Common Symptoms of the Respiratory System

Common Symptoms of the Respiratory System


Cough

Cough is an explosive expiration that provides a protective mechanism for clearing the tracheobronchial tree of secretions and foreign material. However, when excessive, it is one of the commonest presentations (complaint).

As a protective mechanism against foreign or noxious material, cough can be initiated by a variety of airway irritants, which enter the tracheobronchial tree by inhalation (smoke, dust, fumes) or by aspiration (upper airway secretions, gastric contents, foreign bodies).

Any disorder resulting in inflammation, constriction, infiltration, or compression of airways can be associated with cough. Inflammation commonly results from airway infections, ranging from.

Some causes of cough are:

• Inflammation-infection (viral ,bacterial etc ) , bronchitis , bronchiectasis, asthma etc

• Constriction - asthma (it is reversible)

• Infiltration – tuberculosis, neoplasm, granuloma, or sarcoidosis

Examples of parenchymal lung disease potentially producing cough include pneumonia,

interstitial lung disease, and lung abscess.

Patients with congestive heart failure may have a cough, because of interstitial edema.



Approach to the Patient with cough
A detailed history frequently provides the most valuable clues for the etiology of the cough.

Particularly important questions include:

• Is the cough acute or chronic? Factors influencing it?

• Were there associated symptoms suggestive of a respiratory infection?

• Is it seasonal or associated with wheezing? Dyspnea?

• Is there nasal discharge or gastroesophageal reflux (heartburn)?

• Is there a fever or sputum? If sputum is present, what is its character?

• Does the patient have any associated disease or risk factors for disease (e.g. Cigarette smoking, the risk for HIV, environmental exposures eg. pollution)?

The general physical exam may point to a non-pulmonary cause of coughs, such as heart failure, malignancy, or AIDS.

• Auscultation of the chest may demonstrate: inspiratory stridor (indicative of upper airway disease), respiratory wheezing (indicating lower airway disease) or inspiratory

crepitations (a process involving the pulmonary parenchyma, such as interstitial lung disease, pneumonia, tuberculosis, or pulmonary edema).

Complications of cough: may precipitate syncope, fracture of the ribs, etc

Definitive treatment of cough depends on determining the underlying cause and then initiating

specific therapy. Different cough suppressants can be used in addition to specific therapy to decrease the duration of cough.

Chest Discomfort/pain
Chest discomfort is one of the most frequent complaints for which patients seek medical attention. There is little relation between the severity of chest discomfort and the gravity of its cause.

Causes of Chest Discomfort
Pleuritic chest pain – It is usually a brief, sharp, knife-like pain that is precipitated by inspiration or coughing. It is very common and generally results from inflammation of parietal pleura.

A typical example is a pneumonia.


Myocardial ischemia:

• Angina pectoris is usually described as a heaviness, pressure, squeezing, or sensation of strangling or constriction in the chest, but it also may be described as an aching or burning pain or even as indigestion.

• Typically, angina pectoris develops during emotion or physical exertion. The pain typically resolves within 5-30 minutes. The pain is more prolonged in myocardial infarction (MI).

Chest pain due to pericarditis:-

• The pain arises from the parietal pericardium and adjacent parietal pleura. Infectious diseases and inflammation are the main causes of pain.

• Pericarditis can cause pain in several locations like the tip of the shoulder and the neck more often the pain is located in the anterior part of the chest and is relieved by bending forward, but pain may also be in the upper part of the abdomen or at the corresponding region of the back.

• Pericardial pain commonly has a pleuritic component; i.e. it is aggravated by cough and deep inspiration, because of pleural irritation. Sometimes there may be steady substernal discomfort that mimics acute myocardial infarction.

Vascular causes of chest pain: –

• Pain due to the acute dissection of the aorta usually begins abruptly, reaches an extremely sever peak rapidly.

• It is felt in the center of the chest and/ or the back, lasts for hours, and requires unusually large amounts of analgesics for relief of pain. Pain is not aggravated by changes in position or respiration. Usually, there is associated with low blood pressure.

Chest pain due to pulmonary embolism:-

• The pain resulting from pulmonary embolism may resemble that of acute MI because in massive embolism pain is located substernal.

• In patients with smaller emboli, pain is located more laterally, is pleuritic in nature, and sometimes is associated with hemoptysis.

Gastrointestinal causes of chest discomfort:-
• Esophageal pain commonly presents as a deep thoracic burning pain, which is the hallmark of acid-induced pain. Esophageal spasm has acute pain that may be indistinguishable from MI.

• Other diseases like PUD, biliary disease, pancreatitis, and cholecystitis may present as chest discomfort or pain.

Emotional cause of chest pain - Usually, the discomfort is experienced as a sense of "tightness", sometimes called "aching". It is confused with myocardial ischemia. Ordinarily, it lasts for half an hour or more. There is usually associated with emotional strain or fatigue.

Hemoptysis; is defined as expectoration of blood from the respiratory tract, which could be scanty and mixed with sputum or a large amount of frank blood. Massive hemoptysis is defined as expectoration of >600 ml of blood in 24 hours. Hemoptysis can have different causes. Some of

the causes are:

1) Tracheobronchial source
• Neoplasm

• Bronchitis, Bronchiectasis

• Foreign body

• Airway trauma

2) Pulmonary parenchymal source

• Pneumonia, tuberculosis

• Lung abscess

• Lung congestion

3) Primary vascular source

• Mitral stenosis

• Pulmonary embolism

4) Sources other than the lower respiratory tract

• Upper airway (nasopharyngeal) bleeding

• GI bleeding

Tuberculosis and pneumonia are the commonest causes of hemoptysis in developing countries. But bronchitis and bronchogenic ca are common in developed regions. Up to
30% of patients may not have identifiable cause even after complete investigation.


Approach to the patient with hemoptysis

History:
• Blood streaked, mucopurulent sputum suggests bronchitis.

• If it is associated with fever pneumonia should be suspected.

• If sputum smell is putrid, lung abscess is likely.

• Hemoptysis that occurs suddenly with chest pain and dyspnea suggests pulmonary embolism.

• Previous history of renal disease, SLE, or malignancy is all-important for suggesting

DDX.

Physical examination: may reveal

• Pleural friction rub, Localized or diffuse crackles lung parenchymal damage.

• Wheezing Airflow obstruction (chronic bronchitis).

• Cardiac examination may reveal pulmonary hypertension, mitral stenosis or heart failure

Diagnostic evaluation :

• Chest X-ray which may show mass lesion suggestive of bronchiectasis, pneumonia.

• Sputum examination for Gm and AFB stain.

• CBC, coagulation profile, urine analysis,

• BUN and creatinine and

• If possible bronchoscopy is useful in localizing and managing the site of bleeding

Treatment: the rapidity of bleeding and its effects on gas exchange determine the urgency of management.

• If there is only blood streaking sputum with mid hemoptysis, first establish a diagnosis. Put the patient at rest and Giving cough suppressant may help to subside the bleeding

• If massive hemoptysis urgent treatment is necessary to stop bleeding and patients should be referred to a hospital. Massive hemoptysis may require endotracheal intubation and mechanical ventilation. If the bleeding site is known to position the patient
so that the source of bleeding is placed in a dependent position to protect the suffocation of the unaffected lung.