4.2 Respiratory Diseases
Key Takeaways
- Pneumonia red flags include fever, productive cough, pleuritic chest pain, tachypnea, and focal crackles — chest X-ray confirms the impression
- Pleuritic chest pain with sudden dyspnea and unilateral absent breath sounds suggest pneumothorax — emergency evaluation before any thoracic manipulation
- Pulmonary embolism can present with pleuritic pain and dyspnea without leg swelling — do not dismiss when musculoskeletal chest pain is also possible
- COPD and asthma cause expiratory airflow limitation; acute severe asthma with silent chest is a pre-arrest emergency
- Tuberculosis screening matters in chronic cough with weight loss, night sweats, and hemoptysis — isolate and refer before routine office care
4.2 Respiratory Diseases
Quick Answer: Respiratory vignettes on Part II test whether you recognize infection, obstruction, and vascular emergencies from history and basic exam — fever plus focal lung findings suggest pneumonia; sudden pleuritic pain with absent breath sounds suggests pneumothorax; unexplained dyspnea with tachycardia raises pulmonary embolism. Chiropractors must hold thoracic and cervical HVLA when these impressions are active or undiagnosed.
Respiratory Complaints in Chiropractic Practice
Patients with cough, chest tightness, or "can't take a deep breath" frequently accompany thoracic spine or rib complaints. General Diagnosis rewards distinguishing musculoskeletal chest wall pain (reproducible with palpation, no fever, normal breathing effort) from pulmonary pathology (systemic signs, abnormal vitals, desaturation). A wrong impression here is dangerous because thoracic manipulation during acute pneumonia, pneumothorax, or PE can worsen outcomes.
Upper Respiratory Infection and Acute Bronchitis
Viral URI produces rhinorrhea, sore throat, cough, low-grade fever, and gradual improvement within 7–10 days. Cough may persist weeks post-infection — a common outpatient scenario. Chiropractic care for associated cervical stiffness is reasonable when fever has resolved and breathing is comfortable.
Acute bronchitis is a clinical diagnosis: cough lasting up to 3 weeks, often after URI, without focal pulmonary consolidation, pleural rub, or high fever. Sputum may be discolored without proving bacterial infection — most cases are viral. Impression: self-limited lower respiratory inflammation. Antibiotics are not routinely indicated. Refer if dyspnea, high fever, or focal findings suggest pneumonia instead.
Influenza adds abrupt onset fever, myalgia, headache, and dry cough. High-risk patients (elderly, pregnant, immunocompromised) need early antiviral consideration — outside chiropractic prescribing scope but relevant for referral timing.
Pneumonia: Typical and Atypical Patterns
Community-acquired bacterial pneumonia (classically Streptococcus pneumoniae) presents with acute onset fever, productive cough with rust-colored or purulent sputum, pleuritic chest pain, and tachypnea. Exam may reveal focal crackles, bronchial breath sounds, or dullness to percussion over the affected lobe. Elderly patients may present with confusion and minimal cough — always consider pneumonia in older adults with acute mental status change and fever.
Atypical pneumonia (Mycoplasma, Chlamydia) causes gradual onset, prominent cough (sometimes out of proportion to exam findings), headache, and patchy infiltrates. Legionella adds GI symptoms and hyponatremia. Part II may contrast typical lobar consolidation with atypical interstitial patterns.
Diagnosis: chest radiograph shows consolidation or infiltrate. Pulse oximetry may show desaturation. Clinical impression before imaging still matters on Part II — the stem gives fever, focal findings, and productive cough; the answer is pneumonia, not costochondritis.
Red flags requiring hospitalization: hypoxia (SpO₂ below 90%), respiratory rate above 30, multilobar involvement, confusion, hypotension, and significant comorbidity. Chiropractic manipulation is contraindicated during acute pneumonia until medical clearance.
Chronic Obstructive Pulmonary Disease
COPD (emphysema and chronic bronchitis) affects long-term smokers with progressive dyspnea, chronic productive cough, and reduced FEV₁/FVC on spirometry. Exam findings include prolonged expiratory phase, wheeze, and barrel chest in advanced disease. Patients may use accessory muscles and sit leaning forward (tripod position) during exacerbations.
Acute COPD exacerbation adds increased dyspnea, increased sputum volume or purulence, and worsening wheeze beyond baseline. Impression requires medical management — bronchodilators, steroids, oxygen titration, antibiotics when infection suspected. High-velocity thoracic manipulation during an exacerbation risks rib fracture in hyperinflated lungs and is inappropriate.
Distinguish stable COPD (may receive gentle soft-tissue and exercise advice within medical co-management) from acute exacerbation (referral and hold on HVLA).
Asthma
Asthma is reversible bronchospasm with episodic wheeze, chest tightness, cough (especially nocturnal), and dyspnea. Triggers include allergens, exercise, cold air, and NSAIDs in susceptible individuals. Peak flow or spirometry shows variable airflow obstruction with improvement after bronchodilator.
Acute asthma exacerbation severity stratification matters for Part II and clinical safety:
| Severity | Clues |
|---|---|
| Mild | Speaks in full sentences, peak flow above 70% predicted |
| Moderate | Speaks in phrases, peak flow 40–69%, obvious wheeze |
| Severe | Speaks in words only, peak flow below 40%, tachycardia |
| Life-threatening | Silent chest (minimal air movement), cyanosis, altered mental status, bradycardia |
A silent chest during an asthma attack means airflow is so limited that wheeze disappears — this is a pre-arrest emergency, not improvement. Emergency bronchodilator and systemic steroid administration, not chiropractic adjustment.
Between stable episodes, chiropractic patients with asthma may benefit from thoracic mobility work and breathing retraining, but always confirm they have a rescue inhaler and know their action plan.
Pneumothorax and Pleural Disease
Primary spontaneous pneumothorax occurs in tall thin young males — sudden sharp pleuritic chest pain and dyspnea, often at rest. Exam shows decreased breath sounds and hyperresonance on the affected side. Tension pneumothorax adds tracheal deviation away from the affected side, hypotension, and distended neck veins — immediate decompression emergency.
Secondary pneumothorax in COPD or trauma patients carries higher mortality. Any sudden unilateral pleuritic pain with respiratory distress should halt spinal manipulation until chest imaging excludes pneumothorax.
Pleural effusion causes dyspnea and dullness to percussion with decreased breath sounds at the base; large effusions need imaging and possible drainage. Chiropractors may see referred shoulder pain from subdiaphragmatic irritation, but effusion itself is not a manipulation target.
Pulmonary Embolism
PE is a critical Part II topic because it mimics musculoskeletal chest pain and may coexist with leg pain mistaken for sciatica or hamstring strain.
Classic presentation: sudden dyspnea, pleuritic chest pain, and tachycardia. Hemoptysis is less common. Risk factors include recent surgery, immobilization, estrogen therapy, malignancy, prior DVT/PE, and long travel. Leg swelling and calf tenderness support DVT source but PE can occur without leg findings — do not rule out PE because the calf is normal.
Massive PE causes hypotension, syncope, and right-heart strain — emergency thrombolysis or embolectomy territory.
Chiropractic red flag: patient with acute thoracic pain, unexplained dyspnea, and tachycardia after long flight or postoperative period — impression is PE until proven otherwise. No cervical or thoracic HVLA until medically evaluated.
Wells criteria and D-dimer/CT angiography are medical workup steps; Part II tests recognition, not imaging ordering nuance.
Tuberculosis and Chronic Cough Workup
Pulmonary TB presents with chronic cough (weeks to months), weight loss, night sweats, fever, and hemoptysis. Chest radiograph may show upper-lobe cavitary disease or apical infiltrates. TB is airborne — patients with suspected active TB should not wait in a crowded chiropractic waiting room. Mask, isolate, and refer for sputum AFB and public health follow-up.
Chronic cough lasting more than 8 weeks triggers a structured differential: postnasal drip, asthma, GERD, and medication effect (ACE inhibitors). Lung malignancy enters the impression with smoking history, weight loss, hemoptysis, and new persistent cough after age 40. Chiropractors who treat smokers for back pain must recognize when cough is not benign.
Sleep-Disordered Breathing
Obstructive sleep apnea (OSA) causes loud snoring, witnessed apneas, morning headache, and daytime somnolence. It associates with obesity, resistant hypertension, and increased cardiovascular risk. While not an acute respiratory emergency, OSA is a relevant clinical impression when patients report fatigue and snoring — referral for sleep study and CPAP may improve overall health and treatment tolerance. Part II may link OSA to hypertension and arrhythmia risk.
Musculoskeletal Mimics vs Pulmonary Source
| Feature | Musculoskeletal chest wall | Pulmonary pathology |
|---|---|---|
| Fever | Absent | Often present in infection |
| Cough | Absent or mild | Prominent, may be productive |
| Palpation | Reproduces pain | Pain may be pleuritic, less localized |
| Breath sounds | Normal | Crackles, wheeze, or decreased |
| Vitals | Normal | Tachypnea, tachycardia, hypoxia possible |
| Onset | Gradual, movement-related | Acute dyspnea suggests PE or pneumothorax |
Costochondritis and rib subluxation are real — but Part II stems usually include discriminating data pointing to the pulmonary impression when that is the tested concept.
Chiropractic Management Boundaries
Appropriate when stable: gentle mobilization, breathing exercises, postural education for chronic mechanical thoracic pain after pulmonary red flags are excluded.
Hold or refer: acute pneumonia, asthma exacerbation, pneumothorax, PE, active TB, unexplained hypoxia, hemoptysis, and any patient who cannot speak in full sentences due to dyspnea.
Document vital signs (pulse, respiratory rate, SpO₂ when available) when respiratory symptoms accompany spinal complaints — this supports both clinical safety and Part II reasoning about when impression shifts from musculoskeletal to medical.
A 67-year-old smoker presents with 3 weeks of productive cough, fever, pleuritic right chest pain, and tachypnea. Exam reveals crackles and dullness to percussion at the right base. SpO₂ is 91% on room air. What is the most likely clinical impression?
A 24-year-old tall male reports sudden sharp right-sided chest pain and shortness of breath while sitting at rest. Breath sounds are markedly decreased on the right. He is tachycardic but blood pressure is stable. What is the most likely diagnosis?
During an asthma exacerbation, a patient can speak only in single words, has a respiratory rate of 32, and the chest is quiet with minimal wheeze on auscultation. What does the quiet chest most likely indicate?
A 52-year-old woman developed sudden dyspnea and pleuritic chest pain 5 days after knee replacement surgery. Heart rate is 118 bpm. The calf is not swollen. What is the most likely clinical impression?