Chapter 3 Cardiopulmonary Symptoms Mosby items and derived

Learning Objectives After reading this chapter you will be able to: Know causes of the following symptoms: Cough Sputum production Hemoptysis Dyspnea Chest pain Dizziness and fainting Swelling of the ankles Fever, chills, and night sweats Headache, altered mental status, and personality changes Ø Snoring Ø Gastroesophageal reflux Ø Ø Ø Ø Ø Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Overview Primary symptoms of cardiopulmonary disorders Ø Ø Ø Cough Sputum production Hemoptysis Shortness of breath (dyspnea) Chest pain Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Overview (cont’d) Definition of terms associated with symptoms Discuss etiology, and differential diagnosis Familiarity with these symptoms in order to ask relevant questions and provide optimal care Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Cough Protective reflex Simulation of receptors Ø Pharynx, larynx, trachea, large bronchi, lung and visceral pleura Caused by inflammatory, mechanical, chemical, or thermal stimulation of cough receptors Key to determine etiology is careful history, physical exam, and CXR Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of

Cough (cont’d) Afferent pathway Ø Efferent pathway Ø Vagus, phrenic, glossopharyngeal, trigeminal nerves Smooth muscles of larynx and tracheobronchial tree via phrenic, spinal nerves Phases Ø Ø Ø Inspiratory Compression expiratory Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Cough (cont’d) Reduced effectiveness of cough Weakness of inspiratory or expiratory muscles Inability of the glottis to open or close correctly Obstruction, collapsibility, or alteration in shape or contours of the airways Ø Decrease in lung recoil (e. g. , emphysema) Ø Abnormal quantity or quality of mucus production (e. g. , thick sputum) Ø Ø Ø Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Causes and Clinical Presentation Acute Sudden onset; severe, short course; selflimiting Ø Viral infection Ø Chronic Ø Ø Persistent, >3 weeks Postnasal drip, asthma, COPD exacerbation, allergic rhinitis, GERD, chronic bronchitis, bronchiectasis, left heart failure Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Causes and Clinical Presentation (cont’d) Paroxysmal Ø Periodic, prolonged, forceful episodes Mosby items and

Cough (cont’d) Associated symptoms Ø Ø Wheezing Stridor Chest pain Dyspnea Mosby items and

$Cough (cont’d) Complications of cough Ø Ø Ø Ø Torn chest muscle Rib fractures$

Cough (cont’d) Complications of cough Ø Ø Ø Ø Torn chest muscle Rib fractures Disruption surgical wounds Pneumothorax or pneumomediastinum Syncope Arrhythmia Esophageal rupture Urinary incontinence Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Sputum Production Sputum Ø Secretions from tracheobronchial tree, pharynx, mouth, sinuses, nose Phlegm Ø Secretions from lungs and tracheobronchial tree Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Sputum Production (cont’d) Components Ø Mucus, cellular debris, microorganisms, blood, pus, foreign particles Normal sputum 100 ml/day Ø Upward displacement via wavelike motion of cilia until swallowed Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Abnormal Sputum Production Excessive production by inflamed glands Ø Infection, cigarette smoking, allergies Describe Ø Ø Ø Color Quantity Consistency Odor Time of day Presence of blood Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Hemoptysis Expectoration of sputum containing blood Ø From streaking to frank bleeding Causes Ø Ø Ø Bronchopulmonary Cardiovascular Hematologic Systemic disorders Tuberculosis or fungal infections Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 17

Hemoptysis (cont’d) Description Ø Amount • Massive hemoptysis: 400 ml/3 h or 600 ml/24 h Emergency condition Cancer, tuberculosis, bronchiectasis, trauma • Streaky: pulmonary infection, lung cancer, thromboemboli Ø Odor, color, acuteness Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 19

Hemoptysis vs. Hematemesis Vomited blood Determine source Oropharynx • Swallowed from respiratory tract Ø Esophagus or stomach • Alcoholism or cirrhosis of liver Ø Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Shortness of Breath (SOB) Most distressing symptom of respiratory disease Ø Single most important factor limiting ability to function Cardinal symptom of cardiac disease Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Dyspnea Subjective experience of breathing discomfort Components Ø Ø Sensory input to cerebral cortex Perception of the sensation • “Breathless, ” “short-winded, ” “feeling of suffocation” Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Dyspnea Scoring Systems Scale of 0 (no SOB) to 10 (max SOB) Visual analog scales Modified Borg Scale ATS SOB Scale UCSD SOB Questionnaire Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Causes, Types, and Clinical Presentation of Dyspnea WOB abnormally high for the given level of exertion Ø Ventilatory capacity is reduced Ø Asthma and pneumonia Neuromuscular disease Drive to breathe is elevated Ø Hypoxemia, acidosis, exercise Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 28

Clinical Types of Dyspnea Cardiac and circulatory related Ø Ø Psychogenic Ø Ø Inadequate supply of oxygen to tissues Primarily during exercise Panic disorder Not related to exertion Hyperventilating Ø Ø Rate, depth exceeds body’s metabolic need Results in hypocapnia and decreased cerebral blood flow Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 31

Acute and Chronic Dyspnea Acute Children: asthma, bronchiolitis, croup, epiglottitis Ø Adults: pulmonary embolism, asthma, pneumonia, pneumothorax, pulmonary edema, hyperventilation, panic disorder Ø Chronic Ø COPD and CHF most common causes Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 32

Description of Dyspnea Paroxysmal nocturnal dyspnea (PND) Sudden dyspnea when sleeping in recumbent position Ø Associated with coughing Ø Sign of left heart failure Ø Orthopnea Ø Ø Dyspnea when lying down Associated with left heart failure Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 33

Description of Dyspnea (cont’d) Trepopnea Ø Ø Dyspnea when lying on one side Unilateral lung disease, pleural effusion Platypnea Ø Dyspnea in upright position Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 34

Description of Dyspnea (cont’d) Orthodeoxia Ø Hypoxemia in upright position, relieved by returning to a recumbent position Platypnea and orthodeoxia seen in patients with right-to-left intracardiac shunts or venoarterial shunts Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 35

Chest Pain Causes Ø Ø Cardiac ischemia Inflammatory disorders of thorax, abdomen Musculoskeletal disorders, trauma, anxiety Referred pain from indigestion, dissecting aortic aneurysm Cardinal symptom of heart disease Angina See Table 3 -11 Ø Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 37

Pulmonary Causes of Chest Pain Involvement of chest wall or parietal pleura Pleuritic pain Inspiratory, sharp, abrupt in onset Worsens with inspiration, cough, sneeze, hiccup, or laughter Ø Increases with pressure and movement Ø Ø Chest wall pain Ø Ø Intercostal and pectoral muscles Well localized Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 38

Dizziness and Fainting (Syncope) Temporary loss of consciousness: from reduced cerebral blood flow and oxygen Causes Thrombosis, embolism, atherosclerotic obstruction Ø Pulmonary: embolism, bouts of coughing, hypoxia, hypocapnia Ø Vasovagal: most common type of syncope Ø Loss of peripheral venous tone Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 39

Dizziness and Fainting (Syncope) (cont’d) Orthostatic hypotension Sudden drop in blood pressure when a person stands up Ø Dizziness, blurred vision, weakness, syncope Ø Elderly, vasodilators, dehydration Ø Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 41

Dizziness and Fainting (Syncope) (cont’d) Carotid sinus syncope Ø Ø Hypersensitive carotid sinus Slows pulse rate, fall in blood pressure, syncope Tussive syncope Ø Ø Syncope due to strong coughing Seen most often in men with COPD, obesity, a positive smoking history, and frequent use of alcohol Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 42

Dependent Edema is soft tissue swelling from abnormal accumulation of fluid Bilateral peripheral edema Ø Ø Ø Most often occurs in ankles and lower legs Most often caused by right or left heart failure Right heart failure often caused by cor pulmonale Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 43

Fever, Chills, and Night Sweats Euthermia 97° to 99. 5° F (36° to 37. 5° C) Fever (hyperthermia, pyrexia) Ø Ø Sustained Remittent Intermittent Relapsing Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 44

Fever, Chills, and Night Sweats (cont’d) Causes of fever Ø Hot environment, dehydration, reaction to chemicals, drugs, hypothalamic damage, infection, malignancy Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 45

Fever with Pulmonary Disease Pulmonary infections Lung abscess, empyema, tuberculosis, pneumonia Ø Remittent fever in mycoplasma pneumonia, legionnaire’s disease, acute viral infections Ø Infection with no fever Ø Ø Ø High-dose corticosteroids Immunosuppressants Immunocompromised (leukemia, AIDS) Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 48

Headache, Altered Mental Status, and Personality Changes Headache as a manifestation of cerebral hypoxia and hypercapnia Ø Altered mental status in hypercapnia Ø Lung disease, high altitude From affected alertness to coma Personality changes in advanced pulmonary disorders Ø Forgetfulness, inability to concentrate, anxiety, irritability Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 49

Snoring Serious concern when associated with apnea Ø Evaluation for OSA Incidence and causes Ø Ø 10% to 12% of children 10% to 30% of adults Peak at age 50 to 59 (male) 60 to 64 (female) Obesity is one of the most common causes Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 50

Snoring Clinical Presentation Fatigue Excessive daytime sleepiness (EDS) Ø Ø Occupational accidents Motor vehicle accidents Loss of employment Social dysfunction Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 51

Gastroesophageal Reflux Heartburn and regurgitation Extraesophageal manifestations Ø Laryngitis, asthma, chronic and nocturnal dry cough, chest pain, dental erosion GER more than twice a week = GERD Risk factors Ø Obesity, cigarette smoking, pregnancy Mosby items and derived items © 2010 by Mosby, Inc. , an affiliate of Elsevier Inc. 52