Main clinical
symptoms in
lung diseases
10.09.2014.
Case history
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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
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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
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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
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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
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bed rest
sedatives
supression of cough
ice on the chest
chest x-ray, CT, bronchoscopy
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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!