Main clinical symptoms inlung diseases

10.09.2014.

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?HistoryPhysical examTesting -pulsoxymetry -ECG -Chest X-ray -lung function

Pulmonary causes of cough

Acute (< 8 weeks)Lower airwaysasthmaaspiration (1-3 yrs)

inhalation (fire, accident)

Infection

Pleura and lung diseases Pneumonia

Pleurisy Ptx Pulmonary embolism

Chronic (> 8 weeks)Lower airways and parenchymalchronic bronchitis, COPD (chronic obstructive pulmonary

disease)asthma, RADS (Reactive Airways Dysfunction Syndrome)

eosinophilic pulmonary diseaseslung tumorsInfectionILD/DPLD (syst+lung involv.)(Interstitial lung disease/diffuse parenchymal lung d.)

aspirationbronchiectasiscystic fibrosisbronchomalaciarare causes (tracheobronchomegalia, amyloid infiltr,

tracheobronchopathia, osteoplastica, polychondritis)

Extrapulmonary causes of cough Acute (< 8 weeks) Chronic (> 8 weeks)Upper airways Upper airways

- infectious (common cold) - chronic rhinitis, sinusitis,

- allergy pharyngitis, laryngitis - vocal cord dysfunction

Cardiac diseases - OSA (obstructive sleep apnoe syndrome)

with acute pulmomary GERD

congestion Drug (ACE inhibitor: angiotensin converting enzyme)

Cardiac diseases

- any incl. pulmonary congestion

- endocarditis

Urgency in acute cough 1. Haemoptysis

2. Severe chest pain

3. Dyspnoea

4. High fever

5. TB

- epidemiology

- contact with sick person

- homelessness

- illicit drug user

6. Immunsuppressed states

- CVID (common variable immunodeficiency)

- AIDS

- immunsuppressive therapy

Szívbetegség

- bármely,kisvérköri pangással

- endocarditis

7. History of malignant tumor

8. History of heavy smoking

(> 20 pack-year)

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, hospitaladmission if necessary

Infection ? Bacteriological? Further dg and therapy

Symptomatic therapy, if necessary

Drug induced ?(e.g. ACE inhibitor)

Discontinue/replace drug

Improvement within 8 weeks? No further action

Dg according to chronic cough algorithm

no

no

no

yes

Yes

no

noyes

yes

Hystory, physical exam

Cardiac or neurological cause ? Dg and ther

X-ray: PA+lateral

Further dg and therapy

Normal PFT ?

Non-specific provocation pathological ?

Cough due to BHR

Smoking or otherhazardous exposure ?

no

no

no

yes

yes

no

yesyes

Cough explained by result

Succes? No furtheraction

nem

Lung function test

Further E.N.T.dg and therapy

yes absention success

nono

Clinical algorithm for the dg of chronic cough

yes

… continued

Normal E.N.T. ? Reflux ?

Further E.N.T. dg and ther

Is HRCT and bronchos- copy normal ?

In-depth reflux dg:- pH-probe- manometry

noyes

yes

yes

treatmentyes Nofurtheraction

no

No

successyesno

no

Further dg and therapy

SputumEosinophilia ?

Eosinophilicbronchitis

yes

no

pathological ? reflux therno

chronic idiopathic cough due to increased cough reflex

Potential complications of cough I.Respiratory CardiovascularPneumothorax Cardiac dysarhytmias

Subcutaneous emphysema Loss of consciousnes

Pneumomediastinum Subconjunctival hemorrhage

Pneumoperitoneum

Laryngeal damage

Central nervous MusculosceletalSystem Intercostal muscle pain

Syncope Rupture of m. rectus abdominis

Headaches Increase in serum CK

Cervical disc. prolapse

GastrointestinalEsophageal perforation

OtherSocial embarrassment

Depression

Urinary incontinence

Disruption of surgical wounds

Petechiae

Purpura

Potential complications of cough II.

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

• 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

Interventions in hemoptysis

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, COPD, large airway obstruction

2.Reduced lung volume ptx,effusion, scoliosis

3.Impaired gas exchange fibrosis, consolidation, edema, collapse, COPD

4.Reduced compliance- lung or thoracic cage (Bechterew)

Pathological –psychogenic, anaemia, acidosis, increased metabolism (fever, hyper-

thyreoidism)

Time course of dyspnea

• Sudden onset: ptx, pulm.embol., asthmatic attack, pulmonary edema, aspiration

• Days, weeks, months: pneumonia, tbc (bron-chial 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 dyspneaDiff.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 nothing at all0.5 very, very slight (just noticeable)1 very slight2 slight3 moderate4 somewhat severe5 severe6 7 very severe8 9 very, very severe (almost maximal10 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.

Diagnosis Pain Characteristics ECG CXR (chest X-ray)

Associated Features

Angina pectoris

Substernal, constricting

Transient, effort-related

Local ST depression, occasional elevation

Normal 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

Nonspecific; 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 I.

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 ST elevation

Possible enlarged silhouette

Friction rub

Aortic dissection

Substernal, severe

Radiation to the back

Non-specific; LVH or inferior MI(myocardial infarction)

Widened mediastinum

Prostration, loss of pulse, aortic insufficiency

Characteristics of chest pain II.

Diagnosis Pain Characteristics

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

Characteristics of chest pain III.

Thank you for your attention!