Respiratory Signs & Symptoms

• What are the 6 cardinal respiratory symptoms?

  Breathlessness

  Cough

  Sputum

  Haemoptysis (red flag)

  Chest pain

  Hoarseness
• Does breathlessness always mean lungs?

  No

  Can mean heart, brain or muscle pathology
• What is the link between breathing, thinking & functioning?

  Downward spiral of breathlessness that can occur in patient

  If you feel breathless -> start to panic about breathlessness -> get anxiety overlay & can develop low mood -> stop doing things you want to do -> muscles weaken -> less effective when exerting yourself -> become more breathless

  
• What pathologies does the trachea deviate away?

  Tension pneumothorax

  Large pleural effusion
• What pathologies does the trachea deviate towards?

  Lobar collapse

  Pneumoectomy
• The causes of chest pain is really wide.

  Pleura is extremely pain sensitive.
• What are the possible sputum characteristics in a bacterial infection?

  Yellow

  Green

  Rust (blood mixed with yellow sputum)

  Clear/transparent

  Purulent

  Sticky
• What is the colour of sputum in viral infection?

  Blood streaked (not common)
• What are the possible sputum characteristics of a chronic infectious disease?

  More sputum production in the morning

  Sometimes blood streaking
• What are the possible sputum characteristics in cancer?

  Slight, persistent, intermittent blood streaking
• What is blood in sputum a red flag for?

  Cancer
• What do streaks of blood in sputum indicate?

  Trauma due to coughing
• What are the clinical features of radiotherapy-associated skin changes?

  Dry skin

  Scale

  Hyperkeratosis (thickened skin)

  Depigmentation

  Telangiectasia (spider veins)
• What are some red flag clinical features with cough?

  Haemoptysis

  Hoarseness

  Peripheral oedema with weight gain

  Prominent dyspnoea (esp. at rest or at night)

  Trouble swallowing

  Systemic symptoms (weight loss & fever)

  Vomiting
• What are some questions to ask about haemoptysis?

  Duration

  Frequency

  Amount - massive if > 250 ml in 24hrs (medical emergency)

  Is there blood-streaked sputum?

  Is the blood coughed up or vomited?

  Have they seen a dentist recently? - bleeding could be from gums
• What are the different chest wall deformities?


  Asymmetry - pneumonectomy, thoracoplasy

  Pectus excavatum - scooped in chest

  Pectus carinatum - sticking out chest

  Hyperexpansion ('barrel chest')

  • chest wall appears wider & taller than normal
  • associated with obstructive lung diseases
• Breathlessness is a complicated symptom. What questions would you ask about breathlessness?

  Acute/chronic

  • acute: PE
  • chronic: pneumonia

  Onset - on exertion?

  Severity

  Continuous/episodic

  Limitation

  • exercise tolerance (can you get up a flight of stairs? how many lamposts can you walk past?)

  NOTE: Breathlessness is poorly associated with disease severity.
• What conditions can cause haemoptysis?

  Pulmonary HTN

  Severe mitral stenosis

  Decompensated congestive HF
• Describe brocnhial breathing. What is it associated with?

  Harsh-sounding

  Inspiration & expiration are equal (pause between)

  Associated with consolidation
• What should you ask about cough?

  Acute/chronic

  Wet/dry - colour of sputum

  Time of day - how variable is it?

  When is the first cough?

  • pts with reflux will begin to cough when they get out of bed

  Characteristic - chesty/tickly

  Relation to GI eating/speaking/environmental/occupational factors/travel
• Describe fine end inspiratory crackles. What are they associated with?

  Like velcro

  Associated with pulmonary fibrosis
• What is stridor caused by?

  Turbulence in large airways
• What are the causes of hoarseness?

  Laryngitis/pharyngitis

  Laryngopharyngeal reflux

  Singer's nodules

  Disease originating around left hilum of lung - due to course of recurrent pharyngeal nerve
• Describe vesicular breathing.

  Normal quantity of breath sounds in healthy individuals
• What is the MRC dyspnoea scale? When is it used?

  Used in COPD patients

  Shows disease progression & allows clinicians to monitor whether drugs are working

  
• What are the different types of breath sounds?

  Vesicular

  Bronchial

  Quiet breath sounds

  Wheeze

  Stridor

  Coarse crackles

  Fine end inspiratory crackles
• Describe coarse crackles. What are they associated with?

  Discontinuous, brief, popping lung sound

  Typically associated with pneumonia, bronchiectasis & pulmonary oedema
• What are the complications of chronic bronchitis?

  Secondary polycythemia vera (due to hypoxia)

  Pulmonay HTN (due to vasoconstriction from hypoxaemia)

  Cor pulmonale (from chronic pulmonary HTN)
• What is stridor?

  High pitched whistling sound - can be inspiratory or expiratory
• What is important to ask about chest pain?

  Site - central/left-sided/retrosternal/epigastric

  Onset - sudden? how has it porgressed? related to exertion?

  Character - crushing/heavy/tight/pleuritic/burning

  Radiation - left arm, neck, jaw, back?

  Alleviating factors - rest, GTN (angina), sitting forward (pericarditis)

  Timing - relation to exertion to food? any positional element

  Exacerbating factors

  • arm movement, pressing on chest -> suggests MSK
  • exercise, effort -> suggests cardiac

  Severity
• What are the 2 main obstructive phenotypes?

  Blue bloater - chronic bronchitis

  Pink puffer - emphysema

  
• How do you 'set up' before a resp examination?

  Adjust head of the bed to a 45 degree angle

  Adequately expose the patient's chest for the examination (do not need to remove bra)

  Expose lower legs

  Ask is pt has any pain
• What are the symptoms of emphysema?

  Dyspnoea

  Minimal cough

  Increased minute ventilation

  Pink skin, pursed-lip breathing

  Accessory muscle use

  Cachexia

  Hyperinflation, barrel chest

  Decreased breath chest

  Decreased breath sounds

  Tachypnoea
• What are the symptoms of chronic bronchitis?

  Chronic, productive cough

  Purulent sputum

  Haemoptysis

  Mild dyspnoea initially

  Cyanosis

  Peripheral oedema

  Crackles, wheeze

  Prolonged expiration

  Obese
• What are the complications of emphysema?

  Pneumothorax - due to ballae

  Weight loss - due to work of breathing
• If a child has stridor, what should be worry about?

  Epiglottitis
• Describe wheeze.

  A continuous, coarse, whistling sound - produced by turbulent airflow

  May be polyphonic (obstructive airway disease) or monophonic (large airway obstruction)
• What do quiet lung sounds suggest?

  Reduced air entry into that region of the lung
• How do ACE inhibitors impact cough?

  Can cause cause - through bradykinin production
• What is haemoptysis?

  Coughing up blood