Chapter 5 Respiratory system

Important for the examiner is the arrangement of the lobes of the lungs (Fig. 5.1). It will be seen that both lungs are divided into two and the right lung is divided again to form the middle lobe. The corresponding area on the left is the lingula, a division of the upper lobe. Examination of the front of the chest is largely that of the upper lobes, examination of the back is of the lower lobes.

Fig. 5.1 Lobes of the lung: anterior view (upper) and lateral view (lower).

SYMPTOMS OF RESPIRATORY DISEASE

Dyspnoea

Questions to ask: Dyspnoea

• Is the breathlessness recent or has it been present for some time?

• Is it constant or does it come and go?

• What can’t you do because of the breathlessness?

• What makes the breathing worse?

• Does anything make it better?

CAUSES OF BREATHLESSNESS

Differential diagnosis: Some causes of breathlessness

Control and movement of the chest wall and pleura

• Hyperventilation syndrome

• Hypothalamic lesions

• Neuromuscular disease

• Kyphoscoliosis

• Ankylosing spondylitis

• Pleural effusion and thickening

• Bilateral diaphragm paralysis

Diseases of the lungs

• Airways disease

– chronic bronchitis and emphysema

– asthma

– bronchiectasis

– cystic fibrosis

• Parenchymal disease

– pneumonia

– cryptogenic fibrosing alveolitis

– extrinsic allergic alveolitis

– primary and secondary tumour

– sarcoidosis

– pneumothorax

– pulmonary oedema

• Reduced blood supply

– pulmonary embolism

– anaemia

DURATION OF DYSPNOEA

Differential diagnosis: Duration of breathlessness

Immediate (minutes)

• Pulmonary embolism

• Pneumothorax

• Pulmonary oedema

• Asthma

Short (hours to days)

• Pulmonary oedema

• Pneumonia

• Asthma

• Pleural effusion

• Anaemia

Long (weeks to years)

• Chronic airflow limitation

• Cryptogenic fibrosing alveolitis

• Extrinsic allergic alveolitis

• Anaemia

ASTHMA

Asthma due solely to emotional causes probably does not exist; nonetheless, most patients who have asthma are worse if emotionally upset. Nocturnal asthma is very common.

Questions to ask: Asthma

• Does anything make any difference to the asthma?

• What happens if you are worried or upset?

• Does your chest wake you at night?

• Does cigarette smoke make any difference?

• Do household sprays affect you?

• Have you lost time from work/school?

• What happens when sweeping or dusting the house?

• Does exposure to cats or dogs make any difference?

SEVERITY OF DYSPNOEA

Severity can be assessed by rating scales, although it is much better to use some functional measure. Ask patients in what way their breathlessness restricts their activities: can they go upstairs, go shopping, wash the car or do the garden? If they are troubled with stairs, how many flights can they manage? It is important to be certain that any restriction is caused by breathlessness and not some other disability (e.g. an arthritic hip or angina).

ORTHOPNOEA AND PAROXYSMAL NOCTURNAL DYSPNOEA

Orthopnoea is defined as breathlessness lying flat but relieved by sitting up. It is common in patients with severe fixed airways obstruction.

Paroxysmal nocturnal dyspnoea is a feature of pulmonary oedema from left ventricular failure. However, many asthmatics develop bronchoconstriction in the night and wake with wheeze and breathlessness very similar to the symptoms of left ventricular failure.

Cough

Cough may be the only symptom in asthma, particularly childhood asthma. In children, cough occurring regularly after exercise or at night is virtually diagnostic of asthma.

Laryngitis will cause both cough and a hoarse voice. Cough from tracheitis is usually dry and painful. Cough from further down the airways is often associated with sputum production (bronchitis, bronchiectasis or pneumonia). Other possibilities are carcinoma, lung fibrosis and increased bronchial responsiveness. An often overlooked cause of cough is aspiration into the lungs from gastro-oesophageal reflux or a pharyngeal pouch. Cough will then follow meals or lying down. Prolonged coughing bouts can cause both unconsciousness from reduction of venous return to the brain (cough syncope) and also vomiting.

Sputum

Questions on frequency are most useful in the diagnosis of chronic bronchitis. An epidemiological definition of this is ‘sputum production on most days for 3 consecutive months for 2 successive years’. The diagnosis of bronchiectasis is made on a story of daily sputum production stretching back to childhood.

Sticky ‘rusty’ sputum is characteristic of lobar pneumonia, and frothy sputum with streaks of blood is seen in pulmonary oedema.

Questions to ask: Sputum

• What colour is the phlegm?

• How often do you bring it up?

• How much do you bring up?

• Do you have trouble getting it up?

Symptoms and signs: Sputum

White or grey

• Smoking

• Simple chronic bronchitis

• Asthma

Yellow or green

• Acute bronchitis

• Acute on chronic bronchitis

• Asthma

• Bronchiectasis

• Cystic fibrosis

Frothy, blood-streaked

• Pulmonary oedema

Haemoptysis

The blood in haemoptysis is usually bright red at first, then followed by progressively smaller and darker amounts.

All haemoptysis is potentially serious, although the most important is carcinoma of the bronchus. Repeated small haemoptysis every few days over a period of some weeks in a middle-aged smoker is virtually diagnostic of bronchial carcinoma.

Differential diagnosis: Haemoptysis

Common

• Infection including bronchiectasis

• Bronchial carcinoma

• Tuberculosis

• Pulmonary embolism and infarction

• No cause found

Uncommon

• Mitral stenosis and left ventricular failure

• Bronchial adenoma

• Idiopathic pulmonary haemosiderosis

• Anticoagulation and blood dyscrasias

Risk factors: Pulmonary embolism

• Previous deep venous thrombosis or pulmonary embolism

• Surgery

• Immobility, especially stroke and heart failure

• Malignancy

• Pregnancy

• Leg trauma

• Haematological abnormalities

Pain

The lungs and the visceral pleura are devoid of pain fibres, whereas the parietal pleura, chest wall and mediastinal structures are not. The characteristic ‘pleuritic pain’ is sharp, stabbing, worse on deep breathing and coughing and arises from either pleural inflammation or chest wall lesions. Inflammation of the pleura occurs chiefly in pneumonia and pulmonary infarction from pulmonary emboli. Pneumothorax can produce acute transient pleuritic pain.

Most pains from the chest wall are caused by localised muscle strain or rib fractures (persistent cough can cause the latter). These pains are often worse on twisting or turning or rolling over in bed. Bornholm disease is thought to be a viral infection of the intercostal muscles and produces very severe pain. True pleuritic pain is often accompanied by a pleural rub. A particular type of chest wall pain is caused by swelling of one or more of the upper costal cartilages (Tietze’s syndrome). Herpes zoster may cause pain in a root distribution round the chest.

Wheeze and stridor

WHEEZE

Wheeze occurs in both inspiration and expiration but is always louder in the latter. It implies airway narrowing and is common in asthma and chronic obstructive bronchitis. In asthma, the wheeze is episodic and clearly associated with shortness of breath, fulfilling the definition of ‘variable wheezy breathlessness’.

STRIDOR

Stridor is a harsh inspiratory and expiratory noise which can be imitated by adducting the vocal cords and breathing in and out.

Other important points in the history

OTHER BODY SYSTEMS

Lung disease can affect the right side of the heart (cor pulmonale). An early manifestation is peripheral oedema (ankle swelling). Disease of the left heart causes pulmonary oedema (orthopnoea, paroxysmal nocturnal dyspnoea, cough and frothy sputum). Systems that affect the lungs include rheumatoid arthritis, other connective tissue disease (scleroderma and dermatomyositis), immune deficiency syndromes (including AIDS) and renal failure. A variety of neuromuscular diseases and skeletal problems affect the mechanics of breathing.

Weight loss is an important manifestation of lung carcinoma. Less well known is chronic airflow limitation, caused presumably by the increased respiratory effort impairing appetite and diverting calories to the respiratory muscles. Chronic infection, particularly tuberculosis, causes weight loss.

Fever generally implies infection, particularly pneumonia or tuberculosis. If pulmonary embolism is suspected, pain or swelling in the legs suggests a deep venous thrombosis.

SLEEP

In the sleep apnoea syndrome, patients are aroused repeatedly in the night from obstruction of the upper airways.

Previous disease

A history of tuberculosis may explain abnormal shadowing on a chest radiograph. Bronchial damage from tuberculosis can lead to bronchiectasis.

Symptoms and signs: Clinical features suggesting the sleep apnoea syndrome

• Excessive daytime somnolence

• Intellectual deterioration and irritability

• Early-morning headaches

• Snoring

• Restless nights

• Social deteroriation (e.g. job, marriage, driving difficulties)

A history of wheeze in childhood suggests asthma. Whooping cough or pneumonia in childhood may lead to bronchiectasis.

Social history

SMOKING

Smoking is, for practical purposes, the cause of chronic bronchitis and carcinoma of the bronchus.

Ask non-smokers: ‘have you smoked in the past?’ The risk of disease increases with the amount smoked. Cigarettes are the most dangerous; pipes and cigars are not free of risk. Risk declines steadily when smoking stops; it takes 10–20 years for the risk of lung cancer to equal that of lifelong non-smokers.

Inhalation of another person’s smoke at home or at work is increasingly recognised as a factor in lung disease.

Risk factors: Lung cancer

• Smoking

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