Approach to Patient with

Pulmonary Disorders

Marshell Tendean, MD, DPCP

Department of Internal Medicine
Ukrida Faculty of Medicine
Approach to patient :
• Always do relevant clinical
history !
• Try to extract chief complaint.
• Do a relevant history taking and
related family history.
• Document social or epidemiologic
data according to related dissorders.
 Abnormal
Clinical Breath
Percussion Trachea Auscultatio Fremitus
scenario sounds
n

Normal sonor midline Vesicular None normal

Soft to fine
Bronchitis sonor midline Vesicular
crackles
normal

Soft crackles
Left sided sonor midline Vesicular bibasal / normal
heart failure rales

Bronchi or
consolidation Dull midline Bronchial crackles Increased
/ Egophony
 Additional
Clinical Breath
Percussion Trachea breath Fremitus
scenario sounds
sound
Decrease/
Atelectasis Dull Midline Bronchial None
negative

Pleural Dull
Deviated to Weak pleural
Decrease
effusion normal side vesicular friction rub

Weak
Pneumo - Hypersonor
Deviated to
vesicular or None Decrease
thorax normal side
negative

Vesicular
with Wheezing
Asthma Hypersonor Midline
prolonged and Ronchi
Normal
experium
Abnormal Physical
Examination

Urbano & Fedorowski : Medical Percussion : pp. 31–36

 Abnormal breath sounds
Ronki / crackles :
• Wheezing and stridor
• Egophony : Spoken “ee” which will convert into “ay”
Pleural Abnormality
Pneumotoraks
Pleural Effusion
 Pneumothorax
Pneumothorax is defined as the
presence of air or gas in the pleural
cavity (ie, the potential space between
the visceral and parietal pleura of the
lung), which can impair oxygenation
and/or ventilation.

Eur Respir J. 2006 Sep. 28(3):637-50

Pleural Abnormality
Pneumotoraks
Pleural Effusion
 Pleural cavity
• Air does not enter into the pleural space
because the sum of all the partial
pressures of gases in the capillary blood
averages only 93.9 kPa (706 mmHg).
• Hence, net movement of gases from the
capillary blood into the pleural space
would require pleural pressures lower than
-54 mmHg (i.e. lower than -36 cmH2O),
which hardly ever occur in normal
circumstance.
 Classification of
Pneumothorax
• Spontaneous pneumothorax: No clinical signs or
symptoms in primary spontaneous pneumothorax until a
bleb ruptures and causes pneumothorax;
• Iatrogenic pneumothorax: Symptoms similar to those of
spontaneous pneumothorax, depending on patient’s
age, presence of underlying lung disease, and extent of
pneumothorax
• Tension pneumothorax: Hypotension, hypoxia, chest
pain, dyspnea
• Catamenial pneumothorax: Women aged 30-40 years
with onset of symptoms within 48 hours of menstruation,
right-sided pneumothorax, and recurrence
• Pneumomediastinum
Sponaneus pneumothorax
• PSP typically occurs in tall, thin subjects.
• Other risk factors are male sex and cigarette
smoking.
• Contrary to popular belief, PSP typically occurs at
rest; avoiding exercise, therefore, should not be
recommended to prevent recurrences

• Symptoms :

• Chest pain, dyspnea, breathlessness

 Pathogenesis
• Spontaneous pneumothorax (ruptur bleb)
• PSP has an incidence of 7.4 to 18 cases (age-
adjusted incidence) per 100,000 population each
year in males, and 1.2 to 6 cases per 100,000
population each year in females.

Am Rev Respir Dis 1979; 120: 1379–

1382.
Risk Factors of Secondary
Pneumothorax

Eur Respir Rev 2010; 19: 117, 217–219

 Physical Examination and
Radiologic Examination
• Typical Chest examination for Pneumothorax

• Chest X-ray

• CT Scan
 Guideline Treatment for
Pneumothorax (BTS)
• Spontaneous pneumothorax minimal (<15%)
from volume pneumothorax

• Secondary pneumothorax with minimal symptoms

(pneumothorax < 1 cm and apical pneumothorax)

• Symptomatic pneumothorax primary or

secondary

http://www.brit-thoracic.org.uk/clinical-information/pleural-disease.aspx
 Symptomatic Sponateous
Pneumothorax treatment

• Hospital observation:

• Indicated in spontaneous pneumothorax size < 2 cm

• High flow oxygen therapy 10 l. (1.25 - 1.8% volume pneumothorax

within 24 jam)

• Simple aspiration:

• Indicated in symptomatic pneumothorax which require initial

intervention
• Large secondary pneumothorax and secondary
pneumothorax size >2 cm (symptomatic)

• Tube drainage

• Pembedahan torakotomi / VATS (video assisted

thorachoscopy)
 Complications :
• Tension Pneumothorax :

• Treat with needle decompression using 12-14

gauge at 2nd ics midclavicular line
 Pleural Effusion

• The Presence of Pleural Fluid in The Pleural

Cavity

• Transudate

• Exudate
 Light’s Criteria for Pleural
Effusion
• Exudate if fulfil one of the following criteria :
• Ratio protein in pleural effusion / serum > 0.5
• Ratio lactate in pleural effusion / serum > 0.6
• LDH ratio in Pleural effusion at least 2/3 from
upper normal level of normal LDH serum

• Light's criteria have a diagnostic accuracy of 93% to

96%.
Med Clin North Am. 2011;95(6):1055–1070
 Diagnosis
• Anamnesis : sesak napas, dsb

• Pemeriksaan fisik :

• Gerakan nafas toraks menurun, redup / pekak,

suara nafas menghilang

• Pemeriksaan penunjang :

• Pemeriksaan radiologi ( dua posisi AP/LAT)

Pleural Fluid Collection
Parapneumonic Pleural
Effusion

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 10

 Pleural effusion in Specific
Disease

TUBERCULOSIS PLEURAL EFFUSION

Adenosine deaminase levels above 40 U/L distinguish

tuberculous effusions from other lymphocytic pleural
effu- sions (ie, malignancies, lymphoma, collagen
vascular diseases)
Interferon-gamma levels above 140 pg/mL.
Least Diagnosed Pleural Effusion
 Treatment
• Toracentesis

• Pemasangan pleural drain (Indwelling)

• Treatment for Complicated effusion :

• Surgical

• Pleurodesis

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 72 • NUMBER 10

• UTZ GUIDED

• EMPIRIC :

• BLINDED
 Chest tube
• Large bore 20-24 F, Small Bore 8-14 F

• Indicates in:

• Malignant Effusion

• Large Pulmonary Effusion

• Empyema
 Complicated Pleural Effusion
• Large bore or small bore image guide

• Surgical Decortication

• Fibrinolytic installation

• Pleurodesis
 Pleurodesis
Surgical pleurodesis
• A patient treated with surgical pleurodesis has a
recurrence prevention rate of greater than 90%.
• Practice variation depends on local practitioner
experience, resources, and success with approaches
ranging from VATS (recommended by the American
College of Chest Physicians [ACCP]) to surgical
thoracotomy and pleurectomy (recommended by the
British Thoracic Society [BTS] because of the absolute
lowest recurrence rates).

Pnemothorax, Medscape,2017
Nonsurgical pleurodesis
• The main diagnostic and therapeutic indications for
medical thoracoscopy are pleural effusions and
pneumothorax.
• Tetracycline, Bleomycin and talc are well-studied
effective agents for medical pleurodesis; talc was 5%
more effective in one randomized study.
• Success rates for chemical sclerosing agents are up
to 91% versus 95-100% in surgical techniques.