Transcript Slide 1

LUNGS AND RESPIRATORY
SYSTEM
Lung Physical exam:
1- Inspection
2- Palpation
3- Percussion
4-Auscultation
5- Egophony
INSPECTION
• Deformities or asymetry
• Abnormal retraction of the interpaces
• Impairment in respiratory movement
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Tactile Fremitus
Performed by : 1- placing ulnar side of hand or
palm against the patient posterior chest wall.
2 – Have the patient say ninety-nine
Increased tactile fremitus =increased density
of the lungs (consolidation).
Decreased tactile fremitus =excess
subcutaneous tissue on the chest ,air or fluid
Percussion
• Dull =increased density such as fluid in the
lungs , or lung cavity or consolidation
• Tympanic = hollow air-containing structure
• Resonant = structure of air within tissue
• Hyperresonant = decreased density and more
air , such as in emphysema
Auscultation
• Crackles :short discontinuous nonmusical
sounds heard mostly during inspiration
• Wheezes :continuous , musical , high-pitched
heard mostly during expiration.
• Rhonchi:lower-pitched lung sounds
• Pleural rub :Sound produced by motion
pleura, heard best at end of inspiration
/beginning of expiration
Lung auscultation
Egophony
• Spoken words by the patient are increased in
intensity and take on different quality during
auscultation.Patient says eeee”and will heard
as “aaaa”in area of consolidation and in areas
of compressed lung above a pleural effusion
PLEURAL EFFUSION
Definition
Transudate :
1- increased hydrostatic pressure
2- decreased oncotic pressure
3- CHF, Cirrhosis, Nephrosis
Oxidative pleural effusion
• Increased capillary permeability
• Tumors, Trauma, Infection
Diagnosis criteria of exudate
• Ratio of pleural to serum protein >0.5
• Ratio of pleural to serum LDH >0.6
• Pleural fluid LDH >2/3 upper normal limit
Para pneumonic effusion :
• Pleural fluid leukocyte count >10,000/mm
• Always exudates
• WBC >100,000 =empyema
• Empyema =pus in pleural space , positive
cultures, require chest tube
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Gross blood in pleural fluid:
Tumor (breast ,lung cancer, lymphoma)
Trauma
Pulmonary infarction
Aortic dissection
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Low glucose in pleural fluid is associated :
Empyema
Rheumatoid arthritis
Tumor
tuberculosis
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High amylase in pleural fluid is associated :
Pancreatitis
Renal failure
Tumor
Esophageal rupture
• PULMONARY FUNCTION TEST
• Spirometry measures the rate at which the
lung changes during forced breathing
• Forced vital capacity (FVC) :
• Fev1 :the volume of air exhaled in the first
second of the FVC
• Normal FEV1/FVC ratio=>0.7
Spirometry1
Normal spirogram
Obstructive defect and restrictive defect
Lung Infections
• Pneumonia: infection of the lung parenchyma
by any microorganism.
Etiology:
• A- community acquired pneumonia
• 1-S-Pneumonia
• 2- H. influenzae
B- community acquired atypical
• 1- chlamydia pneumoniae
• 2- Legionella pneumophila
• 3- Mycoplasma pneumonia
C- Hospital acquired
• 1- pseudomonas aeruginosa
• 2 S.Aureus
• 3- Enteric organisms
Signs and Symptoms
• A- Typical Symptoms
• 1- Fever
• 2- cough
• 3- pleuritic chest pain
B- Atypical Symptoms
• 1- Dry cough
• 2-headache
• 3- malaise
• 4- Gastrointestinal symptoms
Physical exam
• 1- Dullness to percussion
• 2-Rales
• 3- Tactiles fremitus
• 4- Egophony (E to A changes ) with
stethoscope
Diagnosis
• A – Chest Xray
• 1- upper lobe infiltrate or consolidation
• 2- small cavities w/o air-fluid levels( M.tb
• 3- larges cavities with air-fluid levels (staph)
• 4- diffuse bilateral infiltrate (PCP,
Mycoplasma)
Criteria for admission
• 1- Age >50
• 2-Nursing home residents
• 3- underlying chronic disease
• 4- change in mental status
• 5- Tachypnea, tachycardia, or hypotension
• 6- Pleural effusion
Scenario 1
• A 19 y/o college student male c/o malaise, dry
cough for the last 10 days, denied fever and
pleuritic chest pain .Physical unremarkable ,
CXR showed diffuse bilateral infiltrate.
• Scenario2
A patient comes to the ER with consolidation
and pleural effusion on CXR. What is the most
important test to determine
admission/treatment.
Scenario 3
• A 27 y/o White male brought to the ER c/o
productive cough, fever and pleuritic chest
pain.Physical exam elicited tachypnea and
crackles on R upper lobe .What other physical
finding suggestive of typical pneumonia?
Obstructive Disorders
1. Chronic Obstructive pulmonary Disease:
A-Chronic bronchitis :chronic expiratory airflow
obstruction accompanied by chronic
productive cough for 3 or more months in
each of 2 successive years
• Emphysema :chronic expiratory airflow
obstruction accompanied by permanent
enlargement of the airspace distal to the
terminal bronchioles due destruction of
alveolar septa.
• Pathophysiology of Emphysema
• Centrilobular emphysema affects the
respiratory bronchioles.
• Panlobular emphysema occurs in patients
with alpha-1 antitrypsin deficiency.
• Distal acinar emphysema is associated with
spontaneous pneumothorax.
• Epidemiology
1- Higher prevalence in men
2- Mortality rates are higher in whites
3- Only 15 % of smokers develop COPD
• Risk Factors
• Smoking
• Alpha-1-antitrypsin deficiency
Diagnosis /Findings
 Chest xray: hyperinflated lungs, flattened
diaphragm.
 Physical exam: Barrel chest
 Pulmonary function tests: irreversible
obstructive pattern (low FEV1)
 Computed tomography: loss of alveolar walls
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Symptoms
Cough
Dyspnea on exertion
CO2 retention (chronic bronchitis)
Weight loss (emphysema)
tachypnea
treatment
 Smoking cessation
 Oxygen
 Maintain vaccination against influenza and
S.pneumoniae
 Beta agonist and ipratropium
 Steroid
Asthma
 A chronic condition characterized by:
1- airway inflammation
2- brochoconstriction
3- hypersecretion
PATHOPHYSIOLOGY
• IgE mediated ,associated with histamine
release from mast cells(early phase)
• The late phase is associated with cytokine
release
TRIGGERS
• Exposure to pets, dust ,smoke ,carpets
• Aggravation by exercise ,hot or cold weather
• Seasonal changes
Signs and symptoms
• Chest tightness
• Wheezing
• Shortness of breath
• cough
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Differential diagnosis of wheezing
Reactive airway disease
Congestive heart failure
Foreign body aspiration (most often in
children)
Asthma
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Physical Exam
Wheezing on exhalation
Decreased air entry , increased expiratory
phase
Decreased peak flow and FEV1
Retractions of sternocleidomastoids
• Intercostal muscle use for breathing
• Oxygen saturation <95%
• Inability to speak full sentences
asthma classification and treatment