4.3. Practical task that should be performed during practical training

1. Revealing and assessment of symptoms and signs of focal and lobar pneumonias

2. Revealing and assessment of symptoms and signs of pleurisies

3. Revealing and assessment of symptoms and signs of lung cancer

4. Revealing and assessment of symptoms and signs of pneumosclerosis

5. Assessment of the pleural fluid analysis

Topic content

Pneumonia is an infection of lung parenchyma, which leads to inflammation and exudates filling air spaces with fluid (consolidation). This leads to reduced lung compliance and ventilation-perfusion mismatch or shunt, which results in decreased oxygenation.

Classification:

Community-acquired pneumonia (CAP) acquired outside the hospital; common in nonimmuno-compromised individuals, may be primary or secondary to underlying disease.

Hospital-acquired pneumonia develops after 48-72 hours after hospital admission and is not apparent at admission.

Aspiration pneumonia follows the aspiration of exogenous material or endogenous secretions into the lower respiratory tract. Can be in patients with stroke, myasthenia, bulbar palsies, diminished consciousness (post-ictal, drunk), oesophageal disease (achalasia, reflux), or with poor dental hygiene, risk aspirating oropharyngeal anaerobes.

Pneumonia at immunocompromised patients (AIDS, prolonged systemic corticosteroids and other immunosuppressive therapy)

Causes of CAP:

S. pneumoniae, M. pneumoniae, C. pneumoniae, H. influenzae, S. aureus, Legionella spp., M. catarrhalis, Gram-negative bacilli and Viruses.

Clinical features of lobar CAP

• Breathlessness occurs due to large injury of lung that results to diminution of it function and changing of gas content of blood.

• Chest pain happens due to involving of pleura in inflammatory process.

• Cough can be dry or with purulent bloody sputum. It is depended from stage or form of disease.

• Fever, rigors, malaise, anorexia

Signs of lobar CAP

Visual examination: It is severe condition of the patient; confusion (may be the only sign in the elderly). He has redness in cheek at the affected side, herpes on his lips, sometimes prefers to lie on the affected side. There is tachypnea, cyanosis, tachycardia, hypotension.

Visual examination of the chest: There is limitation of the chest moving at the affected side. Auxiliary muscles take part in breathing.

Palpation of the chest

There is a tenderness of the pleural points, positive Potendzher symptom, because large part of lung with pleura is involved to inflammatory process and surrounded tissues react to this. It is obtained amplifying of voice resonance according to the affected lobe or segments, because consolidated lung tissue conducts acoustic waves better than normal one.

Percussion of the chest

Comparative percussion: Over the consolidated lobe the percussion sound is dull because only solid components of infiltrated lung tissue get to percussion sphere.

Topographic percussion: The lower border of the affected lung lifts up if pathological process localizes in lower lobe. The height of lung apex pulls down if infiltration of the upper lobe is presented. But size of the lung doesn’t change. It is obtaining due to increasing of solidity of lung tissue. There is dimension of lower lung border excursion.

Auscultation of the lung

There is pathological bronchial breathing because all alveoli are filled up with inflammatory exudates, whispering pectoriloquy. There is pleural rub due to inflamed pleura rubbing against each other. You can hear depressed vesicular or bronchial breathing and crepitations in the beginning or end of pathological process.

Lobar CAP has three stages: rising tide, high point and resolution.

During rising tide inflammation process is begun and alveolus walls are impregnated with exudation fluid became adhesive. When air get to them alveoli fill out with sound due to sticking off. This added sound is named crepitations (crackles). The main sound is diminished vesicular during this stage. By percussion you can obtain dullness with tympanic inflection.

During high point alveoli full up with exudates and air cannot gets to them. Vesicular breathing isn’t formed, crackles disappear, but consolidation lung conducts bronchial breathing and whispering speech from vocal cords. By percussion you can obtain dullness.

During resolution exudates gradually disappears from alveoli and changes of their walls same as the first stage. By percussion and auscultation you can receive similar data.

X-ray signs of lobar CAP: There is intensive and homogeneous infiltration of lobe or segments.

Symptoms of the focal CAP: Sometimes there is breathlessness because small part of lung is involved, lung function and gas exchange is not limited.

Cough can be dry or with purulent sputum. It is depended from stage of disease. Sometimes can be subfebrile fever, not significant rigors, malaise.

Signs of the focal CAP:

Visual examination

It is satisfactory or moderate serious. Sometimes there is limitation of the chest moving at the affected side.

Palpation of the chest

May be, there is a tenderness of the pleural points, positive Potendzher symptom, amplifying of voice resonance if the site of consolidation is near surface of chest.

Percussion of the chest

Comparative percussion: If site of consolidation is near of the chest surface it can be dullness of percussion sound. Because account of solid components of lung tissue increase due to infiltration but air presents in alveoli which haven’t been involved to pathological process and they get to percussion sphere. If site of consolidation is deeply in lung percussion sound is clear without change.

Topographic percussion: Some change can be if site of consolidation is near of chest surface. There is dimension of lower lung border excursion.

Auscultation of the lung

There is diminished vesicular breathing because less alveoli involve to act of breathing. There are sonorous bubbling (moist) rales. They are formed in bronchus which around by consolidated lung tissue. Such tissue conduct sounds from bronchus better then healthy and we can hear them as sonorous. Sometimes if site of consolidation is near chest surface crepitations can be heard.

X-ray signs of the focal CAP: There is peribronchial and perivascular and/or focal infiltration of lung tissue.

Data of additional methods of examination of CAP:

Assess oxygenation: oxygen saturation (if SaO₂ <92% analysis of blood gas)

Blood test:

Full blood count: leukocytosis, left shift of blood formula – increasing young forms of neutrophiles.

Urine and enzymes (ALT, AST, LDH), C-reactive protein are increased if CAP severe.

Blood culture and/or sputum culture are positive if patient has bacteriemia and purulent sputum.

If patient has large CAP restrictive pattern of ventilatory disorders is developed.

Pleurisy is inflammation of parietal and visceral pleura. It is secondary condition.

Pleurisy can be dry if small quantity of fluid is in pleura cavity (less than 50 ml). Exudative pleurisy is if more than 50 ml of fluid in pleura cavity.

Symptoms and signs of dry pleurisy:

It is dry cough due to irritation of cough receptors of pleura. It is pleuric chest pain due to irritation of painful receptors of pleura. There is fever, malaise and other symptoms of primary disease.

At the visual examination condition of patient depends from primary disease. There is limitation of the chest moving at the affected side, a tenderness of the pleural points, positive Potendzher symptom and diminished vocal fremitus. You obtain light dullness and dimension of lower lung border excursion by percussion. Vesicular breathing is diminished and rough pleural rub is heard.

X-ray examination can obtain thickening of pleura and its adhesion.

Exudative pleurisy has all symptoms and signs of pleural effusion.

Symptoms of the pleural effusion:

It may be asymptomatic if little quantity of fluid accumulates in pleural space.

It is associated with breathlessness, dry cough, chest pain (suggesting pleural inflammation), chest “heaviness”, palpitation, if quantity of fluid is large (more than 400-500 ml).

Signs of the pleural effusion:

Visual examination

It is a severe condition of the patient. There is tachypnea, cyanosis and limitation of the chest moving at the affected side. Patient prefers to lie on the affected side because it facilitates his breathing.

Palpation of the chest

It is obtained reduced or absent tactile vocal fremitus, because fluid damps acoustic waves, and increased chest resistance. Sometimes, may be positive Potendzher symptom.

Percussion of the chest

Comparative percussion: It is dullness over fluid.

Topographic percussion: Lower lung border has shape named Ellis-Damuazo line which begins near column and rises to scapular then descends to axillary region and continues horizontally. This shape of line makes conditional upon different property of lung tissue to be squeezed.

Auscultation of the lung

There are no any sounds over the fluid. But sometimes may be diminished vesicular breathing if it is little quantity of fluid. You can hear diminished bronchial breathing if quantity of fluid much and squeezed lung has similar density as fluid. Above the fluid it is diminished vesicular breathing and, sometimes, pleural rub.

X-ray signs of the pleural effusion: It is usually detected effusion volumes of 200 ml or more by posterior-anterior position. Lateral chest X-ray is more sensitive and may detect as little as 50 ml pleural fluid. Classical chest X-ray appearance is of basal opacity obscuring hemidiaphragm, with concave upper border. Massive effusion may result in a ‘white-out’ of the hemithorax, with mediastinal displacement away from the effusion. Lack of the mediastinal shift in such cases raises the possibility of associated volume loss due to bronchial obstruction from a primary lung cancer.

Ultrasound is extremely sensitive at detecting fluid volumes of 100 ml or more, and is useful for distinguishing pleural fluid from pleural masses or thickening, and for demonstrating localization.

Laboratory assessment of pleural fluid:

1. Common – visual assessment, comparative density, Rivalt test

2. Biochemistry for measurement of protein, LDH, glucose, cholesterol, triglycerides, amylase, depending on the clinical circumstances.

3. Cytology for examination for malignant cells and differential cell count

4. Microbiology for Gram stain and microscopy, culture, MBT examination

Laboratory signs of transudates and exudates

Sign	transudates	exudates
comparative density	< 1,015-1,018	>1,018
Rivalt test	negative	positive
protein	<30 g/l	>30 g/l
Pleural fluid protein/serum protein ratio	<0,5	>0,5
LDH	<1,6 mMol/l	>1,6 mMol/l
Pleural fluid LDG/serum LDG ratio	<0,6	>0,6
erythrocytes	<10*109/l	>100*109/l
leucocytes	<1*109/l	>1*109/l
pH	>7,3	<7,3
glucose	3,3-5,5 mMol/l	<3,3 mMol/l

Lung cancer usually develops within the wall or epithelium of the bronchial tree. If it develops in the proximal big bronchi it is named central. If it is developed in the distal small bronchi or in the bronchioles it is named peripheral.

Long-time smoking, inhalation of carcinogenic pollutants, work with asbestos can result in lung cancer.

Early-stage lung cancer does not produce symptoms. The following late-stage symptoms are: chronic cough with bloody sputum, hoarseness, wheezing, dyspnea and chest pain, weakness, weight loss, anorexia and shoulder pain.

In case of the central lung cancer symptoms and signs of obstructive atelectasis are developed: Breathlessness, tachypnea, cyanosis. Chest is asymmetric – affected side and chest excursion is diminished; tactile vocal fremitus is diminished or absent, because collapsed lung tissue damps acoustic waves. Chest resistance is increased. Percussion sound is dull over atelectasis. Lower lung border is lifted up by collapsed segments. There are no any sounds over the atelectasis by auscultation because air doesn’t come into alveoli.

In case of the peripheral lung cancer symptoms and signs of consolidation are developed. This type of cancer becomes apparent like lobar pneumonia. But it has not been resolved after antimicrobial treatment.

Diagnostic investigations:

Chest X-ray usually shows an advanced lesion, but it can detect a lesion up to 2 years before symptoms appear.

Sputum cytology, which is 75% reliable, requires a specimen coughed up from the lungs and tracheobronchial tree, not postnasal secretions or saliva.

Computered tomography scan of the chest may help to delineate the tumor’s size and its relationship to surrounding structures.

Bronchoscopy can locate the tumor site and take material for cytologic and histologic examination by a needle biopsy.

Tissue biopsy of accessible metastatic sites includes supreclavicular and mediastinal nodes and pleural biopsies.

Thoracentesis allows chemical and cytologic examination of pleural fluid.

Pneumosclerosis – last stage of any inflammatory of degenerative process in the lung tissue. It can develop after pneumonia, tuberculosis, chronic bronchitis, interstitial lung diseases and other. Clinical presentation depends on spreading of the process and usually manifests by progressive mixed dyspnea and respiratory failure.

7. Reference source

• Handbook of diseases.-.2^nd ed.- Springhouse Corporation, 2000 – P.508-510, 660, 663-666.

Professor assistant Demchuk H.V.