Introduction to the program;

History taking and General

Examination of
Respiratory System
Nina Filippova
Our course
• Introduction to the program; History taking and General Examination
of Respiratory System
• Symptoms of Lung Disease Pathophysiology of Lung Disease
• Tests for Lung Diseases; Lung Diseases: Radiology Spirometry and
functional respiratory tests
https://upload.wikimedia.org/wikipedia/commons/thumb/
5/5e/Respiratory_system_complete_en.svg/1200px-
Respiratory_system_complete_en.svg.png
 Conductive zone of the respiratory
system (upper respiratory tract,
bronchi, bronchioli):

- conduction of air to gas exchange zone

- warming of the air
- passive removing of the foreign
particles and microorganism by ciliated
epithelium and mucus
- immune defense (macrophages,
neutrophils)

https://i.pinimg.com/originals/eb/e1/6f/
ebe16f5cffc897873071d0cde7640c5d.png https://biologydictionary.net/goblet-cells/
 https://bio.libretexts.org/Bookshelves/Human_Biology/Book
%3A_Human_Biology_(Wakim_and_Grewal)/ https://www.pharmacy180.com/article/
16%3A_Respiratory_System/ trachea-3657/
16.2%3A_Structure_and_Function_of_the_Respiratory_System

Respiratory zone of respiratory system

- gas exchange through alveolar capillary membrane
- removal of rest of particles and microorganisms (immune response)
- ACE production in endothelial cells of lower respiratory tract

https://www.pedilung.com/wp-
content/uploads/2015/12/Alveolus.-gas-
exchange.-Pulmonary-alveolus.jpg
https://radiologykey.com/pleura-chest-wall-diaphragm-and-miscellaneous-chest-disorders/ https://www.sciencedirect.com/science/article/pii/
B9780128029008000099

Pleura:
- secretion of lubricating fluid allowing the movement of the surfaces against each other during respiration
- lymphatic drainage – absorbtion of excessive fluid to the lymphatic system, so constant amount of fluid in pleural cavity
is present
 https://arts3science.wordpress.com/humanbeing/respiratory/
https://ptskills.co.uk/cardiovascular-system-structures-functions/ https://quizlet.com/au/517251023/bms192-topic-2-cardiovascular-system-part-7-
anatomy-of-pulmonary-circuit-systemic-arteries-and-veins-flash-cards/

Pulmonary artery: transport of non-oxygenated blood from RV to pulmonary circulation

Pulmonary veins: transport of oxygenated blood from lungs to LA and then to systemic circulation
Pulmonary endothelium: synthesizing of vasoconstrictors (ET-1 and 5-HT) and vasodilators (PGI2 and NO);
secreting of other biologically active substances
 https://www.linkedin.com/posts/dr-ioannis-stavrou-md-phd-fwams-
https://respiratory-research.biomedcentral.com/articles/10.1186/s12931-017-0679-6 993b0a112_innervation-of-the-lungs-activity-6561025518412660736-OFWC/?
trk=public_profile_like_view&originalSubdomain=gr

Innervation: parasympathetic and sympathetic motor fibers; visceral sensory fibers

Visceral sensory fibers: enter lungs through pulmonary plexus
Parasympathetic motor fibers – bronchoconstriction;
Sympathic motor fibers – bronchodilation
Complaints
Directly related to lungs affection
• Dyspnea (inspiratory, expiratory, mixed,
acute or chronic)
• Respiratory discomphort –very mild variant
of dyspnea)
• Cough (dry or with sputum, paroxysmal or
non-paroxysmal)
• Sputum (color, amount, transparency,
viscosity, smell, relation with body position
and other factors)
• Wheezing (heard by the patient or nearby
people)
• Hemopthisis or pulmonary bleeding
• Chest pain (pleural or due to PAH)
Related to the cause of condition or
complications
• Intoxication (fever, perspiration,
sometimes weight loss)
• Extrapulmonary manifestations of
allergy (hay fever, rhinitis, conjunctivitis,
atopic dermatitis)
• Right heart failure syndrome (edema of
foot, heaviness in right hypochondrium,
neck veins distention, increase of
abdomen size during the short period
(ascites), decreased urination)
Anamnesis: onset of the disease/exacerbation
• When started, what factors are related to the onset of the complain (in most
cases except the acute disease the complaints start some time before the
diagnosis is put)
• Severity of complaint at the onset of disease
• What factors were aggravating and what – diminishing;
• For pain syndrome – location, irradiation, what causes, what
eliminates/decreases, character of pain, intensity of pain
• Was there any physician consultation, treatment, medical examination results;
results of treatment - improvement/no improvement/partial improvement
• What happened then – after discharge from hospital, for example, did he
follow the treatment and how the symptom modify
Anamnesis: next step
• How it was between the exacerbations, progression or stability, frequency of
symptoms (for example, dyspnea or respiratory discomphort or wheezing),
treatment, physician observation if present
• Next exacerbation – see previous slide
• All information given in chronological order, for allergic asthma case history is
starting from the allergy symptoms (usually in infancy); for COPD – from start of
smoking, for cancer – from start of smoking and COPD symptoms. Try to find the
key – when were the first manifestations of the syndrome and how it developed
• Special attention and detalization – to the last 1 yr – 6 mo – 3 mo – 1 mo – last
days before the last exacerbation/hospitalization. This is the condition You are
going to treat now, so details are extremely important
 Directly related to lungs affection
• Cyanosis (central or systemic, for lungs diseases systemic is typical, but in minor cases can be seen in lips and tongue only
due to more close vessels location and more thin mucosal layer related to the skin; usually at SpO<90)
• Clubbing (systemic hypoxemia); compensatory polycytemia syndrome
• Breathing pattern disorder
• Chest shape changes
• Lung consolidation syndrome (dull percussion sound, increased bronchophony or vocal fremitus, bronchial or harsh
respiration)
• Rales (moist rales), caliber of rales depend on the condition, small caliber in pneumonia and pulmonary congestion (fluid
in alveoli), middle and large in bronchoectases and cavitary lesions (fluid in lesions)
• Crepitations – air appears in edematous alveoli
• Dry/Velcro rales – edema of alveolar wall in interstitial lung disease (to hear – like pack in the hands)
• Rhonchi – large or moderate caliber, due to air passing through large bronchi in which there are excudates fibers
• Wheezing – small caliber, more at expiration, sometimes heard only at expiration, usually associated with harsh respiration
with prolonged expiration phase
• Emphysema – barrel chest shape, horizontal ribs, rigidity of chest, increased air in lungs (bandbox sound, diminished
respiration)
• Pleural excudation (dull percussion sound with oblique upper border line with maximal in axillar zone, no respiration,
displacement of mediastinum healthy side
• Athelectasis (dull percussion sound, decreased respiration, displacement to the affected side (no air)
 Physical examination

• Related to the cause of condition or complications

• intoxication: weight loss, “pillow sign” – wet upper back especially at

night
• Right chambers overload (neck veins distention, foot edema, liver
enlargement, cardiac beat, ascites, PII accent, may be functional murmur
at pulmonary artery or tricuspid valve)
https://dermnetnz.org/topics/skin-signs-of-respiratory-disease

Cyanosis, clubbing – signs of systemic

hypoxia
Chest inspection: chest shape
• Barrel shape
• Pigeon chest
• Pectus excavatum
• Rachitic chest
• cleft sternum
• asphyxiating thoracic dystrophy
• spondylothoracic dysplasia
Barrel chest: emphysema (increased air in
lungs due to bronchial obstruction)
• Obstruction leads to residual
volume increase and air
retention, fixing chest in
inspiration phase
• Broad chest resembling the
shape of a barrel
• Horisontal ribs
• Large rib cage
• Also resistant to compression in
https://www.facebook.com/medicine.in.picture/photos/barrel-chest-a-barrel-chest-
most of cases
means-a-broad-deep-chest-that-resembles-the-shape-of/1168811979941375/
Barrel chest (also in pink puffers and blue
bloaters)
•

https://ppt-online.org/552079
http://what-when-how.com/acp-medicine/chronic-obstructive-diseases-of-the-lung-part-2/
Barrel chest: general and Xray scheme

https://radiologykey.com/chronic-obstructive-pulmonary-disease-and-diseases-of-the-airways/
Barrel chest - Xray

https://radiologykey.com/chronic-obstructive-pulmonary-disease-and-diseases-of-the-airways/
Barrel chest – Xray, MRI and CT

https://epos.myesr.org/posterimage/esr/esti2014/125173/mediagallery/586168?deliveroriginal=1
Kyphosis, scoliosis
• May lead to the
restrictive
pattern and
PAH (in severe
cases)
Pectus carinatum (PC, or pigeon chest)
• overgrowth of the cartilage between
the ribs and the sternum
(breastbone), causing the middle of
the chest to stick out.
• more common in adolescent males
• May be due to Marfan syndrome,
kyphosis, scoliosis, abnormal growth
patterns, Ehler-Danlos syndrome and
more severe genetic disorders up to
Noonan syndrome etc
• Some patients may have pain in
cartilage zones, mild
dyspnea,tachypnoea, frequent
infections https://www.medicalnewstoday.com/articles/320836
Pectus carniatum

https://radiopaedia.org/articles/pectus-carinatum?lang=us
Pectus excavatum (sunken or “funnel” chest)
• Congenital chest wall deformity, in
which several ribs and the sternum are
growing abnormally so that anterior
chest wall is concave
• 1 in 300-400 births, male-to-female
ratio of 3:1.
• Chest and back pain, mild dyspnea,
scoliosus; pulmonary function vary
from normal to obstructive or
restrictive patterns in severe cases;
anyhow decreased pulmonary reserve
is present
https://emedicine.medscape.com/article/1004953-overview
 Xray, CT

https://radiopaedia.org/cases/pectus-excavatum-26
https://radiopaedia.org/cases/pectus-excavatum-7
 Other changes
Cleft sternum Asphyxiating thoracic dystrophy, or
Jeune syndrome (JS)
- rare congenital • autosomal
defect with failed recessive ciliopathy
midline fusion of the with multiple skeleto-
sternum. muscular abnormalities
•  very narrow thorax,
- complete and  shortened ribs; limb
incomplete forms. shortening
• Respiratory infections,
- leaves the heart and sometimes respiratory
great vessels distress after birth
unprotected

https://onlinelibrary.wiley.com/doi/abs/
https://www.semanticscholar.org/paper/Primary-Closure-of-A-Sternal-Cleft-in-A-Neonate-Ramdial-Pillay/
10.1002/ajmg.a.32962
f3fac2b71887e84b459158cbd9eac8b878209224/figure/0
 Spondylothoracic dysplasia (STD,
Jarcho-Levin syndrome)

• congenital rare disorder manifesting by multiple malformations affecting the spine and ribs.
• portion of the spine supporting the chest is extremely shortened.
• Disproportionally small deformed trunk
• Characterized by restrictive lung disease and PAH due to chest abnormality; in infancy – respiratory
https://onlinelibrary.wiley.com/doi/

distress syndrome possible abs/10.1002/ajmg.a.30011

Dynamic inspection
• Accessory muscles involvement, tripoid position
• Participation of parts of chest in breathing (delay – in pleural
excudation, adhesions, postoperative conditions)
• Types of respiration: thoracic, abdominal, mixed
• Respiration rhythm – regular, irregular
• Respiration rate – normal (16-20 per minute), tachy- or
bradypnoe
Normal and pathological respiration patterns
Normal breathing:
inspiration due to external rib muscles and diaphragm;
At exercise or at pathological conditions:
expiration is passive increase RR and tidal volume
• Muscles of inspiration
• diaphragm
• contracts downward increasing intrathoracic cavity volume
• elevates lower ribs
• external intercostal muscles
• elevate lower ribs
• accessory muscles
• scalenus muscles
• elevate upper ribs
• scternocleidomastoid muscle
• elevate sternum

• Muscles of expiration
• internal and external oblique muscles, rectus abdominis,
transversus abdominis
• compress abdominal cavity and push diaphragm upward
• internal intercostal muscles
• pull ribs downward and inward
https://step1.medbullets.com/respiratory/117007/muscles-of-respiration
Accessory muscles involvement in COPD patient
(note chest and neck hyperemia – compensatory polycytemia
syndrome)

https://www.physio-pedia.com/Muscles_of_Respiration https://www.google.com/search?
q=use+of+accessory+muscles&sxsrf=ALiCzsZKnNkcqxYl9YKrbPMpIqKJqPboHw:1665216177914&source=lnms&tbm=isch&sa=X&ved=2ahUKEwjkwI
jWldD6AhWWHOwKHRMYCCUQ_AUoAXoECAMQAw&biw=1246&bih=520&dpr=1.5#imgrc=Hk4SK6ArtuYbqM

Patients’ video https://www.youtube.com/watch?v=kPWovH4fpFg; https://www.youtube.com/watch?v=U5nrX-RN7hQ

 Breathing through pursed lips (emphysema)

https://www.google.com/search?q=Breathing+through+pursed+lips+pathogenesis&tbm=isch&ved=2ahUKEwiXvJnVvNP6AhVRyxoKHVdoCGAQ2-
https://www.researchgate.net/figure/Pursed-lip-breathing_fig1_6289149 cCegQIABAA&oq=Breathing+through+pursed+lips+pathogenesis&gs_lcp=CgNpbWcQAzoECCMQJzoECAAQHlCWnwxYncIMYLvEDGgAcAB4AIAB6wKIAbIWkg
EIMC4xNi4wLjGYAQCgAQGqAQtnd3Mtd2l6LWltZ8ABAQ&sclient=img&ei=POpCY5euEdGWa9fQoYAG&bih=577&biw=1246#imgrc=ACTR1AFi1qEHMM
Tripoid position

https://www.grepmed.com/images/2179/tripodding-breathing-clinical-position-photo https://www.ccjm.org/content/86/7/439
Knees changes due to prolonged tripoid
position sitting (Dahl’s sign, thinker sign)
hyperkeratotic skin hyperpigmentation

https://www.cureus.com/articles/27189-dahls-sign-an-indicator-of-
severe-chronic-obstructive-pulmonary-disease

https://www.ccjm.org/content/86/7/439
Other abnormal types of respiration

•  Breathing pattern results.

• (a) Eupnea,
• (b) bradypnea,
• (c) tachypnea,
• (d) Biot,
• (e) sighing,
• (f) Cheyne–Stokes,
• (g) Kussmaul,
• (h) CSA.
https://www.mdpi.com/1424-8220/21/20/6750/htm
• Kussmaul respirations
•  Fast, deep breaths in
response to metabolic
acidosis.
• Increase H+ load (DKA,
lactate acidosis)/reduced H+
excretion (renal tubular
acidosis)
• Targeting on removal carbon
dioxide
• Cheyne-Stokes respiration
• periodic breathing (waxing and
waning amplitude of flow or
tidal volume) with crescendo-
decrescendo pattern
• congestive heart failure, stroke
• Hyperventilation leads to fall of
PaCO 2levels triggering a central
apnoea; the apnoea leads to
increase of PaCO 2 leading to
hyperventilation
• Biot’s respiration
• irregular and rapid, with rhythmical
pauses lasting 10–30 s; and with
alternating periods of apnoea and
tachypnoea (clustered respiration)
• damage to the pons due to
stroke, trauma, or uncal
herniation.
• As the injury to the pons
progresses, the pattern becomes
irregular and pattern deteriorates
to ataxic breathing.
•  Sighing
• involuntary inspiration that
is 1.5 to 2 times greater
than normal tidal volume.
• observed in subjects with
from anxiety with no organic
pathology.
• Dyspnea is the subjective
sensation of difficulty
breathing
Sleep apnea:
obstructive, central and mixed (complex)
• Obstructive sleep apnea, • Central sleep apnea (CSA)
• Due to throat muscles • changes in the partial pressure of
relaxation CO2 (PCO2) which falls below
the apneic threshold
• Due to this transient reduction of
breathing rhythm generation by
pontomedullary zone
• in most of cases HF and opioid
use

https://www.alaskasleep.com/blog/types-of-sleep-apnea-explained-
obstructive-central-mixed
Palpation
• Tender areas
• Thorax resistance/elasticity
• Tactile vocal fremitus
• Epigastric angle
 Rigid thorax:

in emphysema

https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-
chest#11
Chest expansion
• chest wall movement during the
respiration
• Inspection while asking the patient
to take a deep breath in and out
• Then palpation maneuver –mostly
posteriorly, with the thumbs placed
together along the midline of the spine
and the 4 fingers held together with the https://www.ccjm.org/content/84/12/943
index finger below the 10th rib
• patient takes a deep breath, the
physician feels for asymmetric
movement of his or her thumbs
• More exact – direct measuring (4-6.5
cm)
• Decreases in emphysema, anlylosing
spondilitis
https://www.researchgate.net/figure/Measurement-procedure-of-a-upper-
chest-expansion-and-b-lower-CE_fig1_331353586
Tracheal deviation
• Put II and IV fingers of the right hand on
the sternal heads of each
sternocleidomastoid
• gently palpate the trachea above
downwards with your III finger along
tracheal rings feeling its direction.
• Normally slight deviation to the right
• Shifted trachea:
• To the side of fibrosis/athelectasis
• From the side of pleural
effusion/pneumothorax https://www.youtube.com/watch?v=TG9-lmnWuUk

• Not deviated in lung consolidation

Vocal fremitus
• Palpable vibration transmitted from
airways to skin through parenchyma
• In more dense parenchyma
(consolidation, compressive
athelectasis) – locally increases
https://www.youtube.com/watch?v=RaRqot7iXIU

• Locally decreases: fluid or air in

pleural cavity (decreases
transmission); fibrosis, (non-
functioning airways); obesity
(subcutaneous fat)
• Variants of voice: RRRR…, “ninety
nine”
• Auscultation equivalent -
bronchophonie https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#12
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://meded.ucsd.edu/clinicalmed/lung.html
https://meded.ucsd.edu/clinicalmed/lung.html
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
Right lateral view
https://meded.ucsd.edu/clinicalmed/lung.html
Left lateral view

https://meded.ucsd.edu/clinicalmed/lung.html
 Very good links for technique
of examination:
https://meded.ucsd.edu/clinic
almed/lung.html

https://rermedapps.com/respi
ratory-examination-osce-guide
/

https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://meded.ucsd.edu/clinicalmed/lung.html
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
 Mark lower
border
at maximum
inspiration
and maximum
expiration

https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
 Traube space (area)

https://www.youtube.com/watch?v=uJ96vJwtVFw
https://www.magonlinelibrary.com/doi/abs/10.12968/hmed.2011.72.Sup11.M166
https://ratedmedicine.wordpress.com/traubes-space/
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
https://slaidy.com/prezentacii-na-razlichnye-temy/percussion-of-the-lungs-palpation-of-the-chest#10
Clinical significance of percussion sound
changes
• Hyper-resonant – Pneumothorax
• Bandbox - emphysema
• Resonant – Normal Lung
• Mild dullness – moderate/small zone of consolidation
• Dull – Consolidation, Lung Fibrosis
• Stony Dull – Pleural Effusion
Normal distribution of the breath sounds

http://patfyz.medic.upjs.sk/simulatorvzorky/
Respiratory%20auscultation.htm
Breath sounds
• Vesicular sounds:  soft, blowing or rustling; throughout “a” – harsh vesicular sound, occurring in bronchial
inspiration, continue without pause through expiration,
and then fade away about one third of the way through obstruction; prolonged expiration period is present
expiration but less than in bronchial one)
• Bronchial sounds: are high pitched, louder and
hollow-sounding; but not as harsh as tracheal breath
sounds. Expiratory sounds last longer than inspiratory
sounds or duration  is the same. Intensity of inspiration
and expiration is the same. There is a short gap between
inspiration and expiration.
• Bronchovesicular sounds:   softer than bronchial
sounds, but have a tubular quality; about equal during
inspiration and expiration; differences in pitch and
intensity are often more easily detected during expiration. https://slideplayer.com/slide/4154391/

• Tracheal breath sounds are heard over the trachea. https://www.semanticscholar.org/paper/Analysis-and-Automatic-Classification-of-Breath-Cohen-Landsberg/

These sounds are harsh and sound like air is being blown5a6315b38c3ec58573804b84f15183a753e9a19e/figure/1
through a pipe. Useful links
http://acoustics.eng.cam.ac.uk/biomedicine/acoustics-of-th
• Rare types – cavernous or amphoric respiration – over
large cavities e-lung-2/
http://patfyz.medic.upjs.sk/simulatorvzorky/Respiratory%20auscultation.htm
https://www.youtube.com/watch?v=DJ0cyDgaRQc
https://www.youtube.com/watch?v=2NvBk61ngDY
https://www.facebook.com/physiosthaan/photos/a.105619097871679/125347845898804/?type=3
 Additional sounds
• Rhonchi: medium and low caliber sounds (mucus fibers resonance in large bronchi)
• Wheezing: high pitched; small airway obstruction; mainly expiratory and occurs
during both phases.
• Rales (fine crackles) -  high pitched sounds mostly heard in the lower lung bases
(fluid in alveoli)
• Coarse crackles – low pitched, more large caliber (bronchoectases, abscess)
• Velcro rales (sometimes called “dry rales”) - discontinuous, short explosive non-
musical sounds predominating during inspiration and best heard over dependent lung
regions - ILDs
• Squawks short inspiratory wheezes (200 ms; 200 - 300 Hz) in late inspiration often
preceded by late inspiratory crackles (pneumonia, ILDs, bronchiolitis obliterabce)
• Pleural (friction) rub is nonmusical, short,. biphasic (inspiro-expiratory)  explosive
sound (grating, rubbing, creaky, or leathery). Can be heard in simulation of respiration
(chest moving with closed nostrils)
Good links to listen the lung sounds
• https://www.youtube.com/watch?v=YgDiMpCZo0w
• https://www.youtube.com/watch?v=z2Ra9UxndI0
• https://www.youtube.com/watch?v=VIe350pTl8Q
• https://www.youtube.com/watch?v=yD2iiSsVgds
• https://www.youtube.com/watch?v=KRtAqeEGq2Q
• https://www.youtube.com/watch?v=eWGxuwVk3gs
• https://www.youtube.com/watch?v=_rHRPjsCu8U
• https://www.youtube.com/watch?v=WfkWMfE9VTY
Clinical symptoms of affection of respiratory
system
• Dyspnea:
• American Thoracic Society defines dyspnea as “a subjective
experience of breathing discomfort that consists of qualitatively
distinct sensations that vary in intensity.. .. 
• inspiratory (reduced respiration surface – alveoli);
• expiratory (bronchial obstruction);
• mixed (both components)
• 7% of patients in hospital emergency rooms and as many as 60% of
those in ambulatory pulmonological practice complain of dyspnea.
Useful link for more deep reading: differential diagnosis of dyspnea syndrome
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5247680/
Inspiratory dyspnea
Patient complaints on air
insufficiency at inspiration

-Decrease of respiratory surface of the lung

- Parenchymal diseases:
alveolar excudation, hemorrhage,
remodelling, fibrosis, large cavities or cysts
occupying space and squeezing normally
functioning parenchyma https://quizlet.com/602928519/chapter-8-respiratory-
system-flash-cards/
https://www.uptodate.com/contents/pneumonia-in-adults-beyond-the-
basics/print
- in LV heart failure - backup congestion
- athelectasis (tumor, foreign body) etc with
decreased air coming through the stenotic
bronchus to the lung
- Pleural exudate/transudate/pneumothorax
(squeezing of functioning parenchyma)

- Decrease of the blood flow (pulmonary

embolism)
- respiratory muscles failure and decrease of
respiratory movements (dermatomyositis for
example)
https://www.researchgate.net/figure/
Diagram-suggesting-pathologies-that-lead-
to-diffuse-alveolar-hemorrhage-DAH-
Shown-is_fig1_339145126
https://acil.med.harvard.edu/interstitial-lung-disease
Expiratory dyspnea
Complaints:
• Chest tightening
• Expiratory respiratory discomfort
• Impossibility to exhale the air
• Sensation of dilating of the chest
size (often with tightness)
• Frequently accompanied with
wheezes
• COPD – constant, progressive
• Asthma – variable during the day,
dependent on the conditions
• Bronchiolitis – constant, usually
related to viral infection or
autoimmunity
• Mixed (expiratory+inspiratiory) –
bronchoectases, some ILDs,
occupational diseases; in COPD if
emphysema is dominating
Evaluation of dyspnea: time

• acute onset, vs. chronic (present for more

than four weeks), vs. acute worsening of pre-
existing symptom

• intermittent vs. permanent

• episodic (attacks)
 Situational
•at rest

• exertion-related (distance in meters or kilometers, steps, stairs in case if

going upstairs, while performing simple domestic activity, while speaking)

• emotional stress - related

•body position –related (orthopnea, tripoid position etc)

• exposure(s) – related – allergens, irritants

•What improves (eliminates or diminishes) – stopping, beta-blockers,

nitrates, beta-mimetics etc)
 Diagnostic situations in patients with dyspnea:
•Patient has other symptoms of respiratory disease and they are dominating currently
(pneumonia, asthma, COPD etc)

•Patient has symptoms relating to the cardiovascular system and they are currently dominating
in his condition (MI, progressive angina, decompensated mitral stenosis, aggravation of heart
failure)

•mixed cardiac and pulmonary causes (but current condition usually is associated with
domination of either cardiac or pulmonary decompensation; in case if difficult to define, check
NT-BNP or BNP)

•other causes, e.g., anemia, thyroid disease, poor physical condition (i.e., muscle
deconditioning)

•mental causes
Cough
Cough: forced expulsive maneuver against the closed associated with
the characteristic sound
Chronic cough – longer than 6 weeks
Dry cough (often paroxysmal) – no secretions
Cough with sputum or upper airways secretions (moist cough)
The color and properties of secretions depend on the cause of the
cough
How to access the cough syndrome
• Dry or with sputum (sputum color, amount, smell, presence of blood)
• Duration: chronic (>6-8 weeks) or acute
• Paroxysmal or not
• Intensity
• What causes/worsens: allergens, infections, smoking procedure, body
position
• By what is accompanied (dyspnea, wheezing, intoxication syndrome,
pleural affection syndrome, lung parenchyma consolidation syndrome)
• What eliminates/improves: broncholytics, antibiotics, body position etc
 Causes of cough: key information
• Acute cough – respiratory viral infection, acute bronchitis, pneumonia, left ventricle failure, foreign body aspiration (stridor
mostly present)
• GERD - Isolated cough without other respiratory symptoms; acidic taste in mouth, worsening at bending or lying, after
excessive meal
• Upper respiratory tract (postnasal drip) – in case of upper respiratory system affection
• COPD – predominantly with sputum, cough itself may not attract so much attention (sputum expectoration almost without
cough)
• Asthma – paroxysmal, with viscous sputum, mostly accompanied by dyspnea, varies during the day, related to extrinsic
factors
• Bronchoectases – expectoration more than 10-50 ml sputum, more in certain body position, purulent sputum, hemopthisis
• Cystic fibrosis – same as bronchiectasis, very viscous sputum, male infertility
• Cancer – paroxysmal, more nocturnal, more in lying on back position, intensive and progressing during the short time, in
most of cases appearing in smokes after a long period of sputum expectoration (after COPD-like cough, the change of
pattern may attract attention of patient)
• Whooping cough - intensive
• ACEI use – cardio-patients, taking ACEI, dry cough
• Also possible at ILD (dry) and heart failure (may be small amount of transparent sputum), in both conditions dyspnea
Useful additional reading;
disturbs more than cough
https://www.aafp.org/pubs/afp/issues/2011/1015/p887.html#:~:text=The%20differential%20diagnosis%20for%20chronic,%2C%20psychogenic%20cough%2C%20and%20GERD.
https://bestpractice.bmj.com/topics/en-us/69
https://www.grepmed.com/images/10546/differential-causes-algorithm-chronic-diagnosis
Hemopthysis
• coughing of blood from a source below the glottis.
• can range from a small amount of blood-streaked
sputum to massive bleeding with life-threatening
consequences due to airway obstruction, hypoxemia,
and hemodynamic instability.
• Non-massive
• Massive - exceeding 600 mL of blood
• Pseudohemopthysis (non-respiratory sources)
Massive hemoptysis
• expectoration of blood from a source below the glottis
• exceeding 600 mL of blood
• over a 24-hour period
• or 150 mL of blood (which may flood the lung dead space)
• over a 1-hour period.
• Clinical effects:
• Airway compromise: obstruction, aspiration, hypoxemia, need for
intubation
• Hemodynamic instability
• Requirement for blood transfusion.
Hemopthisis
• Cancer!!! - age>40, smoking or occupational, dry paroxysmal cough
after long period of coughless sputum expectoration, repeated
pneumonias same location
• Bronchoectases – sputum 10-50 ml and more, recurrent infections,
focal changes with coarse rales, repeated pneumonias same location
• Pulmonary embolism – chest pain of pleural (related to respiration)
and retrosternal (PAH) character, presence of source (Wells and
Geneva scores)
• Tuberculosis – weight loss (may be severe), mild fever, perspiration
• Vasculitis, DAH (diffuse alveolar hemorrhage)
https://www.aafp.org/pubs/afp/issues/2015/0215/p243.html#:~:text=Differential%20Diagnosis&text=In
%20outpatient%20primary%20care%2C%20acute,diagnoses%20in%20patients%20with%20hemoptysis.
Pseudohemopthisis
• Hematemesis is aspirated into the lungs
• Bleeding from the upper airway or the mouth stimulates a cough reflex
• Material is expectorated that looks like blood but is not (e.g., Serratia
marcescens infection).
• Hemoptysis - bright red, frothy sputum that is alkaline.
• Blood from extrapulmonary sources: darker, may have admixed food
particles, and is acidic except brisk bleeding in the gastrointestinal
tract overcomes the acidic environment of the stomach.
• Bleeding from the posterior nasal passage or nasopharynx may mimic
hemoptysis without obvious epistaxis (see oral and nasal cavities)
Pseudohemopthisis – non-respiratory sources
of blood or red pigment

https://www.aafp.org/pubs/afp/issues/2015/0215/p243.html#:~:text=Differential%20Diagnosis&text=In%20outpatient
%20primary%20care%2C%20acute,diagnoses%20in%20patients%20with%20hemoptysis.
 Pain: pleural
• Cause – pleura is rich by the receptors including the
nociceptors
• Inflammatory process leads to rubbing of the leaflets,
so pain appears
• When leaflets are moving intensively, pain increases
(deep respiration, simulation of respiration with
closed nostrils); when patient fixes chest, it decreases
• sudden and intense sharp, stabbing, or burning pain
• localized in the chest (at the site of inflammation;
same zone pleural friction rub)
• Irradiation – at the zone of inflammation; If affection
near the diaphragm- neck or shoulder
• when inhaling and exhaling exacerbated by deep
breathing, coughing, sneezing, or laughing.
• . Decreases during fixing the chest and if fluid in chest
cavity accumulates (leaflets become separated from
each other by fluid)
https://www.dreamstime.com/pleurisy-pleuritis-disease-as-medical-lung-inflammation-outline-diagram-pleurisy-pleuritis-disease-as-medical-
lung-image241033676
More information here
ttps://www.aafp.org/pubs/afp/issues/2017/0901/p306.html
Pain: pulmonary hypertension
• Dull
• Retrosternal
• May radiate to back and
interscapular place
• May partially respond to
nitrates

https://my.clevelandclinic.org/health/diseases/6530-pulmonary-hypertension-ph
Pleural effusion
• collection of excessive fluid in the
pleural cavity
• Dullness with oblique border with
highest levels in axillar zones and
lower anteriorly and posteriorly (due
to accumulation of fluid in sinuses) –
(Ellis) - Damoiseau line
• No respiration heard (fluid between
the lungs and chest doesn’t conduct
sound)
• At the borders with normal tissues
friction rub may be
• In decubitus position line is
horisontal https://app.lecturio.com/#/article/2785
Pulmonary consolidation syndrome:
physical examination
• Dull sound during percussion
• Bronchial/bronchovesicular/harsh respiration
• Increased vocal fremitus and bronchophonie
(dense tissue between bronchi and chest wall –
inflamed lung tissue; it conducts the sound
better)
• Rales usually are heard (fluid in alveoli); mostly
fine type

• Causes (main)
• Pneumonia
• Cancer https://medschool.co/tests/chest-xray/pulmonary-consolidation

• Pulmonary embolism with pulmonary infarction

• Some more syndromes (masses, nodules,
cavities, interstitial changes) are
radiological
• During physical investigation in these
cases the patchy changes are revealed;
harsh respiration in zones increased
density; over the large cavities even
amphoric respiration which is very rare
• In cavities and interstitial changes the
rales are heard (in cavities coarse, in
interstitial fine)
Plan of investigation of pulmonary patient
• Hemogram:
• WBC, neutrophils increase, ESR increase –
inflammatory changes
• Eosinophils increase – some pulmonary eosinophilias,
asthma and allergy, excessive antibiotics use;
• Sputum analysis
• WBC, neutrophils - infection
• Eosinophils - some pulmonary eosinophilias, asthma
and allergy; same - Curshman spirals and Charcot-
Leiden crystals (resides of dead eosinophils – very rare,
in very high eosinophilia) https://www.researchgate.net/figure/Bronchial-washing-Charcot-Leyden-
crystals_fig4_326776440

https://www.facebook.com/PathologyDiscussionForum/posts/
curschmanns-spiralscurschmanns-spirals-are-a-microscopic-
finding-in-the-sputum-o/2080789248698017/
• TB examination
• Blood biochemistry depends on situation, but mostly screening
general includes bilirubin, glucose, ASAT, ALAT, K, Na, protein
• Chest X-ray (if not done), CT
• Pulmonary function test
Pulmonary function test
• Spirography: volumes, velocities
• Gas diffusion capacity – in
https://www.physio-pedia.com/Pulmonary_Function_Test
suspicion to interstitial lungs
disease
• Plethysmography: same as
spirography, but less depends on
subjective efforts of the patient
• Peak-flow – measuring by
patient (PEF only)
Spirometry

https://www.pulmonologyadvisor.com/home/decision-support-in-medicine/pulmonary-medicine/pulmonary-function-testing/

https://www.aapc.com/blog/45209-reach-full-capacity-of-pulmonary-function-test-coding/

.
https://partone.litfl com/spirometry.html
Main indicators
• VC - Vital capacity
• FVC - Forced vital capacity (during extensive expiration)
• FEV1 – forced expiratory volume during 1 second
• FEV1/FVC – Tiffneu test - general test for bronchial obstruction
expecially
• MEF – momentary expiratory flow
• PEF (peak flow)
• MEF 25 (MEF at 25% of FVC)
• MEF 50 (50% of FVC) MEF at 50% of FVC (mostly medium
bronchi)
• MEF 75% - MEF at 75% of FVC (mostly small bronchi)
https://www.nationaljewish.org/conditions/tests-procedures/pulmonary-physiology/pulmonary-function/spirometry

https://www.aapc.com/blog/45209-reach-full-capacity-of-pulmonary-function-test-coding/
Predicted values
• PFT indicators in individuals depend on sex, age,
height and weight
• To understand the normal values for every individual,
predicted values were introduced basing on all these
parameters
• Predicted values are the result of large number of
https://time.com/3583663/worlds-tallest-man-shortest-man-shaking-hands/
healthy people investigation
• Predicted values for all people on the pictures are
different, what is normal for small is the pathological
for tall one
• Because of this the indicators of PFT are given not only
in absolute levels, but also in % to predicted values
https://www.freepik.com/free-photo/selfassured-arrogant-young-female-
student-with-high-ego-standing-cocky-brag-about-herself-
pointi_19564401.htm
• FEV1 – forced expiratory volume - volume of
air that can forcibly be blown out in first 1-
second, after full inspiration
• FVC - Forced  vital capacity () - volume of air
that can forcibly be blown out after full
inspiration
• FEV1/FVC ratio: obstructive pattern <80%
• PEF- Peak expiratory flow - maximal flow (or
speed) achieved during the maximally forced
expiration initiated at full inspiration, measured
in liters per minute or in liters per second.
• Tidal volume - amount of air inhaled or exhaled
normally at rest.
• Total lung capacity (TLC) -
maximum volume of air present
in the lungs.
• Functional residual capacity –
volume, left in air after normal
expiration
• Residual volume – left in lungs
after maximal expiration
• Expiratory reserve volume – can
be exhaled after normal
exhalation
 Obstructive (COPD, asthma) Restrictive (interstitial lung disease,
decrease of working parenchyma)

• Decrease FEV1 more than decrease of FVC

• FEV1/FVC<80% in most of cases
• Decrease FVC more than
• PEF, MEF 50% and MEF 75% decreased decrease of FEV1
• Residual volume increased (excessive air • FEV1/FVC>80%
in lungs due to obstruction)
• Diffusion normal • Diffusion decreased (first
• Plethysmography: bronchial resistance sign, more early than FVC
increase, bronchial permeability decrease decrease)
Peak flow meter – individual device for in-
home obstruction measuring
• Deep inspiration
• Put tube in the mouth
while holding the breath
• Sharp quick expiration
• Repeat 3 times, fix the
worst value
• Measure 2-3 times daily
Chest X-ray

https://twitter.com/radiologistpage/status/1184855705884516352
https://www.grepmed.com/images/4275/cxr-clinical-radiology-anatomy-chestxray
 Good info also here
https://radiologykey.com/normal-anatomy-of-the-lungs/ https://radiologie.usmf.md/sites/default/files/inline-files/ENGL
_an.6_respiratory%20system.pdf
http://www.wikiradiography.net/page/Lung_Anatomy
http://www.wikiradiography.net/page/Lung_Anatomy
 1.Consolidation - any pathologic
process that fills the alveoli with fluid,
pus, blood, cells (including tumor cells)
or other substances resulting in lobar,
diffuse or multifocal ill-defined
opacities.
2.Interstitial - involvement of the
supporting tissue of the lung
parenchyma resulting in fine or coarse
reticular opacities or small nodules.
3.Nodule or mass - any space
occupying lesion either solitary or
multiple.
4.Atelectasis - collapse of a part of the
lung due to a decrease in the amount
of air in the alveoli resulting in volume
loss and increased density.
5. Cavities – defects (destructions)

https://radiologyassistant.nl/chest/chest-x-ray/lung-disease
Lobes in CT

https://radiologyassistant.nl/chest/hrct/basic-interpretation
Parenchymal changes - ground glass opacity
and consolidation
 Consolidation syndrome: CT
• pus, edema, blood or tumor
cell filling the alveoli
• Also advanced fibrotic tissue

https://radiopaedia.org/cases/lung-consolidation-1 https://quizlet.com/477486817/pneumonia-flash-cards/
Consolidation Xray
• airspace opacification
 causing obscuration of
pulmonary vessels
• air bronchograms
 Ground glass opacity: GGO
• either result of air space
disease
• filling of the alveoli – same
cause as consolidation but less
fluid amount
• or interstitial lung disease
(inflammation, fibrosis).
• On the picture – GGO and
fibrotic zone (seen as
consolidation)

https://radiologyassistant.nl/chest/hrct/basic-interpretation
GGO in COVID-2019
GGO on X-ray

https://www.itnonline.com/content/photo-gallery-how-covid-19-appears-medical-imaging

https://pubs.rsna.org/doi/full/10.1148/ryct.2020200028
 Secondary Pulmonary Lobule and Pulmonary Acini
• fundamental structure; smallest unit of the lung
• tertiary bronchi subdivide into the bronchioles
down to the level of the secondary lobules where
the terminal bronchioles are located.
• respiratory bronchioles are subdivisions of the
terminal bronchioles which connect with the
alveolar ducts and sacs that are responsible for
gas exchange.
• SPL is marginated by connective tissue septa
• SPL is generally polyhedral in shape and varies
in size, from 1 to 2.5 cm.
• At the center of the SPL, run a lobular
(preterminal) centrilobular bronchiole and a small
pulmonary artery branch.
• Within the connective tissue septa that marginate
the SPL run the veins and the lymphatics
https://radiologyassistant.nl/chest/hrct/basic-interpretation
Basic inter[pretation of the CT
What is the dominant HR-pattern:
• reticular
• nodular
• high attenuation (ground-glass, consolidation)
• low attenuation (emphysema, cystic)
• Where is it located within the secondary
lobule HR-pattern:
• centrilobular
• perilymphatic
• random
• Is there an upper versus lower zone or a
central versus peripheral predominance
• Are there additional findings:
• pleural fluid
• lymphadenopathy
• traction bronchiectasis

https://radiologyassistant.nl/chest/hrct/basic-interpretation
Foci distribution • Perilymphatic distribution
nodules are related to pleural
surfaces, interlobular septa and the
peribronchovascular interstitium.
Nodules are seen subpleural ,
particularly in relation to the fissures.
• Centrilobular distribution
spare pleural surfaces.
The most peripheral nodules are
centered 5-10mm from fissures or
the pleural surface.
• Random distribution
randomly distributed relative to
structures of the lung and secondary
lobule.
Perilymphatic distrubution

https://radiopaedia.org/articles/perilymphatic-lung-nodules
Clinical associations
Perilymphatic
• sarcoidosis (classic association)
• lymphangitic carcinomatosis: tends to
be interspersed with  • infection with endobronchial spread
interlobular septal thickening
• silicosis
• coal worker's pneumoconiosis: usually
simple coal worker's pneumoconiosis
• nodular pulmonary amyloidosis
• lymphocytic interstitial pneumonia (LI
P)
Centrilobular
• bronchiolitides
• obliterative bronchiolitis 3
• airway spread of tuberculosis
• airway spread of 
non-tuberculous mycobacterial infection
• airway invasive aspergillosis 3
• lung adenocarcinoma with airway spread
• non-fibrosing hypersensitivity pneumonitis 1
• respiratory bronchiolitis interstitial lung disease (
RB-ILD)
 
• pulmonary vasculitides
• eosinophilic granulomatosis with polyangiitis (EGPA) 4
Centrilobular

https://radiopaedia.org/articles/centrilobular-lung-nodules-1
Random distribution (mostly
hematogenous spread f focu)

https://radiopaedia.org/articles/random-pulmonary-nodules
Random distribution (left – miliary tuberculosis,
right – Langerhans cell histiocytosis)

https://radiologyassistant.nl/chest/hrct/basic-interpretation
Crazy paving
•  combination of ground
glass opacity with
superimposed septal
thickening
• Alveolar proteinosis
predominantly
 Tree-in-bud: bronchiolitis sign

https://www.semanticscholar.org/paper/Tree-in-bud-Attaya-Attaya/c97222bcc3205a5482e3bbab2e92a8631e960c80

https://radiologyassistant.nl/chest/hrct/basic-interpretation
https://journal.chestnet.org/article/S0012-3692(15)48699-4/fulltext
Low attenutation patterns
• decreased lung attenuation or air-
filled lesions.

• Emphysema
• Lung cysts
• Bronchiectasis
• Honeycombing

• Most diseases with a low attenuation

pattern can be readily distinguished
on the basis of HRCT findings.
Emphysema
areas of low attenuation • Centrilobular emphysema (clinically blue
without visible walls as a result bloater pattern more common)
of parenchymal destruction. • Most common type
• Irreversible destruction of alveolar walls in the
centrilobular portion of the lobule
• Upper lobe predominance and uneven distribution
• Strongly associated with smoking.
• Panlobular emphysema (clinically pink
puffer pattern more common)
• Affects the whole secondary lobule
• Lower lobe predominance
• In alpha-1-antitrypsin deficiency, but also seen in
smokers with advanced emphysema
• Paraseptal emphysema
• Adjacent to the pleura and interlobar fissures
• Can be isolated phenomenon in young adults, or in
older patients with centrilobular emphysema
• In young adults often associated with spontaneous
pneumothorax

Centrilobular emphysema:
https://radiologyassistant.nl/chest/hrct/basic-interpretation
Centrilobular vs panlobular

Panlobular emphysema: uniform destruction of the underlying

architecture of the secondary pulmonary lobules, leading to
widespread areas of abnormally low attenuation.
Cysts
• Lung cysts: radiolucent
areas with a wall thickness of
less than 4mm.

• Cavities: radiolucent areas

with a wall thickness of more
than 4mm and are seen in
infection (TB, Staph, fungal,
hydatid), septic emboli,
squamous cell carcinoma
and GPA
Bronchiectasis
• Bronchiectasis is defined as localized
bronchial dilatation.
The diagnosis of bronchiectasis is
usually based on a combination of the
following findings:
• bronchial dilatation (signet-ring sign)
• bronchial wall thickening
•
• mucus retention in the broncial lumen
•
• A signet-ring sign represents an axial
cut of a dilated bronchus (ring) with its
https://pubs.rsna.org/doi/abs/10.1148/rg.2015140214?journalCode=radiographics
accompanying small artery (signet).
https://radiologyassistant.nl/chest/hrct/basic-interpretation
Honeycombing
• presence of small cystic
spaces with irregularly
thickened walls composed
of fibrous tissue.

• predominate in the
peripheral and subpleural
lung regions