APPROACH TO THE PATIENT WITH

DISEASE OF THE RESPIRATORY

SYSTEM

James Albert A. Flores, MD, FPCP, FPCCP

Diseases of the Respiratory System

1. Obstructive lung diseases

2. Restrictive disorders
3. Abnormalities of the vasculature
Diseases of the Respiratory System

 Disorders can also be grouped according to gas

exchange abnormalities
1. Hypoxemic
2. Hypercarbic
3. Combined impairment

 However, many diseases of the lung do not manifest as gas

exchange abnormalities
Diseases of the Respiratory System

 Thorough history and a focused physical examination

 Tests and procedures

 Pulmonary function testing
 Chest imaging
 Blood and sputum analysis
 Serologic or microbiologic studies
 Diagnostic procedures- bronchoscopy

 Stepwise approach
Dyspnea
 The cardinal symptoms of respiratory disease
 Obstructive lung disease
 chest tightness
 inability to get a deep breath

 Congestive heart failure

 air hunger
 a sense of suffocation
Dyspnea
 Acute shortness of breath
 laryngeal edema, bronchospasm, myocardial infarction, pulmonary
embolism, or pneumothorax

 COPD and idiopathic pulmonary fibrosis (IPF)

 gradual progression of dyspnea on exertion, punctuated by acute
exacerbations of shortness of breath

 Asthma
 have normal breathing the majority of the time with recurrent episodes
of dyspnea that are usually associated with specific triggers (URTI or
exposure to allergens)
Dyspnea
 Dyspnea on exertion
 Determine the degree of activity that results in
shortness of breath
 Patients adapt their level of activity to accommodate
progressive limitation
 delineate the activities in which they engage and how
these activities have changed over time

 Often an early symptom of underlying lung or heart

disease and warrants a thorough evaluation
Cough
 Generally indicates disease of the respiratory
system
 Inquire about the following
 Duration of the cough
 Whether or not it is associated with sputum
production, and
 Any specific triggers that induce it
Cough
 Acute cough productive of phlegm is often a
symptom of infection of the respiratory system
(sinusitis, tracheitis, bronchitis, bronchiectasi, and
pneumonia)
 Quantity and quality of the sputum
 Hemoptysis warrants an evaluation
 whether it is blood-streaked or frankly bloody
Cough
 Chronic cough
 Defined as that persisting for >8 weeks
 Commonly associated with obstructive lung diseases
 Nonrespiratory diseases  gastroesophageal reflux
and postnasal drip

 Diffuse parenchymal lung diseases, including IPF,

frequently present as a persistent, nonproductive
cough.
Cough
 As with dyspnea, all causes of cough are not
respiratory in origin, and assessment should
encompass a broad differential, including cardiac
and gastrointestinal diseases as well as
psychogenic causes
Additional Symptoms
 Wheezing
 Suggestive of airways disease, particularly asthma

 Hemoptysis
 Infections of the respiratory tract, bronchogenic carcinoma, and pulmonary
embolism

 Pain in the chest from respiratory disorders

 diseases of the parietal pleura (e.g., pneumothorax) or pulmonary vascular diseases
(e.g., pulmonary hypertension)

 Abdominal bloating or distention and pedal edema

 Right-sided heart failure (cor pulmonale)
History
 Current or previous cigarette smoking
 COPD and bronchogenic lung cancer
 Diffuse parenchymal lung diseases (e.g., desquamative
interstitial pneumonitis and pulmonary Langerhans cell
histiocytosis).
 Longer duration and greater intensity of exposure to
cigarette smoke increases the risk of disease

 Second-hand smoke
 Ask about parents, spouses, or housemates who smoke.
History
 Possible inhalational exposures
 Work place (e.g., asbestos, wood smoke)
 Associated with leisure (e.g., excrement from pet
birds)

 Travel
 Risk of tuberculosis
 Fungi found in specific geographic regions or climates
(e.g., Histoplasma capsulatum)
History
 Associated symptoms of fever and chills
 should raise the suspicion of infective etiologies, both
pulmonary and systemic.

 A comprehensive review of systems may suggest

rheumatologic or autoimmune disease presenting
with respiratory tract manifestations.
 Questions should focus on joint pain or swelling, rashes,
dry eyes, dry mouth, or constitutional symptoms.
History
 Carcinomas from a variety of primary sources
commonly metastasize to the lung and cause
respiratory symptoms.

 Therapy for other conditions, including both

irradiation and medications, can result in diseases
of the chest
Physical Examination
 Vital signs  respiratory rate (RR)
 elevated (tachypnea)
 depressed (hypopnea)

 Pulse oximetry  hypoxemia, either at rest or with

exertion
Physical Examination
 INSPECTION
 Respiratory distress, use of accessory muscles of
respiration to breathe
 Severe kyphoscoliosis
 Inability to complete a sentence in conversation is
generally a sign of severe impairment and should result
in an expedited evaluation of the patient
Physical Examination
 PERCUSSION
 establish diaphragm excursion and lung size.
 In the setting of decreased breath sounds, percussion is
used to distinguish between pleural effusions (dull to
percussion) and pneumothorax (hyper-resonant note)
Physical Examination
 PALPATION
 The role of palpation is limited in the respiratory
examination.
 Subcutaneous air in the setting of barotrauma
 Adjunctive assessment with auscultation
 consolidation (increased tactile fremitus) or
 pleural effusion (decreased tactile fremitus)

 The symmetry and degree of chest wall expansion

Physical Examination
 AUSCULTATION
 Wheezes  airway obstruction
 Asthma,
 peribronchial edema in CHF (diffuse wheezes)P
 Polyphonic  multiple different size airways (e.g.,
asthma)
 Monophonic  one size airway (e.g., bronchogenic
carcinoma).
 Clinicians must take care not to attribute all wheezing
to asthma
Physical Examination
 AUSCULTATION
 Rhonchi  obstruction of medium-sized airways, most
often with secretions
 Acute setting  may be a sign of viral or bacterial
bronchitis
 Chronic rhonchi  bronchiectasis or COPD

 Expiratory wheezes and rhonchi, stridor is a high-

pitched, focal inspiratory wheeze, usually heard over
the neck as a manifestation of upper airway obstruction
Physical Examination
 AUSCULTATION
 Crackles or rales  alveolar disease
 Processes that fill the alveoli with fluid may result in
crackles, including pulmonary edema and pneumonia
 Crackles in pulmonary edema are
generally more prominent at the bases
 Diseases that result in fibrosis of the interstitium
(e.g., IPF) also result in crackles that sound like Velcro
being ripped apart.
Physical Examination
 AUSCULTATION
 Crackles associated with alveolar fluid vs associated
with interstitial fibrosis
 Egophony  pneumonia
 Increased whispered pectoriloquy

 Patients with emphysema often have a quiet chest with

diffusely decreased breath sounds
 Pneumothorax or pleural effusion may present with an
area of absent breath sounds
Other Systems
 Pedal edema
 if symmetric, may suggest cor pulmonale
 if asymmetric, it may be due to deep venous thrombosis and associated
pulmonary embolism.

 Jugular venous distention may also be a sign of volume overload

associated with right heart failure.

 Pulsus paradoxus is an ominous sign in a patient with obstructive

lung disease, as it is associated with significant negative
intrathoracic (pleural)
pressures required for ventilation and impending respiratory failure.
Other Systems
 Clubbing can be found in many lung diseases,
including cystic fibrosis, IPF, and lung cancer.

 Cyanosis is seen in hypoxemic

respiratory disorders that result in >5 g of
deoxygenated hemoglobin/dL.
Diagnostic Evaluation
 Acute respiratory symptoms are often evaluated
with multiple tests performed at the same time in
order to diagnose any life-threatening diseases
rapidly (e.g., pulmonary embolism or multilobar
pneumonia).

 In contrast, chronic dyspnea and cough can be

evaluated in a more protracted, stepwise fashion.
Diagnostic Evaluation
 Pulmonary Function Testing
 Spirometry
 An effort-dependent test used to assess for obstructive
pathophysiology as seen in asthma, COPD, and bronchiectasis
 A diminished forced expiratory volume in 1 s (FEV1)/forced
vital capacity (FVC) (often defined as <70%) is diagnostic of
obstruction.
 FEV1 and FVC
 Flow-volume loop (which is less effort-dependent)
 A plateau of the inspiratory and expiratory curves suggests large-
airway obstruction in extrathoracic and intrathoracic locations,
respectively
Diagnostic Evaluation
 Spirometry
 Symmetric decreases in FEV1 and FVC warrants
further testing, including measurement of lung volumes
and the diffusion capacity of the lung for carbon
monoxide (DLCO).
 A total lung capacity <80% of the patient’s predicted
value defines restrictive pathophysiology.
 Restriction can result from parenchymal disease,
neuromuscular weakness, or chest wall or pleural diseases
 Restriction with impaired gas exchange, as indicated by a
decreased DLCO, suggests parenchymal lung disease.
Diagnostic Evaluation
 Spirometry
 Additional testing, such as measurements of maximal
inspiratory and expiratory pressures, can help diagnose
neuromuscular weakness.
 Normal spirometry, normal lung volumes, and a low
DLCO should prompt further evaluation for
pulmonary vascular disease.
Diagnostic Evaluation
 Arterial blood gas testing
 Hypoxemia, while usually apparent with pulse oximetry,
can be further evaluated with the measurement of arterial
PO2 and the calculation of an alveolar gas and arterial
blood oxygen tension difference ([A–a]DO2).
 Patients with diseases that cause ventilation-perfusion mismatch
or shunt physiology have an increased (A–a)DO2 at rest.
 Also allows the measurement of arterial PCO2
 Hypercarbia can accompany disorders of ventilation, as seen in
severe airway obstruction (e.g., COPD) or progressive restrictive
physiology.
Diagnostic Evaluation
 IMAGING
 Most patients with disease of the respiratory system
undergo imaging of the chest as part of the initial
evaluation
 Chest radiography  preferably posterior-anterior
and lateral films
 Ultrasound  can help rapidly diagnose
pneumothorax, pleural effusion, and consolidation of
lung parenchyma
Diagnostic Evaluation
 IMAGING
 CT scan of the chest can also be useful to delineate parenchymal
processes, pleural disease, masses or nodules, and large airways.
 Administration of contrast, the pulmonary vasculature can be
assessed with particular utility for determination of pulmonary
emboli.
 Intravenous contrast also allows lymph nodes to be examined in
greater detail.
 When coupled with positron emission testing (PET), lesions of
the chest can be assessed for metabolic activity; helping
differentiate between malignancy and scar.
FURTHER STUDIES
 Large airway lesions  bronchoscopy (with bronchoalveolar lavage or for
nonsurgical lung biopsies.
 Blood testing may include assessment for hypercoagulable states in the setting
of pulmonary vascular disease, serologic testing
for infectious or rheumatologic disease, or assessment of inflammatory
markers or leukocyte counts (e.g., eosinophils).
 Genetic testing is increasingly used for heritable lung diseases such as cystic
fibrosis.
 Sputum evaluation for malignant cells or microorganisms may be appropriate.
 An echocardiogram to assess right- and left-sided heart function is often
obtained.
 Surgical lung biopsy is needed to diagnose certain diseases of the respiratory
system.
END