Topic content. The main complaints of the respiratory patients are cough, sputum production, dyspnea, wheezes, chest pain

The main complaints of the respiratory patients are cough, sputum production, dyspnea, wheezes, chest pain, and hemoptysis.

Cough (tussis) is a difficult reflex-protective act that arises up at the irritation of areas cough:

· larynx,

· bifurcation of trachea and bronchi,

· gullet,

· pleurae sheets,

· external acoustic ducts.

There are many different factors (sputum, mucus, blood, dust, toxic gases, pieces of meal and other) can provoke cough.

Cough occurs due to inflammatory, mechanical, chemical, thermal irritation of cough receptors. In case of inflammation, exudative processes irritate the mucous membrane of the respiratory tract (laryngitis, tracheitis, bronchitis, and bronchiolitis) as well as from the alveoli (pneumonia, lung abscess). Mechanical irritants are small particles breathed in with the air (dust) or disturbance of the respiratory tract patency due to compression or increased tone. Thermal irritants are very cold or very hot air. Chemical irritants are gases with strong odor, including cigarette smoke.

The clinical description of cough relies to its character, timing and sputum production.

According to the rhythm, three forms of cough can be distinguished: a cough is permanent, periodic and fit-like. Permanent cough occurs in laryngitis, acute bronchitis, bronchogenic tumor of the lungs and in certain forms of tuberculosis.

Periodic cough is characteristic of influenza, pneumonia, pulmonary tuberculosis, and chronic bronchitis.

Certain aspects of the timing of coughing may give useful diagnostic clues. Morning cough is characteristic chronic bronchitis and sometimes asthma. Nocturnal cough is characteristic of tuberculosis, limphogranulomatosis, tumor. Evening cough can happen at the patients with pneumonia and acute bronchitis.

As to the character, the cough can be dry (without sputum, tussis sicca) and productive or moist (with sputum, tussis humida). Dry cough is observed in bronchitis, pleura irritation, miliary tuberculosis, in affection of the bronchopulmonary lymph nodes (pressure on the vagus nerve), whooping cough, asthma; Productive cough is present in bronchitis, pneumonia, lung tumor, purulent diseases of the lungs, bronchiectasis.

As to the timber, there are several patterns:

1) hacking cough, short and long, usually is accompanied by a painful mimic, is observed in dry pleurisy, initial stages of pleuropneumonia;

2) stridor in trachea compression with a tumor, goiter, in hysteria, laryngeal diseases;

4) hoarse — in inflammation of the vocal cords;

5) soundless — in ulceration, edema of the vocal cords, general malaise.

According to perspective of the conditions causing cough or the phenomena accompanying the cough, the following types can be distinguished:

1) cough caused by the changes in the position, observed when cavities in the lungs are present (bronchiectasis, caverns, abscess, gangrene of the lungs);

2) cough associated with meals (especially when food particles are present in the sputum), is seen when the esophagus is joined with the trachea or bronchus (esophageal cancer perforated to the respiratory tract);

3) cough accompanied by abundant sputum discharge, characteristic for emptying cavities, perforation of the abscess or empyema to the bronchus;

4) cough accompanied by vomiting, observed in whooping cough, pulmonary tuberculosis, chronic pharyngitis.

The character of the sputum may be helpful in the differential diagnosis. Thus, a cough producing frothy, pink-tinged sputum occurs in pulmonary edema; clear, white, mucoid sputum suggests viral infection or longstanding bronchial irritation; thick, yellowish or pus-containing (purulent) sputum suggests an infectious cause; rusty sputum suggests pneumococcal pneumonia; blood-streaked sputum suggests tuberculosis, bronchiectasis, carcinoma of the lung, or pulmonary infarction. Large amounts (copious) sputum is characterized Bronchiectasis.

Hemoptysis (haemoptoe). Hemoptysis is blood discharge at cough. If patient expectorates more than 50 ml blood in a day this condition is named pulmonary bleeding. This may be caused by the diseases of the lungs, airways (bronchi, trachea, larynx), cardiovascular system.

The expectoration of blood or of sputum, either streaked or grossly contaminated with blood, may be due to:

1) escape of red cells into the alveoli from congested vessels in the lungs (acute pulmonary edema);

2) rupture of dilated endobronchial vessels that form collat­eral channels between the pulmonary and bronchial venous systems (mitral stenosis);

3) necrosis and hemorrhage into the alveoli (pulmonary infarction);

4) ulceration of the bronchial mucosa or the slough of a caseous lesion (tuberculosis); minor damage to the tracheobronchial mucosa, produced by excessive coughing of any cause, can re­sult in mild hemoptysis;

5) vascular invasion (carcinoma of the lung);

6) necrosis of the mucosa with rupture of pulmonary-bronchial venous connections (bronchiectasis).

Massive hemoptysis may also be due to rupture of a pulmonary arteriovenous fistula; exsanguinating hemoptysis may occur with rupture of an aortic an­eurysm into the bronchopulmonary tree.

Hemoptysis associated with shortness of breath suggests mitral stenosis; in this condition the hemoptysis is often precipitated by sudden elevations in left atrial pressure during effort or pregnancy and is attributable to rupture of small pulmonary or bronchopulmonary anastomosing veins. Blood-tinged sputum in patients with mitral stenosis may also be due to transient pulmonary edema; in these circumstances it is usually associated with severe dyspnea.

A history of hemoptysis associated with acute pleuritic chest pain suggests pulmonary embolism with infarction.

Recurrent hemoptysis in a young, otherwise asymptomatic woman favors the diagnosis of bronchial adenoma.

Hemoptysis associated with congenital heart disease and cyanosis suggests Eisenmenger syndrome.

A history of recurrent hemoptysis with chronic excessive sputum production suggests the diagnosis of bronchiectasis.

Hemoptysis asso­ciated with the production of putrid sputum occurs in lung abscess, whereas hemoptysis associated with weight loss and anorexia in a male smoker suggests carcinoma of the lung. When blunt trauma to the chest is followed by hemoptysis, lung contusion is the probable cause.

A history of drug ingestion may be helpful in elucidating the etiology of hemoptysis; e.g., anticoagulants and immunosuppressive drugs can cause bleeding.

A history of ingestion of contraceptive pills may be a risk factor for the development of deep vein thrombosis and subsequent pulmonary embolism and infarction.

The blood may be bright red (in pulmonary tuberculosis, bronchogenic lung cancer, actinomycosis, vasculitis, bronchiectasis) or rusty-colored (in pleuropneumonia, lung infuriation) due to decomposition of the erythrocytes and hemosiderin formation.

Dyspnea (dyspnoea) may be both subjective and objective. In subjective dyspnoea the patient notices difficulties in respiration. In objective dyspnoea, the frequency, depth and rhythm of respiration change, as well as duration of inspiration and expiration. Subjective dyspnoea is present in hysteria, thoracic radiculitis, diencephalic syndrome, objective is observed in lung diseases (COPD, bronchogenic cancer, pneumonia, tuberculosis, pulmonary emphysema, bronchial asthma, pleura obliteration, etc.). Two types of dyspnoea can be distinguished as to the phase of respiration in which the patient has difficulties: in difficult inspiration — inspiratory, in difficult expiration — expiratory, in simultaneous difficulties in both breathing in and out — mixed dyspnoea. Dyspnoea may be physiological (on physical exercise) and pathological (in diseases of the respiratory system, cardiovascular system, hemopoietic organs, poisoning, etc.).

· Inspiratory dyspnea (dyspnoea inspiratoria) occurs when some mechanical obstacle gets into the upper respiratory tract, at narrowing of the trachea or a large bronchus (chiefly bronchiogenic cancer). The respiration becomes noisy (stridor). Inspiratory edema appears in prolapse of the tracheal or bronchial mucosa.

· Expiratory dyspnea (dyspnoea expiratoria) develops when opening of the small bronchi is narrowed due to inflammatory swelling of the mucous membrane, bronchospasm (bronchial asthma), hypersecretion which prevents reverse movement of the air from the alveoli.

· Mixed dyspnoea occurs in considerable reduction of the respiratory surface of the lungs (thrombosis of the pulmonary artery, pneumonia, bronchiolitis, lung edema, etc.).

Intensive dyspnea frequently accompanied by asphyxia is called suffocation, which develops in bronchial asthma, lung edema, fibrous alveolitis.

Wheezes are caused by air passing through narrowed airways and heard for a distance by patient. They are symptoms of acute bronchial asthma, asthma attack, sometimes COPD.

Origin of difficulty in breathing a patient often binds to the action of allergens (paint, pollen of plants, smoke, domestic chemistry, a dust is domestic, book, tissue).

During the attack of difficulty in breathing of patient occupies the forced position with fixing of overhead humeral belt. Difficulty in breathing is accompanied a fit-like dry cough. Exhalation is laboured. During exhalation dry wheezes are audible. Duration of attack a few minutes to 24 hours. An attack is halted after the removal of action of allergen and application of medications of extending shallow bronchial tubes. At the end of attack a patient expectorates viscid glassy sputum.

In respiratory diseases, pleura involvement results in a chest pain (dolor in pectore), because the pleura contains sensitive nerve endings, which are absent in the lung tissue.

The location of the pathological focus is responsible for the place of the pain. In dry pleurisy the pain develops in the low lateral portions of the chest, "pain in the side". When the diaphragmatic pleura is involved, the pain is felt in the abdomen and mimics such diseases as appendicitis, acute cholecystitis, pancreatitis. The pleural pain is piercing, becomes worse on deep breathing, cough and when the patient is lying on the healthy side. In diaphragmatic pleurisy and spontaneous pneumothorax the pain is usually acute and intensive, accompanying with dyspnea.

Дата добавления: 2015-10-30