Chapter 3 Cardiopulmonary Symptoms

1. Chapter 3Cardiopulmonary Symptoms

2. 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 Snoring Gastroesophageal reflux

3. Overview Primary symptoms of cardiopulmonary disorders Cough Sputum production Hemoptysis Shortness of breath (dyspnea) Chest pain

4. 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

5. Cough Protective reflex Simulation of receptors 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

7. Cough (cont’d) Afferent pathway Vagus, phrenic, glossopharyngeal, trigeminal nerves Efferent pathway Smooth muscles of larynx and tracheobronchial tree via phrenic, spinal nerves Phases Inspiratory Compression expiratory

8. 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 Decrease in lung recoil (e.g., emphysema) Abnormal quantity or quality of mucus production (e.g., thick sputum)

9. Causes and Clinical Presentation Acute Sudden onset; severe, short course; self-limiting Viral infection Chronic Persistent, >3 weeks Postnasal drip, asthma, COPD exacerbation, allergic rhinitis, GERD, chronic bronchitis, bronchiectasis, left heart failure

10. Causes and Clinical Presentation (cont’d) Paroxysmal Periodic, prolonged, forceful episodes

11. Cough (cont’d) Associated symptoms Wheezing Stridor Chest pain Dyspnea

12. Cough (cont’d) Complications of cough Torn chest muscle Rib fractures Disruption surgical wounds Pneumothorax or pneumomediastinum Syncope Arrhythmia Esophageal rupture Urinary incontinence

13. Sputum Production Sputum Secretions from tracheobronchial tree, pharynx, mouth, sinuses, nose Phlegm Secretions from lungs and tracheobronchial tree

14. Sputum Production (cont’d) Components Mucus, cellular debris, microorganisms, blood, pus, foreign particles Normal sputum 100 ml/day Upward displacement via wavelike motion of cilia until swallowed

15. Abnormal Sputum Production Excessive production by inflamed glands Infection, cigarette smoking, allergies Describe Color Quantity Consistency Odor Time of day Presence of blood

17. Hemoptysis Expectoration of sputum containing blood From streaking to frank bleeding Causes Bronchopulmonary Cardiovascular Hematologic Systemic disorders Tuberculosis or fungal infections

19. Hemoptysis (cont’d) Description Amount Massive hemoptysis: 400 ml/3h or 600 ml/24h Emergency condition Cancer, tuberculosis, bronchiectasis, trauma Streaky: pulmonary infection, lung cancer, thromboemboli Odor, color, acuteness

20. Hemoptysis vs. Hematemesis Vomited blood Determine source Oropharynx Swallowed from respiratory tract Esophagus or stomach Alcoholism or cirrhosis of liver

22. Shortness of Breath (SOB) Most distressing symptom of respiratory disease Single most important factor limiting ability to function Cardinal symptom of cardiac disease

23. Dyspnea Subjective experience of breathing discomfort Components Sensory input to cerebral cortex Perception of the sensation “Breathless,” “short-winded,” “feeling of suffocation”

24. Dyspnea Scoring Systems Scale of 0 (no SOB) to 10 (max SOB) Visual analog scales Modified Borg Scale ATS SOB Scale UCSD SOB Questionnaire

28. Causes, Types, and Clinical Presentation of Dyspnea WOB abnormally high for the given level of exertion Asthma and pneumonia Ventilatory capacity is reduced Neuromuscular disease Drive to breathe is elevated Hypoxemia, acidosis, exercise

31. Clinical Types of Dyspnea Cardiac and circulatory related Inadequate supply of oxygen to tissues Primarily during exercise Psychogenic Panic disorder Not related to exertion Hyperventilating Rate, depth exceeds body’s metabolic need Results in hypocapnia and decreased cerebral blood flow

32. Acute and Chronic Dyspnea Acute Children: asthma, bronchiolitis, croup, epiglottitis Adults: pulmonary embolism, asthma, pneumonia, pneumothorax, pulmonary edema, hyperventilation, panic disorder Chronic COPD and CHF most common causes

33. Description of Dyspnea Paroxysmal nocturnal dyspnea (PND) Sudden dyspnea when sleeping in recumbent position Associated with coughing Sign of left heart failure Orthopnea Dyspnea when lying down Associated with left heart failure

34. Description of Dyspnea (cont’d) Trepopnea Dyspnea when lying on one side Unilateral lung disease, pleural effusion Platypnea Dyspnea in upright position

35. Description of Dyspnea (cont’d) Orthodeoxia 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

37. Chest Pain Causes 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

38. 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 Increases with pressure and movement Chest wall pain Intercostal and pectoral muscles Well localized

39. Dizziness and Fainting (Syncope) Temporary loss of consciousness: from reduced cerebral blood flow and oxygen Causes Thrombosis, embolism, atherosclerotic obstruction Pulmonary: embolism, bouts of coughing, hypoxia, hypocapnia Vasovagal: most common type of syncope Loss of peripheral venous tone

41. Dizziness and Fainting (Syncope) (cont’d) Orthostatic hypotension Sudden drop in blood pressure when a person stands up Dizziness, blurred vision, weakness, syncope Elderly, vasodilators, dehydration

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

43. Dependent Edema Edema is soft tissue swelling from abnormal accumulation of fluid Bilateral peripheral edema 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

44. Fever, Chills, and Night Sweats Euthermia 97° to 99.5° F (36° to 37.5° C) Fever (hyperthermia, pyrexia) Sustained Remittent Intermittent Relapsing

45. Fever, Chills, and Night Sweats (cont’d) Causes of fever Hot environment, dehydration, reaction to chemicals, drugs, hypothalamic damage, infection, malignancy

48. Fever with Pulmonary Disease Pulmonary infections Lung abscess, empyema, tuberculosis, pneumonia Remittent fever in mycoplasma pneumonia, legionnaire’s disease, acute viral infections Infection with no fever High-dose corticosteroids Immunosuppressants Immunocompromised (leukemia, AIDS)

49. Headache, Altered Mental Status, and Personality Changes Headache as a manifestation of cerebral hypoxia and hypercapnia Lung disease, high altitude Altered mental status in hypercapnia From affected alertness to coma Personality changes in advanced pulmonary disorders Forgetfulness, inability to concentrate, anxiety, irritability

50. Snoring Serious concern when associated with apnea Evaluation for OSA Incidence and causes 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