RESPIRATORY SYSTEM

By:
DR. AB DULLAH AL-MULHIM
 History of Resp. System
Common symptoms in resp. diseases
include the following:
1. Cough
• Duration: Acute: Few fays to a week usually
due to infection e.g. URTI, pneumonia.
• Chronic cough: Many weeks, months to years:
Indicate chronic infections like pulm. T.B., or
supp. lung disease, e.g. bronchiectasis or
obstructive airway disease, e.g. bronchial
asthma & COPD or chronic interstitial lung
disease as pulm. fibrosis.
History of Resp. System
• Dry versus productive.
• Sputum: Whitish usually indicates viral
infection.
• Greenish yellow usually indicates bacterial
infection. Only exception is bronchial
asthma greenish sputum due to presence of
esinophils in sputum even without infection.
• Blood-streaked sputum indicate hemoptysis
or coughing blood.
 History of Resp. System
2. Hemoptysis: Common causes:
1. Infections: Pneumonia, lung abscess, pulmonary
T.B.
2. Supp. Lung dis: Bronchiectasis.
3. Tumours: Benign bronch, adenoma, bronchogenic
CA.
4. Parasitic lung diseases: Ascariasis, paragonomiasis.
5. Fungal lung diseases: Aspirigilosis, histoplasmosis
& coccidiodomycosis.
6. Cardiac causes: Mitral stenosis.
7. Pulmonary infarction & pulmon. Embolism.
8. Miscellaneous: Malingering psychiatric dis.,
Munchausen syndrome.
History of Resp. System
– Differentiate between hemoptysis &
hematemesis.
– Always with vomiting, ask about
epig. pain, heartburn, history of
gastric disease or use of aspirin &
NSAIDS.
 History of Resp. System
3. Chest Pain
• Cardiac versus pulm. cause
• IHD pain: Usually retrosternal compressing
severe, may refer to L. arm, neck, jaw,
epigast. or inter scapular area, exertion
relieved by rest.
• Risk factors: Middle age male, D.M., HPN,
dyslipedemia, strong F/H IHD or sudden
death at young age.
• Pulmonary chest pain usually due to
pleurisy, sharp pricking, knife-like,
localised, ↑ deep breathing.
• Other atypical chest pain.
History of Resp. System
• GERD, musculo SR, chest pain associated
with heavy weightlifting, with localised
tenderness.
• Spinal-root pain: Encircling chest from front
to back.
• Ankylosing spondylitis pain, ↑ with rest
relieved with exercise.
• Herpes-zoster pain – over intercostal space,
maybe rash.
• Psychogenic chest pain: non-exertional,
chronic last for hours – days, relieved by
exercise, psych. pts. – depression.
 History of Resp. System
4. Dyspnea
• Awareness of your breathing.
• Pulm. causes:
– Common bron. asthma & COPD – associated with
wheezing.
– Interstitial lung disease – exertional dyspnea.
– History of smoking – COPD.
• Cardiac Cause:
– Congestive heart failure – IHD, HPN, DM,
dyslipedemia, valvular heart disease, congenital
heart disease.
– Cardiomyopathy – dilated alcoholism
History of Resp. System

• Psychogenic Dyspnea:
– Psychiatric disease:

Depression – dyspnea at rest,

relieved by exercise.
– Associated with hyperventilation more in
inspiration.
– Sighing attacks.
Examination of Resp. System
General Exam in Relation to Resp.
System:
– Signs of underweight or wasting – Malignancy.
– Look for pallor, cyanosis, peripheral or central.
– Cushingnoid face – Chronic steroid use –
chronic bronch. asthma.
– Horner’s syndrome – Apical bronch. CA.
– Huge goiter – Female upper airway
obstruction.
– Poor oral hygiene & dental care – Lung
abscess & bronchiectasis.
– Sinusitis: Tenderness over face.
Examination of Resp. System
– Examination of Hands
• Clubbing of fingers occur
• Lung abscess, bronchiectasis, idiopathic
pulm. fibrosis, bronch. CA
• Extrapulm. – Causes of clubbing:
– Infective endocarditis, Crohn’s disease, ulcerative
collitis, cong. cyanotic heart disease.
• Signs of Hypercapnia:
– Warm hands – Palmar erythema
– High volume collapsing pulse
– Flapping tremors of hands – Abuse of B2-agonist –
Asthma & COPD.
Examination of Resp. System
– Examination of Chest:
1. Inspection:
– Tachypnea – Resp. rate – Normal: 14-18/min.
– ↑ - A-P diameter of chest – sign of hyperinflation –
COPD.
– Thoracic cage deformities – kyphoscoliosis.
– Morbid obesity – Rest – Lung Disease.
– Thorcotomy scars.
– Mastectomy in females – Breast CA – Radiation →
Radiation – Induced pneumonitis
– Watch chest wall movement & chest expansion.
Examination of Resp. System

2. Palpation
– Palpate chest wall for crepitus – Pneumo
mediastinum & pneumothrorax.
– Tenderness over ribs.
– Measure chest expansion – tape measure – or hands.
– Unilateral reduction of chest expansion occurs
– Consolidation – Pneumonia malignancy, pleural
effusion & pneumothorax.
– Bilateral reduction of chest expansion occurs
– Bilateral pleural effusion, COPD, ankylosing
spondylitis.
Examination of Resp. System
• Tactile vocal fremitus
– Ask pt. say 99 or 44 arabic & palpate chest bilaterally.
– ↑ Consolidation – pneumonia.
– ↓ Pleural effusion & pneumothorax over affected side
compared with normal side.
• Mediastinal displacement
– Upper mediastinum – position of trachea – normal, central
or slightly over right – push finger gently over suprasternal
notch & feel trachea.
– Huge goiter displace upper mediastinum alone.
– Lower mediastinum – Position of apex beat – normal in left
5th ICS at MCL in males or slightly medial.
– Lower mediast. Displace. occurs in:
– Pleural effusion & pneumothorax – Push mediast. away
from lesion.
– Collapse of lung or fibrosis pull mediast. towards lesion
(same side).
Examination of Resp. System
3. Percussion
• Lung apeces, Front – Upper lobe.
• Axillae – Rt → RML

- Lt → Lingulae – LAL
• Back of chest – Lower lobes
• Normal – Resonant.
• Hyper – Resonance – Over air – Cavity or
pneumothorax.
• Decreased resonance – dullness – consolidation or
mass.
• Stony dullness – Pleural Effusion
Examination of Resp. System
4. Auscultation
– Use diaphragm or stethoscope
– Type of breathing.
– Normal – Vesicular – Long insp. phase – followed
directly by shorter exp. phase and no pause or
gap.
– Bronchial breathing – consolidation & collapse –
short insp. phase, then pause - & longer exp.
phase – auscultate over trachea for normal
bronch. breathing.
– Vesicular breathing with prolonged exp. phase
found in broncho constriction - Bronch. asthma
& COPD.
– Assess intensity of breath sounds or air entry.
– ↓ bilaterally in emphysema & listen & compare.
Examination of Resp. System
– Assess insp. & exp.

Phases & compare

– Listen for added or adventitious abnormal sounds.
1. Crepitations – Crackles
» Course – Pan – inspiratory occurs in
pneumonia, bronchiectasis & pulm. Fibrosis.
» Fine – End – Insp. – Fluid in alveoli –LVF &
Pulm. Edema.
– Rhonchi or wheezes
 Examination of Resp.
System
– Due to broncho constriction
» Bronch. asthma & COPD may be exp. or insp &
exp. – severe cases.
– Pleural friction rub – friction sound – 2 layers of
pleura – dry pleurisy.
– Assess vocal resonance. Ask pt. say 99 or 44 –
arabic & listen & compare.
– ↑ in consolidation.
– ↓ in pleural effusion & pneumothorax
• Always TVF & VR over one area of lung either
both ↑↑ or both ↓↓.