BDS Lecture (1) Symptomatology of Resp System

RESPIRATORY SYSTEM
Symptoms of respiratory system

History taking
• Breathlessness
• Wheeze
• Cough
• Sputum
• Hemoptysis
• Stridor
• Chest pain
• Fever
• Weight loss
• Sleepiness
Breathlessness/shortness of breath
Breathlessness (or dyspnoea) denotes the feeling of an ‘uncomfortable need to breathe
most challenging to quantify
Causes
Respiratory
Cardiac dysfunction
Psychological distress.
Metabolic disorders
Respiratory disease can cause breathlessness through a range of mechanisms

Stimulation of intrapulmonary afferent nerves by interstitial inflammation
or thromboembolism
Mechanical loading of respiratory muscles by airflow obstruction
Reduced lung compliance in fibrosis
Hypoxia due to ventilation/perfusion mismatch, stimulating chemoreceptors
How did the breathlessness come on?
•Onset instantaneous over hours insidious onset
•Duration
•Progression
•Aggravating factors .
Tell me something you do that would make you breathless? How far can you walk on a good day?Ask
about exercise
•Relieving factors
•Associated features
How is your breathing at rest and overnight?

Breathlessness provoked by lying down (orthopnoea)
Is your breathing normal some days?

The Medical Research Council (MRC) breathlessness scale
1) Not troubled by breathlessness except on strenuous exercise

2) Short of breath when hurrying on the level or walking up a slight hill
3) Walks slower than most people on the level, stops after a mile or so, or stops after 15 minutes walking at
own pace
4) Stops for breath after walking about 100 yds or after a few minutes on level ground
5) Too breathless to leave the house, or breathless when undressing
Wheeze
High-pitched musical or ‘whistling’ sounds produced by turbulent air flow through small airways narrowed by
bronchospasm and/or airway secretions.
It is most commonly heard during expiration, when airway calibre is reduced.
• Is the wheeze worse during or after exercise?
• Do you wake with wheeze during the night?
• Do you have hay fever or other allergies? Atopy is common in allergic asthma.
A family history of wheeze or asthma
• Is it worse on waking in the morning and relieved by clearing sputum?
• Do you smoke?
• Are there daily volumes of yellow or green sputum or blood
Cough
The cough reflex has evolved to dislodge foreign material and secretions from the central airways, and may be
triggered by pathology at any level of the bronchial tree.
• Duration of the cough (chronic cough is lasting more than 8 weeks duration )
Whether it is present every day.
• Whether it produces sputum.
• If so, how much and what colour?
• Any triggers (such as during swallowing, in cold air, during exercise).
• Smoking
• Wheeze
• Heartburn
• Altered voice or swallowing
• Drug history, especially angiotensin-converting enzyme (ACE) inhibitors
Stridor
This harsh, grating respiratory sound is caused by vibration of the walls

of the trachea or major bronchi when the airway lumen is critically
narrowed by compression, tumor or inhaled foreign material.
Inspiration lowers the pressure inside the extra thoracic trachea, so critical narrowing here leads to inspiratory
stridor.
In contrast, the intrathoracic large airways are compressed during expiration and inspiration by positive pressure
in the surrounding lung, leading to fixed expiratory wheeze or stridor.
Sputum
Normally airway lining fluid coating the tracheobronchial tree ascends the mucociliary escalator to the larynx,
where it mixes with upper respiratory tract secretions and saliva and is swallowed
In acute or chronic airways infection, accumulation of neutrophils, mucus and proteinaceous secretions in the
airways results in cough with expectoration of sputum
Characteristics of sputum onset duration
A change in colour or consistency, increase in volume
Color
• Clear (mucoid)
• Yellow (mucopurulent)
• Green (purulent)
• Red/brown (rusty or red )
• Pink (serous/frothy) acute pulmonary oedema
Volume
• Establish the volume produced over 24 hours
• Small amounts into a tissue or enough to fill a spoon(s) or cup(s).
• Compare the current volume with the patient’s baseline or minimal volume.
Consistency
• An increase in stickiness (viscosity)
• Large volumes of frothy secretions over weeks/months
• Occasionally, sputum is produced as firm ‘plugs
Haemoptysis
Coughing up blood from the respiratory tract.
Never assume haemoptysis has a benign cause until serious pathology has been considered and excluded.
Ask about appearance
how much blood was there,
whether there are associated features and over what time period it came on
Was the blood definitely coughed up from the chest
Blood in the mouth may be vomited
may have come from the nose in epistaxis,
or may appear on chewing or tooth brushing in patients with gum disease.
Larger volumes of haemoptysis (>20 mL, for example) suggest specific causes
Chest pain
•Musculoskeletal
• respiratory
• cardiovascular
• and gastro-oesophageal disease.
Onset
duration
Site and severity.
Character: sharp suggests pleural pain.
Exacerbating or relieving factors worsening with cough or deep breaths suggests pleural disease.
Associated symptoms
Breathlessness, fever and cough suggest an infective cause
A large pulmonary embolus can cause angina-like chest pain, due to increased right ventricular work together
with reduced coronary oxygen.
myocardial ischaemia,
Pain does not originate in the lung parenchyma or visceral pleura, as they have only an autonomic nerve supply.
Pleuritic pain is worse on inspiration and coughing, and is usually described as sharp, stabbing or knife-like. It is
usually sited away from the midline, and may be localised or affect a wide area of chest wall.
Herpes zoster pain persist long after the rash has resolved, often with scarring in the dermatomal distribution.
Burning retrosternal pain may indicate oesophagitis but also occurs with myocardial ischaemia.
Central, constant, progressive, non-pleuritic chest pain may represent mediastinal disease, particularly
malignancy.
Similarly, chest wall pain (without trauma) that is constant, progressive and non-pleuritic suggests chest wall
invasion by malignancy
Fevers/rigors/night sweats
Onset
duration
Progression
character
Patients use a range of terms to describe fever (such as shivers, chills, being ‘hot and bothered’, shakes), so ask
for a detailed account of their symptoms using common terms.
Rigors are generalised, uncontrollable episodes of vigorous body shaking lasting a few minutes. Despite high
fever, the patient may complain of feeling cold and seek extra clothing.
Night sweats are more closely associated with chronic infection

Weight loss
The pathophysiology is complex however,

breathlessness is associated with diminished appetite,
and the systemic inflammatory response is also thought to contribute to weight loss.
Ask the patient to estimate the extent and duration of weight loss,
and enquire about appetite and dietary intake.
Being underweight is a poor prognostic indicator in any chronic respiratory disease
Sleepiness
Excessive daytime sleepiness may be a symptom of an underlying

sleep-related breathing disorder (obstructive sleep apnoea )
In these conditions, frequent episodes of upper airway obstruction at night
cause repeated microarousals from sleep, leading to complete disruption of normal sleep.
Daytime somnolence impairs work and driving performance, causing danger to the patient and others.
Past medical history
These include respiratory disease that may recur
Eczema /Hay fever/whooping cough /measles/inhaled foreign body
Pneumonia/tuberculosis/connective tissue disorders /previous malignancy /
Travel /surgery/neuromuscular disorders / hospitalisation.
Drug and allergy history
Inhalers, nebulised bronchodilators and domiciliary oxygen, non-prescription remedies and recreational drugs.
Always ask and record whether the patient has any known allergies,
as allergic asthma is far more common in those with a history of atopy.
Family history
Ask about a family history of asthma
Respiratory diseases with a known genetic cause are rare
Most patients with cystic fibrosis have unaffected carrier parents but many have affected siblings.
Social history
Always start by identifying the patient’s normal level of daily activity and the impact of their recent symptoms on
this. Can they still manage their work, their self-care and any caring
Home circumstances
Patients limited by chronic respiratory conditions may become confined to their own homes, particularly if they
become too breathless to manage stairs.
Smoking
Ask if others smoke in the house; this can be a major obstacle to smoking cessation.
cannabis and e-cigarettes.
Occupational history
Many respiratory diseases are caused by occupational or domestic exposure to inhaled substances.
Factory /farms/heavy industry/animal contact
• Systematic Inquiry Ask specifically about any risk factors,
such as malignancy for thromboembolism
such as ovarian malignancy presenting with pleural effusion

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RESPIRATORY SYSTEM

Symptoms of respiratory system

Respiratory disease can cause breathlessness through a range of mechanisms

How is your breathing at rest and overnight?

Is your breathing normal some days?

1) Not troubled by breathlessness except on strenuous exercise

This harsh, grating respiratory sound is caused by vibration of the walls

Night sweats are more closely associated with chronic infection

The pathophysiology is complex however,

Excessive daytime sleepiness may be a symptom of an underlying

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