THORAX and LUNGS Leida Marie P. Alarcon, MD, FPAFP LEARNING OBJECTIVES • To review the anatomy and physiology of respiratory system • To know the anatomical landmarks in describing lesions in the chest • To know the salient points in taking the health history of respiratory system • To know important topics on health promotion and counselling of certain diseases affecting the respiratory system • To demonstrate the proper techniques on the examination of the chest and lungs • To know the proper technique in recording the physical examination of the thorax and lungs. Anatomy and physiology The Trachea and Major Bronchi Health history Chest Pain Wheezing Common or Concerning Symptoms Shortness of breath (dyspnea) Cough Hemoptysis Health history Chest Pain Wheezing Common or Concerning Symptoms Shortness of breath (dyspnea) Cough Hemoptysis Sources of chest pain and related causes The myocardium Angina pectoris, myocardial infarction, myocarditis The pericardium Pericarditis The aorta Dissecting Aortic Aneurysm The trachea and large bronchi Bronchitis The parietal pleura Pericarditis, pneumonia, pneumothorax, pleural effusion, pulmonary embolus The chest wall, including the musculoskeletal system and skin Costochondritis, herpes zoster The esophagus Reflux esophagitis, esophageal spasm, esophageal tear Extrathoracic structures such as the neck, gallbladder, and stomach Cervical arthritis, biliary colic, gastritis Health history Chest Pain Wheezing Common or Concerning Symptoms Shortness of breath (dyspnea) Cough Hemoptysis Health history Chest Pain Common or Concerning Symptoms Shortness of Wheezing breath (dyspnea) Cough Hemoptysis Health history Chest Pain Wheezing Common or Concerning Symptoms Shortness of breath (dyspnea) Cough Hemoptysis Health history Chest Pain Wheezing Common or Concerning Symptoms Shortness of breath (dyspnea) Cough Hemoptysis HEALTH PROMOTION AND Counseling: Evidence and Recommendations Tobacco Cessation Immunizations Adverse effects of smoking on health and disease CONDITION Coronary artery disease INCREASED RISK COMPARED WITH NONSMOKERS 2-4 times higher Stroke 2-4 times higher Peripheral vascular disease 10 times higher COPD mortality 12-13 times higher Lung Cancer Mortality 23 times higher in men 13 times higher in women Assessing readiness to quit smoking: Brief Intervention Models 5 As MODEL Ask about tobacco use Advise to quit STAGES of CHANGE MODEL Precontemplation- “ I don’t want to quit” Contemplation – “ I am concerned but not ready to quit now” Assess willingness to make a quit attempt Assist in quit attempt Preparation- “ I am ready to quit” Arrange follow-up Maintenance- “ I quit 6 months ago” Action- “ I just quit.” Lung Cancer • Epidemiology. - second most frequently diagnosed cancer in the United States and the leading cause of cancer death for both men and women. • Risk Factors -Cigarette smoking is by far the leading risk factor for lung cancer. - also has a familial risk LUNG CANCER • Prevention. - smoking cessation strategies. - Avoiding environmental and occupational exposures can also reduce lung cancer risk. • Screening. -cancers diagnosed at an early stage (before metastasis) have a 54% 5-year relative survival. Meanwhile, the 5-year relative survival is a dismal 4% for cancers diagnosed at later stages (metastatic). -only 15% of lung cancers are diagnosed at an early stage. • Screening Tests and Evidence. - lung cancer screening with chest x-ray or sputum cytology is not effective. - National Lung Screening Trial (NLST) showed that screening with low-dose computed tomography (LDCT) reduced the risk of dying from lung cancer compared to chest x-ray screening. Demographics of patients with COVID-19 infection The median age of hospitalized patients varies between 47 and 73 years, with most cohorts having a male preponderance of approximately 60%. Incubation period January to February 2020 showed that the median incubation period was estimated to be 5.1 days (95% CI, 4.5-5.8 days), with almost 98% of patients manifesting within 11.5 days (CI 8.2-15.6 days) of infection(23) CLINICAL MANIFESTATIONS Fever and cough were the most common symptoms first described among patients diagnosed with COVID-19 infection in Wuhan, Hubei Province, China. The incidence of muscle soreness or fatigue was 42.5% Diarrhea, hemoptysis, headache, sore throat, shock, and other symptoms occurred only in a small number of patients. • Olfactory and/or gustatory dysfunctions have been reported in 64% to 80% of patients. • Anosmia or ageusia may be the sole presenting symptom in approximately 3% of individuals with COVID19(26). Anosmia or dysgeusia may precede the respiratory symptoms. Clinical Course of Patients with COVID-19 • Median time from illness onset to dyspnea was 13·0 days (9·0–16·5). • Fever and cough were prolonged, with median duration of 12·0 days • Notably, 62 (45%) of survivors still had cough on discharge and 39 (72%) of non-survivors had cough at the time of death. DIAGNOSTIC TESTING All symptomatic individuals with suspected SARS COV-2 respiratory tract infection should undergo testing for COVID-19 as well as ancillary tests warranted by their clinical condition. Benefits of prompt testing include: 1. Proper allocation of personal protective equipment 2. Prevention of nosocomial spread and subsequent community transmission 3. Guidance in treatment decisions and enrollment in clinical trials Tests for SARS COV-2 (COVID-19) A. Real-time reverse transcription-polymerase chain reaction (RT-PCR) assay The currently recommended test to confirm COVID-19 infection is an RT-PCR assay, which detects the viral RNA. Using this assay, SARS CoV-2 can be detected in nasal or pharyngeal samples, sputum, bronchoalveolar lavage fluid, and other bodily fluids, including feces and blood. False negative results of RT-PCR assays may be due to inadequate sample and inappropriate timing of sample collection in relation to onset symptom RECOMMENDATIONS • All symptomatic individuals suspected of having COVID-19 patients should undergo SARS CoV-2 RT-PCR assay testing to diagnose COVID-19 infection. • Nasopharyngeal specimens rather than oropharyngeal or saliva specimens are preferred for swab-based SARS-CoV-2 testing. • The qualitative reporting of results of SARS-COV-2 RT-PCR as positive or negative is sufficient for DIAGNOSIS but may be supplemented by a CYCLE THRESHOLD report. B.) Rapid Tests based on Antigen Production Rapid antigen test detects the presence of viral proteins (antigens) expressed by the COVID-19 virus in a sample from the respiratory tract of a person. Summary of CDC influenza vaccine recommendations 2010-adults • Adults with chronic pulmonary conditions and chronic medical conditions; adults who are immunosuppressed or morbidly obese • Women who are or who will be pregnant during influenza season • Residents of nursing homes and chronic care facilities • Health care personnel • Household contacts and caregivers of children 5 years of age and younger (especially infants age 6 months and younger) and of adults 50 years of age and older with medical conditions placing them at higher risk for complications of influenza Summary of CDC Pneumococcal vaccine recommendations 2010 • Adults > 65 years • Smokers from 19 years to 64 years old • Children and adults from 2 years to 64 years old with chronic illnesses specifically associated with increased risk of pneumococcal infection ( sickle cell anemia, cardiovascular and pulmonary disease, diabetes, cirrhosis and leaks of cerebrospinal fluid) • Anyone with or about to receive a cochlear implant • Adults and children older than 2 years who are immunocompromised (including from HIV infection, AIDS, steroids, radiation or chemotherapy) COVID 19 VACCINE TECHNIQUES FOR EXAMINATION Chest and Lungs Physical Examination • Correlate with History, • Tools • • • • Inspection Palpation Percussion Auscultation Inspection • Observe the chest for asymmetry or deformity. Note any scars, lesions, or rashes. • Observe the rate, rhythm, depth, and effort of breathing. • Observe the apical impulse if possible. Chest Inspection • Breathing - rate, rhythm, effort • Intercostal retraction • Shape of the thorax • Symmetry • Deformities • Abnormal structures • Mass, discoloration, sinus tract, puncture • Inspect anterior and posterior chest Common Chest Configuration • Normal infant - round in cross section • Normal adult - increase in lateral diameter • Barrel chest - increase in AP diameter • Funnel chest - depression in lower sternum • Pigeon chest - anteriorly displaced sternum • Kyphoscoliosis - curved with variable shape Kyphoscoliosis FUNNEL CHEST PIGEON CHEST Palpation •Identify any areas of tenderness or deformity. •Assess expansion and symmetry of the chest. •Abnormalities - mass, sinus tract •Tactile fremitus Palpation Generating lung sounds… • Acoustic repertoire of the respiratory system The thorax as a damped drum The airways as noise makers Generating lung sounds… • Lung sounds occur within a relatively small (compared to the wavelength of the sound), semirigid enclosed space • Sound originating from an intrathoracic location does not travel in a straight line to the chest wall x Palpation Tactile Fremitus Percussion Percussion Technique • Pleximeter finger • Hyperextend middle finger • Press distal IP joint firmly on the chest • Avoid contact by any other part of the hand • Plexor finger • Hyperextend hand • Partially flex middle finger • Quick, bouncy wrist motion Percussion Technique • Percuss from side to side and top to bottom using the pattern shown in the illustration. Omit the areas covered by the scapulae. • Compare one side to the other looking for asymmetry Percussion Technique Resonant sounds are low pitched, hollow sounds heard over normal lung tissue. Flat or extremely dull sounds are normally heard over solid areas such as bones. Dull or thudlike sounds are normally heard over dense areas such as the heart or liver. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung tissues, such as occurs with pneumonia, pleural effusions, or tumors. Hyperresonant sounds - louder and lower pitched than resonant sounds - are normally heard when percussing the chests of children and very thin adults - diseases with lung hyperinflation (COPD, acute asthmatic attack) and in cases with pneumothorax. Tympanic sounds -are hollow, high, drumlike sounds -normally heard over the stomach, but is not a normal chest sound. Tympanic sounds heard over the chest indicate excessive air in the chest, such as may occur with pneumothorax. Diaphragmatic Excursion Chest Auscultation Chest Auscultation Chest Auscultation • Uses: • Assessing air flow • Detecting obstruction • Identifying structural abnormalities • Two types of sounds: • Breath sounds • Adventitious sounds Chest Auscultation Patient Positioning Normal Lung Sounds • Sounds heard over specific locations of a healthy chest during breathing Vesicular Bronchovesicular Bronchial Tracheal • “Clear lung fields” is ambiguous Adventitious Lung Sounds •NOT inherent to process of NORMAL breathing, therefore denotes underlying abnormality “Harsh breath sounds” is ambiguous ACCP / ATS Classification of Adventitious Breath Sounds Adventitious Sounds Pulmonary Pleural Discontinuous Continuous Friction Rub Click or Crunch (Pleuritis) (Pneumothorax, = CRACKLES Pneumomediastinum) RHONCHI WHEEZE = RALES COARSE FINE Adventitious Lung Sounds WHEEZE = Sibilant Rhonchus Continuous > 250 msec Whistling, musical, expiratory If inspiratory: more severe AO Monophonic vs. Polyphonic e.g. Asthma, COPD RHONCHUS = Sonorous Rhonchus Origin of Continuous Lung Sounds • Interaction of • vibrating walls • gas flowing thru airways on the point of closure • Depends on velocity of gas Generalized – Localized - bronchospasm mucosal edema widespread secretions mass blocking airway Improving diagnostic acumen… 1. WHEEZE – better transmitted thru airways than thru lung / chest wall, therefore LISTEN OVER TRACHEA 2. FORCED EXPIRATORY MANEUVER Adventitious Lung Sounds COARSE CRACKLE = coarse rales Discontinuous < 10 msec Short, explosive, nonmusical Bubbling LOUD, LOW PITCH FINE CRACKLE = fine rales = crepitations Exclusively inspiratory, mid to late Velcro-like SOFTER, HIGH PITCH Timing of Discontinuous Lung Sounds • Inspiratory • Early : Disorders of Airways • Late : Disorders of Parenchyma • Expiratory Origin of Production of Crackles 1. BUBBLING OF GAS THRU SECRETIONS Coarse crackles – in large airways e.g. tracheobronchitis Fine crackles – in smaller airways e.g. pulmo edema 2. SUDDEN OPENING OF A SUCCESSION OF CLOSED / COLLAPSED SMALL AIRWAYS e.g. interstitial lung diseases Lung Sounds Exercises To hear is to Believe. LUNG SOUNDS • TRACHEAL SOUNDS • VESICULAR BREATH SOUNDS • SEVERE WHEEZING IN AN ASTHMATIC PATIENT • FINE CRACKLES • COARSE CRACKLES • DIFFUSE RHONCHI Thank You!
