Complaints in diseases of the respiratory system

Among the complaints made by patients with respiratory diseases, the most typical are coughing, education and separation of sputum, pain in the chest, shortness of breath (shortness of breath, choking). These complaints are more often encountered in acute respiratory diseases, while in the chronic course of the pulmonary process, especially in the early stages of it or outside the exacerbation, the severity of these manifestations is often minimal, making it difficult to diagnose a timely diagnosis without a purposeful study.

[1], [2], [3], [4], [5], [6], [7]

Cough

A typical complaint of the patient is a cough that reflects a reflex act 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 tracheal bifurcation zones, the branches of the bronchi), as well as the pleura. Rarely, the cause of coughing is extrapulmonary processes (for example, a significant increase in the left atrium and irritation of the vagus nerve, reflux esophagitis ) associated with heart disease . Usually, the defeat of the respiratory tract is accompanied by abrupt coughing jerks, sometimes combined with pain, which becomes pronounced when the pleura is involved, especially with a deep breath, which ends with a fit of coughing.

The most common cause of cough is the secretion of bronchial mucosa cells, mucus, pus, blood, as well as tumors, foreign bodies, compression of bronchi from the outside or the inhalation of various dust particles and irritants. In all these cases, the cough push is a natural mechanism for the release of the tracheobronchial tree. Coughing attacks can cause a low ambient temperature.

There are non-productive (usually dry ) and productive (most often wet ) cough.

Dry, unproductive paroxysmal cough, debilitating and not bringing relief, is a typical quick response to the inhalation of substances irritating the mucous membrane and ingestion (aspiration) of a foreign body. It is a characteristic sign of acute bronchitis, early stage of acute pneumonia (especially viral pneumonia ), lung infarction, the initial period of asthma attack, when the mucus is too viscous and is not secreted by coughing, as well as pleurisy, pulmonary embolism.

Dry cough with acute bronchitis is often preceded by a feeling of tightness in the chest, shortness of breath. A prolonged, unproductive, debilitating cough is usually caused by an endobronchial tumor, compression of a large bronchus and trachea from the outside (eg, enlarged lymph nodes of the mediastinum), as well as pulmonary fibrosis, congestive heart failure. Dry non-productive cough (extreme degree) may resemble wheezing difficulty breathing ( stridor ), often occurring at night, which is usually due to a tumor of large bronchus or trachea (as well as their compression from the outside). Often non-productive cough is manifested by painful attacks, with the cough period being followed by deep breathing accompanied by an elongated whistle (pertussis-like cough) associated with a narrowing of the airway lumen (swelling), convulsive spasm, or acute swelling of the vocal cords. If such a fit of coughing is delayed, the swollen enlarged veins of the neck, cyanosis of the neck and face become noticeable, which is caused by stagnation of venous blood due to an increase in intrathoracic pressure and a complicated outflow of blood into the right atrium.

A moist (productive) cough is characterized by sputum secretion, ie, bronchial and alveolar secretions, whose increased formation in the acute stage of the disease is usually a sign of bacterial or viral infection ( acute tracheobronchitis ), inflammatory lung infiltrate (pneumonia). Chronic productive cough is a symptom of chronic bronchitis, bronchiectasis. In all these cases, the force of the cough shock depends primarily on the difference between airway pressure and atmospheric pressure. Moreover, it sharply increases after the closure of the glottis at the height of the deep inspiration under the action of the abdominal press and the diaphragm, which at the time of the subsequent exhalation leads to the fact that the air escapes outwards at a tremendous rate that varies at different levels of the bronchial tree (from 0.5 m / s to a hurricane speed of 50-120 m / s).

Usually, prolonged attacks of cough, ending with sputum, often very heavy before going to bed, and even more pronounced in the morning, after sleep, are characteristic of chronic bronchitis. Sometimes with such an attack of cough, a syncopal condition may arise -a kind of cough syncope.

Among the possible complications of prolonged paroxysmal coughing should be called pneumomediastinum (air penetration into the mediastinum).

For some reasons, the sputum produced, in spite of a strong cough push, in some cases does not expectorate, which is usually associated with its increased viscosity or with an arbitrary swallowing. Often, a small cough and a sparse amount of sputum is not considered a symptom of a patient (for example, the habitual morning cough of a smoker ), which causes the doctor to ask a special question about this. In some situations (the emptying of the lung abscess, large and multiple bronchiectasises), the sputum is discharged simultaneously by a "full mouth", especially at certain positions of the patient's body ("morning toilet of the bronchial tubes" - their postural or positional drainage). With unilateral bronchiectasis, patients prefer to sleep on the affected side to prevent their coughing. But it is in this situation that postural drainage acquires the importance of a therapeutic procedure that promotes the excretion of bronchial contents, which, in addition to a special posture, is assisted by an elongated-forced exhalation, in which a high-speed air current is created that carries with it a bronchial secret.

[8], [9], [10], [11], [12], [13], [14], [15], [16]

Examination of sputum features

Very important for the diagnosis of pulmonary disease is the analysis of sputum, that is, the study of the characteristics of excreted or obtained by special methods ( bronchoscopy with deducing the contents of the bronchi) sputum. Attention is drawn to the amount, consistency, appearance, color, presence of impurities, odor, sputum, and also the data obtained from microscopic (including cytological) examination of it. Sputum production of sputum varies widely, sometimes it can go up to 1.0-1.5 liters (for example, with large bronchiectasises, abscesses and tubercular caverns of the lungs, cardiac and toxic pulmonary edema, emptying through the bronchus of the pleural cavity with purulent pleurisy, bronchorrhoea adenomatosis of the lungs). Sputum can be liquid or more viscous, which is associated with the presence in it of mucus, which is especially plentiful ("mucous" sputum) in acute inflammatory lung diseases, the initial period of asthma attack. Most sputum is mucopurulent, rarely liquid sputum is serous (the predominance of protein transudate), which is found with pulmonary edema, with alveolar-cell carcinoma. These features are revealed when the sputum is upheld, when it separates into layers: pus accumulates on the bottom of the vessel (sometimes an admixture of pulmonary detritus), then a serous fluid flows, the upper layer is represented by mucus. Such a three-layered sputum may have an unpleasant (putrefactive, fetid) smell, which is usually characteristic of anaerobic or combination of anaerobic and streptococcal bronchopulmonary infection.

Yellow and green color of phlegm is typical for bacterial infection, sometimes yellow color sputum is attached to a large number of eosinophils (allergies). With severe jaundice, sputum may resemble light bile, gray and even black color gets sputum in persons inhaling coal dust (miners).

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

[17], [18], [19], [20], [21], [22]

Hemoptysis

The most important clinical significance is the detection of impurities in the sputum, a different amount of which gives it a pink, red, brown color. In the domestic literature , the terms "haemoptysen" and "haemoptoe" are commonly used to denote hemoptysis, and yet in practice it is important to distinguish spotted impurities from sputum (haemoptysen) and the isolation of pure scarlet blood (haemoptoe), which, as a rule, has a foamy character. The massive haemoptoe is said to be bleeding more than 200 ml per day, which usually requires bronchial, angiologic (occlusion of the bronchial artery) or surgical (resection, bronchial artery ligation) intervention. Blood can be found in sputum in the form of bloody veins or a foamy scarlet color and with an alkaline mass reaction (pulmonary bleeding). First of all, it is necessary to exclude the ingress of blood into the sputum from the nose, nasopharynx, ulceration of the larynx, polyps of the upper respiratory tract, stomach contents during bleeding from the esophagus enlarged veins or damage to the gastric mucosa.

An important diagnostic value is the detection of previous hemoptysis episodes of deep vein thrombosis (edema of the lower limbs) with pulmonary thromboembolism and a lung infarction or acute respiratory infection.

Causes of hemoptysis

Frequent

• Bronchogenic cancer.
• Bronchiectasis (especially "dry").
• Pulmonary tuberculosis.
• Lung infarction.
• Increased pulmonary pressure due to persistent cough.
• Abscesses and gangrene of the lungs.
• Acute pneumonia, usually croupier.
• Acute bronchitis, tracheitis, laryngitis in viral defeat.
• Heart disease ( mitral stenosis ).
• Congestive heart failure.
• Foreign bodies of bronchi.
• Injury to pharynx and airborne

Rare

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

Read more about the causes of hemoptysis in this article.

Usually hemoptysis occurs with acute bronchitis, pneumonia (rusty sputum), bronchiectasis (more often "dry", especially dangerous for pulmonary hemorrhage, "dry" vorchne-share bronchiectasis), bronchogenic cancer (usually mild but persistent hemoptysis, less often phlegm in the form of "Raspberry jelly"), with abscesses and tuberculosis (bronchial damage, cavernous process), lung infarction, as well as congestive heart failure, mitral stenosis, trauma and foreign bodies of bronchi, pulmonary arteriovenous fistulas and telangiectasis x (expanding end sections of small vessels).

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

[23], [24], [25], [26], [27], [28], [29]

Pain in the chest

One of the complaints that cause thinking about respiratory diseases is pain in the chest, with the most common cause of pain - pleural lesions in the form of inflammation (dry pleurisy), less often in the form of adhesions (the result of a pleurisy) or a tumor. The distinctive features of pleural pains are their sharpness, a clear connection with the act of breathing (sharp increase at the height of inspiration, with coughing, sneezing, diminishing with immobilization of the chest) and the position of the body (strengthening when flexing to the healthy side and loosening with the body on the sore side) . The latter is primarily characteristic of pleurisy and subpleurally pulmonary densis located (pneumonia, lung infarction, lung tumor), when irritation of the nerve receptors of the parietal pleural leaf occurs during the friction of both its leaves, the pain diminishes or disappears after the appearance in the pleural cavity of fluid (exudate, transudate) .

A special character is acquired by pleural pain in the development of spontaneous pneumothorax (the appearance of air in the pleural cavity). The acute rupture of the visceral pleural leaf leads to a sudden attack of sharp pains in a certain part of the chest accompanied by dyspnea due to acute decay ( atelectasis ) due to the compression of air in the pleural cavity, parts of the lung and hemodynamic disorders (falling blood pressure - collapse) for the displacement of the mediastinum. With concomitant pneumothorax, mediastinal emphysema pain can resemble those with myocardial infarction.

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

Pain in the chest may be due to the involvement of intercostal nerves in the process ( intermittent neuralgia is usually indicated by pain in the palpation of the intercostal space, especially in the spine, in the armpit, in the sternum), muscles (myositis), ribs ( fractures, inflammation of the periosteum), rib- chest joints (chondrite). In addition, pain in the chest occurs with shingles (sometimes even before the appearance of the characteristic interstitial blister rash).

The pain behind the breastbone at the top of it can be caused by acute tracheitis, the more common chest pains of compressive, pressing nature resembling cardiac pain may be associated with pathological processes in the mediastinum (acute mediastinitis, swelling).

It should be remembered about radiating to the chest pain in acute cholecystitis, liver abscess, appendicitis, spleen infarction.

Dyspnea

Shortness of breath (dyspnoe) is one of the frequent complaints associated with pulmonary disease, although with about the same frequency this clinical sign arises with heart disease; sometimes shortness of breath is associated with obesity, severe anemia, intoxication, psychogenic (eg, hysteria ) factors.

For other reasons for shortness of breath, read this article.

Subjectively, dyspnea is felt as a discomfort associated with difficulty breathing, a feeling of tightness in the chest with inhalation and lack of air, the inability of a deep breath and complete release from the air during exhalation, as a general unpleasant condition due to hypoxemia and hypoxia (insufficient oxygenation of blood and tissues) . Severe respiratory failure with hypercapnia (for example, with severe emphysema of the lungs, severe heart failure) can lead to a reduction in the subjective sensation of shortness of breath due to some addiction to dyspnea or a peculiar state of anesthesia. This subjective sensation of shortness of breath has found some explanation only recently. It is believed that an important role is played by the respiratory muscles, from which nervous excitement is transmitted to the respiratory center. The same role is played by the lung receptors, especially those that are located between the pulmonary capillaries and the wall of the alveoli (j-receptors), the irritation of the latter, in particular in the conditions of capillary hypertension and interstitial edema, causes hyperpnoea, which is especially pronounced in compression and pulmonary edema , pulmonary embolism, diffuse fibrotic processes in the lungs. This mechanism is of paramount importance in sensation of dyspnea in left ventricular failure, when compression of the lungs due to stagnation causes stimulation of these receptors, dyspnea decreases in an upright position, for example, in a bed with an elevated head end (orthopnea).

In patients with pulmonary disease, dyspnea is closely associated with impairment of the respiratory mechanism, a level of "breathing work" when a large inspiratory effort, for example, with an increase in the rigidity of the bronchi and lungs (difficulty in bronchial patency, pulmonary fibrosis) or with a large chest (emphysema, asthma attack), leads to an increase in the work of the respiratory muscles (in some cases with the inclusion of additional musculature, including skeletal muscles).

To begin assessing the patient's complaints of dyspnea follows the observation of his respiratory movements at rest and after performing physical exertion.

Objective signs of dyspnea are increased respiration (more than 18 in 1 min), involvement in the work of auxiliary muscles, cyanosis (with pulmonary diseases usually "warm" due to secondary compensatory erythrocytosis).

Distinguish inspiratory (difficulty inhaling), expiratory (difficulty exhaling) and mixed dyspnoea. An inspiratory type of dyspnea occurs when there are obstacles to air penetration into the trachea and large bronchi (swelling of the vocal cords, swelling, foreign body in the lumen of the large bronchi), expiratory type of dyspnea is observed in bronchial asthma, and a mixed variant of dyspnoea is more often noted.

Shortness of breath can acquire the character of choking - a sudden onset of extreme dyspnea, which most often accompanies bronchial and cardiac asthma.

There are 4 types of pathological respiration.

1. The breathing of Kussmaul is deep, frequent, characteristic for patients with diabetic coma, uremia, poisoning with methyl alcohol.
2. The breathing of the Grocco is wavy in character with alternating weak surface breathing and a deeper, marked in the early stages of coma.
3. The Cheyne-Stokes breathing is accompanied by a pause-apnea (from a few seconds to a minute), after which there appears a shallow breathing, increasing in depth to noisy to 5-7th inspiration, 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 severe atherosclerosis of cerebral vessels.
4. Breath breathing manifests a uniform alternation of rhythmic, deep breathing movements with pauses of up to 20-30 seconds. It is observed in patients with meningitis, in the atonal state in patients with severe impairment of cerebral circulation.

With pulmonary diseases, there are often more common complaints: decreased appetite, weight loss, night sweats (often predominantly the upper half of the body, especially the head); characterized by an increase in body temperature with different types of temperature curves: constant subfebrile or febrile (acute pneumonia), hectic fever ( empyema of the pleura and other purulent lung diseases), etc .; possible such manifestations of hypoxia as tremor of hands, convulsions. In the far-reaching stages of the chronic pulmonary process, pains appear in the right upper quadrant ( enlargement of the liver ) and edema of the lower limbs - signs of cardiac failure with a decompensated " pulmonary heart " (a decrease in the contractility of the right ventricular muscle due to the high hypertension in small vessels due to severe pulmonary process).

[30], [31], [32], [33], [34]