Signs and Symptoms in Signs and Symptoms in Pulmonary DiseasePulmonary Disease

נוויל ברקמןנוויל ברקמן פרופ'פרופ'מכון הריאהמכון הריאה

ביה"ח האוניברסיטאי הדסה עין-כרםביה"ח האוניברסיטאי הדסה עין-כרם

DyspneaDyspnea

SubjectiveSubjective feeling of air hunger / feeling of air hunger / abnormally uncomfortable abnormally uncomfortable awareness of breathing.awareness of breathing.– When does it occur? (rest or When does it occur? (rest or

exercise).exercise).– Associated symptoms – pain etc. Associated symptoms – pain etc. – Quantitation - effort tolerance – level, Quantitation - effort tolerance – level,

incline, steps, 6-minute walk.incline, steps, 6-minute walk.– New York Heart Association I - IVNew York Heart Association I - IV

Dyspnea – cont.Dyspnea – cont.

Dyspnea at rest. Dyspnea at rest. DurationDuration

– sudden onset: pneumothorax, sudden onset: pneumothorax, pulmonary emboli, anxiety.pulmonary emboli, anxiety.

Changes over time:Changes over time:

Dyspnea- differential Dyspnea- differential diagnosisdiagnosis

Respiratory – Respiratory – – Airways obstruction – large, small Airways obstruction – large, small – Parenchymal diseaseParenchymal disease– Vascular diseaseVascular disease– Chest wall Chest wall

Heart diseaseHeart disease AnemiaAnemia AnxietyAnxiety

Dyspnea- contDyspnea- cont..

Orthopnea – dyspnea when lying Orthopnea – dyspnea when lying down (heart failure, COPD, down (heart failure, COPD, diaphragmatic paralysis).diaphragmatic paralysis).

Paroxysmal nocturnal dyspnea.Paroxysmal nocturnal dyspnea. PlatypneaPlatypnea Sleep apneaSleep apnea

CoughCough

Acute or chronicAcute or chronic Dry or productiveDry or productive Intermittent or continuousIntermittent or continuous Is it worse at night?Is it worse at night? Change in nature of chronic coughChange in nature of chronic cough Associated symptoms, medicationsAssociated symptoms, medications

Cough – contCough – cont.. Acute infections – bronchitis, pneumonia, Acute infections – bronchitis, pneumonia,

pertussispertussis Chronic infections – bronchiectasis, TB, CFChronic infections – bronchiectasis, TB, CF Airway disease – asthma, chronic bronchitis, post Airway disease – asthma, chronic bronchitis, post

nasal dripnasal drip Parenchymal disease – interstitial fibrosis, Parenchymal disease – interstitial fibrosis,

sarcoidosis, emphysemasarcoidosis, emphysema Tumours Tumours Foreign bodyForeign body Cardiovascular – CHF, PE, aortic aneurysmCardiovascular – CHF, PE, aortic aneurysm Drugs- ACE inhibitorsDrugs- ACE inhibitors Other- reflux, aspirations, middle ear pathology Other- reflux, aspirations, middle ear pathology

Chest PainChest Pain

Pleuritic pain- sharp, stabbing in nature, Pleuritic pain- sharp, stabbing in nature, worsened by cough, deep breathing.worsened by cough, deep breathing.

Usually indicates inflammation or Usually indicates inflammation or tumour.tumour.

““Mediastinal” pain- cardiac, esophageal, Mediastinal” pain- cardiac, esophageal, aneurysm.aneurysm.

MusculoskeletalMusculoskeletal Neuralgia Neuralgia

WheezingWheezing

High-pitched continuous whistling High-pitched continuous whistling sound.sound.

Inspiratory or expiratory or both.Inspiratory or expiratory or both. Indicated airway obstruction.Indicated airway obstruction. Should be differentiated from Should be differentiated from

stridor.stridor.

HemoptysisHemoptysis

Coughing up of blood.Coughing up of blood. Always Always significant!significant! R/O hematemesis, nose bleeding.R/O hematemesis, nose bleeding. Bronchitis, bronchiectasis, Bronchitis, bronchiectasis,

pneumonia, cancer; seldom pneumonia, cancer; seldom tuberculosis, PE, vasculitis.tuberculosis, PE, vasculitis.

OtherOther

Smoking- including passive, time Smoking- including passive, time since cessation.since cessation.– 1 pack year = 20 cigarettes/day for 1 pack year = 20 cigarettes/day for

1yr. 1yr. TravelTravel Family historyFamily history Drugs, hobbiesDrugs, hobbies Sexual habitsSexual habits

OccupationOccupation

What work do you do?What work do you do? Are your symptoms better at Are your symptoms better at

weekends? weekends? Does anyone else at work have Does anyone else at work have

similar symptoms?similar symptoms? Pneumoconioses, moulds, bakers Pneumoconioses, moulds, bakers

etc. etc.

Physical examinationPhysical examination

The respiratory system cannot be The respiratory system cannot be viewed in isolation: respiratory viewed in isolation: respiratory disease often presents with disease often presents with extrapulmonary signs or symptoms extrapulmonary signs or symptoms and extrapulmonary disease may and extrapulmonary disease may present with respiratory findings!!present with respiratory findings!!

Vital signs in ALL patientsVital signs in ALL patients

pulsepulse Blood pressure, pulsus paradoxusBlood pressure, pulsus paradoxus respiratory rate!respiratory rate! temperature temperature conciousness (hypercapnia cause sedation, conciousness (hypercapnia cause sedation,

hypoxemia causes restlessness)hypoxemia causes restlessness)

Respiratory pattern Respiratory pattern – Cheyne-Stokes respirationCheyne-Stokes respiration– Kussmaul’s respirationKussmaul’s respiration

Physical examinationPhysical examinationInspectionInspection

Cough – sputum.Cough – sputum. Cyanosis – central, peripheral.Cyanosis – central, peripheral. ClubbingClubbing Flapping tremorFlapping tremor Chest- deformation, scars, symmetry Chest- deformation, scars, symmetry

(pectus excavatum, carinatum). Barrel-(pectus excavatum, carinatum). Barrel-shaped chest in emphysema.shaped chest in emphysema.

Chest movement (including abdominal Chest movement (including abdominal movement).movement).

Use of accessory muscles.Use of accessory muscles.

CyanosisCyanosis )כחלון( -)כחלון( -

Blue skin colourBlue skin colour Indicates the presence of Indicates the presence of

>5g/100ml of deoxygenated >5g/100ml of deoxygenated hemoglobin.hemoglobin.

Central cyanosis - seen on the Central cyanosis - seen on the tongue. Indicates hypoxemia.tongue. Indicates hypoxemia.

Peripheral cyanosis – indicates Peripheral cyanosis – indicates poor perfusion. poor perfusion.

Clubbing - differential Clubbing - differential diagnosisdiagnosis

Malignancy - lung cancer, Malignancy - lung cancer, mesothelioma.mesothelioma.

Pulmonary fibrosis.Pulmonary fibrosis. Chronic suppurative lung disease: Chronic suppurative lung disease:

bronchiectasis, lung abscess, empyema.bronchiectasis, lung abscess, empyema. Cyanotic congenital heart disease.Cyanotic congenital heart disease. Subacute bacterial endocarditis.Subacute bacterial endocarditis. Cirrhosis, inflammatory bowel disease, Cirrhosis, inflammatory bowel disease,

hyperthyroidism (acropachy).hyperthyroidism (acropachy).

Physical examinationPhysical examinationInspectionInspection

Cough – sputum.Cough – sputum. Cyanosis – central, peripheral.Cyanosis – central, peripheral. ClubbingClubbing Flapping tremorFlapping tremor Chest- deformation, scars, symmetry Chest- deformation, scars, symmetry

(pectus excavatum, carinatum). Barrel-(pectus excavatum, carinatum). Barrel-shaped chest in emphysema.shaped chest in emphysema.

Chest movement (including abdominal Chest movement (including abdominal movement).movement).

Use of accessory muscles.Use of accessory muscles.

Physical examinationPhysical examinationPalpationPalpation

TracheaTrachea Cardiac apexCardiac apex Chest excursionChest excursion LymphadenopathyLymphadenopathy Signs of right-sided (and left-sided) Signs of right-sided (and left-sided)

cardiac disease/ failure. cardiac disease/ failure.

Physical examinationPhysical examinationPercussionPercussion

Cardiac dullness, liver, diaphragmsCardiac dullness, liver, diaphragms Dull - indicates consolidation or Dull - indicates consolidation or

atelectasis.atelectasis. Stony dull – indicates fluid.Stony dull – indicates fluid. Hyperresonance – pneumothorax, Hyperresonance – pneumothorax,

emphysema or bullae.emphysema or bullae. Vocal fremitus – “44”Vocal fremitus – “44”

Vocal fremitusVocal fremitus

Increased - consolidation.Increased - consolidation. Decreased – pleural effusion or Decreased – pleural effusion or

thickening, emphysema, thickening, emphysema, pneumothorax, atelectasispneumothorax, atelectasis

Physical examinationPhysical examinationAuscultationAuscultation

NATURE of breath sounds: NATURE of breath sounds: vesicular or bronchial.vesicular or bronchial.

INTENSITY of breath sounds/ air INTENSITY of breath sounds/ air entry.entry.

DURATION of breath sounds.DURATION of breath sounds.

Vesicular breath soundsVesicular breath sounds

Heard over normal lung.Heard over normal lung. Expiration softer and longer than Expiration softer and longer than

inspirationinspiration Pause between inspiration and Pause between inspiration and

expiration. expiration.

lung sounds lung sounds

Bronchial breathingBronchial breathing

““Tracheal” sounding: inspiration and Tracheal” sounding: inspiration and expiration are of equal intensity. expiration are of equal intensity.

Normal over right anterior superior Normal over right anterior superior chest.chest.

Present in consolidation, atelectasis, Present in consolidation, atelectasis, above pleural effusion.above pleural effusion.

Adventitious soundsAdventitious sounds

WHEEZE (WHEEZE (צפצופיםצפצופים) - sibilant or high ) - sibilant or high pitched continuous sound arising pitched continuous sound arising from medium or small airways, from medium or small airways, indicate obstruction.indicate obstruction.

RHONCUS- sonorous or low-pitched RHONCUS- sonorous or low-pitched rhoncus arising from large airways.rhoncus arising from large airways.

FRICTION RUB – continuous FRICTION RUB – continuous creaking noise, indicates pleural creaking noise, indicates pleural inflammation.inflammation.

Adventitious sounds- Adventitious sounds- CracklesCrackles

((rales, crepitationsrales, crepitations))( (חרחורים )חרחורים) Discontinuous sound. Caused by Discontinuous sound. Caused by

secretions or small airspace secretions or small airspace opening / closure.opening / closure.

Fine - pneumonia, cardiac failure, Fine - pneumonia, cardiac failure, fibrosis.fibrosis.

Coarse – bronchiectasis.Coarse – bronchiectasis. (Wet or dry)(Wet or dry) Inspiratory, expiratory or both. Inspiratory, expiratory or both.

AuscultationAuscultation

Bronchophony (vocal resonance)Bronchophony (vocal resonance) Egophony “e” to “a”Egophony “e” to “a” Whispering pectoriloquyWhispering pectoriloquy

Findings in common lung Findings in common lung conditionsconditions

Bronchial Bronchial breathingbreathing

Breath Breath soundssounds

קולות נשימהקולות נשימה

FremitusFremitus

פרמיטוספרמיטוס

PercussionPercussion

ניקושניקוש

PneumothoraxPneumothoraxPleural Pleural effusioneffusion

ConsolidatioConsolidationn

EmphysemaEmphysema

Accessory muscles, “pursed-lip” Accessory muscles, “pursed-lip” breathing.breathing.

Barrel chest, reduced excursion, Barrel chest, reduced excursion, reduced crico-sternal distance.reduced crico-sternal distance.

Loss of cardiac dullness, low liver, Loss of cardiac dullness, low liver, low diaphragms.low diaphragms.

REDUCED AIR ENTRY “Faulty REDUCED AIR ENTRY “Faulty stethoscope sign”stethoscope sign”

Prolonged expiration, wheeze.Prolonged expiration, wheeze.

AsthmaAsthma

Respiratory rate.Respiratory rate. Talking dyspneaTalking dyspnea Accessory musclesAccessory muscles Pulsus paradoxusPulsus paradoxus Air entryAir entry WheezingWheezing

Pulmonary fibrosisPulmonary fibrosis

ClubbingClubbing End- inspiratory crackles.End- inspiratory crackles. Small lungs, reduced excursion.Small lungs, reduced excursion.