PTR3011

PULMONARY DISEASES AND

REHABILITATION
ASST. PROF. BAHA NACİ

09.11.2023
 ASSESSMENT OF THE RESPIRATORY SYSTEM

TAKING CLINICAL HISTORY (ANAMNESIS)

 There are three elements that must be met in order to reach the correct diagnosis and
treatment for a patient; Taking a good anamnesis, performing a good physical examination
and requesting appropriate laboratory examinations.

 Demographic information (age, marital status, whether or not they have children,
 Complaint
 History (previous diagnoses, laboratory examinations, treatments received, drug history)
 Personal and family history (trauma, accident, surgeries, presence of important diseases
in close relatives, causes of death of close relatives)
 Addictions (Tobacco (pack/year), alcohol use)
 Interrogation of systems (symptoms related to other organs and systems are reviewed)
 Occupational and environmental history (harmful dust, irritant or toxic gases in terms of
occupational asthma, organic dusts in terms of hypersensitivity pneumonia, bird and
chicken feeding, asbestos in terms of asbestos-related diseases)
 BASIC SYMPTOMS
1. Cough

 Cough is an explosive expiration that clears the airways of secretions and prevents
foreign particles/irritants from entering the lower respiratory tract, and is an
important defense mechanism.
 Cough occurs when the glottis closes immediately after rapid inspiration, the
abdominal and thoracic expiratory muscles contract, the pleural and intrapulmonary
pressure increases rapidly, and then the glottis suddenly opens and air comes out of
the mouth in an explosive manner.
 Cough lasting less than 3 weeks is called acute cough, between 3-8 weeks is called
subacute cough, and cough lasting more than 8 weeks is called chronic cough. Acute
cough is often a symptom of viral or bacterial respiratory infections.
 Dry or non-productive cough is a cough that is not accompanied by sputum. The cough
that is frequently seen in clinical practice and causes problems in diagnosis and
treatment is chronic non-productive cough.
 In cough that occurs in attacks; asthma, foreign body aspiration, pulmonary
edema, and psychogenic cough should be considered.

 Postnasal drip should be considered in a cough that occurs as soon as you lie
down, pulmonary edema due to left heart failure should be considered in a
cough that occurs a few hours after lying down, and asthma should be
considered in a cough that occurs in the morning. Cough that occurs when you
wake up in the morning is especially seen in smokers and patients with chronic
bronchitis and bronchiectasis.
 2. Dyspnea
 Breathing is regulated by the brainstem and is generally an involuntary event. When the
person becomes aware of his/her breathing and breathing becomes difficult and
voluntary, it is expressed as "shortness of breath" or "dyspnea".
 In a case presenting with dyspnea, the onset of dyspnea, the presence of wheezing, the
degree of dyspnea, the presence of triggering factors and its relationship with exercise
and position should be questioned.
 Sudden onset of dyspnea is a symptom of a serious condition that requires urgent
investigation. Slowly progressive dyspnea is often associated with chronic pulmonary
diseases.
 Wheezing accompanying dyspnea can be considered as an indication that dyspnea is
associated with respiratory system diseases.
 A person's exercise capacity reflects the degree of shortness of breath. Shortness of
breath, even at rest, is the most severe shortness of breath.
 Shortness of breath should be considered serious in cases that cannot complete their
sentences, speak in interrupted words, cannot lie on their back (supine position), or feel
the need to sit down.
 Dyspnea that occurs in the supine position and improves when sitting is
defined as orthopnea. It is usually seen in congestive heart failure, severe
COPD and diaphragm muscle weakness.
 The patient's need to sit or stand up due to dyspnea and air hunger after
lying down is paroxysmal nocturnal dyspnea and is usually a symptom of left
heart failure.
 Dyspnea that occurs when moving from a supine to a sitting position
(platypnea) is a symptom of chronic liver diseases and the presence of
pulmonary arteriovenous malformation.
 Waking up with dyspnea in the morning is a symptom of asthma.
 Patients with sleep apnea syndrome may also wake up at night with a feeling
of drowning and feel short of breath, but this feeling disappears within
seconds.
3. Hemoptysis
 Hemoptysis is defined as blood expectoration secondary to bleeding in the
lower respiratory tract. The amount of expectorated blood can be seen in a
wide range, from streaking in the sputum to spitting pure blood.
 The most common causes of hemoptysis are; bronchogenic carcinoma,
bronchiectasis, tuberculosis, bronchitis, bacterial pneumonia

4. Chest Pain
 In a case presenting with chest pain, the onset, localization, spread, nature
of the pain, and factors affecting the pain should be questioned.
 It may have an acute or insidious onset. In acute onset pain, pulmonary
thromboembolism, spontaneous pneumothorax, myocardial infarction, angina
and dissecting aortic aneurysm should be considered.
 The pain of pleural diseases is usually localized to the location of the
pathology. Pain due to chest wall pathologies (rib fractures, etc.) is felt in
the area where the pathology occurs. Pain of cardiac origin is felt on the
left chest, pain due to gastric pathologies is felt behind the sternum, and
pain due to dissecting aortic aneurysm is felt between the two scapulae.

 The spread of chest pain can sometimes give an idea about the source of
the pain and the pathology that causes the pain. Pain due to cardiac
pathologies can spread to the left arm, neck and jaw.

 Pleural pain is stabbing and increases with deep inhalation or coughing. Pains
of cardiac origin are generally felt as pressure, squeezing after exertion,
and pains of reflux is felt as burning.
5. Spitting Sputum
 Coughing out secretions from the respiratory tract is called phlegm spitting.
In a person who spits up sputum, the amount, quality and daily amount of
sputum should be questioned.
 Mucoid sputum is a marker of increased bronchial secretion. It is
transparent or white in color. It is seen in viral infections, inflammatory
airway diseases such as asthma, COPD, bronchiolitis, and lung cancer.
 Purulent sputum has a yellow-green color due to the density of cell debris in
it and its fluidity has decreased.
 If purulent sputum also contains mucus, it can be described as
mucopurulent. It is a symptom of respiratory system infections.
 Serous sputum is foamy sputum like water. It is seen in some types of lung
cancer.
Respiratory System Assessment

 Inspection
 Palpation
 Percussion
 Auscultation
INSPECTION

 Cyanotic skin and mucosa have a blue-purple appearance. Cyanosis may be

central or peripheral.
 Central cyanosis develops due to inadequate oxygenation of arterial blood in
the lungs. O2 saturation in arterial blood is below 80%. The mucosa is
cyanotic, the extremities are warm, and cyanosis does not disappear with
warming.
 Peripheral cyanosis develops as a result of sufficient oxygenation in the
arterial blood, but excessive oxygen intake from the peripheral blood as a
result of slow circulation in the capillaries. O2 saturation in arterial blood is
normal, extremities are cold, and cyanosis disappears when warmed.
 Finger clubbing is a painless, non-sensitive enlargement of
the terminal phalanges of the fingers and toes, usually
bilaterally.

 Normally, there is an angle between the nail root and the

rest of the finger that does not exceed 160 degrees. In
the early stages of clubbing, this angle becomes flat, that
is, 180 degrees. Then, the soft tissue around the nail
gradually increases as it curves both horizontally and
longitudinally.
 Claude-Bernard-Horner Syndrome may develop as a result of the sympathetic nerve
being under pressure and paralyzing in the neck and upper chest due to a lung disease.
This Syndrome; It is characterized by myosis, ptosis, orbital collapse and lack of
sweating (anhidrosis) observed on one side of the face.
 In neck inspection, the participation of accessory muscles in breathing, neck swelling,
mass and color change in the neck, neck venous distention and edema are checked. It
is observed as pulsation in the jugular vein on the side of the neck and is a sign of
right heart failure.
 Diffuse edema in lung diseases can be seen in congestive heart failure
resulting from cor pulmonale or in conditions accompanied by renal failure.

 Wheezing along with dyspnea may be observed in asthma attack,

bronchiolitis or cardiac asthma (acute pulmonary edema).

 Stridor, which can be heard during inspiration and occurs in laryngeal and
tracheal stenosis, is a very important finding.

 In advanced emphysema-COPD and cases that occupy space in the

mediastinum, the Adam's apple approaches the upper edge of the sternum
due to the downward pull of the trachea. The gap, which should normally be
2-2.5 cm, narrows. This is called tracheal tug.
Evaluation of respiration:
 During inspection, the rate, rhythm and depth of breathing should be observed. Chest
rises and falls are counted without the patient being aware that the respiratory rate is
being counted. Stopping breathing for more than 10 seconds is called apnea, increasing
its depth is called hyperpnea, and decreasing its depth is called hypopnea.

 Respiratory Type:
 Diaphragmatic breathing; synchronized movement of the upper and lower ribcage and
abdomen. Thoracic breathing; upper ribcage movement predominates.

 Respiratory Rate:
 Normal Respiratory Rate: 12-20 /min.
 Tachypnea: >20/min. (Situations that cause hypoxemia, etc.)
 Bradypnea: <12/min. (Trauma, drug intoxication)
 Apnea: Respiratory arrest for more than 10 seconds (Cardiac arrest, drug intoxication,
obstructive sleep apnea)
 Hyperventilation: It is the condition in which the rate and depth of breathing increase
together.
 Hypoventilation: It is the condition in which the respiratory rate and depth decrease
together.
 Cheyne-Stokes Breathing: Breathing stops for a short time and gradually begins to become
superficial. It gets deeper and deeper. It accelerates and stops again. It is observed in conditions
such as central nervous system diseases, congestive heart failure, and respiratory suppression due
to medications.
 Kussmaul Breathing: Breathing is frequent and deep. It is observed in metabolic acidosis.
 Biot Breathing: Irregular breathing characterized by periods of tachypnea and apnea. Breathing
other than long apnea periods; It can be slow and deep or fast and superficial. It is observed in
cases such as increased intracranial pressure, brain damage, and respiratory suppression due to
medications.
 Stridor: It resembles the sound of forced air passing through a narrow tube during inspiration. The
intercostal muscles are pulled in during inspiration (intercostal retraction).

Increased
Central nervous system
Cardiac intracranial
diseases (brain damage),
Arrest, pressure,
Congestive heart failure,
Obstructive Respiratory
Respiratory suppression metabolic
sleep suppression due
due to medications, acidosis
apnea to drugs, brain
syndrome damage (at
old age pneumonia
medullary level)
Rib cage deformities

 Pectus excavatum (Shoemaker's chest): It is a congenital disorder. The lower part of

the sternum corpus is sunken inwards. It occurs due to incomplete development of the
anterior diaphragmatic muscle.
 Pectus carinatum (Pigeon chest): It is congenital. The lower part of the sternum is
projected forward. It is caused by a congenital anomaly of the diaphragm.
 Flail chest; Fracture of at least two ribs in at least two places. The broken segment
moves inward during inhalation and outward during exhalation (paradoxical movement)
 Scoliosis, kyphoscoliosis
 Paradoxical breathing (abdominal/upper chest): Drawing in during inspiration and moving
out during expiration occurs.

Anteroposterior pectus pectus

kyphosis
diameter increase excavatus carinatus
 PALPATION

The following evaluations are made during palpation:

 Palpation of the trachea and evaluation of the upper mediastinum

 Evaluation of the hemithorax's participation in breathing (expansion)
 Chest wall vibration examination (vibration thoracic, tactile fremitus)
 Muscular activity of the chest wall and diaphragm
Trachea Palpation and Evaluation of the Upper Mediastinum
 Palpation of the trachea is performed with the patient in a sitting position,
the chin in the midline and the head tilted slightly forward.
 If the trachea is in its normal position, the therapist's index finger touches
soft tissues medial to the SCM with an equal width on both sides.
 When the trachea slides to one side, the angle on the side it slides is
narrowed and the finger touches the hard cartilages of the trachea; On the
opposite side, it touches soft tissues at a wide angle.
 In the presence of atelectasis, the trachea is displaced towards the
collapsed side. In cases such as widespread pleural effusion and
pneumothorax, the trachea is displaced to the opposite side.
 Evaluation of the Respiratory Participation (Expansion) of the
Hemithoraxes
 When the patient takes a deep breath, the distances the thumbs move away from the midline
are compared. Normally these distances are equal, approximately 3-5 cm. The upper lobe (thumb
under the clavicles, other hands towards the trapezium), middle lobe (4th rib level) and lower
lobes (posteriorly) are evaluated respectively.
 In cases such as severe pneumothorax, excessive pleural fluid, atelectasis, extensive pneumonia,
rib fractures, and pleural fibrosis, respiratory participation in the semi-chest on that side may
decrease significantly.
 Chest circumference measurements are made with a tape measure from the axillary (2nd
costosternal joint), xiphoid and subcostal (middle umblicus-xiphoid) regions.
 Vocal Fremitus (Vibration Thoracic, Tactile Fremitus)
 Vocal fremitus is an examination performed by evaluating the vibrations transmitted to
the chest wall by feeling them during palpation.
 For thorax vibration examination, while the chest wall is palpated symmetrically, the
patient is asked to repeat out loud one of the high vibration words such as "ninety-nine"
or "blue moon".
 It is evaluated comparatively using the palmar surfaces of the fingers or the ulnar
surfaces of the hands.
 Vocal fremitus decreases or disappears in cases of pleural effusion,
pneumothorax, large masses without an open bronchus, atelectasis with a
completely obstructed bronchus (foreign body or tumor), and emphysema,
where lung tissue density decreases with hyperinflation.

 On the contrary, vocal fremitus increases in cases where the tissue density
of the lungs increases as a result of the alveoli being filled with exudate, in
consolidation areas where the bronchus remains open and therefore sound
waves are transmitted (pneumonia), and in diffuse interstitial fibrosis.

 Bilateral reduction of vocal fremitus can be found in obese or muscular

patients with COPD or an asthma attack with air trapping.
 PERCUSSION
 Lung percussion is an examination method in which the vibrations created by
hitting the chest wall and reflected from the tissues are evaluated to evaluate
the organs within the rib cage. In case of disease, the transmission and quality
of vibrations also change due to the change in normal tissue density.

 Percussed (underlying): Distal interphalangeal joint of the left middle finger.

Percussionist (in hammer position): It is the right middle finger and performs
this action with a light striking style. Each examination area or intercostal space
is tapped 2-3 times and the sounds heard are compared with symmetrical
percussion sounds in the same area in the opposite chest area. Strikes should be
from the wrist without moving the shoulder or elbow. It should be shot sharply,
quickly and precisely. No percussion is made on the scapula and vertebra.
 When struck on organs with high density, such as bones and liver, a dull sound
is produced, this is called dull sound or dullness. When the air-filled organs
with the least density (such as the stomach fundus) are hit, a higher-pitched
sound is produced, which is called tympanic sound.
 Since the lungs contain a unique air-tissue mixture, they produce neither a dull
nor a tympanic sound. This sound occurring on the lung parenchyma is called
sonor sound.
 When the amount of air in the lung increases (emphysema, air trapping,
pneumothorax), the voice becomes closer to the tympanum, which is called
hypersonor voice. A dull sound is heard when the amount of air in the lung
decreases (atelectasis) or when it is filled with a denser substance (pleural
fluid, hemothorax), or over a large mass or consolidated area.
AUSCULTATION

 Auscultation should be done at certain stations, symmetrically, sequentially,

and a respiratory cycle should be listened to at each station. The transition
to the other station should be synchronized with the waiting period
between two respiratory cycles, and the station should not be changed in
the middle of inspiration or expiration.

Sounds heard on auscultation:

 Normal breathing sounds
 abnormal breathing sounds
 additional sounds
 Pleural friction sound
Normal Breathing Sounds
 Normal breathing sound (vesicular sound): These are soft and low-intensity
breathing sounds that are normally heard on the chest wall during inspiration and
expiration. It is the sound in which the inspiration period is heard longer than the
expiration period, and the expiration is heard softer and at a slightly lower pitch.
 Tracheal breathing sound: It is a high-pitched, loud sound normally heard on the
trachea, similar to bronchial breathing, with equal inspiration and expiration times.
 Bronchial breath sound: It is a loud breathing sound in which inspiration and
expiration are close in duration, intensity and frequency. Bronchial sound can
normally be heard over the larynx and suprasternal fossa, around the 6th and 7th
cervical vertebra and the 1st and 2nd thoracic vertebra.
 Bronchovesicular breath sound: It is a breathing sound with a relatively lower
pitch, heard in the 1st and 2nd intercostal spaces at the lung apices and sternum
edges in the front, and in the interscapular area in the back, where the inspiration
and expiration times are close to each other.
BREATHAL SEVERI DURA INTENSITY OF PITCH OF NORMAL LOCALIZATION
SOUND TY TION EXPIRATORY EXPİRATORY
SOUNDS SOUNDS

Very loud Very high Sternal Notch

Loud High Over Manibrum

Middle Middle Apexes Anteriorly, 1st

And 2nd Intercostal
Space, Posterior
Interscapular Space
Soft Low Lung Parenchymal
Areas
 Abnormal Breath Sounds
 Normal breath sounds; It can be evaluated as an abnormal-pathological
sound by changing its intensity, direction and intensity.

 Decrease or disappearance of normal breathing sounds: Normal breathing

sounds are reduced in cases where thorax wall movements are restricted
(ankylosing spondylitis, neuromuscular diseases), pleural fluid,
pneumothorax, severe elevation of the diaphragm, severe emphysema and
atelectasis with complete airway obstruction.

 Increased (intensification) of normal breath sounds: The intensity of

normal breath sounds increases slightly in the presence of exercise, fever,
anemia, metabolic acidosis or single lung. When the air/solid ratio increases
in favor of solid, for example in pneumonia, the alveoli and bronchi are filled
with exudate rich in proteins that are more conductive than air, and since
the bronchi are open, respiratory sounds increase.
 Additional Voices

 Rales: These are non-continuous crackling/cracking sounds heard during

inspiration. Hearing rales indicates that the airway is full.

 Rales heard at the very beginning of inspiration are called coarse rales. It is
seen in chronic bronchitis and bronchiectasis, which cause edema,
inflammation, and increased mucus in the bronchi.
 Rales heard at the end of inspiration are called fine rales. It indicates that
the pathology is in the alveoli or interstitial region (pneumonia, pulmonary
edema, interstitial fibrosis).
 Ronchi: These are continuous, uninterrupted sounds. These are longer lasting
sounds, rather than short ones like rales. There are two types: Sibilan and
sonor.

 Sibilan Rhonchi (wheezing); They are additional high-pitched (high-frequency),

musical-character sounds that originate from small bronchi and bronchioles,
created by high-speed airflow through narrowed airways. It is similar to the
crowing or whistling sound that occurs when blowing through a narrow pipe.
The cause of narrowing is bronchial smooth muscle contraction, as in asthma,
followed by edema, secretions, and is heard during expiration.
 Sonor Ronchi; They originate from medium and large bronchi or trachea. These
are low frequency sounds caused by excessive airway secretion. They are
rough, snoring sounds. They can disappear by coughing or expectoration. They
are heard during inspiration, expiration or both. They are seen in pulmonary
edema and pneumonia.
 Additional Lung Sounds

Lung Sounds Possible Features reasons

 Friction: Pleural friction sound is the Mechanism

term used for the sounds produced by rhonchi Sibilan Rhonchi Rapid airflow
through narrowed
High frequency,
often during
Asthma,
Congestive heart
inflamed or rough pleural surfaces bronchi due to expiration failure, acute
bronchospasm and Bronchitis, Viral
rubbing against each other during mucosal edema Infection

breathing. sonorous Due to rapid airflow Low frequency, Chronic

rhonchi passing through disappears due Bronchitis, acute
 It resembles a series of squeaking narrowed large to coughing up infections with

sounds heard at the end of inspiration

airways filled with secretions increased
secretions secretions,
and at the beginning of expiration. It is Bronchiectasis
Raller Inspiratory and Excessive airway Rough and often Bronchitis,
best heard in the lower lobes and Expiratory secretions moving disappears with Infections

disappears when breathing is held. with Airflow coughing

Early Sudden opening of Rare, heard Bronchitis
Inspiratory central bronchi through mouth, Emphysema
not affected by Asthma
cough
Late Inspiratory Sudden opening of Diffuse, occurs in Atelectasis,
peripheral airways thin dependent Pneumonia,
areas Pulmonary
Edema,
fibrosis
Pleural Frotman Pleural End-inspiratory- pneumonia,
Friction inflammation beginning- Pulmonary
Sound expiratory, does Infarction,
not disappear Fibrothorax
with coughing Uremia
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