378 Rapid Review Pathology

TABLE 17-1 Common Symptoms of Respiratory Disease

SYMPTOM CAUSES/DISCUSSION
Dyspnea Difculty with breathing
Due to stimulation of J receptors causing decrease in full inspiration
Causes:
Decreased compliance (e.g., interstitial brosis)
Increased airway resistance (e.g., chronic bronchitis)
Chest bellows disease (e.g., obesity, kyphoscoliosis)
Interstitial inammation/uid accumulation (e.g., left-sided heart failure)
Cough Cough receptors: located at bifurcations in airways, larynx, distal esophagus
Cough with a normal chest x-ray
Postnasal discharge is the most common cause
Nocturnal cough with:
GERD: due to acid reux in tracheobronchial tree at night
Bronchial asthma: due to bronchoconstriction
Productive cough with:
Chronic bronchitis: due to smoking cigarettes
Typical bacterial pneumonia
Bronchiectasis
Drugs causing cough:
ACE inhibitors: inhibit degradation of bradykinin; causes mucosal swelling and irritation in tracheobronchial tree
Aspirin: causes an increase in LT C-D-E
4
(bronchoconstrictors)
Hemoptysis Coughing up blood-tinged sputum
Mechanisms:
Parenchymal necrosis
Bronchial and/or pulmonary vessel damage
Causes:
Chronic bronchitis (most common cause)
Pneumonia, bronchogenic carcinoma
TB, bronchiectasis, aspergilloma (fungus living in a cavitary lesion)
ACE, Angiotensin-converting enzyme; GERD, gastroesophageal reux disease; LT, leukotriene; TB, tuberculosis.
TABLE 17-2 Signs of Respiratory Disease
SIGN DISCUSSION
Tachypnea Normal respiratory rate: 1420 breaths per minute (bpm) in adults; up to 44 bpm in children
Tachypnea: rapid shallow breathing (>20 bpm)
Causes: restrictive lung disease; pleuritic chest pain; pulmonary embolus with infarction (key
nding)
Chest Palpation
Tracheal shift Causes:
Pressure in contralateral lung: large tension pneumothorax, large pleural effusion
Decreased volume in ipsilateral lung: large spontaneous pneumothorax, resorption atelectasis
Vocal tactile fremitus Palpable thrill (vibration) transmitted through chest when patient says E or 1, 2, 3 or 99
Decreased vocal tactile fremitus with emphysema or asthma, with increased AP diameter from an
increase in total lung capacity
Absent vocal tactile fremitus with atelectasis (collapse of airways); uid (effusion); air
(pneumothorax) in pleural space
Increased tactile fremitus (sound travels well through consolidations) with alveolar consolidation
(e.g., lobar pneumonia)
Percussion Dull percussion with pleural effusion; lung consolidation; atelectasis (no air in the alveoli)
Hyperresonant percussion with pneumothorax; asthma; emphysema
Lung Sounds
General breath sounds Origin for normal breath sounds: trachea
Mechanism: air velocity and turbulence induce vibrations in airway walls
Sites modifying breath sound: terminal airway and alveolar disease modify breath sounds; sounds
heard with the stethoscope are produced in more central (hilar) regions and are altered in
intensity and tonal quality as they pass through pulmonary tissue to the periphery
Site for normal airway resistance: segmental bronchi (turbulent air ow)
Site for laminar airow: begins at the bronchiolessmall airway
Parallel branching: increases cross-sectional area of airways; converts turbulence into laminar
airow
Effects of inammation of small airways (e.g., asthma, chronic bronchitis): air trapping, wheezing,
increased airway resistance
Upper and Lower Respiratory Disorders 379
SIGN DISCUSSION
Tubular breath sounds Sound is like blowing air through a tube
Tracheal breath sound: normal sound over lateral neck or suprasternal notch
Bronchial breath sounds: always an abnormal sound
Loud, high-pitched sound with a peculiar hollow or tubular quality
Expiratory sounds longer than inspiratory
Signicance: consolidation (e.g., lobar/bronchopneumonia)
Mechanism: bronchi must be patent and partially collapsed
Alveolar
consolidation
(exudate,
transudate)
Partially
collapsed
bronchus
Associated with an air bronchogram: air-lled bronchi form silhouette against airless
consolidated parenchyma
Vesicular breath sounds Normal breath sounds: tracheal sounds that are modied (ltered) in alveoli
Sites: most lung elds except trachea and central bronchi
Inspiratory/expiratory ratio is 3 : 1
Present in: normal lungs; chronic bronchitis, emphysema
Diminished in: emphysema and asthma due to increased AP diameter
Absent in: pneumothorax; atelectasis; effusion
Bronchovesicular breath sounds Normal breath sounds heard over main bronchi
Abnormal if heard in lung periphery
Inspiratory and expiratory breath sounds are equal in length
Adventitial sounds Extra sounds that are normally absent in respiratory cycle
Crackles Crackles: usually inspiratory
Early and mid inspiratory crackles: due to secretions in proximal large to medium-sized airways
(e.g., chronic bronchitis); clear with coughing
Late inspiratory crackles: due to reopening of distal airways partially occluded by increased
interstitial pressure (e.g., interstitial uidpus, transudate in CHF); do not clear with coughing;
vary from ne to coarse
Causes: pulmonary edema; lobar pneumonia; interstitial brosis (e.g., sarcoidosis)
Wheezing Wheezing: high-pitched musical sound usually heard in expiration; sometimes inspiration and
expiration; expiration longer than inspiration
Causes: inammation of segmental bronchi, small airways (e.g., asthma, chronic bronchitis);
pulmonary edema constricting airway (called cardiac asthma); pulmonary infarction (release of
TXA
2
from platelets in embolus causes bronchoconstriction)
Rhonchi Rhonchi: low-pitched snoring sound heard during inspiration or expiration; due to secretions in
large airways (bronchus, trachea); usually clear with coughing; common in chronic bronchitis
Inspiratory stridor Inspiratory stridor: high-pitched inspiratory sound; sign of upper airway obstruction
Causes: epiglottitis (Haemophilus inuenzae); croup (parainuenza virus)
Inspiratory and expiratory stridor: sign of xed upper airway obstruction (e.g., from cancer)
Pleural friction rub Pleural friction rub: two inamed surfaces (pleural and parietal) rubbing against each other
Timing: end of inspiration and early part of expiration
Disappears: large effusion is present (separates inamed surfaces); holding breath (continues with
pericardial friction rub)
Causes: pleuritis due to cancer, infarction, pneumonia, serositis (SLE)
Grunting in newborns Grunting in newborns: always abnormal after 24 hours; common nding in RDS
Transmitted voice sounds Bronchophony (sound of bronchi)
Normal lung: spoken syllables or numbers (e.g., 99) are indistinctly heard
Alveolar consolidation: syllables/numbers heard louder and more distinctly
Whispered pectoriloquy (Latin for voice of chest): clear and intelligible words (e.g., patient
whispering 1, 2, 3)
Egophony (Greek for voice of goat): patient saying E sounds like A
AP, Anteroposterior; bpm, breaths per minute; CHF, congestive heart failure; RDS, respiratory distress syndrome; SLE, systemic lupus erythematosus; TXA
2
,
thromboxane A
2
.
TABLE 17-2 Signs of Respiratory Diseasecontd