Pneumology Course for Students
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PNEUMOLOGY DEPARTMENT PNEUMOLOGY COURSE FOR STUDENTS Timișoara 2019 1 Authors (in alphabetical order): Bălă Gabriel, MD, PhD student, pneumology resident doctor Bertici Nicoleta, MD, PhD, Senior Lecturer Ciucă Ioana, MD, PhD, Senior Lecturer Crișan Alexandru, MD, PhD, Associate Professor Fira-Mlădinescu Ovidiu, MD, PhD, Associate Professor Frenț Ștefan, MD, PhD, Assistant Professor Hogea Patricia, MD, PhD student, pneumology resident doctor Manolescu Diana, MD, PhD, Associate Assistant Professor Marc Monica, MD, PhD, Associate Assistant Professor Mihăicuță Ștefan, MD, PhD, Senior Lecturer Mihuța Camil, pneumology resident doctor Oancea Cristian, MD, PhD, Professor Pescaru Camelia, MD, PhD, Assistant Professor Pop Liviu-Laurențiu, MD, PhD, Professor Porojan-Suppini Noemi, MD, PhD student, Associate Assistant Professor Socaci Adriana, MD, Phd, Tuberculosis Department Coordiantor Țiplea Cosmin, MD, specialist pneumology doctor Trăilă Daniel, MD, PhD, Assistant Professor Tudorache Emanuela, MD, PhD, Associate Assistant Professor Tudorache Voicu, MD, PhD, Professor 2 Editura „Victor Babeș‟ Piața Eftimie Murgu 2, cam 316, 300041 Timișoara Tel./Fax: 0256495210 e-mail:[email protected] www.umft.ro/editura Director general: Prof. univ. emerit dr. Dan V. Poenaru Director: Prof. univ. dr. Andrei Motoc Colecția: MANUALE Coordonator colecție: Prof.univ.dr. Sorin Eugen Boia © 2019 Toate drepturile asupra acestei ediții sunt rezervate. Reproducerea parțială sau integrală a textului pe orice suport, fără acordul scris al autoarelor este interzisă și se va sancționa conform legilor în vigoare. ISBN 978-606-786-157-0 3 CONTENT 1. ANAMNESIS AND PHYSICAL EXAMINATION OF THE PATIENT WITH RESPIRATORY PATHOLOGY. ELEMENTS OF FUNCTIONAL ANATOMY (Emanuela Tudorache, Noemi Porojan-Suppini) .......................................................................... 5 2. FUNCTIONAL PULMONARY EXPLORATION IN CLINICAL PRACTICE (Ovidiu Fira-Mladinescu, Emanuela Tudorache, Noemi Porojan-Suppini) ............................... 18 3. MICROBIOLOGICAL DIAGNOSIS IN RESPIRATORY INFECTIONS (Alexandru Crișan) ...................................................................................................................... 35 4. RESPIRATORY FAILURE (Ovidiu Fira-Mlădinescu, Noemi Porojan-Suppini) ................. 40 5. BRONCHIAL ASTHMA OF ADULT (Voicu Tudorache, Camil Mihuța) ............................ 50 6. CHRONIC OBSTRUCTIVE PULMONARY DISEASE AND CHRONIC COR PULMONALE (Voicu Tudorache, Camil Mihuța) ..................................................................... 64 7. SUPERIOR AND LOWER RESPIRATORY TRACT INFECTIONS (Cristian Oancea, Patricia Hogea) .............................................................................................. 81 8. PULMONARY ABCESS (Patricia Hogea, Cristian Oancea) ............................................... 96 9. CYSTIC ECHINOCOCCOSIS (Patricia Hogea, Oancea Cristian) ..................................... 102 10. BRONCHIECTASIS (Voicu Tudorache, Cosmin Țiplea) .................................................. 106 11. CYSTIC FIBROSIS (Ioana Ciucă, Liviu-Laurentiu Pop, Cosmin Țiplea) ......................... 113 12. PLEURAL EFFUSIONS (Ștefan Frenț, Ștefan Mihaicuță) ................................................ 120 13. LUNG CANCER (Emanuela Tudorache, Bălă Gabriel) .................................................... 133 14. SLEEP DISORDERED BREATHING (Ștefan Mihaicuță) ................................................ 133 15. IDIOPATHIC PULMONARY FIBROSIS (Daniel Trailă, Manolescu Diana) .................. 149 16. PULMONARY INVOLVEMENT IN CONNECTIVE TISSUE DISEASES (Nicoleta Bertici) ....................................................................................................................... 156 17. SARCOIDOSIS (Camelia Pescaru) .................................................................................... 165 18. TUBERCULOSIS (Adriana Socaci) ................................................................................... 173 19. PULMONARY EMBOLISM (Noemi Porojan-Suppini, Voicu Tudorache) ....................... 214 20. TREATMENT OF NICOTINE ADDICTION (Monica Marc) ........................................... 227 21. PULMONARY REHABILITATION (Cristian Oancea, Patricia Hogea) ......................... 241 4 1. ANAMNESIS AND PHYSICAL EXAMINATION OF THE PATIENT WITH RESPIRATORY PATHOLOGY. ELEMENTS OF FUNCTIONAL ANATOMY ”EVERY MAN is … Like all other men, … Like some other men, … Like no other man” (Kluckhohn C, Murray HA., Personality in Nature, Society and Culture., 1948) I. Anamnesis and physical examination of the patient with respiratory pathology A careful and complete medical history completed with a thorough clinical examination, are the strengths of a good clinician. For a correct diagnosis, it is important to continue collecting anamnestic information as they become available. 1. Major pulmonary symptoms: Dyspnea is described by the patient as "shortness of breath", "choking sensation", "inability to draw air in the chest", "fatigue"; According to ATS (American Thoracic Society) dyspnea is a subjective perception of respiratory distress, variable in intensity, consisting of qualitatively distinct sensations. - The Borg Scale, and questionnaires, such as the mMRC (Modified Medical Research Council) Dyspnea Scale (Table 1) and Pulmonary Functional Status and Dyspnea Questionnaire can be evaluated. Table 1. mMRC (Modified Medical Research Council) Dyspnea Scale 0 Dyspnea from intense physical effort 1 Dyspnea from sustained walking or on easy slope 2 Dyspnea prevents walking at the same pace with an individual of the same age or requires stops on a flat ground 3 Important dyspnea that requires stops after 100m or a few minutes of walking on flat ground 4 Severe dyspnea in daily activities (getting dressed) It can be determined by cardiac, pulmonary, neuromuscular, metabolic, hematological pathologies. Figure 1 shows the dyspnea diagnosis algorithm 5 Figure 1. The diagnostic algorithm for dyspnea Cough is an essential reflex mechanism (abrupt expiration with closed glottis), with the protective role of the airways from harmful substances, and the protective role of the lungs by draining excess secretions. Figure 2. Cough diagnosis algorithm 6 In the evaluation of a coughing patient, special attention is paid to the following aspects: whether the onset is acute or chronic, whether it is productive or not, the type and quantity of sputum, associated symptoms. Hemoptysis - the elimination by cough of an amount of blood. When it appears de novo, it requires a thorough examination, including tomographic examination, bronchoscopy. The quantity can be: small (under 50 ml), medium (50-100 ml), large (100-300 ml), massive (over 300 ml). Differential diagnosis: haematemesis (digestive pathology, preceded by nausea, colored black- in coffee grounds, accompanied by alimentary content), posterior epistaxis (preceded by salty taste, eliminated by mouth without effort of vomit, highlighted by the objective examination on the posterior pharyngeal wall). Figure 3. Algorithm for diagnosis of patients with hemoptysis Chest pain Figure 4. Diagnostic algorithm of the patient with chest pain 7 2 Family history: provides information on genetic diseases, such as cystic fibrosis, alpha 1- antitrypsin deficiency, Rendu-Osler's disease, imotile cilia syndrome, etc. Family exposure to contagious diseases such as tuberculosis can be identified. 3. History of smoking, other pollutants: the patient should be asked about the smoking habit, if he has ever smoked. If the answer is positive, you should ask when he started smoking, when he stopped smoking, how much he smoked, respectively about different forms of tobacco and exposure in the workplace or at home. In developing countries, steaming, smoke from cooking inside, wood burning stove can be a major risk factor for lung diseases, especially among women. 4. Medication and Allergies: To be noted the complete medication of the patient, possible allergic or toxic reactions that occurred to these drugs. Consumption of alcoholic beverages (their type and quantity) should also be asked and noted. 5. Occupational history: Identifying the relevant occupational exposure can lead to job change, thus preventing progressive and irreversible pulmonary destruction. 6 Travel history: Previous homes in endemic areas for fungal infections such as histoplasmosis or coccidioidomycosis may be helpful in diagnosis. A recent travel history may bring the disscussion of the possibility of contacting diseases specific to certain geographical areas. II. Objective examination of the chest Inspection: of the skin and soft tissue: scars, color changes, edema, tumor formation can be identified Table 2. Chest deformities Barrel chest - globular appearance (antero- posterior diameter = 1), obtuse xiphoid angle, raised shoulders, short neck, full subclavicular pits, horizontal ribs, wide intercostal spaces; met in COPD, BA. Chest with sunken sternum (pectus excavatum) - sunken sternum in cone shape, the heart is rotated and pushed laterally. Chicken chest (pectus carinatum) – sternum is shifted anteriorly, antero-posterior diameter isenlarged. Thoracic kyphoscoliosis - abnormal curvature of the spine, rotation of the vertebrae. 8 Palpation: it is necessary for the examination of the breasts, lymph nodes, bone deformities (such as cervical rib, subcutaneous calcinosis, multiple sclerosis) - palpation of respiratory enlargement The patient positioned in orthostatism, the doctor is behind