Essential respiratory medicine. Shanthi Paramothayan

Chapter 5. Common presentations of respiratory disease

Learning objectives

 To understand how to take a comprehensive respiratory history

 To know how to carry out a respiratory examination

 To understand the differential diagnosis of breathlessness

 To recognise the differential diagnosis of pleuritic chest pain

 To learn about the differential diagnosis of cough

 To understand the differential diagnosis and management of haemoptysis

 To learn about the differential diagnosis and management of upper airways obstruction

 To understand how to conduct a pre-operative respiratory assessment

 To recognise the respiratory problems in a post-operative patient

 To know how to conduct a respiratory assessment of an acutely ill patient

Abbreviations

ABG arterial blood gas

ACE angiotensin converting enzyme

BiPAP bilevel positive airways pressure

CO2 carbon dioxide

COPD chronic obstructive pulmonary disease

CPAP continuous positive airways pressure

CT computed tomography

CTPA computed tomography pulmonary angiogram

CXR chest X-ray

DVT deep vein thrombosis

ECG electrocardiogram

GORD gastro-oesophageal reflux disease

HDU high dependency unit

HIV human immunodeficiency virus

HRCT high-resolution computed tomography

ITU intensive care unit

MRC Medical Research Council

NIV non-invasive ventilation

OSA obstructive sleep apnoea

PE pulmonary embolus

PND paroxysmal nocturnal dyspnoea

SLE systemic lupus erythematosus

TED thromboembolic disease

TVF tactile vocal fremitus

TVR tactile vocal resonance

VQ ventilation perfusion scan

VR vocal resonance

Respiratory history

The aim of taking the respiratory history is to construct a sensible differential diagnosis. The clinical examination will then help to narrow the differential diagnosis and determine which investigations are required to confirm the suspected diagnosis in most cases.

Taking a detailed history in a fluent way is an important skill to learn and will improve with experience. While medical students are taught to take the history in a certain order, this is not critical so long as the history is comprehensive, and the relevant points are covered. A structured approach is, however, essential. Box 5.1 lists the important points to take in a patient presenting with respiratory symptoms or signs. This is demonstrated in the supplementary material (www.wiley.com/go/ Paramothayan/Essential_Respiratory_Medicine).

Box 5.1 Important points in a respiratory history.

 Demographic information

 Presenting complaint or main symptom

 Associated symptoms

 History of presenting complaint

 Past medical history

 Smoking history

 Occupational history

 Recreational history

 History of atopy and allergy

 Family history

 Drug history

 Allergy to medication

 Systemic symptoms

____

Demographic information includes the age, sex, ethnicity, and country of origin of the patient. This is important as certain conditions are more prevalent in males or females, and several respiratory conditions are more common in people from certain countries and ethnic backgrounds.

It is important to elicit what the presenting complaint is, including the onset, nature, severity, and duration of the symptom. It is important to understand what factors exacerbate or relieve the symptom, whether the patient has suffered from this symptom before and if the cause was ever found. It is important to ask about associated respiratory symptoms and systemic symptoms, such as fever, malaise, night sweats, joint pains, rashes, and weight loss, as this information can lead to the correct diagnosis.

Past medical history is always relevant and should include a history of prematurity, immunisations, childhood illnesses, tuberculosis, and contact with anyone with Mycobacterium tuberculosis. A history of previous malignancies and cardiac problems is particularly important.

Smoking is a significant risk factor for several lung diseases, so a detailed history of smoking should be obtained. The number of pack years should be calculated as this can quantify the risk. Patients should be asked about exposure to passive smoking at home, at work, and in social situations. A comprehensive occupational history is important as exposure to industrial dusts, chemicals, asbestos, and silica can result in the development of pulmonary fibrosis, occupational asthma, and hypersensitivity pneumonitis. It may be necessary to ascertain the occupational history of the spouse if there is concern about mesothelioma. History of recent travel abroad may be relevant when the patient presents with symptoms of infection or eosinophilia.

Patients with atopy and allergy may present with symptoms of cough, breathlessness, and wheeze, and may also suffer with nasal symptoms. These patients may have a history of hay fever or eczema. Many people are allergic to a variety of inhaled allergens, for example, house dust mite, which can be demonstrated by doing a skin prick test. It is important to ask about their home environment, whether they have any pets and if their house is damp. Some patients who are exposed to bird ‘bloom’ can develop hypersensitivity pneumonitis, often called ‘bird fancier’s lung’.

A detailed drug history is essential as many drugs can have an adverse effect on the lungs in a variety of ways. This is discussed in Chapter 3. Radiotherapy to the thorax can result in fibrosis, either acutely or many years later. Patients should be specifically asked whether they take or have taken any recreational drugs or any over-the-counter medications.

Ascertaining information about the family history is important as certain respiratory conditions can be inherited, for example, cystic fibrosis, primary ciliary dyskinesia, and alpha 1-antitrypsin. The predisposition to develop lung cancer and asthma is also inherited.

In Box 5.2 the differential diagnosis of common respiratory symptoms is discussed.

Box 5.2 Common respiratory symptoms.

 Breathlessness

 Cough

 Haemoptysis

 Chest pain

 Wheezing

 Snoring

____

Breathlessness

Breathlessness is a common presentation with a wide differential diagnosis. Dyspnoea is the term for difficulty in breathing and tachypnoea means breathing at an increased respiratory rate. A normal respiratory rate at rest is between 12 and 16 breaths per minute but will, of course, increase with exertion. Orthopnoea describes difficulty with breathing when lying flat and may be secondary to cardiac failure, chronic obstructive pulmonary disease (COPD), obstructive sleep apnoea (OSA) or diaphragmatic palsy. Paroxysmal nocturnal dyspnoea (PND) describes the sudden onset of breathlessness, with the patient gasping, requiring them to sit upright in bed. This occurs most commonly with pulmonary oedema, but patients with severe OSA often report waking up gasping for breath. Apnoea means cessation of breathing for more than 10 seconds and may occur repeatedly in OSA. Kussmaul breathing, often described as ‘air hunger’, is deep and laboured breathing that occurs with severe metabolic acidosis, for example, diabetic ketoacidosis or chronic renal failure, when the respiratory centre is stimulated to blow off carbon dioxide as a compensatory mechanism. Cheyne-Stokes respiration occurs in patients with severe heart failure and in those with central sleep apnoea due to the oscillation in the level of carbon dioxide in the blood; there is a cyclical pattern of breathing, from hypoventilation, even apnoea, to hyperventilation.

The onset of breathlessness can be acute or chronic in nature. Table 5.1 lists some common causes of acute and chronic breathlessness.

When asking patients about their symptom of breathlessness, it is essential to establish whether this was acute or gradual in onset, whether it occurs at rest or on exertion. If it occurs on exertion, then it is important to find out how far they can walk and whether their breathlessness affects their activities of daily living. The severity of breathlessness can be graded using the Medical Research Council’s Dyspnoea Grade (MRC Grade) which is described in Box 5.3. The BORG scale can also be used to grade perceived breathlessness, especially in the context of exercise testing. Other important points in the history include the overall duration of breathlessness, whether it is progressively getting worse, whether there is any diurnal variation, or if it is worse when lying down. Patients with diaphragmatic weakness will complain of breathlessness when lying flat and when under water, for example, swimming, as the abdominal contents push up on the diaphragm, reducing ventilation. Collateral history from a member of the family who has observed the patient can be very useful.

Table 5.1 Causes of breathlessness.

Sub-acute onset Chronic onset

System Acute onset (minutes to hours) (hours to days) (weeks to months)

Respiratory

Pulmonary embolus Pneumothorax

Acute asthma

Upper airway obstruction Foreign body inhalation Epiglottitis

Anaphylaxis Hypersensitivity pneumonitis

Exacerbation of asthma

Exacerbation of COPD

Community acquired pneumonia

Bronchiectasis

Hypersensitivity pneumonitis

Idiopathic pulmonary fibrosis

Sarcoidosis

Chronic pulmonary emboli

COPD

Lung cancer

Pleural effusion

Idiopathic pulmonary fibrosis

Sarcoidosis

COPD

Any interstitial lung disease

Pulmonary hypertension Obstructive sleep apnoea

Cardiac

Pulmonary oedema Ruptured heart valves Myocardial infarction Arrhythmia

Aortic dissection Cardiac tamponade

Left ventricular failure Congestive cardiac failure Pericardial effusion Arrhythmia

Congestive cardiac failure Cardiomyopathy

Neuromuscular

Guillain-Barré Botulism

Poliomyelitis

Diaphragmatic palsy

Myasthenia gravis

Diaphragmatic palsy Poliomyelitis

Motor neurone disease Muscular dystrophies Multiple sclerosis Myasthenia gravis Amyotrophic lateral sclerosis

Musculoskeletal

Traumatic fracture Costochondritis

Chest wall disease Post-thoracic surgery

Chest wall disease

Kyphosis

Scoliosis

Chest wall surgery (thoracoplasty)

Central nervous system

Acute stroke

Acute stroke

Parkinson’s disease

Metabolic

Diabetic ketoacidosis Ethylene glycol poisoning Salicylate poisoning

Diabetic ketoacidosis Chronic renal failure Salicylate poisoning

Chronic renal failure

Endocrine

Thyrotoxicosis

Phaeochromocytoma

Hypothyroidism

Large goitre

Haematology

   

Chronic anaemia

Psychological

Panic attack Hyperventilation

Anxiety

C hronic anxiety Phobias

Physiological

Strenuous exercise Acute mountain sickness Deep sea diving

Mountain sickness Pregnancy

Mountain sickness Obesity

Box 5.3 The MRC Dyspnoea grade.

1. No breathlessness except on strenuous exertion

2. Breathless when walking fast or uphill

3. Not able to keep up with contemporaries on level ground and needs to stop for breath

4. Stops for breath after 100 m or after a few minutes on level ground

5. Breathless at rest or on minimal exertion, such as dressing

____

Management of severe breathlessness

Breathlessness can be life-threatening and anyone presenting with this will need immediate attention. The patient should be assessed quickly with regards to the airways and breathing, have their oxygen saturation and arterial blood gas measured, and commenced on the appropriate amount of oxygen through the correct device. If a respiratory arrest is imminent, then the anaesthetist should be called urgently with view to intubation. If intubation and ventilation are not necessary, the patient should have continuous monitoring of oxygen saturation, serial measurement of arterial blood gases, a chest X-ray, and an electrocardiogram (ECG). The management of type 1 and type 2 respiratory failure is discussed in Chapter 13.

Cough

Cough is a violent, forceful, protective reflex provoked by the stimulation of receptors in the larynx, trachea and bronchial tree to remove inhaled irritants, including secretions. Violent coughing can result in cough syncope due to reduction in venous return and cerebral perfusion.

Acute cough is a common presentation to General Practice, is often secondary to a respiratory infection and therefore self-limiting. When taking a history of cough from a patient, it is important to ask whether the cough is acute or chronic, dry or productive, the duration of the cough, whether the patient is a smoker, and whether the patient has any associated symptoms.

Box 5.4 Causes of dry cough in non-smoker with normal CXR.

 Cough-variant asthma

 Gastro-oesophageal reflux disease (GORD)

 Postnasal drip

 Allergy (includes hay fever)

 Post infection

 Medication (angiotensin converting enzyme (ACE) inhibitors)

 Dry mouth

 Foreign body

 Chronic throat clearing

 Psychogenic

____

Patients with a chronic cough, which affects 8% of the population, are often referred for a specialist opinion. Chronic cough (more than six weeks in duration) may be due to several different pathologies, for example, asthma, COPD, or lung cancer. In many cases, there are multiple causes for the cough. It is important to ask about the volume, content, and colour of any sputum produced as this can give clues as to the aetiology of the cough. Yellow or green sputum usually indicates a bacterial infection, persistently green and foul-smelling sputum may suggest bronchiectasis, and large volumes of watery sputum (bronchorrhoea) can occur in those with bronchoalveolar cell carcinoma (Adenocarcinoma in situ).

Patients who present acutely with a productive cough and other symptoms, such as breathlessness and fever, may have a more serious respiratory tract infection, such as community acquired pneumonia, and may require antibiotics. As well as a careful physical examination, they will need blood tests to check the inflammatory markers, and a chest X-ray (CXR) to see if there are any signs of consolidation. A sputum sample should be sent for microscopy, culture, and sensitivity and to look for acid-alcohol-fast bacilli. Patients with recurrent chest infections should have further investigations (see Chapters 6 and 8).

Box 5.4 lists the possible causes of a dry cough in a non-smoker with a normal CXR.

A careful history and examination should point to the most likely diagnosis. If cough-variant asthma is suspected, then a chest X-ray, spirometry, skin prick testing, peak flow homework, methacholine challenge, and high-resolution computed tomography (HRCT) may be required to exclude other pathology and to confirm the diagnosis. Treatment with inhaled steroids should result in the resolution of the cough. If GORD is suspected, then pH studies may be required, although many doctors will prescribe a trial of a proton pump inhibitor to see if there is improvement. If a post-nasal drip is felt to be the most likely cause, then a CT sinus may be helpful. Antihistamines and steroid nasal sprays given in the head-down position should improve the cough. If the likely cause of the cough is not clear, then a nose and throat examination may be helpful in determining whether there are any signs of acid reflux, infection, cobblestoning (which might indicate chronic throat clearing), nasal pathology, and to rule out a foreign body in the airways.

Post-infectious coughs are common and can persist for months. Treatment with oral or inhaled steroids for a minimum of two weeks can result in an improvement in symptoms. In cases of cough secondary to allergy, it is important to identify the triggers and remove them if possible. Antihistamines may also be helpful. Up to 20% of patients on an ACE inhibitor can develop a dry, irritating cough; this may not necessarily occur immediately after commencing the medication.

Most smokers have a persistent ‘smoker’s’ cough and those with COPD and chronic bronchitis have a daily productive cough, mainly in the mornings. However, a persistent cough is the commonest symptom of lung cancer, so a careful history, a clinical examination, and a chest X-ray should be conducted in all patients with a smoking history. Patients with damage to the vagus nerve or with recurrent laryngeal nerve palsy may present with a ‘bovine’ cough which is a non-explosive cough due to an inability to close the glottis. These patients will also have a hoarse voice or dysphonia. These patients should have a computed tomography (CT) thorax and a bronchoscopy.

Haemoptysis

Coughing up blood indicates lung pathology and is alarming for the patient. Occasionally epistaxis, haematemesis, or bleeding from the gums can be misinterpreted as haemoptysis, so a careful history with specific questions about the nature of the blood must be obtained. In most cases, fresh, red blood mixed with sputum indicates lung pathology. Dark, altered blood may be of gastrointestinal origin.

Infection and inflammation of the respiratory tract are the commonest cause of small volume haemoptysis and patients will have other symptoms and signs of infection, including cough and fever. Bronchiectasis, pulmonary tuberculosis, and asper- gilloma are also in the differential diagnosis for haemoptysis. Sputum microscopy and culture are essential to identify the causative organism and to test for antibiotic sensitivities. Haemoptysis is a common presentation of lung cancer, so patients at risk of lung cancer should be investigated quickly with a chest X-ray followed by a CT thorax and a bronchoscopy. Sputum cytology may have a role in patients who are suspected of having lung cancer but who are too frail for invasive tests. Table 5.2 lists the causes of haemoptysis.

Bleeding secondary to a biopsy at bronchoscopy is common and usually settles after a few minutes. Topical adrenaline, 10 ml of 1 : 10,000, should be administered slowly and directly to the site of bleeding while monitoring the patient’s pulse and blood pressure. If the bleeding does not settle, then the patient will have to be managed as described below for life-threatening haemoptysis. Patients having a bronchial biopsy, or a CT-guided biopsy should be informed that they could cough up blood for several days post procedure. If there is evidence of continuous, but non-life-threatening bleeding, then they should be discharged home on oral Tranexamic acid, an antifibrinolytic agent, 1—1.5 g twice or three times a day.

Management of life-threatening haemoptysis

The term massive haemoptysis should be avoided as the definition of what this is varies widely in the literature and it is impossible to quantify the amount of blood loss, as much of the blood may be in the lungs. Most experts agree that the term life-threatening haemoptysis is preferable and the definition is bleeding of >200 ml in 24 hours which results in airway obstruction and abnormal gas exchange, which does not stop, and which causes haemodynamic compromise. The cause of death from uncontrolled haemoptysis would be from asphyxiation.

Table 5.2 Causes of haemoptysis.

Malignancy (see Chapter 9)

Carcinoma of lung

Carcinoma of trachea

Infection (see Chapter 8)

Mycobacterium tuberculosis

Aspergilloma

Community acquired pneumonia

Aspiration pneumonia

Lower respiratory tract infection

Bronchiectasis

Cystic fibrosis

Lung abscess

Histoplasmosis

Vascular (see Chapter 11)

Pulmonary emboli

Arterio-venous malformation

Hereditary haemorrhagic telangiectasia

Goodpasture’s syndrome

Polyangiitis (Wegener’s granulomatosis)

Autoimmune

SLE pneumonitis

Sarcoidosis

Behçet’s disease

Cardiac

Pulmonary oedema

Mitral stenosis

Miscellaneous

Coagulopathies

Anticoagulant therapy

Trauma, including violent coughing Inhalation of foreign body

Pulmonary haemosiderosis

Pulmonary endometriosis

Broncholithiasis

______

Life-threatening haemoptysis is rare, estimated as <1.5% of all cases of haemoptysis. In the past, pulmonary tuberculosis and bronchiectasis were the common causes, now lung cancer, aspergil- loma, and cystic fibrosis are the commonest causes. In these cases, the bleeding occurs due to erosion in the bronchial artery. The mortality depends on the age of the patient, any underlying lung and cardiac disease, the rate of bleeding and the ability of the patient to clear the blood from the airways.

Mortality may be up to 25% in those managed conservatively and up to 20% with surgery, although the estimates vary greatly in the literature.

Patients presenting with life-threatening haemoptysis must be managed in the intensive care unit or high dependency unit by intensivists and respiratory physicians. The patient will require immediate resuscitation with intravenous fluids, airway protection, oxygen supplementation, crossmatched blood, fresh frozen plasma, and the correction of any coagulopathy. Bloods should also be sent for urgent vasculitic screen.

Tranexamic acid has been shown to reduce overall bleeding time, the duration of bleeding, and the overall volume of blood loss, with no shortterm thromboembolic complications. Intravenous tranexamic acid should be given as a slow infusion at a dose of100 mg min-1 followed by 25—50 mg kg-1 over 24 hours.

If the patient is haemodynamically stable, then an urgent computed tomography pulmonary angiography (CTPA) should be carried out to exclude pulmonary embolus and to identify any obvious masses or cavities. The source of the bleeding should be identified, ideally with rigid bronchoscopy, although this may not be easy if there is a lot of blood, and the patient may require selective lung intubation before this can be carried out. Topical adrenaline, a potent vasoconstrictor, may reduce the bleeding and endobronchial tamponade may be effective in stemming the flow of blood. The patient should be nursed lying on the side of the bleeding lung.

The source of the bleeding can be identified by bronchial angiography with embolization of the bronchial artery. Early discussion with a thoracic surgeon is important as surgical resection of the affected part of the lung may be required if the bleeding cannot be stopped. Chronic haemoptysis secondary to lung cancer can be treated by palliative radiotherapy. Patients in whom the source of bleeding cannot be identified are managed conservatively.

Chest pain

Chest pain is a common and worrying symptom. It can be due to significant pathology, so should always be taken seriously. When taking the history of chest pain, it is important to be specific about the nature of the pain, the onset, duration, site, radiation, periodicity, exacerbating factors, and relieving factors.

Chest pain of cardiac origin is generally described as a dull ache with radiation down the left arm, towards the jaw or to the back. Patients with cardiac-sounding pain may also describe breathlessness. Pain arising from the gastrointestinal system (epigastrium, liver, gall bladder, spleen) can radiate to the chest and the shoulders and this can be confused with cardiac or respiratory pain.

Musculoskeletal pain, which is pleuritic in nature, is worse with inspiration and with movement and there will be musculoskeletal tenderness on palpation. The patient may complain of breathlessness if he or she is unable to fully expand his or her lungs due to the pain. Musculoskeletal pain can occur secondary to chest wall trauma and the pain can be severe if ribs have been fractured.

Costochondritis occurs due to inflammation of the costochondral, costosternal, or sternoclavicular joints and is a common cause of musculoskeletal chest pain in young adults. Costochondritis is commoner

in females and in patients with fibromyalgia. It is self-limiting, with symptoms resolving within eight weeks. The term Tietze’s syndrome is used when there is swelling of these joints. Bornholm disease is caused by Coxsackie virus B, which results in muscle aches and pains in the chest wall.

Chest pain secondary to respiratory pathology is usually pleuritic in nature. It is described as sharp and stabbing and aggravated by inspiration and coughing. It occurs due to inflammation of the pleura from any cause. Rubbing of the visceral and parietal pleura against each other stimulates the nerve endings. Crackles may be heard when there is ‘pleurisy’ of any aetiology. Pleuritic chest pain responds well to non-steroidal anti-inflammatory drugs which should be prescribed regularly, so long as there are no contra-indications.

Table 5.3 lists common causes of pleuritic chest pain and the basic investigations that would be required.

Table 5.3 Common causes of pleuritic chest pain.

Onset

System

Diagnosis

Investigations

Acute (minutes to hours)

Respiratory

Pneumothorax

Pulmonary embolus

Chest X-ray CTPA or VQ scan

Acute (minutes to hours)

Musculoskeletal

Trauma

Rib fractures Costochondritis Tietze’s syndrome

Chest X-ray

CT thorax

Clinical examination

Sub-acute (hours to days)

Respiratory

Pneumothorax

Pulmonary embolus

Pleural effusion

Chest X-ray CTPA or VQ scan

Sub-acute (hours to days)

Musculoskeletal

Costochondritis

Tietze’s syndrome

Bornholm disease

Clinical examination

Chronic (days to weeks)

Respiratory

Pneumothorax

Community acquired pneumonia

SLE pneumonitis

Pleural effusion

Chest X-ray

Chest X-ray

CT thorax

Clinical examination

Chest X-ray

CT thorax

Pleural ultrasound

Chronic (days to weeks)

Musculoskeletal

Costochondritis

Tietze’s syndrome

Bornholm disease

Chest wall infiltration with tumour

Clinical examination

CT thorax

MRI thorax

Patients with lung cancer may have chest wall infiltration with tumour which can cause severe pain. Metastases to ribs and bones can also cause severe pain. In these cases, there are likely to be several other symptoms and signs and abnormal radiology. Patients with malignant mesothelioma (see Chapter 9) often present with a persistent dull ache in their chest which progressively gets worse over time. Pain secondary to lung cancer or malignant mesothelioma often requires high doses of opioid drugs to control it. Palliative radiotherapy is also indicated as a treatment for bony pain.

Wheeze

Wheeze is a high-pitched whistling sound made when the airways are narrowed and can occur during inspiration or expiration. Patients may not complain of wheeze but may report breathlessness or chest tightness. Family members may report that they have heard wheezing.

Widespread, polyphonic, expiratory wheezing is commonly associated with obstructive airways disease, such as asthma or COPD. Diurnal symptoms or symptoms made worse with exercise or cold air suggest a reversible cause, such as asthma. Patients with an occupational cause of asthma will report breathlessness and wheezing while at work which improves when they are away from the work environment. Similarly, those who are allergic to pets usually feel better when they are away from the animal. Patients who develop wheezing secondary to obstructive airways disease will improve with bronchodilators and corticosteroids. Cardiac failure can present with widespread wheeze, sometimes termed ‘cardiac asthma’. A monophonic wheeze can be a sign of a fixed obstruction which may be secondary to endobronchial narrowing, for example, with tumour. Wheezing can be audible from the end of the bed, but usually requires a stethoscope to be heard.

Patients with vocal cord dysfunction present with what appears to be a wheeze. However, all the noise is generated in the throat from closure of the vocal cords which move paradoxically and there will be no wheeze heard on auscultation of the chest. The diagnosis and management of this are discussed in Chapter 6.

Hoarse voice

Many viral and bacterial infections can result in a brief period of laryngitis which improves over a few days and weeks. A persistent hoarse voice indicates inflammation or damage to the larynx or to its nerve supply. The left recurrent laryngeal nerve has a long course through the left hemithorax (see Chapter 2) and can be damaged by trauma, thoracic and neck surgery (particularly thyroid surgery), and lung cancer. Persistent hoarse voice in a smoker requires immediate investigation with CXR, CT thorax, and a bronchoscopy.

Snoring

Snoring is a common symptom during sleep which is often not pathological. It describes a sound made by the turbulent flow of air through narrowed upper airways. Snoring is often positional, usually worse when lying on the back, exacerbated by alcohol and sedatives, and worse in older people with lax muscles, and in those who are overweight. It can become a problem when it disturbs the patient’s sleep or their partner’s sleep. Such patients are often referred for polysomnography to rule out obstructive sleep apnoea. This is discussed in Chapter 14, and is demonstrated in the supplementary material.

Examination of the respiratory system

Examination of the respiratory system should be thorough and systematic. It is important to observe the patient from the end of the bed, if possible, positioned at a 45° angle. The respiratory rate at rest should be counted. A normal respiratory rate is between 12 and 16 breaths per minute at rest. The tidal volume is 500 ml with a minute ventilation rate of 6 L min-1. Expiration, which is a passive process, takes slightly longer than inspiration, which is an active process. Hyperinflation will result in a prolonged expiratory phase of breathing.

From the end of the bed, with the patient taking a deep breath in, it is possible to note any abnormality or asymmetry of the chest wall and whether one side of the chest moves less than the other (Figure 5.1). The side that moves less is always the side with the pathology. Observation should also be made of pursed-lip breathing, use of accessory muscles, intercostal recession, and tracheal tug, all of which are signs of hyperinflation.

Figure 5.1 Observing chest expansion on inspiration.

Box 5.5 Chest wall deformities.

 Pectus excavatum (funnel chest) is a congenital abnormality of the anterior chest wall due to abnormal development of the sternum and ribs. It occurs in every 300-400 births, is commoner in males and may be associated with Marfan’s syndrome and Ehlers-Danlos syndrome. This can compromise breathing if severe, and can cause chest pain

 Pectus carinatum (pigeon chest) is an inherited deformity of the chest wall due to overgrowth of cartilage, resulting in protrusion of the sternum and ribs. It is commoner in men and becomes obvious during puberty. If severe, it can affect breathing

 Kyphosis is a common chest wall deformity. The adolescent type, called Scheuermann’s disease, occurs when several vertebrae become wedged together. It is common in the elderly due to degenerative changes, osteoporotic fractures, or spondylolisthesis. It can result in chest discomfort and difficulty breathing. If severe, it can impair rib movement. It is a cause of restrictive lung disease and type 2 respiratory failure

 Scoliosis is the abnormal lateral curvature of the spine. It can be congenital, is commoner in females, and becomes worse during puberty. Due to abnormal movement of the chest wall it can result in reduced lung volumes and type 2 respiratory failure 

_____

Box 5.5 lists some common chest wall deformities which can cause abnormal breathing and lead to the development of respiratory failure.

Box 5.6 lists what to look for in the hands and nails and the causes of clubbing.

Cardiovascular examination should include taking the pulse and the blood pressure and to determine whether there are any signs of right heart failure: elevated jugular venous pressure, signs of pulmonary hypertension (loud P2, right ventricular heave), and peripheral oedema. A displaced apex beat may suggest mediastinal shift, for example, with a large pneumothorax or pleural effusion.

The patient should be examined for evidence of lymphadenopathy which could be due to infective causes (viral, bacterial, Mycobacterium tuberculosis), malignancy (lung cancer, lymphoma), HIV or sarcoidosis. Nodes in the submental, submandibular, cervical, supraclavicular, pre-auricular, postauricular, and occipital areas should be examined. If any lymph nodes are palpated, then the axilla and inguinal areas should also be examined for lymphadenopathy (Figure 5.4).

Box 5.6 Hand and nail changes.

 Nicotine staining indicates cigarette smoking

 Clubbing: differential diagnosis includes bronchial carcinoma, idiopathic pulmonary fibrosis, bronchiectasis, emphysema, and lung abscess. Non-respiratory causes include cyanotic heart disease, endocarditis, atrial myxoma, liver cirrhosis, inflammatory bowel disease, and coeliac disease. Clubbing can be familial and idiopathic. Patients with finger clubbing usually also have clubbing of their toe nails (Figure 5.2)

 Peripheral cyanosis can indicate cardiac or respiratory pathology

 Fine tremor could indicate over-use of β2-agonist medication or thyrotoxicosis

 CO2 retention tremor (asterixis) is a coarse, flapping tremor suggestive of excessive amounts of carbon dioxide in the bloodstream in patients with type 2 respiratory failure (Figure 5.3). The patient should be asked to extend their arms and wrists out and keep their fingers apart for at least 30 seconds. Other clinical signs of CO2 retention include a bounding pulse, drowsiness, and irritability 

______

Figure 5.2 Clubbing of the finger nails and tar staining. Source:ABC of COPD. 3rd edition, Figure 3.3.

The trachea should be examined by inserting the index and middle fingers in the suprasternal notch to look for signs of deviation which could be due to extra-thoracic or intra-thoracic causes. Extrathoracic causes of tracheal deviation include a large, retrosternal thyroid goitre, which can also cause significant tracheal compression or lymphadenopathy. Intra-thoracic causes of tracheal deviation (Figure 5.5, Figure 5.6) include pneumothorax and pleural effusion, which will push the trachea away from the side in which they occur. Upper lobe collapse, which may be due to endobronchial obstruction or chronic apical fibrosis, can cause tracheal deviation towards the side of the lesion.

The conjunctiva should be examined to look for pallor suggestive of anaemia, and the mucous membranes of the mouth, lips, and tongue examined for telangiectasia and central cyanosis. Cyanosis is seen when there is >5 g dl-1 of deoxygenated haemoglobin present. Horner’s syndrome (ptosis, miosis, enophthalmos, and anhidrosis) (Figure 5.7) suggests damage to the sympathetic chain in the neck, for example, by a Pancoast’s tumour (see Chapter 9). Bilateral ptosis is suggestive of Myasthenia Gravis and eye signs secondary to thyroid disease may be obvious. General inspection of the skin may show bruising and thinning secondary to steroid therapy, markers of autoimmune disease (for example psoriatic plaques), or erythema nodosum on the shins.

Examination of the chest

Close examination of the chest includes noting any scars which might indicate previous surgery, chest drain insertion, or radiotherapy. A reduction in the crico-sternal distance may suggest hyperinflation. Note should be made of signs of superior vena cava obstruction, which includes distended, engorged, pulseless veins in the neck, a jugular venous pressure that is fixed and raised, collateral veins on the chest and arms, and facial oedema.

Figure 5.3 Checking for COretention flap.

Figure 5.4 Checking for lymphadenopathy.

Figure 5.5 Checking for tracheal deviation.

Figure 5.6 Close-up view showing how to check for tracheal deviation.

Figure 5.7 Unilateral (right-sided) Horner’s syndrome showing ptosis, miosis, and aniscoria (difference in size of the pupils between the two eyes).

Chest expansion should be conducted anteriorly and posteriorly using both hands in the upper and lower chest wall and comparing the left to the right side. The hands should be placed firmly on the chest wall with the fingers spread apart and with the thumbs in the midline. The patient should be asked to take a deep breath in and the movement apart of the thumbs noted to see if the chest expands normally. Again, note should be made of any asymmetry in chest expansion as this suggests pathology on that side (Figure 5.8, Figure 5.9).

Chest expansion will be reduced bilaterally in conditions affecting both lungs, such as COPD or pulmonary fibrosis, the former due to hyperinflation and the latter due to reduced lung compliance. Asymmetry of chest expansion suggests pathology affecting one side of the lung, for example, pneumonia or pleural effusion (Figure 5.10). Weakness of the diaphragmatic muscles may result in the abdominal wall moving paradoxically inwards during inspiration.

Percussion should be conducted anteriorly and posteriorly in a systematic and symmetrical way, covering the upper, middle, and lower zones of the thorax. The middle finger should be placed flat against the chest wall and should be tapped firmly using a finger from the other hand (Figure 5.11, Figure 5.12). Normal lungs are full of air and the percussion sound is resonant. When there is consolidation (fluid or debris in the alveolar sacs) or if there is a pleural effusion, then there will be dullness on percussion. The percussion note will be hyper-resonant with a large pneumothorax.

Auscultation is usually done using the diaphragm of the stethoscope (Figure 5.13). Normal lungs, full of air, transmit low frequency sounds. Normal breath sounds are described as vesicular.

The listener should describe whether the wheeze occurs during inspiration, expiration, or throughout the respiratory cycle, whether it is monophonic or polyphonic, and in which zones of the chest it can be heard. Polyphonic wheezes, usually heard throughout the lung fields, indicate obstructive airways disease (asthma, COPD, bronchiectasis) but can also be heard with cardiac failure. A monophonic wheeze heard in a fixed position indicates a fixed obstruction, for example, a tumour.

Crackles are caused when the respiratory bronchioles open, and occur when the lungs have reduced compliance. Coarse crackles can be due to pulmonary oedema or bronchiectasis and fine crackles suggest an interstitial abnormality, such as occurs in idiopathic pulmonary fibrosis. Crackles due to secretions will clear on coughing.

Lungs which have consolidation will transmit high frequency sounds. Bronchial breathing, a harsh sound, indicates an air-fluid interface as might be found in pneumonia or on top of a pleural effusion.

Figure 5.8 Checking for chest expansion upper anterior chest.

Figure 5.9 Checking for chest expansion lower anterior chest.

Tactile vocal fremitus (TVF) and vocal resonance (VR) detect the transmission of sound from the lungs to the periphery. The patient is asked to say ‘99’ or ‘111’ and the transmission of the sound is felt either as vibration using the lateral surface of the hands or heard through the stethoscope. TVF and VR will be reduced with a pleural effusion and increased in consolidation. A high- pitched ‘bleating’ sound, called aegophony, can be heard in areas of consolidation. When patients with consolidation are asked to whisper ‘99’, then the high-pitched consonants of speech may be heard (whispering pectoriloquy).

A pleural rub is described as a ‘squeaky’ sound, like the sound of new leather. This is suggestive of pulmonary infarction, for example, after a pulmonary embolus.

Abnormal respiratory sounds can be heard on: www.easyauscultation.com, YouTube, or https:// www.med.ucla.edu. The supplementary video demonstrates how to take a respiratory history and conduct a respiratory examination.

Figure 5.10 Checking for chest expansion posteriorly.

Figure 5.11 Percussion of the chest anteriorly.

Figure 5.12 Percussion of the chest posteriorly.

Figure 5.13 Auscultation of the lungs.

Table 5.4 lists abnormal findings on examination of the chest and what pathology this might indicate.

Pre-operative respiratory assessment

The surgeon and anaesthetist will require some information about the patient’s cardiac and respiratory systems prior to carrying out surgery, particularly if this involves a general anaesthetic. While the anaesthetist will usually assess the patient and make the final decision, they will expect basic respiratory information to be available.

In a patient who has no respiratory problems, this usually includes documentation of a normal respiratory examination, oxygen saturation, and chest X-ray result. In patients who have underlying respiratory disease, a more comprehensive evaluation will be required, and senior respiratory opinion is often sought. The results of full lung function tests, including diffusing capacity, and the results of an arterial blood gas test will be required. Many elderly patients with chronic lung disease are found to be unfit for surgery involving general anaesthetic. For patients with poor lung function in whom surgery with a general anaesthetic cannot be avoided, optimisation of lung function with inhaled therapy, nebulised bronchodilators, and chest physiotherapy is advised. Patients who use a continuous positive airways pressure (CPAP) or bilevel positive airways pressure (BiPAP) machine, for example, for OSA or chronic type 2 respiratory failure, should be advised to bring that with them to the hospital. Such patients should be managed in the high dependency unit or intensive care unit.

Post-operative respiratory problems

Major surgery causes significant physiological changes in the body. In the immediate post-operative period, pain, opioid analgesia, and immobility will result in reduced coughing and the pooling of secretions in the lungs. This can cause atelectasis and increase the risk of pulmonary infection. This can be significant, especially after major abdominal surgery. Patients who have had surgery often develop breathlessness. This should be assessed in a systematic way with clinical examination, CXR, and arterial blood gas (ABG) examination.

Patients with known chronic lung disease may require respiratory support post-operatively. Some may require CPAP non-invasive ventilation (NIV) or intubation. The majority will benefit from nebulised bronchodilators, mucolytic agents, and chest physiotherapy to clear secretions and reduce the risk of atelectasis.

Post-surgery immobility is an increased risk factor for deep vein thrombosis and pulmonary embolus. Patients should be prescribed prophylactic low molecular weight heparin or thromboembolic disease (TED) stockings to prevent this. Doctors looking after patients who have had surgery should be aware of the risk of thromboembolic disease.

Patients are often unable to take adequate oral fluids and are prescribed intravenous fluids. If too much fluid is prescribed without an assessment of fluid status, then the patient may go into acute pulmonary oedema, resulting in breathlessness, especially if the patient is elderly and has cardiac problems.

Table 5.4 Abnormalities on examination of the lungs.

Condition

General observation

Chest expansion

Percussion

TVFandVR

Auscultation

Asthma

Tachypnoea Audible wheeze

Hyperinflated

Normal

Normal

Polyphonic wheeze

COPD

Tachypnoea Pursed-lip breathing

Hyperinflated

Normal

Normal

Polyphonic wheeze

Pneumonia

Fever

Tachypnoea

Reduced on side of consolidation

Dull on side of consolidation

Increased

Coarse crackles Bronchial breathing Whispering pectoriloquy Aegophony

Pleural effusion

Tachypnoea

Tracheal deviation away from side of effusion

Reduced on side of effusion

Dull on side of effusion (stony dull)

Reduced

Reduced breath sounds

Pulmonary

fibrosis

Tachypnoea

Clubbed

Reduced

Normal

Normal

Fine late-inspiratory crackles

Lobar collapse

Tachypnoea

Tracheal deviation towards the side of collapse

Reduced on side of collapse

Normal

Normal

Reduced breath sounds on side of collapse

Pneumothorax

Tachypnoea

Tracheal deviation away from side of pneumothorax

Reduced on side of pneumothorax

Hyper-resonant

Reduced

Reduced breath sounds on side of pneumothorax

Respiratory assessment of an acutely ill patient

Sudden and severe respiratory compromise resulting in respiratory failure is a common problem in hospitals. Such a patient will need clinical examination to elicit the cause of the respiratory failure. Oxygen should be given through the correct device and at the correct rate after measurement of the arterial blood gas (PO2, PCO2, pH and bicarbonate) to determine whether it is type 1 or type 2 respiratory failure. Further investigations should include a CXR, a CT scan, an ECG, and echocardiogram to make a definite diagnosis. A senior medical opinion will be required. The management of respiratory failure is discussed in Chapter 13.

Stridor is an alarming sign to observe in a patient as it suggests impending upper airway obstruction. The sound is worse on inspiration and can be heard without a stethoscope. There are several causes of stridor. Inhalation of a foreign body can cause airway obstruction. A bang on the back of the chest or the Heimlich manoeuvre will be required to remove the object. In children, gentler manoeuvres are advised. Epiglottitis can cause swelling of the upper airways and is a medical emergency which might require intubation by an experienced anaesthetist. Smoke inhalation can also cause severe burns and oedema of the upper airways resulting in obstruction. Anaphylaxis is another cause of upper airway obstruction that will need to be managed with intramuscular adrenaline (0.5 ml of a 1 : 1000 solution), chlorpheniramine, 10—20 mg IV, hydrocortisone 100—500 mg IV and inhaled β2-agonist for bronchospasm.

 A comprehensive history and thorough clinical examination will lead to the correct diagnosis in most cases.

 Breathlessness can be due to many different causes and does not always indicate lung pathology.

 Cough is a common symptom. A sensible algorithm should be used to make the diagnosis.

 Common causes of a dry cough in a nonsmoker with a normal CXR include asthma, GORD, postnasal drip, ACE inhibitor, and post-infectious cough.

 Cough is the commonest presentation of patients with lung cancer, so smokers with persistent cough should have a CXR.

 Pleuritic chest pain indicates inflammation of the pleural surface from any of several causes, including infection, malignancy, and infarction.

 The differential diagnosis of pleuritic chest pain includes pneumothorax, pulmonary embolus, and community acquired pneumonia, so a CXR is required.

 The differential diagnosis for haemoptysis includes infection, malignancy, vasculitides, and coagulopathies.

 Causes of upper airway obstruction include epiglottitis, inhaled foreign body, smoke inhalation, and anaphylaxis. Patients will present with stridor and will require intubation.

 Post-operative respiratory problems include atelectasis, pneumonia, pulmonary embolus, and pulmonary oedema if too much intravenous fluid is given in patients with cardiac dysfunction.

MULTIPLE CHOICE QUESTIONS

5.1 Which one of the following statements is true?

A Breathlessness always indicates a problem with the lungs

B Breathlessness when lying flat always indicates heart failure

C Breathlessness should be graded using the MRC scale

D Breathlessness in pregnancy is always worrying

E All breathless patients need oxygen

Answer: C

Breathlessness may indicate lung pathology, but can also be due to problems with other systems of the body such as the heart, muscles, or thoracic cage. A detailed history and careful examination is required to make a diagnosis. Although orthopnoea, which is breathlessness when lying flat, is often associated with heart failure, it can also occur with COPD, OSA, and diaphragmatic palsy. Breathlessness in pregnancy can be physiological due to the increased demands as well as due to the enlarged uterus pushing up on the diaphragm. Only patients who are hypoxic need oxygen.

5.2 Which of the following statements is true?

A All patients with a cough should have a CXR

B Normal spirometry excludes asthma as a cause of dry cough

C Bronchiectasis usually presents with a dry cough

D Persistent cough in a smoker is a worrying symptom

E GORD is a common cause of productive cough

Answer: D

Smokers who have a persistent cough (longer than three weeks) should have a clinical examination and a CXR to exclude lung cancer. Cough-variant asthma is common and spirometry may be normal. GORD and postnasal drip are common causes of a dry cough. Not all patients with a cough need a CXR, only if there are clinical concerns, such as weight loss, haemoptysis, and if the patient has been a smoker.

5.3 A 55-year-old man presents with haemoptysis. A CXR shows a cavitating lesion. Which of the following diagnoses will you exclude?

A Aspergilloma

B Community acquired pneumonia C Granulomatosis with polyangiitis (Wegener’s)

D Non-small cell lung cancer E Sarcoidosis

Answer: E

All the above, except sarcoidosis, can present with haemoptysis and a cavitating lesion. Infections with Staphylococcus aureus and Streptococcus millieri develop cavities.

5.4 A 26-year-old woman presents with pleuritic chest pain and breathlessness and is found to have pain on palpation of her sternum and chest wall. The most likely diagnosis is which of the following?

A Asthma

B Costochondritis

C Gastro-oesophageal reflux

D Pneumothorax

E Pulmonary embolus

Answer: B

The most likely diagnosis with this presentation is costochondritis or Tietze’s syndrome. Clearly the patient will require a thorough examination and investigations, including a chest X-ray, ECG, and measurement of oxygen saturation to exclude the other conditions.

5.5 Dullness on percussion and an increased vocal resonance indicate which pathology?

A Lung cancer

B Pleural effusion

C Pneumonia

D Pneumothorax

E Pulmonary oedema

Answer: C

Dullness on percussion with increased VR indicates consolidation which occurs with pneumonia.

5.6 Finger clubbing and fine crackles on auscultation are indicative of which condition?

A Bronchiectasis

B Idiopathic pulmonary fibrosis

C Lung abscess

D Pneumonia

E Pulmonary oedema

Answer: B

Clubbing and fine crackles occur in idiopathic pulmonary fibrosis. Clubbing can occur in bronchiectasis, but the crackles are coarse. Clubbing can also occur with lung abscess but no crackles will be heard. Coarse crackles may be heard in both pneumonia and pulmonary oedema.

5.7 A tension pneumothorax on the right hemithorax will result in which condition?

A Tracheal deviation to the left and decreased breath sounds on the left

B Tracheal deviation to the right and decreased breath sounds on the right

C Tracheal deviation to the right and hyperresonance on percussion on the right

D Tracheal deviation to the left and hyperresonance on percussion on the right

E Tracheal deviation to the left and increased breath sounds on the right

Answer: D

A pneumothorax on the right side will push the trachea away towards the left side and there will be mediastinal shift to the left. Percussion on the right side will be hyper-resonant and there will be reduced breath sounds on the right.

5.8 Which clinical features indicate a large left pleural effusion?

A Tracheal deviation to the left, decreased breath sounds, and dullness on percussion on the left

B Tracheal deviation to the right, decreased breath sound, and dullness on percussion on the left

C Tracheal deviation to the right, decreased breath sounds, and dullness on percussion on the right

D Tracheal deviation to the left, increased breath sounds, and dullness on percussion on the left

E Tracheal deviation to the right, increased breath sounds on the right, and dullness on percussion on the left

Answer: B

A large pleural effusion will push the trachea away to the right. There will be reduced chest expansion, reduced breath sounds, and dullness on percussion on the left side.

5.9 Which clinical features indicate right upper lobe collapse?

A Tracheal deviation to the right with reduced chest expansion on the right

B Tracheal deviation to the right with reduced chest expansion on the left

C Dullness to percussion on the right with increased tactile vocal fremitus

D Hyper-resonance on the right with decreased breath sounds on the right

E Dullness to percussion on the left with decreased breath sounds on the right

Answer: A

Right upper lobe collapse will cause tracheal deviation towards the right, with decreased chest expansion and reduced breath sounds on the right.

5.10 A patient with vocal cord dysfunction usually presents with which condition?

A Crackles

B Haemoptysis

C Pleuritic chest pain

D Upper airway noise

E Wheeze on auscultation

Answer: D

Patients with vocal cord dysfunction complain of breathlessness and wheeze, even at rest, but auscultation of the lungs is usually normal. They close off their throat and vocal cords, so they generate a noise that may resemble stridor.



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