1. Differential Diagnosis Pulmonary Disorders

2. Pulmonary pain is usually localized to the anterior chest, side or back Can radiate to the neck, upper trap muscles, costal margins, thoracic region, scapulae or shoulder Usually increased with inspiratory movements such as laughing, coughing, sneezing or deep breathing Associated symptoms include dyspnea (exertional or rest), persistent cough, fever and chills

3. Pulmonary Anatomy

4. Pulmonary Disorders The most common pulmonary conditions that mimic musculoskeletal dysfunction include: Pulmonary artery hypertension Pulmonary embolism Pleurisy Pneumothorax Pneumonia

5. Pulmonary Disorders Any of the following symptoms are associated with lung cancer and requires physician referral for assessment: CNS symptoms Muscle weakness Muscle atrophy Headache Loss of LE sensation Localized or radicular back pain

6. Pulmonary Pain Parietal pleura is sensitive to painful stimuli, but visceral pleura is not Trachea and large bronchi are innervated by the vagus trunk Finer bronchi and lung parenchyma have no innervation Trachebronchial pain is referred to sites in the neck or anterior chest at the same level as the irritation Caused by inflammatory lesions, foreign materials or cancerous tumors

7. Pulmonary Pain Disease may be extensive prior to onset of pain Pain does not occur until it reaches the parietal pleura Pain is described as sharp and localized Aggravated with inspiratory movements Relieved by lying on the affected side (autosplinting)

8. Pulmonary Pain Pleural pain occurs with: Pleurisy Pneumonia Pulmonary infarct Tumor Pneumothorax

9. Pulmonary Pain Diaphragmatic pleural pain Peripheral – Sharp pain referred to costal margins or lumbar region Central – Sharp pain referred to the upper trap or shoulder on the ipsilateral side Cardiac and diaphragmatic pain are often experienced in the shoulder because both are supplied by the C5-C6 spinal segment

10. Diaphragmatic Pleurisy Refers pain to the costal margins or upper trap muscles Aggravated by diaphragmatic motions (coughing, laughing, or deep breathing) Change in position does not reproduce the symptoms If a true intercostal lesion or tear, bending or rotation of the trunk would cause or reproduce the pain

11. Pulmonary Physiology Primary function of the respiratory system is to provide oxygen to and remove carbon dioxide from cells in the body Effectiveness of ventilation is most often measured by arterial blood gas testing

12. Arterial Blood Gases pH * =pKa [HCO 3 ] + log[HCO 3 ] / 0.03 x pCO 2 * Arterial pH * 7.35 – 7.45 PaCO 2 * 35 – 45 mmHg * Measured HCO 3 22 – 26 mEq/L Calculated not measured Obtained with CMP PaO 2 80 – 100 mm Hg Sat O 2 > 95%

13. Oxygen Determination of Oxygen content in blood PaO 2 Sat O 2 Hb (14-18 gm/dl) from CBC PaO 2 Dissolved oxygen in plasma Sat O 2 Reflects oxygen saturation of hemoglobin = [Hb-O 2 / (Hb-O 2 + reduced-Hb)]*100%

14. Porth, 29-22, 2005

15. Oxygen Decrease Manifestations Angina Tachycardia Arrhythmias MI Confusion and Stupor Decreased aerobic capacity Cyanosis

16. Carbon Dioxide and Bicarbonate Bicarbonate (HCO 3 ), extracellular anion Regulation Metabolic activity Loss HCO 3 : Renal CO 2 : Respiratory Physiologic effects Maintain pH Osmotic pressure regulation

17. Porth 34-2, 2005

18. Porth 34-1, 2005

19. pH Calculation Normal pH = 7.35 – 7.45 pH = pKa HCO 3 - +log([HCO 3 - ]/[0.03 x pCO 2 ] H 2 CO 3 pKa = 6.1 ([HCO 3 - ]/[CO 2 ] = 20/1 for pH = 7.4 < 20/1 = acidosis > 20/1 = alkalosis Numerator [HCO 3 - ]: kidney Denominator [CO 2 ]: lungs

20. Porth, 34-1, 2005 H 2 CO 3 mEq/L = 0.03* CO 2 mm Hg

21. Respiratory Acidosis Decreased pulmonary ventilation leads to retention and concentration of carbon dioxide, hydrogen and carbonic acid May result in hypoxia Hyperkalemia and cardiac changes result and could cause cardiac arrest Advancing symptoms may include diaphoresis, shallow rapid breathing, restlessness, and cyanosis These symptoms need immediate medical referral

22. Respiratory Alkalosis Increased respiration decreases the amount of carbon dioxide and hydrogen available  increased pH Usually due to hyperventilation Causes may be neurogenic or psychogenic Muscular tetany and convulsions can occur Cardiac arrhythmias caused by serum potassium loss may occur Respiratory alkalosis is more commonly seen in PT clinics than respiratory acidosis Initially treat with reassurance, facilitate relaxation and slow breathing If hyperventilation continues in the absence of pain or anxiety, immediate physician referral is needed

23. Chronic Obstructive Pulmonary Disease COPD – Considering changing name to CAL (Chronic airflow limitation) Leading cause of morbidity and mortality among cigarette smokers Narrowing of the airways obstructs airflow to and from the lungs Trapped air hinders normal gas exchange and causes alveoli distention Includes disorders of obstructive bronchitis, emphysema and asthma

24. Emphysema Elasticity of the lungs is reduced Marked dyspnea is common Cough is uncommon Uses accessory muscles for respiration Often leans forward with arms braced on the knees to support the shoulder and chest for breathing Barrel chest develops Pursed-lip breathing should be encouraged Routine progressive walking is the most common form of exercise

25. Tuberculosis Bacterial infectious disease Most often affects the lungs Fatigue Dyspnea Dull chest pain, tightness or discomfort Frequent productive cough Can affect the hip joints and vertebrae resulting in arthritic-like damage and possibly avascular necrosis of the hip Pott’s disease (TB of the spine) – Rare but can cause compression fractures of the vertebrae

26. Apical (Pancoast’s) Tumors Tumor of the apex of the lung Frequently extend to C8-T1 nerves within the brachial plexus

27. Apical (Pancoast’s) Tumors Produces sharp, pleuritic pain in the axilla, shoulder and subscapular area on the affected side UE pain in an ulnar nerve distribution Subsequent atrophy of UE muscles Sometime mistaken for subacromial bursitis Also mimics serratus anterior trigger points – Rule out by palpation and lack of neurological deficits

28. Cystic Fibrosis Inherited disorder of the exocrine glands Primarily affects the digestive and respiratory systems Salt accumulates in the cells lining the lungs and digestive tissues. The surrounding mucus is abnormally thick and sticky Bronchioles are obstructed by mucus plugs and trapped air predisposes the patient to infections Persistent coughing and wheezing Excessive appetite but poor weight gain Salty skin/sweat Barrel chest develops Dyspnea is prominent Uses accessory muscles with respiration Cyanosis and digital clubbing present

29. Pulmonary Embolism Signs and symptoms are nonspecific and vary greatly Most common symptoms are dyspnea, pleuritic chest pain and cough Pleuritic chest pain is usually sudden onset and aggravated by breathing May also report hemoptysis, apprehension, tachypnea and fever

30. Pleurisy Inflammation of the pleura Caused by infection, injury or tumor May be wet or dry Symptoms include chest pain, cough, dyspnea, fever, chills and tachypnea Chest pain is sudden and varies in description from vague discomfort to intense stabbing or knifelike Aggravated by breathing, coughing, laughing or other deep inspiratory movements Pain may be referred to the lower chest wall, abdomen, neck, upper trap muscles and shoulder

31. References Arnall D, Ryan M.1995. Screening for Pulmonary System Disease. In: Boissonnault editor: Examination in Physical Therapy Practice Screening for Medical Disease. 2 nd edition. Philadelphia, PA: Churchill Livingstone, p69-100. Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4 th edition. St. Louis, MO: Saunders Elsevier. p332-365. Jarvis C. 2000. Physical Examination and Assessment, 3 rd edition. Philadelphia, PA: WB Saunders. In: Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4 th edition. St. Louis, MO: Saunders Elsevier. p333. Porth, Carol M, Pathophysiology: Concept of Altered Health States, 7th ed., J.B. Lippincott Co., Philadelphia, 2005.