Respiratory Examination Essentials Quiz

Cryptogenic Fibrosing Alveolitis

Like 'creaking leather'

Consolidation or fibrosis

Generalised – Asthma / COPD; Localised – lung tumour

To detect if whispering is heard over a normal lung or in consolidation

To demonstrate an understanding of the process of respiratory examination, to detect signs of respiratory pathology on clinical examination, to relate clinical signs to underlying pathology, and to use history & examination findings to direct appropriate treatment/investigations.

Presenting complaint (PC), history of presenting complaint (HPC), past medical history (PMH), medication/allergies (DH), family history (FH), and social history (SH).

To gather information, refine the differential diagnosis, and use history and examination together to help reach a management plan.

They should be used together to help reach a management plan and not lose sight of findings from history.

Using history and examination together to direct appropriate treatment/investigations and to not lose sight of findings from history.

The key steps involved in the respiratory examination process include inspection, palpation, percussion, and auscultation, which are preceded by systems enquiry/review (SE), general inspection, and close inspection and palpation.

During close inspection and palpation in the respiratory examination, specific signs such as central cyanosis, nail clubbing, and tremors should be focused on as they can indicate underlying respiratory conditions.

Palpation in the respiratory examination is used to assess for Horner’s syndrome, polycythaemia, signs of hyperventilation or severe ventilatory failure, lymph nodes, tracheal position, and mediastinal abnormalities.

Percussion in the respiratory examination is performed at specific sites on the chest to assess resonance, which can help identify conditions such as emphysema, collapse, or pleural effusion.

The aim of the respiratory examination is to systematically assess the patient's respiratory system, identify abnormal findings, and guide further diagnostic and treatment decisions.

The bronchopulmonary segments are functionally independent units within the lung, each supplied by its own tertiary bronchus, artery, vein, and lymphatics. They are clinically significant because they can be individually removed or treated in cases of localized lung diseases or tumors.

The lungs are supplied by the pulmonary arteries and drained by the pulmonary veins. Lymph drainage occurs through lymphatic vessels that accompany the bronchial tree and connect to the pulmonary and bronchopulmonary lymph nodes.

The trachea is related anteriorly to the sternum, posteriorly to the esophagus, and laterally to the right and left brachiocephalic veins.

Each lung is enclosed within the pleural cavity and is surrounded by the diaphragm, ribs, and mediastinum. The right lung has three lobes, while the left lung has two lobes.

The conducting portion of the respiratory tract includes the nose, nasal cavity, paranasal sinuses, pharynx, larynx, trachea, bronchi, bronchial tree, and terminal bronchioles. The respiratory portion includes the respiratory bronchioles and alveoli for gas exchange.

The trachea is a cartilaginous tube that connects the larynx to the primary bronchi. It is composed of C-shaped cartilage rings with posterior trachealis muscle. Surrounding structures include the esophagus, thyroid gland, and various blood vessels and nerves. The neurovascular supply includes the inferior thyroid artery, bronchial arteries, and the pulmonary plexus.

The trachea contains ossified cartilage and ciliated pseudostratified columnar epithelium. Bronchi have smooth muscle and complete cartilage rings, while bronchioles have smooth muscle but no cartilage or glands. The alveoli are lined with a single cell layer and surrounded by capillary beds.

The lungs primarily function in gas exchange and pH balance. They are divided into right and left lobes, separated by fissures, and occupy the lateral parts of the thoracic cavity. They are connected via the hilum, which contains the vasculature and airways entering the lung.

The lung segments are supplied by tertiary (segmental) bronchi, with 10 segments per side. They have a pyramidal shape with apices converging towards the hilum and can be resected as one unit. Infections are typically confined to a segment.

The respiratory system is primarily responsible for gas exchange, maintaining pH balance, and contributing to other metabolic functions such as angiotensin conversion and prostaglandin synthesis.

The lungs are drained by bronchial veins, which drain to the azygous or hemiazygos vein, and pulmonary veins, which carry oxygenated blood towards the heart.

The pulmonary plexus, innervated by the vagus and sympathetic trunk, controls lung function, with parasympathetic input leading to bronchoconstriction and sympathetic input leading to bronchodilation.

Lung lymphatics include the subpleural plexus, intrapulmonary nodes, hilar nodes, tracheobronchial nodes, and paratracheal nodes, which play a role in draining the lower lobes of both lungs.

Clinical considerations for the lungs encompass conditions such as asthma, COPD, cancer, pneumothorax, pneumonia, cystic fibrosis, foreign body aspiration, pulmonary embolism, tracheostomy, and bronchoscopy.

Asthma, the most common lung condition, involves inflammation of the airways and is managed through a hierarchy of pharmacological treatment, including $\beta2$ adrenoreceptor agonists like salbutamol.

The global burden of tuberculosis is significant, with a high number of cases and deaths worldwide. It is considered a major Public Health problem due to its impact on population health, healthcare resources, and socio-economic development.

Mycobacterium tuberculosis causes infection and disease by invading the lungs and other parts of the body, leading to the formation of granulomas and the potential for active tuberculosis disease.

The strengths of current diagnostic methods for tuberculosis include their specificity and ability to detect the presence of Mycobacterium tuberculosis. However, limitations include the time required for results, resource requirements, and challenges in diagnosing extrapulmonary tuberculosis.

Current approaches to treatment of tuberculosis involve the use of combination drug therapy, directly observed treatment, short-course (DOTS), and the consideration of drug resistance patterns when selecting treatment regimens.

Different anti-TB drugs act through various mechanisms, including inhibition of cell wall synthesis, disruption of bacterial protein synthesis, interference with DNA replication, and other mechanisms to target and kill Mycobacterium tuberculosis.

Key discoveries related to tuberculosis include the discovery of Mycobacterium tuberculosis, the Bacillus Calmette-Guérin (BCG) vaccine, and the antibiotic streptomycin. These discoveries have significantly impacted the understanding and management of tuberculosis over time.

The World Health Organisation (WHO) annual report provides crucial insights into the global epidemiology, prevalence, and treatment outcomes of tuberculosis, guiding public health interventions and resource allocation for tuberculosis control and prevention.

The estimated TB incidence showed a fluctuating trend from 2016 to 2021, with variations in different years as reported by the WHO Global TB Reports.

The countries with TB incidence of 100,000 and above in 2019 and 2020 were reported in the WHO Global TB Reports for those respective years.

The percentage of new TB cases diagnosed by WHO approved rapid test in 2021 was reported in the WHO Global TB Report 2022.

The target year to end TB was set as 2035 according to the WHO Global TB Report 2019.

The impacts of COVID-19 on global TB control included increased stigma to TB symptoms, resources diverted to managing COVID-19, reduced access to diagnosis and treatment services, reduction in TB notifications, loss of employment and livelihoods, and excess deaths as mentioned in the WHO Global TB Reports for 2020 and 2021.

The reasons for the failure in global TB control included poverty and health system inadequacies as mentioned in the WHO Global TB Report 2021.

There was a sharp drop in TB case notifications in 2020 as reported by the WHO Global TB Report 2021.

The shrinking global economy put a strain on the available funds for TB response as mentioned in the WHO Global TB Reports for 2020 and 2021.