Clinical Presentationin Respiratory System Disease

1) Respiratory Distress.a. Subjective.

i. Exertional Dyspnoea.ii. Orthopnoea.

b. Objective.i. Tachypnoea

ii. Inspirtory Retractionsiii. Active accessory muscles of respirationiv. Adventitious sounds

2) Cough.a. Dry.b. Productive.

3) Haemoptysis.4) Cyanosis.

a. Central.b. Peripheral.c. Chemical.

Respiratory DistressExertional DyspnoeaDyspnoea: subjective feeling of difficulty in breathing due to increased respiratory effort.Exertional: provoked or increased by physical activity

Types Physiologic: with more than usual daily activity Pathologic

- Psychogenic: mainly at rest, with frequent sighing- Organic

Grades1) Provoked by more than usual daily activity2) Provoked by usual daily activity3) Provoked by less than usual daily activity4) Present at rest

Progression to Grade 4 may occur over: Minutes (Acute Dyspnoea): foreign body aspiration, bronchial asthma,

pulmonary embolism Days: rapidly accumulating pleural effusion

Months: interstitial lung disease Years: emphysema

OrthopnoeaIt is dyspnoea produced or aggravated on lying down,relieved (partially or completely) in the upright position.

It may result from abdominal distension pushing the diaphragm upwards.

Objective Signs of Respiratory DistressTachypnoea

Normal adult rate: 12 – 20/min Tachypnoea is a common sign of respiratory distress. Respiration may be rapid and deep as well: acidotic or Kussmaul breathing.

Inspiratory Retractions Suprasternal, supraclavicular Intercostal Epigastric

Active Accessory Muscles of Respiration Sternomastoid Scalene Trapezius

Adventitious Sounds Wheezes (rhonchi): continuous musical sounds that denote bronchial obstruction Stridor: It sounds like wheezes but arises from obstruction of upper airway

(trachea, above). It is mainly an inspiratory sound.

CoughIt is forced expiratory effort against a closed glottis which then suddenly opens with a jet of air expelled out, possibly along with secretions.

Types Dry (Irritant): The irritant stimulus may be obvious (smoke, dust, pharyngitis)

and may not. Two common "concealed" causes of resistant dry cough are post- nasal discharge and GERD (gastro-oesophageal refflux disease).

Wet (Productive):- Frothy Pink: pulmonary oedema- Mucoid: bronchial asthma, chronic bronchitis- Mucopurulent, Purulent (yellowish, thick): infections- Rusty: lobar pneumonia- Greenish/Bluish: Gram negative infection- Foul Smelling: anaerobic infection

- Blackish: smoker, coal workers

HaemoptysisIt is coughing of blood or blood tinged sputum due to bleeding from the respiratory tract below the vocal cords.Bleeding originating above vocal cords (nose, mouth, larynx) may produce false haemoptysis.

Haemoptysis HaematemesisIt is Coughing of blood Vomiting of bloodColor Bright red Dark redOdor --- sourReaction alkaline acidicMixed with Sputum, air (frothy) foodSputum Blood tinged for 12 – 24 h after the attack normalStool normal melena

CyanosisIt is bluish discoloration of skin, mucous membranes due to presence of:

- > 5 gm deoxy Hb /100 mL blood Or - abnormal Hb (met or sulph Hb) in surface capillaries.

Normal level of deoxy Hb/100 mL blood:- Arterial: 0.75 gm- Capillary 2.25 gm- Venous 3.75 gm

EtiologyCentral Cyanosis ( O2 loading by cardiopulmonary circulation)

1) Hypoventilation- alveolar PO2: eg, high altitude- Obstructive lung diseases- Restrictive lung diseases

2) Shunt- Cardiac Rt to Lt shunt (congenital cyanotic heart disease): eg, Fallot

tetralogy- Pulmonary: pulmonary AV fistula

3) Diffusion Defect (Alveolo-Capillary Block)- Pulmonary fibrosis- Pulmonary oedema

4) Ventilation Perfusion (V/Q) Mismatch- Pulmonary embolism (ventilation > perfusion = dead space effect)

- Atelectasis/collapse (perfusion > ventilation = shunt effect)- Most pulmonary disorders produce hypoxia by more than one mechanism.

V/Q mismatch is the most common.

Peripheral Cyanosis Stagnant circulation Generalized Stagnation (low cardiac output)

- Heart failure- Shock

Localized Stagnation- Arterial:

o Lumen: thrombosis, embolismo Wall:

Spasm: Raynaud`s disease, ergotism Organic Changes: Buerger`s disease

o Outside: compression by space occupying lesion.- Venous: venous obstruction, eg Superior vena cava obstruction

peripheral cyanosis in tongue and lips (exceptional)

Chemical CyanosisAbnormal Hb causes:

Dark color by itself. Reducing the normal Hb, bec it has much higher affinity for O2

Causes of Methaemoglobinaemia: Congenital Nitrite producing intestinal flora (enterogenous cyanosis) Drugs: nitrates, sulphonamides

Central Cyanosis Peripheral CyanosisCause O2 saturation of core arterial

blood ( O2 loading by cardiopulmonary circulation)

Stagnant circulation - peripheral arterial flow- O2 extraction by tissues

Distribution Warm areas (tongue, interior of lips), all over

Cold areas: tip of nose, lobule of ear, fingers, toes

Temperature Warm ColdClubbing + -Polycythaemia + -Effect of- Exercise- Warming- Oxygen

May No effect to variable extent, maximal in low atmospheric PO2 and minimal in shunt

No effect

CyanosisHypoxia Type

CentralHypoxic Hypoxia

PeripheralStagnant Hypoxia

---Anaemic Hypoxia

---Histotoxic Hypoxia