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( BETA EDITION)

With
Prof. Dr Mohammed Abo El-Asrar

Edited By
El-Azhar Medical students 2012

Chest - Dr. Abo-Asrar


Chest INDEX
Total pages = 55
Total time = about 6.5 hours
Lecture number
Pages
1- lecture 56 4 - 18
introduction to chest ( page 4 )
2- lecture 57 19 29
Bronchial asthma ( page 19 )
3- lecture 58 29 37
cont. BA (types of asthma) ( page 29 )
Pneumonia ( intro ) ( page 31 )
Pneumococci ( page 33 )
staph pneumonia ( page 34 )
streptococci + gram -ve ( page 35 )
viral ( page 36 )
4- lecture 59 38 - 56
mycoplasma ( page 38 )
Acute bronchiolitis ( page 38 )
Bronchiectasis ( page 43 )
Croup ( page 50 )
Dry pleurisy ( page 53 )
Pleural effusion ( page 54 )

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56

symptoms chest
Introduction to chest
,, chest
Symptoms in any chest disease
,,,
..
1- cough
,,, dry cough productive cough
2- expectoration

3- Dyspnea
,,, dyspnea ,, Hypoxia
dyspnea grade grades of respiratory distress
:
4- Noisy respiration
,, ( naked ear ,, ) ,, ,,
,, noisy respiration
,,, respiratory tract :
-1 Upper respiratory tract
Nose naso pharynx Larynx
-2 lower respiratory tract
- Medium sized airway
small bronchus small bronchus terminal bronchiole alveoli
terminal bronchiole trachea major bronchus
trachea Major bronchus connectors Upper lower
connectors ,, ring cartilage ring cartilage

,, ,,

chest

inspiration

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- during respiration
upper lower diameter
,,, inspiration Lower respiratory tract
,,, Upper respiratory tract
Inspiration Uppper respiratory tract
,, ,,,
lower respiratory tract
) (
expiration
expiration
,, .. lower respiratory tract upper respiratory tract
elastic ,, alveoli .. alveoli alveoli

.. alveoli recoil ,,, Inspiration


,,
diameter constriction bronchus diameter expiration upper respiratory tract
,, ,,,
inspiration Upper respiratory tract diameter expiration lower respiratory tract diameter airway partial obstruction ,,, noisy respiration
complete partial ,,
partial obstruction ,, partial obstruction

diameter diameter ..
diameter
- so, if upper respiratory problem noisy respiration during inspiration .
- & if lower respiratory partial obstruction noisy respiration during expiration .
expiration Inspiration ,, ,, -

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Noisy respiration

expiration inspiration timing ,,,


lower upper ,,,
noisy respiration ,,

a -nose due to partial obstruction
nasal congestion rhinitis nasal polyp Inspiration ,, inspiration ,,, expiration
b -Naso pharynx
Inspiration partial obstruction adenoid a & b called snoring sound
,,, :
,,
airway parasympathetic ,,
chest
c -Larynx stridor ( charactarstic )
Stridor ... Inspiratory ,,, Upper
,, ,, :
Inspiratory sound ,,
d -medium sized and small bronchus as in bronchospasm Wheeze
- during expiration ( as the disease in lower respiratory tract called wheeze ( )

e -alveoli grunting
- Expiratory sound = pneumonia
alveolar pathology alveolar pathology grunting
pneumonia
larynx pneumonia grunting :

: cells alveoli Type one alveolar cell & Type two alveolar cell
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1- type one alveolar cell ,,


Mucous secretion
.. air way Mucous secretion
airway
expiration inspiration alveoli alveoli 2 surfaces expiration ) ( ) ,,, alveoli ( .. fluid
two layers (
)
.. ,,
2- type two alveolar cell
secretion alveoli wall ) which prevent alveolar collapse during full expiration ( surfactant
Nasal discharge rhinitis (

Mucous secretion alveoli Infection ,, )

surfactant
..
full expiration ) collapse ( pneumonia alveoli .. VC spasm of adductors of the vocal cords

collapse alveoli two layers


grunting
reflex spasm of adductor of VC which prevent collapse during expiration in pneumonia .
F - connectors Trachea & large bronchus
tacheitis bronchitis secretion ) expiratory Inspiratory ( secretions .. rackling sound ) ( 5- chest pain
chest pain ..
a-dry pleurisy stitching pain .
: ,,

b-Muscle strain Diffuse dull aching pain


,, ,,
chest wall abdominal wall Muscle strain 6- hemoptysis


,, tuberculosis

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Infection bronchitis 7- cyanosis


respiratory failure .. :
chest ,, Infection ,, fever Signs in ch est
chest .. examination signs
4
1-inspection
,,
inspection chest
A Signs of respiratory distress :
respiratory distress Which degree distressed 1- 1st degree of respiaratory distress :
respiratory distress
oxygen saturation Carbon dioxide retention respiratory problem ,, ..
respiratory center chemo receptors

brain -

respiratory ,, blood gases


rate
30 say 18 respiratory rate adult say
so, tachypnea
,, .. working ala nasai
first degree respiratory distress ,, ,,
2- 2

nd

degree respiratory distress :


within limits respiratory system respiratory rate
compensation
accessory muscles of respiration accessory muscle of respiration
negative pressure inside the thorax Hyper capnia hypoxia Lung
-: hyper inflation of the lung

vertical diameter of the chest antero posterior diameter of the chest


a- either antero posterior diameter : HOW ?? contraction of intercostal & subcostal ms.
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Intercostal and subcostal retraction


ribs Intercostal muscle Oblique ribs antero posterior diameter Horizontal
Intercostal muscles
subcostal spaces inter costal space indrawing grade .. subcostal & intercostal retraction
b- or vertical diameter : HOW ?? contraction of sternomastoid ms. one of the major accessory muscle
suprasternal & supraclavicular retraction
sternomastoid ,,, clavicle supraclavicular & suprasternal indrowing
.. chest
1- if upper respiratory tract obstruction (as stridor)
sternamastoid acts as accessory ms. (not intercostal ms. ) suprasternal & supraclavicular retraction
working ala nasai .. tachypnea .. supra sternal and supra clavicular retraction ,,,
2- but if lower respiratory tract obstruction (as pnumonia or BA )
intercostal ms act as accessory ms. (not sternomastoid ms. ) intercostal & subcostal retraction
working ala nasai .. tachy pnea .. subcostal retraction intercostal ,,,
anatomy
common dermatome embryology :
,,embryology
embryology refered pain ,,, .. common dermatome

dermatome sterno mastoid upper respiratory system : dermatome accessory muscle upper respiratory tract sterno mastoid
Inter costal Lower respiratory tract ,,, ,,, ,, NB chest
Mental retarded,,, supra clavicular supra sternal subcostal inter costal
,,,!! ENT ..
3- 3rd degree respiratory distress :
= Grunting in pneumonia only .
4- 4

th

degree cyanosis if respiratory failure .


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B chest movement :
) Movement of the chest comment ,,, Inspection (
limitation of movement chest wall ) pathology limitation of movement (
,,, limitation Bilateral pathology
Unilateral
to confirm the movement inspection :
.. fold of skin palpation confirm : Movement of the chest
where is the lesion nothing else bilateral pathology Limitation of movement bilateral ,, Normal ,,, ,, diseased
C - Bulge or retraction :
retraction bulge ,,,
movement , ||
: movement
a - Unilateral bulge or retraction
) (
- if bulge at one side ( means massive pleural effusion,tension pneumothorax or unilateral
emphysema )
if bulged side is bulged ( diseased ) or normal & the other side is retracted ??
- if retraction at one side ( means fibrosis or collapse )
if retracted side is retracted ( diseased ) or normal & the other side is bulged ??

retraction bulge
movement
affected affected
unilateral retraction
collapse fibrosis
,, ,,, ,,,
bulge
bulge

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massive pleural effusion


bulge massive
tension pneumothorax bulge ,,
Pleura tension pneumothorax
Unilateral emphysema Lung
Unilateral bulge
tension pneumothorax

unilateral emphysema

massive pleural effusion

Unilateral retraction : clinical


b - Bilateral bulge
bilateral bulge .. bilateral bulge ,,,
anteroposterior diameter trasnverse diameter of the chest
) ( anteroposterior transverse ,, Transverse : anteroposterior = 3 : 2
transverse diameter antero posterior diameter ,,,
antero posterior diameter
bilateral bulge limitation of movement bilateral ,, Barrel shaped chest
bilateral bulge
1- Air :
lung .. ,,,

attack bronchial asthma ,, bronchiolitis emphysema ,, Lung 2- water :


,, Nephrotic generalized edema Massive bilateral pleural effusion lung
2-palpation 3
A Trachea :
supra sternal notch Index finger resistance ,,, Page |

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trachea trachea Middle line .. slightly to the right


,, resistance
sternomastoid muscle resistance trachea

NB Shifted .. trachea is shifted to the left


trachea examiner !!!

,,, trachea


,, .. trachea pushed to the left side
right side
trachea palpation
1- trache is retracted ( pulled ) to Lt side
pushed .. Inspection :- limitation of mov. In lt side & retraction in lt side
trachea .. Lt ..
trachea ..
2- trache is pushed ( from Rt. side ) to Lt side
retracted .. Inspection :- limitation of mov. In Rt side & bulge in Rt. side
trachea .. Lt ..
trachea ..
,,, NB

pathology bilateral trachea central


B palpable sounds :

Intercostal space supra mammary


mammary area
Infra mammary
- ,,, .. Mid clavicular line ,, anterior axillary Mid axillary

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,,, 1- may wheeze :


broncho spasm palpable wheeze 2- may pleural rub :
friction rub actually ,,
C Tacitile vocal fremitus :
co operative TVF ,, ninity nine ,,,
palpable sounds ,, TVF TVF bilaterally diminished ,, compartive TVF NB
bilaterally

TVF ,, TVF
NB . Any pathology decrease TVF except : 3 Cs
- Pneumonia ( consolidation ) .
- lobe Collapse with patent bronchus .
- Cavity (superficial ) .
3- percussion
Light percussion Normal percussion of the chest wrist percussion light percussion !! elbow mental retarded Heavy percussion !!!!!!!!!!!! shoulder more heavy
wrist Percussion NB
compartive mid clavicular line Percussion infra scapular inter scapular mid axillary compartive anterior axillary Normally resonant lung percussion abnormal ,,,
1- dullness or impaired note :
dullness pathology ,,, Dullness
pleural effusion diagnostic stony dullness stony dullness ,,
2- hyper resonant :
Hyper resonant chest .. Percussion of the chest
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hyper resonance
bilateral
bilateral
emphysema bronchial asthma during the attack bronchiolitis ,,, .. Unilateral hyper resonant chest

Unilateral pnumo thorax ,,, Pleura


Unilateral emphysema ,, lung
4- auscultation

auscultation of the chest comment 3


1- air entry :
( respiratory distress chest respiratory distress ) bronchitis diminished air entry
- bilateral diminished air entry or unilateral diminished air entry
2- breath sound :
A Normal vesicular breath sound
Normallay alveoli alveoli ( Lung
,, ,,,
,, .... )

,,, .. alvoli .. ( inspiration ) ( expiration)


Normal vesicular breathing
B Harsh vesicular breath sound or prolonged expiratory time
:
a- obstruction of air outlet
Outlet alveoli

obstruction airway

b- or not recoil alveoli ( inelastic alveoli )


alveoli In elastic recoil recoil

a or b Harsh vesicular breathing prolonged expiratory time NB harsh vesicular breathing normal breathing

- air way

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normal breathing ,,, ,, harsh vesicular breathing lung pathology NB. No gap
C Bronchial breathing :
Inflammatory secretion alveoli .. Pneumonia ) collapse mass ( alveoli .. alveolus
.. alveoli ,,
During inspiration
nearby bronchus trachea alveoli Gap
,,, alveoli Nearby bronchus .. inspiration gap ,, ,, .. alveoli
Expiration
alveoli ,, expiration
bronchial breathing gap expiration Inspiration ,,,, bronchial breathing
tubular sound tube .. alveoli NB hollow breathing tube
TVF bronchial breathing NB
bronchus TVF
3- advential sound :
creptitation .. rhonchi
A Rhonchi : 2 types
a- sibilant rhonchi = wheeze :
broncho stenosis broncho spasm siblent rhonchi ,, ,,
1- Bilateral sibilant rhonchi : 3 causes
siblent rhonchi viral pneumonia .. bronchiolitis .. bronchial asthma
2- unilateral sibilant rhonchi :
unilateral obstruction Page |

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foreign body -1
unilateral obstruction foreign body inhalation ,,

) bronchus ( Unilateral broncho stenosis -2
tuberculus adenoma ,, adenoma wall of the bronchus -3
bronchus Mass Lymph nodes bronchus -4
,,,
b- sonorous rhonchi :
coarse crepititation sonorous rhonchi coarse sonorous rhonchi bronchus secretion .. crepitus
sonorous rhonchi
snoring
coarse crepititation

B Crepitations :
a- Coarse :
b- Fine crepitations :
In elastic wall of the alveoli

.. alveoli ,, fine crepititation
pneumonia - 1
congestive heart failure - 2
bronchiectasis - 3
Complications
chest complications
: ,,, complications of respiratory diseases
1- Respiratory failure
central cyanosis respiratory failure
respiratory ( respiratory failure central cyanosis ,,,
respiratory respiratory disease ,, ) blood gases failure
failure
2- Heart failure :

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a- toxic myocarditis
toxic myocarditis bacteria toxins ,, bacterial infection
b- viral infection
Heart failure viral myocarditis
c- may be due to cor pulmonale right sided failure
pulmonary Pulmonary artery fibrosis Lung pathology cor pulmonale .. Pulmonary artery pressure .. artery vessel
right ventricle back pressure Pulmonary artery pressure d- also, severe hypoxia may cause cardiomyopathy .
,,
Investigations
1- chest X ray :
diagnostic chest X - ray .. chest X - ray chest
2- CBC :
CBC infection total leucocytic count chest Infection differential count
tuberculus viral .. Lympho cytosis *
bacterial Neutrophils *
asthma allergic .. parastic infection .. visceral larva migrans esinophils *
chronic asthma poly cythemia chest " " NB
hypoxia
3- Blood gases for dignosis of respiratory failure.
: respiratory failure a- PH < 7.1

b- PCO2 > 60 mmHg

c- PO2

< 50 mmHg

7.2 7.1 PH
50 60 mm Hg CO2
PO2
4- specific investigations according to the pathology
specific investigations
Treatment
skeleton
respiratory distress treatment
A If distressed
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1- Hospitalization
respiratory distress
: hospitalizaiton
,, ,, complete bed rest 1
Intra venous fluids ,, ,, 2
maintenance fluids
900 maintenance fluids
600 2/3 600

900 ,,

ADH hypoxia hypoxia


pulmonary edema full maintenance
oxygen therapy oxygen therapy Oxygen 3
2- ttt of underlying etiology .
distress
Pneumoina Pneumonia
3- ttt of complications .
respiratory digoxin ,, diuretics ,, Heart failure distress
mechanical ventilator ,,, respiratory failure 4- symptomatic ttt never give cough sedatives in pediatrics .
symptoms ,,
anti pyretics ,, feverish broncho dilator ,, broncho spasm cough ,, ,, expectorant mucolytic ,, therapy
) cough therapy (
B If not distressed
hospitalization respiratory distress ,, Heart failure respiratory failure distressed complications
symptomatic treatment Underlying etiology
57 56

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Bronch ial asthma


introduction
pathogenesis C / P
bronchial asthma so common ,,, ,,, ,,, ,,, asthma
stress most common type of asthma allergic asthma allergic induced asthma extrinsic asthma
* * extrinsic asthma

...
.. .. ..
.. .. :
1- Exposure to allergens
2- Activation of T helper & B lymphocytes
3- Formation of antibodies & their feedback inhibition
3 2 1
) ?? 4- etiology of extrinsic asthma ( Why the atopic person is an atopic person
5- effects of increased IgE & IgG4 :
6- Effects of the inflammatory mediators :
: Item
,,, ,,, allergen allergens ...
1- Exposure to allergens
allergens
,,, most common allergenviral infection allergen dust fumes .. pollens ,, ,,, ,,, ,, ,,
2- Activation of T helper & B lymphocytes

allergens surface Mucosa skin .. branched cells dendritic cells
dendritic cells .. allergens dendritic cells Interlukin one interlukin one :

activation T helper cell

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B lymphocytes stimulation

B lymphocyte activation activated Once ..T helper cells


: B lymphocytes ,,,
allergen dendritic cells Interlukin one Direct activation

activated T helper cells activation

3- Formation of antibodies & their feedback inhibition


activation
Plasma cells Once activated B lymphocytes Ig E ) ( allergen immune globulins Plasma cells Ig G4
Immune globulin G4 immune globulin E allergens
,,,, atopic .. atopic ,, feedback inhibition " "
immune globulin G4 Immune globulins E
T suppressor cells activation suppression T helper suppression activated Once,, T suppressor cells B lymphocytes
immune globulin G4 production Immune globulin E ,,,

allergens .. viral infection ,,,
dust mites dust dust
,, dust mites

3 2 1
4- etiology of extrinsic asthma ( Why the atopic person is an atopic person ?? )
allergenic asthma extrinsic asthma ..
.. autosomal dominant gene Autosomal male = female
autosomal gene
female male
pre adolescence Incidence ,,, ,,, gene factor .. adolescent period .. female Male
females male exposure
out of control
Dominant +ve family history
pathological gene dominant gene -

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positive family history .. is diseased bronchial asthma atopic diseases


Site
gene chromosome 11
Effect of this gene

asthma gene chromosome 11 colony T suppressor T helper cells
allergen Immune globulin G4 immune globulin E
allergens immune globulins G
block T suppressor activation cycle T helper allergens immune globulins G4 Immune globulins E
,, allergic
allergic allergic pollens allergic
virus Infection virus induced asthma " " defect colony allergen

management
,,,, .. asthma
5- effects of increased IgE & IgG4 degranulation of mast cell & esinophils inflm. mediators
Immune globulin E and immune globulin G4
Immune globulin E specific receptor Y specific cells
cells Mast cells
,, esinophils ,,, basiophils " "
: esinophils mast cells
Immune globulins E surface mast cells esinophils
,, sensitized cells ,,, antibody cell membrane
Is an inert antibody
,, re exposure

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allergen
allergen ,, antibody mast cellsesinophils
antibody .. direct antigen antibody reaction two ends antibody cell membrane
back end antibody binding allergen
Y ,, .. allergens allergens two arms allergens
,, allergen
two limbs .. antibody ( )
antibody allergens ( two limbs ) Y shaped end
(
antibody Y

mast cells esinophils
Y allergen
two ends
allergen


cell membrane
Calcium channels
Calcium channel Calcium channel )
two arms calcium channels Calcium channels calcium Influx mast cells esinophils
.. esinophils Mast cells esinophils Mast cells vesicles ,,, light microscope vesicle
,,, ,,, vesicle Light microscope
granules ,, vesicles
vesicles Inflammatory mediators
allergic inflammatory mediators vesicles
" "

histamine

Prostaglandin E2

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thromboxane E2

prostacyclin

PAF Platelets activating factors

bradykinine

Leukotrines slow releasing substance of anaphylaxis

cell vesicle electron microscope ,,, vesicle actin and myosine Muscle fibers myo epithelial fibers membrane
cytoplasm calcium
sliding of actin over troponine C and troponine S myosin actin myosin
Contraction cell membrane vesicle
cell membrane cell membrane vesicle cell membrane
,, adhesion .. membranes allergic Mediators .. vesicle
vesicle ....
membrane vesicle membrane vesicle allergic mediators vesicle .. vesicle
vesicle Microscope degranulation
reduction of the number of the vesicle inside the cell degranulation
6- Effects of the inflammatory mediators :
Mediators
A at 1st 6 Hours :
just broncho spasm first 6 hours ,, smooth muscle of the bronchus contraction broncho spasm
dramatic response broncho dilator

B after 6 Hours :
: ,,,
bronchus Lumen broncho spasm ,,, broncho spasm

bronchus bronchus Mucosa edema


Lumen secretion ,, Mucous secretion ,,, two factors broncho dilator ,,, secretion edema air way
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..
.. bronchospasm , secretions & odema
mediators .. muscle mucous membrane wall of the bronchus Dry cough .. lumen bronchospasm 6
lower ) Harsh ( prolonged expiration Expiration
palpable .. .. Wheeze secretions mucosal odema 6 : .. productive cough .. Dyspnea sonorus rhonchi & coarse crepitations due to secretions
hyperinflated alveoli bronchus hyperresonant percussion (

( + barrel shaped chest bilateral bulge


bilaterally

alveoli degeneration wall


alveoli
emphysematous bullae
.. .. bullae .. pleura lung pneumothorax
) ( pneumomediastinal pleura lung lung .. surgical emphysema collapse
Clinical manifestations of asthma
clinical manifestations of asthma
Symptoms
general filling space
1.

Cough dry (6 hours) then productive

2.

Expectoration

3.

respiratory distress -- Dyspnea

4.

Wheeze

5.

) (chest pain mostly dull aching pain due to ms strain

6.

respiratory failure central cyanosis


..

Hemoptysis

6 History of repeated attacks of


Signs of bronchia l asthma
1- Inspection

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1- Signs of respiratory distress

Tachypnea

Working ala nasai

Suprasternal and supra clavicular retraction intercostal and subcostal retraction &

central cyanosis
Pneumonia .. grunting

2- Bilateral limitation of movement of the chest


air entry
3- bilateral bulge Barrel shaped chest
2- Palpation
Disease here is bilateral
central trachea
Palpable wheeze Palpable ronchi
TVF

.1
.2
.3

3- Percussion
bilateral hyper resonant chest
4- Auscultation
1- Air entry bilateral diminished air entry
2- breath sounds harsh vesicular breathing
3- advential sound - siblent rhonchi 6
then may sonorous rhonchi & coarse crepitaions
Complications:
1) May HF 3
1- Hypoxia (if severe asthma)
2- Cor pulmonale

If marked emphysema >> alveoli >> wall of alveoli >>


compress the capillaries of the pulm a. >> pulm. HTN >> RSHF (cor pulmonale )
3- If precepitating factor is viral infection >> may viral myocarditis and HF
2) Respiratory Failure.
3) Specific complications
1-

Emphysema

2-

Pneumothorax , pneumomediastinum ( ) may lead to massive lung collapse


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(d.t. severe pneumothorax.)


3-

Surgical emphysema.
Investigations:
1) Chest X-ray Hyperinflated lung
-Not diagnostic in BA (only to exclude other causes of wheezy chest)
D.D. ........ MR << 2) CBC :
- if precipitating factor is infection >>>> Leucocytosis
- In all allergic asthma >>>>> Eosinophilia
3) Blood gases : for Resp. Failure (cyanosis )
4) Specific investigations :

1- Sputum analysis
- in Allergic asthma >>>> Eosinophils
-but If PPFs is infection >>>> Lymphocytes or others
2- IgE & IgG4 >>> in Extrensic asthma
3- In Extrensic asthma >> so, skin brick test
3
a- good +ve But not good ve >>>

antihistaminic

b- means correlation with clinical picture


+ve
c- No age limited (skin brick test)

skin << (skin brick test )
Invitro test

()

4- Pulmonary functions:
(asthma grade of asthma )
Treatment:
distressed <<<< asthma
A - Hospitalization : ( : 3 )
1-

Complete bed rest

2-

IV fluids >>> only maintainance >>> (dehydration )

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(oral intake (
3-

Oxygen therapy.

B - ttt of underlying aetiology ( )


1
) (
23-

4-

Psychological factors :

5-

<<

C - Symptomatic ttt :
a - for asthma
air way
bronchospasm , secretions & odema (mucosal)
<< .. <<< HR .. ..
1- Epinephrin
: ... epinephrine sc 0.01 mg/kg/dose
Mechanism of action
A - on B2 :
- stimulate Adenyl Cyclase convert ATP to cAMP cAMP
smooth ms. of bronchi ( relive bronchospasm ) Bronchodilatation
B - On alpha receptors :
- VC of blood vs >>> odema & secretions

) (


) ( << pulse & bl. Pressure

2- selective B2 agonist as salbutamol
spasm (selective B2 agonist as Salbutamol( B2 )saline( nebulizer inhalation
secretion mucolytic effect VC mucosal decongestion
. nebulizer
<<< <<< 3
3- Parasympatholytic
ipratropium nebulizer parasympatholytic bronchodil,secretion & odema nebulizer ampule
atrovent B2
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aminophyline + 4- Aminophyllin
enz theophilline phosphodiesterase enz cAMP give initial dose then maintainance <<<< cAMP
5- cortisone
cortisone

- as anti-inflammatory >>> prevent release of mediators , immune reaction , block receptors of
inflamatory mediators
epinephrine +

norepinephrine
epinephrine
>> so, Cortisole is life safing in this time
Dose : Give 1 mg/kg/dose 6 >> 1st 24 Hrs

6- ICU
complications ICU
b - for other symptoms
- for fever, expectoration,infection give symptomatic
D In between attacks
:
In between attacks 3
1- Avoid :
triggering factors ( - .)
also avoid psychological factors >>>psychological support
2- Pharmacotherapy >>> (attacks )
a- give single bronchodilator (B2)

b- theophylline
c- inhaler corticosteroids Or leukotrien receptor antagonist :
.. inhaler corticosteroids Or leukotrien receptor antagonist
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d- short course corticosteroids or mast cell stabilizer if frequent attcks.


- attack may give short course corticosteroids
- Or may mast cell stabilizer prevent Ca influx to inside of mast cell .
58 57

Types of Asthma
1- Extrensic autosomal dominant gene ...
2- Intrinsic
A in adult ( )
due chronic irritaion with smoking
B in childern :
post viral repeated viral infection" >>> irritate parasymp. Ns >>> vagus >>> Asthma
So, it as a neurogenic not an allergic asthma
- ( triggering factor viral infection ) + -ve family history + -ve skin test + normal IgE & IgG4
Grades
Grades according to :
1- Frequency of the attacks :
:
) ( attack -1
nebulizer -2
.. -3
2- Frequency of nocturnal symptoms
3- according to Pulmonary function test ( FEV 1 Sec. )
Mild, Moderate, Sever

: .. prognosis a mild & moderate asthma 50 % releaved ) complete improve ( at 10 years max. at 20 yrs
recurrence

b - sever asthma >> only 5%


& 95 % develop adult asthma ( )
Special types of asthma :

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1- Aspirin induced asthma


allergic asthma
: 2 pathways Arachidonic acid A - by Cyclooxygenase PG, Thromboxane, Prostacycline
B - or by Lipooxygenase Leukotriens (slow releasing substance of anaphylaxis)
Mast cells & Esinophils Arachidonic acid Allergic mediators
slow releasing substance (Leukotreins) arachidonic acid

Cyclooxygenase Aspirin
-

Mast cells & Esinophils Vesicles

Aspirin Fever -

Leukotriens as allergic mediator + long acting >> So, cause sever attack
of asthma & may Status Asthmaticus >> anti leukotriens >>
asthma
2- Exercise induced asthma
attacks .. dryness of secretions exercise
mast cell degranulation hyperosmoler state
BA
3- Nocturnal asthma
..
1-

parasymp. Bronchospasm

2-

cortisone level ( circadian rhythm)

3-

Weak cardiac sphincter asthma >> asthma

GER aspiration asthma


Asthma


Risk factors of asthma
1 - Over crowding & Poverty " "
Chronic irritation asthma
Intrinsic asthma << Viral infection << Repeated infection << Over crowding
2 - Early exposure to allergen 6
( allergens 6 .. . )
( +ve family history " )
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3 - Maternal Smoking

chronic irritation

- Also if father is smoker


asthma guide line NB
. asthma ..
4 - Maternal age if 20 years old incidence of having asthmatic child
... asthma 2.5
5 - Psychological factors
Asthma
Pneumonia
Inflamation in lung parynchma = alveoli

Classification :
A - Anatomically

x-ray

1- Alveoli in one lobe is affected


Called lobar pneumonia .
2- or in X ray inflammation around the alveoli around the bronchus called bronchopneumonia
Inflamation Bronchus Alveoli
>> Patchy broncho pneumonia
3- Hilar or Interstitial pneumonia
. hilum of the lung main bronchus
Anatomically

Lobar

Broncho

Interstatial

Unilateral (one lobe

Bilateral & patchy

Bilateral & around hilum

Viral OR bacterial

Viral

only)
Etiologically

Bacterial only ( )
virus

B - Etiological classification :
1- bacterial

as pneumococci, staph, H. infl., psuedomonas, klebs, TB
2- Viral :
Rsv
3- Fungal : as aspergellus , candida only in immunocompromized
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4- Parasetic as pneumocystic carnii


5- Physical Pnuemonia due to sudden change of body temp.


signs of distress
6- Orthostatic or hypostatic pnuemonia

Stagnation of lung secretions >> infection
7- Chemical pneumonia:
hydrocarbons Very irritant to alveoli
8- May due to Radiotherapy >>
: Pneumonia ..
IN ANY PNEUMONIA :
.. ..
.. pneumonia
..
A - Complaint:
1)

Fever >> high grade in bact. & low in viral


) (Infection

2)

Cough >> dry then productive

3)

Expectoration

4)

Dyspnea

5)

Grunting

6)

Chest pain >> d.t. pluerisy

Pluera Surface of the lung Pneumonic patches


Pleurisy
7)

If RF >> Cyanosis

B - Examination
1- Inspection
I.

Respiratory diseress syndrome (Tachypnea_Working ala nasi_intercostal & subcostal retraction &

grunting or cyanosis)
II.

Movement >> Limitation


- lobar >> uni

- Broncho & Interstitial >> Bi

Complication .. Bulge or Retraction


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2- Palpation
I.

Tarachea >> center

II.

Palpaple sound >> rub if pleurisy

III.

TVF >>
- lobar >> on affected lobe
- broncho >> patchy
- interstitial >> parasternal

3- percussion >> dulness


as TVF ) (
-sometimes tender >> if pleurisy )(
4- Auscultation
I.

Air entry >> diminished on affected areas

II.

Breath sound >> bronchial breathing

III.

Adventitial >> fine and medium sized crepitations


Pleural rub

C - Complications
1- RF
2- HF if bact. > HF due to Toxic myocarditis & if viral > HF due to viral myocarditis
3- Plural effusion >>
4- May paralytic illeus (Toxic or Hypoxic)
D - Investigations
1)

Chest x-ray: -type

-complicated or not

2)

CBC >> total leukocytic count infection


Lemphocytes << viral

neutrophils << Bact.

3)

ABG >> for diagnosis of RF "

4)

Isolation of the organism >> culture >>



-sputum or blood sample or pleural tab if pleural effusion

E - TTT
1)

Hospitalization : -Rest

O2 therapy

-IV fluid maintainance

2)

TTT of eitiology: -antibiotics acc. to culture


-G +ve >> penecilline (if resistant >> give cephalosporine)
-G ve >> 3rd generation cephalosporine

3) symptomatic ttt :
i.

Fever >> not aspirin if viable

ii.

If productive couph >> expectorant


4) ttt of complication
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I.

RF >> mechanical ventilator

II.

HF

III.

Effusion >> intercostal tube


organism
1)

Pneumococci most common organism

4 % 90
>>>In infancy period cause bronchopneumonia

>>>in childhood ( > 2 yrs) cause lobar pneumonia

) (
C/P
1- Complaint >> fever Here is high grade
pneumonia symptoms
2- Signs
A - Inspection
- if < 2 Yrs >> limitation of movement (Bilat) ( bronchopneumonia )
- if >2 Yrs >> unilat ( lobar pneumonia )
pneumococci
B - Palpation : TVF
- if < 2 Yrs patchy & bilat
- if >2Yrsunilat affected lobe
C - Percussion :

as TVF

D - Auscultation : as TVF
Complications
A)

If upper lobe affected >> may meningitis


<<Toxins may reach meninges<<Paravertibral plexus of vagus<<Upper lobe
Meningial irritation puncture >> normal

B)

If lobar >> may lung abscess


Investigations
x-ray
-CSF ex. >> if meningism exclude meningitis (clinically )
TTT
G +ve ttt
-

Non comlicated >> penicillin

- Complicated >> 3rd gen cephalosporines


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Prevention :
pneumococcal vaccine
2) Staph. Pneumonia
Staph infection

...

Fruncle or breast abscess in mother <<<<<


NB: staph is very aggressive organism
1-

Very resistant >> penicillinase enz >>no response to ordinary penicilline

2-

Secrete coagulase enz >>> lequifaction & localization of infection


Cause unilat broncopneumonia

(lobar (
C/P

1)

Complaint : high grade fever

2)

Examination

I.

Inspection>> unilat limitation of movement >> mostly on right side

II.

Palpation >> rub + TVF ( unilat & patchy )

III.

Percussion : as TVF

IV.

Auscultation : as TVF
Investigations
X-ray
Complications :

Pl. eff : >> pus=emphysema

Lung abscess
) Abscess )

May meningitis : if reach blood

Pyemic abscess

Encysted plneumatocele <<

TTT
Peniciollinase resistant antibiotics >> Cloxacilline
3)

Streptococci

Brocho or lobar

Complication :
-post streptococcal GN or Rh. Fever

- may septic focus in bone or joint

Investigations : ASO
,,, penicillin ,,, gram positive
third generation cephalosporin ,,,
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4- Gram ve :
penicillin gram negative
A H. influenza pneumonia
,,, Pneumo coccal pneumonia
Complications
Meningitis meningism

complications

Investigations
The same
meningitis meningism Lumbar puncture ,,,
Treatment
gram negative third generation cephalosporin

prevention
H. Influenza vaccine prevention
,,, Pneumonia
pneumo coccal pneumonia
Influenza vaccine

B - klebsiella pneumoina
Immune compromised child .. gram negative bacteria Klebsiella - cause broncho or lobar .
,,,
Mis diagnosed as malignancy
WHY ??
1- if cause lobar in immunocompromised not take triangular shape
tringular Lobar pnuemonia Immune compromised Lobar shape
) tringular shadow ( rounded shadow rounded lobe
tumor mass X ray
,,,,
2- extensive inflam. Reaction friable lung may Hge Hgic effusion
friable surface of the lung extensive inflammatory reaction .. hemorrhagic effusion ,,, effusion .. effusion ,,
Malignancy
klebsiella pneumoina..
lung malignancy

Klebsiella

third generation cephalosporin gram negative Viral pneumonia


virus Para influenza influenza .. respiratory syncytial virus ,,, Page |

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interstitial pneumonia broncho pneumonia : clinically


A Symptoms :
- Symptoms of upper respiratory tract ( catarrhal symptoms 2or 3 days befor pneumonia )
- low grade fever
- Wheeze
vagus irritation ,, virus .. wheeze broncho spasm

para sympathetic over tone

wheezy chest ,,, viral pneumonia


Muscle strain

viral myositis chest pain viral pneumonia ,,, cyanosis B - sign


1-signs of respiratory disterss
2-Limitation of movement bilaterally
interstitial broncho

3-Trachea central
4-palpable sounds

Palpable rhonchi

5-TVF increased
6- percussion dullness
hyper asthma .. asthma viral pneumonia
resonance
7-auscultation ,,,
*air entry diminished
*bronchial breathing
*fine Medium sized consenanting crepitation
*siblent ronchi

due to broncho spasm


complications

1-Respiratory failure
2-Heart failure )viral myocarditis)
3- post viral immune disease
post viral auto immune disease ,, .. complications ,,, viral infection auto immune disease
treatment
1-hospitlization
2- ttt of cause
respiratory syncytial virus para influenza virus Ribavirin ,,,
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3-symptomatic treatment
broncho dilator
4- ttt of complications
59 58

Mycoplasma pneumonia
closed contacts, shcool children .. Organism Mycoplasma Over crowding
Penumonia Mycoplasma pneumonia
1- cold antibodies
37 activated anti body ,,, cold antibody Hypothermia ,,,
auto immune hemolytic anemia ,, cold antibody ,,,

Pneumonia auto immune hemolytic anemia Pneumonia
mycoplasma viral pneumonia ,,, auto immune hemolytic auto immune disorder viral pneumonia
anemia
2-specific drug therapy
anti viral 3rd generation cephalosporin generation erythromycin specific drug therapy ,,, ,,
acute bronchiolitis

Acut e bronchiolitis
Is the mose distressing disease
severe respiratory distress
acute bronchiolitis
Introduction
..
Anatomy & Histology
embryology
small bronchus Musclosa ,,, In between Mucosa serosa
.. budding embryology small bronchus Page |

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serosa Mucosa two layers budding


: budding
a- alveoli
alveoli ,, b- terminal bronchiole
terminal bronchiole small bronchus
alveoli terminal bronchiole
Physiology
1- at birth
5 % ( gas exchange mechanism alveoli )
gas exchange mechanism 90 % terminal bronchiole ,,, at birth terminal bronchioles
2- with progression of age :
,,, terminal bronchioles :
,, ,,,
,,,
alveoli gas exchange mechanism 95 % terminal bronchiole 5 % Pathology
- So, bronchiolitis

Means inflammation in terminal bronchiles

,, edematous mucosa inflammation ,,,


1- at birth ( < 2 years )
, gas exchange 90 % edematous terminal bronchioles .. alveoli gas exchange ,, alveoli
marked distress

gas exchange
2- after 2 years
terminal bronchioles Inflammation .. Pathology ,,, gas exchange 5 %
alveoli edema .. Lumen ) 95% of gas exchange at this age ( alveoli
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silent infection ,,, bronchiolitis asthmatic bronchitis


respiratory distress ,, ,, More severe respiratory distress bronchiolitis ,,



.. ..
- age of onset 1st 2 years of life
- mor common & more severe in 1st 6 months of life
,, bronchiolitis
Pathogenesis
acute broncheolitis
may mild .. cough inflammation Expectoration
even cyanosis so early ... severe dyspnea droplet infection virus RSV .. virus
) ( bronchospasm irritation of parasympathatic airway virus Wheeze .. small & medium sized bronchus
sibilant Rhonchi
harsh vesicular breath sound dimished air entry barrel chest hyperinflation .. limitation of mov inspection central trachea hyperresonant percussion inflammation in adjacent alveoli ... rapid spreading virus alveoli
alveolar reaction that leading to pneumonitis & inelastic alveolar wall so, may fine crepitation .
Etiology
Inflammation in terminal broncheoles caused mainle by viral infection
( mostly RSV .. & may influnza , parainf. Viruses ,measles & mycoplasma )
Clinical pictures
A Symptoms :
1- History of upper respiratory tract catarrhal symptoms
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low grade fever ,,, sneezing rhinitis ,, 39 maximum ,,


2- Severe cough
expectoration
3- dyspnea
4- wheeze
5- & may central cyanosis
central cyanosis And very rapidly
B Examination :
1-Inspection
*signs of respiratory distress

Tachypne

Working ala nasai

Intercostal and subcostal retratction

If alveolar pathology grunting

cyanosis

*limitation of movement of the chest bilateral


*bulge bilateral ( Hyper inflated chest )or (barrel chest)
2-Palpation
*trachea central
*palpable wheeze or palpable rhonchi dueto broncospasm
TVF ,,, bilaterally diminished
comperative signs
3-percussion
*bilateral hyper resonant chest
4-auscultation

air entry diminished ,,bilateral


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breath sounds ,,, harsh vesicular

addventious sounds

broncho spasm siblent ronchi

pneumonic reaction fine crepititation


viral pneumonia bronchiolitis :
acute bronchiolitis
viral pneumonia
,,,
percussion main diagnostic
dullness viral pneumonia Hyper resonant ,,, Complications

1-respiratory failure
2-heart failure due to

viral myocarditis

severe hypoxia
.. cor pulmonale ,,,
,, ,, ,,, severe acute
Cor pulmonale

3-emphysematous bullae )due to hyperinflated chest ) may rupture


surgical emphysema Pneumo mediastinum pneumo thorax
Investigations
1- Chest X - ray hyper inflated lung
2-CBC
total leucocytic count + Lymphocytosis
3-Blood gases
respiratory failure
CO2 - 50 PO2 - 7.2 PH
failure respiratory
4-viral marker

virus ,,,

5-sputum cultures
secondary bacterial infection
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Treatment
1- Hospitalization :
,, bronchiolitis

oxygen therapy 2/3

IV fluids -

2- ttt of virus :
Most common anti viral Ribavirin ,, 3- Symptomatic treatment
anti pyretics

feverish -

,,, mucolytics and expectorant

broncho dilators broncho spasm cortico steroid edema : ,,, controversal ,, .. viral infection : cortico steroids

cortico steroids .. ,,,
cortico steroids Some of the authors recommend
terminal bronchioles edema severe distress
4- ttt of complications :
heart failure ,, Heart failure ,,, ventilators mechanical ,, respiratory failure Bronch iectasis
...
Definition
Persistent cystic dilatation of the bronchi (small or medium sized bronchus )
. stagnant secretions dilatation medium sized bronchus infected secretion super added infection stagnant secretion Infected sputum

micro abscesses Medium sized bronchus small bronchus Lower lobes basal bilateral unilateral

Localized upper lobe ,,, Upper lobe


local cause Upper lobe
Etiology :

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A - congenital
: congenital
1- isolated :
Medium sized bronchus small bronchus ,,, ,, isolated 2ry infection stagnant secretion .. dilated
Lobe .. bilateral Unilateral 2- as a part of immotile cilia syndrome
: syndrome a- Bronchiectasis :
Kartagnar syndrome immotile cilia syndrome stagnant secretion ,,, Immotile cilia ,,, Cilia super added infection +

) lower lobes ( dominant lobes

Bronchiectatic changes
b- chronic sinusitis :
chronic sinusitis ,,,, Bronchiectasis frontal sinus frontal chronic sinusitis drainage

good cilia

sinus good drainage ,,, cilia sinus stagnant secretion


infection
sinusitis

chronic

air sinuses sinusitis inflammatory secretions


absent frontal air sinus Skull X - ray
c- Dextrocardia :
cardiology Heart
apex of the heart heart cilia cardic tube .. apex apex .. cardic tube ,, cilia
heart ,,, cilia isolated Dextrocardia
B - acquired causes
1- any chronic infection in respiratory tract :
bronchiectatic changes respiratory tract chronic infection

healing by fibrosis ,, bronchus chronic infection Page |

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secretion stagnantion ,,, wall fibrous tissue bronchus


secretion ,, bronchus ,,, wall .. wall
2-Obstruction
,, obstruction
a- in lumen as FB or dried secretions :
bronchus Lumen ,,, chest Lumen ,,,
inspissated secretion foreign body
secretion dryness anti histaminic prolonged cough ,,, foreign body airway
b- outside lumen tumors or LNs
tumors Lymph nodes ,,,
tumor lymph nodes ,,, bronchus
c- from the wall granuloma of TB
Obstruction ,,, wall bronchus wall T.B. granuloma T.B. obstruction
complete partial broncheactasis obstruction bronchectasis
Pathophysiology
C/P .. C/P
inspissated dilated bronchus bronchi .. lower lobes ,,, pathology infected sputum pus
,,, fever ..

Hectic fever .. : ,,, ,,

,,,
Productive cough cough air way Inflammation expectoration Huge amount of sputum ,,, greenish yellowish colored .. :
secondary infection organism
,,, Infected sputum
On leaning forward ,,, ,, : ,,

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sputum ,,, Lower lobe of the lung ,,,


,, ,,, .. Pus

- symptoms in winter
respiratory Infection ,,, :
system
,,,
Normal air way secretion .. ,,, sputum broncho spasm .. right lung Middle lobe upper lobe
) Upper lobe ( Upper lobe broncho spasm )Mild dyspnea) dyspnea :
,,, .. Wheeze hyper inflated Upper lobe alveoli .. broncho spasm limitation of movement Upper lobe
Upper lobe

hyper resonant percussion

bulge ,,,

chronic infection ,,, Lower lobe


alveoli Inflammation ,,, chronic infection healing by ,,, Pneumonia pneumonia
dullness retraction lower part .. fibrosis
fine creptitation .. bronchial breathing Pneumonic reaction secretion Lower lobes ,,, rhonchi secretion ,,, coarse creptitation snorous rhonchi secretion
siblent rhonchi rhonchi broncho spasm Chronic infection ,,, proliferation ,,, chronic toxemia .. chronic toxemia very toxic
clubbing .. nail bed

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Nephrotic Syndrome .. kidney amyloidosis chronic toxemia ,,, .. generalized edema ,,


Kidney amyloidosis puffiness
,, amyloidosis ,, Hypo proteinemia
anorexia

chronic toxemia :

edema .. hypo proteinemia

..,, ,,,

ulcer ,, .. wall of the bronchus Infection ,, ,,, ulcer


hemoptysis ,,, ,,,
upper Localized bronchiectasis first sign ,, hemoptysis
lobe

good drainage bronchectatic changes ,,, upper lobe
first sign hemoptysis .. ,, ,,
Upper lobe Localized bronchiectasis
Clinical pictures
..
A - Symptoms
1-fever

2- cough
3-expectoration
,,, expectoration
colored huge amount on leaning forward Related to certain posture
early morning winter time 4-hemoptysis
air way Ulceration
5-wheeze
Upper lobe broncho spasm
6-chest pain
chronic cough Muscle strain ) dry pleurisy( pleurisy
chronic disease central cyanosis
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B - examination
a ) general examination
1-fever 2-very toxic 3-may pallor

4-may clubbing

5-Puffiness of the eyelids


puffiness of eyelids
chronic cough

productive cough Hypo proteinemia ,,,

renal amyloidosis ,,,


chronic infection fibrosis Pulmonary artery fibrosis capillaries of the pulmonary artery Hyper inflated alveoli ) Pulmonary hypertension) Pulmonary artery pressure generalized edema right sided heart failure
6-Lower limb edema
chronic cough
b ) local examination
1-Inspection
*Mild respiratory distress
tachypnea

working ala nasai

Inter costal and subcostal retraction

grunting Pneumonic reaction ,,,


*limitation of movement ( bilateral)
*bulge in the upper part but retraction in the lower part
2-Palpation
*trachea central
*palpable sounds
palpable wheeze Upper lobe Pleurisy pleural rub Page |

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*TVF
,, .. diminished
3-percussion
dullness Impaired .. hyper resonance ,,,
4-auscultation
*air entry
bilaterally diminished
*breath sounds
Harsh vesicular ,,, Pneumonia bronchial ,,, *adventious sounds
siblent rhonchi ,,, secretion coarse crepititation sonorous rhonchi ,, fine crepititation
Pneumonia surrounding pleural rub
Complications
1-renal amyloidosis
2-Lung
*Lung abscess , empyema , Pleural effusion , cor pulmonale & Pyopneumothorax
Investigations
1-Chest X - ray
bilateral basal honey comb appearance hyper inflated upper lobe 2-CBC
) infection ( ,,, total leucocytic count bacterial infection Neutrophils
3-blood gases NO NEED
complications respiratory failure blood gases
4-sputum analysis and culture
Organism
5-broncho scopic examination
broncho scope ,, broncho graphy
:
infection Obstruction
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secretion aspiration

Local antibiotic therapy

broncho scope
bronchial tree ,,, cilia electron microscope Immotile cilia
Treatment
1-Postural drainage
2-mucolytic and expectorant
3-broncho dilators
4-antibiotics
5-resistant cases
surgical treatment .. Hemoptysis ,,
lobe stridor Croup ,,,
Croup
Croup .. stridor

,,,
larynx .. croupy cough Irritative cough Larynx
croupy cough
hoarseness of voice ,, vocal cord stridor larynx respiratory distress
Definition
clinical condition, characterized by croupy cough, hoarseness of voice, stridor with or without respiratory
distress .
Of obstruction of the airway degree of with or without respiratory distress
etiology
larynx
A - mechanical obstruction :
.. very common
1- foreign body
coins
2- congenital anomaly in Larynx as :
a-laryngeal web

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,, ,,,
:

b-larngeo malacia
,, :
larynx collapse ,,
c-Mechanical compression as
goiter

para pharyngeal abscess retro pharyngeal abscess

larynx larynx angioneurotic edema

B - Inflammatory conditions :
a- viral infection
virus Measles Influenza para influenza .. Respiratory Syncytial Virus
viral larngitis

laryngeo trachitis
acute laryngeo tracheo bronchitis

b- H influenza acute epiglotitis


stridor ,,, larynx .. acute epiglotitis epiglotis severe respiratory distress *
40 *
*
drolling of saliva ,, *
,, ,,, Prone position *
)Is absolutely contraindicated( throat examination epiglotis .. cardic arrest throat examination ,,
Highly innervated by vagus
c- Diphtheria
stridor .. ,, Larynx ,,, laryngeal diphtheria
C - tetany :
spasm of the adductors of the vocal cords
laryngismus stridulus

D - papilloma :
vocal cord papilloma vocal cord hemorrhagic polyp ,,,

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Clinical pictures
A Symptoms :
1-croupy cough
2-hoarsness of voice
3-stridor

4-respiratory distress
NB. Here on examination surasternal & supraclvicular retraction ( as the problem in upper not lower
)
B - Sign
Lower is free ,, upper normal auscultation ,,, Percussion ,, palpation ,, Inspection
.. medical emergency ,,
Investigations
1-plain X - ray
lateral Posterior antero coin radio opaque foreign body X - ray
- radio opaque foreign body
- epi glotis ,, edematous
- Narrowing below epiglotis
acute laryngeo tracheo bronchitis
Management ,, x-ray
Management
1-hospitlization
a- bed rest
b- oxygen
cold modified ,, Oxygen laryngeal edema ,,
laryngeal edema .. vaso constriction of the capillaries c- IV fluids
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2- TTT of the cause
ribavirin viral infection .. foreign body
3- If no improvement give supportive ttt
a- give Epinephrin
Inhaler epinephrine Racemic epinephrine larygeal edema vaso constriction epinephrine .. inhalation nebulizer
capillaries
laryngeal edema
b- if not present give cortisone IV
c- If no improvement do tracheostomy
Acut e spasmodic croup
,, ,,
allergic in nature .. irritative cough
Diseases of the pleura
Dry pleurisy
.. dry pleurisy
Definition
dry fibrinous inflammation of the pleura
Etiology
1-primary
pleura Primary pathology
a- viral infection
Pleura viremia virus ,, viral infection
dry pleurisy
b- renal failure
dry pleurisy pleura deposit urea
c- rheumatic fever
dry pleurisy dry peritonitis dry pleurisy dry pericardititis
d- T.B.
dry pleurisy .. pleura Primary
2-secondary
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a- lung as
Pneumonia

,, bronchiectasis,, abscess,, infarction

b- Mediastinum as
mediastinitis
c- chest wall
Osteomyelitis fracture rib
d- Infra diaphragmatic as
Liver abscess
Clinical pictures
A - Symptoms
primary cause mainly - chest pain stiching in character
holding of breathing respiration cough
B - signs
1- inespection
- limitation of movement
- tachypnea
2- palpation
pleural rub
3- Percussion
tender percussion .. Pleurisy
4- auscultation
pleural rub
Investigations
-Chest X ray to know the underlying cause
other pathology

rib chest X -ray

lung abscess Chest X - ray

Lobar pneumonia

bronchiectasis

Treatment
,,
pain analgesics

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Pleura l effusion
) ( X - ray pleural effusion
,,, pleural effusion
pleural sac fluid collected
: fluid
1- transudate :
bilateral effusion transudate generalized edema ,, )transudate) ,, 2- Exudate :
,, pleura ,, Mediastinum ,, Lung surrounding pathology ,, exudate infra diaphragmatic,,, diaphragmatic
3- Pus :
Lung abscess ,, staph pneumonia ,,, Pus 4- Hemorrhagic effusion :
cancer .. chest wall trauma ,, T.B. klebsiella
5- chylus : ( Lymph )
thoracic duct trauma lymphatic system obstruction
6- idiopathic exuadate :
exudates primary pleurisy .. Primary pleurisy
Symptoms
1-Symptoms of the cause
2-Respiratory distress
Signs
1-Inspection
signs of respiratory distress

affected side Limitation of movement of the chest


bulge

2-Palpation
*trachea ,,, pushed to the opposite side
*TVF diminished
3-percussion
diagnostic stony dullness
4-auscultation
*air entry diminished in the affected side
underlying pathology adventious sounds breath sounds *
Investigations
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Chest - Dr. Abo El-Asrar


A - Chest X - ray
B - CBC
empyema marked neutrophilia tuberculus marked lymphocytosis C - blood gases
respiratory failure
D - Pleural tap
:
1- Physical examination

,, transudate
exudate

hemorrhagic hemorrhagic

chylus

LDH

Chloride chemistry

2- for chemistry

3- for cytology

mesenchymal cells transudate

pus cells empyema

Lymphocytes caseous material Tuberculosis

malignant cells malignant effusion


4- culture and sensitivity
Treatment
1-TTT OF CAUSE
2-Inter costal tube IF :
* massive effusion respiratory distress
* ,, Pus



www.facebook.com/dr.tafreegh


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