratching sounds caused by inflamed surfaces of the pleura rubbing together. Usually associated with pain on deep inspirations.

o Pleurisy, TB, Pneumonia, and Lung Cancer

PROBLEMS ASSOCIATED PROBLEMS ASSOCIATED WITH THE UPPER WITH THE UPPER

RESPIRATORY TRACTRESPIRATORY TRACT

Epistaxis

• Most caused by injury o Irritation, dryness, Inhalation of drugs High blood pressure

and blood clotting abnormalities

o Most nosebleeds occur in the front part of the nasal septum

o In most cases, nasal bleeding can be controlled easily by tilting the head forward and using a firm 15 minute nose pinch (include the soft bulb of the nose)

o If the patient is currently taking anticoagulants be sure to notify the MD.

o It is important not to pick, rub, or blow after bleeding has stopped.

o Avoid hot liquids. Aspirin and smoking can also promote bleeding.

o If the bleeding cannot be controlled, the clots may need removed and a nasal packing inserted to stop the bleeding.

o The nasal pack may be left in for 1-2 days before removal

Allergic Rhinitis

o Inflammation and irritation of the nasal mucosa in response to allergic stimuli: pollen, dust, dander, fungus, molds, foods, grasses

o Symptoms: clear nasal discharge, itchy nose, sneezing, watery and itchy eyes.

o The nasal mucosa may appear pale, engorged, and bluish grey in client with allergic rhinitis.

o To exam-tilt the clients head back and use a pen-light.

o Evaluation will involve physical exam of the nasopharanax for signs of pale edematous mucosa and nasal polyps, which are a frequent complication of allergic rhinitis.

o May involve allergy testing with conventional skin testing, or blood testing.

o Sinus x-rays may be performed to rule out sinus infection

Upper Respiratory Infections or Colds

o The "common cold" is the most common infectious upper respiratory illness (URI).

o Viral infection transmitted by inhalation or self-innoculation

o Frequent hand washing prevents spread o Usually lasts 3-7 days o Symptoms are congestion, runny nose with clear

to white mucous, sneezing, watery eyes, sore throat and dry cough.

o Dark yellow or green nasal drainage could indicate a bacterial infection such as sinusitis.

o Treatment - Good nutrition, vitamins, plenty of fluids, and rest. Decongestants and antihistamines, and cough suppressants can help with the symptoms

o Persistent symptoms, high fevers, chills, dark colored nasal drainage, productive cough, shortness of breath, or chest pains on coughing could indicate a more serious infection

Sinusitis or Sinus Infection

o Viral or bacterial infection of the sinuses

o Pt with allergic rhinitis have greater incidence of Sinusitis.

o Common symptoms of sinusitis

o runny nose, posterior nasal drip, yellowish or greenish nasal discharge, dull facial pain or headache in the area of the sinuses is common. Cough can develop secondarily post-nasal drip .

o Sinus headaches frequently become worse with position changes

Evaluation

o History and physical examination

o Palpation will increase pain.

o X-rays - Sinus Series

o Culture and Sensitivity

o CT scan if indicated

Tonsillitis and Pharyngitis

o Inflammation of the pharynx and/or tonsils from a viral or bacterial infection

o Often coexist and are treated in the same manner

o Majority of cases are viral -But a culture needs done to rule out strep throat

o antibiotics will have no effect on viral pharyngitis

Symptoms of viral pharyngitis

o Red painful throat, hoarse voice, but usually no great difficulty with swallowing, and no difficulty opening the mouth

o Treatment of viral pharyngitis

Rest, fluids, Tylenol, anesthetic lozenges and gargling with warm saline.

PROBLEMS ASSOCIATED WITH THE LOWER RESPIRATORY

TRACT

• Laryngitis and Voice Strain -Inflammation of the larynx

o Viral infection in the larynx or secondary to postnasal drip

o Voice strain can cause mechanical laryngitis

Symptoms

o Hoarse or raspy voice o May be associated with a sore throat, fever,

posterior nasal drip, or congestion of the sinuses.

o It should not be accompanied by difficulty swallowing food or fluids. This symptom could indicate epiglottitis or peritonsillar abscess

Evaluation

• History and physical examination • Direct visual inspection of the throat done to

check for signs of bacterial infection • In questionable cases, x-rays of the neck may be

useful to diagnose more serious bacterial upper airway infections. A throat culture may be needed to exclude the possibility of strep throat.

• Any hoarseness of greater than 3 weeks duration Any hoarseness of greater than 3 weeks duration should be evaluated by a physician or ENT specialist.should be evaluated by a physician or ENT specialist.

Laryngeal Cancer

Laryngeal Cancer

• Laryngeal Tumors can initially result in a hoarse voice, or, in more serious cases, the total blockage of the airway.

• Slow onset of a hoarse voice occurring over a period of weeks

• Laryngeal cancer is most commonly seen in those over 40 years of age who smoke or "chew" tobacco

INFLUENZA

• Etiology• Viral upper respiratory infection that commonly

affects a large percentage of children and adults • Occurs more often in the winter months • Transmitted through inhalation of particle

droplets • Wide variety of viruses responsible for flu-like

illness • Incubation period 1 to 6 days before onset of

symptoms

• Viral upper respiratory infections can lead to pneumonia and sinusitis

• Children are commonly infected because they transmit these infections so easily.

• Flu in the elderly patient, more serious, can lead to a secondary bacterial infection with dehydration

Symptoms

• Fever, chills, runny nose, sore throat, swollen lymph nodes, frontal headache, muscle and body aches, joint pains, dry cough, pleurisy with coughing, and weakness

• Children and infants can have wheezing, particularly in a related infection, known as bronchiolitis

Evaluation

o H&P rule out bacterial infection

o CBC, blood cultures, and Chemogram as indicated

o Chest x-ray to rule out pneumonia as indicated

o Urinalysis to rule out UTI may be indicated

Treatment

• Flu is usually nonserious and self-limited • Observe for signs of dehydration in infants and elderly • Rest, nutrition, fever control, fluids , avoid alcohol

and caffeine • Wheezing may require bronchodilators, Cool mist

vaporizer can reduce congestion in children • Saltwater nose drops followed by suctioning with a

bulb syringe are helpful in infants • Vaccines against certain viruses (flu shot) have been quite successful

and may be indicated in the elderly, diabetics, health-care workers, and other high risk groups.

BRONCHITIS

• Etiology and Symptoms• Inflammation of the bronchi in the lungs, most

often occurs secondary to a bacterial infection in the airways

• Bronchitis common in the smoking population • Smokers have difficulty clearing their

secretions (mucus) due to impaired ciliary action and have diminished immunity against infection.

• Productive cough (in smokers, may be bloody) fever, and chills, Shortness of breath is seen in more severe cases

• Similar symptoms to pneumonia

• Smokers may develop expiratory wheezes, breathing OUT more difficult than breathing IN.

PNEUMONIA

Symptoms • Productive cough, fever, shaking chills and extreme

fatigue • Examination will usually reveal rales on asculatation, • WBC over 11,000 cu/ml • Consolidation on the chest x-ray • Crackling rales are likely to be heard anytime there is

fluid in interstitial and alveolar areas. • More severe pneumonia - associated SOB and/or

pleuritic chest pain (pain worse with coughing and movement).

Evaluation

• History and physical examination for evidence of fever or upper respiratory infection

• A chest x-ray can diagnose pneumonia, and, in most cases, is necessary for definitive diagnosis.

• CBC, Blood Cultures, Chemogram and sputum cultures may be indicated

• ABG's for evaluation of oxygenation in those who are short of breath.

PLEURISY AND PLEURITIS

Etiology/ Symptoms• Pleura of the lung become inflamed • Resulting chest pain is known as pleurisy • Pain is sharp or "knife-like", and increases in

severity as the patient breathes in • Pleurisy is often one-sided and can radiate pain

to the neck or shoulder. • Movement of the thorax, including bending,

stooping, or even turning in bed can increase pleural pain

• Shortness of breath with pleurisy may indicate a more serious problem such as pulmonary embolism

• Pleurisy can easily confused with chest wall pain which is much less serious. Chest wall pain can sometimes be distinguished from pleurisy by pressing down (palpation) on a region of the chest wall which will reproduce pain in the patient

Causes of pleurisy

• Pneumonia (viral or bacterial)

• Pulmonary Embolism

• Pneumothorax

• Lung cancer

Evaluation

• Chest x-ray to rule out pneumothorax or pneumonia.

• Those short of breath may require ABG's.

• May need an EKG to exclude the possibility of angina (angina pain in rare cases can be pleuritic in nature)

EMPHYSEMA

• Etiology• Chronic progressive disease • Enlargement of air spaces - destruction of the

alveolar walls by enzymes. • Smoking is primary cause but any continuous

irritant (coal dust) can destroy alveoli. • Deficiency of alpha-antitrypisn (an enzyme

inhibitor) also indicated in the development/ progression of emphysema.

• Enzymes in the lung destroy elastic structure around the alveoli; resulting in loss of elasticity, stiffening of the lungs, and decreased compliance.

• The loss of alveolar function diminishes lung recoil (like an overstretched elastic band) and weakens expiration.

• The lung therefore remains partially expanded following expiration, producing air trapping and a visible barrel chest over time.

Symptoms

• Chronic cough • Dyspnea - hallmark of emphysema, worsens

over time, may be present even at rest and is severe on exertion.

• Pursed-lip breathing with prolonged expiration. • Barrel chest • Use of accessory muscles • Hyperresonance on percussion • Decreased vocal fremitus on palpation.

• Distant Breath and heart sounds • Anorexia, Weakness, Decreased muscle, Weight

loss • The patient remains acyanotic until very late in

the disease because of compensatory mechanisms. Thus, emphysema patients are referred to as "pink puffers" as opposed to the oxygen-starved "blue bloaters" with chronic bronchitis.

RESPIRATORY EMERGENCI

• PNEUMOTHORAX-• Air in the chest cavity - leads to collapsed lung• Common symptoms of a pneumothorax include

the sudden onset of breathing difficulty, accompanied by chest pain (pleurisy) that INCREASES while breathing in. Will also have diminished lung sounds on the affected side. CXR will show collapsed lung.

HEMOTHORAX -collection of blood

within the chest cavity

• Common symptoms include: chest pain, difficulty in breathing, and hemorrhagic shock, if the accumulation of blood in the chest is massive.

• Evaluation includes a chest x-ray which allows diagnosis and estimation of the hemothorax size. Blood tests (CBC) to check blood counts will help gauge the overall extent of blood loss.