1. Symptoms and Signs in Respiratory System Dr. Nawal N Binhasher Assistant professor, Medical Consultant department of medicine

2. History: Symptoms: Cough Sputum Hemoptysis Dyspnea Chest pain (chest tightness) Wheezing

3. cough Definition: cough reflex arc

4. Types: 1.Acute ( < 3 wks ) ex: RTI 2.Subacute ( 3-8 wks ) ex: post RTI 3.Chronic ( >8 wks ) ex: bronchiectasis

5. Causes of acute cough: 1.Acute upper respiratory tract infection. 2.Acute lower respiratory tract infection (pneumonia). 3.Acute exacerbation of underlying chronic pulmonary disease. 4.Pulmonary Embolism (PE).

6. Causes of subacute cough: 1.Post-infection of upper or lower respiratory tract. 2.Angiotensin Converting Enzyme Inhibitors (ACE-I) medication.

7. Common causes of chronic cough usually with a normal CXR: 1.Upper airway cough syndrome ( it is related to allergic, non-allergic or vasomotor rhinitis, naso- pharyngitis, & sinusitis. i.e postnasal drip «PND») 2.Bronchial Asthma 3.Gastroesophageal reflux disease

8. Other Respiratory Causes: 1.Chronic bronchitis (COPD, eosinophilic) 2.Bronchiectasis 3.Neoplasm 4.Interstitial lung disease (ILD) 5.Lung abscess 6.Obstructive sleep apnea (OSA) 7.Tracheobronchial foreign body or mass 8.Nasal polyps & others……

9. Non-Respiratory Causes: Mediastinal: external tracheal compression ex: enlarged LN Tumors, cysts, masses Cardiac: LVF Severe MS ENT: Acute/chronic sinusitis PND (perennial, allergic, or vasomotor rhinitis)

10. Cont’n: GI: GERD Esophageal dysmotility, stricture, or pouch Esophago-bronchial fistula CNS: CVA MS MND Parkinson’s disease

11. Cont’n Drugs: ACE-Inhibitors Some inhaler preparations can cause cough Others: Idiopathic Ear wax (vagal nerve stimulation) Psychogenic

12. Sputum: Amount: N amount < 100mls of mucus/day Color: N, clear & white mucus Smell: N, not smelly Ex: chronic large amount of purulent sputum may suggest bronchiectasis while acute one may indicate lobar pneumonia. Ex: foul-smelling purulent sputum may indicate lung abscess with anaerobic infection Ex: pink frothy secretions occurs in pulmonary edema

13. Hemoptysis: It’s a blood-stained sputum Varies from streaks of blood to massive bleeding (>100 - 600mls /24 hrs) It should be investigated thoroughly Commonest cause is acute infection like exacerbation of copd but other serious causes should be rolled out Other causes: PE, Bronchogenic ca., pul TB, bronchiectasis, lung abscess,

14. Cont’n Pulmonary hemorrhage from any cause like: Goodpasture’s syndrome or rupture of a mucosal blood vessel after a vigorous coughing Non-respiratory causes: CVS: severe MS, & acute LVF. Bleeding Diathesis should be excluded. Rusty sputum (when purulent sputum is mixed with blood) eg: lobar pneumonia

15. Dyspnoea: Defined as: experience of discomfort in breathing or an awareness of respiratory distress & physiologically its an ↑ in the level & work of breathing. Onset: 1.Instantaneous: pneumothorax, PE 2.Min.s – hrs: * Aw disease: (BA, copd exacerbʼn, UAW obstrcʼn) * parenchymal disease: (pneumonia, pul hage, pul edema..) * pul vascular disease: (PE) * cardiac disease: ( MI,……. ) * metabolic acidosis * hyperventilation syndrome.

16. Cont’n: 3. Subacute (days): * Many of the above plus: * Pl. effusion * lobar collapse * Acute Interstitial pneumonia * SVC obstruct’n * Pul vasculitis 4. Chronic (months-years): * COPD & BA * Diffuse parenchymal dis: (IPF, sarcoidosis, bronchiectasis) * Hypoventilat’n:(neuromuscular weakness, chest wall defor) * Anemia * Thyrotoxicosis

17. Cont’n: Severity (grading): Dyspnea can be graded from І – IV based on the NYHA classification. Chest pain: Pul causes of CP: 1. pul vasculature: Acute PE Pul HTN & Corpulmonale 2. Lung parenchyma: Pneumonia Cancer sarcoidosis

18. Cont’n: 3. Pleura & plural spaces: Pneumothorax Pleuritis & serositis Pleural effusion 4. psychogenic/psychosomatic Wheezing: It’s a continuous whistling, not diagnostic for asthma & can occur in other resp diseases like copd.

19. Other symptoms: 1.Runny, blocked nose & sneezing: may occur in both common cold & allergic rhinitis (loss of smell = inosmia, runny nose = rhinorrhea) 2.Nocturnal fever may accompany TB, pneumonia, & mesothelioma. 3.Nocturnal sweating can occur in TB, lymphoma, & lung abscess. 4.Hoarseness may be secondary to laryngitis, VC tumor, & RLN palsy in apical lung CA. 5.Symptoms of corpulmonale (abd & ankle swelling, ….)

20. Other aspects of history: Details of the respiratory system symptom should be inquired such as; onset, duration, character, radiation/severity/grading, frequency, aggravating & relieving factors, & associated symptoms. PMH of a respiratory disease Smoking history in details Drug history including IV drug abuser (lung abscess) & alcohol consumption (aspiration pneumonia) Inquiry about occupat’n & or previous jobs Pets history

21. Clinical examination (signs): * General appearance * General system * Chest examination In general appearance, look for: Respiratory distress {count RR, normal 14-20bpm Tachypnea = ↑ rate of breathing Hyperapnea = ↑ level of ventilation, and look to the accessory muscles; sternomastoids, scalene, platysma & strap muscles of neck & abdominal muscles, if they are in use?}

22. Cont’n Coughing; character (bovine cough…) Sputum; Abnormal sound; stridor (croaking noise, loudest on inspiration 2° to larynx, trachea or large airways obstruction), or wheezing. Abnormal voice; hoarseness Surroundings; like containers of sputum, O 2 mask, IV lines or medications respiratory aids or machines..

23. General system examination: Hands: 1.Clubbing (check respiratory causes) 2.Tar staining 3.Weakness of hand’s small muscles (abduction) Wrist: 1.Pulse: rate & character 2.Flapping tremors (asterixis) BP: pulsus paradoxux (asthma), hypotension

24. Cont’n Neck: 1.JVP: ↑ in corpulmonale & SVC obstruct’n but not pulsatile. 2.LN: enlargement in CA bronchus or mets Face: 1.Eye: Horner’s syndrome in CA bronchus 2.Tongue : central cyanosis 3.SVC obstruction: plethoric & cyanosed, periorbital edema, injected conjuctvae & +ve Pemberton’s sign

25. Chest examination: Inspection: 1.Shape: AP diameter compared to transverse (barrel-chest), pectus excavatum, pectus carinatum, kyphoscoliosis,…. others 2.Symmetry: assessment of upper & lower lobes should be done posteriorly looking for ↓ or delayed chest movement during moderate respirat’n. 3.Scars: from previous operat’n or chest drains or cautery marks or radiotherapy markings. 4.Prominent veins: in case of SVC obstruct’n

26. Palpation: 1.Trachea: normally central, slight Rt displacement could be N. Check for gross displacement. Tracheal tug means the N distance bet sternal notch & cricoid cartilage is < 3-4 finger breadths & occurs in chest overexpansion as copd. 2.Apex beat & mediastinum: Check for displacement. 3.Chest expansion: N expansion ≥ 5cm 4.Tactile vocal fremitus (TVF): can be done with the palm of one hand.

27. Percussion: Should be done symmetrically (Lt compared with the Rt), posteriorly (the back), anteriorly (the front) & laterally (the sides). Supraclavicular area, then clavicles should be percussed directly to evaluate the upper lobes. Liver dullness: of the upper edge starting at the 6 th rib MCL, resonant note below this area indicates hyper- inflation (copd, severe asthma) Cardiac dullness: may be ↓ in hyperinfated chest.

28. Auscultation: Using the diaphragm of a stethoscope & comment on the following: 1.Breath sounds (BS): Intensity: N or ↓ as in (consolidation, collapse, pl effusion, pneumothorax, lung fibrosis) Quality: Vesicular or bronchial in consolidation Differentiation between vesicular & bronchial BS: Vesicular: louder &longer on inspiration than expiratory phase & has no gap between the 2 phases Bronchial: louder &longer on exp phase & has a gap between the 2 phases

29. 2. Added Sounds: Type: Wheezes or Crackles or friction rub Timing: inspiratory or expiratory Wheezes: are continuous musical polyphonic sound, heard louder on expiration & can be heard on inspiration which may imply severe AW narrowing. High pitched- wheezes are found in BA due to acute/chronic airflow limitation & low pitched in copd. Localized monophonic wheeze due to fixed AW obstruct’n in CA bronchus. Crackles: interrupted non-musical inspiratory sound coarse medium fineCrackles may be early, late or pan-inspiratory & fine, medium or coarse. Ex: late/pan-insp coarse crackles in bronchiectasis, late/pan-insp medium crackles in pul edema, late/pan-insp fine crackles in pul fibrosis

30. friction rub: It’s due to thickened or roughened pl surfaces rub together as lungs expand & contract & give off a continuous or intermittent grating sound. It indicates pleurisy & may be heard in pneumonia or pul infarction. 3.Vocal Resonance: It’s the ability to transmit sounds. Ask patients to say 44 (Arabic) or 99 (English) & listen for the transmitted sound which may be ↓ or ↑ or N (low pitched component of speech heard with booming & high pitched become attenuated).

31. 4. Egophony: When the patient with consolidation is asked to say ‘e’ it sounds like ‘a’ 5.Whispering pectoriloquy: The whispered speech is heard very loudly over the consolidated area. Other signs should be looked for to complete the respiratory system examination “signs of complications” 1.Signs of pul HTN or corpulmonale. 2. Signs of SVC obstruction. 3. Signs of CA bronchus mets, or extension

32. Secondary pul HTN or corpulmonale: Should be suspected in: 1.Chronic airflow limitation such as copd 2.Pulmonary fibrosis 3.Chronic pul thromboembolism 4.OSA 5.Severe kyphoscoliosis/marked obesity Signs: loud P 2 of S 2 + signs of RHF Thank you Any ?