Cardiopulmonary Symptoms Cough One of the most common symptoms associated with lung disease Powerful protective mechanism for the lung and airways Caused by mechanical, chemical, inflammatory, or thermal stimulation of the cough receptors Cough Stimulated by reflexes in Pharynx Larynx Trachea Large airways (carina) Cough Made up of four phases 1. Stimulus 2. Inspiratory phase Opening of Glottis Contraction of diaphragm 3. Compression phase Closure of glottis Relaxation of diaphragm Accessory muscles contract 4. Expiratory phase Opening of glottis Explosive release of trapped intrathoracic air Causes and Clinical Presentation Acute cough most often associated with viral infection of the upper airway Chronic cough often associated with Postnasal drip Asthma COPD Gastroesophageal reflux (GERD) Left ventricular failure Descriptions The type of cough present should be documented using commonly accepted adjectives Productive—mucus is produced with the cough Effective—a strong cough Weak—ineffective Dry—no secretions present Chronic productive—patient produces phlegm most days for at least 3 weeks Characteristics Barking Brassy (horse) Wheezy (high pitched) sometimes called a “tight cough” Hacking (usually chronic from smoking) Time of day when cough is most prevalent is important Sputum Production Sputum is the mucus expelled from the tracheobronchial tree that has been contaminated by the mouth Phlegm is the term used to describe mucus strictly from the tracheobronchial tree Causes and Descriptions Caused by inflammation of the mucus secreting glands that line the airways Inflammation from Infection Cigarette smoke Allergies Sputum should be described by Color Consistency Quantity Odor Presence of blood Causes and Descriptions Thick but clear sputum is consistent with dehydration Pink frothy sputum is consistent with pulmonary edema Thick, purulent (pus-containing) sputum is consistent with infection Hemoptysis Causes Tuberculosis Persistent strong coughing Acute infection Bronchogenic carcinoma Cardiovascular disease Trauma Anticoagulant therapy Descriptions Streaky hemoptysis refers to bloodtinged sputum Massive hemoptysis refers to more than 400 mL of blood in 3 hours or 600 mL in 24 hours. Hematemesis Determining if the blood is from the lung versus the stomach is important Blood from the lung is often associated with pulmonary symptoms Blood from the stomach is associated with GI symptoms Shortness of Breath (Dyspnea) Dyspnea is a common symptom of patients with lung or cardiac problems Dyspnea is a subjective complaint that varies with pathologic and psychologic variables The degree of dyspnea may not correlate with objective measures of impairment Dyspnea should always be investigated even if initial tests are normal Dyspnea Dyspnea occurs when increased WOB increased drive to breath decreased ventilatory capacity Types of Dyspnea Physiologic Cardiac Circulatory Chemical Central Psychogenic Descriptors Apnea – Cessation of breathing Dyspnea- Patients expression of SOB Eupnea- Normal Bradypnea- Slow Tachypnea- Fast Hypopnea- Decreased depth Hyperpnea Increase depth Descriptors Platypnea- Dyspnea sitting up Orthopnea- Dyspnea reclining position common in CHF secondary to pooling of fluid in lungs during sleep. Hyperventilation Common in CHF Paroxysmal nocturnal dyspnea (PND) Can be caused by patent foramen ovale Can only be described by ABG Hypoventilation Can only be described by ABG Questions to Assess Dyspnea When How What What else happens Cynosis Cough How much can you do before dyspnea Exposures Chest Pain Chest pain is the cardinal symptom of heart disease Chest pain may be seen in patients with lung disease when the pleural lining is abnormal Classic chest pain associated with heart disease is known as angina, and it signals a medical emergency Pulmonary Chest Pain Pain associated with lung disease is most often the result of pleural inflammation Pneumonia and pulmonary infarction may cause pleural pain Descriptions Chest pain from heart disease is often described as aching, squeezing, pressing, or viselike Often increases with exercise Patients with pleuritic chest pain may be leaning toward one side and describe the pain as stabbing or burning. Often state the pain increases with deep Dizziness and Fainting (Syncope) Syncope is a temporary loss of consciousness due to reduced blood flow and oxygen to the brain Syncope is caused by a large variety of disorders from something as simple as dehydration to serious cerebral thrombosis Patients with lung disease who cough very forcefully may experience syncope Swelling of the Ankles (Dependent Edema) Patients with chronic hypoxemia often develop right heart failure Right heart failure leads to reduced venous return and increased hydrostatic pressure in the peripheral venous blood vessels especially in the dependent tissues (e.g., ankles) Ankle edema thus can be a sign of chronic lung disease Ankle edema may also simply be a sign of heart disease not associated with lung disease Fever / Chills Sustained fever is a continuously elevated fever that varies little during a 24-hour period Remittent fever is continuously elevated but has larger variations and spikes in a 24-hour period Intermittent fever refers to spikes in body temperature cycling with periods of normal or subnormal temperatures Fever is a concern because it may signal infection and it increases oxygen consumption Fever with Pulmonary Disorders Pneumonia Lung abscess Tuberculosis Empyema A lack of fever does not rule out infection. Headache, Altered Mental Status, and Personality Changes Lung disease can lead to headache when chronic hypoxemia or hypercarbia is present Sudden changes in personality are common in patients with chronic lung disease and may be due to hypoxia, medications, or psychologic issues RTs must be sensitive to personality changes because they may be indicative of acute lung problems in the patient with chronic lung disease Snoring Snoring occurs in about 5% to 10% of children and 10% to 30% of adults Snoring is caused by excessive narrowing of the upper airway with breathing during sleep Obesity is the most common cause of obstructive sleep apnea Enlarged tonsils, a large tongue, a short thick neck, and nasal obstruction may contribute to the upper airway narrowing during sleep Alcohol and sleeping medications can also make snoring worse Clinical Presentation Patients with obstructive sleep apnea always snore during sleep OSA patients will complain of excessive daytime sleepiness because their sleep continuity is abnormal OSA patients may also complain of poor concentration skills, bedwetting, impotence, high blood pressure, and other complaints Case Study 68 y/o male cc chest pain and DOE dyspnea on exertion. Smokes 1.5 ppd x 40years. General appearance- Mildly obese, cyanotic in extremities and dyspnic. Case Study Physical exam shows increase AP diameter, HR 108, RR 22 with prolonged expiratory time, BP 160/95, and a temp of 39c. Auscultation reveals diminished breath sounds bilaterally but more so in the right lower lobe. Case Study Palpation shows decrease chest expansion on right and slight tracheal deviation to the right. Percussion shows hyper resonance throughout except for RLL. Patient does not exhibit increased tactile fremitus. Case Study Patient states that he coughs up about two table spoons of thick green mucus in the morning and more throughout the day and has had chills at night for a week.