Respiratory Medicine

Respiratory Examination 4. Neck

a) Accessory muscles of respiration: sternocleidomastoid, arm support, alae flaring

b) JVP: t in: - Pulmonary hypertension - SVCO (non-pulsatile), due to

3. Face - General a) Eyes:

• Conjunctivae: pallor (anaemia) • Sclera: jaundice (cor pulmonale,

cystic fibrosis) • Horner's syn. (Pancoast tumour)

b) Mouth: • Central cyanosis

c) Cheeks, nose: • Flushed (polycythaemia,

SVCO, mitral stenosis) • Rash (SLE, scleroderma,

sarcoid, caricnoid) d) General habitus:

• Obese (Pickwickian syn.) • Cachexia (TB, ca., bronchiectasis' • Marfanoid (pneumothorax)

2. Pulse, ABP, RR a) Pulse: t in PE, infection,

severe asthma b) ABP • i in PE, infection,

severe asthma • Pulsus paradoxus:

> 10mmHg i on inspiration (severe asthma)

1. Hands a) Clubbing (ca., bronchiectasis) b) Nicotine staining (actually due to tar) c) Hand wasting: T1 wasting

(Pancoast tumour) d) Arthritis, sclerodactyly (fibrosis) e) Hand flap: C02 retention

5. Chest a) Inspection:

• Barrel chest, pectus carinatum • Kyphosis: ankylosing spondylitis

thoracic vertebral fracture (TB) • Concavity: lobe-or pneumonectomy • Scars: chest drain, thoracotomy,

radiation marks b) Palpation:

• Front: trachea + apex beat (mediastinal shift, LVF)

parasternal heave • Back: lymphadenopathy

c) Expansion: i with most pathologies

d) Percussion: Include clavicle + axillary areas

e) Auscultation: • Air entry: intensity, quality • Added sounds: creps, wheeze

f) Manoeuvres: • Tactile vocal fremitus (TVF) • Vocal resonance • Whispering pectoriloqy

(For all: transmission loud with consolidation, soft with effusion, collapse)

1. Consolidation a) Palpation: lymphadenopathy in TB, HIV b) Expansion: 4 c) Percussion note: dull d) Auscultation: • air entry: 4, bronchial breathing

• added: coarse creps e) Tactile vocal fremitus or vocal resonance T

whispering pectoriloquy (whispering sounds loud + harsh)

2. Pleural effusion a) Palpation: mediastinum shifts away b) Expansion: 4 c) Percussion note: stony dull d) Auscultation: • air entry: absent

• bronchial breathing just above effusion e) Tactile vocal fremitus or vocal resonance 4

egophony (patient's voice sounds like bleeting sheep just above effusion)

3. Collapse (or lobectomy, or pneumonectomy or thoracoplasty) a) Palpation: mediastinum shifts towards b) Expansion: 4 c) Percussion note: • dull (collapse)

• stony dull (pneumonectomy, due to fluid replacement) d) Auscultation: air entry: 4 e) Tactile vocal fremitus or vocal resonance I

4. Fibrosis a) Palpation: mediastinum shifts towards c) Expansion: 4 d) Percussion note: dull e) Auscultation: • air entry: 4, bronchial breathing

• added: end-inspiratory fine or coarse creps, don't shift with coughing

5. Pneumothorax a) Palpation: mediastinum shifts away (with large or tension pneumothorax) b) Expansion: 4 c) Percussion note: hyper-resonant d) Auscultation: air entry: 4 e) Tactile vocal fremitus or vocal resonance 4

+ Hamman's sign: systolic click, heard in time with heart (left-side pn.tx.) + coin sign (tap on coin placed on chest —• ringing sound heard)

6. Bronchiectasis a) Clubbing, cyanosis; b) Coarse crepitations; c) Extra: fever, copious green sputum in pot 7. Pleural fibrosis a) Dull percussion note; b) Bronchial breathing; c) TVF t , but vocal resonance 4 8. Cavity Amphoric breathing (like blowing over a bottle top)

3. Bogginess of nail bed: 'rocking'

2. Loss of concave nail fold angle

i J . Longitudinal and

transverse curvature T

4. Soft tissue bulk of distal phalanx t : 'drumsticks'

1. Cancer: i) Bronchial, esp. squamous cell carcinoma

- assoc. hypertrophic pulmonary osteoarthropathy (HPOA) ii) Mesothelioma (or asbestosis)

2. Cystic fibrosis + other Chronic suppurative disease: i) Lung abscess / bronchiectasis

ii) Empyema - may occur within a few weeks iii) TB - uncommonly associated

3. Cryptogenic fibrosing alveolitis

1. Congenital cyanotic heart disease 2. Infective endoCarditis 3. Cancer: Myxoma

1. Cirrhosis 2. Crohn's 3. Coeliac 4. Cancer: Gl Lymphoma

1. Congenital 2. T4 3. Local: Brachial AVM

Cyanosis Def Blue discolouration of mucosal membranes / skin, caused when:

Pa02 < 8kPa (or at lower 0 2 concentration if anaemic)

Types: 1. Peripheral: Cold, blue peripheries, e.g. nail beds 2. Central: Blue tongue, lips; warm peripheries; digital pulses present

1. High-altitude acclimatization: i) t bicarbonate excretion: counters hypoxia-driven

hyperventilation + respiratory alkalosis ii) t Hb 2,3-DPG 4 affinity for 0 2 iii) polycythaemia

2. Nitrite-contaminated water 3. Cold exposure (peripheral cyanosis)

1. Ventilation 4: COAD, musculoskeletal A 2. 0 2 diffusion 4 : Pulmo. oedema, pneumonia, fibrosing alveolitis 3. V/Q mismatch: PE, shunts: pulmonary AVM

e.g. hereditary hemorrhagic telangiectasia, cirrhosis

1. Congenital i) R^L shunt: Eisenmenger's (ASD, VSD, PDA), Fallot's ii) R + L mixing: - Transposition of Great Arteries iii) Pulmonary blood flow 4: Pulmonary atresia

2. Cardiac output 4 i) Mitral stenosis in Systolic LVF

3. Vascular (peripheral cyanosis) i) Arterial obstruction: Raynaud's, thromboembolic disease ii) Venous obstruction: DVT, constrictive pericarditis iii) Shock: sympathetic redistribution

Red-Blood Cells 1. Hereditary low-affinity Hb: i) Hb Kansas ii) Methaemaglobinaemia = Cyt B5 reductase deficiency

2. Acquired low-affinity Hb: i) MetHbaemia ii) SulphHbaemia iii) CarboxyHbaemia: (CO poisoning): pt appears cherry red

3. Polycythemia (peripheral cyanosis): due to sluggish circulation

Respiratory Failure Def The respiratory system has 2 main functions + 2 associated consequences of failure:

0 2 Supply Pa02 < 8.0 kPa (Type 1 respiratory failure)

1. Diffusion failure

2. V/Q mismatch ( +alveolar ventilation failure)

C0 2 Removal (acid-base balance)

PaC02 > 6.5 kPa pH < 7.35 (Type 2 respiratory failure)

1. Alveolar ventilation failure

failure Pa0 2 i PaC02 t pH I Alveolar-arterial grad. normal

Obstructive Restrictive Small airway:

1. COAD 2. Asthma - severe 3. Bronchiectasis 4. Bronchiolitis

Large airway: 5. Intrathoracic:

Ca., LN, FB 6. Extrathoracic:

Ca., OSA, Epiglottitis

Extraparenchymal: a) Neuromuscular:

1. CNS A , sedatives 2. High - cervical cord A 3. Lower-motor neurone:

MND, GBS, myasthenia b) Structural:

1. Ankylosing spondylitis + other skeletal A

2. Pleural disease 3. Obesity

Pa02 4 PaC02 i pH t Alveolar-arterial grad. t

Fluid a) Pulmonary oedema b) Pneumonia c) Infarction d) Blood

Fibrosis Both also cause V/Q mismatch + alveolar ventilation failure, due to lung compliance i => work of breathing t

Vascular a) PE b) PHT c) Pulmonary shunt

Acute 1. Cyanosis (deoxyHb > 5 g/dl) 1. Tachypnoea 2. Cardiac: 2. Cardiac:

i) Angina, Ml i) Peripheral vasodilation (warm), ii) Arrhythmias, esp. VT pulse volume t

3. Cerebral: encephalopathy ii) Arrhythmia, esp. sinus tachycardia, SVT 3. Cerebral: encephalopathy, inc.:

asterixis, papilledema, miosis, reflexes i

Chronic 1. Polycythaemia Renal compensation: HC03" t 2. Pulmonary hypertension / CI" 1

cor pulmonale 3. Renal: ATN (vasoconstriction)

he 1.ABG: a) pH / HC03": Determines chronicity and whether renal compensation has occurred:

Equivalent concentrations in acute respiratory disturbance PaC02 : pH : HC03 13 : 1 : 50

b) Alveolar - Arterial Gradient (PA02 -Pa0 2) PA0 2 (Alveolar 02) =20 -(PaC0 2 x 1.25)

Normal A-a gradient = 2 kPa (50-yr-old, at sea-level, room air) Raised A-a gradient indicates Diffusion Failure orV/O Mismatch

Rx Underlying Cause: e.g. BDZ's - Flumazenil; Opiates - Naloxone

- Oxygenation failure (Pa02 < 8.0 kPa): 1. Low / high-flow 0 2, e.g. nasal cannulae, Venturi face-mask, reservoir bag

&: Chronic Ventilatory Failure: ventilation depends on hypoxaemic drive! 2. Continuous Positive Airway Pressure (CPAP) - tight-fitting mask (non-invasive) 3. Mechanical Ventilation via Intubation or Tracheostomy

1. CPAP 2. Mechanical ventilation 3. Respiratory stimulant, e.g. iv doxapram

v . /

FVCI

T L C t , RVt

Small Airways

1. C0AD, Irreversible: chronic bronchitis / emphysema

2. Asthma: peak flow depressed most at lower lung volumes

3. Bronchiectasis 4. Bronchiolitis

Flow

PEFR

Flow-Volume Loop

—I Vol 0

Large Airways

5. Intrathoracic: fixed obstruction • Bronchial carcinoma, lymph node,

foreign body • Relapsing polychondritis:

intermittent bronchial collapse

6. Extrathoracic: collapse on inspiration only a) Laryngeal carcinoma, epiglottitis,

tracheal stenosis b) Foreign body in throat c) Goitre, cervical lymph nodes d) Obstructive sleep apnoea:

• Obesity: pharynx hypotonia during REM sleep • Acromegaly

Restrictive Intraparenchymal Extraparenchymal

1 sec. Time

IntraParenchymal

1. Fibrosing alveolitis 2. Pulmonary oedema, severe 3. Pulmonary hypertension

ExtraParenchymal

= expiratory and inspiratory weakness

1. Neuromuscular: high spinal cord injury, Guillain-Barre syndrome, motor neurone disease

2. Chest wall: ankylosing spondylitis

FVCi i

TLC4,RV4

variable

FVCI I

T L C i , RVt

KCO normal

Flow-Volume Loop

Restrictive - Inspiratory Weakness Only Causes

1. Neuromuscular: Isolated diaphragm paralysis a) Muscular dystrophy, acid maltase def., polymyositis b) Selective neuropathy: brachial neuritis, polio, zoster

2. Chest wall: a) Skeletal: thoracoplasty, kyphoscoliosis b) Pleural: asbestosis, thickening, mesothelioma c) Obesity-hypoventilation syndrome

PC TSOB + 0 2 i on lying down due to pressure effect and

t V/Q mismatch

Ix 1. Max. Insp. Pressure (MIP) i andFVC I , and are posture-dependent (FEVT / FVC may be normal)

2. Fluoroscopy: diaphragm moves upward on sniffing

3. Phrenic nerve conduction studies

Reticular Miliary or linear nodules

( < 2mm)

= Interstitial disease

Nodules Q \ ( > 5mm)

Fibrosis a) Upper zones:

pneumoconioses, extrinsic allergic alveolitis seronegative arthropathies, TB, aspergillosis

b) Mid zones: sarcoid c) Lower zones: SLE, CFA, asbestosis, radiotherapy, drugs

Infection a) Atypical pneumonia: psittacosis, Q-fever b) Viral, VZV pneumonitis: nodular

Neopl asia a) Lymphangitis carcinomatosis: reticular b) Thyroid carcinoma (follicular): "snowstorm" appearance c) Other: renal cell, melanoma, lymphoma: nodular

Edema a) Pulmonary oedema: Kerley B lines (horizontal, peripheral) b) Long-standing pulmo. oedema / haemosiderosis: nodular

Fibrosis a) Upper zones:

pneumoconioses (progressive massive fibrosis) b) Lower zones: rheumatoid arthritis

Abscess a) Bacterial: staphylococci, TB, Klebsiella b) Mycetoma, Aspergillus c) Hydatid cyst; amoebic cyst

Neoplasia a) 1°, 2° b) Benign: hamartoma, bronchial cyst

Granulomatous Rheumatoid arthritis, Wegener's

Structural a) AVM b) Pulmonary infarction c Traumatic haematoma

Fluid: a) Oedema 2° to LVF or ARDS b) Alveolar proteinosis

Cells: a) Neutrophils: • Pneumonia: bacterial, viral, TB, PCP • Infarction 2° to PE

b) Eosinophilis: • Pulmonary eosinophilia, ABPA

c) Red blood cells (pulmonary haemorrhage): • Goodpasture's, Wegener's • Mitral stenosis, L —• R shunt, e.g. VSD • Idiopathic pulmonary haemosiderosis

d) Tumour: • Bronchioalveolar cell carcinoma, Kaposi's sarcoma

Patterns observed with lobar collapse: Upper lobe Middle lobe / lingula Lower lobe

confluent shadowing

air bronchogram

- Pleural Disease Effusion Plaques: holly-leaf plaques or linear shadows

a) Asbestos exposure / mesothelioma (but not asbestosis) b) TB c) Old haemothorax

Thyroid (retrosternal goitre); Thymoma, Teratoma, TB (or sarcoid) lymph nodes + Terrible diagnoses!!!: lymphoma or aneurysm/dissection!!!