Respiratory System

35% of all acute medical

Disease of the respiratory tract accounts for

admissions. Surgeons and anaesthetists are

more consultations with general practitioners

very interested in ensuring an adequate

than any other of the body systems. It is also

respiratory system in any patient who needs a

responsible for more new spells of inability to

general anaesthetic.

work and more days lost from work.

For example, asthma now affects

Radiologists, pathologists and microbiologists are intimately involved in the

approximately 10% of the population of many

diagnosis of lung conditions. Consequently,

Western countries; lung cancer is the most

doctors in many branches of medicine spend a

common male cancer and in some places has

very substantial portion of their professional

already exceeded breast cancer as the most

working life in the diagnosis and treatment of

common female malignancy. Tuberculosis, for

lung disease.

so long the staple of the respiratory physician

As with any other disease, a good history

is, after a long period of decline, increasing

is the basis for a diagnosis of lung disease

again. The respiratory complications of HIV

particularly as examination may be normal

infections have added to the burden. Increases

even in advanced disease. A good history is

in pollution, new industrial processes and the

aided by a knowledge of structure and

growing worldwide consumption of tobacco

function. Fortunately, two fairly

all have implications for the lungs. The

straightforward techniques, radiography and

average family practitioner, therefore, is likely

spirometry (the analysis of the volume of

to spend more of his working day examining

expired air overtime), illustrate normality and

the respiratory system than any other.

help the physician to understand the abnormal.

Respiratory disease is common in

hospital practice. It accounts for approximately

STRUCTRUE AND FUNCTION

4% of all hospital admissions and

The respiratory tract extends from the nose to

the.

app
rox
ima
tely

Fig. 5.1 arrangement of the major airways

the alveoli and includes not only the air

conducting passages but the blood supply as
well. The arrangement of the major airways is
shown in Figure 5.1. An appreciation of this
arrangement helps in the interpretation of
radiographs (Fig. 5.2) and is essential for the
bronchoscopist. More important for the
examiner is the arrangement of the lobes of the
lung (Fig. 5.3). 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 lingual, a
division of the upper lobe. Figure 5.4
transposes this pattern on to a person, outlining
the surface markings of the lungs.
Examination of the front of the chest is largely
that of the upper lobes, examination of the
back the lower lobes. It will be seen how much
Fig. 5.2 Normal radiograph: posteroanterior
view (left) and right lateral view (right)

more lung there is posteriorly than anteriorly,

so it comes as no surprise that lung disease
that primarily affects the bases is best detected
posteriorly. Note how much lung is against the
lateral chest wall. Students often examine a
narrow strip of chest down the front and the
back. Many signs are found laterally and in the
axilla.
Computerised tomography (CT) adds an
extra dimension to visualisation of the chest
(Figs 5.55.8).
The fine detail of the airways is
beautifully illustrated by wax injection models
(Fig. 5.9). The same technique can be used to
illustrate the intimate relationships between
the supply of blood and air to the lungs (Fig.
5.10).

cells, together with secretions from deeper in

the lungs, form a sheet of fluid which is
propelled upwards continuously by the beat of
the cilia lining the bronchial epithelium (Figs
5.11 and 5.12). This cilial action can fail either
from the rare immotile cilia syndromes or
commonly from cigarette smoke.
The chief defence of the alveoli is the
alveolar macrophage (Fig. 5.13) which in
conjunction with complement and
immunoglobulin ingests foreign material that
is then transported either up the airways or into
the pulmonary lymphatics. T and B
lymphocytes are present throughout the lung
substance and most of the immunoglobulin in
the lung is made locally. The blood supplies
neutrophils that pass into the lung structure in
inflammation.

LUNG DEFENCE AND HISTOLOGY

The lung is exposed to 6 1 of potentially
infected and irritant-laden air every minute.
There are, therefore, numerous defence
mechanisms to ensure survival. The nose
humidifies, warms and filters the air and
contains lymphocytes of the B series which
secrete immunoglobulin A. The epiglottis
protects the larynx from. inhalation of material
from the gastrointestinal tract.
The cough reflex is both a protective and
a clearing mechanism. Cough receptors are
found in the pharynx, larynx and larger
airways. A cough starts with a deep inspiration
followed by expiration against a closed glottis.
Glottal opening then allows a forceful jet of air
to be expelled.
The main clearance mechanism is the
remarkable mucociliary escalator. Bronchial
secretions from bronchial glands and goblet

Thus, alteration in pCO2 is the most important

factor in respiratory control in health.

The sensitivity of the medullary

chemoreceptor to pCO, can be reset either
upwards in prolonged ventilatory failure or
downwards as when a patient is placed on a
mechanical ventilator. The first situation is
most commonly seen in chronic airflow
limitation (chronic obstructive lung disease)
when patients may become dependent on
hypoxic drive to maintain respiration. The
injudicious administration of oxygen can then
lead to ventilatory failure and death. In the
second situation, weaning a patient away
from a ventilator is difficult because the
medullary centre demands a low pCO, that
cannot be maintained by the patient unaided.
Ventilation is largely performed by nerve
impulses in the phrenic nerve acting to
contract the diaphragm and expand the volume
of the chest. Scalene and intercostal muscles
act mainly by stabilising the chest wall. The
result is to decrease the pressure in the pleura
LUNG FUNCTION

(already less than atmospheric). As the air

The function of the lung is to oxygenate the

inside the airways is at atmospheric pressure,

blood and to remove carbon dioxide. To

the lungs must follow the chest wall through

achieve this, ventilation of the lungs is

pleural apposition and expand, sucking in air.

performed by the respiratory muscles under

Expiration is largely a passive process; when

the control of the respiratory centre in the

brain. The rhythm of breathing depends on
various inhibitory and excitatory mechanisms
within the brainstem. These -can be influenced
voluntarily from higher centres and from the
effect of chemoreceptors. The medullary or
central chemorecepors in the brainstem
respond to changes in partial pressure of
carbon dioxide in the blood (pCO2).
Chemoreceptors in the aortic and carotid body
respond to low partial pressure of oxygen
(pO2) but only when this falls below 8 kPa.

the muscles relax the lung recoils under the

influence of its own elasticity. Ventilation is,

When attempting to take as deep an inspiration

therefore, much more than just forcing air

as possible we are eventually stopped partly by

through tubes. Higher brain centres, the brain-

the resistance of the chest wall to further

stem, spinal cord, peripheral nerves, intercostal

deformation and partly by the inability to

muscles, spine, ribs and diaphragm are all

stretch the lung tissues any further (Fig- 5.14).

involved. Moreover, the lung tissue itself must

Total lung capacity (TLC) at one end is,

overcome its own inertia and stiffness.

therefore, largely influenced by this

Malfunction of any of these can lead to

stretchability or elasticity of the lung. The

respiratory failure.

stiffer the lung, as in fibrosis or scarring, the

Diaphragm function is in two parts:

less distensible it will be. Conversely, damage

contraction leads to descent of the diaphragm

to the elastic tissue of the lung (e.g.

and the costal parts elevate the lower ribs. A

emphysema) with destruction of the alveolar

common consequence of chronic airflow limit-

walls will make it more distensible leading to

ation and hyperinflation is a low flat

an increase in TLC. TLC is also high is some

diaphragm which may null the ribs inwards

patients with asthma and chronic obstructive

rather than out.

bronchitis probably because the lungs are

overexpanded in an attempt to widen the
airways.

ASSESSING RESPIRATORY FUNCTION

As the function of the lungs is to add oxygen
to the blood and to remove carbon dioxide, it
might be thought that measurement of the pO2,
and pCO2, in the blood would be an adequate
assessment of its efficiency. However, the lung
has such an enormous reserve capacity that it
can sustain considerable damage before blood
gases are affected. There are, nonetheless, a
number of other tests of lung function that are
briefly described here. These are tests of static
lung volumes, ventilation or dynamic lung
volumes and gas exchange across the alveolar
capillary membrane.

As already indicated, breathing out from

TLC is largely passive by progressive
retraction of the lung; this process will end at
functional residual capacity (FRC) when the
tendency of the lung to contract is balanced by
the thorax resisting further deformation. This

Static lung volumes

point is also the end of normal expiration.

Further expiration is an active process

involving expiratory muscles. By using these

muscles, more air can be forced out until, at
least in older individuals, the limiting factor is
closure of the small airways which have been
getting smaller along with the alveoli. Beyond
this the lungs can only become smaller by
direct compression of gas (Boyles law) by the
expiratory muscles. At this point, the amount
of air left in the lung is designated residual
volume (RV).
In chronic bronchitis, the small airways
are narrowed and inflamed; in emphysema, the
elastic tissue supporting the small airways is
lost and. they collapse in expiration. Both
mechanisms lead to an increase in RV.
Conversely, if the lungs are stiffer (fibrosis)

that volume exhaled in the first second. These

the increased tension in the lung tissue holds

are then expressed as a ratio of the FEV1, over

the airways open with closure occurring later

the FVC (FEV1%). This is normally

in expiration thus reducing the RV.

approximately 75% which indicates that a

In summary, stiff lungs from fibrosis

normal person can exhale forcibly three

cause a low TLC and low RV, emphysema

quarters of their VC in I S. VC and FVC, one

causes a high TLC and a high RV and chronic

in slow expiration and the other in fast

bronchitis causes a high RV. Vital capacity

expiration, give similar results in normal

(VC) depends on the relative changes in RV

individuals although FVC is reduced because

and TLC but usually the overall effect in lung

of premature airway closure in many disease

disease is a reduction.

states.
In diseases causing airways obstruction,

Dynamic lung volumes

the proportion of the VC that can be exhaled in

Assessment of airflow involves

I S is reduced and the FEV1% falls.

measuring the volume exhaled in unit time by

Conversely, in restrictive lung disease the

use of a spirometric trace (Fig 5.15). This is

airways are held open by the stiff lungs and the

produced by a forced exhalation from TLC to

FEV1% is normal, even increased.

RV. The conventional parameters derived from

Nevertheless, the FVC will be reduced

this trace are the forced vital capacity (FVC)

because the TLC is reduced. In restrictive lung

and the forced expiratory volume in I S (FEV1)

disease, FEV1 is reduced in proportion to FVC;

the amount exhaled forcefully from a single

in airways obstruction, it is reduced

deep inspiration, FEV1, is the fraction of

disproportionately.

gas but oxygen is affected in a similar way. TF

is reduced when there is destruction of the
alveolarcapillary bed as in emphysema and
also when there is a barrier to diffusion. This
may occur when the alveolarcapillary
membrane is thickened or where there is lack
of homogeneity in the distribution of blood
and air at alveolar level. Both mechanisms are
important in lung fibrosis.
The TF will naturally be reduced if the
lungs are small or if one has been removed
(pneumonectomy). The transfer co-efficient
(KCO or DLCO divided by alveolar volume,
calculated separately) is a more useful
measurement because it reflects the true
situation in the ventilated lung.
LUNG VOLUMES IN DISEASE
In summary, it is possible to distinguish two
main patterns of abnormal lung function. An
obstructive pattern is seen in asthma, chronic
obstructive bronchitis and emphysema. FVC,
FEV1 and FEV1% are all reduced and RV
increased; TLC is often reduced but high in
emphysema. TF is low in emphysema but
Peak flow
The peak expiratory flow rate (PEFR) is
the flow generated in the first 0.1 sofa, forced
expiration, the resulting figure is extrapolated
over I min. It can be measured easily by a
variety of portable .devices (Fig. 5.16) and
serial recordings can be very useful in the
diagnosis and monitoring of asthma (Fig.
5.17).
Gas exchange
The transfer factor (TF) is a
measurement of gas transference across the
alveolarcapillary membrane. For technical
reasons carbon monoxide is used as the test

otherwise normal. A restrictive pattern is seen

in lung fibrosis, such as occurs in cryptogenic
fibrosing alveolitis. TLC, VC, FEV1, RV and
are all reduced but FEV1% is normal or high.
When other results do not give a clear
pattern, RV can be very helpful being high in
airways obstruction and low in fibrosis.

DISTRIBUTION OF VENTILATION AND

PERFUSION
Distribution of air within the lung is best
assessed for clinical purposes, by radioactive
isotopes. The usual tracer gas is radioactive
xenon. The measurement of radioactivity over
the lung gives a measure of the distribution
and also the rate at which gas enters and leaves
various parts of the lung. Thus, it can be used
to detect air trapping or absence of
ventilation. Perfusion of blood can be
measured in a similar way usually by microaggregates of albumin labelled with
technetium 99m and injected into a peripheral
vein. These micro-aggregates form small
emboli within the lung and the radioactivity
they give off is a measure of blood
distribution. These tests are most useful in the
diagnosis of pulmonary embolism when
perfusion to an area of lung is reduced but
ventilation is maintained (Fig. 5.18). If both
ventilation and perfusion are reduced, then the
detect probably lies within the airways and is a
failure of ventilation with secondary changes
in the blood supply.
BLOOD GASES
Blood gases can be measured directly by
electrodes in blood obtained by arterial
puncture. The results are expressed as partial
pressure of gas in the plasma (pO2 and pCO2).

It is important to realise that this is not the

same as the amount of gas carried by the
blood. If all the red cells were removed, the
pO2 would be unchanged, yet the patient
would be in a perilous state. The haemoglobin
in the red cell packages and transports oxygen
and carbon dioxide just as a subway train
packages and transports passengers.
The relationship between pO2 and
saturation of the haemoglobin by oxygen (and
hence the volume of oxygen carried) is given
by the oxygen dissociation curve (Fig. 5.19). It
will be seen that the pO2 can drop significantly
before there is a drop in the saturation, clearly
a good thing in the early stages of lung
disease. Nevertheless, it means that
overventilation of the lung's good parts cannot
fully compensate for underventilation of bad
parts because the good parts on the flat part of
the curve cannot increase the carriage of
oxygen in the blood supplied to them beyond a
certain maximum. Thus, when there is a shunt
of blood from the right to the left heart, either
directly through the heart or through
unventilated lung then the total amount of

oxygen carried is bound to be reduced and

retain carbon dioxide. In cases of metabolic

cannot be restored to normal either by

acidosis (e.g. diabetic ketoacidosis, renal

increasing ventilation or administering

failure), the lungs can blow off carbon

oxygen.

dioxide to restore the pH towards normal. In

The steep part of the curve indicates that

cases of metabolic alkalosis (e.g. prolonged

a small increase in inspired oxygen gives a

vomiting with loss of acid from the stomach),

large increase in the amount of oxygen carried;

the retention of carbon dioxide again restores

clearly useful for oxygen therapy in sick

the pH towards normal. Retention or secretion

patients. It .also indicates how readily hypoxic

of carbon dioxide as a result of lung disease

tissues can remove large amounts of oxygen

(respiratory acidosis and alkalosis) alters pH

from the blood.

which is then secondarily restored by excretion

The dissociation curve for carbon

or retention of bicarbonate by the kidney.

dioxide .is very different to that of oxygen;

Thus, changes in arterial pCO2 (whether

lowering the pCO2 continuously lowers the

primary or secondary) can be regarded as

saturation and hence the volume of gas carried

functions of the lung and changes in

(Fig. 5.20). This means that overventilation in

bicarbonate (again, either primary or

one part of the lung can compensate for

secondary) can be regarded as functions of the

underventilation elsewhere. Arterial pCO2 is a

kidney.

good measure of overall alveolar ventilation,

being increased in alveolar hypoventilation

Case history

(e.g. severe chronic airflow limitation) and

Severe airflow obstruction

decreased in alveolar hyperventilation (e.g.

anxiety states, heart failure, pulmonary

History: A 63-year-old man presents with

embolus, asthma), in which hypoxia and other

a history of progressive breathlessness for 5

factors stimulate an increase in ventilation.

years.
On examination: On examination he is
cyanosed with maked ankle oedema and a
raised jugular venous pressure. He is thought
ton be in congestive cardiac failure and is
commenced on diuretics.
Investigations: Blood gas estimations
show: pH 7.35, partial pressure of
oxygen(pO2) 6.9 kPa, partial pressure of
carbon dioxide (pCO2) 7.3 kPa and
bicarbonate (HCO3.) 36 mmol/l. Spirometry

The lungs help to regulate the acid

base balance by their ability to excrete or to

shows: forced vital capacity (FVC) 1.9 l,

forced expiratory volume in 1 s (FEV1) 0.8 l,
ration of the FEV1 over the FVC (FEV1%) 43.

Disorders
Comments: The blood gases are

Some causes of breathlessness

incompatible with a diagnosis of congestive

cardiac failure because the pCO2 is raised. The

Control and movement of the chest

pulmonary function tests reveal the true cause

wall and pleura

of the breathlessness by demonstrating severe

Hyperventilation syndrome

airflow obstruction. This has led to hypoxia,

Hypothalamic lesions

pulmonary hypertension and right ventricular

Neuromuscular disease

failure. The raised bicarbonate is a reaction of

Kyphoscoliosis

the kidneys to the acidosis induced by reaction

Ankylosing spondylitis

of the kidneys to the acidosis induced by

Pleural effusion and thickening

retention of carbon dioxide. As this response is

Bilateral diaphragm paralysis

slow it indicates that the situation has existed

for some time.
Treatment should also include low flow

Diseases of the lungs

Airways disease

oxygen (with careful monitoring) and

- Chronic bronchitis and emphysema

bronchodilators.

- Asthma
- Bronchiectasis
- Cystic fibrosis

SYMPTOMS OF RESPIRATORY

Parenchymal isease,

DISEASE

- Pneumonia

History taking must follow the principles

- Cryptogenic fibrosing alveolitis

outlined earlier. Here, we are concerned with

- Extrinsic allergic alveolitis

the analysis of the main symptoms of

- Primary and secondary tumour

respiratory disease in turn. These are

- Sarcoidosis

dyspnoea, cough, sputum, haemoptysis, pain

- Pneumothorax

and wheeze.

- Pulmonary oedema
Reduced blood supply

DYSPNOEA

- Pulmonary embolism

Most lung diseases will cause dyspnoea or

- Anaemia

difficulty in breathing. Patients will express

this in different ways as shortness of breath,

may well be angina which is in itself

shortwindedness, cant get my breath or in

associated with breathlessness. If asked

terms of functional disability (can't do the

directly, patients can usually tell you whether

housework).

their tightness means pain or breathlessness.

Some patients will talk about

Some patients with pleuritic pain complain of

tightness. It may not be immediately clear

breathlessness, but what they really mean is

whether they are describing breathlessness or

that they are unable to take a deep breath

pain. If the complaint is really a pain then this

because of pain. It is of interest to consider

why patients complain of breathlessness. Most

normal people do not regard themselves

degeneration), neuropathies (e.g. GuillainBarr syndrome), myopathies and chest wall

Disorders

problems (e.g. kyphoscoliosis, ankylosing

Duration of breathlessness

spondylitis).
Lung diseases may require more work to

Immediate (minutes)

overcome obstruction to airflow (e.g. chronic

- Pulmonary embolism

obstructive bronchitis, emphysema, asthma) or

- Pneumothorax

to stretch stiff lungs (e.g. pulmonary oedema,

- Pulmonary oedema

lung fibrosis).

- Asthma

Hypoxia needs to be severe to stimulate

Short (hours to days)

respiration but may be the mechanism in.

- Pulmonary oedema

pneumonia, severe heart failure and other

- Pneumonia

causes of pulmonary oedema. Pulmonary

- Asthma

embolism leads to wasted ventilation in the

- Pleural effusion

affected area. Severe anaemia reduces the

- Anaemia

oxygen-carrying capacity of the blood.

Long (weeks to years)

J receptors are vagal nerve endings and

- Chronic airflow limitation

are adjacent to pulmonary capillaries.

- Cryptogenic fibrosing alveolitis

Stimulation of these by pulmonary oedema,

- Extrinsic allergic alveolitis

fibrosis and lung irritants is an additional

- Amaemia

mechanism causing breathlessness.

as ill when they are short of breath say when

Duration of dyspnoea

running for a bus. It seems probable that the

The duration of dyspnoea may give a clue to

sensations reported by patients are the same as

the cause and can conveniently be divided into

the rest of us but they recognise that the work

immediate (over minutes), short (hours to

the lungs are being asked to do is

disproportionate to the task the body is

Questions to ask

performing, that is, it feels inappropriate.

Dyspnoea

Causes of breathlessness

The causes of breathlessness may be listed as

been present for sometime?

those to do with the control and movement of

the chest wall, lung disease itself and problems
with the blood and its supply to the lungs. The

Is the breathlessness recent of has it

- Is it constant or does it come and go?

What cant you do because of the

breathlessness?

control of breathing can start with

- What makes the breathing worse?

psychological factors in the brain, problems

- Does anything make it better?

with the control centre in the medulla (rare)

and the increased effort needed to overcome
the effects of spinal cord disease (trauma or

days) and long (weeks to years). There is

some overlap but contrast, for example, the

patient with a large pulmonary embolism who

Asthma

collapses in minutes in acute distress

Asthma due solely to emotional causes

compared with the progressive relentless

probably does not exist; nonetheless, most

disability extending over a decade in the

patients who have asthma are worse if

patient with smoking-related airflow

emotionally upset. Patients may feel that

limitation. Some patients find it difficult to

admitting to stress is respectable when they

remember duration accurately. Many report

would deny other emotions. Nocturnal asthma

symptoms as lasting for only a few weeks

is very common. Few asthmatics smoke

when they mean worse for a few weeks. A

because they know it makes them worse. Ask

question like when could you last run for a

what happens if they go into a bar. Many will

bus may indicate problems stretching back.

say they are unable to do so because of smoke.

for years. A spouse is often more accurate in

The response to household aerosol sprays can

this respect than the patient.

be helpful. Many breathless patients with a

variety of illnesses will think it logical, rightly

Variability of dyspnoea

or wrongly, that dust or fumes will make

Questions about variability can be couched as

them worse but only true asthmatics seem to

does it come and go or is it much the same or

notice a deterioration with the ubiquitous

do you have good days and bad days or is it

domestic spray can.

much the same from one day to another. A

reply suggesting variability is highly
characteristic of variable airflow limitation,

Case history

that is, asthma. If asthma is suspected, this can

Cough caused by asthma

be followed-up by questions on aggravating

factors. Follow this up with some more

History: A 25-year-old woman presents to her

directed questions about particular factors.

doctor complaining of a persistent dry cough.

These are important not only as potentially

On direct questioning she admits to the

preventable causes but because positive replies

occasional wheeze and shortness of breath.

strengthen the diagnosis. The house-dust mite

The cough is particularly worse at night and is

is the most common allergen;

keeping her awake for long periods. It is better

patients will report worsening of

during the day but does recur when she is

symptoms on sweeping, dusting or making the

exposed to cigarette smoke (she does not

beds. Exercise, at least in children, is a potent

smoke herself). A physical; examination and

trigger of asthma but exercise will also make

chest radiograph are normal. Peak flow

other forms of breathlessness worse. The

recordings show marked variation, with

difference is that in asthma the attack is caused

particularly low levels at night.

by the exercise, may indeed follow it and may

A diagnosis of asthma is made. Low

last for 30 min or more. In other causes of

dosage inhaled steroids are prescribed with

breathlessness, recovery starts as soon as

complete resolution of her symptoms.

exercise stops.

Comments: Cough is a common

manage? Do they stop half way up or at the

presenting complaint in asthma and wheezy

top? Questions about gardening are useful, at

breathlessness may not be prominent. The

least in the summer, as it is possible to grade

precipitating factors are however the same.

activity from pulling out a few weeds to

The finding of variability in the peak flow

digging the potato patch. It is important to be

recordings confirms the diagnosis.

certain that any restriction is caused by

The normal examination in the day

should not deter you from the diagnosis; it

breathlessness and not some other disability

(e.g. an arthritic hip or angina).

would probably be very different at night.

Orthopnoea and paroxysmal
noctural dyspnoea
Questions to ask
Asthma

Orthopnoea and paroxysmal nocturnal

dyspnoea need special consideration. Both are
usually regarded as manifestations of left

Does anything make any difference to

ventricular failure, yet this is an

the asthma?

oversimplification. Orthopnoea is defined as

What happens if you are worried or

breathlessness lying flat but relieved by sitting

upset?

up. It is common in patients with severe fixed

Does your chest wake you at night?

airways obstruction, as in some chronic

Does cigarette smoke make any

difference?

bronehitics who may admit to not having slept

flat for years. Normal people when they lie
flat, breathe more with the diaphragm and less

Do household sprays affect you?

Have you lost time from work/school?

What happens when sweeping or

inefficient and may even draw the ribs inwards

dusting the house?

rather than out. Thus, when they lie down the

Does exposure to cats or dogs make

diaphragm cannot provide the ventilation

and difference?

required.

with the chest wall. In patients with airways

obstruction, the diaphragm is often flat and

The term paroxysmal nocturnal dyspnoea

is self-explanatory and is a feature of
pulmonary oedema from left ventricular
failure. However, many asthmatics develop
Severity of dyspnoea

bronchoconstriction in the night and wake with

Severity can be assessed by rating scales,

wheeze and breathlessness very similar to the

although it is much better to use some

symptoms of left ventricular failure. In

functional measure. Ask the patient in what

contrast, patients with severe fixed flow

way their breathlessness restricts their

limitation usually sleep well even if they do

activities: can they go upstairs, go shopping,

have to be propped up.

wash the car or do the garden? If they are

troubled with stairs, how many flights can they

The hyperventilation syndrome

The hyperventilation syndrome is more

relatively little dyspnoea (blue bloaters). In

common than is generally realised but

contrast, some patients with emphysema seem

produces a distinct pattern of symptoms. It is

to need to keep their blood gases normal by a

usually associated with anxiety and patients

heroic effort of breathing (pink puffers); they

overbreathe inappropriately. The initial

are very dyspnoeic.

complaint is often, although not always, of

breathlessness. The hyperventilation is the

Disorders

response to this sensation. It may be described

Features suggestive of the hyperven-

by the patient as a difficulty in breathing in

tilation synodrome

or an inability to fill the bottom of the lungs.

The hyperventilation induces a reduction in the

Breathlessness at rest

pCO2, creating a variety of other

Breathlessness as severe with

symptoms:paraesthesiae in the fingers, tingling

mild exertion as with greater

around the lips, dizziness, lightheaded-ness

exertion

and sometimes frank tetany. Chest pain is the

probable consequence of increased chest wall
movement. The onset is often .triggered by
some life event especially workrelated (e.g.
redundancy or dismissal). The diagnosis can
be confirmed by the 20 deep breaths test
which will reproduce the symptoms.
Dyspnoea and hypoxia

breathlessness

More difficulty breathing in than

out

Paraesthesiae of the fingers

Numbness around the mouth

Lightheadedness

Feelings of impending collapse or

remoteness from surroundings

Dyspnoea should be distinguished from

tachypnoea (increased rate of breathing) and

Marked variability in

Chest wall pain

from hypoxia. It is-a symptom, not a .sign, nor

is. it necessarily an indication of lung disease.
Psychological factors, such as the
hyperventilation syndrome and acidosis from
diabetic ketosis or renal failure, may produce
tachypnoea which may be felt as dyspnoea.

Summary

Many patients think that if they are short of

Allergic and non-allergic factors in

breath, they must be short of oxygen. This is

asthma

sometimes the case but as mentioned earlier,

hypoxia only stimulates respiration when

Allergic

relatively severe. To illustrate the distinction

- House dust mite

between hypoxia and dyspnoea consider that

- Animals (especially cats)

many patients with airflow limitation from

- Pollens (especially grass)

chronic bronchitis have hypoxia severe enough

to cause right-sided heart failure, yet they have

Non-allergic

- Exercise

completely despite having just coughed in

- Emotion

front of the examiner. In these patients, a

- Sleep

change in the character of the cough can be

- Smoke

highly significant.

- Aerosol sprays

Patients can often localise cough to

- Cold air

above the larynx (a tickle in the throat) or

- Upper respiratory tract infections

below. Postnasal drip from rhinitis can cause

the former and may be accompanied by
sneezing and nasal blockage.
Laryngitis will cause both cough and a

Disorders

hoarse voice. Recurrent laryngeal nerve palsy

Clinical features of sputum

causes a hoarse voice and an ineffective cough

because the cord is immobile. The usual cause

White or grey

is involvement of the left recurrent laryngeal

- Smoking

nerve by tumour in its course in the chest.

- Simple chronic bronchitis

Cough from tracheitis is usually dry and

- Asthma

painful. Cough from further down the airways

is often associated with sputum production

Yellow or green

(bronchitis, bronchiectasis or pneumonia). In

- Acute bronchitis

the latter, associated pleurisy makes coughing

- Acute on chronic bronchitis

very distressing and reduces its effectiveness.

- Asthma

Other possibilities are carcinoma, lung fibrosis

- Bronchiectasis

and increased bronchial responsiveness (this is

- Cystic fibrosis

an inflammatory condition of the airways,

thought to be part of the mechanism

Frothy, blood-streaked

underlying asthma and often made worse by

- Pulmonary oedema

the factors in the summary box on allergic and

non-allergic factors in asthma. An uncommon
cause of cough and often overlooked is

COUGH

aspiration into the lungs from gastro-

Cough arises from the cough receptors in the

oesophageal reflux or a pharyngeal pouch.

pharynx, larynx and bronchi; cough, therefore,

Cough will then follow meals or lying down.

results from irritation of these receptors either

Prolonged coughing bouts can cause both

from infection, inflammation, tumour or

unconsciousness from reduction of venous

foreign body. Cough may be the only symptom

return from the brain (cough syncope) and also

in asthma, particularly childhood asthma.

vomiting. Sometimes the history of cough is

Cough in children occurring regularly after

omitted making diagnosis difficult!

exercise or at night is virtually diagnostic of

asthma. Many smokers regard cough as

Questions to ask

normal: only a smokers cough or may deny it

Sputum

Probably not serious

What colour is the phlegm?

- Young

How often do you bring it up?

- Recent infection

How much do you bring up?

- Never smoked

Do you have trouble getting it

up?

- Single episode
- Small amount-if single episode
SPUTUM

Disorders
Causes of haemoptysis
Common

Patients may understand the term phlegm

better than sputum. It is the result of excessive
bronchial secretion; itself a manifestation of
inflammation and infection. Like cough,
smokers may not acknowledge its existence.

Infection including bronchietasis

Bronchial carcinoma

-Tuberculosis

relates to the chest, because some patients

Pulmonary embolism and

have difficulty in distinguishing sputum

infarction

production from gastro-intestinal reflux,

No cause found

postnasal drip or saliva. Sometimes asking the

Children usually swallow their sputum. It is

essential to be certain that the complaint

patient to show me what you have to do to get

Uncommon

Mitral stenosis and left

sputum, a cough producing a rattle (a loose

ventricular failure

cough) suggests that it is present.

Bronchial adenoma

Idiopathic pulmonary
haemosiderosis

it up can be helpful. If the patient denies

Anticoagulation and blood

dyscrasias

Summary
Pointers to the significance of an
episode of haemoptysis
Probably serious
- Middle-aged or elderly
- Spontaneous
- Previous or current smoker
- Recurrent
- Large amount

Sputum caused by chronic irritation is

usually white or grey, particularly in smokers;
if infected it becomes yellow from the
presence of leukocytes and this may turn to
green by the action of the enzyme
verdoperoxidase. Yellow or green sputum in
asthma can be caused by the presence of
eosinophils rather than infection. 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. Sputum production is
common in asthmatics and is occasionally the
main complaint. The diagnosis
ofbronchiectasis is made on a story of daily
sputum production stretching back to

childhood.
Patients can often give an estimate of the
amount of sputum they bring up each day

in a middle-aged smoker is virtually diagnostic

of bronchial carcinoma.
Other serious causes are pulmonary

usually in terms of a cup or teaspoon and so

embolism (sudden onset of pleuritic chest pain

on. Large amounts occur in bronchiectasis and

and dyspnoea followed by haemoptysis),

lung abscess and in the rare bronchiolo-

tuberculosis (weight loss, fever, cough and

alveolar cell carcinoma.

sputum) and bronchiectasis (long history of

sputum production and the haemoptysis

Sticky rusty sputum is characteristic of

associated with an exacerbation and increased

lobar pneumonia and frothy sputum with

sputum purulence). Blood-tinged sputum in

streaks of blood is seen in pulmonary Oedema.

pneumonia and pulmonary oedema has already

Highly viscous sputum sometimes with

been mentioned.

plugs is characteristic of asthma and in some

patients with chronic bronchitis. Small

PAIN

bronchial casts, like twigs, may be described

The lungs arid the visceral pleura are devoid of

by a patient with the condition of

pain fibres, whereas the parietal pleura, chest

bronchopulmonary aspergillosis associated

wall and mediastinal structures are not. The

with asthma.

characteristic pleuritic pain is sharp,

stabbing, worse on deep breathing and

HAEMOPTYSIS

coughing and arises from either pleural

The coughing up of blood is often a sign of

inflammation or chest wall lesions. Pain from

serious lung disease. Nevertheless, it is

the pleura is caused by the two pleural surfaces

common in. trivial respiratory infections. Like

rubbing together. The pain may interfere with

sputum production, it is essential to establish

breathing: I have to catch my breath.

that it is coming from the lungs and not the

Inflammation of the pleura occurs chiefly in

nose or mouth or being vomited

pneumonia and pulmonary infarction from

(haematemesis). Bleeding from the nose may

pulmonary emboli. Pneumothorax can produce

run into the pharynx and be coughed out but

acute transient pleuritic pain.

usually the patient will also describe bleeding

Most pains from the chest wall are

from the anterior nares. Bleeding in the mouth

caused by localised muscle strain or rib

causes confusion, it is usually related to

fractures (persistent cough can cause the

brushing the teeth (gingivitis).

latter). These pains are often worse on twisting

The blood in haemoptysis is usually

or turning or rolling over in bed; an

bright red at first, then followed by

uncommon feature of other disease. Bornholm

progressively smaller and darker amounts.

disease is thought to be a viral infection of the

This would be unusual in haematemesis.

intercostal muscles and produces very severe

All haemoptysis is potentially serious,

pain. True pleuritic pain is often accompanied

although the most important is carcinoma of

by a pleural rub; this is absent in chest wall

the bronchus. Repeated small haemoptyses

pain but there may be striking local rib

every few days over a period of some -weeks

tenderness reproducing the symptoms.

Unfortunately, this is not entirely reliable, for

chronic obstructive bronchitis. In asthma, the

pleurisy can be associated with local

wheeze is episodic and clearly associated with

tenderness. A particular type of chest wall pain

shortness of breath, fulfilling the definition of

is caused by swelling of one or more of the

variable wheezy breathlessness.

upper costal cartilages (Tietzes syndrome),

Nevertheless, some asthmatics may have little

however, this is rare and it is much more

wheeze and acute severe attacks can be

common to find tenderness without swelling.

associated with a silent chest. In chronic

Severe constant pain not related to breathing

obstructive bronchitis and emphysema, the

but interfering with sleep usually indicates

associations are less clear cut, with wheeze,

malignant disease involving the chest wall.

shortness of breath, cough and sputum

Moreover, spinal disease and herpes zoster

occurring in various proportions.

may cause pain in a root distribution round the

chest.
Pleural pain is usually localised

Stridor
Stridor is a harsh inspiratory and

accurately by the patient, yet if the pleura

expiratory noise which can be imitated by

overlying the diaphragm is involved pain may

adduction the vocal cords and breathing in and

be referred either to the abdomen from the.

out. It is often more evident to the observer

costal part of the diaphragm or to the tip of the

than the patient.

shoulder from the central part because the pain

fibres run in the phrenic nerve (C3-5). Pain may

OTHER IMPORTANT POINTS IN THE

subside when an effusion develops.

HISTORY

Although the lungs are insensitive to

pain, the mediastinal structures are not. Cancer

Other body systems

The lungs do not exist in isolation from

of the lung and other central lesions produce a

the rest of the body. Lung disease can affect

dull, poorly localised pain, presumably from

other structures and disease elsewhere can

pressure on mediastinal structures.

affect the lungs. The closest relationships are

A third type of pain is a central soreness

over the trachea in acute tracheitis.

naturally with the heart. Lung disease can

affect the right side of the heart (cor
pulmonale). An early manifestation is

WHEEZE AND STRIDOS

peripheral oedema (ankle swelling). Disease of

Wheeze

the left heart causes pulmonary oedema

Most patients will understand wheeze as

(orthopnoea, paroxysmal nocturnal dyspnoea,

a high-pitched whistling sound, although some

cough and frothy sputum). Diseases of other

require a demonstration by the doctor before

systems that affect the lungs include

they recognise it. It occurs in both inspiration

rheumatoid arthritis, other connective tissue

and expiration but is always louder in the

disease (scleroderma and dermatomyositis),

latter. Spouses sometimes pick tills up better

immune deficiency syndromes (including

than patients particularly if the wheeze is

AIDS) and renal failure. A variety of

mainly at night. It implies airway nan-owing

neuromuscular diseases and skeletal problems

and is, therefore, common in asthma and

affect the mechanics of breathing.

Weight loss is an important manifestation

of lung carcinoma, although by the time it
occurs there are usually metastatic deposits in

and the carbon dioxide retention to morning

headaches.
Many diseases of the respiratory system

the liver. Less well known is chronic airflow

produce lasting disability and some are fatal.

limitation, caused presumably by the increased

Therefore, depression and anxiety are to be

respiratory effort impairing appetite and

expected and may influence the history.

diverting calories to, .the respiratory muscles.

Chronic infection, particularly tuberculosis,
causes weight loss. Gain in weight may be a

Disorders

cause of increased dyspnoea. One cause is

Clinical features suggesting the sleep

steroid therapy for lung disease (iatrogenic

apnoea syndrome

Cushings syndrome).
Fever must be distinguished from feeling
hot or sweating and generally implies

Excessive daytime somnolence

Intellectual deterioration and

infection, particularly pneumonia or

tuberculosis. Less commonly, it is caused by
malignancy or connective tissue disease
affecting the lungs. If pulmonary embolism is
suspected, pain or swelling in the legs suggests
a deep venous thrombosis.

irritability

Early morning headaches

Snoring

Restless nights

Social deteroriation (e.g. job,

marriage, driving difficulties)

Sleep

PREVIOUS DISEASE

Sleep disturbance may be caused by

A history of tuberculosis may explain

pain, breathlessness and cough from airways

abnormal shadowing on a chest radiograph.

obstruction or from depression. In the sleep

Current symptoms may be caused by relapse,

apnoes syndrome, patients are aroused

especially if the patient was treated before the

repeatedly in the night from obstruction of the

start of the antibiotic era (1950). Some

upper airways. The cause is not always clear

operations for tuberculosis from those days

but obesity and hypertrophied tonsils often

(thoracoplasty and phrenic crush) produce life-

contribute. Sudden obstruction leads to greater

long chest or radiographic deformity.

and greater inspiratory efforts by the patient

Bronchial damage from tuberculosis can lead

who, in a half-awake state, will thrash around

to bronchiectasis.

and eventually overcome the obstruction to the

BCG vaccination reduces the risk of

accompaniment of loud snoring noises. This

tuberculosis. In most areas in the UK it is

may be repeated many times during the night.

performed at school at the age of 12 or 13

Wives (the patients are usually men) will

years. Babies bom to immigrant mothers often

describe this in graphic detail! The poor

receive it at birth. For children, Heaf testing to

quality of sleep leads to daytime somnolence

assess sensitivity to tuberculin is performed

first. A history of these procedures helps in the

assessment of a possible case of tuberculosis.
A history of wheeze in childhood
suggests asthma; This may have gone into
remission and been forgotten only to occur in
later life. Whooping cough or pneumonia in
childhood may lead to bronchiectasis and
patients may. have been told by their parents
that their problems started with such an
episode.
Chest injuries, operations or pneumonia
can all lead to permanent radiographic changes
which otherwise would be very difficult .to

they only stopped last month, last week or

explain. Previous radiographs can be

even on the way to hospital! Ask nonsmokers:

invaluable in these circumstances and may be

have you smoked in the past?. The risk of

available. Health checks may have included

disease increases with the amount smoked.

chest radiography. Many patients will have had

Cigarettes are the most dangerous; pipes and

chest radiography before an operation.

cigars are not free of risk. Risk declines

steadily when smoking stops; it takes 1020

SOCIAL HISTORY

years for the risk of lung cancer to equal that

Smoking

of life-long nonsmokers.

The importance of enquiry about

Inhalation of another person's smoke at

smoking in lung disease can hardly be

home or at work is increasingly recognised as

overemphasised (Figs 5.21 and 5-22).

a factor in lung disease. This is particularly

Smoking is, for practical purposes, the cause

true for asthma. Children in households with

of chronic bronchitis and carcinoma of the

smokers have more respiratory infections.

bronchus and neither diagnosis is likely to be

correct in .a life-long nonsmoker. Patients

Pets and hobbies

seem to be generally accurate about their

For many asthmatics, cats and dogs are

tobacco consumption .contrasting sometimes

common sources of allergen. The allergen may

with alcohol.

remain in the house long after the offending

It is important not to appear censorious

when enquiring about smoking. Tobacco is

animal has been banished.

Exposure to racing pigeons, budgerigars,

highly addictive and most patients would give

parrots and other caged birds can cause

up if only they could and are not being

extrinsic allergic alveolitis. The cause is

perverse when they continue despite evidence

protein material derived from feathers and

of lung damage. You should be aware that

droppings. Acute symptoms are usually seen in

some patients claim to be nonsmokers when

pigeon fanciers who a few hours after cleaning

out their birds develop cough, breath-lessness
and flu-like symptoms. Recovery takes place

over the next day or two unless there is reexposure. Chronic symptoms are seen in

coal miners.
Enquiry may need to be searching and, if

budgerigar owners presumably because they

occupational lung disease is suspected, then a

are exposed continuously to low doses of

full. list of all jobs performed will need to be

antigen. Their complaint is of progressive

constructed. For example, in the case of

breathlessness.

asbestos there can be an interval of 30 years

Parrots and related species transmit the

between exposure, say in shipyard work, and

infectious agent of psittacosis, a cause of

the development of asbestosis or

pneumonia. You may need to extend your

mesothelioma. Some will deny working with

enquires beyond the home because patients

asbestos but nevertheless were exposed when

may be exposed to birds belonging to friends

others were performing lagging (putting

and relations.

asbestos on pipes) or stripping (taking it off).

Other occupations in which exposure may not

Occupation

be obvious although real nonetheless are

The question what work do you do? is

building and demolition work, electrical repair

more important for respiratory disease than for

work, railway engineering and gas mask and

any other. The nature of the job and not just

cement manufacture. Environmental exposure,

the title is important because the latter may

including that of wives of asbestos workers,

convey no meaning to you at all. The question

seems important occasionally.

is important in two ways. Respiratory disease

The easiest way to diagnose

pneumoconiosis is to ask the patient. Miners in
the UK undergo regular chest radiography
while working. If significant pneumoconiosis
is diagnosed the patient will be told.
Occupational asthma
The list of causes of occupational asthma
grows longer yearly. A good screening
question to any asthmatic is does your work
make any difference to your symptoms and
follow this up with questions about
improvement at weekends or on holiday. The
latter is important because symptoms caused at
work may not be manifest until the evening or
night and sometimes changes take place over

may affect a patient's ability to perform a job

but may also be the result of the occupation.

days or even weeks.

Common causes are isocyanates (paint

Any job involving exposure to noxious agents

hardeners and plastic manufacture) and

of a respirable size is potentially damaging, the

colophony (soldering and electronics). The

most obvious example is pneumoconiosis in

lack of an obvious culprit should not put you

off the scent if the evidence is otherwise

manifestation of AIDS, remembering that this

suggestive. Much detective work is necessary

is now becoming more common in the

in individual cases.

heterosexual population especially in

individuals who have travelled abroad,

Extrinsic allergic alveolitis

particularly to Africa and Asia.

Extrinsic allergic alveolitis can be caused

by occupation as well as birds. The best

DRUG HISTORY

example is farmer's lung: the agent is the

The most useful questions are those

micro-organism thermophilic actinomycetes

concerning past treatment. Successful use of

contaminating stored damp hay. The story is of

bronchodilators and corticoids in airways

shortness of breath, cough and chills a few

obstruction will indicate asthma. Aspirin and

hours after forking out fodder for cattle in the

sometimes other nonsteroidal anti-

winter. Other occupations with similar risks

inflammatory drugs and -adrenergic receptor

are mushroom workers, sugar workers

receptor can make asthma worse and

(bagassosis: mouldy sugar cane), malt-workers

angiotensis-converting enzyme inhibitors

and woodworkers, although the antigens vary

cause chronic dry cough. Steroid therapy

in each case.

predisposes to infections including

tuberculosis.

FAMILY HISTORY
The most common lung disease with a genetic
basis is asthma, although the development .of
the disease in an individual is much more
complicated. A family history of asthma and
the related conditions of hay fever or eczema
are often found but these diseases are so
prevalent that enquiry beyond the immediate
family is of little value. Other diseases that run
in the family include cystic fibrosis and -1antitrypsin deficiency, a rare cause of
emphysema.
Tuberculosis is usually passed on within
families. In the UK, tuberculosis is common in
Asian migrants, particularly in their first 10
years in the country and inindividuals who
have revisited the subcontinent. Most of the
increased incidence of the disease seen in
recent years has occurred in conditions of
poverty.
Enquiry into sexual habits will be
necessary if the illness could be a

GENERAL EXAMINATION
Examination starts on first encounter. You
should be able to continually pick up and store
clues while talking and listening to the patient.
As with all body systems, a good look at the
patient as a whole will provide important
evidence that will be missed in a rush to lay a
stethoscope on the chest. Your findings should
be divided into first impressions, then a more
directed search for signs outside the chest
likely to be helpful in lung disease and, finally,
examination of the chest itself.
Disorders
Some occupational causes of lung
disease
Occupation

Agent

Disease

Mining

Coal dust

Pneumoconiosis

Quarrying

Silica dust

Silicosis

Foundry work Silica dust

Silicosis

Asbestos

Asbestosfibres Asbestosis

(Mining, heating,

Mesothelioma

Building, demolition)

Lung cacer

Farming

ActinomycetesAlveolitis

Paint spraying Isocyanates

Asthma

Plastics
Manufacture Isocyanates

Asthma

Soldering

Asthma

Colophony

FIRST IMPRESSIONS
How breathless does the patient appear? Is it
consistent with the story? If seen in the clinic
or office can the patient walk in comfortably
and sit down or does the patient struggle to get
in? Perhaps the patient is in a wheelchair; if so,

After extracting as much information as

is it because of breathing troubles or

you can, position the patient comfortably on

something else? Can the patient carry on a

the bed or couch with enough pillows to

conversation with you or do they break up

support the chest at an angle of approximately

their sentences? How breathless is the patient

45 and begin the formal examination. This

when getting undressed? Details of breathing

can conveniently start with the hands and a

patterns are considered later but is the patient

search for clubbing.

obviously distressed or quite comfortable? Is

there stridor or wheeze? Is there cough,

Clubbing

confirming or perhaps at variance with the

This refers to an increase in the soft

history? Is there evidence of weight loss

tissues of the nail bed and the finger tip. The

suggesting carcinoma or weight gain from

earliest stage is some softening of the nail bed

steroid therapy?

which can be detected by rocking the nail from

Do not ignore clues around the patient.

side to side on the nail bed (Fig. 5.23). This

An air compressor by the bed will be used to

sign can be present to some extent in normal

deliver bronchodilator drugs. A packet of

individuals but is exaggerated in the early

cigarettes in the pyjama jacket will have the

stages, of clubbing. Next, the soft tissue of the

opposite effect. In hospital you will be

nail bed fills in the normal obtuse angle

deprived of some of these features but not how

between the nail and the nail bed. This is

the patient is positioned, does the patient have

usually approximately 160 but the area

to sit up to breathe? Confirming a history of

becomes flat, even convex in clubbing (Fig.

orthopnoea. Is the patient receiving oxygen?

wrists, ankles and knees. The pain is not in the

joint itself but over the shafts of the long bones
adjacent to the joint. It is caused by
subperiosteal new bone formation which can
be seen on a radiograph (Fig. 5.27). The
condition is almost invariably associated with
clubbing, although it can occur alone. Any
cause of clubbing can also cause hyper-trophic
pulmonary osteoarthropathy, however, it is
usually associated with a squamous carcinoma
of the bronchus. The condition is often
mistaken for arthritis with consequent delay in
diagnosis. Successful treatment of the cause
will relieve clubbing and the pain of
hypertrophic pulmonary osteoarthropathy.
5.24). This is seen best by viewing the nail

While searching for clubbing, note any

from the side against a white background, say

nicotine staining of the fingers.

the bedsheets. Not surprisingly, there can be

considerable disagreement about the presence

Disorders

or absence of clubbing in the early stages.

Some common causes of clubbing

When normal nails are placed 'back to back'

there is usually a diamond-shaped area

Pulmonary

between them. This is obliterated early in

- Bronchial carcinoma

clubbing (Fig. 5.25).

- Chronic pulmonary sepsis

In the next stage, the normal

Empyema

longtitudinal curvature of the nail increases.

Lung abscess

Some normal nails have a pronounced curve

Bronchiectasis

but in clubbing the increase in soft tissue in the

Cystic fibrosis

nail beds needs to be present as well. In the

- Cryptogenic fibrosing alveolitis

final stage, the whole tip of the finger becomes

- Asbestosis

rounded (a club) (Fig. 5.26). Clubbing less

commonly affects the toes.
The pathogenesis of clubbing is
unknown. There is increased vascularity and

Cardiac
- Congenital cyanotic heart disease
- Bacterial endocarditis

tissue fluid and this seems to be under

neurogenic control because it can be abolished

Other

by vagotomy.

- Idiopathic/familial

Clubbing is sometimes associated with

- Cirrhosis

hypertrophic pulmonary osteoarthropathy; this

- Ulceravtive colitis

presents with pain in the joints particularly the

- Coeliac disease

- Crohns disease
Cyanosis
Cyanosis, a bluish tinge to the skin and
mucous membranes, is seen when there is an
increased amount of reduced haemoglobin in
the blood (Fig. 5.28). Traditionally, it is
thought to become visible when there is
approximately 5 g/dl or more of reduced
haemoglobin corresponding to a saturation of
approximately 85%. However, there is a good
deal of interobserver variation. Severe anaemia
and cyanosis cannot coexist otherwise most of

Central cyanosis

the haemoglobin would be reduced.

Although the whole patient may appear

Conversely, in polycythaemia in which there is

cyanosed, the best place to look is the mucous

an increase in red cell mass, there may be

membranes of the lips and tongue (Fig. 5.29);

enough reduced haemoglobin to produce

Good natural light is best. Any severe disease

cyanosis, even though there is enough

of the heart and lungs will cause central

oxygenated haemoglobin to maintain a normal

cyanosis but the most common causes are

oxygen carrying capacity.

severe airflow limitation, left ventricular

Cyanosis can be divided into central and

failure and pulmonary fibrosis.

peripheral varieties. Central cyanosis is caused

by disease of the heart or lungs and the blood

Peripheral cyanosis

leaving the left heart is blue. Peripheral

Here, the peripheries, the fingers and the

cyanosis is caused by decreased circulation

toes, are blue with normal mucous membranes.

and increased extraction of oxygen in the

The usual cause is reduced circulation to the

peripheral tissues. Blood leaving the left heart

limbs, as seen in cold weather, Raynauds

is normal.

phenomena or peripheral vascular disease. The

peripheries, are usually also cold. There may
be an element of peripheral cyanosis in heart
failure when the perfusion of the extremities is
reduced.
Cyanosis can rarely be caused by the
abnormal pigments methaemoglobin and
sulphaemoglobin. Arterial oxygen tension is
normal.

in cor pulmonale (right-sided heart failure due

to lung disease). The common cause in the UK
is chronic airflow limitation leading to
hypoxia. The main mechanism is pulmonary
vasoconstriction. Other signs are peripheral
oedema (probably as much due to renal
hypoxia as back pressure from the right heart),
hepatomegaly and a left parasternal heave,
indicating right ventricular hypertrophy. In
severe cases, functional tricuspid regurgitarion
will lead to a pulsatile liver, large V waves in
the jugular venous pulse and a systolic
murmur in the tricuspid area (see Chapter 6).
Sometimes overinflation the lungs will
Fig.5.29 Central cyanosis of the tongue.

displace the liver downwards and also obscure

Tremors and carbon dioxide retention

the cardiac signs leaving the jugular venous-

The most common tremor in patients

pulse as the only sign.

with respiratory disease, is a fine finger tremor

Superior vena cava obstruction is a

from stimulation of b-receptors in skeletal

common presentation of carcinoma of the

muscle by bronchodilator drugs. Carbon

bronchus, but can rarely be caused by

dioxide retention is seen in severe chronic

lymphoma, benign tumours and mediastinal

airflow limitation. Clinically, it can be

fibrosis. The tumour compresses the superior

suspected by a flapping tremor (indistin-

vena cava near the point where it enters the

guishable from that associated with hepatic

right atrium. The resulting high pressure in the

failure), vasodilation manifested by warm

superior vena cava causes distension of the

peripheries, bounding pulses, papilloedema

neck, fullness and oedema of the face, dilated

and headache.

collateral veins over the upper chest (Fig.

5.30) and chemosis or oedema of the

Pulse and blood pressure

conjunctiva. The internal jugular vein is, of

Pulsus paradoxus is a drop in blood

course, distended but may be difficult to see

pressure on inspiration. A minor degree occurs

because it does not pulsate (the dog-in-the-

normally. Major degrees occur in pericardial

night-time syndrome). The external jugular

effusion and constrictive pericarditis but also

vein should be visible. The patient may have

in severe asthma. However it probably adds

noticed that shirt collars have become tighter.

nothing to other measures of severe asthma.

For further discussion see Chapter 6.

Lymphadenopath
Lymph nodes may enlarge either because

Jugular venous pulse and cor

pulmonal
The jugular venous pulse may be raised

of generalised disease (e.g. lymphoma) or

from local disease spreading through the
lymphatics to the nodes. Both may be

important in respiratory disease. Palpation of

lymph nodes is considered in Chapter 2, so
here the examination of only those lymph
nodes draining the chest is considered.
Lymphatics from the lungs drain
centrally to the hilum then up the paratracheal
chain to the supraclavicular (scalene) or
cervical nodes. Chest wall lymphatics,
especially from the breasts drain to the axillae.
Lung disease, therefore, rarely involves the
axillary nodes. Examination of the cervical
chain can be carried out by palpation from the
front of the patient. Supraclavicular

Examination of the axillary nodes is

lymphadenopathy is best detected from behind

shown in Figure 5.32. Abduct the patient's

the patient by placing your fingers either side

arm, place the fingers of your hand high up in

of the neck behind the tendon, of the

the axilla, press the tips of the fingers against

sternomastoid muscle. It helps if the neck is

the chest wall, relax the patient's arm and draw

bent slightly forward (Fig. 5.31). Cervical

your fingers downwards over the ribs to roll

nodes can be palpated this way too.

the nodes between your fingers and ribs.

It is sometimes difficult to examine in

the supraclavicular area because lymph nodes

Skin

may be only slightly enlarged. If palpable, the

The early stages of sarcoidosis and

nodes are usually the site of disease. Careful

primary tuberculosis are often accompanied by

comparisons should be made between the two

erythema nodosum (Fig. 5.33); painful red

sides. If lymph nodes are enlarged then biopsy

indurated areas usually on the shins, although

or aspiration may be a simple way to confirm a

occasionally more extensive, they fade through

diagnosis. Beware of performing a cervical

bruising. Severely affected patients may also

node biopsy too readily. Throat cancer can

have arthralgia. The most common cause of

involve these nodes and painstaking block

erythema nodosum in the UK is sarcoidosis.

dissection is the correct treatment.

Sarcoidosis can also involve the skin,

Respiratory diseases that involve, these

particularly old scars and tattoos, with nodules

nodes are carcinoma, tuberculosis and

and plaques. Lupus oerbui is a violaceous

sarcoidosis. Nodes containing metastatic

swelling of the nose from involvement by

carcinoma are hard and fixed. Tuberculous

sarcoid granuloma.

nodes, common in Asian patients in the UK,

are soft and matted and may have discharginh
sinuses. Healing and calcification leave small
hard nodes.

Disorders
Common respiratory causes of

Eyes

supraclavicular lymphadenopathy

Homer's syndrome (miosis [contraction

of the pupil), enophthalmos [backward

Lung cancer

displacement of the eyeball in the orbit], lack

Lymphoma

of sweating on the affected side of the face and

Tuberculosis

ptosis [drooping of the upper eyelid] [see also

Sarcoidosis

HIV infection

Chapter 11) is usually due to involvement of

the sympathetic chain on the posterior chest
wall by a bronchial carcinoma
Sarcoidosis and tuberculosis can cause

Disorders
Causes of erythema nodosum
Infections

iridocyclitis. Miliary tuberculosis can produce

tubercles visible on the retina by
ophthalmoscopy. Papilloedema can be caused
by carbon dioxide retention and cerebral
metastases.

Streptococci

Tuberculosis

of inspection, palpation, percussion and

Systemic fungal infections

auscultation, not forgetting contemplation

Leprosy

(Osier).

You should follow the classical sequence

INSPECTION OF THE CHEST WALL

Others

First look for any deformities of the chest

Sarcoidosis

Ulcerative colitic

Crohns disease

Sulphonamides

Oral contraceptive pill and

the anteroposterior diameter may be greater

pregnancy

than the lateral. The amount of trachea

wall. In barrel chest the chest wall is held in,

hyperinflation (Fig. 5.34). In normal people
the anteroposteior diameter of the chest is less
than the lateral diameter but in hyperinflation

enlarged and displaced to the left. In pectus

carinatum (pigeon chest), the sternum and
costal cartilages project outwards. It may be
secondary to severe childhood asthma.
Examine the chest wall for any operative
scars or the changes of thoracoplasty. This was
an operation performed in the 1940s and 1950s
for tuberculosis and designed to reduce the
volume ofthe chest. It can produce marked
distortion of the chest wall, more clearly seen

from the back (Fig. 5.36).

palpable above the suprastemal notch is

Flattening of part of the chest can be due

reduced. The normal bucket handle action of

either to underlying lung disease (which

the ribs moving, upwards and outwards,

usually has to be long standing) or to scoliosis.

pivoting at the spinous processes and the

Kyphosis is forward curvature ofthe

costal, cartilages, is converted into a pump

spine (Fig. 5.37) and scoliosis is a lateral

handle up and down motion. Barrel chest is

curvature. Both, but scoliosis in particular, can

seen in states of chronic airflow limitation,

lead to respiratory failure.

with the degree of deformity correlating with

its severity.
In pectus excavatum (funnel chest)

Air in the subcutaneous tissue is termed

surgical emphysema, although it is as
commonly associated with a spontaneous

(Fig. 5.35), the sternum is depressed: the

pneumothorax as trauma to the chest. The

condition is benign and needs no treatment but

tissues of the upper chest and neck are

can produce unusual chest radiographic

swollen, sometimes grossly so (Michelin

appearances, with the heart apparently

man); although the condition is not dangerous

in itself. The tissues have a characteristic

crackling sensation on palpation. In

Patients may seem unaware of the condition.

Is there any prolongation of expiration?

pneumothorax, the air probably tracks from

The typical patient with airflow limitation has

ruptured alveoli, through the root ofthe lungs

trouble breathing out. Inspiration may be brief,

to the mediastinum, thence up into the neck.

even hurried but expiration is a prolonged

On auscultation of the precordium, you may

laboured manoeuvre. Many of these patients

hear a curious extra sound in time with the

breathe out through pursed lips as if they were

heart (mediastinal crunch) but this can occur in

whistling, this mechanism maintains a higher

pneumothorax without pneumomediastinum.

airway pressure and keeps open the distal

Mediastinal air may be visible on a radiograph.

airways to allow fuller although longer

expiration.
Note if the chest expands unequally. If

BREATHING PATTERNS

this is so and there is no structural abnormality

A good deal can be learnt from simple

ofthe chest or spine to account for it then air is

observation of the chest wall movements. Note

probably not entering the lung so well on the

rate, depth and regularity. Does the chest move

affected side. The difference has to be marked

equally on the two sides? Does breathing

to be appreciated. The causes will be

appear distressing? Is it noisy?

considered under palpation. It is possible to

Counting the respiratory rate is a

measure overall expansion with a tape-

traditional nursing observation, yet the precise

measure (the result is of little value and

rate is rarely of practical importance. You

certainly no substitute for measures of lung

should note an increase in rate or depth. An

volume). Breathing mainly with the diaphragm

increase in. rate may occur in any severe lung

suggests chest wall problems (e.g. pleural

disease and in fever. Patients with

pain, ankylosing spondylitis). Breathing

hyperventilation may breath both faster and

mainly with the rib cage suggests diaphragm

more deeply, although the increase can be

paralysis, peritonitis or abdominal distension.

subtle and easily missed. Patients with acidosis

Normally, as the diaphragm descends in

from renal failure, diabetic ketoacidosis and

inspiration the anterior abdominal wall will

aspirin overdosage will have deep sighing

move outwards. If it moves inwards

(Kussmaul) respirations as they try to excrete

(abdominal paradox) then the diaphragm is

carbon dioxide. Acute massive pulmonary

probably paralysed. Similarly, in tetraplegia,

embolism gives a similar pattern.

when the chest wall muscles are paralysed,

Is the breathing regular? Cheyne-Stokes

respiration is a waxing and waning of the
respiratory depth over a minute or so from

descent of the diaphragm produces indrawing

of the chest wall (chest wall paradox).
Is the patient distressed by breathing?

deep respirations to almost no breathing at all.

Can the patient carry on a normal conversation

It is thought to be caused by a failure of the

or do they have to break up their sentences,

central respiratory control to respond

even perhaps to single words at a time?

adequately to changes in carbon dioxide and is

Patients Patients with severe respiratory

often seen in patients with terminal disease.

distress use their accessory muscles of

respiration. They fix the position of the

emphysema. Cough and sputum are less

shoulder girdle by pressing the hands on the

common, but the patients are breathless.

nearest fixed object and throw back their

Carbon dioxide levels in the blood are normal

heads. This gives a purchase for accessory

or low.

muscles of respiration, mainly the

sternomastoids.
PALPATION
Does the patient breathe more
comfortably in certain positions? Can the

Trachea and mediastinum

Start palpation by feeling for the position

patient lie flat or do they have to be propped

of the trachea. Do this from the front by

up? Patients with pulmonary oedema and

placing two fingers either side of the trachea

severe airflow limitation will be unable to lie

and judging whether the distances between it

down for long but then most patients with

and the sternomastoid tendons are equal on the

breathing difficulty are more comfortable

two sides (Fig. 5.40). An alternative is to

sitting up. Is breathing audible? Wheeze is a

examine the patient from behind and hook

prolonged expiratory noise often audible to the

your fingers round the tendons to meet the

patient as well as the doctor and implies

trachea. The trachea may be displaced by

airflow limitation. Stridor is a harsh, chiefly

masses, in the neck such as thyroid

inspiratory noise and implies obstruction in the

enlargement. Nonetheless, the trachea gives an

central airways. This may be at laryngeal level

indication about the position of the

when the voice is usually hoarse but otherwise

mediastinum, although often you will only be

implies tracheal or major bronchial

confident about tracjeal displacement after you

obstruction. In children, croup and foreign

have seen the radiograph.

bodies are the usual causes, in adults,

carcinoma or extrinsic compression.

The position of the apex beat also gives

information about the position of the
mediastinum so long as the heart is not

Pink puffers and blue bloaters

enlarged. The trachea moves with the upper

The terms pink puffers and blue

part of the mediastinum, the apex beat with the

bloaters are applied to the overall appearances

lower. The mediastinum may be pushed or

of some patients with chronic airflow

pulled to either side. Large effusions push the

limitation. They describe polar groups and

position of the apex beat but very large

most patients are in between. Blue boaters

effusions are needed to displace the trachea.

(Fig. 5.38) are cyanosed from hypoxia and

Pneumothorax pushes the mediastinum

bloated from right-sided heart failure. Further

even.though the lung collapses. This is

investigation shows features of chronic

because the pressure in the pleural space

obstructive bronchitis. Cough and sputum are

approaches or even exceeds atmospheric

common but breathlessness less so. Carbon

pressure, that is, increases. Lung collapse and

dioxide retention is a feature. Pink puffers

fibrosis pull the mediastinum (Fig. 5.41).

(Pig. 5.39) are not cyanosed and are thin.

Tumour, especially the pleural tumour

Investigation shows features associated with

mesothelioma, may fix the mediastinum so

that it cannot move despite these changes.

between the two sides of the body as

abnormality is likely to be confined to one
side. Start from the front at the apex of the
lung and work downwards comparing each

side immediately with the other. Remember

Chest wall

that the heart will influence the result on the

If the patient complains of chest pain,

left. Do not forget the lateral sides and the

then you should gently palpate the chest for

axillae. Then sit the patient forwards and

local tenderness. If present, this usually

examine the back. Sometimes you will need an

indicates disease of bones, muscles or

assistant to help a sick patient to lean

cartilage. As indicated earlier, one variety is

forwards. When examining from the back,

called Tietzes syndrome in which there is pain

place the arms of the patient forwards in the

and swelling of one or more of the upper

lap. This will move the scapulae laterally and

costal cartilages but much more commonly

uncover more of the chest wall.

than this syndrome there is merely pain and

tenderness of the cartilage but no swelling.
Chest wall tenderness may also be present in
pleurisy; point tenderness over a rib or:
cartilage is almost always due to benign local
disease and the worried patient can be
reassured.
A SYSTEMATIC APPROACH
From this point on, as with most parts of the
physical examination, comparison is made

Disorders
Causes of mediastinal displacement
Away from the lesion

Pneumothrax

Effusion (large)

Towards the lesion

Lung collapse from central airway

obstruction

Localised fibrosis

Vocal fremitus
This is performed by placing either the
edge or the Hat of your hand on the chest and
asking the patient to say ninety-nine or count
one, two, three. The vibrations produced by
this manoeuvre are transmitted through the
lung substance and are felt by the hand. The
test is crude and the mechanism and the
alterations in disease are the same as for vocal
resonance.

Chest expansion
The purpose of this test is to determine if
both sides of the chest move equally. Students
often have difficulty with this examination. A
good method is to put the fingers of both your
hands as far round the chest as possible and
then to bring the thumbs together in the

Disorders
Causes of dullness to percussion
Moderate

Consolidation

Fibrosis

Collapse

midline but to keep the thumbs off the chest

wall. The patient is then asked to take a deep
breath in, the chest wall, by moving outwards,
moves the moving outwards and the thumbs
are in turn distracted away from the midline
(Fig. 5.42). The thumbs must be free, if they
are also fixed to the chest wall they will not
move. It is important to keep your fingers and
thumbs in the same relationship to each other,

Stony

for it is easy to move the thumb the way you

- Pleural fluid

think it ought to go. Examination can be

performed on both the front and the back.

Expansion can be reduced on both sides

should be a flick of the wrist and the striking

equally. This is difficult to detect as there is no

finger should be at right angles to the other

standard of comparison but is produced by

finger. As well as hearing the percussion note,

severe airflow limitation, extensive

vibrations will be felt by your hand on the

generalised lung fibrosis and chest wall

chest wall. Again, each side is compared with

problems (e.g. ankylosing spondylitis.

the equivalent area on the other from top to

Unilateral reduction implies that air

cannot enter that side and is seen in pleural

bottom. Do not forget the sides.

The finger on the chest should be parallel

effusion, lung collapse, pneumothorax and

to the expected line of dullness (e.g. in an

pneumonia.

effusion, parallel to the floor). This will then

produce a clearly defined change in note from

PERCUSSION

normal to dull; a finger straddling the

The purpose of percussion is to detect the

demarcation will not do this. It should be

resonance or hollwness of the chest. Use both

placed in the intercostal spaces. Do not percuss

hands, placing the fingers of one hand on the

more heavily than is necessary, it gives no

chest with the fingers separated and strike one

more information and can be distressing to

of them with the terminal phalynx of the

patients. The apex of the lung can be examined

middle finger of the other hand (Fig. 5.43); it

by tapping directly on the middle of the

must be removed again immediately, like the

clavicle (Fig. 5.44). Remember that the lung

clapper inside a bell, otherwise the resultant

extends much further-down posteriorly than

sound will be damped. The striking movement

anteriorly (see Fig. 5.4).

The degree of resonance depends on the

anteriorly readies as high as the sixth costal

cartilage and over the heart. Resonance in

thickness of the chest wall and on the amount

these areas, again a subjective finding, implies

of air in the structures underlying it; The

increased air in the lungs and is common in

possibilities are increased resonance/dullness

overinflation and emphysema. Bilateral basal

and stony dullness. Obese patients and

dullness is more usually due to failure or

individiuals with thick chest walls show less

inability to take a deep breath, to obesity or to

resonance, yet it is equal on the two sides.

abdominal distension, than to bilateral pleural

Incontrast, patients with overinflated lungs,

effusions. The right diaphragm is normally

particularly those with emphysema, have

higher than the left so expect a slightly higher

increased resonance, however, it is generalised

level of dullness.

and without a reference point is difficult to

grade. It might be thought that air in the

AUSCULTATION

pleural space. (pneumothorax) would increase

Many doctors prefer to use the diaphragm of

resonance but the difference is often

the stethoscope for auscultation of the chest

insufficient to identify from percussion alone

(Fig. 5.45). In thin bony chests, the bell may

which is the affected side.

give a more airtight fit and is less likely to

Resonance is decreased moderately in

consolidation and fibrosis of thelung and
markedly if there is fluid of any kind between

.trap hairs underneath, which produce a

crackling sound.
Ask the patient to take deep breaths

the lung and the chest wall, that is, stony

through the mouth, then listen in sequence

dullness; A collapsed lobe can compress to a

over the chest as before. Start at the .apices

very small volume and compensatory

and compare each side with the other. Some

overinflation of the other lobe fills the space;

patients fail to understand the instruction to

The percussion note may then be normal. A

breathe through the mouth but -the sounds are

whole lung cannot collapse completely (unless

much clearer if they do. To help .them you:

there is also a pneumothorax) so the chest will

may have to press gently on the jaw to open it.

be dull. Percussion can also be used to

Some take enormous slow deep breaths that

determine movement of the diaphragm

although otherwise satisfactory, do prolong the

because the level of dullness will descend as

examination. A quick demonstration of what

the patient breathes in (tidal percussion).

you want will resolve any problems.

The breath sounds are produced in the
large airways, transmitted through the airways
and then attenuated by the distal lung structure
through which they pass. The sounds you hear
at the lung surface are therefore different from
the sounds heard over the trachea and are
modified further if there is anything
obstructing the ailways, lung tissue, pleura or

Dullness is to be expected over the liver which

chest wall. When reporting on auscultatory

changes, you must distinguish between the

breath sounds and the added sounds. Breath

Bronchial breathing

sounds are termed either vesicular or bronchial

Bronchial breathing causes much

and the added sounds are divided into crackles,

confusion because the essential feature of

wheezes and rubs.

bronchial breathing, the quality of the sound,

is difficult or impossible to put into .words.

Vesicular breath sounds

Traditionally, it is described by its timing as

This is the sound heard over normal

occurring in both inspiration and expiration

lungs, it has a rustling quality and is heard on

with a gap in between (Fig. 5.47). In this way

inspiration and the first part of expiration.

it is contrasted with vesicular breathing. These

(Fig. 5.46), Reduction in vesicular breath

features are undoubtedly true but lead to the

sounds can be expected with airways

confusion in the mind of the student that if

obstruction as in asthma, emphysema or

anything is heard in middle or late expiration it

tumour. The so-called silent chest is a sign of

must be bronchial, breathing. Many normal

severe asthma: so little air enters the lung that

people and individuals with airways

no sound is produced. The breath sounds can

obstruction have prolonged expiratory

be strikingly reduced in emphysema,

component to the breath sounds (this is

particularly over a bulla. Generalised reduction

sometimes designated bronchovesicular but

in breath sounds also occurs with a thick chest

this term increases the confusion rather than

wall or obesity.

diminishing it). It is best to forget about the

Anything interspersed between the lung

timing and concentrate on the essential feature,

and the chest wall (air, fluid or pleural

the quality of the sound. It can be mimicked to

thickening) will reduce the breath sounds; this

some extent by listening over the trachea with

is likely to be unilateral and therefore more

the stethoscope, although a better imitation can

easily detected.

be obtained by putting the tip of your tongue

Avoid the term diminished air entry
when you mean diminished breath sounds. The
two are not necessarily synonymous.

on the roof of your mouth and breathing in and

out through the open mouth.
Bronchial breathing is heard when sound

generated in the central airways is transmitted

breathing probably because of the

more or less unchanged through the lung

consolidation around it. Dense fibrosis is an

substance. This occurs when the lung

occasional cause. Breath sounds over an

substance, itself is solid as in consolidation but

effusion will be diminished but bronchial

the air passages remain open. Sound is

breathing may be heard over its upper level

conducted normally to the small airways but

perhaps because the effusion compresses the

then instead of being modified by air in the

lung.

alveoli, the solid lung conducts the sound

Bronchial breathing is only heard over a

better to the lung surface and, hence, to the

collapsed lung if the airway is patent. This is

stethoscope. If the central airways, are

rare as the collapse is usually caused by an

obstructed by say a carcinoma, then no

obstructing carcinoma. Nevertheless, there is

transmission of sound will take place and no

an exception with the upper lobes (see above).

bronchial breathing will occur even though the

Bronchial breathing has been divided

lung may be solid. An exception is seen in the

into tubular, cavernous and amphoric but

upper, lobes. Here, if the bronchi to either lobe

attempts to score points on ward rounds by

are blocked, sounds from the central airways

using these terms are best left to others.

can still be transmitted directly from the

trachea through the solid lung to the chest wall

Vocal resonance

(Fig. 5.48).

This is the auscultatory equivalent of

vocal fremitus. Place the stethoscope on the
chest and ask the patient to say ninety-nine.
Normally the sound produced is fuzzy and
seems to come from the chest piece of the
stethoscope. The changes in disease should by
now be predictable. The sound is increased in
consolidation (better transmission through
solid lung) and decreased if there is air, fluid
or pleural thickening between the lung and the
chest wall. The changes, of vocal fremitus are
the same. 'Both tests are of little value in
themselves, yet a refinement of vocal
resonance can be very useful: Sometimes, the
increased transmission of sound is so marked
that even when the patient whispers, the sound
is still heard clearly over the affected lung

The main cause of bronchial breathing is

(whispering pectoriloquy). When this is well

consolidation, particularly from pneumonia, so

developed there is a striking difference

much so that in the minds of most clinicians

between the normal side, where the sound

the three terms are synonymous. Lung abscess,

appears to come from the end of the

if near the chest wall, can cause bronchial

stethoscope and the abnormal side where the

syllables are much clearer and seem as if they

limited value.

are being whispered into your ear.

Wheezes
Emergency
Signs of asthma in adults

These are prolonged musical sounds

largely occurring on expiration, sometimes on
inspiration, and are due to localised narrowing

Signs of acute severe asthma in adults

within the bronchial tree. They are caused by

Unable to complete sentences

the vibration of the walls of a bronchus near to

Pulse > 110 beats/min

its point of closure. Most patients with wheeze

Respirations > 25 breaths/min

have many, each coming from a single,

Peak flow < 50% predicted or

best

Signs of life-threatening asthma in adults:

narrowed area. As the lung gets smaller on

expiration so the airways get smaller too, each
nan-owed airway reaches a critical phase when
it produces a wheeze then ceases to do so.
Thus, during expiration, numerous narrowings

Silent chest

Cyanosis

Bradycardia

then suggest a single narrowing often caused

Exhaustion

by a carcinoma or foreign body (fixed

Peak flow < 33% predicted or

wheeze).

best

produce numerous wheezes in sequence and

together. A single wheeze can occur and may

Wheezes are typical of airway narrowing

from any cause. Asthma arid chronic
bronchitis are the most common and the

Bronchial breathing and whispering

narrowing is caused by a combination of

pectoriloquy often occur together.

smooth muscle contraction, inflammatory

Consequently, if you are in doubt about the

changes in the walls and increased bronchial

presence of bronchial breathing then

secretions. Sometimes patients with these

whispering pectoriloquy may confirm it. Like

conditions have few or no wheezes. If so, ask

bronchial breathing, whispering pectoriloquy

the patient to take a deep breath and then to

is characteristic of consolidation but can also

blow out hard. This may produce a marked

occur with lung abscess and above an effusion.

wheeze. Occasionally, wheezing is heard in

pulmonary oedema, presumably because of

Added sounds
There are three types of added sounds:

bronchial wall oedema.

The term bronchospasm suggests

wheezes, crackles and pleural rubs. Much

narrowing caused only by smooth muscle

confusion has been generated in the past by

contraction and should be avoided as the

other terms such as rhonchi which are

bronchial narrowing is usually multifactorial.

equivalent to wheezes and crepitations and

Wheeze-like breath sounds can disappear

rales which are equivalent to crackles. Further

in severe asthma and emphysema because of

subdivision is often attempted but is of very

low rates of airflow. The amount of wheeze is

not a good indicator of the degree of airways

ventricular failure, fibrosis and pneumonia

obstruction. Peak expiratory flow

tend to produce crackles later on inspiration.

measurement is much better.

This distinction is of clinical value.

Note whether the crackles are localised.

Stridor

This would be expected in pneumonia and

Stridor may be heard better without a

mild cases of bronchiectasis. Pulmonary

stethoscope by putting your ear close to the

oedema and fibrosing alveolitis typically affect

patient's mouth and asking the patient to

both lung bases equally.

breathe in and out: As indicated earlier, it is a

Normal people, especially smokers, may

sign of large airway narrowing either in the

have a few basal crackles; these often clear

larynx, trachea or main bronchi.

with a few deep breaths.

Crackles;

Disorders

In a sense the term crackles is self-

Causes of crackles

explanatory. Problems arise because of various

descriptions that are often added such as

Left ventricular failure

coarse, medium, fine, wet or dry. These add

Fibrosing alveolitis

little to our understanding, nonetheless, it is

Extrinsic allergic alveolitis

Pneumonia

Bronchiectasis

heard that clears or alters as the secretions

Chronic bronchits

causing the sound are shifted on coughing or

Asbestosis

possible to distinguish two main types. The

first occurs when there is fluid in the larger
bronchi and a coarse bubbling sound can be

deep breathing.
The sound of other fine crackles can be
imitated by rolling the hairs of your temple

Pleural rub
This is caused by the inflamed surfaces

together between your fingers. They occur in

of the pleura rubbing together. The sound has

inspiration and are high-pitched, explosive

been likened to new leather when it is bent or

sounds. The mechanism of their production is

more vividly to the creaking noises made in a

thought to be as follows. Many conditions lead

sailing ship heeling to the wind which you

to premature closure of the small airways at

may have experienced from films if not in

the end of expiration. During the succeeding

reality. Some idea of the quality of the sound

inspiration, these units can only be reopened

can be obtained by placing one hand over the

by overcoming the surface tension that keeps

ear and rubbing the back of that hand with the

them closed. When they eventually pop open

fingers of the other. Pleural rubs are usually

crackles are produced. During inspiration,

heard on both inspiration and expiration. At

larger bronchi will open before smaller ones so

first you may think that you are moving the

crackles from chronic bronchitis and

stethoscope on the chest. Sometimes coarse

bronchiectasis tend to occur early. Conditions

crackles can sound like rubs; a cough will shift

that largely involve the alveoli, such as left

the former. If there is any pain, ask the patient

to point to the site of the pain, this often

localises the, rub too. Rubs are heard in all

Comments: Clubbing is seen in approximately

varieties of pleural inflammation such as in

60% of patients with fibrosing alveolitis. The

pneumonia and pulmonary embolism. Any

differential diagnosis of clubbing and basal

effusion will separate the pleura and the rub

crackles includes fibrosing alveolitis,

may well go but sometimes remain above the

bronchiectasis and asbestosis. Bronchiectasis

effusion.

is diagnosed on a history of chronic productive

cough and asbestosis on a history of relevant
exposure.

Case history
Fibrosing alveolitis
History: A 62-year-old taxi driver
presents with progressive shortness of breath

Disorders
Some causes of pneumonia

over the previous 4 months. There is no

significant day to day variation in his

Streptococcus pneumoniae

symptoms and no complaint of cough and

Mycoplasma pneumoniae

wheeze. He has a history of cigarette smoking

Haemophilus influenzae

for 48 years.

Influenza virus

Legionella pneumophilia

Psitticosis

Q fever

Chemical (for example,

Investigations and progress: Marked bilateral

basal crackles are found. A diagnosis of left
ventricular failure is made and diuretics are
commenced.

aspiration of vomit)

Two weeks later he returns, reporting no

improvement in his symptoms. The signs are

Radiation

unchanged and he is referred to hospital. On

review, he is noted to be centrally cyanosed
and to have finger clubbing.
A diagnosis of fibrosing alveolitis is
considered. A chest radiograph shows bilateral
basal interstitial shadowing and pulmonary

Disorders
Some causes of pleural fluid
Transudates

function tests show a typical restrictive

Congestive cardiac failure

pattern. The diuretics are stopped and the

Cirrhosis

patient commenced on corticoids with some

Nephrotic syndrome

improvement.

Exudates

means different things to different specialists.

Tumours- primary, secondary, and

To a radiologist it means an alveolar-filling

lymphomas

process with no presumption about aetiology.

Pneumonia

To a pathologist it means a heavy airless lung

Tuberculosis

and to a clinician it means bronchial breathing

Rheumatoid arthritis and other

connective tissue disorders

that is usually equated with pneumonia. To,

use-pneumonia as an example, the affected
lung or lobe is the same size or very slightly
larger than normal lung. The alveoli are full of

Blood

Trauma

Pulmonary embolism

Tumours

exudates, yet the air passages are open. The

pleura are inflamed. The disorders box lists
some causes. Note that not all are infections.
Inspection of die chest may show
diminished movement on the affected side,

Pus

palpation shows no shift of the mediastinum

Pneumonia

but expansion is reduced, vocal fremitus may

Trauma

be increased, percussion note will be

moderately impaired, breath sounds will be

Lymph

Tumours, especially lymphoma

bronchial over the affected area with

whispering pectoriloquy and there may be a
pleural rub. Early and late in die disease
process there may also be crackles and there

COMMON PATTERNS OF
ABNORMALITY
This section summarises what has been
said before but from the perspective of the
disease process. The diagnosis itself will need
the integration of the history and any other
information. Those considered are
consolidation, pleural fluid, pneumothorax,
chronic airflow limitation, lung or lobar
collapse and fibrosis. Not all the signs are
present in every case and often there is more
than one disease process at a time. The
radiograph often illustrates the anatomical
nature of the process, so examples are shown.
CONSOLIDATION
Consolidation is a confusing term as it

may be the only auscultatory change in mild

cases. In lobar pneumonia, the changes are
localised to a lobe which means that the signs
are detected either anteriorly or posteriorly but
not usually both. More widespread changes
suggest broncho-pneumonia, a complication
of chronic bronchitis, or atypical pneumonia
caused by viruses, mycoplasma and other
organisms. Radiology may show an air
bronchogram: air in the bronchi outlined by
fluid in the alveoli (Fig. 5.49).
PLEURAL FLUID
Whether this be from an increase in pleural
trasudate, Pleural exudates from inflammation,
blood, pus or lymph, the signs are the same. A
large amount of fluid is needed to displace the
heart and an even larger amount, filling most

of the hemithorax, to displace the trachea. The

Mediastinum central
Expansion
Percussion note
Breath sounds bronchial
Whispering pectoriloquy
Crackles
Pleural rub

Case history
Lung collapse
History: A, 73-year-old woman presents to the
emergency department one evening with a
history of progressive shortness of breath for
the previous 2 months. She has also coughed
up small amounts of blood but there is no
history of wheeze. She has smoked heavily
most of her life but stopped about 4 months
previously.

Fig. 5.49 Consolidation (unusual because it

affects both lugs). Enlarged view showing air
bronchogram.
displacement is away from the fluid.
Expansion is diminished on the affected side,
vocal fremitus is reduced, percussion note is
markedly reduced, stony dullness, and breath
sounds are absent or markedly reduced.
Bronchial breathing and a rub may be heard at
the upper level of the effusion. An effusion, if
large enough, is detected both anteriorly and
posteriorly (Figs 5.50 and 5.51)

On examination: Examination reveals

that the left side of her chest moves less than
the right, is dull to percussion and that breath
sounds are absent. A chest radiograph shows
that the left lung field is entirely opaque.
A diagnosis of a left pleural effusion is
made and an aspiration needle inserted into the
chest. To the surprise of the doctor, no fluid is
obtained.
Review of the patient shows that the
trachea is displaced to the left and this is
confirmed on review of the radiograph. A
diagnosis of lung collapse is made.
Comments: It is a common mistake to

confuse lung collapse with effusion and the

to detect and it is the conjunction of dimin-

diagnosis depends on. spotting that the

ished breath sounds with a normal percussion

mediastinum has moved towards the lesion

note that distinguishes it from other causes of

and not away.

Mediastinum central
Expansion
Percussion
Breath sounds
Sometimes bronchial breathing
Or a pleural rub at upper level

Mediastinum displaced
Expansion
Percussion
Breath sounds

Mediastinum sometimes
displaced
Expansion
Percussion normal or
Breath sounds
No added sounds
diminished breath sounds when there is also
PNEUMOTHORAX

dullness to percussion. Vocal resonance is

The pressure in the pleural space is normally

reduced and there are no added sounds (Fig.

negative with respect to atmospheric pressure.

5.52). Some causes of pneumothorax are given

In a pneumothorax, the affected side is at a

in the disorders box.

higher pressure, that is, less negative. This

pressure tends to displace the mediastinum to

CHRONIC AIRFLOW LIMITATION

the opposite side and if there is a flap valve

This term covers the entities of chronic

effect producing a tension pneumothorax, this

obstructive bronchitis, emphysema and asthma

can be extreme and dangerous. The affected

which are not always readily distinguishable

side moves less well, vocal fremitus is reduced

from each other. There may be hyperinflation

and the percussion note is normal. The

of the chest, pursed lip breathing and use of

expected increased resonance can be difficult

accessory muscles of respiration. Expansion

may well be reduced but usually equally so.

capacity of the chest to shrink but if a lobe is

The mediastinum is not displaced. Vocal

involved, then the other lobe can fill the space

fremitus is normal, percussion is usually

and the affected, lung may come to occupy

normal but there may be increased resonance

only a very small area. Lung collapse can also

and reduced hepatic and cardiac dullness.

follow infection: tuberculosis and

bronchiectasis are good examples. Here the
airways remain open.

The findings on examination depend on

Breath sounds are vesicular and. Sometimes

whether the whole lung or only one lobe is

reduced, presumably from low flow rates; the

involved. There is diminished movement on

added sounds are wheezes and often crackles.

the affected, side, with the mediastinum

The radiograph is usually normal but

deviating to that side. The percussion note is

sometimes shows overinflation with low flat

markedly reduced if the whole lung is

diaphragms (Fig. 5.53)

involved but can be difficult or impossible to

detect if only a lobe is involved and has shrunk

LUNG AND LOBAR COLLAPSE

to a small space. Breath sounds are diminished

The usual cause is a central bronchial

but remain vesicular in lobar collapse and may

carcinoma, although a foreignbody has the

be absent if the whole lung is involved. Vocal

same effect. If the lung or lobe is not

resonance is decreased. As already indicated,

ventilated, the air within it is absorbed by the

bronchial breathing, increased vocal resonance

blood and the lung whole lung is involved,

and whispering pectoriloquy can be heard in

then the degree of collapse is limited by the

upper lobe collapse because of direct

transmission of sound from the trachea.

Bronchial breathing is also heard in collapse of
other lobes if (unusually) the airways remain
patent (Fig. 5.54). Crackles and wheeze may
be present if the cause is damage from an old
infection.

Examination of elderly people

LUNG FIBROSIS

Respiratory examination

This may be the end result of many lung

conditions and minor degrees are undetectable

The method of taking a respiratory history and

clinically. Localised changes produce similar

examining the respiratory system in the elderly

signs to lung collapse. Generalised disease is

is not very different from that in younger

best illustrated by cryptogenic fibrosing

people. The major difficulty for the student is

alveolitis. The lungs are stiff, expansion may

when the patient has more than one problem

be reduced, but equally, and the mediastinum

which needs identification or when one

is central. Vocal fremitus is normal, percussion

problem interferes with the assessment of

note is normal or slightly reduced, breath

another. Both are more common in older

sounds are vesicular although occasionally

people but/of course, are not confined to them

bronchial, yet there are marked crackles

Do not neglect an occupational history

initially confined to the bases but later

just because the patient has retired. Asbestosis

extending up the chest (Fig. 5.55).

and mesothelioma can occur decades after

exposure. Similarly, the, changes of coal

workers pneumoconiosis remain on the chest

the other remains unchanged. Careful

radiograph for life.

assessment is needed to ensure that treatment

The nature of the respiratory disease that

is well directed

afflict people does riot change so very greatly

as they grow; one exception is cystic fibrosis.
Mistakes are sometimes made by having too
rigid a conception of the likely diagnosis in the
elderly. There is, for example, a tendency to
regard most older breathless patients as having
chronic obstructive pulmonary disease with
fixed narrowed airways, sometimes on slender
evidence. This can lead to therapeutic nihilism.
Although it is true that lung function as a
whole declines with age, significant airway
obstruction is not an inevitable consequence of
the ageing process. A history of smoking is as
helpful as in younger patients in the diagnosis.
Asthma, on the other hand, is by no
means a disease only of the young. Its onset
may be in the eighth, ninth decades or even
later. Appropriate treatment can be just as
effective.
Major problems can occur in trying to

Review Framework for the routine

examination of the respiratory system

distinguish respiratory from cardiac causes of

breathlessness and in the elderly both may be

1. While taking the history, watch for

present to some degree and need separate

respiratory distress, particularly while talking.

assessment and treatment. Right ventricular

Note any clues from the patient's surroundings

failure as a consequence of lung disease (cor

2. Look at the hands for clubbing,

pulmonale) may be particularly difficult to

cyanosis and evidence of carbon dioxide

distinguish from congestive cardiac failure.

retention

Both may have a raised jugular venous pulse

and peripheral oedema and the basal crackles
of left ventricular failure may be confused
with those of chronic airway obstruction.
Assessment of disability may be difficult
when more than one disease is present. For
example, both chronic airflow limitation and
intermittent claudication are common in a

3. Look at the mucous membranes for

central cyanosis
4. Check the jugular venous pulse for
evidence of cor pulmonale
5. Palpate for supraclavicular lymph
nodes
6. Inspect the chest wall for deformities
and inequalities

smoking population; both may limit exercise.

7. Note the pattern of breathing

Improvement in one may be of little account if

8. Palpate the trachea for any

displacement
9. Palpate the front of the chest for vocal
fremitus and for right ventricular hypertrophy
10. Assess expansion of the chest from
the front and note any inequalities
11. Percuss the front of the chest
comparing one side with the other and noting
any areas of dullness; include the axillae
12. Auscultate the chest similarly and
decide on the presence and nature of the breath
sounds
13. Test for vocal resonance and, where
appropriate, whispering pectoriloquy
14. Note any added sounds
15. Repeat last 6 steps on the back of the
chest
16. If appropriate, measure the peak flow
rate