Main clinical symptoms in lung diseases 10.09.2014.
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Transcript of Main clinical symptoms in lung diseases 10.09.2014.
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!