Kursk State Medical University

Propaedutics of Internal
Diseases Department
Main Clinical Syndromes
in Respiratory Medicine

Syndrome of focal consolidation

of pulmonary tissue
Causes:
Pneumonia

(filling of alveolai with

inflammatory fluid & fibrin)
Lung infarction (filling of alveolai with blood)
Pneumosclerosis, carnification (connective
tissue growing)
Tumor

Syndrome of focal consolidation

of pulmonary tissue
Clinical symptoms
Dyspnoea
Pain in the chest (only in involvement of the

pleura in peripherally located inflammatory

focus)
If fever - moderate hyperemia of the face,
cyanosis of the lips.
Tachypnoea (24-30 per min).

Clinical sings

In large peripherally
located focus
Trachea in normal position
Thoracic lagging of affected
side (in pleura involvement)
Vocal fremitus increased
Dull percussion
If small deeply located
focus: palpation,
percussion, auscultation
may be non-effective

Syndrome of focal lung consolidation

Auscultation
Bronchovesicular
(mixed
respiration: inspiration as
vesicular (F), expiration
as bronchial (H)
or

Bronchial breathing

Syndrome of focal lung consolidation

Consonating moist
crackles, dry rales,
Auscultation
crepitation
Exaggerated bronchophony

Syndrome of focal
lung consolidation

Investigations
X-ray:

focal consolidations
at least 1-2 cm in diameter
(increased density in lung tissue)

Blood test: mild leucocytosis, moderately increased ESR.

Sputum: mucopurulent; great number of leucocytes, macrophages
and columnar epithelium. Bacterial flora is varied.

Syndrome of lobar consolidation

of pulmonary tissue
Complaints
Severe dyspnoea
Pleuritic pain in the chest (on the affected
side) in lower lobe involvement may
simulate acute appendicitis, hepatic colics
May be shaking chills or rigor, fever

(39400C), cough with sputum expectoration

Syndrome
of lobar
lung consolidation
General condition
- grave

May be confusion
(hallucinations & delirium)
Central cyanosis

In lobar typical pneumonia facies pneumonica:

Hyperemia of the cheeks, more
pronounced on the affected side
Participation of the nostrils in
breathing
Herpes nasalis & labialis.

Syndrome of lobar lung consolidation

Normal trachea position

Lagging of the affected
side
Tachypnea (30-40 per
min)
Increased vocal fremitus
Dull percussion sound
Bronchial breathing
Pleural friction rub
Consonating crackles,
crepitation

Syndrome of lobar lung consolidation

Increased bronchophony
Egophony (ee as ay)
Whispered pectoriloquy.
Cardiovascular symptoms:
tachycardia

Syndrome of lobar lung consolidation

X-ray

examination:
Homogeneous
opacity localized to
the affected lobe

Syndrome of cavity in the lung

Reasons:
Lung abscess
Lung tuberculosis (cavern)
Lung tumor degradation

Syndrome of cavity in the lung

Complaints

Weakness
Cough with meager sputum (sudden release
of ample offensive purulent sputum - full
mouth - on standing separates into three
layers: mucous, serous and purulent (from
200 ml to 1-2 L/day)
Pain in the chest
Dyspnoea
May be fever (remittent or hectic), chills

Syndrome of cavity in the lung

Unilateral thoracic lagging
Vocal fremitus increased
Percussion:
dulled tympany
metallic sound bell
tympany (large smooth-wall
cavity D=6-8 cm)
crackled-pot sound
(superficial cavity
communicates with
bronchus through a narrow
slit soft dull & clinking
sound)

Syndrome of cavity in the lung

Auscultation:
Bronchial breathing
(amphoric / cavernous)
Resonant (consonating)
medium & large moist
crackles

Syndrome of cavity in the lung

Pathological bronchial respiration
(amphoric)
Large smooth-wall

cavity (D>5-6 cm)

communicated with a
large bronchus
(abscess, cavern)

Additional high overtones

(strong resonance)
with the main low-pitch
laringotracheal breathing

Syndrome of cavity in the lung

Pathological bronchial respiration
(cavernous)

Cavernous sound over

the cavity
Low-toned form of
bronchial breathing
(more hollow in quality)
Imitated by breathing
into a tumbler

If the cavity is well filled,

no abnormal breath
sounds will be heard,
though breathing may
be faint

Syndrome of cavity in the lung

Metallic character of crackles

In superficially located large cavity (D>5-6 cm)

Syndrome of cavity in the lung

Gutta cadens falling-drop sound
In lung or pleural cavities with liquid pus & air
Pus sticks to the surface of the cavity
in changing patients position pus falls down in
drops at the bottom (one by one)

Syndrome of cavity in the lung

Investigations
Sputum:
Offensive smell
On standing separates into
three layers: mucous,
serous, purulent
Elastic fibers
Leucocytes and
erythrocytes
Dittrichs plugs (resemble
the lenticular formations
with offensive odour on
pressing )

Syndrome of cavity in the lung

X-ray:
cavity with liquid level

Syndrome of air accumulation in

the pleural
(Pneumothorax)
Presence
of gascavity
in

the pleural space

Communicated
bronchi with
pleural cavity:
Subpleural
tuberculosis
cavern or lung
abscess
Chest injury
Iatrogenic
pneumothorax

Pneumothorax
1. Spontaneous pneumothorax occurs without

1. Spontaneous pneumothorax occurs without

antecedent trauma to the thorax
A. Primary spontaneous occurs in an
individual without underlying lung disease
(subpleural bullae rupture)
B. Secondary with underlying lung disease
(bullae rupture in emphysema, asthma,
abscess, tumor, eosinophilic granuloma)
2. Traumatic pneumothorax caused by
penetrating or non-penetrating chest injuries
(rib fracture, penetrating chest wall injury,
during pleural or pericardial aspiration)

Pneumothorax

3 types
Tension (valvular) - positive pressure (more
than atmospheric) in the pleural space
throughout the respiratory cycle (one-way
valve: air entered to the pleural cavity during
inspiration, not removed during expiration
trapped)
Closed - air entered to the pleural cavity
Open communication between the bronchus
& pleural cavity (broncho-pleural fistula)
pressure same as atmospheric

Complaints
Sudden unilateral tightness in the chest
Pain in the chest with inspiratory increasing
Dyspnea
Dry cough
Palpitation

Pneumothorax
Tension (valvular):
Medical emergency (if not treated death within
short time). General condition - suddenly,
rapidly. Severe dyspnea progressive with
each inspiration. Central cyanosis.
Closed:
Dyspnea (not severe) improves (2-4 weeks)
after air absorbtion
Open:
Dyspnea not improved without surgery

Clinical manifestations
Inspection

Asymmetrical chest
Displacement of the
trachea to the
opposite side
Lagging of the
affected side
Intercostal spaces increased,
smoothed

Clinical manifestations
Palpation
Subcutaneous
emphysema
(in traumatic
pneumothorax)
Increased unilateral
regidity

Vocal fremitus decreased or

absent

Clinical manifestations
Percussion
Tympanic percussion sound

Metallic sound - bell tympany in

large pneumothorax (coin test)

Shift of the mediastinum to the opposite

side

Clinical manifestations
Auscultation

Diminished vesicular
breathing or absent
In open pneumothorax
-connection of the pleural
cavity with bronchus
(broncho-pleural fistula)
bronchial (amphoric or
metallic breathing)
Succussion (air + fluid in
pyopneumothorax)

Pathological bronchial respiration

(metallic)
Large open

pneumothorax

Loud & high

Resembles the metal
struck

Investigations
X-ray
Light pulmonary
field without
pulmonary pattern
(translucent zone)
Shadow of the
collapsed lung
toward the root
Shifted (pushed
out) mediastinum

Pneumothorax
treatment
Tension (valvular):

Medical emergency. Wide needle with

rubber tube - inserted in the intercostal
space for air aspiration
Closed: small without treatment, large air aspiration
Open: surgical treatment

Syndrome of increased
airness of the lungs
(syndrome of hyperinflation)
Distention of the air
spaces distal to the
terminal bronchiole
with destruction of
alveolar septa
Reduced lung
elasticity

Syndrome of hyperinflation
(lung emphysema)
Pink puffers
face

Tachypnea with
prolonged expiration
trough pursed lips /
expiration with
grunting sound
Increasing
breathlessness - an
exertional expiratory
dyspnea
Minimal cough with
small amounts of
mucoid sputum

Lips tightly apposed

at height of inspiration,
Lips held narrowly apart during
expiration

Syndrome of hyperinflation
(lung emphysema)

Asthenic constitution with weight loss

Barrelshaped chest (increased
anteroposterior diameter)
Use of accessory muscles in
respiration
Tracheal tug
Tachypnea
Prolonged expiration through pursed
lips
Lower intercostal spaces retract with
each inspiration
Neck veins distended during
expiration

Syndrome of hyperinflation
(lung emphysema)
Palpation:
Increased rigidity
Decreased vocal
fremitus
Diminished excursion

Syndrome of hyperinflation
(lung emphysema)
Percussion:
Hyperresonant (bandbox)
sound
Upper borders: protruded
Lower borders: descendent
Limited mobility
Decreased liver & cardiac
dullness
Auscultation: diminished
vesicular breathing
(diffuse dry rales in bronchitis)

Syndrome of hyperinflation
(lung emphysema)
Cardiac

dullness severely reduced

Decreased heart sounds
Presystolic gallop accentuated during
inspiration

Syndrome of hyperinflation
(lung emphysema)
Pulmonary function tests:
TLC and RV - increased
VC - low
Maximal expiratory flow rates - diminished

Syndrome of hyperinflation
(lung emphysema)

X-ray of the chest:

Diaphragm low,
flattened
Bronchovascular
shadow do not extend
to the periphery of
the lungs
Cardiac silchouette
lengthened, narrowed
Overinflation

Syndrome of compressive
atelectasis

Compressed
alveoli due to
accumulation of
fluid in the
pleural cavity

Syndrome of compressive
atelectasis
Dyspnea (inspiratory)
Cough - dry (reflexogenous)
In mediastinal pleurisy with
effusion:

Dysphagia (compression of
the esophagus)
Compression of the superior
vena cava - Stocks collar
(edema of the neck), cyanotic
face, dilated chest wall veins

Pembertons sign
Compression of the recurrent
nerve - hoarseness

Objective Examination
Inspection
Asymmetry of the
chest
Tracheal
displacement away
from the fluid
Lagging of the
affected side
Protrusion of the
intercostal spaces

Objective Examination
Palpation
Vocal fremitus
increased over the
compressed lung
Increased rigidity of
the affected chest
part

Syndrome of compressive
atelectasis - Garlands triangle
Garlands
triangle

Damoiseaus
Curve
Effusion

RauchfussGrocco
triangle
(displacement
mediastinum)

Garlands triangle on the affected side: dulled

tympanic sound (lung pressed by the effusion)

Skodaic tympany
Zone above the
fluid
dilated air sacs
in the lung
just above
the compressed
part

Syndrome of compressive atelectasis

Auscultation
Above the effusion
(Garlands triangle) bronchial breathing echo like compressive
bronchial breathing,
temporary crepitation
(during first deep
inspirations)
Increased bronchophony

Syndrome of obstructive atelectasis

Occlusion of the

bronchus by tumor,
retained secretions,
foreign body air
absorbed, affected
part of the lung
collapsed

Syndrome of obstructive atelectasis

Causes
1.

Intraluminal:

Mucus (postoperative, asthma, cystic fibrosis)

Foregn body
Aspiration

2.

Mural:

Bronchial carcinoma

3.

Extramural:

Peribronchial lymphadenopathy
Aortic aneurysm

Syndrome of obstructive atelectasis

Dyspnea (inspiratory)
If compression of the
trachea stridor
Expansion: reduced on the
affected side with flattening
of the chest wall
(narrowing, retruction of
the intercostal spaces)
Lagging of the affected side
Displacement of the
trachea & mediastinum
toward the affected side

Syndrome of obstructive atelectasis

Percussion: dull over

the collapsed area
Vocal fremitus: absent
Breath sounds:
reduced, with or
without bronchial
breathing above the
collapsed area
Bronchophony: absent

Syndrome of incomplete
obstructive atelectasis
Diminished vocal fremitus
Dulled tympanic sound (air in alveoli -

incomplete closure of adductive bronchus)

Diminished vesicular breathing
(hypoventilation), local wheezing
(obstruction in trachea / main bronchi
stridor)

3 grades
of local obstructive atelectasis
Grade I

diminished possibility for air to

pass through a narrowed airway during
both respiratory phases:
Locally increased vesicular breathing or
harsh breathing sound
Fixed monophonic wheezes
Vocal fremitus & bronchophony present

3 grades
of local obstructive atelectasis
Grade II diminished possibility for air to pass
through a narrowed airway only during
inspiration & closure during expiration: inability
for air to leave obstructed area
Local tympany
Reduced vesicular breathing sound over
hypoventilated area
Fixed monophonic wheezes
Vocal fremitus & bronchophony present, but
diminished

3 grades
of local obstructive atelectasis
Grade III total closure of affected airway

& subsequent formation of complete

obstructive atelectasis (atelectatic silence)
Recurrent pneumonia - hypoventilation &
disturbed airway clearance

Syndrome of increased
thickening of pleural layers
(dry pleurisy)
Complaints:

Knifelike or shooting pain in the chest (increased

by deep breathing, coughing, laughing, thoracic
motions)
Dry cough
Subfebrile temperature
Generalized weakness

Objective Examination
Inspection
forced posture
(on the affected side
or sitting with fixation
to decrease the
movement of the
affected side)
superficial respiration
unilateral thoracic
lagging

Objective Examination
Palpation
Painful palpation of trapezoid & large
thoracic muscles (Sternbergs &
Pottengers signs):

a.

b.

irritation of central portion of pleural surface of

diaphragm pain at superior border of trapezoid
muscle, supraclavicular fossa
irritation of peripheral portion of pleural surface of
diaphragm pain in skin supplied by T-6
dermatome

May be palpable pleural friction rub

Decreased
vocal fremitus

Normal

Pleurofibrothorax

Objective Examination
Percussion & auscultation

Dulled tympanic
sound
Decreased mobility of
the lung border on the
affected side
Diminished vesicular
breathing
Pleural friction rub

Investigations
X-ray

- Limited mobility of the diaphragm

Blood test
- Moderate leukocytosis

Brochoobstructive syndrome
Syndrome of difficult air passage through the
bronchi due to obstruction of the bronchial
tree
Reasons:
Hypertrophy of the mucus-secreting
glands, increased number of goblet cells in
bronchi & bronchiole with a consequent
decrease in ciliated cells
Mucosal oedema & permanent structural
damage of the airway walls reduce the
caliber of the air passages
Increased mucus in the airways

CLINICAL FEATURES

Cough
Initially productive cough during winter, later - constant
Tightness in the chest in the
morning (disappeared by
coughing)
Expectoration
Sputum may be little, mucoid
and tenacious or cup of
mucopurulent / purulent
Breathlessness
expiratory dyspnea,
later episodes of sleep
apnea

OBJECTIVE EXAMINATION
Blue bloater:

overweight
edematous
cyanotic

RESPIRATORY SYSTEM
EXAMINATION
Inspection:

1) respiratory rate is normal or slightly

increased
2) there is no apparent usage of
accessory muscles
3) flapping tremor (asterixis)
Palpation: reduced expansion
Percussion: resonant sound

Auscultation
Hush breathing

(with prolonged
expiration)
Coarse ronchi &
wheezes

Respiratory failure
Definition
Inability to maintain PO2 (> 60 mm Hg) &
PCO2 (< 50 mm Hg) in arterial blood
Inadequate lung function for metabolic

requirements of individual

Respiratory failure classification

absence / presence hypercapnia

Respiratory failure

Type I
PO2 < 60 mm Hg
PCO2 < 50 mm Hg

Type II
PO2 < 60 mm Hg
PCO2 > 50 mm Hg

Respiratory failure

Acute
during minutes or
hours

Chronic
during days or
weeks

Respiratory failure
Type I
PO2 < 60 mm Hg
PCO2 < 50 mm Hg

Acute:

Acute asthma
Pulmonary embolus
Acute respiratory
distress syndrome
Pneumothorax
Pneumonia

Chronic:
Emphysema

Lung fibrosis
Lymphangitis
carcinomatosa
Right-to-left shunts
Anemia

Respiratory failure
Type II - asphyxia
PO2 < 60 mm Hg
PCO2 > 50 mm Hg

Acute:

Acute severe asthma

Inhaled foreign body
Respiratory muscle
paralysis
Flail chest injury
Sleep apnea
Brain-steam lessions

Chronic:

COPD
Primary alveolar
hypoventilation
Kyphoscoliosis
Ankylosing
spondiloartritis

Respiratory failure
Manifestations
Dyspnea
Tachycardia
Cyanosis
Edema (in late stage - cardiac failure)

Respiratory failure
Late stage
Respiratory failure

+
RV incompetence
Pulmonary hypertension due to Euler-

Liiestrand reflex

Euler-Liliestrand reflex

Insufficient lung
ventilation &
Alveolar hypoxia

Limited
blood supply
of Insufficiently
ventilated lung

Sclerotic changes in lungs

Pulmonary hypertension

Respiratory failure
Mechanisms

Obstructive type

Restrictive type

Mixed type

Respiratory failure
Obstructive type difficult air

passage through the bronchi:

Bronchitis
Bronchospasm
Trachea / large bronchus compression

Respiratory failure
Restrictive type limited lung

ability to expand & collapse:

Pneumosclerosis
Hydrothorax
Pneumothorax
Massive pleural adhesions
Kyphoscoliosis
Limited ribs mobility

Respiratory failure
Mixed type combination of

obstructive & restrictive types (with

or without prevalence of one of them):
Long-standing lung & heart diseases

Adult respiratory
distress syndrome
Respiratory failure - type I (PO2 < 60 mm Hg, PCO2
< 50 mm Hg) by development of pulmonary edema
from non-cardiogenic causes (damage to alveolar
epithelium & capillary endothelium)
Acute hypoxemic respiratory failure following a
systemic or pulmonary insult without evidence of
heart failure
Essentials of diagnosis:
Acute onset of respiratory failure
Bilateral radiographic pulmonary infiltrates
Absence of elevated left atrial pressure
PaO2/FiO2 (fractional concentration of inspired
oxygen) ratio < 200

Adult respiratory
distress syndrome (ARDS)
Risk factors:
Sepsis (1/3 of all ARDS)
Gastric contents aspiration
Shock
Infection
Lung contusion
Non-thoracic trauma
Toxic inhalation
Near-drowning
Multiple blood transfusions
Pancreatitis

Adult respiratory
distress syndrome (ARDS)
Rapid onset (12-48 hours after event)
Profound dyspnea (hyperventilation)
Labored breathing
Intercostal retractions
Bilateral crackles
BP falls
Chest X-ray: diffuse or patchy bilateral infiltrates
- rapidly confluent (fluffy homogeneous
shadows)

KURSK STATE
MEDICAL UNIVERSITY
DEPARTMENT OF PROPAEDEUTIC
OF INNER DISEASES

Respiratory pathology
Main clinical syndromes

Focal consolidation
In presence of large focus,
if it is located peripherally
(over the limited part of the
chest):

vocal fremitus increased

dull percussion sound
vesiculobronchial or
bronchial breathing,
dry / consonating moist
rales,
crepitation

Lobar consolidation

Lagging of the affected side.

Dyspnoea.
Vocal fremitus is increased.
Dulled-tympanic / dull
percussion sound.
Auscultation diminished
vesicular breathing,
crepitation indux,
bronchial breathing,
increased bronchophony

Cavity in the lung

Unilateral thoracic lagging

Vocal fremitus
increased
Percussion: tympanic /
metallic sound; crackled pot sound
Auscultation: bronchial
(amphoric / cavernous)
breathing;
resonant moist rales;
gutta cadens (falling
drop sound)

Obstruction of the bronchi

Blue Bloater:

overweight,
edematous,
cyanotic.

Obstruction of the bronchi

Inspection:

1) respiratory rate is normal or slightly

increased.
2) there is no apparent usage of accessory
muscles.
3) flapping tremor (asterixis)
Palpation: hyperinflated chest with reduced
expansion.
Percussion: resonant sound.

Obstruction of the bronchi

Hush breathing
(prolonged expiration)

Coarse ronchi &

wheezes
may be
non-consonating
crackles

(change in location / intensity

after a deep and productive
cough)

Emphysema
Pink puffer
Tachypnea with
prolonged expiration
trough pursed lips /
expiration with
grunting sound
Lips tightly apposed
at height of inspiration,
Lips held narrowly apart during
expiration

Emphysema

Asthenic constitution with weight

loss.
Barrelshaped chest (increased
anteroposterior diameter).

Use of accessory muscles in

respiration.
Tachypnea.
Prolonged expiration
through pursed lips.
Lower intercostal spaces
retract with each
inspiration.
Neck veins distended during
expiration.

Emphysema
Palpation:

Increased rigidity
Decreased vocal
fremitus
Diminished excursion

Emphysema
Percussion:
Hyperresonant (bandbox) sound
Upper borders protruded
Lower borders: descendent
limited mobility
Decreased liver & cardiac dullness
Auscultation: diminished vesicular
breathing
(diffuse dry rales in bronchitis)

Obstructive atelectasis

Occlusion of the
bronchus.
Symptoms of obstructive
atelectasis.
Displacement of
mediastinum toward the
affected side.
Displacement of the
trachea.

Hydrothorax

Accumulation of
fluid in the pleural
cavity
Compressive
atelectasis

Hydrothorax
Asymmetry of the
chest
Tracheal
displacement away
from the fluid
Lagging of the
affected side
Protrusion of the
intercostal spaces

Hydrothorax
Palpation
Vocal fremitus
Increased over the
compressed lung
Diminished or

not transmitted at
the area of the fluid
accumulation

Hydrothorax
Percussion

Dullness over the area of fluid.

Damoiseaus curve.
Garlands triangle on the affected side characterized by
a dulled tympanic sound. It corresponds the lung
pressed by the effusion compression atelectasis.
Rauchfuss-Grocco triangle is found on the healthy side
and is a kind of extension of dullness determined on the
affected side. The sides of the triangle are formed by the
diaphragm and the spine, while the continued
Damoiseaus curve is the hypotenuse.
Absence of the Traubes space in the left sided pleuritis

Hydrothorax
Percussion
Garlands
triangle

Damoiseaus
Curve
Effusion

RauchfussGrocco triangle
(due to
displacement of
the
mediastinum)

Hydrothorax
Auscultation

In the region of accumulated

fluid -diminished vesicular
breathing or not auscultated

Above the effusion - bronchial

breathing - echo like
(compressive atelectasis)

Bronchophony over the

effusion is not determined

Dry Pleurisy
Complaints:
Pain in the chest ( increased during

breathing and coughing)

Dry cough
Subfebrile temperature. General
weakness.

Objective Examination
Inspection

forced posture (on

the affected side
or sitting)
superficial
respiration
unilateral thoracic
lagging

Objective Examination
palpation and percussion

Painful palpation of trapezoid and large

thoracic muscles (Sternbergs and Pottengers
signs).
decreased mobility of the lung border on the
affected side

Objective Examination
Auscultation

pleural friction rub

Pneumothorax
Presence of gas in the pleural
space

Complaints
Pain in the chest
Dyspnea
Dry cough
Palpitation

Clinical manifestations
Inspection.

asymmetrical
chest.
Displacement of
the trachea to the
opposite side
lagging of the
affected side
intercostal spaces
are increased and
smoothed

Clinical manifestations.
Palpation.

Subcutaneous
emphysema (in
traumatic
pneumothorax )
vocal fremitus is
decreased or absent

Clinical manifestations.
Percussion.

tympanic percussion sound

shift of the mediastinum to the opposite side

Clinical manifestations.
auscultation.

diminished vesicular
breathing or absent
Connection of the pleural
cavity with bronchus
amphoric breathing
In open pneumothorax
metallic breathing