Chapter 3 Cardiopulmonary Symptoms

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Chapter 3Cardiopulmonary Symptoms


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


Overview

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


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


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



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


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)


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


Causes and Clinical Presentation (cont’d)

Paroxysmal Periodic, prolonged, forceful episodes


Cough (cont’d)

Associated symptoms Wheezing Stridor Chest pain Dyspnea


Cough (cont’d)

Complications of cough Torn chest muscle Rib fractures Disruption surgical wounds Pneumothorax or pneumomediastinum Syncope Arrhythmia Esophageal rupture Urinary incontinence


Sputum Production

Sputum Secretions from tracheobronchial tree,

pharynx, mouth, sinuses, nose Phlegm

Secretions from lungs and tracheobronchial tree


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


Abnormal Sputum Production

Excessive production by inflamed glands Infection, cigarette smoking, allergies

Describe Color Quantity Consistency Odor Time of day Presence of blood



Hemoptysis

Expectoration of sputum containing blood From streaking to frank bleeding

Causes Bronchopulmonary Cardiovascular Hematologic Systemic disorders Tuberculosis or fungal infections



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


Hemoptysis vs. Hematemesis

Vomited blood Determine source

Oropharynx• Swallowed from respiratory tract

Esophagus or stomach • Alcoholism or cirrhosis of liver



Shortness of Breath (SOB)

Most distressing symptom of respiratory disease Single most important factor limiting ability to

function Cardinal symptom of cardiac disease


Dyspnea

Subjective experience of breathing discomfort

Components Sensory input to cerebral cortex Perception of the sensation

• “Breathless,” “short-winded,” “feeling of suffocation”


Dyspnea Scoring Systems

Scale of 0 (no SOB) to 10 (max SOB) Visual analog scales Modified Borg Scale ATS SOB Scale UCSD SOB Questionnaire





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




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


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


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


Description of Dyspnea (cont’d)

Trepopnea Dyspnea when lying on one side Unilateral lung disease, pleural effusion

Platypnea Dyspnea in upright position


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



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

AnginaSee Table 3-11


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


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



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


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


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


Fever, Chills, and Night Sweats

Euthermia 97° to 99.5° F (36° to 37.5° C) Fever (hyperthermia, pyrexia)

Sustained Remittent Intermittent Relapsing


Fever, Chills, and Night Sweats (cont’d)

Causes of fever Hot environment, dehydration, reaction to

chemicals, drugs, hypothalamic damage, infection, malignancy




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)


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


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


Snoring Clinical Presentation

Fatigue Excessive daytime sleepiness (EDS)

Occupational accidents Motor vehicle accidents Loss of employment Social dysfunction


Gastroesophageal Reflux

Heartburn and regurgitation Extraesophageal manifestations

Laryngitis, asthma, chronic and nocturnal dry cough, chest pain, dental erosion

GER more than twice a week = GERD Risk factors

Obesity, cigarette smoking, pregnancy

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Chapter 3 Cardiopulmonary Symptoms