Specific symptoms - history Cough - productive (with sputum) - non productive (dry cough) hemoptysis hemoptoe Dyspnea Wheezing Chest pain Voice changes – hoarse, rancous, croaking, rattling Breathing Eupnoea means normal breathing with a frequency of 16 - 18 breaths per minute. Tachypnoea - manifests by increased breath frequency e.g. in anger, pain, fever, or in bronchopulmonary and cardiac disorders. Bradypnoea - means decreased breath frequency, e.g. in alcohol poisoning or intracranial hypertension. Apnoea - means halted breathing, may be temporary or permanent (death). Hyperpnoea - means deepened breathing, e.g. fever, severe anaemia, or acidosis, also called Kussmaul respiration (decompensated diabetes mellitus, uraemia). Periodical breathing (Cheyne-Stokes breathing) is characterised by an increasing speed and deepness of breathing, followed by speed and deepness decrease, apnoea appears and the cycle repeats. It occurs with severe cerebral apoplexy. During sleep it can be a marker of incipient left sided heart insufficiency. A. Respiratory frequency B. Respiratory depth – periodical breathing C.Mode of breathing – intercostal muscle abdominal muscle , diaphragm Dyspnea - breathlessness • It is a subjective feel of air deficiency, which need not express any objective sign. Physiologically it originates at excessive physical load, pathologically it is related to many diseases: Obstructive breathlessness - is conditioned by an obstruction in respiratory tract (mucus), by spasm (chronic obstructive bronchopulmonary disease, bronchial asthma) • Restrictive breathlessness - accompanies infiltrative processes (bronchopneumonia) or depressing by aneurysm, eventually atelectasis • Other reasons of breathlessness - metabolic disorders (diabetic coma, uraemia), heart diseases. •According to clinical manifestation we recognise: Inspiratory breathlessness - with more difficult inspiring (aspiration of foreign body, stenosis of larynx, compression of trachea and bronchi • Expiratory breathlessness - with remarkably prolonged expiring (bronchial asthma). Dyspnea - breathlessness anamnéza dušnosti příčiny dyspnoe podklad dyspnoe Cough - history scan0008 Cough - history kašel příčiny hemoptysa fyzikální vyšetření osnova fyzikální vyšetření hrudníku pic00061 cyanozy obrázek typy cyanozy pic00015 pic00022 Observation A normal thorax is symmetrical, widening evenly with breathing. It is necessary to notice possible breathlessness, cyanosis, or painful breathing before starting the physical examination. Shape variations of the thorax: Pyknic - the front-back diameter is longer, ribs stand horizontally. Asthenic - is long and flat. Funnel shaped - the inferior part of the sternum is intracted. Barrel-shaped - is short, fixed in the inspirational state, with a longer front-to-back diameter, occurs in emphysema or chronic bronchopulmonary obstructive disease. Kyphoscoliotic - is asymmetrical, with gibbus, dextro- or sinistroscoliosis, occurs in rickets during childhood. Avian (bird-like) - is characterised by swollen cartilaginous ends of the ribs after rickets. Retraction of hemithorax - may occur in atelectasis, because of adhesions, or after thoracoplasty. Thoracal arching - occurs with a massive pneumothorax or pleural exudate. deformity hrudníku kyfoskoliza jizva po cabg_pic01-22 During examination, it is possible to notice kyphosis or kyphoscoliosis. Post-operative scars after thoracotomy (lung and heart surgery) should also be concerned. Palpation Of the thoracic wall is used mainly for detection: of thoracic vibrations, a pleural frictional murmur, the quality of thoracic wall, tenderness, and resistance. Thoracic vibrations (fremitus pectoralis) are normally symmetrical on both halves of the thorax. Strengthened vibrations - are found over an infiltrated lung tissue (pneumonia, bronchopneumonia - better conductivity of the tissue). Weakened or missing vibrations - occur with fluidothorax or pneumothorax (isolating layer decreases conduction of the vibrations) and emphysema. technika perkuse technika poklepu příklad poklepu poklep přední stěny poklep zadní stěny hrudníku Percussion In healthy person it is full, bright, even on both halves of the thorax. typy poklepu Shortened - appears with a loss of air supply (pneumonia, atelectasis), with fluidothorax (the shape is parabolic with the top located in axilla). Hypersonic - is connected with excessive air supply (emphysema) or with pneumothorax, when it can be also tympanic poklep fyzikalni_plicni vysetreni typy poklepu typy dýchání auskultace Auscultation Under physiological circumstances, clear alveolar breathing is present over the lungs, without any side phenomena. Tubal or tubular breathing can only be heard over the upper sternum and between the scapulae. Alveolar breathing : Sharpened diffusely - during stronger breathing, e.g. acidotic breathing (decompensated diabetes mellitus, uraemia). unilaterally - compensatory manifestation (broad infiltration, compressio by fluidothorax). Weakened - present with emphysema, atelectasis, pleural exudate, and pneumothorax. With prolonged expiration - occurs with obstruction of the airways fyzikalni_plicni vysetreni patologie dýchacích šelestů přídatné zvuky výpotek_rtg_pic00006 fyzikalni_plicni vypotek rtg výpotek Pleural exudate Presence of fluid between the two pleural layers. It can be detected when the volume exceeds 500 ml. Usually without breathlessness, but it depends on the size of the exudate. Fremitus pectoralis weakened in the area of exudate. Percussion shortened or even obscured, edge in parabolic shape with the top in axilla. Near the upper edge the percussion is hypersonic or even tympanal (skodaic resonance). Bronchophony weakened. Kinds of exudates according to aetiology: Transudate - low amount of proteins, specific weight up to 1013 g/l, amount of proteins less then 30 g/l, appears most frequently in case of cardiac insufficiency. Exudate - high amount of proteins, specific weight higher then 1013 g/l, amount of proteins higher than 30 g/l, occurs in case of TBC, tumours, pleuropneumonia, or collagenoses. Empyema - means presence of pus in the pleural cavity. Haemothorax - presence of blood in the pleural cavity (trauma). Chylothorax - presence of lymph in the pleural cavity in case of a damaged thoracic duct. pneumonie_rtg_pic00001 fyzikalni_vysetreni_pneumonie rtg ca a bronchopneumonie_pic00009 Pneumonia (croupous) The finding described below is seen only rarely in practice, because of current antibiotic treatment. Breathlessness (may be manifested). Fremitus pectoralis strengthened. Percussion shortened. Initially, crepitations are audible (crepitus indux), later tubal breathing (phase of hepatisation), crepitations again (crepitus redux during resorbence), progressive weakening of tubal breathing. Bronchophony strengthened. rtg pneumothorax_pic00002 Pneumothorax presence of air in the pleural cavity (trauma, rupture of emphysematous bulla, iatrogenic origin). Breathlessness depends on the size and cause of the pneumothorax. Limited breathing movements of the affected half of thorax. Fremitus pectoralis weakened or missing. Percussion hypersonic. Breathing weakened or missing if the lung is completely collapsed. Bronchophony weakened. atelektaza vpravo_pic00007 fyzikalni_plicni atelektasa Atelectasis means loss of air supply to alveoli, bronchi, bronchioles, or the whole lung. The size of affection depends on its cause. In case of larger atelectasis there is breathlessness and cyanosis present. Fremitus pectoralis weakened. Percussion shortened. Breathing shortened. Bronchophony weakened. emfyzem_rtg_pic00005 emzyzem Emphysema Barrel-shaped thorax. Fremitus pectoralis weakened. Percussion hypersonic. Breathing alveolar, weakened. If there is a chronic bronchitis present, the dry or wet phenomena are often heard. Bronchophony weakened. acinus lung objemy plic abr rovnovaha volume Gas exchange respiratory failure diff dg severe dyspnoe plicni segmenty