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Pan Dianzhu
The respiratory department of the
first affiliated hospital of liaoning
medical college
1
Common respiratory symptoms
• Cough
• Expectoration
• Hemoptysis
• Chest pain
• Dyspnea
• Cyanosis
2
What is chest pain?
Chest pain is one of the common symptoms
and often likely to be accompanied by fear of
heart disease.
we shall pay more attention to the history
taking because there may be no physical signs
associated with chest pain.
3
Attributes of chest pain
Provocative-palliative (Influential)
factors
Quality /feature
Exertional, respiration,
food intake,
administration
(pricking /bursting /pressing
/blunt/colic/distention/burning/stabbing/
crushing /throbbing)
Region /location
Severity
Timing/ Duration
–
angina pectoris
myocardial infarction
Referred pain
4
Diagnostic approach
First : assess the risk for major vascular
disease and acute coronary events
Second :develop the differential diagnosis of
noncardiovascular explanations
Acute coronary events may be missed in younger patients,
women, and people with normal ECGs, so careful risk factor
assessment and a high index of suspicion are necessary.
Chest pain
Chest pain with tenderness
Deep retrosternal or precordial pain
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Chest pain with tenderness
The distinction between respiratory pain with
tenderness and chest pain with tenderness is
somewhat artificial; the conditions may present in
either manner, or with both pain at rest and with
respirations.
The patient may recognize the pain as superficial
,sharp, and well localized. Almost always, this type
of pain is accompanied by localized tenderness. The
structures involved are the skin and subcutaneous
tissues, the fat, skeleton, or the breasts.
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Skin and Subcutaneous Structures
Inflammation, trauma, and neoplasm in these tissues offer no special
diagnostic problems, provided that they are considered and searched
for. The presence of bruises, lacerations, ulcers, hematomas, masses,
or tenderness is usually diagnostic.
7
Chest Wall Syndrome
Ask your patient to point to the region of pain.Next, perform four
maneuvers: (1) Palpate the chest wall for tenderness by applying firm,
steady pressure to the sternum, the costosternal junctions the intercostal
spaces, the ribs, and the pectoralis major muscles and their insertions.
(2) Flex the arms horizontally by lifting one arm after the other
by the elbow and pulling it across the chest toward the contralateral
side, with the head rotated toward the ipsilateral side . (3) Extend the
neck by having the patient look toward the ceiling as the arms are
pulled backward and slightly upward. (4) Exert vertical pressure on the
head. If any of these tests reproduces the patient's pain, review the
history to ascertain whether your patient forgot recent minor trauma or
strain of the chest muscles.
8
Costochondritis of Rib and Tietze Syndrome
This is a common cause of chest pain. The onset may be sudden or
gradual. The pain is usually dull. It may be intensified by respiratory
motion and movements of the shoulder girdle . The sole physical sign is
tenderness at the costochondral junction of bone and cartilage . There is
no swelling and there are no X-ray findings. In Tietze syndrome the pain
is accompanied by tender, fusiform
swelling of one or more
costicartilages, often that attached to the second rib. The overlying skin
is reddened. Pain may radiate to the shoulder, neck, or arm. There is no
lymphadenopathy. It may subside in a few weeks or persist for months.
The swelling may persist for months after the pain and tenderness
subside. The cause is unknown and the condition must be distinguished
from osteitis , periostitis , rheumatic chondritis , and neoplasm of the
ribs.
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Fractured Rib
The history may suggest pleurisy. The patient complains of pain in the
chest with breathing. Movement of rib fragments causes well-localized,
sharp,lancinating pain. Inspiration is limited and palpation discloses
point tenderness on a rib. There may be a history of direct chest trauma;
if not, ask about recent severe coughing which the patient may not
recognize as a cause of fracture. The edges of the fracture may be felt,
but bone crepitus is absent when the fragments are well opposed. With
one hand supporting the back, compression of the sternum with the other
elicits pain at the untouched fracture site
(Figure 1-1). The diagnosis is made readily when the patient gives a
history of trauma to the thorax.Fractures of several contiguous ribs are
usually caused by external violence; the chest wall may be so weakened
as to produce the flail chest.
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Cough Fracture
Any rib from the fifth to the tenth is likely to break. The fracture is
usually anterior to the attachments of the serratus anterior that pulls the
rib upward , and posterior to the fixations of the abdominal external
oblique muscle that pulls the rib downward creating a shearing force
on the rib. A single cough is not enough to produce fracture; breaking is
attributed to the fatigue ( stress fracture ) from repeated coughing.
Cough fracture was described by Robert Graves sometime before 1833.
The patient has been coughing for some time and pain begins to occur
with respiratory movements and coughing. The typical signs of fracture
of a rib are present. When palpation of the ribs is not .performed, the
condition is usually diagnosed as pleurisy.
12
Tender Sternum
Many normal persons have slight tenderness in the lower third of the
sternum, elicited when the finger is drawn over it.
Fractured Sternum
The profile of the sternum usually has abnormal angulation, the site of
which is tender. Pain prompts the patient to bend the head and thorax
forward with the shoulders rotated inward.
13
Thrombophlebites of the Thoracoepigastric
Vein (Mondor Disease)
The pain is felt along the anterolateral chest wall with radiation to the
axilla or inguinal region. A tender cord, 3—4mm in diameter, is usually
palpable and often visible when the skin is stretched. The disease is selflimited and lasts 2—4weeks.
Tender Muscle in the Thorax
Frequently, a tender muscle is mistaken by the patient and the physician
for intrathoracic disease.
14
Fat
In a rare form of obesity, symmetrical fat lobuleson the trunk and limbs
are painful and tender. The condition is known as adiposis dolorosa (
Dercum disease) . If inflammation is present, consider one of the forms
of panniculitis.
Breasts
Painful lesions are fissures of the nipples, cystic mastitis, fibroadenosis,
acute breast abscess, and,occasionally, breast carcinoma.
Xiphisternal Arthritis
The pain may be ascribed to myocardial ischemia unless the xiphoid
cartilage is palpated and the pain reproduced.
15
Deep retrosternal or precordial pain
Deep visceral pain behind the sternum or in the precordial region
is not specific for cardiac disorders. Rather, it is the primary
symptom for the entire region supplied by dermatomes Tl to T6.
The neuroanatomy of the region furnishes the structural basis for
this concept, which clinical experience confirms.
16
Pathophysiology
17
Clinical Occurrence
Congenital hypertrophic cardiomyopathy. Endocrine retrostemal thyroid. Idiopathic
esophageal spasm , gastroesophageal reflux. Inflammatory/Immune esophagitis,
pericarditis, pleuritis, myocarditis , postcardiotomy syndrome , pancreatitis,
cholecystitis , gastritis . Infectious infectious pericarditis and pleuritis, myocarditis,
subphrenic abscess. Metabolic/Toxic acid or alkali ingestion . Mechanical/Trauma
pneumothorax, esophageal rupture, esophageal obstruction ( extrinsic, foreign body,
neoplasm, web, or ring), esophageal diverticulum , gastric perforation . Neoplastic
carcinoma ( primary or metastatic ) of the esophagus, pericardium, lung, mediastinum,
pleura, lymphoma . Thymoma . Teratoma ; testicular cancer . Neurologic postherpetic
neuralgia , diabetic radiculopathy , intercostal neuritis . Psychosocial somatization
disorder , panic attack , hypochondriasis ,
Malingering , Munchausen syndrome. Vascular myocardial ischemia ( coronary
atherosclerosis , spasm, embolism, thrombosis, vasculitis), pulmonary embolism and
infarction, aortic dissection.
.
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But the pain may extend to the upper band of Tl to T4 through
posterior, connections in the sympathetics, so that the pattern
may be indistinguishable from that arising above the diaphragm.
To determine the cause of deep chestpain: ( 1 ) Ask the location
of the pain, accepting the location of the pain as indicating only
that the source is somewhere in the six-dermatome band (the
myocardium, pericardium, aorta, pulmonary artery, mediastinum,
esophagus, gallbladder, pancreas, duodenum, stomach, or
subphrenic region). (2) Ask the patient to state the intensity of
the pain on a scale of 1 to 10. (3) Shorten the list of possibilities
by carefully searching for provocative-palliative factors and
timing. (4) Make appropriate tests to distinguish between the
disorders on the shortened list.
19
Cardiovascular disease
• Cardiac ischemia pain is a dull,crushing retrosternal
pain, often radiating to the jaw or arms, building up
over a few minutes and may brought on by exercise,
emotion, or cold weather, resolving on resting or with
glyceryl trinitrate(GTN),
• Dissecting aortic aneurysm cause a tearing
interscapular pain with sudden onset.
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The radiating pain of angina pectoris
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Respiratory disease
• Pleuritic chest pain is a sharp pain that is worse on
deep inspiration, coughing, or movement.
• Spontaneous pneumothorax and pulmonary embolism
usually cause sudden onset of pleuritic pain (the
patient often remembers exactly what they were doing
at the time).
• Pulmonary disease causes unilateral pain which the
patient can often localize specifically.
22
Chest pain: accompany symptoms
• Cough, sputum and/or fever
– Respiratory diseases
• Dyspnea
– Severe pneumonia, pneumothorax, pleurisy, pulmo
embolism
• Hemoptysis
– Carcinoma, pulmo embolism
• Shock
– myocardial infarction, dissecting aneurysm
(rupture ), large area pulmo embolism
• Dysphagia
– Esophageal disease
23
Common respiratory symptoms
•
•
•
•
Cough
Expectoration
Chest pain
Hemoptysis
• Dyspnea
• Cyanosis
24
25
Dyspnea results from abnormalities of gas
exchange ( decreased oxygenation,
hypoventilation, hyperventilation) , and
increased work of breathing because of
changes in respiratory mechanics and/or
anxiety.
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Definition
subject feeling: insufficiency of air、breathing Exertion
objective manifestation:
respiratory movement Exertion
buccal respiration、flaring of alae nasi
orthopnea
cyanosis
accessory respiratory muscles partake action
Changes in breathing frequency, vertical extent and rhythm
27
The process of gas exchange
arteriole
alveoli capillary network
venule
alveoli
capillary
pulmonary alveoli
O2
O
CO2
28
reduced hemoglobin turn into oxyhemoglobin
causes
air（oxygen）
all over the
body
lung
blood
heart
29
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Dyspnea: causes
• Respiratory system
–
–
–
–
–
Obstruction: asthma, COPD, tumor
Pulmo Diseases: pneumonia, interstitial lung disease,
Chest wall or pleural: pleurisy, pneumothorax, trauma
neuro-muscles: poliomyelitis , myasthenia gravis)
Diaphragma movement disorder: obviously elevated
pressure in abdominal cavity
• Cardiovascular system
– Heart failure
– Pulmo embolism
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Dyspnea: causes
• Poisoning
– ketoacidosis
• Central nervous system
– Cerebral tumor , trauma, abscess,
hemorrhage, encephalitis, meningitis
• hematological system
– Severe anemia
33
Mechanism and manifestation
respiratory dyspnea
Respiratory diseases → ventilation,
ventilatory dysfunction → O ↓and/or CO ↑
2
2
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CLINICAL OCCURRENCE
• Decreased Fraction of Inspired Oxygen
High altitudes. Qinghai-Tibet Plateau
• Airway Obstruction
Larynx and Trachea infections (laryngeal diphtheria , acute
laryngitis, epiglottitis , Ludwig angina ) ,
angioedema , trauma ( hematoma or laryngeal edema) ,
neuropathic ( abductor paralysis of vocal cords ) ,
foreign body, tumors of the neck ( goiter ,carcinoma, lymphoma
, aortic aneurysm) , ankylosis of the cricoarytenoid joints ;
Bronchi and Bronchioles (acute and chronic bronchitis, asthma,
retrosternal goiter , aspirated foreign bodies, extensive
bronchiectasis, bronchial stenosis).
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CLINICAL OCCURRENCE
• Abnormal Alveoli
Alveolar Filling pulmonary edema from left ventricular
failure or acute lung injury, pulmonary infiltrations
(infectious and aspiration pneumonia, carcinoma,
sarcoidosis, pneumoconioses) , pulmonary hemorrhage,
pulmonary alveolar proteinosis. Alveolar Destruction
pulmonary emphysema, pulmonary fibrosis, cystic disease
of the lungs. Compression of the Alveoli atelectasis,
pneumothorax, hydrothorax,abdominal distention.
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pneumonia
Alveolar Filling with Inflammatory exudate
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CLINICAL OCCURRENCE
• Restrictive Chest and Lung Disease
Paralysis of the respiratory muscles ( especially the
intercostals and the diaphragm) , thoracic deformities
( kyphoscoliosis , thoracoplasty ) , scleroderma of the
thoracic wall, pulmonary fibrosis.
• Abnormal Pulmonary Circulation
Pericardial tamponade , pulmonary artery stenosis ,
arteriovenous shunts in heart and lungs, pulmonary
thromboemboli and infarction, other emboli( fat, air,
amniotic fluid ) , arteriolar stenosis ( primary pulmonary
hypertension-Ayerza disease, irradiation) .
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PE triad
Dyspnea
Chest pain
Hemoptysis
pulmonary thromboembolism
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CLINICAL OCCURRENCE
• Oxyhemoglobin Deficiency
Anemia, carbon monoxide poisoning
( carboxyhemoglobinemia
) , methemoglobinemia and sulfhemoglobinemia, cyanideand
cobaltpoisoning.Abnormal Respiratory Stimuli
• Pain from respiratory movements
exaggerated consciousness of respiration ( effort
syndrome) , hyperventilation syndrome, secondary
respiratory alkalosis (increased intracranial pressure,
metabolic acidosis ).
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CLINICAL OCCURRENCE
• Paroxysmal Dyspnea
There is a transient increase in pulmonary capillary
pressure associated with redistribution of fluid from
edematous extremities to the lungs with recumbency, or
ischemia-induced transient decreases in left ventricular
performance. This is characterized by sudden paroxysms
of breathlessness. When sleep is interrupted, it is termed
paroxysmal nocturnal dyspnea. These attacks are attended
by orthopnea and coughing. The patient often finds that
walking a few minutes relieves the dyspnea, permitting the
patient to resume sleep. This can be distinguished ''from
true asthma by finding that the lungs do not clear when the
patient inhales a bronchodilator.
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CLINICAL OCCURRENCE
• Orthopnea
Redistribution of extracellular fluid from the periphery to the
lungs, elevation of the diaphragm from obesity or ascites, and
muscular weakness all contribute to dyspnea when lying flat.
Orthopnea is dyspnea associated with recumbency leading the
patient to assume a resting position that elevates the head and
chest. Many patients experience awakening severely short of
breath in the supine position (paroxysmal nocturnal dyspnea).
Severity may be judged by the number of pillows the patient
requires to achieve a comfortable position. Orthopnea is often
overlooked if the patient does not mention it and is only
examined in the seated position; the physician must
specifically ask about it or observe the patient supine.
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Respiratory Dyspnea
• Inspiratory dyspnea
____obstruction in large airway
– Three depression sign
• depression in suprasternal fossa, supraclavicular fossa,
intercostal space
• Expiratory dyspnea
—obstruction in small airway or alveolar elasticity decreased
– Prolonged expiratory time
– Expiratory rhonchi
• Mixed dyspnea
____deficient gas exchange
– Respiratory rate increased
– Shallow breathing
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supraclavicular
fossa
suprasternal fossa
intercostal space
Three depression sign
44
Cardiac dyspnea ____ Heart failure
Mechanism of left heart failure

Pulmo edema

Alveolar tension increased
receptor
diffusion capacity decreased (blood retention)
stimulating stretch
excitation of vagus nerve
excitation of
respiratory center

Alveolar elasticity decreased
vital capacity decreased

Increased pressure of pulmo circulation
stimulating
respiratory center
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Features of dyspnea by left heart failure
• Underlying diseases
• Mixed dyspnea
exercise and Position related dyspnea
• crackles or rhonchi in both lungs
• Relief of symptoms after digitalis, diuretic,
vasodilator agent used
46
Nocturnal paroxysmal dyspnea
Characteristics
• Awoken due to chest tightness or dyspnea
• Forced sitting position or orthopnea
• Severe sweat
• Pink frothy sputum
Cardiac asthma
• crackles or rhonchi in both lungs
• Tachycardia
• gallop rhythm
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Nocturnal paroxysmal dyspnea
Mechanism
Elevated excitation of vagus nerve

Contraction of coronary artery
myocardial ischemia

Contraction of bronchiole

Vital capacity decreased in supine position

Returned blood volume increased

Sensitivity of respiratory center decreased
decreased alveolar ventilation
pulmo edema
reaction
after obvious hypoxia
48
Poisoning dyspnea
• Underlying diseases of metabolic acidosis
(uremia, diabetic ketoacidosis )
• deep breathing (Kussmaul breathing)
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Other dyspnea
Nervous and psychogenic dyspnea
Cerebral tumor , trauma, abscess, hemorrhage,
encephalitis, meningitis
Hematologic dyspnea
Severe anemia methemoglobinemia
large blood loss
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Dyspnea: accompany signs (1)
• Rhonchi
–
–
–
–
Asthma
Acute left heart failure (cardiac asthma)
Foreign body in large airway
Acute laryngeal edema
• Chest pain
–
–
–
–
–
Infection
Pneumothorax
Pulmo embolism
Lung cancer
Acute myocardial infarction
51
Dyspnea: accompany signs (2)
• Fever
– Infection
• Cough and sputum
– COPD
– Infection
– Left heart failure
• Unconsciousness
– CNS disorder
– Uremia
– diabetic ketoacidosis
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Questions:
1.the common causes of hemoptysis?
2.the common causes of dyspnea?
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