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Eko Budiono Pulmonology/Internal Medicine Departement, Faculty of Medicine, Gadjah Mada University Dr. Sardjito Hospital, Yogyakarta
Eko Budiono Pulmonology/Internal Medicine Departement, Faculty of Medicine, Gadjah Mada University Dr. Sardjito Hospital, Yogyakarta
Depth
Factors involved:
◦ effort to breath
◦ muscle fatigue
◦ blood pH
◦ PaCO2/PaO2
Findings Possible diagnosis
Wheezing, Pulsus paradoxus, accessory muscle use Acute asthma, COPD
exacerbation
Wheezing, clubbing, barrel chest, decreased breath COPD exacerbation
sounds
Fever, crackles, increased fremitus Pneumonia
Oedema, neck vein distension, S3 or S4 hepatojugular Congestive heart failure,
reflux, murmurs, rales, hypertension, wheezing pulmonary oedema
Wheezing, friction rub, lower extremity swelling Pulmonary embolism
Absent breath sounds, Hyperresonance Pneumothorax
Inspiratory stridor, rhonchi, retractions Croup
Stridor, drooling, fever Epiglottitis
Stridor, wheezing, persistent pneumonia Foreign body aspiration
Wheezing, intercostal retractions, apnoea Bronchiolitis
Sighing Hyperventilation
Sudden Over days/weeks
◦ Lung collapse - CHF
◦ Inhaled foreign body - Pleural effusion
◦ Spontaneous Pneumothorax - Ca bronchus/trachea
◦ Pulmonary Embolism
Rapid (hrs) Over months/years
◦ Asthma - TB
◦ Extrinsic Allergic alveolitis - Fibrosing alveolitis
◦ High altitude - Pneumoconiosis
◦ LVF (acute pulmonary Oedema)
◦ Pericardial tamponade Non respiratory causes
◦ Poisons - Anaemia
- Hyperthyroidism
- Obesity
Prolonged questioning can be
counterproductive
◦ Yes/No questions if significantly dyspneic
◦ Unlike pain, severity of dyspnea = severity of disease
Pneumonia
Pulmonary embolism
Pneumothorax
Obstructive lung disease
◦ Asthma/COPD
Pneumonia
Pulmonary embolism
Pneumothorax
Acute coronary syndromes
CHF
Dysrhythmias
CHF
Dysrhythmias
Severe anemia
Pregnancy
Hyperventilation syndrome
Ability to speak
Patient position
Cyanosis
◦ Central vs. peripheral (acrocyanosis)
Mental status
◦ Altered MS - hypoxemia/hypercapnia
Pulmonary
◦ Use of accessory muscles
◦ Intercostal retractions Signs of severe
◦ Abdominal-thoracic discoordination respiratory
distress
◦ Presence of stridor
Cardiac
◦ Check neck for presence of JVD
Inspection
◦ Use of accessory muscles
◦ Splinting
◦ Intercostal retractions
Percussion
◦ Hyper-resonance vs. dullness
◦ Unilateral vs. bilateral
Auscultation
◦ Air entry
Stridor = upper airway obstruction
◦ Breath sounds
Normal
Abnormal
Wheezing, rales, rhonchi, etc.
◦ Unilateral vs. bilateral
Neck
◦ ? JVD
Auscultation
◦ Abnormal S2 splitting
◦ Present of S3 and/or S4
◦ Rubs
◦ Murmurs
What does
clubbing suggest?
Chronic Hypoxemia
Common upper airway problems
◦ Infection
Croup
Retropharyngeal abscess
Epiglottitis
◦ Foreign body aspiration
Common lower airway problems
◦ Anaphylaxis
◦ Asthma
◦ Bronchiolitis
◦ Bronchopulmonary dysplasia
◦ Cystic fibrosis
◦ Foreign body aspiration
◦ Pneumonia
Venous thrombosis/pulmonary embolism
◦ 3/1000 pregnancis
◦ Risk continues to the postpartum period
◦ Heparin outpatient treatment of choice
Asthma
◦ Rule of 1/3
◦ Rx same as non-pregnant patient
Pulmonary edema
◦ Preeclampsia
◦ Postpartum cardiomyopathy
Dyspnea is common complaint
Severity of dyspnea = severity of disease
Dyspnea high potential for significant
morbidity & mortality
Respiratory rate is one of most sensitive
indicators of respiratory distress
Mainstay of Rx = supplemental O2
The #1 chief complaint in primary care
physicians’ offices is cough
Most-- but not all-- cough seen by PCP’s
is acute cough related to viral upper and
lower respiratory tract infections
Chronic cough is one of the most
common reasons for consultation with a
pulmonologist
Health care costs for cough exceed
several billion dollars annually
Attract attention
Signal displeasure
Protect the airway from pathogens,
particulates, food, other foreign bodies
Clear the airways of accumulated secretions,
particles
Vagus nerve is major
afferent pathway
• Lung abscess
• Respiratory failure/ ARDS
• Bronchiectasis
• Pulmonary fibrosis
Evidence-based
Includes guidelines for
pediatric cough
Should be used in
conjunction with
“clinical judgment”
Divides cough in adults
by duration: acute,
subacute, chronic
Cough lasting less than 3 weeks
Key questions:
1. Is it life-threatening?
2. Are antibiotics needed?
Acute Cough
Life-threatening Dx History,
Examination, Non-life-threatening Dx
Investigations
Figure 1: The acute cough algorithm for the management of patients aged ≥ 15
years with cough lasting < 3 weeks. For diagnosis and treatment recommendations
refer to the section indicated in the algorithm. PE = pulmonary embolism; Dx =
diagnosis; Rx = treatment. For other abbreviations, see handout.
Upper respiratory tract infection (URTI or URI)-
- “The Common Cold”
◦ Caused by viruses, e.g. rhinoviruses
◦ Nasal congestion, drainage
◦ Post-nasal drainage irritates larynx
◦ Inflammatory mediators increase sensitivity of
sensory afferents
◦ Antibiotics are NOT indicated
◦ Decongestants, cough suppressants of questionable
value
Cough lasting 3-8 weeks
Key questions:
1. Is it post-infectious?
2. If post-infectious, are antibiotics needed?
Subacute Cough
History and
Post-infectious Physical Exam Non-postinfectious
Workup same as
Pneumonia and chronic cough
other serious
diseases New onset or exacerbation of pre-
existing condition
Pertussis
UACS Asthma GERD Bronchitis
Figure 2: Subacute cough algorithm for the management of patients aged ≥ 15 years
with cough lasting 3 to 8 weeks. For diagnosis and treatment recommendations refer
to section indicated in algorithm. AECB = acute exacerbation of chronic bronchitis.
For other abbreviations, please see syllabus.
Cough lasting longer than 8 weeks
Top 4 in immunocompetent patient with
normal CXR:
◦ Upper airway cough syndrome
◦ Asthma
◦ Gastroesophageal reflux disease
◦ Non-asthmatic eosinophilic bronchitis
Cough may have more than one cause-- a
diagnostic challenge!
Terima Kasih