Approach to the Patient with Respiratory Disease
Dr. Andre Angelo TanqueJune 4, 2015
Chapter 305: Approach to the Patient with Disease of the
Respiratory System
Lecture Objectives1. Describe the epidemiology of respiratory
diseases in the Philippines and in the world.2. Discuss the
pathophysiology behind disturbances in respiratory function.3.
Demonstrate the skill and art of history taking and physical
examination as they pertain to the respiratory system and its
diseases.4. Explain the uses of different invasive and non-invasive
diagnostic modalities for confirming respiratory diseases.5.
Recognize the components of the arterial blood gas (ABG) and their
significance.6. Identify basic chest x-ray findings which may
pertain to specific medical conditions.
Top 10 Leading Causes of Morbidity in the Philippines1. Diarrhea
pediatric patients2. Bronchitis/bronchiolitis usually URTI3.
Pneumonia4. Influenza5. Hypertension6. Tuberculosis pulmonary or
extrapulmonary*4/10 belong to Respiratory Diseases
7. Diseases of the heart8. Malaria9. Measles10. Chicken poxTop
10 Leading Causes of Mortality in the Philippines1. Heart disease
usually MI2. Vascular system disease3. Cancer no 1 cause of
mortality is cigarette smoking4. Road Accidents VA, Thoracic
injury5. Pneumonia6. Tuberculosis death due to hemoptysis or
secondary infection7. Dengue Fever death usually due to
hemorrhage8. Chronic lower pulmonary diseases abscesses and
exacerbation of COPD pero seldom lang9. Diabetes mellitus10.
Perinatal conditions
3 major categories of Respiratory Disease 1. obstructive lung
diseases most common e.g. asthma, COPD, bronchiectasis and
bronchiolitis2. restrictive disorders parenchymal lung diseases,
abnormalities of the chest wall & pleura, neuromuscular
disease3. abnormalities of the vasculature pulmonary embolism,
pulmonary hypertension and pulmonary veno-occlusive diseaseHow to
detect Respiratory Problems in a Patient?I. History of Symptoms A.
Common/Cardinal Symptoms:1. Dyspnea/ Shortness of breath (SOB)
subjective complaint COPD Patients: Chest Tightness or Inability to
take a deep breath (di makahinga) CHF Patients: Air Hunger or Sense
of Suffocation (kinukulang sa paghinga) Tempo & Duration of
dyspnea are helpful in determining the etiology: Acute SOB is due
to physiologic changes (e.g. MI, pulmonary embolism, laryngeal
edema, bronchospasm) Progressive SOB common for patients with
underlying lung diseases (e.g. COPD and IPF) Recurrent Episodes of
SOB are common to patients with asthma associated with specific
triggers Dyspnea on exertion is often an early symptoms of
underlying lung or heart disease & warrants a thorough
evaluation Not all dyspnea are respiratory in origin
TIMELINE FOR SHORTNESS OF BREATHAcute (mins days)Sub Acute (days
weeks)Chronic
Airways (e.g. smoke and obnoxious, reaction to airway)Lung
parenchyma (e.g., gunshot wound and stab wound)
Pleural space (e.g., complicated pneumonia, trauma and
hemothorax)
Pulmonary vasculature (pulmonary embolism) Hypercoagulable
states such as malignancy, cancer, trauma and critically ill
patients
*pag na expose sa noxious stimuli nageedema ang airway,
traumaExacerbation of airways disease (e.g., Asthma, COPD and slow
infection)
Slow infection or inflammation (e.g., immunocompetent who is
self-medicating, partially resolving pneumonia)
Neuromuscular disease (e.g., Myasthenia Gravis, ALS/Lou Gehrigs
disease)
Chronic cardiac disease (e.g., Heart Failure, right side of
heart blood stasis) hindi lahat ng SOB pulmonary in origin kaya you
need to rule out
Exacerbations
Remissions
COPD
CILD Chronic Interstitial Lung Disease; common sa US
Chronic cardiac disease
2. Cough May indicate the presence of lung disease Sputum
suggest airway disease Not all causes of cough are respiratory in
origin Clinician should take note of the following: Duration of
cough Association with sputum production Specific triggers that
induce it Quantity Quality/Color (Normal Sputum: Colorless to
Whitish) Acute productive cough ( 2 weeks, (Harrisons: >8 weeks)
(e.g., Most common in the Philippines; Pulmonary Tuberculosis,
Gastroesophageal Reflux, Asthma. US; Post-nasal Drip)
B. Less Common Signs/Symptoms Hemoptysis Blood-tinged cough Must
be distinguished from epistaxis or hematemesis Can be a symptom of
a variety of lung diseases (e.g. infection of respiratory tract,
bronchogenic carcinoma and pulmonary embolism) Should warrant
further evaluation
AirwaysInflammatory bronchitis bronchiectasis cystic
fibrosisNeoplastic tumors
Lung ParenchymaLocalized pneumonia lung abscess foul smelling
sputum tuberculosis aspergillosisDiffuse
VasculaturePulmonary thromboembolic diseaseArteriovenous
malformations
Chest Pain or Pleurisy Lung parenchyma is not innervated with
pain fibers Pain in the chest from respiratory disorder usually
results from either diseases of the parietal pleura or pulmonary
vascular disease Pleuritic pain during respiration Accentuated by
respiratory motion Maybe due to neoplasms/inflammation involving
pleura Parenchymal disorders extending to the pleura Chest pain in
pleural effusion are usually relieved by change of position
C. Additional Historic Information/Risk Factors Smoking Current
and past Cigarettes compute for pack years Number of years
Intensity Smoking cessation Usually associated with COPD and cancer
Duration and intensity of exposure to cigarette smoke increases the
risk of disease Inhalational Exposures / Inhaled Agents Asbestos,
silica dusts pneumoconiosis Molds, animal proteins hypersensitivity
pneumonitis Dust mites, pet dander, cockroach allergens
exacerbation of asthma Exposure to infectious agents/contact with
infected individuals Coexisting illness dahil hindi lahat ng
dyspnea ay pulmonary ang origin. CHF, MG, Gynecological infection
na nagseseptic emboli usually treat lang with antibiotics AIDS
Pneumocystis carinii, Pneumocystic jiroveci, TB Previous treatments
Some chemotherapeutic drugs can cause pulmonary fibrosis Patients
taking Coumadin usually presents with hemoptysis/hematemesis.
Intervention is to immediately stop taking it. Nagtetake ng
Coumadin na hindi nagfofollow-up sa cardiologist nagprepresent ng
hemoptysis. Family history Cystic Fibrosis which is common to
Caucasian population are usually prone to develop
Bronchiectasis
D. Physical Examination of the Respiratory System should be
meticulous often begin with Vital Signs
1. Inspection Severe kyphoscoliosis can result in restrictive
pathophysiology.2. Palpation Consolidation (Increased Tactile
Fremitus), Pleural Effusion (Decreased Tactile Fremitus)3.
Percussion Establish diaphragm excursion & lung size Pleural
Effusion (dull), Pneumothorax (hyperresonant)4. Auscultation
Expiratory wheezes (asthma) Rhonchi obstruction of Middle Sized
Airways (COPD, Bronchiectasis) Inspiratory Stridor obstruction of
upper airway Crackles or Rales sign of Alveolar Disease (Pneumonia:
Focal crackles vs. Pulmonary Edema: Base Crackles) Egophony (e
magiging a) is associated with Pneumonia but not in Interstitial
Lung Disease Emyphysema: Diffusely decreased breath sounds Pleural
Effusion & Pneumothorax: Absent breath sounds5. Extrapulmonary
manifestations
REMEMBER THIS TABLE!!!
Di lahat ng crackles kailangan bigyan ng antibiotics kasi merong
crackles na di nawawala. For example, chronic TB na
nagbronchiectasis. Hindi nawawala ang crackles. Ang egophony din
pwede din gamitin for tool marker for chest tube insertion sa mga
pleural effusion. Insert 2 or 3 ICS below Enlarged lymph nodes
Mentation Signs pointing to smoking Clubbing cystic fibrosis, lung
CA Extrapulmonary findings Cyanosis usually if >5g of
deOxygenated Hgb Pedal edema if symmetric Cor Pulmonale if
assymetric Deep Vein Thrombosis Jugular Venous Distention Right
heart Failure Pulsus Paradoxus Obstructive Lung Disease
II. Diagnostic Procedures in Respiratory Disease Imaging studies
CXR: best; maximize to PA Lateral kung kaya ng patient, in order to
localize Techniques for acquiring specimens sputum or lavage Direct
visualization Pulmonary function testing to differentiate
obstructive from restrictive Ancillary procedures
A. Imaging studies
1. Chest X-ray initial evaluationViews: Posteroanterior and
Lateral ideal; 2 dimension; easier to localize Lateral decubitus
usually pag effusion. Importance niya is if magagravitate ang
effusion. If it gravitates laterally, hindi siya magiging loculated
so pwede siyang tusukin Apicolordotic usually for TB or suspicion
of densities at apices Anteroposterior usually for bedridden
patients; lumalaki ang heart due to cardiac shadow
DI Review: Pulmonary Vascular markings prominent inferiorly,
medially and tapers peripherally.
On the PA chest-film, it is important to examine all the areas
where the lung borders the diaphragm, the heart and other
mediastinal structures. At these borders lung-soft tissue
interfaces are seen resulting in a: Line or stripe for instance the
right paratracheal stripe Silhouette for instance the normal
silhouette of the aortic knob or left ventricle These lines and
silhouettes are useful localizers of disease, because they can be
displaced or obscured with loss of the normal silhouette
(silhouette sign). The paraspinal line may be displaced by a
paravertebral abscess, hemorrhage due to a fracture or
extravertebral extension of a neoplasm. Widening of the
paratracheal line (> 2-3mm) may be due to lymphadenopathy,
pleural thickening, hemorrhage or fluid overload and heart failure.
Displacement of the para-aortic line can be due to elongation of
the aorta, aneurysm, dissection and rupture. The anterior and
posterior junction lines are formed where the upper lobes join
anteriorly and posteriorly. These are usually not well seen. An
important mediastinal-lung interface to look for is the
azygoesophageal line or recess (blue arrow).
Costophrenic Angle should be well-defined and sharp (blunted may
suggest effusion) Trachea should be midline differentiates
atelectasis (towards the lung pathology) vs. effusion (away) Heart
borders In pneumonia, cardiac borders are usually obscure, (+)
Silhoutte Sign
Whenever you see an area of increased density within the lung,
it must be the result of one of these four patterns:1.
Consolidation any pathologic process that fills the alveoli with
fluid, pus, blood, cells (including tumor cells) or other
substances resulting in lobar, diffuse or multifocal ill-defined
opacities (usually alveolar pathology kaya patchy distribution
Interstitial); Diffuse CHF2. Interstitial involvement of the
supporting tissue of the lung parenchyma resulting in fine or
coarse reticular opacities or small nodules; Fine opacities common
at the base3. Nodule or mass any space occupying lesion either
solitary or multiple. 3cm Mass4. Atelectasis collapse of a part of
the lung due to a decrease in the amount of air in the alveoli
resulting in volume loss and increased density.
Fine Reticular Interstial: common sa bases in Interstitial Lung
Disease so do CT Scan Solitary Pulmonary Nodule: do CT scan din to
confirm
Pneumonia with cavitation (air sa loob surrounded by a wall). If
may air fluid level, ABSCESS na.
Deviated trachea due to atelectasis. Ang lungs kasi di na
nagreregenerate.
Ang case na ito usually prolonged hypertension and DOB so CHF na
may Pulmonary Edema. Pero if may hyperdensity with batwing isipin
mo na may concominant pneumonia.
Pneumothorax absence of pulmonary vascular markings in the
affected area Usual presentation in the ER: Mabilis huminga
Naghahabol ng hininga Sudden No fever Smoker Decreased breath
sounds
Deviated ang trachea to the right. Usually patient presents with
sudden dyspnea without fever and other symptoms Usually decreased
breath sounds Example: yung patient ko lost to follow-up na
asthmatic patient na nagka-hemothorax kaya pina-chest tube ko
Right pneumothorax. Pansin niyo yung visible pleural line? Mga
around 40% ito. So Chest Tube lang. (15y.o. ata ito eh presenting
with DOB)
Ito yung nag-VATS (Video Assisted Thoracoscopic Surgery) sila
using laparoscopic surgery. Pwede ito bullectomy pag open surgery
kaso since laparoscopic surgery, endostapler sila. Pag VATS, double
lumen endotracheal tube ang ginagamit kasi during VATS i-cocollapse
mo yung ooperahan mo.
Case of pneumoperitoneum caused by blunt trauma to the patient.
Meron siyang perforation.
Silhouette sign
The illustration above summarizes the findings of the different
types of lobar atelectasis. RUL collapsed right upper lobe RLL
silhouette sign
Right upper lobe atelectasis
Notice that the trachea is deviated to the right side. Why is
this not a case of lobar pneumonia or simple pneumonia? Because
there should be no deviation of the trachea.
Common causes of atelectasis in a hospital setting: Malalim yung
pagkakalagay ng trach tube mo during intubation so pwedeng
mag-collapse yung lung Or sa ICU, sobrang dami ng secretions tapos
yung respiratory therapist di nagsusuction regularly so nag-mucus
plug so pwede rin yun.
Right lower lobe atelectasis
Left: Notice that the right cardiac border should be
convex.Right: After suctioning or expectorating. Medyo gumanda
na.
Right middle lobe atelectasis
Minsan may mga subsegmental atelectasis na mga linya-linya lang
yung nakikita. Di mo pwedeng sabihin na interstitial iyon. These
narrow lines are not Kerley lines but rather, your subsegments.
Right lung atelectasis
Left: Total right lung atelectasis due to mucus plugging. Pwede
rin siyang mapagkamalan na effusion so you have to rely on your
PE.Right: After suctioning.
Left Lung atelectasis
Ito naman nag-intubate sa right tapos nag-collapse yung left
lung. Kapag nag-pass ka kasi ng ET tube tapos malalim, pupunta iyon
sa right lung kasi yung left lung mo mas vertical so kunwari ang
na-intubate mo lang yung ay yung right, mag-cocollapse yung
trachea. Dito mapapansin niyo na halos clotted na yung left
diaphragm tapos halos hyperaerated na yung right. So ang gagawin
dito, ia-adjust mo lang yung ET tube. Paano mo malalaman kung
malalim yung pagkaka-intubate mo? Dapat yung ET tube mo, isesecure
mo lang sa Levels 21-22 (males) or Levels 19-20 or Level 18 (lower
levels in females due to the shorter length of the trachea)Is this
an atelectasis or effusion? Effusion. If this is atelectasis, dapat
mag-dedeviate yung trachea towards the lung pathology. Pero dito,
halos tinutulak niya pakaliwa at hindi to the right yung trachea.
So more likely, effusion. It is important to correlate your PE with
your x-ray.
Meniscus sign - crescent-shaped inclusion of air surrounded by
consolidated lung tissue (red curve in the image)
Pneumothorax
Meron siyang air and fluid. Yung air, i-pupush niya pababa yung
fluid. Instead of a meniscus sign, straight yung top part nung
white area.
Causes of effusion: either problems in: excess production (e.g.
pneumonia) drainage (e.g. lymphomas cause obstruction)
2. CT ScanAscending aortaDescending aorta
This is called mediastinal view since there is no lung
parenchyma
Conventional CT cuts every 5-7 spaces so pwede kang may ma-miss
compared to high-res CT Helical CT CT angiography Administering
contrast to check the vasculature for diagnosis (e.g., pulmo
embolism) High-resolution CT (HRCT), multi-slice cuts every 1-2mm;
usually requested for interstitial lung diseases to see
honeycombing appearance Virtual bronchoscopy yung cuts na tinake mo
irereconstruct ng computer para magmukhang bronchoscopyConventional
CT vs. HRCT main difference is in the cuts
Cavity surrounded by a thick wallCyst surrounded by a thin
wallEmphysema no surrounding wall
Example of lung cuts in mediastinal view. There is absence of
pulmonary markings dahil mas gusto mong ma-enhance yung mediastinal
structures or mga lymph nodes. In the bottom picture, there is a
mass in the right medial area.
3. Virtual Bronchoscopy
Reconstructs structures in such a way na para ka na ring
nag-bobronchoscopy. Mas madaling malolocate ng bronchoscopist kung
saan siya papasok at mas ma-plan niya kung saan siya dadaan.
4. Magnetic Resonance Imaging (MRI) not good for lung pathology
due to holding of breath for 30-40secs which is difficult and
uncomfortable for patients
5. Scintigraphic Imaging Radioactive isotopes
Ventilation-perfusion scanning Albumin macroaggregates labeled with
technenium 99 for the perfusion part Inhaled radiolabeled xenon gas
for the ventilation part
6. Positron Emission Tomographic Scanning (PET scan) Identify
malignant lesions Increased uptake and metabolism of glucose
F-fluoro-2-deoxyglucose (FDG) Drawback: very expensive
Solitary pulmonary nodule
Pulmonary MassWhole body PET Scan
7. Pulmonary Angiography Pulmonary artery Pulmonary
embolismfilling defectcutoff Pulmonary AVMs Arterial invasion by
neoplasm Being replaced by CT Angiography since Pulmonary
Angiography is considered too invasive
8. Ultrasound uses sonar limited use; doesnt pass through bone
or air-filled spaces used to quantify pleural effusion and to guide
percutaneous needle aspiration of accessible masses/fluid
B. Obtaining Biologic Specimens
Sputum Collection for GS/CS Percutaneous needle aspiration
CT/UTZ guided Thoracentesis collection of fluid for histopath and
culture Bronchoscopy obtain specimen from airway VATS to see if
pleural lining is smooth or has masses Thoracotomy if hindi kaya ng
VATS Mediastinoscopy/Mediastinotomy invasive procedures
1. Sputum Collection Spontaneous expectoration Sputum induction
nebulize with hypertonic saline solution to irritate and
expectorate sputum easily Adequate specimen (ideal sputum
characteristic): PMNs > 25/LPF; SECs < 10/LPF (If >10/LPF
SECs, contaminated yung specimen with mouth flora, tell the pt. To
gargle before obtaining the specimen) Grams staining and culture
Mycobacteria or fungi TB Viruses Pneumocystis carinii Ag staining
Cytologic staining Polymerase chain reaction amplification DNA
probes
2. Bronchoscopy
Right: Rigid bronchoscopy. The ENT who performs this procedure,
needs the patient to undergo General Anesthesia. Oral cavity
only.Left: Flexible bronchoscopy: pwede pati nose and oral
cavity
Endobronchial pathology on Bronchoscopy Tumors Granulomas Sites
of bleeding Bronchitis Foreign bodies Treatment: Laser therapy
Cryotherapy Electrocautery Stent placement for collapsed airway to
dilate
Therapeutic Uses of Bronchoscopy Remove retained
secretions/mucus plugs Remove foreign bodies Remove abnormal
endobronchial tissue Perform difficult intubation
3. Video-Assisted Thoracoscopic Surgery (VATS)4. Thoracotomy5.
Mediastinoscopy and Mediastinotomy used to harvest lymph nodes
before the advent of CT scan, to know the status of the lymph
nodes; it is now seldom used
C. Pulmonary Function Testing
1. Blood gases
assessment of oxygenation capacity assessment of oxygen pressure
to guide therapy assessment of respiratory adequacy assessment of
acid-base balance
Normal Arterial Blood Gas Values pH:7.35 7.45 (7.45 alkalotic)
pO2: 80 100 mmHg (45mmHg hyerpercarbic) HCO3: 22 26 meq/L SaO2: 97
100% (SAT) can be invasive or non-invasive (using a pulse oximeter
not reliable if patient is hypotensive)
Contraindications for Arterial Puncture Anticoagulant therapy
History of a clotting disorder (haemophilia) History of arterial
spasms following previous punctures Severe peripheral vascular
disease Abnormal or infectious skin processes at or near the
puncture sites Arterial grafts
Pulse Oximetry Alternative method to assess oxygenation
Calculates oxygen saturation (not PaO2 ) An arterial PO2 of 60 mmHg
corresponds to an SaO2 = 90% If hypotensive, this is not
reliable
2. Spirometry Measures rate at which lung volume is changing as
a function of time during breathing maneuvers Simply put: measures
lung volume and airflow from fully inflated lungs
Indications for Spirometry To evaluate symptoms, signs or
abnormal laboratory tests To measure the effect of disease on
pulmonary function To screen persons at risk of having lung disease
To assess preoperative risk (esp. if the patient is a smoker or
will undergo thoracic surgery bec of inc risk for atelectasis,
pneumonia, etc. in post op) To assess prognosis To assess health
status before enrollment in strenuous physical activity
programs
Need for spirometry Essential in separating obstructive from
restrictive lung diseases Necessary to judge response to therapy
Necessary in plotting the course and prognosis of many lung
diseases Surrogate marker for risks of other common
life-threatening illnesses, e.g., lung cancer Predictive of
mortality
Petty, T, Simple Spirometry for Frontline Practitioners,
1998
What does spirometry measure?1. Measurement of Volume FVC FEV1
FEV1/FVC if < 0.7 (70%) = obstructive, if > 0.7 (70%) =
normal; dapat same value so kung Liters, Liters din dapat gamitin
as units
2. Measurement of Air Flow PEFR/ Peak Flow/MEF FEF25-75, FEF50,
FEF75 assesses medium-sized airways, commonly decreased in asthma
patients due to bronchoconstriction Inspiratory counterparts
MVV
If all are decreased, suspect for restrictive lung disease but,
using values from spirometry di ka pwedeng mag-label na restrictive
kasi ang kailangan mo total lung capacity (TLC). Kasi sa
restrictive, sa TLC mo lang siya ma-identify. Decreased TLC =
restrictive lung disease Parameters are expressed as actual values
and their % predicted
References:Dr. Tanques lectureHarrisons Principle of Internal
Medicine 19th ed. p1661
Legend: Red recording of the lectureBlack
lecture/powerpointGreen Harrisons12 | Page