Respiratory exam. F Medical

The timing and character of the cough are usually not useful in establishing a cause. • Dyspnea (at rest or with exertion) may reflect a more serious condition. • Cough-variant asthma: consider in adults with prominent nocturnal cough. • Pneumonia: tachycardia, tachypnea, fever, rales, decreased breath sounds, tactile fremitus, egophony. • Acute bronchitis: wheezing and rhonchi. • Chronic sinusitis: postnasal drip, sore throat, facial pain. • The presence of posttussive emesis or inspiratory whoop modestly increases the likelihood of pertussis and absence of paroxysmal cough decreases its likelihood in cough lasting more than 1 week. • Chronic obstructive pulmonary disease (COPD): cough with phlegm production, abnormal match test (inability to blow out a match from 10 inches away). • Heart failure: symmetric basilar rales, elevated jugular venous pressure, positive hepatojugular reflux.

ECG findings are abnormal in 70% of patients, usually with sinus tachycardia and nonspecific ST-T changes. • Acute respiratory alkalosis, hypoxemia, and widened arterial-alveolar O2 gradient (A-a Do2) may be seen, but these findings are not diagnostic. • D-dimer testing is very sensitive but is nonspecific for VT.

New cough or change in chronic cough, dyspnea, hemoptysis, anorexia, weight loss • Enlarging nodule, mass, or persistent opacity on chest radiograph or CT scan • Cytologic or histologic findings of lung cancer in sputum, pleural fluid, or biopsy specimen

Acute or subacute onset of fever, cough with or without sputum, and dyspnea may be present. • Rigors, sweats, chills, pleurisy, chest discomfort, and hemoptysis are common. • Fatigue, anorexia, headache, myalgias, and abdominal pain may be present. • Physical findings include fever or hypothermia, tachypnea, tachycardia, decreased oxygen saturation, rales or abnormal breath sounds, and dullness to percussion. • Symptoms may be more nonspecific in HAP and VAP; two or more clinical findings (fever, leukocytosis, and purulent sputum) in the setting of a new or progressive pulmonary opacity on chest radiograph are suggestive.

Inquire about Fever, cough, chest pain; onset, duration, severity, and periodicity of symptoms Vital sign measurement and pulse oximetry Cardiac and chest examination findings Chest radiography findings; arterial blood gas (ABG) measurement in selected patients

Supplemental oxygen in hypoxemic patients increases survival and reduces hospitalizations. • Bronchodilators offer improvement in symptoms, exercise tolerance, and overall health. • Ipratropium bromide and short-acting β2-agonists (eg, albuterol) are used, often in combination. • Long-acting β2-agonists (formoterol, salmeterol, indacaterol, arformoterol, vilanterol) and anticholinergics (tiotropium, aclidinium, and umeclidinium) are also beneficial. • Corticosteroids are often used for exacerbations; they are generally not effective in outpatients. • Antibiotics slightly improve outcomes when used to treat acute exacerbations of chronic obstructive pulmonary disease and when used to prevent acute exacerbations of chronic bronchitis. • Preventative use of azithromycin or moxifloxacin can reduce the frequency of exacerbations in patients with frequent exacerbations despite optimal medical therapy. • Opioids and sedative-hypnotic drugs can manage severe and refractory dyspnea.

What is the differential diagnosis of asthma?

Third most common cause of death in hospitalized patients; often not recognized antemortem. • Risk factors: immobility, hyperviscosity, increased central venous pressures, vessel damage (trauma, prior DVT, orthopedic surgery), hypercoagulable states. • PE develops in 50% to 60% of patients with proximal lower extremity DVT; 50% are asymptomatic; hypoxemia results from vascular obstruction leading to dead space ventilation, right-to-left shunting, and decreased cardiac output. • Other types of pulmonary emboli: fat embolism, air embolism, amniotic fluid embolism, septic embolism (eg, endocarditis), tumor embolism, foreign body embolism, and parasite egg embolism (schistosomiasis).

Chest radiography for abnormal vital signs or chest examination, elderly and immunocompromised persons, and unexplained cough lasting more than 3 to 6 weeks

Smoking cessation is the single most important goal and includes both behavioral and pharmacologic interventions. • Noninvasive positive-pressure ventilation in exacerbation reduces the need for intubation, shortens intensive care unit lengths of stay, and may reduce the risk of health care-associated infections.

Episodic wheezing and difficulty breathing, chest tightness, and cough • Excess sputum production • Symptoms are frequently worse at night • Common aeroallergens include dust mites, cockroaches, cats, and pollen • Nonspecific precipitants include exercise, respiratory tract infections, rhinitis and sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in weather, and stress • Tobacco smoke increases symptoms and decreases lung function • Certain medications (including aspirin and nonsteroidal anti-inflammatory drugs) may be triggers • Nasal findings consistent with allergy and evidence of allergic skin disorders • Wheezing with normal breathing or a prolonged forced expiratory phase

For hospital-acquired sinusitis, removal of a nasogastric tube, improved nasal hygiene, and endoscopic or transantral cultures (particularly in HIV-infected or other immunocompromised patients) may be helpful.

Sore throat, fever, anterior cervical adenopathy, and tonsillar exudate suggest group A β-hemolytic streptococcus infection.

Long-term control therapies include inhaled corticosteroids, inhaled long-acting β2-agonists (often in combination with inhaled corticosteroids), systemic corticosteroids, leukotriene modifiers, mediator inhibitors, and phosphodiesterase inhibitors. • Relief therapy or “rescue” therapies include short-acting inhaled β2-agonists, inhaled anticholinergics, and systemic corticosteroids. • Acute exacerbations are treated with inhaled short-acting β2-agonists with or without systemic corticosteroids depending on the severity. • Severe exacerbations (PEFR <40% predicted or personal best) may also require oxygen treatment, inhaled ipratropium bromide, and intravenous magnesium sulfate. • Chronic asthma treatment is guided by asthma severity. • Mild intermittent asthma treatment requires inhaled short-acting β2-agonists for rescue. • Mild persistent asthma treatment includes daily use of a long-term control therapy. • Moderate persistent asthma treatment requires increased corticosteroid dose or adding long-acting inhaled β2-agonist. • Severe persistent asthma treatment requires daily high-dose inhaled corticosteroid and long-acting β2-agonist. • Theophylline is a less-preferred alternative to long-acting bronchodilators.

Dyspnea is the subjective perception of uncomfortable breathing. • Can result from psychogenic origins or from conditions that Increase the mechanical effort of breathing (eg, chronic obstructive pulmonary disease [COPD], restrictive lung disease, respiratory muscle weakness) Produce compensatory tachypnea (eg, hypoxemia or acidosis) • The following factors play a role in how and when dyspnea presents in patients: Rate of onset Previous dyspnea Medications Comorbidities Psychological profile Severity of underlying disorder

The most common chest radiography findings are atelectasis, infiltrates, pleural effusions, Westermark sign (focal oligemia with a prominent central pulmonary artery), and Hampton hump (pleural-based area of increased density from intraparenchymal hemorrhage). • Lung scanning (V/Q scan) can exclude PE if findings are normal or make the diagnosis if high probability; indeterminate scans are common and do not help diagnostic efforts. • Helical CT arteriography is the initial diagnostic study of choice because it is very sensitive and noninvasive, but it does require administration of intravenous radiocontrast dye. • Venous thrombosis studies include lower extremity Doppler ultrasonography and may establish the need for treatment, precluding invasive testing in patients with high suspicion for PE. • Pulmonary angiography is the reference standard for the diagnosis of PE but is invasive.

Acute cough • Most often viral upper respiratory infection or postviral infection cough but may be postnasal drip (allergic rhinitis), pneumonia, pulmonary edema, or pulmonary embolism Persistent cough • Most common causes: postnasal drip, asthma, gastroesophageal reflux disease (GERD) • Pulmonary infections: postviral, pertussis, bronchiectasis, eosinophilic bronchitis, tuberculosis, cystic fibrosis, Mycobacterium avium complex, Mycoplasma or Chlamydia infection, respiratory syncytial virus • Noninfectious pulmonary diseases: asthma (cough-variant), COPD, angiotensin-converting enzyme inhibitors, environmental exposures, endobronchial lesions (eg, tumor), interstitial lung disease, sarcoidosis, chronic microaspiration, β-blockers (causing asthma) • Nonpulmonary: GERD, postnasal drip (allergic rhinitis), sinusitis, heart failure, laryngitis, ear canal or tympanic membrane irritation, psychogenic or habit cough

Chest radiograph findings range from patchy airspace opacities to lobar consolidation with air bronchograms to diffuse alveolar or interstitial opacities. • Clearing of opacities can take 6 weeks or longer.

The presence of the four Centor diagnostic criteria strongly suggests group A β-hemolytic streptococcus infection, and some would treat the patient regardless of laboratory results. • When three of the four Centor criteria are present, there is an intermediate likelihood of GABHS. • When two or three Centor criteria are present, throat cultures or rapid antigen detection testing of a throat swab should be obtained. • When zero or one Centor criterion is present, group A β-hemolytic streptococcus infection is unlikely; throat culture or rapid antigen detection testing of a throat swab is not necessary. • A single-swab throat culture is 90% to 95% sensitive and the rapid antigen detection testing (RADT) is 90% to 99% sensitive for GABHS. • With about 90% sensitivity, lymphocyte to white blood cell ratios of greater than 35% suggest EBV infection, not tonsillitis. • Consider HIV antibody or viral load testing for acute HIV infection.

Antibiotics should be given if symptoms last more than 10 days or if severe symptoms such as fever, facial pain, and periorbital swelling are evident on presentation. • First-line therapy is amoxicillin, TMP-SMZ, or doxycycline. • After recent antibiotic use, levofloxacin or amoxicillin-clavulanate is appropriate. • Second-line therapy includes amoxicillin-clavulanate or moxifloxacin. • Hospital-acquired infections may require broad-spectrum agents. • Oral or nasal decongestants may be used for symptom improvement. • Intranasal corticosteroids (such as mometasone furoate) for 21 days are recommended by clinical practice guidelines.

Thoracentesis and cytology of malignant effusions; fine-needle aspiration of lymph nodes (which may be CT guided). • Bronchoscopy with or without electromagnetic navigation, mediastinoscopy, video-assisted thoracoscopic surgery, or thoracotomy, if needed, for tissue diagnosis

Predisposition to venous thrombosis, usually of the lower extremities • Usually dyspnea, chest pain, hemoptysis, or syncope • Tachypnea and a widened alveolar-arterial Po2 difference • Elevated rapid D-dimer and characteristic defects on CT arteriogram of the chest, ventilation-perfusion lung scan, or pulmonary angiogram

Upper respiratory tract infection • Viral rhinitis • Allergic rhinitis • Nasal polyposis • Dental abscess • Rhinocerebral mucormycosis • Otitis media • Pharyngitis • Dacryocystitis • Paranasal sinus cancer

Pulmonary embolectomy is an emergency procedure with a high mortality rate performed at few centers.

Rapid onset, severe dyspnea: suggests pneumothorax, pulmonary embolism, or flash pulmonary edema. • Pleuritic chest pain: suggests pneumothorax, pulmonary embolism, pericarditis, or pleurisy • Immobilization or hospitalization, cancer, or lower extremity trauma: suggest pulmonary embolism. • Cough and fever: suggest pulmonary disease, particularly infections, myocarditis, or pericarditis. • Wheezing: suggests acute bronchitis, chronic obstructive pulmonary disease (COPD), asthma, foreign body, or vocal cord dysfunction. • Prominent dyspnea with no accompanying features: suggests noncardiopulmonary causes such as anemia, metabolic acidosis, panic disorder, neuromuscular disorders, respiratory muscle weakness, chronic pulmonary embolism, or other causes of impaired oxygen delivery (eg, methemoglobinemia, CO poisoning). • Inspection of respiratory pattern can suggest obstructive airway disease (pursed-lip breathing, accessory respiratory muscle use, barrel-shaped chest), asymmetric expansion (pneumothorax), or metabolic acidosis (deep Kussmaul respirations). • Focal wheezing may suggest foreign body or bronchial obstruction. • Accentuated pulmonic second heart sound (loud P2): suggests pulmonary hypertension or pulmonary embolism. • Orthopnea (dyspnea that occurs in recumbency) and paroxysmal nocturnal dyspnea (shortness of breath that occurs abruptly 30 minutes to 4 hours after going to bed and is relieved by sitting or standing up) and other findings suggestive of elevated LV end-diastolic pressure suggest cardiac disease and heart failure.

Over 75% of patients are symptomatic at diagnosis; presentation depends on the type and location of the tumor. • Anorexia, weight loss, and asthenia, new or changed cough, hemoptysis, pain from metastases. • Local spread may result in endobronchial obstruction and postobstructive pneumonia, effusions, or a change in voice caused by recurrent laryngeal nerve involvement. • Superior vena cava syndrome. • Horner syndrome. • Brain metastases may present with headache, nausea, vomiting, dizziness, or seizures. • Paraneoplastic syndromes, including the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) (10%–15% of SCLC) and hypercalcemia.

Sputum induction and fiberoptic bronchoscopy are indicated for patients who cannot provide samples or who may have PCP or Mycobacterium tuberculosis. • Serologic assays, polymerase chain reaction tests, specialized culture tests, and other diagnostic tests can help identify organisms such as viruses, Legionella, M pneumoniae, and C pneumoniae • Thoracentesis with pleural fluid analysis should be performed in all patients with effusions. • Endotracheal aspiration and fiberoptic bronchoscopy with lavage in patients with VAP.

Common disease affecting nearly 20 million Americans annually. • Usually is a result of impaired mucociliary clearance and obstruction of the ostiomeatal complex, or sinus “pore.” • Edematous mucosa causes obstruction of the complex, resulting in the accumulation of mucous secretion in the sinus cavity that becomes secondarily infected by bacteria. • The typical pathogens are S pneumoniae; other streptococci; H influenza; and less commonly, Staph aureus and M catarrhalis. • Discolored nasal discharge and poor response to decongestants suggest sinusitis.

Treatment is based on risk factors and severity of illness. • Outpatient therapy for community-acquired pneumonia may use a macrolide (clarithromycin or azithromycin) or doxycycline. • Inpatient therapy may involve a macrolide plus a β-lactam (cefotaxime, ceftriaxone, or ampicillin), or a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin). • Intensive care unit patients must receive both a β-lactam plus azithromycin or a respiratory fluoroquinolone. • Treatment in hospitalized patients at risk for Pseudomonas infection must include an antipneumococcal, antipseudomonal β-lactam (piperacillin-tazobactam, cefepime, imipenem, meropenem) plus ciprofloxacin or levofloxacin; or an antipneumococcal β-lactam plus an aminoglycoside (gentamicin, tobramycin, amikacin). • HAP and VAP patients require empiric coverage for both Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) (vancomycin).