THE RESPIRATORY SYSTEMCONTENTSI. GENERM4TIES1.1. History1.2. Family and social history1.3. Occupation and other enviromental hazardsn. SYMPTOMS OF RESPIRATORY DISEASES 2. l.Thoracic pain2.2. Dyspnoea2.3. Wheeze2.4. Cough2.5. Sputum

2.6. Haemoptysisffl. THE PHYSICAL EXAMINATION OF RESPIRATORY SYSTEM3.1. The external feature of respiratory disease3.2. General inspection3.3. Examination of the chest: inspection -palpation -percussion auscultationIV.RESPIRATORY SYNDROMES4.1. Bronchial syndromes4.2. Consolidation syndromes4.3. Pulmonary tuberculosis syndrome4.4. Pulmonary suppurative syndrome4.5. Airways obstruction syndrome4.6. Pleural syndromes4.7. Chronic obstructive pulmonary disease4.8. Pulmonary insufficiencyV.FURTHER INVESTIGATIONS OF THE RESPIRATORY SYSTEM5.1.Radiological examination radiography tomography pulmonary angiography fluoroscopy5.2. Examination of the sputum5.3. Examination of the blood5.4. Intradermal tests5.5. Tests of respiratory function5.6. Bronchoscopy5.7. Bronchoalveolar lavage5.8. Bronchography5.9. Pleural aspiration and biopsy5.10.Lymph node biopsy5. ll.Lung biopsy

12111. GENERALITIES 1.1. HISTORYThe approach to history taking in patients thought to have respiratory disease differs according to the nature of the illness, the main distinction being between an acute or subacute illness and a chronic respiratory disorder.In an acute respiratory illness it is always important to enquire carefully about the onset of the illness which may provide a valuable clue to its nature. In pneumococcal pneumonia, for example, systemic disturbance (rigor, pyrexia, malaise) seldom precedes the first respiratory symptom (often pleural pain) by few hours, while in viral pneumonia the patient may be generally unwell for several days before there are any symptoms or signs to suggest pulmonary involvement.Acute dyspnoea represents a symptom of particular importance since it often demands urgent treatment, and an error in diagnosis between, let's say, tension pneumothorax, an acute attack of bronchial asthma, and left heart failure may have catastrophic consequences.In chronic disorders history-taking is always a complex and time consuming procedure. In the case of acute episodes, such as exacerbations of chronic bronchitis, an enquiry should be made into the events which preceded them on the course of the disease.The course of disease may be adversely influenced by treatment of coexisting disorders, for example, a beta-adrenoreceptor blocking drug for hypertension or angina in a patient with chronic asthma. The influence of environmental factors, such as weather and time of year, changes of temperature and exposure to smoke and dust, should always be recorded.1.1 FAMILY AND SOCIAL HISTORYThe family history of patients with respiratory disease may be singnificant in three ways:1.certain infections, notably tuberculosis, may be transmitted from one person to another. In such cases a history of contact with an infected person is, of course, more important than the family relationship.2.in allergic disorders, such as some bronchial forms of asthma, there is often an inherited predisposition, and a family history is not uncommon.3.in chronic bronchitis, although an inherited predisposition cannot be excluded, the liability of several members of one family to develop the disease is more likely to be related to the conditions under which they all live. Social problems, such as housing, finance and employment, loom large in the management of patients with all types of chronic respiratory disease and should be fully documented in every case.Cigarette smoking is now accepted as the most important cause of bronchial carcinoma and chronic bronchitis. A smoking history should include details such as the time when regular smoking started, the average consumption of tobacco and the age when cough started being productive.1.3. OCCUPATION AND OTHER ENVIROMENTAL HAZARDSSince both acute and chronic respiratory disease may be caused by the inhalation of certain inorganic and dust and chemical substances, it is important to record a complete occupational history, covering both present and previous employment.Such hazards may be encountered by workers in the coal, iron and steel, and pottery industries, by stonemasons and farm workers, and by those who are liable to inhale asbestos dust and chemical substances, such as isocyanates, in the course of their work. Whenever such an occupational history is obtained detailed information should be obtained regarding the degree and duration of exposure, and its time relationship at the onset of symptoms. This may establish a diagnosis of occupational asthma or allergic alveolitis.Persons in close contract with pigeons, parrots, buderigars or canaries may develop allergic alveolitis or psittacosis, while atopic subjects may develop allergic rhinitis or bronchial asthma when exposed to allergens such as pollen, house dust or certain types of fungal spores.fill. SYMPTOMS OF RESPIRATORY DISEASESThe six principal symptoms of respiratory disease are: 2.1. thoracic pain 2.2. dyspnoea 2.3. wheeze 2.4. cough 2.5. sputum 2.6. haemoptysis2.1. THORACIC PAINGENERALITIES3

In practice, by far the most common cause of severe thoracic pain in the middle-aged or elderly is ischaemic heart disease.

Pain worsening on breathing is almost always pleuritic in origin, and in a woman on the oestrogen containing contraceptive pill or in a post-operative patient it should suggest a pulmonary embolus. Trauma is a likely cause in the young whilst extra-thoracic causes increase in frequency with advancing age. In any case, by anamnesis we must precise: the type of onset of the pain location radiation character duration incidence

aggravating and relieving factors associated symptoms TYPE OF ONSET can be:

acute in pneumonia, pleuresy, pneumothorax, pulmonary embolism

chronic: bronchial cancer, pleuresy LOCATION AND RADIATION retrosternal: if the pain radiates to shoulder, arm, it orients you to cardiac disease; if it does not radiate it can suggest an acute tracheitis, laryngotracheitis, esophagities, cancer of the oesophagus

anterior pain suggests sufferance of anterior mediastinum

-apexian pain usually appears in tuberculosis, neoplasmDURA TIONAND INCIDENCEThe time and circumstance of the first appearance of the pain should be ascertained and whether the incidence is sudden, diurnal, episodic or constant. A sudden onset is seen in such major disorders as myocardial infarction, pulmonary embolism, pneumothorax, or vertebral collapse.

AGGRA VA TING OR RELIEVING FACTORSIn cardiac diseases pain is often aggravated by exertion or emotional stress. It is relieved by rest and in case of angina, it dramatically ceases by the administration of trimtroglycerin.

Pleuritic pain is increased by coughing and deep inspiration whilst pain arising from the spine is often increased by sneezing, blowing the nose and movement. Changes of posture such as lying down or bending encourage oesophageal reflux, and the pain of reflux oesophagitis is usually relieved by milk or antacids.

ASSOCIA TED SYMPTOMSCardiac disorders are often associated with dyspnoea, palpitations and oedema of the lower limbs. Cough, especially if there is purulent or bloody sputum, points to a pulmonary cause, whilst dysphagia is almost always of oesophageal origin. Anorexia and rapid weight loss are ominous symptoms which may suggest an underlying carcinoma of the oesophagus or bronchus. Both are known to be commoner in the heavy smoker.

CAUSES OF THE THORACIC PAINThoracic pain has been classified as having intrathoracic, thoracic wall and extrathoracic causes. The most frequent of these causes are those which lie within the chest The intrathoracic pain can have respiratory, cardiovascular and oesophageal causes.

/. INTRATHORACIC CAUSESA.RESPIRATORY CAUSES:

pneumonia

pleurisy pulmonary embolism

pneumothorax

neoplasm

tracheitis

B.CARDIOVASCULAR CAUSES:

angina pectoris

myocardial infarction

pericarditis

cardiomyopathy

aortic aneurysm

C.ESOPHAGEAL CAUSES:

esophagitis

esophageal spasm

esophageal carcinoma //. THORACIC WALL CAUSES:A. NON-INFLAMMATORY CAUSES:

trauma

Tietze's disease

4 ostheo-arthritis osteoporosis osteomalacia Paget's disease neoplasmB. INFLAMMATORY CAUSES: herpes Zoster Bomholm disease tuberculosis of the bones ankylosing spondylitis ///. EXTRATHORACIC CAUSES cervical spondylosis gall stones hepatic abscess subphrenic abscess splenic disease psychogenic causes. DIAGNOSTIC APPROACHThree types of chest pain are directly due to respiratory disease:l.upper retrosternal pain of the type experienced in acute tracheitis;2.retrosternal pain associated with lesions of the mediastinum, e.g. tumors, acute mediastinitis and mediastinal emphysema. This type of pain, which is an uncommon but important symptom, has a constrictive or oppresive character similar to that of cardiac pain and may radiate into the arms or neck, but is seldom severe and is not related to exertion.3.pleural pain caused by stretching of an inflamed parietal pleura, can occur in all forms of pleurisy. Identical pain is produced by fractures of ribs. Pleural pain is recognised by its sharp, stabbing character and its relationship to breathing and coughing. It may be present only at the end of a deep inspiration or during cough; in a more severe status -even a shallow breathing may produce intense pain. The pain is aggravated by exertion and occasionally by movements of the thoracic spine. Pleural pain often, but not invariably, subsides when an effusion develops.In spontaneous pneumothorax pleural pain may be present, particularly if the amount of air in the pleural space is small. More often, however, after a brief mitral episode of severe unilateral pain the patient complains mainly of tightness across the front of the chest, which may later become localised to the affected side. Rarely, there may be central retrosternal pain resembling that of myocardial infarction, with radiation into the neck and upper limbs. This type of pain may be due to mediastinal emphysema and spontaneous pneumothorax which associates with it occasionally. Other intrathoracic disease may produce central chest pain, e.g. lesion of the heart arid great vessels or/of the oesophagus. Piercing unilateral chest pain may be due to involvement of a spinal nerve root by a vertebral lesion or by herpes zoster.Pain caused by invasion of the chest wall by a malignant pulmonary tumor or by a metastatic deposit in a rib is constant, severe, aching and usually unrelated to breathing, while that produced by simple rib fractures or Coxsackie B infection (Bornholm's disease) resembles pleural pain. Chest pain in the absence of organic disease may be a manifestation of anxiety.2.2. DYSPNOEADEFINITIONDyspnoea is a subjective complaint and represents the patient's perception that breathing is excessive, difficult or uncomfortable.It is described like: breathlessness, shortness of breath, the sensation of difficult, labored or uncomfortable breathing.CAUSES OF DYSPNOEAA. RESPIRATORY CAUSES:obstruction - foreign body anaphylactic reaction -tetanus

poliomyelitis invasive thyroid cancer bronchial asthma bronchitis emphysema bronchial/lung carcinoma pneumonia pneumothorax pleural effusion pneumoconiosis5 extrinsec fibrosing alveolitis cryptogenic fibrosing alveolitis sarcoidosis pulmonary embolism B. CARDIAC CAUSES: heart failure - especially left heart failure coronary heart disease myocardial infarction valvular disease: aortic stenosis, mitral stenosis congenital heart disease pericarditisC GENERAL CAUSES: drugs: aspirin, p-blockers hyperthyroidism Addison's disease terminal renal failure anxiety state TYPES OF DYSPNOEAL PHYSIOLOGIC DYSPNOEA the most common type of dyspnoea is that associated with physical exertion also common during acute hypoxia, as at high altitude2.PULMONARY DYSPNOEAa.Restrictive dyspnoea - due to low compliance of the lungs or chest wall (e.g. pulmonary fibrosis or chestdeformities). These patients are ussually comfortable at rest but become intensely dyspneic when exertion causes pulmonaryventilation to approach their greatly limited breathing capacity.b.Obstructive dyspnoea - due to high airway resistance (e.g. obstructive emphysema or asthma).In this type increased ventilatory effort induces dyspnoea even at rest and breathing is labored and retarded, especially during expiration.3.CARDIAC DYSPNOEAa* Cardiac asthma is a state of acute respiratory insufficiency accompanied by severe breathlesness. Its manifestations may be indistinguishable from other types of asthma, but it originates in failure of the left ventricle.b. Periodic or Cheyne-Stokes respiration is characterized by alternate periodes of apnea and hyperpnea, often including both neurologic and cardiologic componente. In heart failure, slowing of the circulation is the predominant cause; acidosis, and hypoxia in the respiratory centres contribute importantly.a Orthopnea is the respiratory discomfort that occurs while the patient is supine (thus impelling him to set up). It is precipitated by an increase in venous return of blood to left ventricle. Orthopnea, usually a manifestation of left ventricular failure, sometimes occurs in other cardiovascular disorders (e.g. pericardial effusion).d. Paroxysmal nocturnal dyspnoea - (which may be dramatic and terrifying) the patient awakens gasping for breath. It may occur in mitral stenosis, aortic insufficiency, hypertension, or other conditions affecting the left ventricle.4.CIRCULATORY DYSPNOEA "air hunger" (acute dyspnoea occuring in the terminal stages of exsanguinating haemorrhage) also occurs with chronic anemia, coming on only during exertion.5.CHEMICAL DYSPNOEA could be: KussmauTs breathing, diabetic acidosis (blood pH 7,2~6,95) induces a distinctive pattern of slow, deep respiration in fburtimes: deep inspiration - apnee, deep expiration - apnee

in uremia the patient may complain of dyspnoea because of severe panting brought about by a combination of acidosis, heart failure, pulmonary edema and anemia.

6.CENTRAL DYSPNOEA-Biot's respiration: central lesions such as haemorrhage are often associated with intense hyperventilation that issometimes noisy and stertorrous and occasionaly irregulary periodic. It is also called agonic respiration.7.PSYCHOGENIC DYSPNOEA. Hie hysterical types of overbreathing are the most common: in one type there is continous hyperventilation, sometimes leading to acute alkalosis from "blowing of C02, and positive Trousseau's and Chvostek's signs from lowered senium calcium ion levels.. other type is characterized by deep, sighing respirations, the patient breathing at .naxin^ depth until respiration "is satisfactory", at which time hyperventilatory impulse subsides. DIAGNOSTIC APPROACHThis will vary with the type of onset and age of the patient.Sudden breathlessness may tesult from: spontaneous pneumothorax pulmonary embolus myocardial infarction rapiddly forming pleural effusion obstruction by a foreign body in the air passages.6 Paroxysmal bouts of dyspnoea are ussually due to asthma and may be precipitated by an upper respiratory infection, exertion, emotional upsets or exposure to a potential allergen.Progressive dyspnoea at first only at exertion, at the beginning, is commonly due to: chronic bronchitis emphysema diffuse pulmonary fibrosis ischemic heart disease.In childhood acute respiratory infections and asthma are the the most common causes of expiratory dyspnoea.In the very young age a very frequent cause of inspiratory dyspnoea it is an inhaled foreign body. When taking a history in adults it is very important to enquire about previous illnesses, drugs recently taken, smoking habits, hobbies and occupations.a sudden onset with chest pain in a healthy young man is probably caused by a spontaneous pneumothorax, but similar symptoms in a woman on the contraceptive pill or during the last trimester of pregnancy are more likely to be due to pulmonary embolism;the inhalation of fumes or dust at work in susceptible individuals may provoke attacks of occupational asthma or the insidious pulmonary fibrosis of extrinsic fibrosing alveolitis. Farm workers and bird founder are obvious victims but many others work in enviroments where exposure to industrial dusts is common place. Miners, stonemasons, foundrymen, sandblasters and those who work with asbestos, in one form or another are liable to develop pneumoconiosis and massive fibrosis may occur long after they have moved to safer occupations. Cigarette smoking may exacerbate these dust diseases quite apart from its role in causing chronic bronchitis and emphysema. With advancing age cardiovascular causes assume increasing importance.Associated symptoms must be noted for they will often point to the most probable cause (e.g. chest pain will, as a rule, be prominent on myocardial infarction, pulmonary embolism, pleurisy and pneumothorax). Cough, haemoptysis and fever may be present in both respiratory and cardiac disorders.The extent of the physical examination will obviously depend upon the circumstance but should always involve a thorough examination of chest and the cardiovascular system. Clubbing of the fingers is seen in congenital heart disease, bacterial endocarditis, bronchiectasis, bronchial carcinoma, tuberculosis and disorders which give rise to progressive pulmonary fibrosis.2.3. WHEEZEWhen a patient complains of wheeze it is important first to discover what this term means:Some patients use it merely to describe noisy and laboured breathing while others apply it to rattling of secretions in the upper air passages. Wheeze should, however, be applied only to the musical sounds produced by the passage of air through narrowed bronchi. It is invariably louder during expiration and is often confined to that phase of the respiratory cycle. It is always more conspicuous during deep breathing and sometimes may become audible only when the depth of respiration is increased. Many patients become too accustomed to wheeze that they cease to be aware of its presence until a relative or friend draws attention to it.Another sound is stridor.Patients with stridor may describe it as wheeze. Care must be taken to distinquish between these two sounds because stridor is usually caused by local obstruction of a major airway, a tumor or an inhaled foreign body, and thus demands urgent investigation and treatment2.4. COUGHDEFINITION: an explosive expiration required for the self-cleaning of the lungs. It is a reflex act generaly arising from stimulation of the mucosa of the airways. CAUSES OF COUGHA.CAUSES IN RESPIRATORY TRACT: laringo-tracheo-bronchitis (croup) whooping cough laryngitis laryngeal neoplasm acute bronchitis chronic bronchitis bronchiectasis asthma bronchial neoplasmB.CAUSES IN THE LUNGS: pneumonia abscess tuberculosis7 fibrosis embolism C. CARDIAC CAUSES:cardiac failure - left ventricular failureTYPES OF COUGHThe frequency, severity and character of cough are dependent on several factors including: the situation and nature of the lesion responsible for the cough the presence or absence of sputum coexisting abnormalities such as vocal cord paralysis, impairment ventilatory function and pleural pain COUGH produced by stimuli arising in the pharyngeal mucosa occurs in pharingitis or may be caused by secretion trickling down the posterior pharyngeal wall from the nasal sinuses. It is typically a persistent cough, but may be paroxysmal.

COUGH arising in the larinx has a harsh barking quality and may be painful, especially in acute laryngitis. If a vocal cord is paralysed, a cough, whatever its site of origin will cease to be as effective in clearing the respiratory tract of secretion.

WHOOPING-COUGH is characterized by prolonged severe paroxysms culminating in a long, stridulous inspiratory whoop produced by laryngeal spasm.

COUGH arising in the trachea is usually caused by tracheitis in which it is harsh, dry and painful at first, becoming loose, productive and painless later.

COUGH caused by a malignant tumor partially obstructing the trachea is associated with stridor, persistent and at times severe and suffocating. Such patients may become deeply cyanosed and even unconscious during paroxysms of coughing.

COUGH of several different types may be produced by stimulation of nerve endings in the bronchial mucosa. COUGH in acute bronchitis in the early stages sounds dry; later it becomes loose and productive usually of purulent sputum.

COUGH in chronic bronchitis has other typical features: it is particularly frequent and severe when the patient retires to bed at night and, even more so, on getting up in the morning, because of sudden changes in posture and in the temperature and humidity of the inspired air. Sleep is seldom disturbed by coughing, but most patients with chronic bronchitis wake up in the morning with a wheeze and a sensation of tightness in the chest. a chronic, non-productive COUGH occurs in bronchial asthma and diffuse pulmonary fibrosis. The presence of other diseases such as rheumatoid arthritis, lupus erytematosus or systemic sclerosis should remind one of the possibilities of cryptogenic fibrosing alveolitis.

COUGH in bronchial carcinoma may be an early and persistent symptom. At first it is frequent short dry cough, but later it may become more severe and distressing. COUGH in bronchiectasis, uncomplicated by chronic bronchitis or asthma, is characteristically loose and readily productive of sputum. Large amounts of sputum are coughed up, particulary on rising in the morning. It may be brought on by changes in posture -postural cough.

COUGH in pneumonia is dry and irritant at first, later becaming loose and productive, frequent haemoptysis.

COUGH in acute pulmonary edema sedondary to left heart failure is generally short, paroxysmal, persistent and exhausting. A paroxysm of coughing in an elderly patient which wakes him from sleep may herald the onset of pulmonary edema.DIAGNOSTIC APPROACHHealthy individuals seldom cough unless exposed to noxious fumes or a dusty environment A persistent cough is abnormal and enquiry should be made about its character, duration and any accompanying symptoms. An acute nonproductive cough, particulary if it is associated with sore throat or nasal discharge, is likely to be due to an upper respiratory infection. In pneumonia the cough may be dry at first but it most cases it will eventually produce some purulent sputum.Paroxysms of coughing ending in the high-pitched sound of inspiratory stridor due to laryngeal spasm is virtually diagnostic of whooping cough.A chronic non-productive cough occurs in asthma and diffuse pulmonary fibrosis.A dry cough accompanied by hoarseness in a middle-aged adult is commonly due to chronic lanyngitis from excessive smoking or overuse of the voice. Hoarseness persisting for more than a month should be investigated further, for it may be due to laryngeal carcinoma or to involvment of the recurrent laryngeal nerve by a bronchial neoplasm.A chronic productive cough is seen in chronic bronchitis, bronchiectasis, pulmonary tuberculosis and neoplasms of the bronchus. In bronchiectasis large volumes of purulent sputum are coughed up, particularly on rising in the morning.The timing of cough may throw some light on its probable cause. A persistent cough at night is commonly due to obstructive airways disease but a paroxysm of coughing in an elderly patient which wakes him from sleep may also herald the onset of pulmonary edema.Associated symptoms such as fever and sweating would point to infection, whilst loss of weight would bring tuberculosis or neoplasm on mind.8 The extent of the physical examination will obviously depend upon the age of the patient, the history and the likely pathology. Finger clubbing is an important sign and should be sought. Common pulmonary causes include bronchiectasis, bronchial neoplasm, tuberculosis, lung abscess and fibrosing alveolitis.2.5. SPUTUMDEFINITIONIt is a result of expectoration. Expectoration represents elimination of the sputum from the tracheo-broncho-alveolar territory by the act of coughing.GENERALITIESWhen a patient has sputum, information should be obtained as to amount, character, viscosity and taste or odour. If it is important to obtain precise information about the amount of sputum, the patient should be given a graded container and a 24-hour collection is measured. Some patients deny cough while admitting to the presence of sputum, saving that they bring it up merely by clearing the throat.CHARACTER OF THE SPUTUMThis is seldom described accurately by the patient and, wherever possible, a specimen should be inspected by the doctor. Apart from haemoptysis, there are four types of sputum: serous, mucoid, purulent and mucopurulentSerous sputum - which is usually described by the patients as clear frothy, is seen in acute pulmonary edema, in which it may acquire a pink colour through mixture with red blood cells, and in the rare condition of alveolar-cell carcinoma;Mucoid sputum - which is a characteristic feature of chronic bronchitis, is usually described by patients as grey, clear, or sometimes black (when it contains soot particles);Purulent and mucopurulent sputum is usually described as yellow or green, but occasionally white sputum proves on inspection to be purulent. The term "dirty spit" used by many patients is misleading as it may refer either to purulent sputum or to mucoid sputum containing soot particles. Mucoid sputum may be copious and frothy in some cases of chronic bronchitis and asthmaHysterical patients may spit out large amounts of saliva which they claim to be sputum.Viscosity - mucoid sputum is often more viscous than purulent sputum and for that reason is more difficult to cough up. Sputum is particularly viscous in the early stages of pneumococcal pneumonia and in severe asthma. Serous sputum is watery with a low viscosity;TASTE OR ODOURWhen described as "nasty" the patient may merely be referring to the normal taste of purulent sputum only when terms such as offensive, nauseating or putrid are used can it be assumed that sputum is fetid (as in bronchiectasis or lung abscess with anaerobic bacterial infection). The observer's own sense should be used to assess odour.2.6. HAEMOPTYSISDEFINITION: coughing up of blood as a result of bleeding from the respiratory tractGENERALITIESHaemoptysis, particularly if an appreciable quantity of blood or if recurrent, is a frightening and potentially fatal event and all diagnostic resources must be used to establish the etiology. More than two tea spoons of bright red blood is omnious because it suggests severe hemorrhage. Not only the quantity but the precise location of the bleeding must be determined. Haemoptysis must be differentiated from hematemesis and from blood or hemorrhagic exudate dripping into the tracheobronchial passage from the nose, mouth or nasopharynx. Although most patients realise whether blood has been coughed up or vomited, haemoptysis is occasionally confused with hematemesis.The history, physical examination, and chest X-ray usually define the more obvious causes of hemoptysis such as trauma, tumor, tuberculosis, bronchiectasis, heart failure, or pulmonary infarction (embolism).A.Laringeal causes of haemoptysis and pharingeal: lymphoma carcinoma tuberculous ulcerationB.Tracheal and in the large bronchi: benign or malignant primary tumor teleangiectasia erosion by an aortic aneurysm brochogenic cyst broncholithiasis erosion by a caseocalcific node erosion by a tumor from nodes, esophagus or other mediastinal structures severe acute bronchitis -trauma

C.Smaller bronchial structures: carcinoma adenoma (carcinoid or cylindromatous) acute bronchitis9

bronchiectasis

bronchopulmonary sequestration

chronic bronchitis

D.Pulmonary parenchyma: primary or metastatic tumor -infarct

abscess active granulomatous disease (tuberculosis, funga, parasitic, luetic)

fungus ball (aspergillus) in an old cavity

acute pneumonia

idiopathic hemosiderosis

Good Pasture's syndrome

E.Cardiovascular: left ventricular failure

mitral stenosis pulmonary embolism/infarct

primary pulmonary hypertension

pulmonary arteriovenous fistula

atrial myxoma

fibrous mediastinals with pulmonary vein obstruction

aortic aneurysm with leakage into the pulmonary parenchyma

F.Clotting defects:-thrombocytopenia

vitamin K - dependent factors: prothrombin (II), Stuart factor (X), factor (VH), Christmas factor (IX)

diffuse intravascular coagulation

heparin therapy

fibrinolytic therapy: urokinase, streptokinase

-miscellaneous congenital coagulation defects.The most important causes of haemoptysis are:

pulmonary tuberculosis broncho-pulmonary neoplasm pulmonary abscess pneumonia

acute pulmonary edema mitral stenosis pulmonary infarction thoracic traumatism haemorrhagic syndrome periarteritis nodosa TYPES OF HAEMOPTYSISFRANK HAEMOPTYSIS, in which the material coughed up consists wholly of blood, occurs most commonly in bronchiectasis, pulmonary infarction and tuberculosis. A rough estimation should be made of the amount of blood lost, bearing in mind that most patients tent to overestimate this.

BLOOD-STAINED SPUTUM, in which the blood and sputum are intimately mixed in various proportions, occurs in bronchial infections and suppurative pneumonia.

BLOOD-STREAKED SPUTUM, in which streaks or specks of blood are present in mucoid or purulent sputum, is a fairly frequent symptom in bronchial carcinoma and chronic bronchitis.

RUSTY SPUTUM, in which degraded products of haemoptysis give the sputum a colour varying between rust and golden-yellow, is a common feature of pneumococcal pneumonia and occurs in few other coditions. DIAGNOSTIC APPROACHThis will depend to some extent upon the severity of the blood loss. Profuse haemorhage is uncommon and the patient may die rapidly of asphyxiation, before a diagnosis can be made. In such cases immediate bronchoscopy is vital for this will enable the airways to be cleared of blood and the source of bleeding to be identified.

In young adults the most likely cause of massive haemoptysis is acute pulmonary tuberculosis; less commonly it is due to a lung abscess or bronchiectasis.

In older patients it may arise from a bronchial neoplasm, chronic cavitated pulmonary tuberculosis or a mycetoma. Rarely, it may be due to a necrotising vasculitis, as in Goodpasture's syndrome, or to a haemorrhagic pneumonia where the infection is accompanied by some gross disturbance of the clotting mechanism such as occurs with disseminated intravascular coagulation.

Fortunately the haemoptysis is less severe in most patients and may only amount to the expectation of some blood-tinged sputum. There is time to take a careful history of past illnesses, smoking habits, current state of health and any accompanying symptoms.

10In the young, tuberculosis remains the most likely cause but this one and bronchiectasis may both present with malaise, fever, loss of weight and a productive cough. There is often a history of previous respiratory illnesses, or of a contact with a known case of tuberculosis at work or in the iamily.

During pregnancy and in femals on the contraceptive pill the possibility of pulmonary embolism should always be kept in mind.

The same applies to all post-operative patients and those who have been confined to bed with major illnesses. The haemoptysis is likely to have been preceded or accompanied by pleuritic pain and some shortness of breath. Similar symptoms will be seen in pneumonia but frank haemoptysis will favour embolism.

A small haemoptysis in a middle aged or elderly subject with a smoker's cough may be the first indication of the presence of a squamos cell carcinoma or pulmonary tuberculosis; chronic bronchitis should never be accepted as an adequate explanation without further investigation.

Examination of the patient is essential for the diagnosis procedures.

mil THE PHYSICAL EXAMINATION OF RESPIRATORY SYSTEM3.1. THE EXTERNAL FEATURE OF RESPIRATORY DISEASEInitial impression: there are a number of features which may have become evident during the course of history-taking and should immediately cause the observer to suspect respiratory disease. There are some important elements: -cough

wheeze and stridor

laboured breathing

abnormality of the voice

to foetor of the breath (which can suggest an anaerobic infection of the lung) -state of nutrition

3.2. GENERAL INSPECTIONCyanosisCentral cyanosis of respiratory origin is most frequntefy seen in chronic obstructive airways disease. In such cases peripheral vasodilatation leads to warm blue hands, but the colour of the tongue is a more reliable indicator of central cyanosis.

It may also he present in: pneumonia

bronchial asthma

pulmonary infarction

fibrosing alveolitis

sarcoidosisPeripheral cyanosis affecting the face and the neck, and in some cases the upper limbs also, is one of the features of superior vena cava obstruction.

EdemaThe detection of peripheral edema in patients with chronic obstructive airways suggests the development of right ventricular failure.

Edema of a different distribution is seen in obstruction of the superior vena cava.

This condition is a fairly common complication of bronchial carcinoma, but may also occasionally be caused by a large benign tumor. Obstruction of superior vena cava is manifested by:

grossly external jugular veins without venous pulsation

dilated veins and venules on the anterior and lateral aspects of the chest wall

swollen face and neck

-conjunctival edema (chemosis)Clubbing of the fingersThe phenomenon occurs in a variety of respiratory, cardiovascular and alimentary diseases, including: 1.- bronchial carcinoma and certain other intrathoracic tumors

bronchiectasis

pulmonary abscess and empyema

fibrosing alveolitis

2.- cyanotic congenital heart disease

-infective endocarditis

3.- the malabsorbtion syndrome 4. - Crohn's disease

ulcerative colitis

hepatic cirrhosis

11It has also been observed as a familial trait and may occur unilaterally in association with an aneurysm of the subclavian artery.Examination of the eves:-Horner's syndrome, phlyctenular keratoconjunctivitis which may be a manifestation of primarytuberculosis iridocyclitis which may be seen in tuberculosis or sarcoidosis chemosis and dilatation of the conjunctival and retinal veins are very common in secondary hypercapnia to chronic obstructive airways disease

Examination of the scalene lymph nodesThese nodes are often involved when a pathological process, such as carcinoma, lymphoma, sarcoidosis or tuberculosis affects the mediastinal nodes, and aspiration or biopsy of enlarged scalene node may provide information of conclusive diagnostic value.Nodes which are greather then 0,5cm in diameter, firm in consistence and round in shape are usually of pathological signifiance, many of them containing metastatic deposits from a bronchial carcinoma.Large, fixed masses are present in some of these cases. Hard, crraggy nodes may be caused by healed and calcified tuberculosis.3.3. EXAM1NA TION OF THE CHESTPhysical examination of the chest makes use of the tehniques of inspection, palpation, percussion and auscultation.3.3.1. INSPECTION AND PALPATION1.Abnormalities in the shape of the chest. Those of clinical importance are as follows:The anteroposterior diameter may be increased as compared to the lateral diameter. In normal subjects the ratio is usually about 5:7, and in flat-chested patients without respiratory disease, it may be as low as 1:2.In some patients with emphysema, however the two measurements may approximate - barrel-chest. Chest deformity in emphysema is not a reliable clue to the severity of the functional defect. It is seen most frequently in patients who have developed chronic respiratory disease (bronchitis or asthma) relatively early in life.-Pectus carinatum (pigeon chest) is a common sequel to chronic respiratory disease in childhood. It consists of a localised prominence of the sternum and adjacent costal cartilages, often accompanied, by indrawing symmetrical horizontal grooves above the margins, which are themselves everted. These deformities are though to result from lung hyperinflation with repeated strong contractions of the diaphragm while the bony thorax is still in a pliable state. Pectus excavatum (funnel-chest) is a developmental defect in which there is either a localised depression of the lower end of the sternum, or, less commonly, depression of the whole length of the body of the sternum and of the costal cartilages attached to it. This produces displacement of the apex beat to the left, and the ventilatory capacity of the lungs may be restricted when there is a very marked degree of depression of the sternum.

Thoracic kyphoscoliosis ranges in degree from the minor changes in spinal curvature seen in may otherwise healry subjects to grossly disfiguring and disabling deformities. Severe kyphoscoliosis may have profound effects on pulmonary function as the chest deformity reduces ventilatory capacity of the lungs and increases the work of breathing. Many such patients develop hypoxaemia, hypercapnia and heart failure at an early age.

Thoracic operation, particularly thoracoplasty, may result in a considerable degree of chest deformity, of which scoliosis may be an important secondary failure.

2.Lesion of the chest wall. Combined inspection and palpation of the whole chest wall is essential for the detectionof abnormalities which may include: cutaneous lesion, e.g. skin eruption, sarcoid or other nodules, purpuric spots, bruises, scars, discharging sinuses.

subcutaneous lesion, e.g. inflammatory swellings, metastatic tumor, nodules, neurofibromas, lipomas subcutaneous emphysema (air in the subcutaneous tissues) may cause diffuse swelling of the chest wall, the neck and in some cases the face. The condition is recognised by the characteristic crackling elicited by palpation of the air containing tissues.

vascular abnormalities, e.g. spider teleangiectasis, enlarged vascular channels localised preeminences and deformitis involving clavicles, scapulae, sternum, ribs, costochondral junctions and spinous processes

localised tenderness on palpation, e.g. from a fractured rib, from tumors invading the chest wall, from spinal injury or in association with pleural or nerve root pain

lesions of the breasts and enlargement of the axilary lymph nodes.3.The observation of respiration movementsa. Respiratory frequencyThe number of breaths is counted by surreptitiously observing the movements of the chest wall, with the fingers held on the pulse to avoid drawing the patient's attention to breathing.The normal frequency at rest in a healthy adult is about 14 respirations per minute. The rate is increased in a variety of pathological states, including pyrexia from any cause, acute pulmonary infections, particularly those accompanied by12 pleural pain, and conditions in which there is a sudden increase in the work of breathing: bronchial asthma and acute pulmonary edema.b.Respiratory depthIn massive pulmonary embolism and in metabolic acidosis, usually due to diabetic ketosis, or uremia, pulmonary ventilation at rest may be considerably raised. This can be recognised clinically by an increase in the depth of respiration which may give rise to the subjective of dyspnoea.In periodic or Cheyne-Stokes breathing there is a clinical variation in the depth of respiration, with periods of overventilation alternating with complete apnoea. This occurs in left ventricular failure and in certain neurological conditions.Overventilation may also occur in patients who are unconscious as a result of severe brain caused by trauma, haemorrhage or infarction.c.Maximum chest expansionThis is estimated by placing a tape measure round the lower third of the chest and recording the maximum inspiratory/expiratory difference in the chest circumference.Chest expansion is diminished in almost every type of diffuse, broncho-pulmonary disease, e.g. bronchial asthma, emphysema and pulmonary fibrosis, and in conditions which restrict movement of die ribs, such as ankylosing spondylitis.d.Mode of breathingWomen make more use of the intercostal muscles then of the diafragm and their respiratory movements are predominantly thoracic.Men, on the other hand, rely more on the diaphragm and their respiratory movements at rest are abdominal. Babies of both sexes are also diaphragmatic breathers.If respiratory movements are exclusively thoracic this indicates that diaphragmatic movement is inhibited by pain caused, for example, by peritoneal irritation, or restricted by increased intraabdominal pressure in conditions such as ascities, gazeous distension of the bowel, a large ovarian cyst or pregnancy.If respiratory movements are exclusively abdominal, ankylosing spondylitis, intercostal paralysis or pleural pain may be responsable for the lack of chest expansion.c Methods of comparing range of movement of the chest wallThe object of these procedures is to detect differences in the range of movement on the two sides of the chest.1. Respiratory movement in the infraclavicular regions is compared by inspecting the chest with the patient supine and the head resting on a pillow. The observer views the infraclavicular regions tangentially and asks the patient to take steady deep breaths. By this techique unilateral impairement of chest wall movement can usually be recognised. Breathless patients should not be examined in this way because their distress is increased if they lie flat.2. Respiratory movement at the costal margins can also be accurately gauged by inspection if the patient is thin. In other cases, however, palpation in the only tehnique avaible for this purpose. The sides of the chest are grasped with the fingers in such a way as to approximate the tips of the outstreched thumbs in the region of the xiphoid process. The hand should be adjusted to ensure that there is a loose fold of skin between the two thumbs so that they can move apart as the chest expends. The movement of the two thumbs with deep breathing can then be used to estimate the relative degree of movement on the sides.3. Respiratory movement of the lower ribs posteriorly, where inspection is seldom helpful, have to be estimated by a similar technique. With the patient sitting erect the chest is grasped from behind with the two hands and the tips of the outstretched thumbs are brought together in the region of the tenth thoracic spine.f.The significance of reduced movementUnilateral reduction of chest wall movement occurs in many types of respiratory disease.In pleural effusion and emphysema, movement may be absent, and if the lesion has persisted for some weeks retraction of the ribs and intercostal spaces may produce flattening of the affected side of the chest. Less marked reduction of movement occurs in pulmonary consolidation and collapse.-in pneumothorax the limitation of movement is related to the amount of air in the pleural space; in tensionpneumothorax the affected side of the chest may be immobilised in a position of almost full inspiration.-in bronchial asthma, emphysema and diffuse pulmonary fibrosis movements of the chest wall aresymmetrically reduced.g.Vocal fremitusThis crude test provides no information that is not obtained by vocal resonance. It is perfomed by placing the palm of the hand on equivalent areas of the chest wall and asking the patient to say "one, one, one" or "33, 33, 33". h. Palpable accompanimentsThe vibrations from a low pitched rhonchus or a coarse pleural rub can occasionally be detected by a hand placed on the chest wall.In such cases an unusually loud rhonchus or rub is invaribly present on auscultation and there is seldom any difficulty in distinquishing between the two.A palpable rhonchus generally has its origin in a large bronchus and, if persistent and unilateral, it suggests partial bronchial obstruction by a tumor or a foreign body.3.3.2. PERCUSSION13The object of percussion is to compare the degree of resonance over equivalent areas on the two sides of the chest, and to map out any area in which the percussion note is abnormal.

Fig. 18/8 116

The percussion note has normal resonance whenever aerated lung tissue is separated from the chest wall by pleural fluid or thickening, or when lung tissue is rendered airless by consolidation, collapse or fibrosis. Over such lesions the percussion note is impaired or dull. The most marked degree of dullness on percussion is found over a large pleural effusion.Fig. 22a/23/24 p 118/119

Percussion over a solid organ such as the heart or the liver will elicit a dull note, but the area of dullness is always less extensive than would be expected from anatomical surface marking since aerated lung is interposed between part of the organ and the chest wall.

A hyperresonant percussion note may be found over a large thin walled pulmonary cavity, over a pneumothorax, particulary if the pleural pressure is above atmospheric level, and also over lung wich is markedly emphysematous. An apparent finding of generalised hyperresonance must, however, be accepted with reserve since a change in the absolute pitch of percussion note is always difficult to recognise and may depend mainly upon the thickness of the chest wall. For that reson it is not usually advisable to attempt to distinguish between normal resonance and hyperresonance when the percussion note is equally resonant on the two sides. The sound produced by percussion over a hollow organ is described as tympanitic.

TECHNIQUE OF PERCUSSIONThe basic technique of percussion is as follows:

1. the left hand is placed on the chest wall, palm downwards and with the fingers slightly separated, so that the second phalanx of the middle finger is precisely over the area to be percussed.2. the middle finger of the left hand is then pressed firmly against the chest wall and the centre of its second phalanx is struck shapfy with the tip of the right middle finger. In order to produce a satisfactory percussion note the right middle finger must be held at a right angle (to produce a "hammer" effect) and the entire movement must come from the wrist joint.The positions in which the percussion note on the two sides should be compared are as follows:

Fig. 9/117

ANTERIOR CHEST WALL

Clavicle infraclavicular region

Second to sixth intercostal spaces.Fig. 22b/118

LATERAL CHEST WALL

Fourth to seventh intercostal spaces.

Fig. 21/117POSTERIOR CHEST WALL

Trapezius, percussing downwards on lung apex. Above spine of scapula. At intevals of 4 to 5 cm from below spine of scapula down to eleventh rib.

The technique of clavicular percussion which may be of value in detecting lesions of the upper lobes, differs from that used elsewhere in the clavicles can be percussed directly with the right middle finger or if preferred, with the right index, middle and ring fingers held closely together.

The lung apices are percussed by placing the left middle finger across the anterior border of the trapezius, overlapping the supraclavicular fossa, and directing the percussion downwards.

3.3.3. AUSCULTATIONAuscultation of the lungs has an important place in the diagnosis of certain respiratory diseases but is of little or no value in others. In bronchial asthma and pleuresy, for example, the stethoscope provides information of positive diagnostic value which can not be obtained in any other way. In contrast, auscultation is unhelpful in the early diagnosis of pulmonary tuberculosis, which may reach an advanced stage before any abnormality can be detected.

TECHNIQUE OF AUSCULTATIONAuscultation should be carried out with the patient relaxed, breathing deeply and fairly rapidly. The mouth should be kept wide open and the patient should be specifically asked not to purse the lips during expiration. It should be borne in mind by the beginner that prolonged deep breathing may cause giddiness or even tetany.

The following information can be obtained from auscultation:

1. the type and amplitude of the breath sounds2. the type and number of any added sounds and their position in the respiratory cycle3. the quality and amplitude of the conducted voice sounds. A. BREATH SOUNDS AND VOICE SOUNDSBreath sounds are produced by vibration of the vocal cords caused by the turbulent flow of air through the larynx during inspiration and expiration. The sounds so produced are transmitted along the trachea and bronchi and through the lungs to the chest wall.

Diseases of the bronchi, lungs and pleura may alter the breath sounds in three main ways: 1. Diminished vesicular breath sounds14 If the conduction of the breath sounds to the chest wall is attenuated by airflow limitation (as in bronchial asthma, or local, as when a large bronchus is obstructed by a tumor) or by a shallow pneumothorax, a small pleural effusion or pleural thickening, they remain vesicular but are diminished in amplitude.2.Bronchial breath soundsIf the lung tissue through which the breath sounds are transmitted from the air passages to the chest wall has lost its normal spongy consistence and has become firm or solid e.g. in consolidation of fibrosis, the sounds picked up by the stethoscope resemble more closely those produced at the larynx than those heard over normal lung.Voice sounds (vocal resonance) conducted through consolidated lung tissue also resemble more closely those produced at the larynx than those heard over normal lungs, or that they are louder and more distinct In some cases the whisperead voice may be transmitted almost without distorsion, so that individual syllables can be clearly recognised (whispering pectoriloquy).High-frequency sounds are selectively conducted throught consolidated lung tissue, high-pitched bronchial breath sounds are heard in lobar or segmental pneumonia.Fibrotic lung tissue, on the other hand transmits sounds of lower frequency and thus produces low-pitched bronchial breath sounds.When bronchial breath sounds traverse air-containing cavities in their passage to the chest wall, they may occasionally acquire a resonating amphoric quality, resembling the sound produced by blowing across the top of bottle.3.Intermediate breath soundsBreath sounds may be intermediate in type between vesicular and bronchial, for example, vesicular with prolonged expiration.This type is heard commonly in the presence of diffuse pulmonary fibrosis, chronic bronchitis and emphysema.B. ADDED SOUNDSAdded sounds heard on auscultation of the chest are therefore of three types: rhonchi, crepitations and pleural sounds.1.Rhonchi. These are musical, high, medium or low pitch sounds produced by the passage of air throughnarrowed bronchi. Rhonchi caused by mucosal edema or spasm of the bronchial musculature are usually superimposed uponthe expiratory phase of the respiratory murmur, which is always prolonged when rhonchi are present.Rhonchi heard during inspiration are more often due to secretion in the large bronchi and may disappear, or at least become less numerous after coughing. A constant low-pitched rhonchus (fixed rhonchus) usually indicates partial obstruction of a major bronchus by a local lesion in a large bronchus, such as a tumor or an inhaled foreign body.2.Crepitations. These are non-musical sounds, called crackles by some clinicians, mainly audible duringinspiration.A frequent cause of crepitations in lung disease is the explosive reopening, during inspiration of peripheral small airways which have become occluded, during expiration. These crepitations are most numerous during the second half of inspiration and in some cases confined to the last part of the breath (in end-inspiratory crepitations). Such crepitations are not influenced by coughing, and are more conspicuous over the lower parts of the lungs because in the upright position small airway closure is more liable to occur mere than in the upper lobes.Another distinct type of crepitation may be heard or heard over a pneumothorax when fluid is present in the pleural space. These sounds, which have a thickling quality usually indicate that the air in the pneumothorax is under tension and are often audible only during coughing, which creates the sounds by agitating the fluid in the pleural space.3.Pleural sounds. A pleural rub is a leathery or cracking sound produced by movement of the visceralpleura over the parietal pleura, when both surfaces are roughened as by fibrinous exudate. It is usually heard at two separatestages in the respiratory cycle, towards the end of inspiration and just after the beginning of expiration. A pleural rub may beinaudible during normal breathing but can be heard when the patient is asked to breathe deeply.It is sometimes, difficult to distinguish between a low-pitched rhonchus, coarse crepitations and a pleural rub. If there is any doubt as to the nature of sound auscultation it should be repeated after a forceful cough, when rhonchi or crepitations will usually alter in character or disappear, while a pleural rub will remain unchanged.THE INTERPRET A TION OF A VSCUL TA TORY FINDINGS1. high-pitched bronchial breath sounds are heard in areas of pneumonic consolidation, over a collapsed lung or lobe when the large bronchi are patent, over some large superficial pulmonary cavities, and sometimes over a lung compressed by a large pleural effusion or a tension pneumothorax. In all these conditions when bronchial breath sounds are audible the voice sounds are louder than normal and whispering pectoriloquy is present.2. low-pitched bronchial breath sounds are heard over localised areas of pulmonary fibrosis, e.g. in chronic pulmonary tuberculosis, chronic suppurative pneumonia or bronchiectasis. In all these conditions the vocal resonance is louder and more distinct, and whispering pectoriloquy usually present.3. breath sounds are diminished or absent over a pleural effusion thickened pleura, a pneumothorax or a collapsed lung, lobe or segment where the major bronchus supplying it is obstructed. The breath sounds are symmetrically diminished over both lungs in emphysema in these conditions the vocal resonance is decreased in amplitude to the same degree as the breath sounds are diminished.4. rhonchi are heard diffusely over both lungs in bronchial asthma and in most cases of acute and chronic bronchitis. In asthma the rhonchi are typically expiratory and medium or high pitched and are mainly heard during expiration which is prolonged. In bronchitis they are usually low and expiratory. A localised rhonchus may be heard over a partially obstructed large bronchus. If the obstruction is caused by a fixed lesion, such as a tumour or foreign body in large bronchus,15 the rhonchus is usually louder during inspiration, is not altered by coughing and is often accompanied by stridor. If due to secretions, these are usually removed by coughing, which causes the rhonchus to disappear.

5. crepitations caused by secretions within the larger bronchi in acute or chronic bronchitis, or in resolving bronchopneumonia, are widespread and bilateral, while those audible over resolving lobar or segmental pneumonic consolidation, dilated bronchi (bronchiectasis), lung abscesses or tuberculous cavities are localised to the site of the lesions. In all these conditions they are audible throughout inspiration, and alter after coughing. Crepitations in other parenchymal lung conditions, such as interstitial pulmonary edema, allergic and fibrosing alveolitis and perhaps early pneumonic consolidation and miliary tuberculosis, are in contrast audible mainly during the second half of inspiration, and are uninfluenced by coughing.6. a pleural rub is heard over areas of pleurisy. It disappears as soon as the visceral and parietal pleura are separated by fluid, but often remains audible above an effusion. If pleurisy involves the pleura adjacent to the pericardium, a pleuro-pericardial rub may also be heard. This is a rather misleading term since the pericardial element in the sound is not due to pericarditis. It is caused merely by roughened pleural surface adjacent to the pericardium being moved across one another by cardiac pulsation. A pleuro-pericardial rub may, in some cases, be impossible to be distinguished from a pericardial rub.IIV1. RESPIRATORY SYNDROMES4.1. BRONCHIAL SYNDROMES4.1.1.ACUTE BRONCHITISDEFINITIONIt is an acute inflammation of the tracheobronchial tree, generally self limited and with eventual complete healing and return of function. ETIOLOGY acute infectious bronchitis, most prevalent in winter acute irritative bronchitis may be caused by various mineral and vegetable dusts SYMPTOMS AND SIGNSAcute infectious bronchitis is often preceded by symptoms of upper respiratory infection: coryza, malaise, chilliness, slight fever, back and muscle pain, and sore throat.

Onset of cough usually signals onset of bronchitis.

The cough is initially dry and nonproductive, but small amounts of viscoid sputum are raised after a few hours or days.

The sputum later becomes more abundant and mucoid or mucopurulent Obvious, purulent sputum suggests superimposed bacterial infection.

In a severe uncomplicated case, fever to 38,3 or 38,9 C may be present for up to 3 or 5 days, following which acute symptoms subside (though cough may continue for 2 to 3 weeks). Persistent fever suggests complicating pneumonia. Dyspnoea may be noted secondary to the airways obstruction.

Pulmonary signs are few in uncomplicated acute bronchitis.

Scattered sibilant or sonorous rhonchi may be heard, as well as occasional crackling or moist rales at the bases. Wheezing, especially after cough, is commonly noted.

Persistent localized signs suggest development of bronchopneumonia. Serious complications are usually seen only in patients with an underlying chronic respiratory disorder. In such patients, acute bronchitis may lead to severe blood gas abnormalities (acute respiratory failure).

DIAGNOSISDiagnosis is usually possible on the basis of the symptoms and signs, but a chest X-ray is to rule out. Other diseases or complications are suspected, if symptoms are serious or prolonged. Arterial blood gases should be monitored when serious underlying chronic respiratory disease is present. In cases that do not respond to antibiotic therapy, or in special circumstances such as immunosuppresion, Gram stain and culture of sputum should be done for specific etiologic diagnosis.

4.1.2.CHRONIC BRONCHITISDEFINITIONChronic bronchitis represents a progressive and unspecific chronic inflammation of the bronchi and bronchioles, which is clinically manifest by cough with expectoration at least 3 months per year, two years successively. ETIOLOGY In this etiology are involved many factors, but none of them can explain all the clinical manifestations:

-irritant factors (tobacco), industrial factors, physical, chemical factors, infectious factors and allergicfactors.

CLINICAL FEATURESThe chief symptom is a persistent cough with the expectoration of mucoid or mucopurulent sputum. Cough in chronic bronchitis tends to occur in prolonged paroxysms, which usually culminates in the production of sputum. Bouts of coughing in these patients often produce severe dyspnoea, frequently accompanied by wheezing, and might be very

16 distressing. Cough is particularly frequent and severe when the patient retires to bed at night and, even more so on getting up in the morning. Most patients with chronic bronchities waken in the morning with a wheeze and a sensation of tightness in the chestMucoid sputum, which is a characteristic feature of chronic bronchitis, is usually described by patients as grey, clear, or sometimes black (when it contains soot particles). Blood-streaked purulent sputum is occasionally seen in chronic bronchitis.Dyspnoea may be denied but the capacity for exertion is progressively impaired. With the development of emphysema this becomes more prominent than the cough except during acute exacerbations.On examination the chest may appear barrel - shaped and respiratory movements are poor.Rhonchi will be audible throughout the lung and fields and may be accompanied by wheezing.In an advanced case cyanosis and finger clubbing are present.DIAGNOSIS is usually based on the clinical features but examination of the sputum, a chest X-ray, spirometry and in particulary cases bronchoscopy are also helpful.4.2. CONSOLIDATION SYNDROMESThe consolidation syndromes can be divided into two categories:A.CONSOLIDATION SYNDROMES WITH FREE BRONCHIa.consolidation by inflammatory processes - pneumoniab.consolidation by tumoral process - tumors of the lungc.unretractable consolidation syndrome - thromboembolism and infarctionB.CONSOLIDATION SYNDROMES WITH OBSTRUCTED BRONCHI - ATELECTASIS.A. CONSOLIDATION SYNDROMES WITH FREE BRONCHIThe most common cause is lobar pneumonia, which may be the result of a variety of bacterial infections. The signs of consolidations may occasionally be found over a lung abscess or a large area of pulmonary embolization. Consolidation is infrequent in viral infections. Signs of consolidations may be found at times over areas of confluent bronchopneumonia, which is as usual characterized by one or more patches of pneumonia.The signs of consolidation are: limitation of lung expansion of the side involved, often palpable limitation of expansion increase of vocal fremitus dull percussion note-bronchial breath sounds with fine or medium rales at the end of inspiration. Bronchophony andpectoriloquy may be heard, and occasionally egophony is present. A friction rub is occasionally audible.a. Consolidation by inflammatory processes - pneumoniaPneumonia is an acute infection of the parenchyma (alveolar spaces and/or interstitial tissue) of the lung.Pneumonia can be bacterial or viral.Pneumococcal pneumonia, the most common bacterial pneumonia, is usually lobar but it may be segmental.SYMPTOMS AND SIGNS onset is usually sudden, with a shaking chill, sharp pain in the involved hemitorax (pleurisy), cough with early sputum production, fever and headache. dyspnoea is frequent, respiration is rapid (25 to 45/min) delirium may occur, especially in alcoholic patients, when fever is high or cyanosis is marked the patients are cyanotic and sweating profusely-the temperature rises rapidly to 38 to 40,5 C. The pulse accelerates to between 100 and 130.Signs of consolidation involving part of one or more lobes are found.The cough, initially dry, usually occurs in extremely rjainful paroxysms.The sputum, pinkish or blood-flecked at first, becomes rusty at the height of the illness, then yellow and mucopurulent during resolution.Herpes infection is often present, usually in the lips and face.Physical signs are moist rales initially, with evidence of consolidation later.Streptococcal pneumoniaETIOLOGYHemolytic streptococci of Lancefield's group A are the most common organisms, though other streptococci are occasionally responsible. The disease is now infrequently seen except as a complication of measles or influenza.SYMPTOMS, SIGNS AND DIAGNOSISThe disease, which occured in epidemics in military camps in both world wars, usually begins with a sore throat, accompanied or followed by laryngitis and tracheobronchitis with presternal soreness and pain on coughing.It spreads by way of the bronchial and pleural lymphatics, producing bronchopneumonic lesions and pleural effusion. Toxemia is often pronounced.Early in the course of the pneumonia, presence of a large pleural effusion, frequently bloody, suggests a streptococcal pneumonia.A history of recent pharingitis, measles, or influenza, with early development of emphysema is suggestive.17Diagnosis is confirmed by demonstration of streptococci in sputum, blood, and pleural exudate. The gross appearance of sputum is not of diagnostic significance, but stained smears may show chains of Gram-positive cocci that can be identified by culture on blood AGAR.

Staphylococcal pneumoniaETIOLOGYStaphylococcal pneumonia is usually caused by coagulase-positive Staphylococcus Aureus. It is often a complication of influenza, but may be primary, particularly in infants and the aged.

SYMPTOMS AND SIGNSSome or all of the symptoms of Pneumococcal pneumonia (pleural pain, dyspnoea, cyanosis, productive cough) may be present in varying degres of severity and in cases complicating influenza, may appear at any stage of the illness.

Sputum may be copious and salmon-colored. Prostration may be often marked.

Physical examination of the lungs frequently demonstrates patchy involvment of several pulmonary segments, but lobar involvment may also occur. Pneumatoceles from