LUNGS AND RESPIRATORY SYSTEM

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LUNGS AND RESPIRATORY SYSTEM
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• Lung Physical exam
• 1- Inspection
• 2- Palpation
• 3- Percussion

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• 4-Auscultation
• 5- Egophony

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• INSPECTION
• Deformities or asymetry
• Abnormal retraction of the interpaces
• Impairment in respiratory movement

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• Tactile Fremitus
• Performed by 1- placing ulnar side of hand or
  palm against the patient posterior chest wall.
• 2 Have the patient say ninety-nine
• Increased tactile fremitus increased density of
  the lungs (consolidation).
• Decreased tactile fremitus excess subcutaneous
  tissue on the chest ,air or fluid

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• Percussion
• Dull increased density such as fluid in the
  lungs , or lung cavity or consolidation
• Tympanic hollow air-containing structure
• Resonant structure of air within tissue
• Hyperresonant decreased density and more air ,
  such as in emphysema

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• Auscultation
• Crackles short discontinuous nonmusical sounds
  heard mostly during inspiration
• Wheezes continuous , musical , high-pitched
  heard mostly during expiration.
• Rhonchilower-pitched lung sounds
• Pleural rub Sound produced by motion pleura,
  heard best at end of inspiration /beginning of
  expiration

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Lung auscultation
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• Egophony
• Spoken words by the patient are increased in
  intensity and take on different quality during
  auscultation.Patient says eeeeand will heard as
  aaaain area of consolidation and in areas of
  compressed lung above a pleural effusion

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• PLEURAL EFFUSION
• Definition
• Transudate
• 1- increased hydrostatic pressure
• 2- decreased oncotic pressure
• 3- CHF, Cirrhosis, Nephrosis

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• Oxidative pleural effusion
• Increased capillary permeability
• Tumors, Trauma, Infection

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• Diagnosis criteria of exudate
• Ratio of pleural to serum protein gt0.5
• Ratio of pleural to serum LDH gt0.6
• Pleural fluid LDH gt2/3 upper normal limit

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• Para pneumonic effusion
• Pleural fluid leukocyte count gt10,000/mm
• Always exudates
• WBC gt100,000 empyema
• Empyema pus in pleural space , positive
  cultures, require chest tube

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• Gross blood in pleural fluid
• Tumor (breast ,lung cancer, lymphoma)
• Trauma
• Pulmonary infarction
• Aortic dissection

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• Low glucose in pleural fluid is associated
• Empyema
• Rheumatoid arthritis
• Tumor
• tuberculosis

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• High amylase in pleural fluid is associated
• Pancreatitis
• Renal failure
• Tumor
• Esophageal rupture

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• PULMONARY FUNCTION TEST
• Spirometry measures the rate at which the lung
  changes during forced breathing
• Forced vital capacity (FVC)
• Fev1 the volume of air exhaled in the first
  second of the FVC
• Normal FEV1/FVC ratiogt0.7

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Spirometry1
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Normal spirogram
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Obstructive defect and restrictive defect
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• Lung Infections
• Pneumonia infection of the lung parenchyma by
  any microorganism.
• Etiology
• A- community acquired pneumonia
• 1-S-Pneumonia
• 2- H. influenzae

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• B- community acquired atypical
• 1- chlamydia pneumoniae
• 2- Legionella pneumophila
• 3- Mycoplasma pneumonia

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• C- Hospital acquired
• 1- pseudomonas aeruginosa
• 2 S.Aureus
• 3- Enteric organisms

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• Signs and Symptoms
• A- Typical Symptoms
• 1- Fever
• 2- cough
• 3- pleuritic chest pain

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• B- Atypical Symptoms
• 1- Dry cough
• 2-headache
• 3- malaise
• 4- Gastrointestinal symptoms

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• Physical exam
• 1- Dullness to percussion
• 2-Rales
• 3- Tactiles fremitus
• 4- Egophony (E to A changes ) with stethoscope

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• Diagnosis
• A Chest Xray
• 1- upper lobe infiltrate or consolidation
• 2- small cavities w/o air-fluid levels( M.tb
• 3- larges cavities with air-fluid levels (staph)
• 4- diffuse bilateral infiltrate (PCP, Mycoplasma)

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• Criteria for admission
• 1- Age gt50
• 2-Nursing home residents
• 3- underlying chronic disease
• 4- change in mental status
• 5- Tachypnea, tachycardia, or hypotension
• 6- Pleural effusion

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• Scenario 1
• A 19 y/o college student male c/o malaise, dry
  cough for the last 10 days, denied fever and
  pleuritic chest pain .Physical unremarkable , CXR
  showed diffuse bilateral infiltrate.

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• Scenario2
• A patient comes to the ER with consolidation and
  pleural effusion on CXR. What is the most
  important test to determine admission/treatment.

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• Scenario 3
• A 27 y/o White male brought to the ER c/o
  productive cough, fever and pleuritic chest
  pain.Physical exam elicited tachypnea and
  crackles on R upper lobe .What other physical
  finding suggestive of typical pneumonia?

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• Obstructive Disorders
• Chronic Obstructive pulmonary Disease
• A-Chronic bronchitis chronic expiratory
  airflow obstruction accompanied by chronic
  productive cough for 3 or more months in each of
  2 successive years

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• Emphysema chronic expiratory airflow obstruction
  accompanied by permanent enlargement of the
  airspace distal to the terminal bronchioles due
  destruction of alveolar septa.

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• Pathophysiology of Emphysema
• Centrilobular emphysema affects the respiratory
  bronchioles.
• Panlobular emphysema occurs in patients with
  alpha-1 antitrypsin deficiency.
• Distal acinar emphysema is associated with
  spontaneous pneumothorax.

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• Epidemiology
• 1- Higher prevalence in men
• 2- Mortality rates are higher in whites
• 3- Only 15 of smokers develop COPD

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• Risk Factors
• Smoking
• Alpha-1-antitrypsin deficiency

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• Diagnosis /Findings
• Chest xray hyperinflated lungs, flattened
  diaphragm.
• Physical exam Barrel chest
• Pulmonary function tests irreversible
  obstructive pattern (low FEV1)
• Computed tomography loss of alveolar walls

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• Symptoms
• Cough
• Dyspnea on exertion
• CO2 retention (chronic bronchitis)
• Weight loss (emphysema)
• tachypnea

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• treatment
• Smoking cessation
• Oxygen
• Maintain vaccination against influenza and
  S.pneumoniae
• Beta agonist and ipratropium
• Steroid

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• Asthma
• A chronic condition characterized by
• 1- airway inflammation
• 2- brochoconstriction
• 3- hypersecretion

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• PATHOPHYSIOLOGY
• IgE mediated ,associated with histamine release
  from mast cells(early phase)
• The late phase is associated with cytokine
  release

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• TRIGGERS
• Exposure to pets, dust ,smoke ,carpets
• Aggravation by exercise ,hot or cold weather
• Seasonal changes

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• Signs and symptoms
• Chest tightness
• Wheezing
• Shortness of breath
• cough

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• Differential diagnosis of wheezing
• Reactive airway disease
• Congestive heart failure
• Foreign body aspiration (most often in children)
• Asthma

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• Physical Exam
• Wheezing on exhalation
• Decreased air entry , increased expiratory phase
• Decreased peak flow and FEV1
• Retractions of sternocleidomastoids

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• Intercostal muscle use for breathing
• Oxygen saturation lt95
• Inability to speak full sentences

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asthma classification and treatment

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