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Dyspnea and Coughing

Thomas R. Bodette, D.C., CCSP

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Dyspnea

History questions:

1) Pain on full inspiration?

Direct trauma (pneumothorax, rib fracture)

Muscle strain 2) Chest tightness/pressure?

Radiation to jaw/left arm? (A: Cardiac

related)

Headache, dizziness, multiple joint pains?

(A: Depression)

3) With exertion? (CHF, exercise-

induced asthma)

4) Position related (orthostatic)?

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Dyspnea

Asthma

A) Extrinsic

Childhood onset, family Hx

of allergies

Testing with spirometry,

allergen challenge

Monitor with peak flow meter

Distinguish from hyperactive

airway

Asthma

B) Intrinsic

Usually an adult over the age

of 40 years

Secondary to URI, smoking,occupational exposure to

toxins

No relationship to allergies

Patients get progressively

worse

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Dyspnea Asthma

C) Acute-phase medications:

Epinephrine

Beta-agonists (ie: ventolincan actually

give you a chronic cough, along with

ACE inhibitors )

Methyl-xanthines (theophyline)

D) Prophylactic medications:

Cromolyn sodium (Intal)

Leukotriene receptor antagonists (blockcytokine formation pathwaysanti-

inflammatory)

Beta-2-agonists (ie: Salmeterol)

Oral and aerosol corticosteroids (anti-

inflammatory) 4

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Coughing

Chronic, non-productive cough

seen in:

Post-nasal drip (longer than three

weeks duration, worse at night) Hyperactive airway disease (cough-

variant asthma)

Gastroesophageal reflux (may

stimulate lower part of coughreceptors)

Chronic bronchitis (in smokers)

Wheezes = obstruction (mucus or

narrowed airway) 5

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Coughing

Chronic Obstructive

Pulmonary Disease

(COPD):

Exhalation most affected

Due to mucus or bronchial

constriction

Decrease in FEV1 (forced

expiratory volume)

Increased residual volume

Wheezes and rhonchi (upon

auscultation)

Examples: asthma, chronic

bronchitis, emphysema,

bronchiectasis

Chronic Restrictive

Pulmonary Disease

(CRPD):

Affects all aspects of

respiration

Sources are extrapulmonary

Neuromuscular (Myasthenia

gravis, Guillain-Barr)

Skeletal deformity (kyphosis,

obesity, etc.) Pleural

Rales more prevalent on

auscultation

Examples: asbestosis,

sarcoidosis, eosinophilia 6

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Coughing

Blue Bloater:

Centrilobular

(respiratory bronchiole

expanded) Blockage of distal

bronchioles

Decreased CNS

sensitivity to CO2, leadsto cyanosis

Not in apparent distress

Chronic cough (smoker)

Pink Puffer:

Panacinar (respiratory

bronchiole AND alveoli

expanded)

Destruction of distal alveoli(no blockagetotally

destroyed)

25% of total body energy

needed to breathe

Thin, frail, flushed (breathesthrough pursed lips to

normalize pressure)

Barrel-chest appearance

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Other conditions

Pulmonary embolism:

Chest pain, dyspnea, coughing,

diaphoresis

Thrombi in lower extremity travelsto lungs (results in vascular blockage

or infarction)

Physical exam: tachycardia,

tachypnea, accentuated S2 atpulmonic location

Treatment: antithrombolytic therapy

(tissue plasminogen activator,

heparin, warfarin)8

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Other conditions

Congestive heart failure:

Dyspnea upon exertion and/or lying supine at night

(orthopnea)

Increased venous pressure (blood doesnt get back to theheart as fast as it should)

Ascites, bilateral leg edema, rales upon auscultation

Increased chance of mortality with high Na diet and

overweight Treatment: diuretics, strict low-fat diet, gradual supervised

exercise

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