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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: Thelower 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 dryif 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

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