Main Clinical Syndromes in Respiratory System

7/24/2019 Main Clinical Syndromes in Respiratory System

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Kursk State Medical UniversityKursk State Medical University

Propaedutics of InternalPropaedutics of Internal

Diseases DepartmentDiseases Department

Main Clinical Syndromes

in Respiratory Medicine


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Syndrome of focal consolidationSyndrome of focal consolidation

of pulmonary tissueof pulmonary tissue

Causes:Causes:

PneumoniaPneumonia (filling of alveolai with(filling of alveolai with

inflammatory fluid & firin!inflammatory fluid & firin!"ung infarction"ung infarction (filling of alveolai with lood!(filling of alveolai with lood!

Pneumosclerosis# carnificationPneumosclerosis# carnification(connective(connective

tissue growing!tissue growing!$umor$umor


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Syndrome of focal consolidationSyndrome of focal consolidation

of pulmonary tissueof pulmonary tissue

Clinical symptomsClinical symptoms

DyspnoeaDyspnoea

Pain in the chest (only in involvement of thePain in the chest (only in involvement of thepleura in peripherally located inflammatorypleura in peripherally located inflammatory

focus!focus!

If fever % moderate hyperemia of the face#If fever % moderate hyperemia of the face#cyanosis of the lipscyanosis of the lips

$achypnoea ('%)* per min!$achypnoea ('%)* per min!


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+linical sings+linical singsIn large peripherallyIn large peripherally

located focuslocated focus

Trachea in normal positionTrachea in normal position

Thoracic lagging of affectedThoracic lagging of affected

side (in pleura involvement)side (in pleura involvement)

Vocal fremitus increasedVocal fremitus increased

ull percussionull percussion

If small deeply locatedIf small deeply locatedfocus: palpation!focus: palpation!

percussion! auscultationpercussion! auscultation

may "e non#effectivemay "e non#effective


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Syndrome of focal lung consolidationSyndrome of focal lung consolidation

,uscultation,uscultation -ronchovesicular (mi.ed-ronchovesicular (mi.edrespiration/ inspiration asrespiration/ inspiration as

vesicular (012!# e.pirationvesicular (012!# e.piration

as ronchial (032!as ronchial (032!

oror

-ronchial reathing-ronchial reathing


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Syndrome of focal lung consolidationSyndrome of focal lung consolidation

,uscultation,uscultation Consonating moist crac$les! dry rales!Consonating moist crac$les! dry rales!crepitationcrepitation

%&aggerated "ronchophony%&aggerated "ronchophony


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Syndrome of focalSyndrome of focal

lung consolidationlung consolidation

InvestigationsInvestigations '#ray:'#ray:

focal consolidationsfocal consolidationsat least # cm in diameterat least # cm in diameter

(increased density in lung tissue)(increased density in lung tissue)

-lood test/-lood test/ mild leucocytosis# moderately increased 4S5mild leucocytosis# moderately increased 4S5

Sputum/Sputum/mucopurulent6 great numer of leucocytes# macrophagesmucopurulent6 great numer of leucocytes# macrophagesand columnar epithelium -acterial flora is variedand columnar epithelium -acterial flora is varied


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Syndrome of lo"ar consolidationSyndrome of lo"ar consolidation

of pulmonary tissueof pulmonary tissueComplaintsComplaints

Severe dyspnoeaSevere dyspnoea

Pleuritic pain in the chest (on the affectedPleuritic pain in the chest (on the affectedside! 7 in lower loe involvement mayside! 7 in lower loe involvement may

simulate acute appendicitis# hepatic colicssimulate acute appendicitis# hepatic colics

May e shaking chills or rigor# fever ()8%May e shaking chills or rigor# fever ()8%

****+!# cough with sputum e.pectoration+!# cough with sputum e.pectoration


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Syndrome of lo"ar lung consolidationSyndrome of lo"ar lung consolidation *eneral condition # grave*eneral condition # grave May "e confusionMay "e confusion

(hallucinations + delirium)(hallucinations + delirium) Central cyanosisCentral cyanosis

In lo"ar typical pneumonia #In lo"ar typical pneumonia #,facies pneumonica:,facies pneumonica:

3yperemia of the cheeks# more3yperemia of the cheeks# morepronounced on the affected sidepronounced on the affected side

Participation of the nostrils inParticipation of the nostrils inreathingreathing

3erpes nasalis & laialis3erpes nasalis & laialis


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Syndrome of lo"ar lung consolidationSyndrome of lo"ar lung consolidation -ormal trachea position-ormal trachea position .agging of the affected.agging of the affected

sideside

Tachypnea (/0#10 perTachypnea (/0#10 permin)min)

Increased vocal fremitusIncreased vocal fremitus ull percussion soundull percussion sound 2ronchial "reathing2ronchial "reathing 3leural friction ru"3leural friction ru" Consonating crac$les!Consonating crac$les!

crepitationcrepitation


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Syndrome of lo"ar lung consolidationSyndrome of lo"ar lung consolidation

Increased "ronchophonyIncreased "ronchophony

%gophony (,ee4 as ,ay4)%gophony (,ee4 as ,ay4) 5hispered pectorilo6uy75hispered pectorilo6uy7

Cardiovascular symptoms:Cardiovascular symptoms:

tachycardiatachycardia


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'#ray'#ray

e&amination:e&amination:

3omogeneous3omogeneousopacity locali9ed toopacity locali9ed to

the affected loethe affected loe

Syndrome of lo"ar lung consolidationSyndrome of lo"ar lung consolidation


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Syndrome of cavity in the lungSyndrome of cavity in the lung

5easons/5easons/

"ung ascess"ung ascess

"ung tuerculosis (cavern!"ung tuerculosis (cavern!"ung tumor degradation"ung tumor degradation


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ComplaintsComplaints 5ea$ness5ea$ness Cough 8ith meager sputum (sudden releaseCough 8ith meager sputum (sudden release

of ample offensive purulent sputum # ,fullof ample offensive purulent sputum # ,fullmouth4 # on standing separates into threemouth4 # on standing separates into threelayers: mucous! serous and purulent (fromlayers: mucous! serous and purulent (from00 ml to # .9day)00 ml to # .9day)

3ain in the chest3ain in the chest yspnoeayspnoea May "e fever (remittent or hectic)! chillsMay "e fever (remittent or hectic)! chills


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nilateral thoracic laggingnilateral thoracic lagging Vocal fremitus increasedVocal fremitus increased 3ercussion:3ercussion: dulled tympanydulled tympany metallic soundmetallic sound "ell "ell

tympanytympany (large smooth#8all(large smooth#8allcavity ;


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>uscultation:>uscultation:2ronchial "reathing2ronchial "reathing

(amphoric 9 cavernous)(amphoric 9 cavernous)Resonant (consonating)Resonant (consonating)

medium + large moistmedium + large moist

crac$lescrac$les


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Pathological ronchial respirationPathological ronchial respiration

(amphoric(amphoric!! "arge smooth%wall"arge smooth%wall

cavity (D:;%< cm!cavity (D:;%< cm!

communicated with acommunicated with alarge ronchuslarge ronchus(ascess# cavern!(ascess# cavern!

>dditional high overtones>dditional high overtones

(strong resonance)(strong resonance)

8ith the main lo8#pitch8ith the main lo8#pitchlaringotracheal "reathinglaringotracheal "reathing


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(cavernous(cavernous!! Cavernous sound overCavernous sound over

the cavitythe cavity .o8#toned form of.o8#toned form of

"ronchial "reathing"ronchial "reathing(more hollo8 in 6uality)(more hollo8 in 6uality)

Imitated "y "reathingImitated "y "reathinginto a tum"lerinto a tum"ler

If the cavity is 8ell filled!If the cavity is 8ell filled!

no a"normal "reathno a"normal "reathsounds 8ill "e heard!sounds 8ill "e heard!though "reathing maythough "reathing may

"e faint"e faint


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Metallic character of crac$lesMetallic character of crac$les

In superficially located large cavity (D:;%< cm!In superficially located large cavity (D:;%< cm!


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*utta cadens falling#drop sound*utta cadens falling#drop sound In lung or pleural cavities with li=uid pus & airIn lung or pleural cavities with li=uid pus & air

Pus sticks to the surface of the cavity 7Pus sticks to the surface of the cavity 7

in changing patient>s position pus falls down inin changing patient>s position pus falls down in

drops at the ottom (one y one!drops at the ottom (one y one!


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InvestigationsInvestigations

Sputum:Sputum: ?ffensive smell?ffensive smell

?n standing separates into?n standing separates intothree layers: mucous!three layers: mucous!serous! purulentserous! purulent

%lastic fi"ers%lastic fi"ers .eucocytes and.eucocytes and

erythrocyteserythrocytes ittrich@s plugs (resem"leittrich@s plugs (resem"le

the lenticular formationsthe lenticular formations8ith offensive odour on8ith offensive odour onpressing )pressing )


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'#ray:'#ray:

cavity with li=uid levelcavity with li=uid level


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Syndrome of air accumulation inSyndrome of air accumulation inthe pleural cavity (3neumothora&)the pleural cavity (3neumothora&)3resence of gas in3resence of gas inthe pleural spacethe pleural space

CommunicatedCommunicated

"ronchi 8ith"ronchi 8ithpleural cavity:pleural cavity:

Su"pleuralSu"pleuraltu"erculosistu"erculosis

cavern or lungcavern or lunga"scessa"scess Chest inAuryChest inAury IatrogenicIatrogenic

pneumothora&pneumothora&


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neumothorax

neumothorax

?? SpontaneousSpontaneouspneumothora& occurs 8ithoutpneumothora& occurs 8ithout

antecedent trauma to the thora&antecedent trauma to the thora&

>7>73rimary3rimaryspontaneous occurs in anspontaneous occurs in an

individual 8ithout underlying lung diseaseindividual 8ithout underlying lung disease

(su"pleural "ullae rupture)(su"pleural "ullae rupture)2727SecondarySecondary 8ith underlying lung disease 8ith underlying lung disease

("ullae rupture in emphysema! asthma!("ullae rupture in emphysema! asthma!

a"scess! tumor! eosinophilic granuloma)a"scess! tumor! eosinophilic granuloma)

77TraumaticTraumaticpneumothora& caused "ypneumothora& caused "ypenetrating or non#penetrating chest inAuriespenetrating or non#penetrating chest inAuries

(ri" fracture! penetrating chest 8all inAury!(ri" fracture! penetrating chest 8all inAury!

during pleural or pericardial aspiration)during pleural or pericardial aspiration)


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PneumothoraxPneumothorax

3 types3 types TensionTension(valvular)(valvular)# positive pressure (more# positive pressure (more

than atmospheric) in the pleural spacethan atmospheric) in the pleural space

throughout the respiratory cycle (,one#8ay4throughout the respiratory cycle (,one#8ay4valve: air entered to the pleural cavity duringvalve: air entered to the pleural cavity during

inspiration! not removed during e&piration inspiration! not removed during e&piration

trapped)trapped)

ClosedClosed# air entered to the pleural cavity# air entered to the pleural cavity ?pen?pen communication "et8een the "ronchus communication "et8een the "ronchus

+ pleural cavity ("roncho#pleural fistula) + pleural cavity ("roncho#pleural fistula)

pressure same as atmosphericpressure same as atmospheric


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+omplaints+omplaints

Sudden unilateral tightness in the chestSudden unilateral tightness in the chest

Pain in the chest with inspiratory increasingPain in the chest with inspiratory increasing

DyspneaDyspnea Dry coughDry cough

PalpitationPalpitation


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TensionTension(valvular):(valvular):

Medical emergency (if not treated death 8ithinMedical emergency (if not treated death 8ithin

short time)7 *eneral condition # suddenly!short time)7 *eneral condition # suddenly!

rapidly7 Severe dyspnea progressive 8ithrapidly7 Severe dyspnea progressive 8itheach inspiration7 Central cyanosis7each inspiration7 Central cyanosis7

Closed:Closed:

yspnea (not severe) improves (#1 8ee$s)yspnea (not severe) improves (#1 8ee$s)

after air a"sor"tionafter air a"sor"tion ?pen:?pen:

yspnea not improved 8ithout surgeryyspnea not improved 8ithout surgery


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Clinical manifestationsClinical manifestations

InspectionInspection

>symmetrical chest>symmetrical chest

isplacement of theisplacement of the

trachea to thetrachea to theopposite sideopposite side

.agging of the.agging of the

affected sideaffected side

Intercostal spaces #Intercostal spaces #

increased!increased!

smoothedsmoothed


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PalpationPalpation

Su"cutaneousSu"cutaneous

emphysemaemphysema(in traumatic(in traumatic

pneumothora&)pneumothora&)

Increased unilateralIncreased unilateral

regidityregidity Vocal fremitus #Vocal fremitus #

decreased ordecreased or

a"senta"sent


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PercussionPercussion $ympanic percussion sound$ympanic percussion sound

MMetallic sound - bell tympany inetallic sound - bell tympany in

large pneumothorax (coin test)large pneumothorax (coin test)

Shift of the mediastinum to the oppositeShift of the mediastinum to the opposite

sideside


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AAuscultationuscultation

iminished vesiculariminished vesicular

"reathing or a"sent"reathing or a"sent

In open pneumothora&In open pneumothora&

#connection of the pleural#connection of the pleural

cavity 8ith "ronchuscavity 8ith "ronchus

("roncho#pleural fistula) ("roncho#pleural fistula)

"ronchial (amphoric or"ronchial (amphoric or

metallic "reathing)metallic "reathing) SuccussionSuccussion (air B fluid in(air B fluid in

pyopneumothora&)pyopneumothora&)


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(metallic(metallic!!

"arge open"arge open

pneumothora.pneumothora.

"oud & high"oud & high

5esemles the metal5esemles the metal

struckstruck


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[email protected] pulmonary.ight pulmonary

field 8ithoutfield 8ithout

pulmonary patternpulmonary pattern(translucent one)(translucent one)@Shado8 of theShado8 of the

collapsed lungcollapsed lung

to8ard the rootto8ard the root@Shifted (pushedShifted (pushed

out) mediastinumout) mediastinum


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treatmenttreatment TensionTension(valvular):(valvular):

Medical emergency Aide needle withMedical emergency Aide needle with

ruer tue % inserted in the intercostalruer tue % inserted in the intercostal

space for air aspirationspace for air aspiration

Closed:Closed: small 7 without treatment# large %small 7 without treatment# large %

air aspirationair aspiration

?pen:?pen: surgical treatmentsurgical treatment


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Syndrome of increasedSyndrome of increased

airness of the lungsairness of the lungs

(syndrome of hyperinflation)(syndrome of hyperinflation) Distention of the airDistention of the air

spaces distal to thespaces distal to theterminal ronchioleterminal ronchiole

with destruction ofwith destruction of

alveolar septaalveolar septa 5educed lung5educed lung

elasticityelasticity


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Syndrome of hyperinflationSyndrome of hyperinflation

(lung emphysema)(lung emphysema) Pink pufersPink pufers

aceace Tachypnea withTachypnea with

prolonged expirationprolonged expiration

trough pursed lips /trough pursed lips /expiration withexpiration withgrunting soundgrunting sound

IncreasingIncreasingbreathlessness - anbreathlessness - an

exertional expiratoryexertional expiratorydyspneadyspnea

ini!al cough withini!al cough withs!all a!ounts os!all a!ounts o!ucoid sputu!!ucoid sputu!

.ips tightly apposed.ips tightly apposed

at height of inspiration!at height of inspiration!

.ips held narro8ly apart during.ips held narro8ly apart during

e&piratione&piration


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(lung emphysema)(lung emphysema) >sthenic constitution 8ith 8eight loss>sthenic constitution 8ith 8eight loss

2arrelshaped chest (increased2arrelshaped chest (increasedanteroposterior diameter)anteroposterior diameter)

se of accessory muscles inse of accessory muscles in

respirationrespiration Tracheal tugTracheal tug

TachypneaTachypnea 3rolonged e&piration through pursed3rolonged e&piration through pursed

lipslips .o8er intercostal spaces retract 8ith.o8er intercostal spaces retract 8ith

each inspirationeach inspiration

-ec$ veins distended during-ec$ veins distended duringe&piratione&piration


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(lung emphysema)(lung emphysema)Palpation"Palpation"

Increased rigidityIncreased rigidity

#ecreased $ocal#ecreased $ocal

re!itusre!itus #i!inished excursion#i!inished excursion


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(lung emphysema)(lung emphysema)Percussion"Percussion" %yperresonant &bandbox'%yperresonant &bandbox'

soundsound (pper borders" protruded(pper borders" protruded )ower borders" descendent)ower borders" descendent )i!ited !obility)i!ited !obility #ecreased li$er * cardiac#ecreased li$er * cardiac

dullnessdullness

+uscultation"+uscultation"di!inisheddi!inished$esicular breathing$esicular breathing&difuse dry rales in bronchitis'&difuse dry rales in bronchitis'


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(lung emphysema)(lung emphysema)

Cardiac dullness severely reducedCardiac dullness severely reduced

Decreased heart soundsDecreased heart sounds

Presystolic gallop accentuated duringPresystolic gallop accentuated during

inspirationinspiration


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(lung emphysema)(lung emphysema)

Pulmonary function tests/Pulmonary function tests/

$"+ and 5B % increased$"+ and 5B % increased

B+ % lowB+ % low Ma.imal e.piratory flow rates % diminishedMa.imal e.piratory flow rates % diminished


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(lung emphysema)(lung emphysema),-ray o the chest",-ray o the chest"

#iaphrag! low.#iaphrag! low.

attenedattened

0roncho$ascular0roncho$ascularshadow do not extendshadow do not extend

to the periphery oto the periphery o

the lungsthe lungs

1ardiac silchouette 1ardiac silchouette lengthened. narrowedlengthened. narrowed

2$erination2$erination


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Syndrome of compressiveSyndrome of compressive

atelectasisatelectasis

+ompressed+ompressed

alveoli due toalveoli due to

accumulation ofaccumulation of

fluid in thefluid in the

pleural cavitypleural cavity


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Syndrome of compressiveSyndrome of compressive

atelectasisatelectasis yspnea (inspiratory)yspnea (inspiratory) Cough # dry (refle&ogenous)Cough # dry (refle&ogenous) In mediastinal pleurisy 8ithIn mediastinal pleurisy 8ith

effusion:effusion: ysphagia (compression ofysphagia (compression of

the esophagus)the esophagus) Compression of the superiorCompression of the superior

vena cava #vena cava # Stoc$@s collarStoc$@s collar

(edema of the nec$)! cyanotic(edema of the nec$)! cyanoticface! dilated chest 8all veinsface! dilated chest 8all veins 3em"erton@s sign3em"erton@s sign Compression of the recurrentCompression of the recurrent

nerve # hoarsenessnerve # hoarseness


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Objective ExaminationObjective Examination

InspectionInspection,symmetry of the,symmetry of thechestchest$racheal$racheal

displacement awaydisplacement awayfrom the fluidfrom the fluid"agging of the"agging of the

affected sideaffected sideProtrusion of theProtrusion of theintercostal spacesintercostal spaces


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Skodaic tympanySkodaic tympany

Zone above theZone above the

fuid fuid dilated air sacsdilated air sacs

in the lungin the lung

!ust above!ust abovethe compressedthe compressed

partpart


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Syndrome of compressive atelectasisSyndrome of compressive atelectasis

>uscultation>uscultation

,ove the effusion,ove the effusion

(Carland>s triangle! %(Carland>s triangle! %

ronchial reathing %ronchial reathing %0echo2 like0echo2 likecompressivecompressive

ronchial reathing#ronchial reathing#

temporary crepitationtemporary crepitation

(during first deep(during first deep

inspirations!inspirations!

Increased ronchophonyIncreased ronchophony


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Syndrome of ostructive atelectasisSyndrome of ostructive atelectasis

cclusion of thecclusion of the

ronchusronchus yytumor#tumor#

retained secretions#retained secretions#

foreign odyforeign ody7 air7 airasored# affectedasored# affected

part of the lungpart of the lung

collapsedcollapsed


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Syndrome of ostructive atelectasisSyndrome of ostructive atelectasis

CausesCauses

77 Intraluminal:Intraluminal: Mucus (postoperative! asthma! cystic fi"rosis)Mucus (postoperative! asthma! cystic fi"rosis)

Doregn "odyDoregn "ody >spiration>spiration

77 Mural:Mural: 2ronchial carcinoma2ronchial carcinoma

/7/7 %&tramural:%&tramural: 3eri"ronchial lymphadenopathy3eri"ronchial lymphadenopathy >ortic aneurysm>ortic aneurysm


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Syndrome of ostructive atelectasisSyndrome of ostructive atelectasis yspnea (inspiratory)yspnea (inspiratory) If compression of theIf compression of the

trachea trachea stridorstridor %&pansion: reduced on the%&pansion: reduced on the

affected side 8ith flatteningaffected side 8ith flatteningof the chest 8allof the chest 8all(narro8ing! retruction of(narro8ing! retruction ofthe intercostal spaces)the intercostal spaces)

.agging of the affected side.agging of the affected side isplacement of theisplacement of the

trachea + mediastinumtrachea + mediastinumto8ard the affected sideto8ard the affected side


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Syndrome of o"structive atelectasisSyndrome of o"structive atelectasis

3ercussion: dull over3ercussion: dull over

the collapsed areathe collapsed area

Vocal fremitus: a"sentVocal fremitus: a"sent

2reath sounds:2reath sounds:reduced! 8ith orreduced! 8ith or

8ithout "ronchial8ithout "ronchial

"reathing a"ove the"reathing a"ove the

collapsed areacollapsed area

2ronchophony: a"sent2ronchophony: a"sent


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Syndrome of incompleteSyndrome of incomplete

o"structive atelectasiso"structive atelectasis

Diminished vocal fremitusDiminished vocal fremitus

Dulled tympanic sound (air in alveoli %Dulled tympanic sound (air in alveoli %

incomplete closure of adductive ronchus!incomplete closure of adductive ronchus!

Diminished vesicular reathingDiminished vesicular reathing

(hypoventilation!# local whee9ing(hypoventilation!# local whee9ing

(ostruction in trachea E main ronchi 7(ostruction in trachea E main ronchi 7

stridor!stridor!

/


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/ grades/ grades

of local o"structive atelectasisof local o"structive atelectasis

*rade I*rade I diminished possiility for air todiminished possiility for air to

pass through a narrowed airway duringpass through a narrowed airway during

oth respiratory phases/oth respiratory phases/

"ocally increased vesicular reathing or"ocally increased vesicular reathing or

harsh reathing soundharsh reathing sound

1i.ed monophonic whee9es1i.ed monophonic whee9es

Bocal fremitus & ronchophony presentBocal fremitus & ronchophony present

/ d


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/ grades/ grades


*rade II*rade II diminished possiility for air to passdiminished possiility for air to pass

through a narrowed airway only duringthrough a narrowed airway only during

inspiration & closure during e.piration/ inailityinspiration & closure during e.piration/ inaility

for air to leave ostructed areafor air to leave ostructed area

"ocal tympany"ocal tympany

5educed vesicular reathing sound over5educed vesicular reathing sound over

hypoventilated areahypoventilated area

1i.ed monophonic whee9es1i.ed monophonic whee9es

Bocal fremitus & ronchophony present# utBocal fremitus & ronchophony present# ut

diminisheddiminished

/ d


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/ grades/ grades


*rade III*rade IIItotal closure of affected airwaytotal closure of affected airway

& suse=uent formation of complete& suse=uent formation of complete

ostructive atelectasis (atelectatic silence!ostructive atelectasis (atelectatic silence!

5ecurrent pneumonia % hypoventilation &5ecurrent pneumonia % hypoventilation &

distured airway clearancedistured airway clearance


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yn!rome of increase!yn!rome of increase!

thic"ening of pleural layersthic"ening of pleural layers#!ry pleurisy$#!ry pleurisy$

+omplaints/+omplaints/

Knifelike or shooting pain in the chest (increasedKnifelike or shooting pain in the chest (increasedy deep reathing# coughing# laughing# thoracicy deep reathing# coughing# laughing# thoracicmotions!motions!

Dry coughDry cough Suferile temperatureSuferile temperature

Cenerali9ed weaknessCenerali9ed weakness

Obj ti E i ti


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forced postureforced posture

(on the affected side(on the affected side

or sitting with fi.ationor sitting with fi.ationto decrease theto decrease the

movement of themovement of the

affected side!affected side!

superficial respirationsuperficial respiration unilateral thoracicunilateral thoracic

lagginglagging


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PalpationPalpation Painful palpation of trape9oid & largePainful palpation of trape9oid & large

thoracic musclesthoracic muscles ((Sternerg>s &Sternerg>s &

Pottenger>s signs!Pottenger>s signs!//a7a7 irritation of central portion of pleural surface ofirritation of central portion of pleural surface of

diaphragm pain at superior "order of trapeoiddiaphragm pain at superior "order of trapeoid

muscle! supraclavicular fossamuscle! supraclavicular fossa

"7"7 irritation of peripheral portion of pleural surface ofirritation of peripheral portion of pleural surface of

diaphragm pain in s$in supplied "y T#


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#ecreased#ecreased

$ocal re!itus$ocal re!itus

Pleuro"brothoraxPleuro"brothorax#ormal#ormal


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PercussionPercussion&&auscultationauscultation Dulled tympanicDulled tympanic

soundsound

Decreased moility ofDecreased moility ofthe lung order on thethe lung order on the


Diminished vesicularDiminished vesicular

reathingreathing

Pleural friction ruPleural friction ru

I ti tiI ti ti


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F%rayF%ray

% "imited moility of the diaphragm% "imited moility of the diaphragm

-lood test-lood test

% Moderate leukocytosis% Moderate leukocytosis


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2rochoo"structive syndrome2rochoo"structive syndrome

Syndrome of difficult air passage through theSyndrome of difficult air passage through the"ronchi due to o"struction of the "ronchial"ronchi due to o"struction of the "ronchialtreetree

Reasons:Reasons: $ypertrophy o% the mucus-secreting$ypertrophy o% the mucus-secreting

glands& increased number o% goblet cells inglands& increased number o% goblet cells inbronchi ' bronchiole ith a conseuentbronchi ' bronchiole ith a conseuentdecrease in ciliated cellsdecrease in ciliated cells

*ucosal oedema ' permanent structural*ucosal oedema ' permanent structuraldamage o% the airay alls reduce thedamage o% the airay alls reduce thecaliber o% the air passagescaliber o% the air passages

+ncreased mucus in the airays+ncreased mucus in the airays


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C.I-IC>. D%>TR%SC.I-IC>. D%>TR%S 1ough1ough

Initially producti$e cough -Initially producti$e cough -during winter. later - constantduring winter. later - constant

Tightness in the chest in theTightness in the chest in the!orning &disappeared by!orning &disappeared bycoughing'coughing'

5xpectoration5xpectoration6putu! !ay be little. !ucoid6putu! !ay be little. !ucoidand tenacious or 7 cup oand tenacious or 7 cup o!ucopurulent / purulent!ucopurulent / purulent

0reathlessness0reathlessnessexpiratory dyspnea.expiratory dyspnea.

later episodes o sleeplater episodes o sleepapneaapnea


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-G4+$IB4 4F,MIH,$IH-G4+$IB4 4F,MIH,$IH

00-lue loater2-lue loater2//

overweightoverweight

edematousedematous

cyanoticcyanotic

54SPI5,$5 SS$4M54SPI5,$5 SS$4M


67/111

54SPI5,$5 SS$4M54SPI5,$5 SS$4M

4F,MIH,$IH4F,MIH,$IH Inspection:Inspection:

?! respiratory rate is normal or slightly?! respiratory rate is normal or slightly

increasedincreased

'! there is no apparent usage of'! there is no apparent usage of

accessory musclesaccessory muscles

)! flapping tremor (asteri.is!)! flapping tremor (asteri.is!

3alpation:3alpation:reduced e.pansionreduced e.pansion

3ercussion:3ercussion:resonant soundresonant sound


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>uscultation>uscultation

3ush reathing3ush reathing

(with prolonged(with prolonged

e.piration!e.piration!

+oarse ronchi &+oarse ronchi &

whee9eswhee9es


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Respiratory failureRespiratory failure

efinitionefinition

Inaility to maintainInaility to maintain PP''(:


70/111

Respiratory failure classification Respiratory failure classification

a"sence 9 presence hypercapniaa"sence 9 presence hypercapnia


Type IP'P'J


71/111


>cute>cute77during minutes orduring minutes or

hourshours

ChronicChronic77during days orduring days or

weeksweeks


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Type IType IP' J


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Type II # asphy&iaType II # asphy&iaP' J


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ManifestationsManifestations

DyspneaDyspnea

$achycardia$achycardia+yanosis+yanosis

4dema (in late stage % cardiac failure!4dema (in late stage % cardiac failure!

R i f il


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.ate stage.ate stage


BB

RV incompetenceRV incompetence

3ulmonary hypertension due to %uler#3ulmonary hypertension due to %uler#

.iiestrand refle&.iiestrand refle&


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%uler#.iliestrand refle&%uler#.iliestrand refle&

.imited.imited

"lood supply"lood supply

of Insufficientlyof Insufficiently

ventilatedventilatedlunglung

Sclerotic changes in lungs Sclerotic changes in lungs

3ulmonary hypertension3ulmonary hypertension

Insufficient lungInsufficient lung

ventilation +ventilation +>lveolar hypo&ia>lveolar hypo&ia


77/111


MechanismsMechanisms

?"structive type?"structive type RestrictiveRestrictivetypetype Mi&ed typeMi&ed type


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?"structive type difficult air?"structive type difficult air

passage through the "ronchi:passage through the "ronchi:-ronchitis-ronchitis

-ronchospasm-ronchospasm

$rachea E large ronchus compression$rachea E large ronchus compression


79/111


Restrictive type limited lungRestrictive type limited lunga"ility to e&pand + collapse:a"ility to e&pand + collapse:

PneumosclerosisPneumosclerosis

3ydrothora.3ydrothora.

Pneumothora.Pneumothora.

Massive pleural adhesionsMassive pleural adhesionsKyphoscoliosisKyphoscoliosis

"imited ris moility"imited ris moility

f


80/111


Mi&ed type com"ination ofMi&ed type com"ination of

o"structive + restrictive typeso"structive + restrictive types(with(withor without prevalence of one of them!/or without prevalence of one of them!/

"ong%standing lung & heart diseases"ong%standing lung & heart diseases


81/111

>dult respiratory>dult respiratory


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distress syndrome (>RS)distress syndrome (>RS) 5isk factors/5isk factors/ Sepsis (?E) of all ,5DS!Sepsis (?E) of all ,5DS! Castric contents aspirationCastric contents aspiration

ShockShock

InfectionInfection "ung contusion"ung contusion Hon%thoracic traumaHon%thoracic trauma

$o.ic inhalation$o.ic inhalation Hear%drowningHear%drowning Multiple lood transfusionsMultiple lood transfusions PancreatitisPancreatitis



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distress syndrome (>RS)distress syndrome (>RS) 5apid onset (?'% hours after event!5apid onset (?'% hours after event!

Profound dyspnea (hyperventilation!Profound dyspnea (hyperventilation!

"aored reathing"aored reathing

Intercostal retractionsIntercostal retractions -ilateral crackles-ilateral crackles

-P falls-P falls

+hest F%ray/ diffuse or patchy ilateral infiltrates+hest F%ray/ diffuse or patchy ilateral infiltrates% rapidly confluent (fluffy homogeneous% rapidly confluent (fluffy homogeneous

shadows!shadows!

ERSE ST>T%ERSE ST>T%


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ERSE ST>T%ERSE ST>T%

M%IC>. -IV%RSITFM%IC>. -IV%RSITF

%3>RTM%-T ?D 3R?3>%%TIC%3>RTM%-T ?D 3R?3>%%TIC?D I--%R IS%>S%S?D I--%R IS%>S%S

Respiratory pathologyRespiratory pathology

Main clinical syndromesMain clinical syndromes

1 l lid i1 l lid ti


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1ocal consolidation1ocal consolidation

In presence of large focus!In presence of large focus!

if it is located peripherallyif it is located peripherally

(over the limited part of the(over the limited part of the

chest):chest):

vocal fremitus 7 increasedvocal fremitus 7 increased

dull percussion sounddull percussion sound

vesiculoronchial orvesiculoronchial or

ronchial reathing#ronchial reathing#

dry E consonating moistdry E consonating moist

rales#rales#

crepitationcrepitation

"oar consolidation"oar consolidation


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"oar consolidation"oar consolidation

"agging of the affected side"agging of the affected side DyspnoeaDyspnoea Bocal fremitus is increasedBocal fremitus is increased

Dulled%tympanic E dullDulled%tympanic E dullpercussion soundpercussion sound

,uscultation 7 diminished,uscultation 7 diminishedvesicular reathing#vesicular reathing#

crepitation 0indu.2#crepitation 0indu.2#ronchial reathing#ronchial reathing#increased ronchophonyincreased ronchophony


87/111

t ti f th hi t ti f th hi


88/111

struction of the ronchistruction of the ronchi

00-lue -loater2-lue -loater2//

overweight#overweight#

edematous#edematous#

cyanoticcyanotic



89/111


Inspection:Inspection:

?! respiratory rate is normal or slightly?! respiratory rate is normal or slightlyincreasedincreased

'! there is no apparent usage of accessory'! there is no apparent usage of accessorymusclesmuscles

)! flapping tremor (asteri.is!)! flapping tremor (asteri.is!

3alpation:3alpation:hyperinflated chest with reducedhyperinflated chest with reducede.pansione.pansion

3ercussion:3ercussion:resonant soundresonant sound



90/111


3ush reathing3ush reathing(prolonged e.piration!(prolonged e.piration!

+oarse ronchi &+oarse ronchi &

whee9eswhee9es may emay e

non%consonatingnon%consonating

cracklescrackles

(change in location E intensity(change in location E intensity

after a deep and productiveafter a deep and productive

cough!cough!

4 h4 h


91/111

4mphysema4mphysema

0 0Pink puffer2Pink puffer2

$achypnea with$achypnea with

prolonged e.pirationprolonged e.piration

trough pursed lips Etrough pursed lips Ee.piration withe.piration with

grunting soundgrunting sound

"ips tightly apposed"ips tightly apposed

at height of inspiration#at height of inspiration#

"ips held narrowly apart during"ips held narrowly apart duringe.piratione.piration

4 h4 h


92/111

4mphysema4mphysema

,sthenic constitution with weight,sthenic constitution with weightlossloss

-arrel7shaped chest-arrel7shaped chest (increased(increasedanteroposterior diameter!anteroposterior diameter!

,se o% accessory muscles in,se o% accessory muscles in

respirationrespiration .achypnea.achypnea Prolonged expirationProlonged expiration

through pursed lipsthrough pursed lips /oer intercostal spaces/oer intercostal spaces

retract ith eachretract ith eachinspirationinspiration #eck veins distended during#eck veins distended during

expirationexpiration

4 h4 h


93/111

4mphysema4mphysema

Palpation0Palpation0 +ncreased rigidity+ncreased rigidity

Decreased vocalDecreased vocal

%remitus%remitus

Diminished excursionDiminished excursion

4 h4mphysema


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4mphysema4mphysema

Percussion"Percussion" $yperresonant (bandbox) sound$yperresonant (bandbox) sound

,pper borders protruded,pper borders protruded

/oer borders0 descendent/oer borders0 descendentlimited mobilitylimited mobility

Decreased liver ' cardiac dullnessDecreased liver ' cardiac dullness

+uscultation"+uscultation"diminished vesiculardiminished vesicular

breathingbreathing

(di1use dry rales in bronchitis)(di1use dry rales in bronchitis)


95/111

Obstructive atelectasis

bstructive atelectasis

cclusion of thecclusion of theronchusronchus

Symptoms of ostructiveSymptoms of ostructive


Displacement ofDisplacement ofmediastinum toward themediastinum toward the


Displacement of theDisplacement of the

tracheatrachea

%y!rothorax%y!rothorax


96/111


,ccumulation of,ccumulation offluid in the pleuralfluid in the pleural

cavitycavity

+ompressive+ompressive


% !rothora%y!rothorax


97/111


,symmetry of the,symmetry of thechestchest$racheal$rachealdisplacement awaydisplacement awayfrom the fluidfrom the fluid"agging of the"agging of theaffected sideaffected side

Protrusion of theProtrusion of theintercostal spacesintercostal spaces



98/111


PalpationPalpation

Bocal fremitusBocal fremitus IncreasedIncreasedover theover the

compressed lungcompressed lung

DiminishedDiminishedoror

not transmitted atnot transmitted atthe area of the fluidthe area of the fluidaccumulationaccumulation



99/111

%y!rothoraxy! ot o a

PercussionPercussion Dullness over the area of fluidDullness over the area of fluid Damoiseau>s curveDamoiseau>s curve Carland>s triangleCarland>s triangleon the affected side characteri9ed yon the affected side characteri9ed y

a dulled 7 tympanic sound It corresponds the lunga dulled 7 tympanic sound It corresponds the lung

pressed y the effusion 7 compression atelectasispressed y the effusion 7 compression atelectasis 5auchfuss%Crocco triangle5auchfuss%Crocco triangleis found on the healthy sideis found on the healthy side

and is a kind of e.tension of dullness determined on theand is a kind of e.tension of dullness determined on theaffected side $he sides of the triangle are formed y theaffected side $he sides of the triangle are formed y thediaphragm and the spine# while the continueddiaphragm and the spine# while the continued

Damoiseau>s curve is the hypotenuseDamoiseau>s curve is the hypotenuse ,sence of the,sence of the $raue>s space$raue>s spacein the left sided pleuritisin the left sided pleuritis



100/111

%y!rothoraxy

PercussionPercussion

2arland3striangle

4auch%uss-2rocco triangle(due todisplacement o%

themediastinum)

Damoiseau3s

Curve

51usion



101/111

%y!rothoraxy

,uscultation,uscultation

In the region of accumulatedIn the region of accumulated

fluid %fluid %diminished vesiculardiminished vesicular

reathing or not auscultatedreathing or not auscultated

,ove the effusion %,ove the effusion % ronchialronchial

reathing % 0echo2 likereathing % 0echo2 like

(compressive atelectasis!(compressive atelectasis!

-ronchophony over the-ronchophony over the

effusioneffusion is not determinedis not determined

ry leurisy


102/111

&ry leurisy

+omplaints/+omplaints/

Pain in the chest ( increased duringPain in the chest ( increased during

reathing and coughing!reathing and coughing! Dry coughDry cough

Suferile temperature CeneralSuferile temperature Ceneral

weaknessweakness

Objective ExaminationOb

jective Examination


103/111

jj


forced postureforced posture (on(on

the affected sidethe affected side

or sitting!or sitting! superficialsuperficial

respirationrespiration

unilateral thoracicunilateral thoracic

lagginglagging


jective Examination


104/111

jj

palpation and percussionpalpation and percussion Painful palpation of trape9oid and largePainful palpation of trape9oid and large

thoracic muscles (thoracic muscles (Sternerg>s and Pottenger>sSternerg>s and Pottenger>s

signs!signs!

decreased moility of the lung order on thedecreased moility of the lung order on theaffected sideaffected side


jective Examination


105/111

jj

,uscultation,uscultation pleural friction rupleural friction ru

neumothorax

neumothorax


106/111

Presence of gas in the pleuralPresence of gas in the pleural

spacespace



107/111


Pain in the chestPain in the chest DyspneaDyspnea

Dry coughDry cough

PalpitationPalpitation



108/111

Inspection'Inspection'

asymmetricalasymmetrical

chestchest

Displacement ofDisplacement of

the trachea to thethe trachea to theopposite sideopposite side

lagging of thelagging of the


intercostal spacesintercostal spacesare increased andare increased and

smoothedsmoothed

Clinical manifestations'Clinical manifestations'


109/111

Palpation'Palpation'

SucutaneousSucutaneous

emphysemaemphysema (in(in

traumatictraumatic

pneumothora. !pneumothora. ! vocal fremitus isvocal fremitus is

decreased or asentdecreased or asent



110/111

Percussion'Percussion' tympanic percussion soundtympanic percussion sound shift of the mediastinum to the opposite sideshift of the mediastinum to the opposite side



111/111

auscultation'auscultation'

diminished vesiculardiminished vesicular

reathing or asentreathing or asent

+onnection of the pleural+onnection of the pleuralcavity with ronchus 7cavity with ronchus 7

amphoric reathingamphoric reathing

In open pneumothora. 7In open pneumothora. 7metallic reathingmetallic reathing

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Main Clinical Syndromes in Respiratory System

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