Respiratory Medicine Diagnosis (PDF)

Diagnosis of Respiratory Disorders ANGELICA JOY B. ARAFAG, MD, FPCP, DPCCP Objective: At the end of the session you should be able to know and understand the diagnosis of respiratory disorders. Specific Objectives: 1.List the common presenting symptoms for patients with respirat...

Diagnosis of Respiratory Disorders ANGELICA JOY B. ARAFAG, MD, FPCP, DPCCP Objective: At the end of the session you should be able to know and understand the diagnosis of respiratory disorders. Specific Objectives: 1.List the common presenting symptoms for patients with respiratory disease 2.Describe the physical examination of the respiratory system 3.Explain the importance of chest radiography 4.Describe briefly the following diagnostic procedures in respiratory disease 4.1. Routine chest radiography 4.2. Computed tomography 4.3. Magnetic resonance imaging 4.4. Ultrasound 4.5. Collection of sputum 4.6. Percutaneous needle aspiration 4.7. Thoracentesis 4.8. Bronchoscopy  Approach to the Patient with Disease of the Respiratory System  respiratory system present with cough and/or dyspnea and fall into one of three major categories: (1) OBTRUCTIVE Obstructive pathophysiology is most common and primarily results from airway diseases, such as asthma Chronic obstructive pulmonary disease (COPD) Bronchiectasis, and bronchiolitis. (2) RESTRICTIVE Parenchymal lung diseases abnormalities of the chest wall and pleura neuromuscular disease.  three major categories: (3) VASCULAR DISEASES Pulmonary embolism Pulmonary hypertension pulmonary venoocclusive disease (SVC) Disorders can also be grouped according to gas exchange abnormalities, including 1. Hypoxemia 2. Hypercarbia 3. Combined impairment  HISTORY  Dyspnea and Cough DYSPNEA Dyspnea has many causes, some of which are not predominantly due to lung pathology. Patients with obstructive lung disease often complain of “chest tightness” or “inability to get a deep breath,” congestive heart failure more commonly report “air hunger” or a sense of suffocation. DYSPNEA The onset and the duration of a patient’s dyspnea are helpful in determining the etiology. Acute shortness of breath is usually associated with sudden physiologic changes, such as acute airway narrowing (e.g., laryngeal edema, bronchospasm, or mucus plugging), acute hypoxemia (e.g., pulmonary edema, pneumonia, or pulmonary embolism) sudden changes in the work of breathing (e.g., pneumothorax). Chronic Dyspnea Patients with COPD and idiopathic pulmonary fibrosis (IPF) experience a gradual progression of dyspnea on exertion (acute exacerbations of shortness of breath)  Dyspnea and Cough COUGH Forced expiratory effort against a closed glottis that opens with the expulsion of secretion and foreign particles out of the airways, producing a distinctive sound Most common adult OPD consult Affects approximately 10-12% of the population. female than male (2:1) Peak age at onset is the sixth decade.  Dyspnea and Cough COUGH Acute cough – Present for up to 3 weeks Subacute cough – Present for 3- 8 weeks Chronic cough – Present for >8 weeks  Dyspnea and Cough COUGH Acute cough productive of phlegm is often a symptom of infection of the respiratory system, including processes affecting the upper airway (e.g., sinusitis, tracheitis), the lower airways (e.g., bronchitis, bronchiectasis), and the lung parenchyma (e.g., pneumonia). Chronic cough (defined as that persisting for >8 weeks) is commonly associated with obstructive lung diseases, particularly asthma, COPD, and chronic bronchiectasis, as well as “nonrespiratory” diseases, such as gastroesophageal reflux and postnasal drip. Diffuse parenchymal lung diseases, including IPF, frequently present as a persistent, non- productive cough. OTHER SYMPTOMS: Wheezing, suggestive of airways disease, particularly asthma. Hemoptysis can be a symptom of a variety of lung diseases, including infections of the respiratory tract, bronchogenic carcinoma, and pulmonary embolism. Chest pain or discomfort can be respiratory in origin. As the lung parenchyma is not innervated with pain fibers, pain in the chest from respiratory disorders usually results from either diseases of the parietal pleura (e.g., pneumothorax) or pulmonary vascular diseases (e.g., pulmonary hypertension). All patients should be asked about current or previous cigarette smoking Predispose to COPD, bronchogenic lung cancer, parenchymal lung diseases E-cigarette or vaping use can lead to acute or subacute lung injury (i.e., E-cigarette or vaping use-associated lung injury [EVALI]). Secondhand smoke also increases risk for respiratory disorders, so patients should also be asked about parents, spouses, or housemates who smoke. Possible inhalational exposures at work (e.g., asbestos, silica) or home (e.g., wood smoke, excrement from pet birds) should be explored Travel predisposes to certain infections of the respiratory tract (tuberculosis) Potential exposure to fungi is increased in specific geographic regions or climates (e.g., Histoplasma capsulatum)  Physical Examination Inspection. Patients with respiratory disease may be in distress and using accessory muscles of respiration to breathe Severe kyphoscoliosis can result in restrictive pathophysiology. Inability to complete a sentence in conversation is generally a sign of severe impairment and should result in an expedited evaluation of the patient. Percussion used to establish diaphragm excursion and lung size In the setting of decreased breath sounds, percussion is used to distinguish between pleural effusions (dull to percussion) and pneumothorax (hyper-resonant).  Physical Examination Palpation Palpation can demonstrate subcutaneous air in the setting of barotrauma. used adjunctive assessment to determine whether an area of decreased breath sounds is due to consolidation (increased tactile fremitus) or a pleural effusion (decreased tactile fremitus). To detect unilateral disorders of ventilation, the symmetry and degree of chest wall expansion can be assessed AUSCULTATION: The majority of the manifestations of respiratory disease present as abnormalities of auscultation. Wheezes are a manifestation of airway obstruction. (asthma, peribronchial edema, congestive heart failure can also result in diffuse wheezes, as can any other process that causes narrowing of small airways.  Physical Examination Rhonchi obstruction of medium-sized airways, most often with secretions viral or bacterial bronchitis. Chronic rhonchi suggest bronchiectasis or COPD. Stridor is a high-pitched, focal inspiratory wheeze, usually heard over the neck as a manifestation of upper airway obstruction. Crackles, or rales, are commonly a sign of alveolar disease. alveoli with fluid may result in crackles, including pulmonary edema and pneumonia. Crackles in pulmonary edema are more prominent at the bases. Diseases that result in fibrosis of the interstitium (e.g., IPF) also result in crackles that sound like Velcro being ripped apart.  Physical Examination Egophony is the auscultation of the sound “AH” instead of “EEE” when a patient phonates “EEE.” change in note is due to abnormal sound transmission through consolidated parenchyma and is present in pneumonia but not in IPF. Areas of alveolar filling have increased whispered pectoriloquy as well as transmission of larger-airway sounds (i.e., bronchial breath sounds in a lung zone where vesicular breath sounds are expected). Other Systems Pedal edema if symmetric, may suggest cor pulmonale if asymmetric, it may be due to deep venous thrombosis and associated pulmonary embolism. Jugular Venous Distention sign of volume overload associated with right heart failure. Pulsus paradoxus sign in a patient with obstructive lung disease, as it is associated with significant negative intrathoracic (pleural) pressures required for ventilation and impending respiratory failure. Clubbing including cystic fibrosis, IPF, and lung cancer. Cyanosis seen in hypoxemic respiratory disorders that result in >5 g of deoxygenated hemoglobin/dL.  DIAGNOSTIC EVALUATION Pulmonary Function Testing The initial pulmonary function test obtained is spirometry. This study is an effort-dependent test used to assess for obstructive pathophysiology as seen in asthma, COPD, and bronchiectasis A diminished-forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) (often defined as