Symptoms and signs of
pulmonary diseases
Symptoms of pulmonary
diseases
Dyspnea – the sensation of breathlessness that is
excessive for any given level of physical activity.
- D of pulmonary origin- disorders of the airways,
lung parenchyma, pleura, respiratory muscles or
chest wall.
-D of extrapulmonary origin: heart disease (heart
failure), shock, anemia, abdominal distension,
physical deconditioning or anxiety.
-paroxysmal nocturnal dyspnea and orthopnea
(dyspnea on recumbency) usually are caused by LV
dysfunction, but may also be noted in asthma and
chronic obstructive pulmonary diseases.
Persistent cough
Is always abnormal; the cough reflex may be triggered by
stimulation of the receptors located in the tracheobronchial
tree, the upper airway, sinuses, pleura, pericardium,
esophagus, stomach and diaphragm.
Chronic, persistent cough often caused by cigarette
smoking, asthma, bronchiectasis, chronic obstructive
pulmonary disease
Sometimes caused by drugs (ACE inhibitors), cardiac
disease and psychogenic factors.
An upper respiratory tract infection occasionally induces
cough that may be persistent for 6-8 weeks.
Complications of severe cough: worsening of
bronchospasm, vomiting, urinary incontinence, occasionally
syncope.
Stridor- a crowing sound during breathing caused by
turbulent airflow through a narrowed upper airway;
-inspiratory stridor suggests extra thoracic
airway obstruction
-expiratory stridor suggest intrathoracic airway
obstruction
-inspiratory and expiratory stridor occurring
together suggests fixed obstruction anywhere in
the upper airway
Wheezes – continuous musical or whistling noises
caused by turbulent airflow through narrowed
intrathoracic airways.
Most complaints of wheezing are due to asthma.
Hemoptysis
The expectoration of blood or blood tinged sputum
Often the first indication of serious
bronchopulmonary disease
The history usually distinguishes it from
hematemesis and from nasopharyngeal bleeding.
Bright red, frothy blood implies a
bronchopulmonary origin of bleeding
Most common causes: bronchitis, bronchiectasis;
carcinoma must always be excluded.
Massive hemoptysis= coughing up of more than
200- 600ml of blood in 24 h; usually caused by TBC
or other suppurative parenchymal disease.
Signs of pulmonary
diseases
Tachypnea- rapid, shallow breathing; defined as a
respiratory rate in excess of 18/min
Hyperventilation- an increase of the amount of
air entering the alveoli, causing hypocapnia
(defined as arterial PCO2< 40mmHg).
Thoracic asymmetry at rest- observed in
scoliosis, chest wall deformity, severe fibrothorax;
Symmetrically reduced chest expansion
during deep inspiration- neuromuscular diseases.
Asymmetric chest expansion during inspiration-
unilateral airway obstruction
Signs of pulmonary
diseases
Paradoxic pulse: a fall in systolic arterial
BP of 10 mmHg or more in inspiration (the
arterial BP normally falls about 5 mmHg in
inspiration).
This exaggerated response occurs in severe
asthma or emphysema, upper airway
obstruction, pulmonary embolism,
constrictive pericarditis or tamponade,
restrictive cardiomyopathy.
Signs of pulmonary
diseases
Cyanosis- bluish coloration of the skin or
mucous membranes caused by increased
amount (>5 g/dL) of unsaturated Hb in the
blood.
Central cyanosis- usually caused by
hypoxemia from respiratory failure or right-
to-left shunting, is apparent on inspection of
the mucous membranes;
Peripheral cyanosis- more likely due to
nonrespiratory causes (reduced cardiac
output and vasoconstriction).
Digital clubbing- the anteroposterior thickness of
the index finger at the base of the fingernails
exceeds the thickness of the distal interphalangeal
joint.
Symmetric clubbing occurs in lung cancer,
bronchiectasis, lung abscess, pulmonary
arteriovenous malformation, idiopathic pulmonary
fibrosis and cystic fibrosis; rarely seen in chronic
obstructive pulmonary disease and chronic asthma.
Nonpulmonary causes of symmetric clubbing
include congenital heart disease, carditis, cirrhosis
and inflammatory bowel disease.
Clubbing may be congenital.
Signs of pulmonary
diseases
Hyper resonance to percussion occurs in
diseases accompanied by hyperinflation
(asthma, emphysema), and in
pneumothorax.
Dullness to percussion- in thickening of
the chest wall or pleura, pleural
effusion, atelectasis, parenchymal
infiltration or consolidation, elevation of
the diaphragm or displacement of the
abdominal contents into the thorax.
Signs of pulmonary diseases
Vesicular breath sounds are normal soft, low-
pitched sound heard at the periphery of the lung.
Harsh bronchial (tracheal ) breath sounds in
areas where vesicular sounds are normally heard
implies consolidation, compression, or
infiltration of the lung
Diminished breath sounds imply inspiratory
obstruction to airflow in large airways, pleural
disease (especially effusion), pneumothorax,
marked obesity.
Signs of pulmonary diseases
fine crackles are heard in interstitial diseases, early
pneumonia or pulmonary edema, patchy atelectasis;
coarse crackles are heard late in the course of
pulmonary edema or pneumonia.
Tactile (vocal) fremitus- voice vibrations in the chest
wall.
Localized reduction in fremitus- in pleural effusions,
pneumothorax, thickening of the chest wall.
Increased fremitus- suggests lung consolidation.
Pulmonary function tests
To measure the ability of the respiratory system to
perform gas exchange by assessing its ventilation,
diffusion and mechanical properties.
Indications for pulmonary function testing include
the following:
1. Evaluation of the type and degree of pulmonary
dysfunction
2. Evaluation of dyspnea, cough and other
symptoms
3. Early detection of lung dysfunction
4. Surveillance in occupational settings
5. Follow-up of response to therapy
6. Preoperative evaluation
7. Disability assessment.
Spirometry and measurement of lung volumes
allow determination of the presence and severity of
obstructive and restrictive pulmonary
dysfunction.
The hallmark of obstructive pulmonary
dysfunction: reduction in airflow rates (asthma,
chronic bronchitis, emphysema, upper airway
obstruction).
Restrictive pulmonary dysfunction –
characterized by reduction in lung volumes
(pulmonary infiltrates, lung resection, pleural
diseases, chest wall disorders).
Tests
Forced vital capacity (FVC): the volume of gas
that can be forcefully expelled from the lungs after
maximal inspiration
Forced expiratory volume in 1 sec. (FEV1):
the volume of gas that can be expelled in the first
second of the FVC maneuver.
Peak expiratory flow rate (PEFR): the maximal
airflow rate achieved in the FVC maneuver
Maximal voluntary ventilation (MVV): the
maximum volume of gas that can be breathed in 1
minute (usually measured for 15 sec and multiplied
by 4)
Lung volumes
Slow vital capacity: the volume of gas that can
be slowly exhaled after a maximal inspiration
Total lung capacity (TLC): the volume of gas in
the lungs after a maximal inspiration
Functional residual capacity (FRC): the volume
of gas in the lungs at the end of a normal tidal
expiration
Residual volume (RV): the volume of gas
remaining in the lungs after maximal expiration
Expiratory reserve volume (ERV): the volume
of gas representing the difference between
functional residual capacity and residual volume.
Obstructive dysfunction is graded according to
the reduction in the ratio of forced expiratory
volume in 1 sec (FEV1) to forced vital
capacity (FVC).
Restrictive dysfunction is graded by reduction
to the FVC or total lung capacity, comparing
observed values with predicted values.
Predicted values are derived from studies of
normals and in general vary with gender, age and
height.
Spirometry provides a spirogram that displays
time versus expired volume and an expiratory flow-
volume curve that plots expiratory volume versus
expiratory airflow rate.
If airway obstruction is evident, spirometry is
repeated 10-20 minutes after an inhaled
bronchodilator is administered.
Arterial blood gas analysis is indicated whenever
a clinically important acid- base disturbance,
hypoxemia or hypercapnia is suspected.
Oximetry provides a mean of monitoring of
oxyhemoglobin saturation with oxygen.
Bronchoscopy- uses a fiberoptic bronchoscope used
for:
- evaluation of airways,
- diagnosis and staging of bronchogenic carcinoma,
- evaluation of hemoptysis,
- biopsy of lung infiltrates,
- diagnosis of pulmonary infections,
- removal of retained secretions and foreign bodies
of the airways.
