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Investigation of Respiratory Disease Chapter 4.2 (B)

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Investigation of Respiratory Disease Chapter 4.2 (B) 4.1 THE CLINICAL PRESENTATION OF CHEST DISEASES 347 Table 1 Modified Borg Scale∗ Chapter 4.1 Number Verbal description 10 Severe The clinical presentation of chest 9 diseases 8 Moderately severe 7 D. J. Lane 6 5 Moderate 4 The predominant symptoms of chest diseases are cough, breath- 3 lessness, chest pain and haemoptysis. 2 Slight 1 0 None ∗Modified from Borg, G.A.V. (1982). Psychological basis of perceived exertion. Cough Medical Science of Sports and Exercise, 14, 377–81. The cough reflex is initiated by stimulation of receptors in the larynx and major airways, by mechanical or chemical irritants. The afferent fibres run in branches of the superior laryngeal nerve and vagus. Haemoptysis A dry cough, short and repeated, is heard in tracheobronchitis A definite cause is only found in some 50 per cent of cases and it is and early pneumonia. In laryngitis the sound is hoarse and harsh. important to be sure that the blood does truly come from the lungs In abductor paralysis of the vocal cords it is prolonged and and not from the nose or gastrointestinal tract. Haemoptysis is a blowing. Weakness of thoracic muscles lessens the expulsive force classical presenting feature of tuberculosis, carcinoma, and bronchi- and cough may be suppressed when there is severe thoracic or ectasis, but there are many other causes, for instance Goodpasture’s upper abdominal pain. Cough with expectoration in the morning syndrome, mitral valve disease, coagulation defects, or even endo- is characteristic of chronic bronchitis and large volumes of yellow metriosis. It is rare in pulmonary embolism, when it reflects infarction sputum throughout the day suggests bronchiectasis. Bouts of of the lung. coughing when eating point to oesophageal or neuromuscular disease causing aspiration. A dry cough over many weeks can Treatment of cough signify a neoplasm. A cough may be dry because there is nothing Cough suppressants act centrally; most are opiate derivatives. They to produce, because secretions are swallowed, because of muscular are invaluable in terminal bronchial carcinoma. Atropine can be weakness, or because secretions are too viscid. useful to reduce the production of bronchial mucus and corti- costeroids reduce secretion in alveolar cell carcinoma and in asthma. Phlegm and sputum Aerosolized water is an effective expectorant. Volatile oils probably Phlegm from the lower respiratory tract is often combined with act as irritants. Mucociliary clearance increases under the influence secretions from the nose and pharynx and saliva to form sputum. of guiaphenesin, inhaled -adrenergic agonists, or hypertonic saline. In health, only about 100 ml of phlegm is produced each day Mucolytic agents are ineffective. A source of life threatening haemo- and most of this is swallowed. Intrabronchial mucus exists in two ptysis is only rarely found at bronchoscopy, but topical adrenaline, layers, one of low viscosity and high elasticity touching the cilia balloon tamponade, or cold saline lavage may help, as may em- and above this, a more viscous layer. Elasticity of phlegm depends bolization of the appropriate bronchial artery. on the rate of beating of the bronchial epithelial cilia. Airway mucus is 95 per cent water, the remainder being serous fluid and Breathlessness glycoprotein. There is a shift towards glycoprotein production in chronic bronchitis and greater transudate formation in asthma. A complaint of breathlessness may reflect true dyspnoea, hyperpnoea, Breakdown of leucocytes in infection increases the DNA content or hyperventilation. The history is critical in detecting the true nature of the complaint and the clinician must evaluate the quality of of sputum, making it less viscid and debris of cells and micro- breathlessness, its timing, severity, and the circumstances which pre- organisms give it a yellow colour. Non-infected sputum is clear cipitate or relieve it. and often jelly-like (mucoid). Viscid mucoid sputum often with pellets or branching plugs is seen in asthma. City dwellers produce Quality Asthmatics tend to recognize wheeze and usually find it more grey sputum. In lower respiratory tract infection, pus mixed with difficult to breathe in than out. A sense of suffocation is a feature of mucus produces mucopurulent sputum, but pure pus suggests a pulmonary oedema or massive pleural effusion. Phrases like I can’t lung abscess or stagnant bronchiectatic cavity. Anaerobic organisms fill my lungs properly’ suggest psychogenic breathlessness, but muscle ff give sputum a particularly o ensive odour. Large quantities of weakness must be excluded. watery mucus may come from alveolar cell carcinoma. Laboratory examination of sputum may be unrewarding in de- Severity A simple visual analogue scale relating breathlessness to tecting infecting organisms, but cytology may reveal an underlying activity (Table 1) can be useful, but no scale deals with breathlessness carcinoma and eosinophilia suggests airway allergy. which is significantly variable. 348 RESPIRATORY DISEASE 4 Table 2 Conditions causing breathlessness classified by rate of onset depress respiration; there has been a sad failure to find opiate derivatives with a more selective action on breathlessness. 1. Dramatically sudden: over 4. Chronic: over months or years minutes Chronic airflow obstruction Pneumothorax Diffuse fibrosing conditions Pulmonary embolism Chronic non-pulmonary causes, Chest pain Pulmonary oedema e.g. anaemia, hyperthyroidism The greater part of the lower respiratory tract is insensitive to pain. 2. Acute: over hours 5. Intermittent: episodic Acute pulmonary infiltrations, breathlessness Most parenchymal lung disorders proceed to an advanced state e.g. allergic alveolitis Asthma without pain. However, the parietal pleura is exquisitely sensitive Asthma Left ventricular failure to painful stimuli and unpleasant sensations can arise from the Left ventricular failure tracheobronchial tree. Pneumonia 3. Subacute: over days Pleurisy Pleural effusion Bronchogenic carcinoma Typical pleural pain is sharp and accentuated by respiratory move- Subacute pulmonary ment. Afferent pain fibres from the central diaphragm run in the infiltrations, e.g. sarcoidosis phrenic nerve to the cervical cord (C3/4), giving referred pain in the shoulder tip. The outer diaphragm is served by intercostal nerves (T7–12), causing referred pain to the upper abdomen. Most conditions giving rise to pleuritic pain are acute and in- flammatory in origin: either infection or infarction. Recurrent pleurisy should suggest bronchiectasis or embolism. In pleural effusion, the Timing and occurrence The rate of onset can give a clue to diagnosis typical pleuritic pain largely disappears and is replaced by a dull (Table 2), as can the circumstances precipitating breathlessness. ache. Pleural fibrotic disease is rarely painful, but pleural neoplasia Psychogenic breathlessness bears no relation to exertion. Breath- frequently is. A superior sulcus tumour of bronchial origin (Pancoast’s lessness made worse by lying flat (orthopnoea) is characteristic of left tumour) infiltrating the brachial plexus gives very severe pain in the ventricular failure or diaphragmatic paralysis. Nocturnal wakening shoulder and arm. with severe breathlessness (paroxysmal nocturnal dyspnoea) suggests left ventricular failure. The asthmatic wakes in the night with breath- Pain from the chest wall lessness, coughing, and wheezing. Postexertional breathlessness and Chest-wall pain can mimic pleurisy. Epidemic myalgia or Bornholm the triggering of wheezing breathlessness by irritants and allergic disease (see Chapter 16.22) is a bothersome manifestation of Coxsackie stimuli also suggest asthma. B infection which can involve the intercostal muscles (pleurodynia). The pre-eruptive stage of thoracic herpes zoster gives a stabbing pain. Investigation of the breathless patient Costal cartilage pain is generally not inflammatory, but can be If the clinical history points to chest disease simple lung function troublesome. Rib fractures can present diagnostic problems. Metastatic tests and radiology are the most useful investigations. Spirometry will disease of bone may be symptomatic before radiological change is define three groups; normal, an obstructive pattern, or a restrictive evident. pattern (see Chapter 4.3). The chest radiograph is of most value in Fleeting transient chest pains are often part of chronic, somatized furthering the diagnosis of conditions giving a restrictive pattern. The anxiety states. farther investigation of a patient with airflow obstruction is dealt with in Chapters 4.14 and 4.17. Breathlessness in a patient with Central chest pain normal spirometry and a clear chest radiograph presents special Sensations arising from the major airways are unpleasant and referred problems. Asthmatics, when well may have normal lung function and to the anterior chest wall. Tracheal inflammation causes a raw, painful cardiac conditions may be occult or intermittent. Neurological or sensation retrosternally. Persistent coughing can itself lead to soreness muscular disorders affecting the muscles of respiration must always in the upper airways and trachea. be considered and pulmonary hypertension is all too easily missed. The mediastinal structures of the thorax are responsible for a Hyperthyroidism and anaemia should not be forgotten as causes of multitude of pains. Of central pulmonary lesions likely to give breathlessness. Clues to psychogenic breathlessness include the sensation of in- mediastinal pain, neoplasia is the most likely culprit. ability to take a full breath,
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