Differential Diagnosis

Pulmonary Disorders

Pulmonary Disorders Pulmonary pain is usually localized to the

anterior chest, side or back Can radiate to the neck, upper trap muscles,

costal margins, thoracic region, scapulae or shoulder

Usually increased with inspiratory movements such as laughing, coughing, sneezing or deep breathing

Associated symptoms include dyspnea (exertional or rest), persistent cough, fever and chills

Pulmonary Anatomy

Pulmonary Disorders

The most common pulmonary conditions that mimic musculoskeletal dysfunction include:• Pulmonary artery hypertension

• Pulmonary embolism

• Pleurisy

• Pneumothorax

• Pneumonia

Pulmonary Disorders

Any of the following symptoms are associated with lung cancer and requires physician referral for assessment:• CNS symptoms

• Muscle weakness

• Muscle atrophy

• Headache

• Loss of LE sensation

• Localized or radicular back pain

Pulmonary Pain Parietal pleura is sensitive to painful stimuli,

but visceral pleura is not Trachea and large bronchi are innervated by

the vagus trunk Finer bronchi and lung parenchyma have no

innervation Trachebronchial pain is referred to sites in the

neck or anterior chest at the same level as the irritation• Caused by inflammatory lesions, foreign materials or

cancerous tumors

Pulmonary Pain

Disease may be extensive prior to onset of pain

Pain does not occur until it reaches the parietal pleura• Pain is described as sharp and localized

• Aggravated with inspiratory movements

• Relieved by lying on the affected side (autosplinting)

Pulmonary Pain

Pleural pain occurs with:• Pleurisy

• Pneumonia

• Pulmonary infarct

• Tumor

• Pneumothorax

Pulmonary Pain

Diaphragmatic pleural pain• Peripheral – Sharp pain referred to costal

margins or lumbar region

• Central – Sharp pain referred to the upper trap or shoulder on the ipsilateral side

• Cardiac and diaphragmatic pain are often experienced in the shoulder because both are supplied by the C5-C6 spinal segment

Diaphragmatic Pleurisy

Refers pain to the costal margins or upper trap muscles

Aggravated by diaphragmatic motions (coughing, laughing, or deep breathing)

Change in position does not reproduce the symptoms• If a true intercostal lesion or tear, bending or

rotation of the trunk would cause or reproduce the pain

Pulmonary Physiology

Primary function of the respiratory system is to provide oxygen to and remove carbon dioxide from cells in the body

Effectiveness of ventilation is most often measured by arterial blood gas testing

Arterial Blood Gases

pH * =pKa [HCO3] + log[HCO3] / 0.03 x pCO2 * Arterial pH * 7.35 – 7.45 PaCO2 * 35 – 45 mmHg

• * Measured

HCO3 22 – 26 mEq/L• Calculated not measured

• Obtained with CMP

PaO2 80 – 100 mm Hg Sat O2 > 95%

Oxygen

Determination of Oxygen content in blood• PaO2

• Sat O2

• Hb (14-18 gm/dl) from CBC

PaO2

• Dissolved oxygen in plasma

Sat O2

• Reflects oxygen saturation of hemoglobin

• = [Hb-O2 / (Hb-O2 + reduced-Hb)]*100%

Porth, 29-22, 2005

Oxygen Decrease

Manifestations• Angina

• Tachycardia

• Arrhythmias

• MI

• Confusion and Stupor

• Decreased aerobic capacity

• Cyanosis

Carbon Dioxide and Bicarbonate

Bicarbonate (HCO3), extracellular anion Regulation

• Metabolic activity

• Loss

• HCO3: Renal

• CO2: Respiratory

Physiologic effects• Maintain pH

• Osmotic pressure regulation

Porth 34-2, 2005

Porth 34-1, 2005

pH Calculation

Normal pH = 7.35 – 7.45 pH = pKa HCO3

- +log([HCO3-]/[0.03 x pCO2]

• H2CO3 pKa = 6.1

([HCO3-]/[CO2] = 20/1 for pH = 7.4

• < 20/1 = acidosis

• > 20/1 = alkalosis

• Numerator [HCO3 -]: kidney

• Denominator [CO2]: lungs

Porth, 34-1, 2005H2CO3 mEq/L = 0.03* CO2 mm Hg

Respiratory Acidosis Decreased pulmonary ventilation leads to

retention and concentration of carbon dioxide, hydrogen and carbonic acid

May result in hypoxia Hyperkalemia and cardiac changes result and

could cause cardiac arrest Advancing symptoms may include diaphoresis,

shallow rapid breathing, restlessness, and cyanosis

These symptoms need immediate medical referral

Respiratory Alkalosis Increased respiration decreases the amount of carbon

dioxide and hydrogen available increased pH Usually due to hyperventilation

• Causes may be neurogenic or psychogenic Muscular tetany and convulsions can occur Cardiac arrhythmias caused by serum potassium loss

may occur Respiratory alkalosis is more commonly seen in PT

clinics than respiratory acidosis Initially treat with reassurance, facilitate relaxation and

slow breathing If hyperventilation continues in the absence of pain or

anxiety, immediate physician referral is needed

Chronic Obstructive Pulmonary Disease COPD – Considering changing name to CAL

(Chronic airflow limitation) Leading cause of morbidity and mortality

among cigarette smokers Narrowing of the airways obstructs airflow to

and from the lungs Trapped air hinders normal gas exchange and

causes alveoli distention Includes disorders of obstructive bronchitis,

emphysema and asthma

Emphysema Elasticity of the lungs is reduced Marked dyspnea is common Cough is uncommon Uses accessory muscles for respiration Often leans forward with arms braced on the

knees to support the shoulder and chest for breathing

Barrel chest develops Pursed-lip breathing should be encouraged Routine progressive walking is the most

common form of exercise

Tuberculosis Bacterial infectious disease Most often affects the lungs

• Fatigue• Dyspnea• Dull chest pain, tightness or discomfort• Frequent productive cough

Can affect the hip joints and vertebrae resulting in arthritic-like damage and possibly avascular necrosis of the hip

Pott’s disease (TB of the spine) – Rare but can cause compression fractures of the vertebrae

Apical (Pancoast’s) Tumors

Tumor of the apex of the lung Frequently extend to C8-T1 nerves within the

brachial plexus

Apical (Pancoast’s) Tumors

Produces sharp, pleuritic pain in the axilla, shoulder and subscapular area on the affected side

UE pain in an ulnar nerve distribution Subsequent atrophy of UE muscles Sometime mistaken for subacromial bursitis Also mimics serratus anterior trigger points –

Rule out by palpation and lack of neurological deficits

Cystic Fibrosis Inherited disorder of the exocrine glands Primarily affects the digestive and respiratory systems Salt accumulates in the cells lining the lungs and digestive

tissues. The surrounding mucus is abnormally thick and sticky Bronchioles are obstructed by mucus plugs and trapped air

predisposes the patient to infections Persistent coughing and wheezing Excessive appetite but poor weight gain Salty skin/sweat Barrel chest develops Dyspnea is prominent Uses accessory muscles with respiration Cyanosis and digital clubbing present

Pulmonary Embolism

Signs and symptoms are nonspecific and vary greatly

Most common symptoms are dyspnea, pleuritic chest pain and cough

Pleuritic chest pain is usually sudden onset and aggravated by breathing

May also report hemoptysis, apprehension, tachypnea and fever

Pleurisy Inflammation of the pleura Caused by infection, injury or tumor May be wet or dry Symptoms include chest pain, cough, dyspnea, fever,

chills and tachypnea Chest pain is sudden and varies in description from

vague discomfort to intense stabbing or knifelike Aggravated by breathing, coughing, laughing or other

deep inspiratory movements Pain may be referred to the lower chest wall, abdomen,

neck, upper trap muscles and shoulder

References Arnall D, Ryan M.1995. Screening for Pulmonary System

Disease. In: Boissonnault editor: Examination in Physical Therapy Practice Screening for Medical Disease. 2nd edition. Philadelphia, PA: Churchill Livingstone, p69-100.

Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p332-365.

Jarvis C. 2000. Physical Examination and Assessment, 3rd edition. Philadelphia, PA: WB Saunders. In: Goodman CC, Snyder TE. 2007. Screening for Pulmonary Disease. In: Differential Diagnosis for Physical Therapists Screening for Referral. 4th edition. St. Louis, MO: Saunders Elsevier. p333.

Porth, Carol M, Pathophysiology: Concept of Altered Health States, 7th ed., J.B. Lippincott Co., Philadelphia, 2005.