Mechanoreceptors respiratory muscles

Hypoxia carotid and aortic bodies

Airflow airway and parenchymal receptors

Changes in pCO2/pH medullary center

Irritants airway and parenchymal receptors

Medullary centre afferent input and efferent output

Cortical function sense of effort

Arrhythmia Valvular
• Atrial fibrillation • Aortic stenosis/regurgitation
• Sinus tachycardia • Mitral stenosis/regurgitation
• Sick sinus syndrome/bradycardia • Tricuspid regurgitation/stenosis
• Ventricular tachycardia/fibrillation • Pulmonic regurgitation/stenosis

Myocardial Pericardial
• Cardiomyopathy • Pericarditis
• Hypertensive heart disease • Pericardial effusion
• Congestive cardiac failure • Pericardial tamponade
• Myocarditis • Pericardial constriction

Coronary vessels
• Myocardial ischaemia Congenital
• Acute myocardial infarction • Atrial septal defect
• Chronic ischaemic myocardial dysfunction • Tetralogy of Fallot
Obstructive Alveolar
• Asthma • Bronchoalveolar carcinoma
• Chronic obstructive pulmonary disease • Tuberculosis
• Bronchitis • Bacterial pneumonia
• Bronchiectasis • Pneumocystis pneumonia
• Bronchiolitis obliterans • Eosinophilic pneumonitis
• Intrabronchial neoplasm • Aspiration
• Tracheomalacia • Hypersensitivity pneumonitis
Interstitial
• Obstructive sleep apnoea • Drugs (methotrexate, amiodarone)
• Radiation therapy
Restrictive
• Passive congestion/pulmonary oedema
• Interstitial lung disease
• Lymphangitic spread of malignancy
• Sarcoidosis
• Kyphoscoliosis Vascular
• Obesity • Pulmonary embolus (acute/chronic)
• Pleural disease/effusion • Idiopathic pulmonary hypertension
• Pneumothorax
Haematological Neurological
• Anaemia • Amyotropic lateral sclerosis
• Methaemoglobinaemia • Polio
• Sulfhaemoglobinaemia • Other acute viral anterior horn infections
• Carbon monoxide poisoning • Guillain-Barré syndrome
• Thrombotic thrombocytopenic purpura • Myasthenia gravis
• Paraneoplastic myasthenia syndrome
Metabolic
• Thyroid disease
• Cushing’s syndrome Physiological
• Psychogenic Anxiety and panic attacks • Exercise
• Normal ageing
• Obesity
Abdominal
• Ascites
• Gastro-oesophageal reflux disease
• Peptic ulcer disease
 Dyspnea
Dyspnea
Dyspnea

Exercise-Induced Asthma
Pulmonary Hypertension
Dyspnea
Orthopnea
Dyspnea
Obesity
Pulmonary Hypertension
 Dyspnea
Asthma
Chronic Obstructive Pulmonary Disease COPD
Congestive Heart Failure
Orthopnea Dyspnea
Congestive Heart Failure
Emphysema
Dyspnea
Gastroesophageal Reflux

Food Allergy
Tobacco
Emphysema
Chronic Bronchitis
Asthma
Asbestos
Interstitial Lung Disease

Carbon Monoxide Poisoning

 Obstructive Lung Disease
Adenosine
Beta Blocker
NSAID Aspirin
Interstitial Lung Disease
Amiodarone

Methotrexate
Nitrofurantoin
Allergic Rhinitis Wheezing Family History
Asthma

Panic Attack
Hyperventilation
Chest Trauma
Pneumothorax
Chest Wall Pain
AIDS
Aspergillus
Coccidioidomycosis
Cytomegalovirus
Legionella
Pneumocystis carinii Pneumonia
Tuberculosis
Pleuritic Chest Pain
Pericarditis
Pulmonary Embolism
Pneumothorax
Pneumonia
Dysphagia
Gastroesophageal Reflux
Aspiration Pneumonia
 Cough
Asthma
Pneumonia
Congestive Heart Failure
Gastroesophageal Reflux
Hemoptysis
Lung Cancer
Pneumonia
Bronchiectasis
Mitral Stenosis
Grade Degree Characteristics
0 None Only with strenuous activity

1 Slight When hurrying on level ground or climbing

a slight incline
2 Moderate Needs to walk more slowly than others of
the same age or has to stop for breath
when walking at own pace on level ground
3 Severe Stops for breath after 100 metres or after
a few minutes
4 Very severe Housebound or dyspnoea when dressing
or undressing
 Question
Associated only with exertion?
Associated with exertion and occurs at night?
Cough and wheeze?
Associated with exertion, chest, arm or neck
discomfort and concurrent nausea or sweating?
Worse when assuming upright position?
Present in the lateral decubitus position?
Fast onset when supine, relieved by lateral or
upright positioning?
Occurring within minutes or hours of becoming
recumbent?
Probable Pathophysiology
Heart failure, restrictive or obstructive
lung disease
Asthma or heart failure
Angina pectoris
Liver disease with arteriovenous
shunts at the lung bases (platypnoea)
Unilateral lung or pleural disease
(trepopnoea)
Bilateral phrenic nerve dysfunction
Heart failure (orthopnoea)
 Symptoms in the history Possible diagnosis

Cough Asthma, COPD, pneumonia

Severe sore throat Epiglottitis

Pleuritic chest pain Pericarditis, pulmonary embolism,

pneumothorax, pneumonia, pleural effusion
Orthopnoea, nocturnal paroxysmal Congestive heart failure
dyspnoea, oedema
Tobacco use COPD, congestive heart failure, pulmonary
embolism
Indigestion Gastroesophageal reflux disease, aspiration

Barking cough Croup

Examination

•
• •

• •

•
•
•
• •
•
•
•
•
General Appearance and Vital Signs

•
General Appearance and Vital Signs

•
Respiratory

•
Cardiovascular

• Displaced apex beat and character

• Parasternal heave

•
Neck

•
Abdominal Examination

•
Extremities
•

Neurological examination
•
•
•
•
•

Endocrine
•
Findings Possible diagnosis
Wheezing, pulsus paradoxus, accessory Acute asthma, COPD exacerbation
muscle use
Wheezing, barrel chest, decreased breath COPD exacerbation
sounds
Fever, crackles, increased fremitus Pneumonia

Oedema, neck vein distension, S3 or S4 Congestive heart failure, pulmonary

hepatojugular reflux, murmurs, crackles, oedema
hypertension, wheezing
Wheezing, friction rub, lower extremity Pulmonary embolism
swelling
Absent breath sounds, hyperresonance Pneumothorax
Findings Possible diagnosis
Inspiratory stridor, wheezes, retractions Croup

Stridor, drooling, fever Epiglottitis

Stridor, wheezing, persistent pneumonia Foreign body aspiration

Wheezing, flaring, intercostal retractions, Bronchiolitis

apnea

Sighing Hyperventilation
•
•

•
•
•

•
•
•
•

•
 Possible Radiography Pulse oximetry or Other tests
diagnosis spirometry
Acute asthma, Hyperinflated lungs Decreased O2 sat, -
COPD exacerbation decreased PEFR
and FEV1
Pneumonia Infiltrates, effusion, Decreased or Normal or high WCC
consolidation normal O2 sat

Congestive heart Interstitial edema, Decreased O2 sat LVH, ischemia, or

failure effusion, arrhythmia on ECG;
cardiomegaly low Hb
Pulmonary Normal, atelectasis, Decreased O2 sat RBBB on ECG;
embolism pleural effusion, tachycardia
wedge-shaped
density
Pneumothorax Lung atelectasis, Decreased O2 sat -
mediastinal shift
 Possible Radiography Pulse oximetry or Other tests
diagnosis spirometry
Croup Subglottic narrowing Decreased or -
by PA plain film or normal O2 sat
CT
Epiglottitis Enlarged epiglottis Decreased or High WCC
normal O2 sat

Foreign body Visualized foreign Decreased or Normal or high WCC

aspiration body, air trapping, normal O2 sat
hyperinflation
Bronchiolitis Hyperinflation, Decreased or Normal WCC; RSV
atelectasis normal O2 sat swab

Hyperventilation Normal Normal -