Complaints in respiratory diseases

Among the complaints presented by patients with respiratory diseases, the most typical are cough, formation and separation of sputum, chest pain, difficulty breathing (dyspnea, suffocation). These complaints are more common in acute diseases of the respiratory system, while in the chronic course of the pulmonary process, especially in its early stages or outside of exacerbation, the severity of these manifestations is often minimal, which complicates timely diagnosis without targeted research.

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Cough

A typical patient complaint is cough, which reflects a reflex action caused by irritation of the nerve endings located in the larynx, the mucous membrane of different parts of the respiratory tract, but primarily the trachea and bronchi (especially in the areas of tracheal bifurcation, bronchial branches), and the pleural sheets. Rarely, cough is caused by extrapulmonary processes (for example, significant enlargement of the left atrium associated with a heart defect and irritation of the vagus nerve, reflux esophagitis ). Usually, damage to the respiratory tract is accompanied by abrupt coughing impulses, sometimes combined with pain, which becomes pronounced when the pleura is involved, especially with a deep breath, which ends a coughing attack.

Most often, cough is caused by secretions of bronchial mucosa cells, mucus, pus, blood, as well as tumors, foreign bodies, compression of the bronchi from the outside, or inhalation of various dust particles and irritants in the lumen of the respiratory tract. In all these cases, the cough impulse is a natural mechanism for releasing the tracheobronchial tree. Coughing attacks can be caused by low ambient temperatures.

A distinction is made between unproductive (usually dry ) and productive (usually wet ) cough.

A dry, unproductive, paroxysmal cough that is exhausting and does not bring relief is a typical rapid response to the inhalation of substances that irritate the mucous membrane and the entry (aspiration) of a foreign body. It is a characteristic sign of acute bronchitis, the early stage of acute pneumonia (especially viral), pulmonary infarction, the initial period of an asthma attack, when the mucus is too viscous and is not released with coughing fits, as well as pleurisy, pulmonary embolism.

Dry cough in acute bronchitis is often preceded by a feeling of tightness in the chest, difficulty breathing. A prolonged, unproductive, exhausting cough is usually caused by an endobronchial tumor, compression of a large bronchus and trachea from the outside (for example, by enlarged lymph nodes of the mediastinum), as well as pulmonary fibrosis, congestive heart failure. Dry unproductive cough (extreme degree) can resemble wheezing difficulty breathing ( stridor ), often occurring at night, which is usually caused by a tumor of a large bronchus or trachea (as well as their compression from the outside). Often, unproductive cough manifests itself in painful attacks, with the coughing period being replaced by deep breathing, accompanied by an extended whistle (whooping cough), associated with a narrowing of the lumen of the respiratory tract (swelling), convulsive spasm or acute edema of the vocal cords. If such an attack of coughing is prolonged, then swollen dilated veins of the neck, cyanosis of the neck and face become noticeable, which is caused by stagnation of venous blood due to increased intrathoracic pressure and obstructed outflow of blood into the right atrium.

A wet (productive) cough is characterized by the release of sputum, i.e. bronchial and alveolar secretion, the increased formation of which in the acute stage of the disease is usually a sign of a bacterial or viral infection ( acute tracheobronchitis ), inflammatory infiltrate of the lungs (pneumonia). Chronic productive cough is a symptom of chronic bronchitis, bronchiectasis. In all these cases, the strength of the cough impulse depends primarily on the existing difference between the pressure in the respiratory tract and the atmospheric pressure. At the same time, it increases sharply after closing the glottis at the height of a deep inhalation under the action of the abdominal press and diaphragm, which at the moment of subsequent exhalation leads to the fact that the air bursts out at an enormous speed, which varies at different levels of the bronchial tree (from 0.5 m / s to a hurricane speed of 50-120 m / s).

Usually long coughing fits ending with expectoration of sputum, often especially severe before bedtime and even more pronounced in the morning after sleep, are characteristic of chronic bronchitis. Sometimes such a coughing fit can cause syncope - a kind of cough fainting syndrome.

Among the possible complications of prolonged paroxysmal coughing, pneumomediastinum (air breakthrough into the mediastinum) should be mentioned.

For some reasons, the sputum that forms, despite a strong cough impulse, is not expectorated in some cases, which is usually due to its increased viscosity or voluntary swallowing. Often, a slight cough and a scanty amount of sputum are not considered by patients as a sign of illness (for example, a smoker's habitual morning cough ), which makes the doctor ask a special question about this. In some situations (emptying a lung abscess, large and multiple bronchiectasis), sputum discharge occurs at one time "with a full mouth", especially in some positions of the patient's body ("morning toilet of the bronchi" - their postural or positional drainage). With unilateral bronchiectasis, patients prefer to sleep on the affected side to prevent the cough that bothers them. But it is in this situation that postural drainage acquires the significance of a therapeutic procedure that promotes the removal of bronchial contents, which, in addition to a special posture, is assisted by an extended forced exhalation, which creates a high-speed air flow that carries away bronchial secretions.

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Study of sputum characteristics

Sputum analysis is of great importance for the diagnosis of pulmonary disease, i.e. the study of the characteristics of the sputum secreted or obtained by special methods ( bronchoscopy with the removal of bronchial contents). In this case, attention is paid to the amount, consistency, type, color, presence of impurities, smell, stratification of sputum, and data obtained during its microscopic (including cytological) examination are also taken into account. Daily sputum secretion fluctuates within wide limits, sometimes it can reach 1.0-1.5 liters (for example, with large bronchiectasis, abscesses and tuberculous cavities of the lungs, cardiac and toxic pulmonary edema, emptying through the bronchus of the pleural cavity with purulent pleurisy, bronchorrhea with pulmonary adenomatosis). Sputum may be liquid or more viscous, which is associated with the presence of mucus in it, which is especially abundant ("mucous" sputum) in acute inflammatory diseases of the lungs, the initial period of an attack of bronchial asthma. Most often, sputum has a mucopurulent appearance, rarely liquid sputum has a serous character (predominance of protein transudate), which is found in pulmonary edema, in alveolar cell carcinoma. The specified features are revealed when settling sputum, when it is divided into layers: pus accumulates at the bottom of the vessel (sometimes an admixture of pulmonary detritus), then comes serous fluid, the upper layer is represented by mucus. Such three-layer sputum can have an unpleasant (putrid, fetid) odor, which is usually characteristic of anaerobic or a combination of anaerobic and streptococcal bronchopulmonary infection.

Yellow and green sputum is typical for bacterial infection, sometimes a large number of eosinophils (allergy) give yellow sputum. In severe jaundice, sputum may resemble light bile, gray and even black sputum is acquired by people who inhale coal dust (miners).

When examining a patient with a productive cough, it is necessary to obtain material from the tracheobronchial tree (not saliva) and stain it using Gram staining.

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Hemoptysis

Of major clinical importance is the detection of blood in sputum, varying amounts of which give it a pinkish, red, brown color. In domestic literature, the terms "haemoptysen" and "haemoptoe" are usually used to denote hemoptysis, but in practical terms it is important to distinguish between bloody impurities in sputum (haemoptysen) and the release of pure scarlet blood (haemoptoe), which, as a rule, is foamy. Massive haemoptoe is said to occur when bleeding exceeds 200 ml per day, which usually requires bronchological, angiological (bronchial artery occlusion) or surgical (resection, ligation of bronchial arteries) intervention. Blood can be detected in sputum in the form of bloody streaks or a foamy scarlet mass with an alkaline reaction (pulmonary hemorrhage). First of all, it is necessary to exclude the entry of blood into sputum from the nose, nasopharynx, ulcers of the larynx, polyps of the upper respiratory tract, stomach contents in case of bleeding from dilated veins of the esophagus or damage to the gastric mucosa.

Of great diagnostic importance is the detection of episodes of deep vein thrombosis (swelling of the lower extremities) with pulmonary thromboembolism and pulmonary infarction or acute respiratory infection preceding hemoptysis.

Causes of hemoptysis

Frequent

• Bronchogenic cancer.
• Bronchiectasis (especially "dry").
• Pulmonary tuberculosis.
• Pulmonary infarction.
• Increased intrapulmonary pressure due to persistent cough.
• Abscesses and gangrene of the lungs.
• Acute pneumonia, usually lobar.
• Acute bronchitis, tracheitis, laryngitis due to viral infection.
• Heart defect ( mitral stenosis ).
• Congestive heart failure.
• Foreign bodies in the bronchi.
• Trauma of the pharynx and airways

Rare

• Pulmonary embolism
• Goodpasture's syndrome.
• Vasculitis.
• Lung damage in diffuse connective tissue diseases.
• Pulmonary arteriovenous fistulas.
• Thrombocytopenic purpura.
• Actinomycosis of the lungs.
• Hemophilia.
• Rendu-Osler syndrome (congenital telangiectasia).

Read more about the causes of hemoptysis in this article.

Usually hemoptysis occurs in acute bronchitis, pneumonia (rusty sputum), bronchiectasis (usually "dry", especially dangerous in terms of pulmonary hemorrhage, "dry" upper lobe bronchiectasis), bronchogenic cancer (usually moderate but persistent hemoptysis, less often sputum in the form of "raspberry jelly"), with abscesses and tuberculosis (bronchial damage, cavernous process), pulmonary infarction, as well as congestive heart failure, mitral stenosis, trauma and foreign bodies of the bronchi, pulmonary arteriovenous fistulas and telangiectasias (dilation of the terminal sections of small vessels).

In true hemoptysis, the blood is initially bright red, and then (1-2 days after the bleeding) begins to darken. If a small amount of fresh blood is constantly released over several days, bronchogenic cancer should be suspected.

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Chest pain

One of the complaints that makes one think about respiratory diseases is chest pain, and the most common cause of pain is pleural damage in the form of inflammation (dry pleurisy), less often in the form of an adhesive process (the result of previous pleurisy) or a tumor. Distinctive features of pleuritic pain are its severity, a clear connection with the act of breathing (a sharp increase at the height of inhalation, when coughing, sneezing, a decrease with immobilization of the chest) and body position (increased when bending to the healthy side and weakened when the body is positioned on the diseased side). The latter is characteristic primarily of pleurisy and subpleural pulmonary compaction (pneumonia, pulmonary infarction, lung tumor), when irritation of the nerve receptors of the parietal pleura occurs when both of its layers rub, the pain decreases or disappears after the appearance of fluid in the pleural cavity (exudate, transudate).

Pleuritic pain acquires a special character with the development of spontaneous pneumothorax (the appearance of air in the pleural cavity). Acute rupture of the visceral pleural leaflet leads to a sudden attack of sharp pain in a certain part of the chest, accompanied by shortness of breath due to acute collapse ( atelectasis ) due to compression of part of the lung by air that has entered the pleural cavity and hemodynamic disorders (a drop in blood pressure - collapse) due to the displacement of the mediastinal organs. With mediastinal emphysema accompanying pneumothorax, pain may resemble that of myocardial infarction.

A certain feature is pleural pain associated with the involvement of the diaphragmatic part of the pleura in the process (diaphragmatic pleurisy). In these cases, irradiation is noted in the corresponding half of the neck, shoulder or abdomen (irritation of the diaphragmatic part of the peritoneum) with imitation of the picture of acute abdomen.

Chest pain may be caused by the involvement of the intercostal nerves ( intercostal neuralgia is usually revealed by pain during palpation of the intercostal spaces, especially at the spine, in the armpit, at the sternum), muscles (myositis), ribs ( fractures, inflammation of the periosteum), costosternal joints (chondritis). In addition, chest pain occurs with shingles (sometimes even before the appearance of characteristic vesicular rashes along the intercostal space).

Pain behind the sternum in its upper part can be caused by acute tracheitis; more common chest pains of a squeezing, pressing nature, reminiscent of heart pain, can be associated with pathological processes in the mediastinum (acute mediastinitis, tumor).

It is necessary to remember about pain radiating to the chest in acute cholecystitis, liver abscess, appendicitis, and splenic infarction.

Dyspnea

Dyspnea is one of the common complaints associated with pulmonary disease, although this clinical sign occurs with approximately the same frequency in heart disease; sometimes dyspnea is associated with obesity, severe anemia, intoxication, psychogenic (eg, hysteria ) factors.

Read about other causes of shortness of breath in this article.

Subjectively, dyspnea is felt as discomfort associated with difficulty breathing, a feeling of tightness in the chest when inhaling and lack of air, the impossibility of taking a deep breath and completely releasing air when exhaling, as a general unpleasant condition due to hypoxemia and hypoxia (insufficient oxygen saturation of the blood and tissues). Severe respiratory failure with hypercapnia (for example, with severe pulmonary emphysema, severe heart failure) can lead to a decrease in the subjective sensation of dyspnea due to some habituation to dyspnea or a specific state of anesthesia. Such a subjective sensation of dyspnea has found a definite explanation only recently. It is believed that the respiratory muscles play a major role, from which nervous excitation is transmitted to the respiratory center. The same role is played by the receptors of the lungs, especially those located between the pulmonary capillaries and the wall of the alveoli (j-receptors), irritation of the latter, in particular, under conditions of capillary hypertension and interstitial edema causes hyperpnea, which is especially pronounced with compression and edema of the lungs, pulmonary embolism, diffuse fibrosing processes in the lungs. This mechanism is of leading importance in the sensation of dyspnea in left ventricular failure, when compression of the lungs due to congestion causes stimulation of the above receptors, dyspnea decreases in a vertical position, for example in a bed with an elevated head end (orthopnea).

In patients with lung diseases, dyspnea is closely associated with disturbances in the respiratory mechanism, such a level of "breathing work" when a large effort during inhalation, observed, for example, with increased rigidity of the bronchi and lungs (difficulty in bronchial patency, pulmonary fibrosis) or with a large chest volume (pulmonary emphysema, an attack of bronchial asthma), leads to an increase in the work of the respiratory muscles (in some cases with the inclusion of additional muscles, including skeletal).

The assessment of a patient's complaints of shortness of breath should begin with observing his breathing movements at rest and after physical exertion.

Objective signs of dyspnea are increased respiratory rate (more than 18 per 1 min), involvement of accessory muscles, cyanosis (in pulmonary diseases, usually “warm” due to secondary compensatory erythrocytosis).

A distinction is made between inspiratory (difficulty inhaling), expiratory (difficulty exhaling) and mixed dyspnea. Inspiratory dyspnea occurs when there are obstacles to air entering the trachea and large bronchi (swelling of the vocal cords, tumor, foreign body in the lumen of large bronchi), expiratory dyspnea is observed in bronchial asthma, and a mixed variant of dyspnea is more often noted.

Shortness of breath can take on the character of suffocation - a sudden attack of extreme shortness of breath, which most often accompanies bronchial and cardiac asthma.

There are 4 types of pathological breathing.

1. Kussmaul breathing is deep, rapid, and characteristic of patients with diabetic coma, uremia, and methyl alcohol poisoning.
2. Grocco's breathing has a wave-like character with alternation of weak shallow breathing and deeper breathing, observed in the early stages of comatose states.
3. Cheyne-Stokes breathing is accompanied by a pause - apnea (from a few seconds to a minute), after which shallow breathing appears, increasing in depth to noisy by the 5th-7th breath, then it gradually decreases and ends with the next pause. This type of breathing can be in patients with acute and chronic cerebral circulatory insufficiency, in particular, in elderly people with pronounced atherosclerosis of the cerebral vessels.
4. Biot's breathing is manifested by a uniform alternation of rhythmic, deep breathing movements with pauses of up to 20-30 sec. It is observed in patients with meningitis, in an atonal state in patients with severe cerebrovascular accident.

In pulmonary diseases, there are often more general complaints: loss of appetite, weight loss, night sweats (often mainly in the upper half of the body, especially the head); an increase in body temperature with different types of temperature curves is characteristic: constant subfebrile or febrile (acute pneumonia), hectic fever ( pleural empyema and other purulent lung diseases), etc.; such manifestations of hypoxia as hand tremors and convulsions are possible. In advanced stages of the chronic pulmonary process, pain in the right hypochondrium ( liver enlargement ) and swelling of the lower extremities appear - signs of heart failure with decompensated " pulmonary heart " (a decrease in the contractility of the right ventricular muscle due to persistent high hypertension in the vessels of the pulmonary circulation due to a severe pulmonary process).

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