Respiratory system is very important in clinical setting. Every doctor must be aware about this system. As oxygen is important for life, similarly understanding of the respiratory system is essential for sustaining the medical practice of any doctor. Good aspect of this fact is that anybody can learn the entire respiratory system in a very simple way and theory of the respiratory system can be understood in one page and its usual practice in clinical setting makes every doctor confident in understanding of the respiratory system.
Common symptoms of diseases of the respiratory system are dyspnea, cough, fever, hemoptysis, chest pain, weight loss. So, just knowing the details about each symptom can help in making a provisional diagnosis of diseases of the respiratory system.
History-
Dyspnea or Dyspnoea is difficulty in breathing which may be in the form of breathlessness.
Cough may be dry of with sputum ( Expectoration).
Dry cough is commonly seen in Legionella.
Purulent Sputum- Klebsiella ( Thick Red Currant Jelly like sputum )
So, the history taking is important in making a diagnosis of respiratory system. History of tubercular contact is common in Tuberculosis. History of smoking is common in COPD and lung carcinoma. History of significant weight loss is common in Tuberculosis and lung carcinoma.
Clinical Examination of patients should be done in a systematic manner. Start with
Inspection-
On inspection alone certain diagnosis of respiratory system can be made. Measure respiratory rate, observe the pattern of the breathing ( abdominothoracic or thoracoabdominal), Dyspnea, use of accessory muscles of respiration, movement of the chest, any structural abnormality of the chest wall, curvature of the spine ( kyphosis, scoliosis ), any tumor of the chest, e.g., chondroma.
Palpation-
Extent of chest expansion can be measured by placing both palm across the spine and asking the patient to take deep breath.
On palpation of the chest wall cutaneous emhysema can be detected. Cutaneous emphysema is the air in the subcutaneous tissue of the chest and it feels like crepitations while compressing sknn over the chest wall.
Vocal fremitus is examined by placing the ulnar aspect of the hand over different areas of the chest wall feeling the vibration of the sound with and while patients produces repetitive words like one, one , one. Vocal fremitus is decreased in pleural effusion but it is increased in pneumonia.
Extent of any bony tumor like chondroma of the ribs or costochondral junction can be felt by palpation.
Fracture of the ribs can be detected on palpation. Tenderness of the chest wall can be detected on palpation. Any paraspinal collection or cold abscess can also be detected on palpation which is very common in Tuberculosis.
Percussion-
Placing the middle finger of of one hand over the chest wall and tapping with index finger of other hand will commonly elicit tympanic or dull percussion over the chest wall. The normal percussion sound over the lungs is tympanic. In hemothorax the percussion will be dull. In hydropneuomathorax it will dull below and tympanic in upper part of pneumothorax. In Pneumonia ( Consolidation of the lungs ) it is dull but this is stony dull in case of pleural effusion. Tympanic sound is increased in case of emphysema of the lungs. In pneumothorax the percussion is hyperresonant.
Auscultation-
Auscultation is done with stethoscope and all doctors should own a stethoscope. The usual breath sound are either vesicular or amphoric. The breath sounds are inreased in consolidation ,i.e., in pneumonia. The breath sounds are decreased, i.e., muffled, in pleural effusion. Breath sounds will be decreased in hemothorax.
Crepts are heard in lung infection, pulmonary edema.
Ronchi or whistle like sounds are heard in bronchoconstriction and in asthma.
So, the with clinical examination will be sufficient to make the diagnosis of tension pneumothorax.
Pleural effusion, pneumothorax, hydropneumothorax, pneumonia, emphysema can be provisionally diagnosed on clinical examination itself. It can further be clearly diagnosed with chest X ray.
Investigations-
Chest X-Ray Postero-anterior view (PA) is very common radiological investigation. It helps in diagnosis of rib fracture, flail chest, pneumothorax, hydropneumorax, COPD, brochiectasis, pleural effusion, Cor pulmonale, cardiomegaly, mediastinal widening, carcinoma ung, Tuberculosis, chest metastasis.
In Pnumonia, cosolidation or cavitation is seen on chest ray depending upon type of pneumonia
In consolidation, the lungs shadow appear radiopaque on chest x ray.
Lobar consolidation is seen in pneumococcal pneumonia.
Bibasal consolidation is seen in Legionella pneumonia.
Patchy shadows- Chlamydia psittaci. If Bilateral then Mycoplasma.
In cavitation, pneumonia is due to
Bilateral cavitation- Staphylococcal
Upper lobe cavitation- Klebsiella
Bilateral perihilar interstitial shadowing is seen in Pneumocystis carnii pneumonia.
Tram line ang ring shadows are seen in brochiectasis.
Spirometry can diagnose the restrictive and obstructive disease of the lungs.
FEV1 is helpful in the diagnosis of asthma.
V/Q scan ( Ventilation perfusion scan)
CT scan or HRCT ( High resolution CT scan) of the chest helps in the diagnosis of brochiectasis, and lung carcinoma.
Pulmonary angiography- clot in the 5th order pulmonary artery can be seen in Pulmoary embolism which usually occurs on 10th post operative day.
Bronchoscopy and biopsy
Montoux test, sputum culture and sensitivity test is useful in diagnosis of Tuberculosis.
Legionella serology
Treatment of respiratory diseases
Tension pneumothorax- Tension pneumothorax is a medical emergency. Tracheal deviation is noticed in a patient who complaints of sudden shortness of breaths and neck veins are distended. Patient becomes cyanosed. So, needle thoracocentesis is done immediately.
Pneumororax oxygen, needle aspiration, chest tube drain.
Hemothorax- chest tube drainage
Bronchogenic carcinoma- It can present with fever if there is secondary pneumonia and it requires antibiotic therapy. Surgery is for Non small cell lung cancer. Radiotherapy is treatment of choice if patient's age is more than 65 years.
Bronchiectasis- steroid inhaler, antibiotics if there is associated infection. Postural drainage.
Pneumonia-
Streptococcus pneumoniae- Ampicillin or cefuroxime
Legionella- Erythromycin
Staphylococcus- Flucloxacillin
Pneumocystis carnii pneumonia- high dose co-trimoxazole, or pentomidine
Pulmonary embolism-Anticoagulant
Acute pulmonary edema- Patient develops acute breathlessness and cough productive of frothy and pink sputum. Patient cannot lie flat & on examination crackles are present both mid zones with scattered wheezes. Treat it with IV Frusemide.
Acute astham attack- young patient presents with breathlessness and becomes too breathless to speak. There is tachycardia. Chest x ray may be normal. Treat with nebulized salbutamol.
Foreign body obstructing bronchial airway, patient is choked-Heimlich manoeuvre. Commonly observed that a person becomes suddenly breathless while eating. Person develos marked stridor, develops choking and drooling.
Pneumothorax and Pleural effusion- Needle aspiration. if recur, chest drain.
In PLAB examination, the common themes on which the questions are framed comprise of
1. Pneumonia- types of pneumonia, investigations, treatment of pnemonia
2. Hemoptysis- causes, investigations
3. Asthma- presentation, dignosis, treatment
4. Chest pain- causes, investigations, treatment
5. Breathlessness- causes, investigations
6. Pulmonary oedema- presentation, investigations, treatment
7, Cough- presentation, causes
8.Wheeze- investigation, treatment
9. Pleural effusion- presentation, investigations and treatment
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