Thorax and Lungs Examination 1111111.pptx

thorax and lung

1. Thorax and Lungs Examination

2. Thorax The thorax is the region of the body located between the neck and the abdomen. It is commonly referred to as the chest. The thorax contains vital organs and structures, including the heart, lungs, major blood vessels, and several components of the respiratory and cardiovascular systems.

3. Chest Wall The chest wall is the bony and muscular framework that encases and protects the thoracic organs. It includes the ribs, sternum (breastbone), and the thoracic vertebrae of the spine. The muscles of the chest wall, such as the intercostal muscles, play a crucial role in respiration.

4. Lungs The thorax houses the two lungs, which are responsible for breathing and oxygenating the blood. The right lung has three lobes, while the left lung has two lobes. Heart The heart is located within the thorax, slightly to the left of the midline. It is enclosed within a protective sac called the pericardium.

5. Major Blood Vessels The major blood vessels of the cardiovascular system pass through the thorax. The aorta, which carries oxygenated blood from the heart to the rest of the body, originates in the thoracic region. The superior vena cava and inferior vena cava return deoxygenated blood from the upper and lower parts of the body to the heart Thoracic Spine The thoracic vertebrae make up the upper portion of the vertebral column (spine). These vertebrae provide structural support and protection for the spinal cord.

6. Respiratory Structures The trachea, or windpipe, runs through the thorax and connects the larynx to the bronchi. The bronchi branch into bronchioles, which lead to the alveoli where gas exchange occurs in the lungs. Pleural Cavity The thorax contains two pleural cavities, one on each side, which surround the lungs. The pleura are double-layered membranes that protect and lubricate the lungs as they expand and contract during breathing.

7. Key Components of the Thorax and Lung Examination Survey respiration (rate, rhythm, depth, effort of breathing, signs of respiratory distress). Examine the anterior and posterior chest: Inspect the chest (deformities, muscle retraction, lag). Palpate the chest (tenderness, bruising, sinus tracts, respiratory expansion, fremitus). Percuss the chest (flat, dull, resonant, hyper resonant or tympanic). Auscultate the chest (breath sounds, adventitious, transmitted voice sounds).

8. Before Starting Introduce yourself to the patient. Confirm their name and date of birth. Explain the examination and obtain their consent. Position them at 45°, and ask him/her to remove his top(s). Ask them if he/she is in any pain or distress. Ensure that them is comfortable. Wash your hands.

9. General Inspection From the end of the couch, observe the patient’s general appearance (age, state of health, nutritional status, and any other obvious signs). Is he/she visibly breathless or cyanosed? Does he/she must sit up to breathe? Is his/her breathing audible? Are there any added sounds (cough, wheeze, stridor)? Note: the rate, depth, and regularity of his/her breathing any deformities of the chest (barrel chest, pectus excavatum, pectus carinatum) and spine any asymmetry of chest expansion the use of accessory muscles of respiration and planting of hands the presence of operative scars, including in the axillae and around the back Next observe the surroundings. Is the patient on oxygen? If so, note the device, the concentration (%), and the flow rate. Look for inhalers, nebulisers, peak flow meters, intravenous lines, chest drains, and chest drain contents. If there is a sputum pot, make sure to inspect its contents.

10. Inspection and examination of the head and neck Inspect the patient’s eyes. Look for a ptosis and for anisocoria. Ipsilateral ptosis, miosis, enophthalmos, and anhidrosis are strongly suggestive of Horner’s syndrome, which may result from compression of the sympathetic chain by an apical lung tumour. Next inspect the sclera and conjunctivae for signs of anaemia. Ask the patient to open his/her mouth and inspect the underside of the tongue for the blue discoloration of central cyanosis. Assess the jugular venous pressure (JVP) and the jugular venous pulse form . A raised JVP is suggestive of right-sided heart failure. Examine the lymph nodes from behind with the patient sitting up. Have a systematic routine for examining all the submental, submandibular, parotid, pre- and post-auricular, occipital, anterior cervical, posterior cervical, supra- and infra-clavicular, and axillary lymph nodes

11. Inspection and examination of the hands Take both hands and assess them for temperature and colour. Peripheral cyanosis is indicated by a bluish discoloration of the fingertips. Test capillary refill by compressing a nail bed for 5 seconds and letting go. It should take less than 2 seconds for the nail bed to return to its normal colour. Look for tar staining and finger clubbing. When the dorsum of a finger from one hand is opposed to the dorsum of a finger from the other hand, a diamond-shaped window (Schamroth’s window) is formed at the base of the nailbeds. Inspect and feel the thenar and hypothenar eminences, which can be wasted if there is an apical lung tumour that is invading or compressing the roots of the brachial plexus. Test for asterixis , the coarse flapping tremor of carbon dioxide retention, by asking the patient to extend both arms with the wrists in dorsiflexion and the palms facing forwards. Ideally, this position should be maintained for a full 30 seconds. Note that generalised fine tremor may be related to excessive use of B2 agonist. During this time, assess the radial pulse and determine its rate, rhythm, and character. Is it the bounding pulse of carbon dioxide retention? Indicate that you would like to measure the blood pressure.

12. Causes of Clubbing Respiratory Cardiac Gastrointestinal Familial (congenital)

13. Causes of Asterixis Hepatic Failure Renal Failure Cardiac Failure Respiratory failure Hypoglycemia Hypokalemia Hypomagnesaemia Drug intoxication CNS causes

14. Deformities of the Thorax Barrel Chest Traumatic Flail Chest Funnel Chest (pectus Excavatum) Pigeon Chest (pectus Carinatum) Thoracic Kyphoscoliosis

15. Respiration (ventilation) Respiration is the act of breathing. Inhalation or inspiration refers to the intake of air into the lungs. Exhalation or expiration refers to breathing out or the movement of gases from the lungs to the atmosphere

16. Mechanics of Breathing During inhalation the diaphragm contracts (flattens), the ribs move upward and outward, and the sternum moves outward, thus enlarging the thorax and permitting the lungs to expand. During exhalation , the diaphragm relaxes, the ribs move downward and inward, and the sternum moves inward, thus decreasing the size of the thorax as the lungs are compressed.

17. Respiration (Ventilation) Costal (Thoracic) Breathing Diaphragmatic (Abdominal) Breathing Costal breathing involves the external intercostal muscles and other accessory muscles, such as the sternocleidomastoid muscles. It can be observed by the movement of the chest upward and outward Diaphragmatic breathing involves the contraction and relaxation of the diaphragm, and it is observed by the movement of the abdomen, which occurs as a result of the diaphragm’s contraction and downward movement.

18. Assessing Respirations Resting respirations should be assessed when the patient is relaxed because exercise affects respirations, increasing their rate and depth. Respirations may also need to be assessed after exercise to identify the patient’s tolerance to activity. Rate Depth Rhythm Quality Effectiveness

19. Several factors increase respiratory rate: Exercise (increases metabolism) Stress (readies the body for “fight or flight”) Increased environmental temperature Lowered oxygen concentration at increased altitudes Several factors decrease respiratory rate: decreased environmental temperature Certain medications (e.g., narcotics) Increased intracranial pressure. Eupnea - Normal respiratory rate Bradypnea - Abnormally slow respiratory rate Tachypnea – Abnormally fast respiratory rate Apnea – Absence of breathing Respiratory Rate

20. Assessing Respiration Assess respiratory rate, depth, and rhythm by inspection (observing and listening) or by listening with the stethoscope Determine the rate by counting the number of breaths per minute. If respirations are very shallow and difficult to detect, observe the sternal notch, where respiration is more apparent

21. Assessing Respiration Action While your fingers are still in place for the pulse measurement, after counting the pulse rate, observe the patient’s respirations Note the rise and fall of the patient’s chest. Using a watch with a second hand, count the number of respirations for 30 seconds. Multiply this number by 2 to calculate the respiratory rate per minute. Rationale The patient may alter the rate of respirations if he or she is aware they are being counted. A complete cycle of an inspiration and an expiration composes one respiration. Sufficient time is necessary to observe the rate, depth, and other characteristics.

22. Assessing Respiration If respirations are abnormal in any way, count the respirations for at least 1 full minute. Note the depth and rhythm of the respirations. When measurement is completed, remove gloves, if worn. Cover the patient and help him or her to a position of comfort.

23. Special Considerations The patient is breathing with such shallow respirations that you cannot count the rate: Sometimes it is easier to count respirations by auscultating the lung sounds. Auscultate lung sounds and count respirations for 30 seconds. Multiply by 2 to calculate the respiratory rate per minute. If the respiratory rate is irregular, count for a full minute. Notify the physician of the respiratory rate and the shallowness of the respirations. If respiratory rate is irregular, count respirations for 1 minute. For infants, count respirations for 1 full minute due to a normally irregular rhythm. Assess respirations in infants and children when the child is resting or sitting quietly, because respiratory rate often changes when infants or young children cry, feed, or become more active. The most accurate respiratory rate is obtained before disturbing the infant or child. Infants’ respirations are primarily diaphragmatic; count abdominal movements to measure respiratory rate. After one year of age, count thoracic movements.

24. Breathing Rate Rhythm When observing respiratory patterns, note the rate, depth, and regularity of the patient’s breathing. Traditional terms, such as tachypnoea, are given below so that you will understand them, but simple descriptions are recommended.

25. Abnormalities in Rate and Rhythm of Breathing Rapid Shallow Breathing (Tachypnea) Rapid shallow breathing has numerous causes, including salicylate intoxication, restrictive lung disease, pleuritic chest pain, and an elevated diaphragm. Rapid Deep Breathing (Hyperpnea, Hyperventilation) In hyperpnea, rapid deep breathing occurs in response to metabolic demand from causes such as exercise, high altitude, sepsis, and anaemia. In hyperventilation, this pattern is independent of metabolic demand, except in respiratory acidosis. Light-headedness and tingling may arise from decreased CO2 concentration. In the comatose patient, consider hypoxia, or hypoglycaemia affecting the midbrain or pons. Kussmaul breathing is compensatory over breathing due to systemic acidosis. The breathing rate may be fast, normal, or slow.

26. Abnormalities in Rate and Rhythm of Breathing Slow Breathing (Bradypnea) Slow breathing with or without an increase in tidal volume that maintains alveolar ventilation. Abnormal alveolar hypoventilation without increased tidal volume can arise from uraemia, drug-induced respiratory depression, and increased intracranial pressure. Cheyne–Stokes Breathing Periods of deep breathing alternate with periods of apnoea (no breathing). This pattern is normal in children and older adults during sleep. Causes include heart failure, uraemia, drug-induced respiratory depression, and brain injury (typically bi hemispheric).

27. Abnormalities in Rate and Rhythm of Breathing Ataxic Breathing (Biot Breathing) Breathing is irregular—periods of apnoea alternate with regular deep breaths which stop suddenly for short intervals. Causes include meningitis, respiratory depression, and brain injury, typically at the medullary level. Sighing Respiration: Breathing punctuated by frequent sighs suggests hyperventilation syndrome —a common cause of dyspnoea and dizziness. Occasional sighs are normal. Obstructive Breathing In obstructive lung disease, expiration is prolonged due to narrowed airways increase the resistance to air flow. Causes include asthma, chronic bronchitis, and COPD.

28. Normal Tachypnea Hyperpnea Bradypnea Cheyne-stokes Biot Sighing Obstructive

29. Palpation of the chest Inspect the chest more carefully, looking for asymmetries, deformities, and scars. Inspect the precordium and palpate for the position of the cardiac apex. Difficulty palpating for the position of the cardiac apex may indicate hyper expansion, although this is not a specific sign. Palpate for equal chest expansion, comparing one side to the other. Reduced unilateral chest expansion might be caused by pneumonia, pleural effusion, pneumothorax, and lung collapse. If there is a measuring tape, measure the chest expansion.

30. Intercostal Spaces While palpating the chest, focus on areas of tenderness or bruising, respiratory expansion, and fremitus. Identify tender areas. Carefully palpate any area where the patient reports pain or has visible lesions or bruises. Note any palpable crepitus, defined as a crackling or grinding sound over bones, joints, or skin, with or without pain, due to air in the subcutaneous tissue. Assess any skin abnormalities such as masses or sinus tracts (blind, inflammatory, tube-like structures opening onto the skin).

31. Chest expansion Test chest expansion. Place your thumbs at about the level of the 10th ribs, with your fingers loosely grasping and parallel to the lateral rib cage. As you position your hands, slide them medially just enough to raise a loose fold of skin between your thumbs over the spine. Ask the patient to inhale deeply. Watch the distance between your thumbs as they move apart during inspiration and feel for the range and symmetry of the rib cage as it expands and contracts. This movement is sometimes called lung excursion.

32. Fremitus Palpate both lungs for symmetric tactile fremitus. Fremitus refers to the palpable vibrations that are transmitted through the bronchopulmonary tree to the chest wall as the patient is speaking and is normally symmetric. Fremitus is typically more prominent in the interscapular area than in the lower lung fields and easier to detect over the right lung than the left. It disappears below the diaphragm.

33. Oedema Oedema, also spelled "oedema," is a medical term used to describe the abnormal accumulation of fluid in the interstitial spaces of tissues. This excess fluid causes swelling or puffiness, and it can occur in various parts of the body. Oedema is often a symptom rather than a specific medical condition and can be caused by a variety of underlying factors.

34. Common causes of oedema include: Heart Failure: In heart failure, the heart's pumping ability is compromised, leading to fluid retention in the lungs and other tissues. Kidney Disease: Conditions that affect kidney function can result in the retention of sodium and water, leading to systemic oedema. Liver Disease: Liver cirrhosis and other liver diseases can lead to decreased production of proteins (albumin) responsible for maintaining fluid balance, causing fluid to accumulate in tissues. Venous Insufficiency: Inadequate blood circulation in the veins can result in fluid pooling in the lower extremities, causing peripheral oedema. Pregnancy: Oedema is common during pregnancy due to hormonal changes, increased blood volume, and pressure on blood vessels. Inflammation: Inflammatory conditions, such as arthritis or cellulitis, can cause localized oedema in affected areas. Lymphatic Obstruction: Damage to or obstruction of the lymphatic system can result in the accumulation of lymph fluid and oedema, a condition known as lymphedema. Deep Vein Thrombosis (DVT): Blood clots in the deep veins, especially in the lower extremities, can impede blood flow and cause oedema.

35. Tracheal Deviation Palpate for tracheal deviation by placing the index and middle fingers of one hand on either side of the trachea in the suprasternal notch. Alternatively, place the index and annular fingers of one hand on either clavicular head and use your middle finger to palpate the trachea. Deviated Trachea: Tension Pneumothorax Large Pleural Effusion Collapsed Lung Pneumonectomy

36. Tracheal Descent during inspiration Patients with chronic airflow obstruction may show downward displacement of trachea during inspiration. This sign is called Campbell sign and it is different from tracheal tug seen in patients with an aortic aneurysm (pulsation of aorta palpable through the trachea)

37. Crico-Sternal Distance This is the distance between the lower border of the cricoid cartilage and the suprasternal notch. In healthy people the distance should be 3-4 fingers. Distance is shorter in Hyperinflated lungs (e.g. COPD)

38. Percussion of the chest Percuss the chest. Start at the apex of one lung, and compare one side to the other. Do not forget to percuss over the clavicles and on the sides of the chest. For any one area, is the resonance increased or decreased? A hyper-resonant or tympanic note may indicate emphysema or pneumothorax, whereas a dull or stony dull note may indicate consolidation, fibrosis, fluid, or lung collapse. If you uncover any variation in the percussion note, be sure to map out its geographical extent.

39. Steps of Percussion

40. Percussion Notes and their Characteristics Relative intensity Relative Pitch Relative Duration Example of Location Pathologic Examples Flat Soft High Short Thigh Large Pleural Effusion Dull Medium Medium Medium Liver Lobar Pneumonia Resonant Loud Low Long Healthy lung Simple chronic bronchitis Hyperresonant Very loud Lower Longer Usually none COPD, Pneumothorax Tympanic Loud High Longer Gastric air bubble or puffed-out check Large pneumothorax

41. Auscultation of the chest Ask the patient to take deep breaths through the mouth and, using the diaphragm of the stethoscope, auscultate the chest in the same locations as for percussion. Start at the apex of one lung, in the supraclavicular fossa, and compare one side to the other. Normal breath sounds are described as ‘vesicular’ and have a low pitched and rustling quality. Reduced breath sounds may indicate consolidation. Listen carefully for added sounds such as wheezes (rhonchi), crackles (crepitations), bronchial breathing, and pleural friction rubs. Test for vocal resonance by asking the patient to say “ninety nine”. Both consolidation and pleural effusions can lead to a dull percussion note, but in consolidation vocal resonance is increased whereas in pleural effusion it is decreased. Both vocal resonance and tactile fremitus provide the same sort of information.

42. Vesicular Lung Sounds This is the sound heard over the chest at a distance from large airways. It is a "soft" sound that has been compared to the sound of wind blowing through the leaves of a tree. This is the most common sound heard in the absence of lung disease.

43. Bronchial Lung Sounds This is the sound heard over large airways. It has a "tubular" quality -it has been compared to the sound of air blowing through a cardboard tube. This sound is abnormal when heard at a distance from large airways. Bronchial breathing anywhere other than over the trachea, right clavicle or right interscapular space is abnormal. Presence of bronchial breathing would suggest: Tension Pneumothorax Consolidation Massive pleural effusion with complete atelectasis of lung Complete alveolar atelectasis with patent airways Cavitation Mass interposed between chest wall and large airways In all these conditions, there are no ventilation into alveoli and the sound that is heard originates from bronchi and is transmitted to the chest wall.

44. Sounds Duration of sounds Intensity of Expiratory Sound Pitch of Expiratory Sound Locations Where Heard Normally Vesicular Inspiratory sounds last longer than expiratory sounds Soft Relatively low Over most of both lungs Broncho-vesicular Inspiratory and Expiratory sounds are almost equal Intermediate Intermediate Often in the first and second interspaces anteriorly and between the scapulae Bronchial Expiratory sounds last longer then inspiratory ones. Loud Relatively high Over the manubrium (larger proximal airways) Tracheal Inspiratory and Expiratory sounds are almost equal Very loud Relatively high Over the trachea in the neck

45. Vesicular Breathing

46. Bronchial Breathing

47. Broncho-vesicular

48. Tracheal

49. Crackle Lung Sounds These are “discontinuous” i.e. intermittent, “explosive” sounds. Laennec described them as sounding like the crackling noise made when salt is heated on a frying pan. They are caused by airway opening. Crackles are intermittent explosive sounds that have been described as being similar to the crackling sound heard as wood burns. Crackles appear in the time domain as intermittent spike-like deflections. Considerable evidence has been presented in support of the hypothesis that crackles are caused by the sudden opening of airways. It is likely that they are also caused by fluid in the airways. Crackles are divided into two types, fine and coarse by their acoustic properties

50. Fine Crackles Fine crackles, also known as "rales," are a type of abnormal lung sound that can be heard during auscultation (listening to the chest with a stethoscope). They are characterized by brief, high-pitched, and discontinuous popping or crackling sounds that occur during the late phase of inspiration. Fine crackles typically suggest the presence of underlying lung or airway abnormalities.

51. Fine Crackles

52. Coarse Crackle Lung Sounds These are intermittent "bubbling" sound. Laennec compared these sounds to the sound of water being poured from a bottle. They are caused by airway opening and secretions in airways.

53. Coarse Crackle

54. Wheeze Lung Sounds These are high pitched, whistling or sibilant sounds. They are caused by airway narrowing, secretions. Wheezes are described as relatively "continuous" sounds as compared to crackles. They usually last for more than 200 milliseconds and have a musical quality. On time expanded waveform analysis they can be seen to have a sinusoidal pattern. Wheezes are believed to be caused by airway narrowing. While bronchospasms a common cause of the narrowing that causes wheezing, a variety of other conditions can also produce this adventitious sound including airway oedema, secretions, endobronchial tumours and extrinsic compression of an airway. Wheezing in congestive heart failure is likely due to increased fluid in peri bronchial lymphatic causing airway compression.

55. Wheezing (expiratory)

56. Rhonchi Lung Sounds These are low pitched, snore-like sounds. They are caused by airway secretions and airway narrowing. They usually clear after coughing. Rhonchi are also described as "continuous" sounds. They are lower in pitch than wheezes and have a snoring quality. They also have a sinusoidal pattern on waveform, but the number of deflections per unit time is less than that of wheezes as they are of lower frequency. Although rhonchi are almost always due to airway secretions and usually clear with cough, they may be present in other conditions that cause airway narrowing.

57. Rhonchi (1)

58. Rhonchi (2)

59. Rhonchi (3)

60. Stridor Respiratory distress and a narrow space between the vocal cords that produces a high pitched tone during both inspiration and expiration. During the end of expiration there is an abrupt reduction in the pitch of the expiratory tone.

61. Stridor

62. Pleural friction Pleural friction is a medical term used to describe a rough, grating, or scratchy sound heard during the respiratory cycle when the two layers of the pleura (the thin membranes that line the lungs and the chest wall) rub against each other. This friction can occur due to various underlying conditions, and it is typically a sign of pleural irritation or inflammation.

63. Pleural friction sound

64. Transmitted Voice Sounds If you hear abnormally located bronchovesicular or bronchial breath sounds, assess transmitted voice sounds using the three techniques below. With the diaphragm of your stethoscope, listen in symmetric areas over the chest wall for abnormal vocal resonances suspicious for pneumonia or pleural effusion. Egophony. Ask the patient to say “ee.” You will normally hear a muffled long E sound. Bronchophony. Ask the patient to say “ninety-nine.” Normally the sounds transmitted through the chest wall are muffled and indistinct. Louder voice sounds are called bronchophony. Pectoriloquy. Ask the patient to whisper “ninety-nine” or “one-two-three.” The whispered voice is normally heard faintly and indistinctly, if at all.

65. Egophony Egophony is a clinical phenomenon encountered during the physical examination of the chest and lungs. It is a type of abnormal vocal resonance that can be heard when a healthcare provider listens to a patient's lungs using a stethoscope. Egophony is characterized by a specific change in the quality of the patient's spoken words when auscultated. This change indicates potential underlying lung or pleural abnormalities. During the evaluation of egophony, the healthcare provider typically asks the patient to say a specific word or phrase while the chest is being examined. When the patient speaks, the provider listens to the sounds over different areas of the chest.

66. Egophony

67. Pectoriloquy Pectoriloquy is a clinical phenomenon used in physical examination to assess the respiratory system and diagnose certain lung conditions. It involves the transmission of vocal sounds from the patient's chest or back to the healthcare provider's stethoscope as the patient speaks. Pectoriloquy is typically evaluated during auscultation, which is the process of listening to sounds in the body using a stethoscope.

68. Pectoriloquy

69. Conditions most likely to come up in a respiratory system examination station COPD Cryptogenic Fibrosing Alveolitis Lobectomy

70. Inspection and examination of the legs Inspect the legs for erythema and swelling. Palpate for tenderness and pitting oedema. A unilateral red, swollen, and tender calf suggests a DVT, whereas bilateral swelling may indicate right-sided heart failure.

71. After the examination Indicate that you would look at the observations chart, examine a sputum sample, measure the peak expiratory flow rate, and order some simple investigations such as a chest X-ray and a full blood count. Cover the patient up and ensure that they are comfortable. Thank the patient. Wash your hands. Summarise your findings and offer a differential diagnosis.

72. Peak Expiratory Flow Rate (PEFR) Introduce yourself to the patient. Confirm his name and date of birth. Check his understanding of asthma and of the PEFR meter. Explain the importance of using a PEFR (Peak Expiratory Flow Rate) meter and the importance of using it correctly. Explain that the PEFR meter is to be used first thing in the morning and at any time he has symptoms of asthma.

73. Explain the use of a PEFR meter Attach a clean mouthpiece to the meter. Slide the marker to the bottom of the numbered scale. Stand or sit up straight. Hold the peak flow meter horizontal, keeping his fingers away from the marker. Take as deep a breath as possible and hold it. Insert the mouthpiece into his mouth, sealing his lips around the mouthpiece. Exhale as hard as possible into the meter. Read and record the meter reading. Repeat the procedure three to six times, recording only the highest score. Check this score against the peak flow chart or his previous readings. Check the patient’s understanding by asking him to carry out the procedure. Ask him if he has any questions or concerns.

74. FEV 1 /FVC The ratio of forced expiratory volume in one second to forced vital capacity, is a critical parameter in pulmonary function testing. It provides valuable information about a person's lung function and is commonly used to diagnose and assess various respiratory conditions, such as obstructive and restrictive lung diseases. The FEV1/FVC ratio is calculated by dividing FEV1 by FVC: FEV1/FVC = (FEV1 / FVC) x 100% This ratio is typically expressed as a percentage.

75. FEV1 (Forced Expiratory Volume in One Second) FEV1 measures the volume of air a person can forcefully exhale in the first second of a forced expiratory manoeuvre. It is expressed in millilitres (mL) or litters (L). FEV1 is a valuable indicator of the ability to expel air quickly and is sensitive to obstructive lung diseases like chronic obstructive pulmonary disease (COPD) and asthma.

76. FVC (Forced Vital Capacity) FVC represents the total volume of air a person can exhale during a maximal forced expiratory manoeuvre, which usually takes place over several seconds. It is also expressed in millilitres (mL) or litters (L). FVC is a measure of lung capacity and is influenced by both obstructive and restrictive lung diseases.

77. Interpretation of FEV1/FVC Ratio Normal Lung Function: A healthy individual will have an FEV1/FVC ratio greater than 70-75%. This means that they can expel a significant portion of their total lung capacity (FVC) within the first second of a forced exhalation. Obstructive Lung Diseases: In obstructive lung diseases like COPD and asthma, there is airway obstruction that limits the ability to expel air quickly. This results in a reduced FEV1/FVC ratio, often less than 70%. The more severe the obstruction, the lower this ratio becomes. Restrictive Lung Diseases: Restrictive lung diseases, such as pulmonary fibrosis or chest wall disorders, affect lung capacity. In these conditions, both FEV1 and FVC may be reduced, but the FEV1/FVC ratio is often normal or even increased (88%). This is because both FEV1 and FVC are reduced proportionally.

78. Problem Cough and Sputum Associated Symptoms and Setting Laryngitis Dry cough, may become productive of variable amounts of sputum Acute fairly minor illness with hoarseness. Often associated with viral rhinosinusitis. Acute Bronchitis Cough, may be dry or productive Acute often viral, illness generally without fever or dyspnea, at times with burning retrosternal discomfort. Mycoplasma and Viral Pneumonias Dry hacking cough, may become productive of mucoid sputum Acute febrile illness, often with malaise, headache, and possibly dyspnea. Bacterial Pneumonias Sputum is mucoid or purulent, may be blood-streaked, diffusely pinkish, or rusty Acute illness with chills, often high fever, dyspnea, and chest pain. Commonly from Streptococcus pneumoniae, Hemophilus influenzae, Moraxella catarrhalis, Klebsiella pneumoniae in alcoholism, especially if underlying smoking, chronic bronchitis, and COPD, cardiovascular disease, diabetes.

79. Problem Cough and Sputum Associated Symptoms and Setting Chronic Bronchitis Chronic cough; sputum mucoid to purulent, may be blood streaked Or even bloody Often with recurrent wheezing and dyspnoea, and prolonged history of tobacco abuse. Bronchiectasis Chronic cough; Sputum purulent, often copious and foul-smelling; may be blood streaked Or bloody Acute febrile illness, often with malaise, headache, and possibly dyspnea. Pulmonary Tuberculosis Cough, dry or with mucoid or Purulent sputum; may be blood streaked Or bloody Early, no symptoms. Later, anorexia, weight loss, fatigue, fever, and night sweats. Lung Abscess Sputum purulent and foul-smelling; may be bloody Usually from aspiration pneumonia with fever and infection from oral anaerobes and poor dental hygiene; often with dysphagia or episode of impaired consciousness. Asthma Cough, at times with thick mucoid sputum, especially near end of an attack Episodic wheezing and dyspnoea, but cough may occur alone. Often with a history of allergies. Gastroesophageal Reflux Chronic cough, especially at night or early in the morning Wheezing, especially at night (often mistaken for asthma), early morning hoarseness, and repeated attempts to clear the throat. Often with heartburn and regurgitation.

80. Thank you for your attention