Kursk State Medical University
Propaedutics of Internal
Diseases Department
Main Clinical Syndromes
in Respiratory Medicine
Syndrome of focal consolidation
of pulmonary tissue
Causes:
Pneumonia
(filling of alveolai with
inflammatory fluid & fibrin)
Lung infarction (filling of alveolai with blood)
Pneumosclerosis, carnification (connective
tissue growing)
Tumor
Syndrome of focal consolidation
of pulmonary tissue
Clinical symptoms
Dyspnoea
Pain in the chest (only in involvement of the
pleura in peripherally located inflammatory
focus)
If fever - moderate hyperemia of the face,
cyanosis of the lips.
Tachypnoea (24-30 per min).
Clinical sings
In large peripherally
located focus
Trachea in normal position
Thoracic lagging of affected
side (in pleura involvement)
Vocal fremitus increased
Dull percussion
If small deeply located
focus: palpation,
percussion, auscultation
may be non-effective
Syndrome of focal lung consolidation
Auscultation
Bronchovesicular
(mixed
respiration: inspiration as
vesicular (F), expiration
as bronchial (H)
or
Bronchial breathing
Syndrome of focal lung consolidation
Consonating moist
crackles, dry rales,
Auscultation
crepitation
Exaggerated bronchophony
Syndrome of focal
lung consolidation
Investigations
X-ray:
focal consolidations
at least 1-2 cm in diameter
(increased density in lung tissue)
Blood test: mild leucocytosis, moderately increased ESR.
Sputum: mucopurulent; great number of leucocytes, macrophages
and columnar epithelium. Bacterial flora is varied.
Syndrome of lobar consolidation
of pulmonary tissue
Complaints
Severe dyspnoea
Pleuritic pain in the chest (on the affected
side) in lower lobe involvement may
simulate acute appendicitis, hepatic colics
May be shaking chills or rigor, fever
(39400C), cough with sputum expectoration
Syndrome
of lobar
lung consolidation
General condition
- grave
May be confusion
(hallucinations & delirium)
Central cyanosis
In lobar typical pneumonia facies pneumonica:
Hyperemia of the cheeks, more
pronounced on the affected side
Participation of the nostrils in
breathing
Herpes nasalis & labialis.
Syndrome of lobar lung consolidation
Normal trachea position
Lagging of the affected
side
Tachypnea (30-40 per
min)
Increased vocal fremitus
Dull percussion sound
Bronchial breathing
Pleural friction rub
Consonating crackles,
crepitation
Syndrome of lobar lung consolidation
Increased bronchophony
Egophony (ee as ay)
Whispered pectoriloquy.
Cardiovascular symptoms:
tachycardia
Syndrome of lobar lung consolidation
X-ray
examination:
Homogeneous
opacity localized to
the affected lobe
Syndrome of cavity in the lung
Reasons:
Lung abscess
Lung tuberculosis (cavern)
Lung tumor degradation
Syndrome of cavity in the lung
Complaints
Weakness
Cough with meager sputum (sudden release
of ample offensive purulent sputum - full
mouth - on standing separates into three
layers: mucous, serous and purulent (from
200 ml to 1-2 L/day)
Pain in the chest
Dyspnoea
May be fever (remittent or hectic), chills
Syndrome of cavity in the lung
Unilateral thoracic lagging
Vocal fremitus increased
Percussion:
dulled tympany
metallic sound bell
tympany (large smooth-wall
cavity D=6-8 cm)
crackled-pot sound
(superficial cavity
communicates with
bronchus through a narrow
slit soft dull & clinking
sound)
Syndrome of cavity in the lung
Auscultation:
Bronchial breathing
(amphoric / cavernous)
Resonant (consonating)
medium & large moist
crackles
Syndrome of cavity in the lung
Pathological bronchial respiration
(amphoric)
Large smooth-wall
cavity (D>5-6 cm)
communicated with a
large bronchus
(abscess, cavern)
Additional high overtones
(strong resonance)
with the main low-pitch
laringotracheal breathing
Syndrome of cavity in the lung
Pathological bronchial respiration
(cavernous)
Cavernous sound over
the cavity
Low-toned form of
bronchial breathing
(more hollow in quality)
Imitated by breathing
into a tumbler
If the cavity is well filled,
no abnormal breath
sounds will be heard,
though breathing may
be faint
Syndrome of cavity in the lung
Metallic character of crackles
In superficially located large cavity (D>5-6 cm)
Syndrome of cavity in the lung
Gutta cadens falling-drop sound
In lung or pleural cavities with liquid pus & air
Pus sticks to the surface of the cavity
in changing patients position pus falls down in
drops at the bottom (one by one)
Syndrome of cavity in the lung
Investigations
Sputum:
Offensive smell
On standing separates into
three layers: mucous,
serous, purulent
Elastic fibers
Leucocytes and
erythrocytes
Dittrichs plugs (resemble
the lenticular formations
with offensive odour on
pressing )
Syndrome of cavity in the lung
X-ray:
cavity with liquid level
Syndrome of air accumulation in
the pleural
(Pneumothorax)
Presence
of gascavity
in
the pleural space
Communicated
bronchi with
pleural cavity:
Subpleural
tuberculosis
cavern or lung
abscess
Chest injury
Iatrogenic
pneumothorax
Pneumothorax
1. Spontaneous pneumothorax occurs without
1. Spontaneous pneumothorax occurs without
antecedent trauma to the thorax
A. Primary spontaneous occurs in an
individual without underlying lung disease
(subpleural bullae rupture)
B. Secondary with underlying lung disease
(bullae rupture in emphysema, asthma,
abscess, tumor, eosinophilic granuloma)
2. Traumatic pneumothorax caused by
penetrating or non-penetrating chest injuries
(rib fracture, penetrating chest wall injury,
during pleural or pericardial aspiration)
Pneumothorax
3 types
Tension (valvular) - positive pressure (more
than atmospheric) in the pleural space
throughout the respiratory cycle (one-way
valve: air entered to the pleural cavity during
inspiration, not removed during expiration
trapped)
Closed - air entered to the pleural cavity
Open communication between the bronchus
& pleural cavity (broncho-pleural fistula)
pressure same as atmospheric
Complaints
Sudden unilateral tightness in the chest
Pain in the chest with inspiratory increasing
Dyspnea
Dry cough
Palpitation
Pneumothorax
Tension (valvular):
Medical emergency (if not treated death within
short time). General condition - suddenly,
rapidly. Severe dyspnea progressive with
each inspiration. Central cyanosis.
Closed:
Dyspnea (not severe) improves (2-4 weeks)
after air absorbtion
Open:
Dyspnea not improved without surgery
Clinical manifestations
Inspection
Asymmetrical chest
Displacement of the
trachea to the
opposite side
Lagging of the
affected side
Intercostal spaces increased,
smoothed
Clinical manifestations
Palpation
Subcutaneous
emphysema
(in traumatic
pneumothorax)
Increased unilateral
regidity
Vocal fremitus decreased or
absent
Clinical manifestations
Percussion
Tympanic percussion sound
Metallic sound - bell tympany in
large pneumothorax (coin test)
Shift of the mediastinum to the opposite
side
Clinical manifestations
Auscultation
Diminished vesicular
breathing or absent
In open pneumothorax
-connection of the pleural
cavity with bronchus
(broncho-pleural fistula)
bronchial (amphoric or
metallic breathing)
Succussion (air + fluid in
pyopneumothorax)
Pathological bronchial respiration
(metallic)
Large open
pneumothorax
Loud & high
Resembles the metal
struck
Investigations
X-ray
Light pulmonary
field without
pulmonary pattern
(translucent zone)
Shadow of the
collapsed lung
toward the root
Shifted (pushed
out) mediastinum
Pneumothorax
treatment
Tension (valvular):
Medical emergency. Wide needle with
rubber tube - inserted in the intercostal
space for air aspiration
Closed: small without treatment, large air aspiration
Open: surgical treatment
Syndrome of increased
airness of the lungs
(syndrome of hyperinflation)
Distention of the air
spaces distal to the
terminal bronchiole
with destruction of
alveolar septa
Reduced lung
elasticity
Syndrome of hyperinflation
(lung emphysema)
Pink puffers
face
Tachypnea with
prolonged expiration
trough pursed lips /
expiration with
grunting sound
Increasing
breathlessness - an
exertional expiratory
dyspnea
Minimal cough with
small amounts of
mucoid sputum
Lips tightly apposed
at height of inspiration,
Lips held narrowly apart during
expiration
Syndrome of hyperinflation
(lung emphysema)
Asthenic constitution with weight loss
Barrelshaped chest (increased
anteroposterior diameter)
Use of accessory muscles in
respiration
Tracheal tug
Tachypnea
Prolonged expiration through pursed
lips
Lower intercostal spaces retract with
each inspiration
Neck veins distended during
expiration
Syndrome of hyperinflation
(lung emphysema)
Palpation:
Increased rigidity
Decreased vocal
fremitus
Diminished excursion
Syndrome of hyperinflation
(lung emphysema)
Percussion:
Hyperresonant (bandbox)
sound
Upper borders: protruded
Lower borders: descendent
Limited mobility
Decreased liver & cardiac
dullness
Auscultation: diminished
vesicular breathing
(diffuse dry rales in bronchitis)
Syndrome of hyperinflation
(lung emphysema)
Cardiac
dullness severely reduced
Decreased heart sounds
Presystolic gallop accentuated during
inspiration
Syndrome of hyperinflation
(lung emphysema)
Pulmonary function tests:
TLC and RV - increased
VC - low
Maximal expiratory flow rates - diminished
Syndrome of hyperinflation
(lung emphysema)
X-ray of the chest:
Diaphragm low,
flattened
Bronchovascular
shadow do not extend
to the periphery of
the lungs
Cardiac silchouette
lengthened, narrowed
Overinflation
Syndrome of compressive
atelectasis
Compressed
alveoli due to
accumulation of
fluid in the
pleural cavity
Syndrome of compressive
atelectasis
Dyspnea (inspiratory)
Cough - dry (reflexogenous)
In mediastinal pleurisy with
effusion:
Dysphagia (compression of
the esophagus)
Compression of the superior
vena cava - Stocks collar
(edema of the neck), cyanotic
face, dilated chest wall veins
Pembertons sign
Compression of the recurrent
nerve - hoarseness
Objective Examination
Inspection
Asymmetry of the
chest
Tracheal
displacement away
from the fluid
Lagging of the
affected side
Protrusion of the
intercostal spaces
Objective Examination
Palpation
Vocal fremitus
increased over the
compressed lung
Increased rigidity of
the affected chest
part
Syndrome of compressive
atelectasis - Garlands triangle
Garlands
triangle
Damoiseaus
Curve
Effusion
RauchfussGrocco
triangle
(displacement
mediastinum)
Garlands triangle on the affected side: dulled
tympanic sound (lung pressed by the effusion)
Skodaic tympany
Zone above the
fluid
dilated air sacs
in the lung
just above
the compressed
part
Syndrome of compressive atelectasis
Auscultation
Above the effusion
(Garlands triangle) bronchial breathing echo like compressive
bronchial breathing,
temporary crepitation
(during first deep
inspirations)
Increased bronchophony
Syndrome of obstructive atelectasis
Occlusion of the
bronchus by tumor,
retained secretions,
foreign body air
absorbed, affected
part of the lung
collapsed
Syndrome of obstructive atelectasis
Causes
1.
Intraluminal:
Mucus (postoperative, asthma, cystic fibrosis)
Foregn body
Aspiration
2.
Mural:
Bronchial carcinoma
3.
Extramural:
Peribronchial lymphadenopathy
Aortic aneurysm
Syndrome of obstructive atelectasis
Dyspnea (inspiratory)
If compression of the
trachea stridor
Expansion: reduced on the
affected side with flattening
of the chest wall
(narrowing, retruction of
the intercostal spaces)
Lagging of the affected side
Displacement of the
trachea & mediastinum
toward the affected side
Syndrome of obstructive atelectasis
Percussion: dull over
the collapsed area
Vocal fremitus: absent
Breath sounds:
reduced, with or
without bronchial
breathing above the
collapsed area
Bronchophony: absent
Syndrome of incomplete
obstructive atelectasis
Diminished vocal fremitus
Dulled tympanic sound (air in alveoli -
incomplete closure of adductive bronchus)
Diminished vesicular breathing
(hypoventilation), local wheezing
(obstruction in trachea / main bronchi
stridor)
3 grades
of local obstructive atelectasis
Grade I
diminished possibility for air to
pass through a narrowed airway during
both respiratory phases:
Locally increased vesicular breathing or
harsh breathing sound
Fixed monophonic wheezes
Vocal fremitus & bronchophony present
3 grades
of local obstructive atelectasis
Grade II diminished possibility for air to pass
through a narrowed airway only during
inspiration & closure during expiration: inability
for air to leave obstructed area
Local tympany
Reduced vesicular breathing sound over
hypoventilated area
Fixed monophonic wheezes
Vocal fremitus & bronchophony present, but
diminished
3 grades
of local obstructive atelectasis
Grade III total closure of affected airway
& subsequent formation of complete
obstructive atelectasis (atelectatic silence)
Recurrent pneumonia - hypoventilation &
disturbed airway clearance
Syndrome of increased
thickening of pleural layers
(dry pleurisy)
Complaints:
Knifelike or shooting pain in the chest (increased
by deep breathing, coughing, laughing, thoracic
motions)
Dry cough
Subfebrile temperature
Generalized weakness
Objective Examination
Inspection
forced posture
(on the affected side
or sitting with fixation
to decrease the
movement of the
affected side)
superficial respiration
unilateral thoracic
lagging
Objective Examination
Palpation
Painful palpation of trapezoid & large
thoracic muscles (Sternbergs &
Pottengers signs):
a.
b.
irritation of central portion of pleural surface of
diaphragm pain at superior border of trapezoid
muscle, supraclavicular fossa
irritation of peripheral portion of pleural surface of
diaphragm pain in skin supplied by T-6
dermatome
May be palpable pleural friction rub
Decreased
vocal fremitus
Normal
Pleurofibrothorax
Objective Examination
Percussion & auscultation
Dulled tympanic
sound
Decreased mobility of
the lung border on the
affected side
Diminished vesicular
breathing
Pleural friction rub
Investigations
X-ray
- Limited mobility of the diaphragm
Blood test
- Moderate leukocytosis
Brochoobstructive syndrome
Syndrome of difficult air passage through the
bronchi due to obstruction of the bronchial
tree
Reasons:
Hypertrophy of the mucus-secreting
glands, increased number of goblet cells in
bronchi & bronchiole with a consequent
decrease in ciliated cells
Mucosal oedema & permanent structural
damage of the airway walls reduce the
caliber of the air passages
Increased mucus in the airways
CLINICAL FEATURES
Cough
Initially productive cough during winter, later - constant
Tightness in the chest in the
morning (disappeared by
coughing)
Expectoration
Sputum may be little, mucoid
and tenacious or cup of
mucopurulent / purulent
Breathlessness
expiratory dyspnea,
later episodes of sleep
apnea
OBJECTIVE EXAMINATION
Blue bloater:
overweight
edematous
cyanotic
RESPIRATORY SYSTEM
EXAMINATION
Inspection:
1) respiratory rate is normal or slightly
increased
2) there is no apparent usage of
accessory muscles
3) flapping tremor (asterixis)
Palpation: reduced expansion
Percussion: resonant sound
Auscultation
Hush breathing
(with prolonged
expiration)
Coarse ronchi &
wheezes
Respiratory failure
Definition
Inability to maintain PO2 (> 60 mm Hg) &
PCO2 (< 50 mm Hg) in arterial blood
Inadequate lung function for metabolic
requirements of individual
Respiratory failure classification
absence / presence hypercapnia
Respiratory failure
Type I
PO2 < 60 mm Hg
PCO2 < 50 mm Hg
Type II
PO2 < 60 mm Hg
PCO2 > 50 mm Hg
Respiratory failure
Acute
during minutes or
hours
Chronic
during days or
weeks
Respiratory failure
Type I
PO2 < 60 mm Hg
PCO2 < 50 mm Hg
Acute:
Acute asthma
Pulmonary embolus
Acute respiratory
distress syndrome
Pneumothorax
Pneumonia
Chronic:
Emphysema
Lung fibrosis
Lymphangitis
carcinomatosa
Right-to-left shunts
Anemia
Respiratory failure
Type II - asphyxia
PO2 < 60 mm Hg
PCO2 > 50 mm Hg
Acute:
Acute severe asthma
Inhaled foreign body
Respiratory muscle
paralysis
Flail chest injury
Sleep apnea
Brain-steam lessions
Chronic:
COPD
Primary alveolar
hypoventilation
Kyphoscoliosis
Ankylosing
spondiloartritis
Respiratory failure
Manifestations
Dyspnea
Tachycardia
Cyanosis
Edema (in late stage - cardiac failure)
Respiratory failure
Late stage
Respiratory failure
+
RV incompetence
Pulmonary hypertension due to Euler-
Liiestrand reflex
Euler-Liliestrand reflex
Insufficient lung
ventilation &
Alveolar hypoxia
Limited
blood supply
of Insufficiently
ventilated lung
Sclerotic changes in lungs
Pulmonary hypertension
Respiratory failure
Mechanisms
Obstructive type
Restrictive type
Mixed type
Respiratory failure
Obstructive type difficult air
passage through the bronchi:
Bronchitis
Bronchospasm
Trachea / large bronchus compression
Respiratory failure
Restrictive type limited lung
ability to expand & collapse:
Pneumosclerosis
Hydrothorax
Pneumothorax
Massive pleural adhesions
Kyphoscoliosis
Limited ribs mobility
Respiratory failure
Mixed type combination of
obstructive & restrictive types (with
or without prevalence of one of them):
Long-standing lung & heart diseases
Adult respiratory
distress syndrome
Respiratory failure - type I (PO2 < 60 mm Hg, PCO2
< 50 mm Hg) by development of pulmonary edema
from non-cardiogenic causes (damage to alveolar
epithelium & capillary endothelium)
Acute hypoxemic respiratory failure following a
systemic or pulmonary insult without evidence of
heart failure
Essentials of diagnosis:
Acute onset of respiratory failure
Bilateral radiographic pulmonary infiltrates
Absence of elevated left atrial pressure
PaO2/FiO2 (fractional concentration of inspired
oxygen) ratio < 200
Adult respiratory
distress syndrome (ARDS)
Risk factors:
Sepsis (1/3 of all ARDS)
Gastric contents aspiration
Shock
Infection
Lung contusion
Non-thoracic trauma
Toxic inhalation
Near-drowning
Multiple blood transfusions
Pancreatitis
Adult respiratory
distress syndrome (ARDS)
Rapid onset (12-48 hours after event)
Profound dyspnea (hyperventilation)
Labored breathing
Intercostal retractions
Bilateral crackles
BP falls
Chest X-ray: diffuse or patchy bilateral infiltrates
- rapidly confluent (fluffy homogeneous
shadows)
KURSK STATE
MEDICAL UNIVERSITY
DEPARTMENT OF PROPAEDEUTIC
OF INNER DISEASES
Respiratory pathology
Main clinical syndromes
Focal consolidation
In presence of large focus,
if it is located peripherally
(over the limited part of the
chest):
vocal fremitus increased
dull percussion sound
vesiculobronchial or
bronchial breathing,
dry / consonating moist
rales,
crepitation
Lobar consolidation
Lagging of the affected side.
Dyspnoea.
Vocal fremitus is increased.
Dulled-tympanic / dull
percussion sound.
Auscultation diminished
vesicular breathing,
crepitation indux,
bronchial breathing,
increased bronchophony
Cavity in the lung
Unilateral thoracic lagging
Vocal fremitus
increased
Percussion: tympanic /
metallic sound; crackled pot sound
Auscultation: bronchial
(amphoric / cavernous)
breathing;
resonant moist rales;
gutta cadens (falling
drop sound)
Obstruction of the bronchi
Blue Bloater:
overweight,
edematous,
cyanotic.
Obstruction of the bronchi
Inspection:
1) respiratory rate is normal or slightly
increased.
2) there is no apparent usage of accessory
muscles.
3) flapping tremor (asterixis)
Palpation: hyperinflated chest with reduced
expansion.
Percussion: resonant sound.
Obstruction of the bronchi
Hush breathing
(prolonged expiration)
Coarse ronchi &
wheezes
may be
non-consonating
crackles
(change in location / intensity
after a deep and productive
cough)
Emphysema
Pink puffer
Tachypnea with
prolonged expiration
trough pursed lips /
expiration with
grunting sound
Lips tightly apposed
at height of inspiration,
Lips held narrowly apart during
expiration
Emphysema
Asthenic constitution with weight
loss.
Barrelshaped chest (increased
anteroposterior diameter).
Use of accessory muscles in
respiration.
Tachypnea.
Prolonged expiration
through pursed lips.
Lower intercostal spaces
retract with each
inspiration.
Neck veins distended during
expiration.
Emphysema
Palpation:
Increased rigidity
Decreased vocal
fremitus
Diminished excursion
Emphysema
Percussion:
Hyperresonant (bandbox) sound
Upper borders protruded
Lower borders: descendent
limited mobility
Decreased liver & cardiac dullness
Auscultation: diminished vesicular
breathing
(diffuse dry rales in bronchitis)
Obstructive atelectasis
Occlusion of the
bronchus.
Symptoms of obstructive
atelectasis.
Displacement of
mediastinum toward the
affected side.
Displacement of the
trachea.
Hydrothorax
Accumulation of
fluid in the pleural
cavity
Compressive
atelectasis
Hydrothorax
Asymmetry of the
chest
Tracheal
displacement away
from the fluid
Lagging of the
affected side
Protrusion of the
intercostal spaces
Hydrothorax
Palpation
Vocal fremitus
Increased over the
compressed lung
Diminished or
not transmitted at
the area of the fluid
accumulation
Hydrothorax
Percussion
Dullness over the area of fluid.
Damoiseaus curve.
Garlands triangle on the affected side characterized by
a dulled tympanic sound. It corresponds the lung
pressed by the effusion compression atelectasis.
Rauchfuss-Grocco triangle is found on the healthy side
and is a kind of extension of dullness determined on the
affected side. The sides of the triangle are formed by the
diaphragm and the spine, while the continued
Damoiseaus curve is the hypotenuse.
Absence of the Traubes space in the left sided pleuritis
Hydrothorax
Percussion
Garlands
triangle
Damoiseaus
Curve
Effusion
RauchfussGrocco triangle
(due to
displacement of
the
mediastinum)
Hydrothorax
Auscultation
In the region of accumulated
fluid -diminished vesicular
breathing or not auscultated
Above the effusion - bronchial
breathing - echo like
(compressive atelectasis)
Bronchophony over the
effusion is not determined
Dry Pleurisy
Complaints:
Pain in the chest ( increased during
breathing and coughing)
Dry cough
Subfebrile temperature. General
weakness.
Objective Examination
Inspection
forced posture (on
the affected side
or sitting)
superficial
respiration
unilateral thoracic
lagging
Objective Examination
palpation and percussion
Painful palpation of trapezoid and large
thoracic muscles (Sternbergs and Pottengers
signs).
decreased mobility of the lung border on the
affected side
Objective Examination
Auscultation
pleural friction rub
Pneumothorax
Presence of gas in the pleural
space
Complaints
Pain in the chest
Dyspnea
Dry cough
Palpitation
Clinical manifestations
Inspection.
asymmetrical
chest.
Displacement of
the trachea to the
opposite side
lagging of the
affected side
intercostal spaces
are increased and
smoothed
Clinical manifestations.
Palpation.
Subcutaneous
emphysema (in
traumatic
pneumothorax )
vocal fremitus is
decreased or absent
Clinical manifestations.
Percussion.
tympanic percussion sound
shift of the mediastinum to the opposite side
Clinical manifestations.
auscultation.
diminished vesicular
breathing or absent
Connection of the pleural
cavity with bronchus
amphoric breathing
In open pneumothorax
metallic breathing
