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Main clinical symptoms in lung diseases 02.09.2015. Case history • • • • • • 28 years old male Excercise induced dyspnea for 2 years No connection with daytime, season, meal Dry cough in lying position No chest pain Nonsmoker • Physical exam: Stridor Chest x-ray Lung function (flow-volume curve) Bronchoscopy CT scan CT scan Main points in medical history of pulmonary disorders • • • • • • • • • Present complaints Previous lung, heart or kidney, other diseases Smoking (pack-year) Previous haemoptysis, infection Family history (cc, allergy) Skin symptoms Travelling Exposition to dust, gases (asbest) NSAID (Nonsteroid anti-inflammatory drug), salicylate, anticoagulant therapy • Upper or lower GI (gastrointestinal) disease Main clinical symptoms • • • • cough haemoptysis dyspnoe chest pain What to do? History Physical exam Testing -pulsoxymetry -ECG -Chest X-ray -lung function Pulmonary causes of cough Chronic (> 8 weeks) Acute (< 8 weeks) Lower airways asthma aspiration (1-3 yrs) inhalation (fire, accident) Infection Pleura and lung diseases Pneumonia Pleurisy Ptx Pulmonary embolism Lower airways and parenchymal chronic bronchitis, COPD (chronic obstructive pulmonary disease) asthma, RADS (Reactive Airways Dysfunction Syndrome) eosinophilic pulmonary diseases lung tumors Infection ILD/DPLD (syst+lung involv.) (Interstitial lung disease/diffuse parenchymal lung d.) aspiration bronchiectasis cystic fibrosis bronchomalacia rare causes (tracheobronchomegalia, amyloid infiltr, tracheobronchopathia, osteoplastica, polychondritis) Extrapulmonary causes of cough Acute (< 8 weeks) Upper airways - infectious (common cold) - allergy Cardiac diseases with acute pulmomary congestion Chronic (> 8 weeks) Upper airways - chronic rhinitis, sinusitis, pharyngitis, laryngitis - vocal cord dysfunction - OSA (obstructive sleep apnoe syndrome) GERD Drug (ACE inhibitor: angiotensin converting enzyme) Cardiac diseases - any incl. pulmonary congestion - endocarditis Urgency in acute cough 1. Haemoptysis 7. History of malignant tumor 2. Severe chest pain 3. Dyspnoea 8. History of heavy smoking 4. High fever (> 20 pack-year) 5. TB - epidemiology - contact with sick person - homelessness - illicit drug user 6. Immunsuppressed states - CVID (common variable immunodeficiency) - AIDS - immunsuppressive therapy Chronic cough without definite chest X-ray or lung function 1. Upper airway disease 2. „cough variant asthma” 3. GERD (gastroesophageal reflux disease) 4. Taking ACE inhibitor Chronic cough in diffuse parenchymatous lung – or autoimmune disease 1. Due to lung involvement (Sjögren sy, Wegener, systemic sclerosis, Churg-Strauss sy, IIP:idiopathic interstitial pneumonia, sarcoidosis) 2. Due to treatment (methotrexate, cyclophosphamide) 3. Due to infection in the immunocompromised host End-stage ILD, honeycomb lung Frequent mistakes in the diagnostic workup 1. Extensive diagnostics in patients taking ACE inhibitor 2. Trivialisation of cough in smokers without diagnostics 3. Extrapulmonary causes (E.N.T:ears, nose and throat, cardiac, neurologic) are disregarded 4. Change of the established sequence of tests without reason (e.g. HRCT before BHR: bronchial hyperresponsiveness testing, PFT: pulmonary function test) 5. No bronchoscopy though cause not determined 6. Psycogenic cough diagnosed, tumor overlooked Clinical algorithm for the dg of acute cough History, physical exam Immediate dg necessary ? Appropriate dg, hospital admission if necessary yes no Infection ? Yes Bacteriological? Further dg and therapy no no Symptomatic therapy, if necessary Drug induced ? (e.g. ACE inhibitor) no yes Discontinue/replace drug Improvement within 8 weeks? yes No further action no Dg according to chronic cough algorithm Clinical algorithm for the dg of chronic cough Hystory, physical exam Cardiac or neurological cause ? no Dg and ther yes Succes? nem yes No further action X-ray: PA+lateral Cough explained by result yes Further dg and therapy no Lung function test Normal PFT ? yes no Non-specific provocation pathological ? yes no Further E.N.T. dg and therapy Smoking or other hazardous exposure ? yes Cough due to BHR absention success no no … continued No Normal E.N.T. ? no yes Reflux ? yes treatment no Is HRCT and bronchoscopy normal ? yes no Further Further E.N.T. dg and therapy dg and ther successyes no Sputum yes Eosinophilia ? No further action Eosinophilic bronchitis no In-depth reflux dg: - pH-probe - manometry pathological ? yes reflux ther no chronic idiopathic cough due to increased cough reflex Potential complications of cough I. Respiratory Pneumothorax Subcutaneous emphysema Pneumomediastinum Cardiovascular Cardiac dysarhytmias Loss of consciousnes Subconjunctival hemorrhage Pneumoperitoneum Laryngeal damage Central nervous System Syncope Headaches Musculosceletal Intercostal muscle pain Rupture of m. rectus abdominis Increase in serum CK Cervical disc. prolapse Potential complications of cough II. Gastrointestinal Esophageal perforation Other Social embarrassment Depression Urinary incontinence Disruption of surgical wounds Petechiae Purpura Productive cough • • • • Serous Mucoid Purulent Bloody Hemoptysis • Hemoptysis is the expectoration (coughing up) of blood or of blood-stained sputum from the bronchi, larynx, trachea, or lungs. • The origin of blood can be identified by observing its color. Bright-red, foamy blood comes from the respiratory tract, whereas dark-red, coffee-coloured blood comes from the gastrointestinal tract. Etiology of hemoptysis I. Neoplastic Primary bronchial cc., pulmonary metastatic disease, bronchial adenoma, Kaposi’s sarcoma Infection Bacterial pneumonia, tb, lung abscess, aspergillus disease, parasitic disease, viral infection (influenza, varicella) Pulmonary Bronchiectasis, bronchitis, cystic fibrosis, cryptogenic organizing pneumonia Vascular PE, PH, AV malformations, bronchial artery malformations, congenital vascular abnormalities, aortic aneurysm, valvular heart diseases, amniotic fluid embolism, hepatopulmonary sy, pulmonary venous hypertension/congestive heart failure Haematological Coagulopathies, lung transplant rejection, thrombolysis, abnormal platelet function Etiology of hemoptysis II. Systemic disease Vasculitis, Goodpasture-sy, SLE, idiopathic pulmonary haemosiderosis, diffuse alveolar haemorrhage/capillaritis Iatrogenic Bronchoscopy, percutaneous lung biopsy, radiotherapy, Swan-Ganz catheters, implantable cardiac defibrillators Drugs Anticoagulants, aspirin, amiodarone, penicillamine, solvents, crack cocaine Miscellaneous Foreign body inhalation, pulmonary amiloid, thoracic endometriosis, tongue biting, gingival disease, GERD, pulmonary sequesteration, Behcet’s sy, pulmonary allograft Interventions in hemoptysis • • • • • bed rest sedatives supression of cough ice on the chest chest x-ray, CT, bronchoscopy • • • • • • • endotracheal tube suction balloon catheter under bronchoscopy blood transfusion surgical interventions (pulmonary resection) catheter embolization of bronchial artery laser , electrocauter Dyspnoe • Unpleasent or uncomfortable breathing • Difficulty in breathing, often associated with lung or heart disease and resulting in shortness of breath. Causes of dyspnea Increased demand Impaired performance Physiological – exercise, pregnancy, high altitude 1.Airflow limitation -asthma, Pathological – psychogenic, anaemia, acidosis, increased metabolism (fever, hyperthyreoidism) COPD, large airway obstruction 2.Reduced lung volume ptx,effusion, scoliosis 3.Impaired gas exchange fibrosis, consolidation, edema, collapse, COPD 4.Reduced compliancelung or thoracic cage (Bechterew) Time course of dyspnea • Sudden onset: ptx, pulm.embol., asthmatic attack, pulmonary edema, aspiration • Days, weeks, months: pneumonia, tbc (bronchial spreading), anemia, tumorous occlusion, pleurisies, CHF, obesity • Years: asthma, COPD, ILD, pneumoconiosis, autoimmune diseases with lung involvement Types of dyspnea • Orthopnea: Discomfort in breathing that is relieved by sitting or standing in an erect position. Inability to breathe except in an upright position • Platypnea (orthodeoxia): accentuation of arterial hypoxemia in the erect position. • Trepopnea: dyspnea that is sensed while lying on one side but not on the other. It results from disease of one lung, one major bronchus, or chronic congestive heart failure. • Exercise-induced dyspnoe Types of dyspnea Diff.dg. - hyperpnea (increase in VE: minute ventilation):abnormal increase in depth and rate of respiration - hyperventilation (increase in VA: alveolar ventilation)Abnormally fast or deep respiration resulting in the loss of CO2 from the blood, causing a decrease in blood pressure and sometimes fainting. Pulmonary ventilation rate greater than that metabolically necessary for gas exchange, resulting from an increased respiration rate, and/or increased tidal volume. It causes an excessive intake of O2 and elimination of CO2 and may cause hyperoxygenenation. Hypocapnia and respiratory alkalosis then occur, leading to dizziness, faintness, numbness of the fingers / toes, possibly syncope, and psychomotor impairment. Modified Borg Category Scale for subjective judgment of shortness of breath 0 0.5 1 2 3 4 5 6 7 8 9 10 nothing at all very, very slight (just noticeable) very slight slight moderate somewhat severe severe very severe very, very severe (almost maximal maximal • Anamnesis – Sudden sharp chest pain on right side – Dyspnea • Physical exam – Hyperresonant percussion right side – No breathing sounds on right side by auscultation Chest pain • The heart, lung, esophagus, great vessels provide afferent visceral input through the same thoracic autonomic ganglia. • Painful stimuli from thoracic organs can produce discomfort described as pressure, burning, aching, and sometimes sharp pain. • Lung parenchyma and visceral pleura are insensitive to pain • Consider cardiac origin in case of risk factors or exertional symptoms • For anyone with chest pain minimal testing includes pulse oxymetry, ECG, chest-Xray. Characteristics of chest pain I. Diagnosis Pain Characteristics ECG CXR (chest X-ray) Associated Features Angina pectoris Substernal, constricting Transient, effort-related Local ST Normal depression, occasional elevation Relief with NTG (nitroglycerin) MI Substernal, crushing Persistent, severe Local ST elevation or depression Possible vascular congestion or cardiomegaly Relief with opiates, possible hypotension; troponin Pulmonary embolism Pleuritic, substernal Sudden onset with dyspnea Nonspecifi c; occasional RV strain Normal or opacities ± small pleural effusion Risk factors for venous thrombosis Pulmonary artery hypertension Gradual onset Associated with dyspnea, fatigue and edema Tall right precordial R waves, right axis deviation, RV strain Prominent pulmonary arteries Exclude pulmonary thromboembolism and interstitial lung disease Characteristics of chest pain II. Diagnosis Pain Characteristics ECG CXR Associated Features Bacterial pneumonia Pleuritic Onset in minutes to hours Normal Consolidation Fever, productive cough Pneumothorax Sharp, unilateral Sudden onset with dyspnea Normal Collapsed lung Asthenic habitus, recurrence Pericarditis Pleuritic Either side, gradual onset Generalized Possible ST elevation enlarged silhouette Aortic dissection Substernal, severe Radiation to the Nonback specific; LVH or inferior MI (myocardial infarction) Widened mediastinum Friction rub Prostration, loss of pulse, aortic insufficiency Characteristics of chest pain III. Diagnosis Pain Characteristi cs ECG CXR Associated Features Esophageal spasm/reflux Substernal May mimic angina; burning Normal or ST-T changes Normal Relief with NTG or antacids Costochondritis Dull-achy, localized by cough or deep breath Normal Normal Localized tenderness Herpes zoster Sharp, unilateral Dysesthesia Normal Normal Vesicular rash Thank you for your attention!
