Approach to Respiratory Symptoms Flashcards
Name the 3 most common causes of a chronic cough
asthma
GERD
rhinosinusitis
How long is an acute cough?
< 3 weeks
How long is a chronic cough?
> 8 weeks
What are the 3 components to a cough?
- deep inspiration
- expiration against a closed glottis
- opening of glottis and expiration
Involuntary cough is mediated by structures innervated by which nerve?
vagus nerve
Define nociceptors
receptors sensitive to irritants
stimulation of nociceptors and mechanoreceptors in the structures involved in coughing is relayed to what first structure in the brain?
medulla oblangata
The etiology of chronic coughs is thought to be driven by what process?
hyper responsiveness
- markedly increased response to inhaled capsaicin
- increased responsiveness or density of sensory nerves
What is the first step in evaluation a cough?
Establishing the length of the cough
What are the 3 most common causes of an acute cough?
viral RTIs
exacerbations of chronic conditions
pneumonia
Hemoptysis is an alarm symptom for a cough. What are the 4 things on the differential for this?
malignancy
TB
PE
pneumonia
Systemic symptoms such as weight loss and fever are alarm symptoms in evaluating a cough. What are 3 diseases they indicative of?
malignancy
TB
Pneumonia
A current smoker comes in with a new cough. What is this an alarm symptom of?
a malignancy
Wheezing and shortness of breath is an alarm symptom for evaluation of a cough. What do they indicate?
Asthma
COPD
CHF
Weight gain, nocturnal dyspnea, and peripheral edema accompanied by a new acute cough are all indicative of what condition?
congestive heart failure
In addition to other alarm symptoms such as hemoptysis, systemic symptoms, wheezing/shortness of breath, smoking history, weight gain, NPD, and edema, what is something you should ask about?
ability to swallow when eating and drinking
chest pain ** (PE, MI, pneumothorax)
hoarseness (malignancy)
What is the most common class of medications associated with a cough?
ACE inhibitors
- up to 20% of patients develop an acute cough which resolves with discontinuation of the medication
In addition to alarm symptoms, comorbidities, and medications, what are two things you should always ask about when evaluating an acute cough?
smoking activity and environmental factors
If a patient has a suspected viral RTI without alarm symptoms, what is NOT indicated?
diagnostic testing
patient should be re evaluated in 4 to 6 weeks to see if symptoms have resolved
What are the 4 steps of evaluating a chronic cough?
- Identify and treat the obvious causes
- Stepwise testing and treating of GERD, rhinosusitis, and asthma
- Investigation of more uncommon causes of the cough
- Treat unexplained chronic cough (UCC)
What is cough variant asthma?
when a patient presents with a cough without wheezing
What are the 3 steps in testing and treating for asthma in a chronic cough?
- evaluation for wheezing (may or may not be present)
- spirometry followed by methacholine challenge if negative
- trial of empiric inhaled corticosteroids
What is both diagnostic and treating of a chronic cough suspected to be GERD?
an empiric 3 month trial of acid suppression therapy (i.e. proton pump inhibitors)
What are the 2 steps in evaluating a chronic cough that is suspected to be rhinosinusitis?
- ENT referral
- empiric trial of nasal corticosteroids and antihistamine therapy
A 65 year old male presents to urgent care for evaluation of a cough that has been present for 10 weeks. He has smoked 1 pack of cigarettes per day for 40 years. He notes sputum is frequently streaked with blood and that he has lost 15 pounds in the past 2 months. His vital signs are unremarkable and he has no focal findings on physical exam. The appropriate next step in management is:
a. arrange for a non urgent CXR and prescribe a cough suppressant
b. trial of an inhaled corticosteroid for possible cough-variant asthma
c. urgent CXR, CBC and chem panel
d. prescribe a 5 day course of azithromycin for possible bacterial pneumonia
a. arrange for a non urgent CXR and prescribe a cough suppressant
b. trial of an inhaled corticosteroid for possible cough-variant asthma
c. urgent CXR, CBC and chem panel
- A chronic cough with alarm symptoms (hemoptysis and weight loss) requires urgent evaluation for malignancy. Basic lab testing and CXR are standard.
d. prescribe a 5 day course of azithromycin for possible bacterial pneumonia
A 35 year old male present to the ED for 2 weeks of dry coughing. He is a non-smoker, has no known medical problems, and denies any alarm symptoms. His vital signs and physical examination are unrevealing. A chest radiograph is normal. Which of the following is the appropriate next step?
a. Chest CT
b. Cough suppressant therapy with outpatient follow-up in 4 weeks
c. bronchoscopy
d. 5 day course of antibiotic therapy for community acquired pneumonia
a. Chest CT
b. Cough suppressant therapy with outpatient follow-up in 4 weeks
- an acute cough with normal physical exam and normal CXR suggest viral RTI which can be managed conservatively with close follow up and symptom management
c. bronchoscopy
d. 5 day course of antibiotic therapy for community acquired pneumonia
Dyspnea associated with congestive heart failure is frequently described how?
rapid or heavy breathing
hunger for air
suffocation
Dyspnea associated with interstitial lung disease is frequently described as what feeling?
increased effort
shallow breathing
gasping for air
Chest tightness is classically associated with what condition?
asthma/bronchospasm
What suggests that dyspnea is interpreted by the brain as a primal survival signal?
it is processed by the corticolimbic structures and the brainstem
i.e. insular cortex, cingulate gyrus, amygdala, and cerebellum
Studies in quadriplegic and healthy subjects who were given a neuromuscular blocking agent found that dyspnea in the setting of what gas imbalance can occur in the absence of respiratory muscle activity?
hypercapnia
Is hypercapnia or hypoxemia a more frequent cause of dyspnea?
hypercapnia
Patients with nasal congestion often report increased dyspnea, while someone sitting in front of a fan may not. What receptors are responsible for this?
flow receptors in the upper airway and trigeminal nerve skin
Rapidly adapting fibers in pulmonary stretch receptors are responsible for the sensation of dyspnea during dynamic airway collapse, which is associated with what condition?
COPD
Activation of slow adapting pulmonary stretch receptors with lung inflation increases or decreases the sensation of dyspnea?
bonus: which drug significantly decreases dyspnea when given by inhalation due to its action on or against these receptors?
Decreases it
Furosemide (loop diuretic) potentiates these receptors and decreases dyspnea when inhaled
What are C fibers? Where are they found?
irritant receptors in the lung and upper airways that contribute to dyspnea
modulate bronchoconstriction in the upper airway epithelium and dyspnea sensed during pulmonary edema in the alveoli
What is neuromechanical uncoupling (or length tension mismatch)?
When the actual work performed by the respiratory system does not match the intensity of the motor command
What are the 2 most common reasons for neuromuscular uncoupling?
increased load
respiratory muscle weakness
Effort sense during neuromuscular uncoupling is a function of what ratio?
pressure generated by inspiratory muscles for a given breath (Pi) v. maximal pressure achiveable by the muscles (P max)
What is the main cause of breathlessness in COPD?
hyperinflation
What are the 3 aspects of the clinical history for the evaluation of dyspnea?
Dyspnea characteristics (OLDCARTS, including associated symptoms, nocturnal symptoms, orthopnea)
Impact on daily life
collateral information (ie family and friends)
What are pertinent positives for the general physical exam when evaluating dyspnea?
obesity or notable catexia
What are pertinent cardiac positives on the dyspnea ROS?
pleural rub
JVD
gallop
murmur
lower extremity edema
What are pertinent positives for the ROS in dyspnea?
crackles, wheezes, decreased breath sounds, pattern
What are pertinent positives for the MSK in a dyspnea ROS?
clubbing, skeletal deformities
What is the hall walk in an evaluation of dyspnea?
walking with a dyspneic patient while they are connected to a pulse ox. watch for hypoxemia or tachycardia on ambulation. Especially informative for lower extremity weakness, claudication, or joint pain as major causes of limitations other than dyspnea
How is acute dyspnea defined?
over the course of minutes to days up to 4 weeks
What is the definition of chronic dyspnea?
> 4 weeks
What are the most common causes of chronic dyspnea? (5)
asthma, COPD, ILD, CHF, and obesity/deconditioning
When are opioids an appropriate treatment for dyspnea?
Palliative medication in end stage cardiopulmonary disease (i.e. ICU at end of life)
A 34 year old woman presents with worsening breathlessness over the past 3 days. She describes the sensation as “chest tightness” The most likely diagnosis is:
a. pneumonia
b. pneumothorax
c. asthma exacerbation
d. pulmonary embolism
a. pneumonia
b. pneumothorax
c. asthma exacerbation
“Chest tightness” is a commonly associated descriptor for bronchospasm
d. pulmonary embolism
A 34 year old man with hereditary hemorrhagic telangiectasia presents with worsening dyspnea on exertion for 3 months’ duration. On exam he appears pale but in no acute distress. Vital signs are normal except for a resting HR of 105 bpm. Examination demonstrates lip telangiectasia, normal heart tones, and normal breath sounds. His oxygen saturation on room air is normal. The most likely cause of this patient’s dyspnea is:
a. pulmonary hemorrhage
b. anemia
c. myocardial ischemia
d. pulmonary embolism
a. pulmonary hemorrhage
b. anemia
the others are important causes of ACUTE dyspnea. anemia is the only one that would cause CHRONIC dyspnea (especially since he is pale)
c. myocardial ischemia
d. pulmonary embolism
A 68 year old man has severe smoking related COPD causing lung hyperinflation. He takes an inhaled corticosteroid, an inhaled long-acting beta agonist, and an inhaled long-acting muscarinic antagonist daily. He uses 2 liters per minute supplemental oxygen to maintain adequate oxygen saturation at rest and with activity. The patient reports significant dyspnea with activity. The LEAST likely explanation for this patient’s dyspnea is:
a. hypoxemia
b. lung hyperinflation
c. deconditioning
d. severe airflow obstruction
a. hypoxemia
Chronic dyspnea has well described associations with the other 3. hypoxemia and dyspnea have a much less consistent association in COPD
b. lung hyperinflation
c. deconditioning
d. severe airflow obstruction
