Assesment of health status of the patients of respiratory
system diseases: complaints, overview of physical
examination and history taking, laboratory and
instrumental examination, the main syndromes.
Bronchitic syndrome, Infiltrative syndrome, Pleural
effusion, Lung cavity, Bronchial obstruction syndrome,
Lung restriction, respiratory failure.
Dr. Jonas Jucevičius
Complaints: cough
1. Duration: acute < 3 weeks (infection
viral/bacterial, inhaled foreign body, inhalation of
irritant dusts/ fumes) ; chronic > 8weeks
(GORD, Asthma, tumour etc..)
2. Dry (tracheitis, pneumonia)/moist
(productive) (bronchial infection,
bronchiectasis)
3. Timing: nocturnal- asthma, heart failure,
morning- chronic bronchitis.
4. Provoking/alleviating factors
5. Sound (wheezing- asthma, COPD)
https://i0.wp.com/92127.zcodemagazines.com/wp-content/uploads/sites/2/2010/11/cough2.jpg?w=320
Complaints: Sputum production.
• Expectorated sputum- always abnormal.
• Amount: Small ( asthma, COPD , pneumonia), large –
(bronchiectasis large volumes of purulent, sudden
production of large- rupture of abscess or empyema).
• Appearance: colour, smell, taste, viscosity.
• Frequency: how many times a day (activity of
disease)
• How much effort to expectorate is needed.
• Duration.
Types of sputum
1. Serous: clear watery frothy
pink (pulmonary oedema. Alveolar cell
cancer)
2. Mucoid: clear, grey, white,
viscid (asthma, chronic bronchitis, COPD)
3. Purulent: yellow- bronchopulmonary
infection, astma exacerbation, COPD
exacerbation; green- longer standing
infection.
4. Rusty red- pneumococcal pneumonia.
https://mylungsmylife.org/wp-content/uploads/CHSS_sputum_chart.jpg
Complaints: haemoptysis
• Shoud be differentiated from gastrointestinal bleeding.
(Bleeding from GI tract- blood darker, associated with vomiting, may be mixed with blood particles, history of
gastrointestinal tract diseases; Bleeding from respiratory tract- blood brighter, associated with cough, history of
respiratory diseases)
• Physical examination and history- other possible sites of bleedingmouth/pharynx, gastrointestinal tract.
• Causes: 1. tumour (malignant, benign), 2. infection (tuberculosis, bronchiectasis,
abscess, cystic fibrosis), 3. vascular (pulmonary infarcion, arteriovenous
malformations), 4. vasculitis, 5. trauma, 6. cardiac causes, 7. haematological
pathology.
• If bleeding from respiratory tract: 1. amount and appearance of expectorated
blood, 2. duration and frequency should be assessed.
• Large amount (> 500ml/24 hours)- check for posthaemorrhagic anaemia, shock.
Complaints: chest pain. Questions to ask
OR
Site
Onset (gradual/ sudden)
Character
Radiation
Associations
Timing (duration, course, pattern)
Exacerbating/relieving factors
Severity)
Chest pain
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1.
2.
3.
4.
5.
6.
7.
Site
Radiation
Character (type)
Intensity (severity)
Duration, Onset
Exacerbating/relieving factors
Associated symptoms
Complaints: chest pain
• Types: 1) Pleural- sharp, stabbing (may be of varying intensity), in lower parts of chest or axillary region,
intensified by inspiration/ coughing/bending to healthy side, alleviated by lying on affected side, not radiating, may
, 2) Restrosternal/mediastinal (central, retrosternal unrelated to respiration/
cough, constricting), 3) Muscular (intensifies while coughing, bending to healthy side, after vigorous coughing or
direct trauma), 4) Intercostal neuritis- intensifies while bending to unhealthy side, painful sites near
be with dry cough
sternum/ spine;
• Cardiovascular (Myocardial ischaemia, pericarditis, Aortic aneurysm
disection), Pulmonary (tracheobronchitis, pleuritic), GI and other
(GERL, esophageal spasm, chest wall pain, anxiety).
Complaints: breathlessness/dyspnoea
• Subjective sensation of shortness of breath- nonpainful but
uncomfortable awareness of breathing that is inappropriate to the
level of exertion
• Causes: 1. Non-cardiorespiratory- anaemia (circulatory), metabolic acidosis (chemical),
obesity, psychogenic, neurogenic (central). 2. Cardiac (LVF, mitral valve disease, CMP, Constrictive
pericarditis, pleural effusion); 3. Respiratory (Airways – COPD, Asthma; Parenchymarestrictive deseases; Pulmonary circulation (Pulmonary embolism); Pleural; Chest wall;
Neuromuscular).
Dyspnoea
• Questions to ask: 1.Intermittent (acute episodes) or persistent, 2.
Onset, 3. Duration, 4. Alleviating factors, 5. Associated symptoms.
• Severity: various grades/scales e.g. I⁰ going uphill, II ⁰ at normal physical exertion,
III ⁰ minimal physical exertion, IV ⁰ at rest.
• Inspiratory/ expiratory/ mixed.
Duration
Intermittent/ persistent
How is your breathing at rest
and overnight?
Is your breathing normal some
days?
Alleviating/ relieving factors
Setting/ onset
How did the
breathlessness come
on?
When does the
breathlessness come
on?
Tell me something you
do that would make you
breathless?
Accompanying symptoms
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Dyspnea
Complaints: Additional breathing sounds heard by the patient
Wheeze
High pitched whistling sound
produced by air passing
through narrowed small
airways.
Most commonly heard during
expiration
Associated with asthma and COPD but
can also occur with acute respiratory
tract infection or with exacerbations of
bronchiectasis
Stridor
Harsh, grating respiratory sound caused by
vibration of the walls of the trachea or major
bronchi when the airway lumen is critically
narrowed by compression, tumour or inhaled
foreign material.
Critical narrowing inside the extrathoracic trachea
leads to inspiratory stridor
Upper airway obstruction (laryngitis, laryngeal cancer)
Complaints: apnoea
• Absence of breathing.
• Reduction in airflow or respiratory movements by > 50proc. For
10secs or more.
• Obstructive sleep apnoea/hypopneae- obesity, snoring
• Other reasons: central- brain tumors, hypercapnia,
Complaints: Symptoms of upper respiratory
tract impairment
• Nose, nasopharyngeal pathology (common cold/ runny nose, painful
swallowing)
• Impairment of vocal cords- sore throat, hoarseness, stridor.
Complaints: Fever
• Lower respiratory tract infections (pneumonia, exacerbation of COPD/
asthma, purulous diseases [bronchiectasis, lung abscess, pleural epyema],
• Tuberculosis,
• Lung cancer,
• Acute viral upper respiratory tract infections.
History taking. The patient should be asked
about:
• Previous illnesses (respiratory and non-respiratory/ infectious),
• Past hospitalisations/ performed laboratory and instrumental tests
(esp. Chest x-rays, Chest CT scans),
• Medication history ( if COPD, Asthma- inhaler, its dose, effectiveness)
• Family history (cystic fibrosis, asthma, allergies)
• Social and occupational history/ risk factors: 1. Smoking (if the patient is
smoking ask how many years and how many cigaretes per day. Calculate pack years) 2. Pets
(allergenes) 3. Air pollutants 4. Past diseases 5. Poor nutrition.
Physical examination : general inspection (1)
• Position: free, or is the
patient forced to take
some position because
of pain/ dyspnoea
• Active forced lateral
decubitus – pleuritis,
lung abscess (patient
lies on impaired side),
• Active forced sittingpulmonary oedema,
asthma attack.
https://www.wikihow.com/Ease-Pleurisy-Pain
https://www.blf.org.uk/support-for-you/breathlessness/how-to-managebreathlessness/positions-for-obstructive-lung
Physical examination : general inspection (2)
• Skin and mucous membranes- cyanosis (central- lips, tongue, mucous
membranes. Extremities are warm)- blue discoloration of the skin and
mucous membranes (increased concentration of deoxygenated
haemoglobin)
• Peripheral cyanosis (face, arm)- superior v. cava compression (mediastinal
tumors), also facial swelling - venous distention in the neck and distended
veins in the upper chest and arms)
• Enlargement of neck and supraclavicular lymphnodes
• Horner‘s symptom
• Lip vesicular eruption
• Pursed Lip Breathing (COPD)
Physical examination : general inspection (3)
• Clubbing- loss of the normal angle between the nail and nail bed,
increased nail curvature in later stages, increased bulk of the soft
tissues over the terminal phalanges. (chronic infections purulent
diseases, empyema).
• Discolouration of the fingers and nails (brownish stain on the fingers
and nails in cigarette smokers.
• Finger tremor- ventilatory failure.
• High JVP- right heart insufficiency (cor pulmonale), increased
intrathoracic pressure, SVC obstruction.
Clubbing
https://clinicalexams.co.uk/wp-content/uploads/2016/02/Finger-or-nail-clubbing-600x600.jpg
https://en.wikipedia.org/wiki/File:Acopaquia.jpg
Physical examination (special inspectionstatic chest dimensions)
• Shape of the chest: normostenic/ hyperstenic/ astenic.
• Increase in anteroposterior diameter, short chest, wide and horizontal
intercostal spaces: barrel-shaped chest (lung hyperinflation/
emphysema).
• Spine deformations (kyphosis/ scoliosis/ kyphoscoliosis).
• Pectus carinatum (pigeon chest)- rachitic (prominence of the sternum
and adjacent costal cartilages).
• Pectus excavatum (funnel chest)- depression of lower end of sternum.
Special inspection – Static chest dimensions
https://fitlyfedotblog.files.wordpress.com/2017/03/conditions-with-indented-chest.jpg
Special Inspection- Dynamics of Respiration
Symmetricity/ Equality
Type (thoracic/ abdominal)
Rhythmicity
Exp/Ins
Prolonged expiration may be sign of
obstruction
Depth
https://image.shutterstock.com/image-vector/breathingvector-icon-having-breath-600w-695922688.jpg
Respiratory
rate
Use of accessory muscles
(sternocleidomastoids, platysma, pectoral)
Special Inspection- Dynamics of Respiration
Pathological breathing patterns:
• Periodic breathing – Cheyne-Stokes
respiration)
• Hyperventilation with deep, sighing
respirations (Kussmaul respiration)
• Hyperventilation- deep irregular,
sighing, inabillity to fill lung completely
• Tachy/ Bradypnea (<12 or >20 bpm)
• Biot‘s respiration.
Picture from: https://en.wikipedia.org/wiki/File:Breathing_abnormalities.svg
Palpation
• Palpation of the lymph nodes– supraclavicular- axillary
• Palpating the chest from top to bottom- identification of tender areas
(bruises), assesment of any observed anomalities (masses).
• Assessing elasticity of chest [decreased- emphysema, pneumosclerosis]
• Checking for pleural rub [dry pleurisy]
• Assessing tactile fremitus (TF)- compare both sides of the chest using ball
or ulnar surface of hand, while the patient is saying „99“. Normally fremitus
is decreased or absent over precordium [Increased TF- increased pulmonary tissue densitypneumonia, TBC; empty cavities- cavernous tb, drained abscess. Decreased TF – tumours, pleuritis,
pneumothorax, emphysema]
• Chest expansion [Unilateral decrease or delay- fibrosis of lung or pleura, pleural effusion, lobar pneumonia,
pleural pain]
Physical examination: percussion
• Types of sound:
• Resonant – normal lung
• Hyper-resonant (box)- Emphysema
• Hyper-resonant (Tympanic)pneumothorax
• Dull- Pulmonary consolidation, pleural
effusion, haemothorax.
https://image.slidesharecdn.com/medicine-compentsofhistorytaking2014-141125072308-conversiongate01/95/medicine-compents-of-history-taking-2014-56-638.jpg?cb=1416901791
Percussion
• Comparative percussion (comparing right and left at same areas).
Check for assymetry.
• Done in main anatomical lines.
• Topographic percussion- used to check lower and margins of the
lungs, expansion of lungs, topography of lung lobes.
Auscultation
• Usually with diaphragm of stethoscope
• Listening: Anteriorly, from above clavicle to the 6th rib; laterally from
axilla to the 8th rib, posteriorly down to level of 11th rib.
• 1. Listening to breathing sounds, comparing both sides for asymetry
• 2. Assesing any adventitious sounds
• 3. Auscultating while patient is forced exhaling
• 4. Vocal resonance (whispering one one one, ninety nine,)- normal
lung= sound diminishes, consolidated lung= clearly audible,
effusion/collapse= muffled sound.
Auscultation (breath sounds)
1. Vesicular – inspiratory (soft) sounds lasts longer than expiratory
ones- heard over most of both lungs
2. Bronchovesicular – inspiratory (intermediate) and expiratory sounds
are about equal- between scapulae and 1st and 2nd interspaces
anteriorly
3. Bronchial – expiratory longer – over manubrium
4. Tracheal- equal insipration and expiration, very loud- at the neck.
Pathology:
• Diminished vesicular
breathing
• Bronchial or
bronchovesicular sound
(where it shoudn‘t be
heard)
• Increased vesicular
breathing sound
• No breathing sound
• Amphoric breath sound
Bates' Guide to Physical Examination and History Taking By Lynn S. Bickley, Peter G. Szilagyi, Barbara Bates
Auscultation
• Diminished vesicular breathing : 1. Reduced conduction ( obesity/
thick chest wall/ pleural effusion/ pneumothorax) 2. Reduced airflow
(COPD- generalized , collapsed lung- localized)
• Bronchial or bronchovesicular sound (where it shoudn‘t be heard):
lung consolidation, localized pulmonary fibrosis, top of pleural
effusion.
• Increased vesicular breathing sound: deap breathing, thin chest wall,
narrowed small bronchi (COPD, ASTHMA)
• No breathing sound: pneumothorax, large hydrothorax.
• Amphoric breath sound: large empty superficial lung cavity.
Auscultation (adventitious sounds)
• Continuous
1. Wheezes:
– sibilant (hissing sound)
- sonorous (snoring sound- rhonci)
2. Pleural friction rub (creaking sound, similar to treading in fresh snow. Usually confined to relatively
small area; lower portion of lateral thorax)
• Discontinous
1. Crackles (rales) [heard during both phases of respiration bet better on inspiration] :
-coarse/ medium/ fine;
-loud/soft
2. Crepitations (fine, brief, interrupted, explosive sounds heard only on expiration)
Auscultation (adventitious sounds- wheezes
and rhonchi)
• Wheezes- arise from turbulent airflow and the vibration of small airways in
which there is partial obstruction to airflow. Heard on both phases of
respiration but predominantly during expiration.
• Reason is narrowing of airways- bronchospasm, oedema, collapse,
neoplasm, foreign body.
• Continuous.
• Like dashes in time.
• Relatively high pitched with hissing or shill quality.
• Rhonci- relatively low pitched, gurgling with snoring quality- clear or
change significantly after effective cough.
• Asthmatic breathing- expiratory phase several times longer than in
bronchial and much higher pitch.
Auscultation: crackles (rales)
• Discontinuous
• Intermittent, nonmusical, brief
• Like dots in time
• Fine crackles- very brief. Coarse crackles- louder, brief
• Early inspiration- small airways desease (fine)
• Middle inspiration- pulmonary oedema (fine)
• Late inspiration- pulmonary oedema, pulmonary fibrosis, bronchial
secretions in COPD, pneumonia.
• Biphasic- bronchiectasis (coarse crackles)
Bates' Guide to Physical Examination and History Taking By Lynn S. Bickley, Peter G. Szilagyi, Barbara Bates
Laboratory and instrumental examination
• Chest xray: anteroposterior and lateral if needed.
https://image.slidesharecdn.com/readingcxr-151003105437-lva1-app6892/95/reading-chest-xray-5-638.jpg?cb=1443869796
Laboratory and instrumental examination
• Full blood count: WBC, Haematocrit, Eosinophils.
• CRP- infectious diseases
• Examination of sputum: Macroscopic exam, Microscopic exam
(neutrophils- infectious diseases, eosinophils- asthma, parasitic diseases, atypical cells- tumors,
elastic fibers- diseases destroying lungs, tubular cells- acute bronchitis, asthma),
Bacteriological exam (tuberculosis, other infections), microbiological culture.
Laboratory and instrumental examination:
Pleural effusion and Thoracentesis.
• The fluid from pleural cavity is tested: physical tests (amount, SG, colour,
transparency), chemical tests, cytological test, bacteriological test.
https://image.slidesharecdn.com/seminar-151001050841-lva1-app6891/95/effusion-cytology-diagnosis-7-638.jpg?cb=1443676343
Blood gas analysis
• Arterial blood gas (PaO2, PaCO2) and pH status are obtained.
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Spirometry
• Dynamic lung volumes are measured by inhaling to total lung capacity
and exhaling into spirometer with maximal effort.
• Volume exhaled in 1st second- FEV1.
• Total volume exhaled – FVC.
• FEV1/FVC ratio
• Reduction of ratio- obstruction.
• Severity of obstruction- check FEV1.
• Interstitial lung diseases- decrease in FVC.
Main syndromes
Bronchitic Syndrome (airway irritation
syndrome)
• Caused by irritants (dust, tobacco smoke, alergenes, pollutants),
chronic and acute bronchitis.
• Dry or productive cough. Persistent or intermittent, may be
accompanied by tracheic and/or intercostal muscle pain.
• Usually no changes found on inspections, palpations or pecussion.
• Increased vesicular breathing sound; prolonged forced exhaling,
wheezes, fine crackles may be heard.
• Xray- intensified lung picture.
Infiltrative (consolidation) syndrome
•
•
•
•
Causes: pneumonia, infiltrative tuberculosis.
Productive cough, dyspnoea, fever, sweating, lateral (pleuritic) pain.
Flushed face, sometimes- herpetic rash can be seen.
Complete infiltration- tachypnoea, asymmetry of breathing, forced lateral
or sitting position, increased fremitus (over the affected area), dull
percussion sound (over the affected area), bronchovesicular or bronchial
breathing sound, some times crepitations can be heard on auscultation.
• Partial infiltration- Tachypnoea, slightly increased fremitus, normal or dull
precussion sound, increased alveolar or bronchoalveolar breathing sound,
crackles, slightly increased vocal resonanse.
• Leucocytosis, increased CRP, sputum exam, xray- increased density areas in
lungs.
Pleural effusion (fluid in pleural cavity)
• Persistent dyspnoea (increases during physical activity), symptoms of underlying disease.
• Anamnesis- signs of underlying disease may be found (heart/ renal failur, lung cancer,
pneumonia, tuberculosis).
• Tachypnoae (may be forced sitting or lateral position), assymetric chest, assymetric
breathing.
• Decreased or diminished tactile fremitus (over the area where the fluid is).
• Increased tactile fremitus above the fluid.
• Dull percussion sound (over the area where the fluid is and above)
• Diminished vesicular breathing sound over the affected area, decreased vocal resonanse
• Increased vesicular breathing sound above the affected area.
• Xray- costophrenic angle blunting.
• Thoracentesis is needed.
Air Accumulation in the Pleural Cavity
• Causes- chest trauma, cavernous tuberculosis, spontaneus.
• Symptoms- acute dyspnea, dry cough, pain fo the damaged side of the
chest.
• Inspection- tachypnea, active forced sitting position, assymetric breathing
and assymetric chest (wide intercostal spaces and reduced or absent
breathing movements of the damaged chest side).
• Palpation- decreased or absent tactile fremitus over the damaged side.
• Percussion- tympanic sound over the damaged area.
• Auscultation- decreased or absent vesicular (or any) breathing sound over
the damaged area.
• Chest x-ray-light pulmonaryfield along the chest border without pulmonary
pattern. Mediastinum displaced to contralateral side.
Lung cavity syndrome
• Causes: drained lung abscess, tumor lysis, cavernous tuberculosis,
bronchiectasis.
• Productive cough (large amount of sputum), general malaise, fever.
• Tachypnoea, forced lateral position, finger clubbing.
• At site of cavity- increased tactile fremitus, tympanic percussion
sound (if the cavity is empty); Bronchial breathing sound (sometimes
amphoric), coarse crackles, increased vocal resonanse.
• Xray- lower density area with clear borders .
• Mucus examination- neutrophills, erythrocytes, elastic fibers,
microorganisms.
Increased airiness in the lung syndrome
(Emphysema)
• Main smptom- exertional dyspnea.
• Usually a history of long time smoking or chronic respiratory diseases are
found.
• Patient may be in active forced sitting position. Prolonged expiration can be
noticed (because of bronchial obstruction).
• Central cyanosis; Barrel-shape chest.
• Decreased tactile fremitus over whole lung area, decreased chest elasticity
and expansion.
• Hyperresonant (box) sound on percussion over whole lung area; low
position of lower borders of the lungs and decreased active mobility of the
lower borders of the lungs.
• On auscultation- reduced vesicular breathing sound over whole lung area.
Bronchial obstruction syndrome
• Causes: bronchial smooth muscle spasm, inflammation of mucosal layer of
bronchi, emphysema (reduced elasticity of lung tissue), accumulation of
secretion in respiratory tract.
• Asthma, COPD, bronchectasis, Pulmonary emphysema.
• Expirational dyspnoea, prolonged expiration.
• Wheezes.
• Obstructive ventilation impairment in spirometry. FVC normal.
• Often – hyperresonant (box) percussion sound, decreased lung elasticity,
decreased vesicular breathing, decreased vocal resonanse.
• Xray- diffuse reduction of lung tissue density.
• At later stages- respiratory failure.
Lung restriction syndrome
• Causes: reduced respiratory surface or chest wall movements- after
lung resections, lung tumors, sarcoidosis, fibrosis, radiation damage,
pneumo or hydrothorax, respiratory muscle weakness, deformations
of chest wall, obesity.
• Dyspnoea (increases during physical activity), shallow breathing.
• Restrictive pattern of ventilatory impairment (decreased TLC, FVC).
FEV1, FEV1/FCV normal.
• Symptoms of underlying (main) disease.
• Respiratory failure at later stages.
Respiratory failure syndrome
• Respiratory stage at which normal blood gas levels can not be maintained,
or can only be maintained at rest.
• Acute/ chronic.
• Causes: respiratory diseases, musculosceletal diseases, chest deformations,
obesity, impaired control of ventilation in brain.
• Dyspnoea, Tachypnoea (bradypnoea), use of accessory muscles in
breathing, shallow breathing (restrictive diseases), central cyanosis), forced
sitting position, tachycardia, Signs of pulmonary hypertension,
Erythrocytosis (in full blood count test), Impairment of conciousness,
headache, symptoms of underlying main disease.
• Blood gas examination.
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