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Lecture IV
PHYSICAL ASSESSMENT
Evaluation of the respiratory system, especially of the lungs, is carried out by the process
of auscultation and percussion. While diagnosing the ailments of the respiratory system,
a physician inspects the symmetry, color and movements of the thoracic cavity.
He determines the respiratory rate which, in normal case, should range from 16 to 20.
The physician also uses a stethoscope and listens for any extra sound like rales, rhonchi,
or wheezes. He palpates the back and checks for the presence of fremitus. Percussion of
the chest allows the physician to find out if there is any dull sound or edema present.
The physician asks the patient if he/she experiences any shortness of breath or dyspnea.
PATHOLOGY
Bronchiectasis
Bronchiectasis is characterized by the dilation of the bronchi, especially the lower lungs.
Mucopurulent sputum (sputum mixed with mucus and pus) and hemoptysis are the
associated symptoms. Treatment includes mucolytics, bronchodilators, antibiotics, and
postural drainage.
Bronchopneumonia
Bronchopneumonia is an infectious inflammatory condition of the lungs, caused by a
variety of agents. Bronchopneumonia affecting only one side of the lung is referred to as
lobar pneumonia, while that affecting both sides of the lungs is called bilateral or double
pneumonia. Due to the pathological engorgement, the lungs may develop solidification or
consolidation. The condition is characterized by chest pain, mucopurulent sputum, and
hemoptysis.
Pneumocystis carinii pneumonia (PCP) is an important consideration in this regard.
The causative fungus resides in the normal flora and causes no harm as long as the
individual remains healthy. However, with the compromise of the immune system,
the organism becomes opportunistic. Physicians diagnose the condition with the help of a
biopsy and lavage.
COPD
COPD stands for chronic obstructive pulmonary disease or it can be also termed as
COLD (chronic obstructive lung disease) and are also used as synonyms. However,
COLD should not be mistaken for common cold that we usually get infect with. Hence,
generally, COPD term is used. This is a respiratory disorder characterized by cough and
dyspnea due to the obstruction in the air passages. The three major diseases, which come
in this category are asthma, chronic bronchitis, and emphysema.
Asthma is characterized by the spasms of the bronchus. These bronchospasms can by
paroxysmal (sudden and violent in nature) causing dyspnea. They can also be
characterized by productive cough and thickening of the epithelial cells of the bronchial
passages. Causes of this disease can be exposure to allergens and irritants, stress, cold,
and exercise. Treatment includes administration of mucolytics and bronchodilators.
Chronic bronchitis, as is evident from the name itself, is the chronic inflammation of the
bronchi. It is primarily caused by the smoking and air pollution, though viruses and
bacteria can also be the contributing factors. This is characterized by swelling of the
mucosa, heavy and productive cough, chest pain, exercise intolerance, wheezing, and
shortness of breath. Bronchodilators and expectorants are required to expand the air
passages.
Long-term heavy smoking or other disease, such as asthma, tuberculosis, or chronic
bronchitis, may cause the alveoli to lose its elasticity. The air sacs expand, but they are
unable to contract, and the residual air gets trapped inside. This results in a 'barrel chest'
appearance and is referred as emphysema. People afflicted with emphysema often suffer
from another condition called orthopnea, i.e. they find it easier to breathe while sitting or
standing.
CROUP
Croup refers to an acute obstruction of the lungs caused by allergens, infection, foreign
body, or new growth. It is characterized by a resonant, barking cough, laryngeal spasms,
suffocation or difficulty in breathing, and the formation of a membrane.
Cystic fibrosis
Cystic fibrosis is a hereditary and systemic disorder, which affects the exocrine glands.
The condition is characterized by the production of viscous mucus, which blocks the
bronchioles. The treatment includes use of aerosols and postural drainage. This is a very
fatal disease and almost results in loss of life.
Lung cancer
Smoking is the leading cause of lung cancer, and the most commonly affected site is the
epithelium of the bronchial passage. The lung cancer of the bronchial passage is called
bronchogenic carcinoma. This is characterized by the rapid division of the basal cells
located at the base of the epithelium and metastasis to the other areas of the body.
Treatment includes surgery, radiation, and chemotherapy.
Pleural effusions
Pleural effusions refer to the excessive accumulation of the fluid in the pleural cavity.
Congestive heart failure, ascites, and infectious lung diseases can be conducive to pleural
effusions. Physicians generally diagnose the pleural effusions with the help of what we
call auscultation and percussion. Auscultation is listening to the sounds of the chest
cavity with the help of a stethoscope, while percussion refers to tapping the chest with
the fingers to determine the size position, and consistency of the underlying structures.
Different types of pleural effusions are:
1. Empyema: Pus in the pleural space
2. Hydrothorax: serum in the pleural space
3. Hemothorax: blood in the pleural space
4. Pneumothorax: air in the pleural space
5. Pyopneumothorax: pus and air in the pleural space
Treatment often includes thoracocentesis or thoracentesis to remove the excess fluid.
Rales, rhonchi, and wheezes:
Rales are abnormal crackling sounds heard on inspiration produced by the passage of air
that contains moisture. Rales are noted by a stethoscope and indicate a pneumonia like
condition.
Accumulation of fluids in the airways produces this abnormal chest sound, which
resembles snoring. These snoring sounds are known as rhonchi.
Partially obstructed airways produce a whistling musical sound during breathing called
wheezing. It may be caused by general obstruction of the airways (as in asthma and
COPD) or local obstruction (as in tumors).
Respiratory distress syndrome
Lungs require surfactants in order to fill with air and expand, also known as compliance.
Surfactants assist in decreasing the surface tension of the alveoli. Deficiency or
impairment of the surfactants may cause the collapse of the alveoli and inhalation
becomes difficult. When this condition is found in the infants, this is known as IROS
(infant respiratory distress syndrome) or HMO (hyaline membrane disease). IROS or
HMO is common among the premature infants or the infants born of the diabetic
mothers. ARDS (adult respiratory distress syndrome) is caused by the impairment of the
surfactants or accidental inhalation of foreign substances, water, smoke, or chemical
fumes.
Stridor
Blockages of the throat, voice box, and windpipe produce a crowing sound during
breathing, especially during inhalation, which is known as stridor. The sound is caused
by a turbulent airflow through a narrowed airway. It may be due to the epiglottitis, tumor,
or edema.
Tuberculosis
Aerosol transmission or particles of dry sputum containing the tuberculosis (TB)
organism, Mycobacterium tuberculosis cause the spread of the disease. These organisms
can remain viable and infectious for a period of 6 to 8 months even when they arc outside
the body. This disease develops into three stages: primary tuberculosis, formation of
granulomas, and the immunocompromised state of full-blown disease. This lung disease
can infect even the meninges, bones, genital tract, and the peritoneum.
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