00:00
Wheeze is a noise when you're inspiring or
expiring, when you're breathing in or out.
00:05
And what that indicates is that there's turbulent
airflow in the trachea. Instead of having
a nice, smooth tracheal bronchial tree with
air flowing down it nicely, there's some tightness,
and that causes turbulent flow, which means
that the patient will hear a noise when they're
breathing in and out. It's actually a very
variable symptom. It tends to come and go.
00:27
It obviously will be worse when the disease
is suffering exacerbation and people are feeling
worse and may be better when they're… when
that is controlled.
00:36
The main causes or causes of airway obstruction:
So that's asthma, COPD, bronchiectasis, and
also large airways obstruction. So for example,
you have a stricture of the trachea; that
will cause a wheeze, but that's usually on
inspiration and not on expiration. And an
inspirational wheeze is called stridor. And
large airways obstruction wheezes can be positional,
so when the patient lies back, it gets worse;
when they sit forward, it feels easier for
them.
Chest pain is pretty common in patients with
respiratory disease. But actually, only rarely
is it due to a serious cause. So how can we
differentiate patients who've got chest pain
which is not a serious cause from those with
a potentially… potential serious cause which
requires further investigation? Well, there
are certain warning signs, warning symptoms.
So if a pain is occurring in one area around
the chest wall, and it's constant (it's there
the whole time) but increasing in intensity
over time, that is a very worrying situation,
because that's the sort of pain that would
happen if you have a cancer that's affecting
the chest wall. With… as the cancer gets
worse, the pain progresses, and because it's
always invading the chest wall, the pain is
constant.
Pleuritic chest pain is quite different. This
reflects inflammation of the pleurae, and
this is a sharp, localized pain that occurs
in the area of inflammation. So for example,
if you have a left-sided lower lobe pneumonia
and overlying pleural inflammation, as you
breathe in, you'll get a very sharp pain here
overlying where the pleurisy is. And that
stops you from taking a deep breath. The patient
will describe, "I get a pain when I breathe
in, and I really try not to breathe in," and
they're breathing shallowly as a complication…
as a consequence. This is an indication of
pleural inflammation. That occurs mainly in
infection or in pulmonary emboli, but it can
occur in other situations where you get pleural
inflammation.
02:40
Central exertional chest pain is not a respiratory
problem; that would suggest ischemia of the
heart and angina, and that requires cardiologic
investigation. And somebody who presents with
sudden onset of chest pain—one minute they're
fine; the next second they've got quite marked
chest pain—then you need to think about
pneumothorax or PEs (pulmonary emboli).
03:01
Many patients with respiratory disease will
have what we describe as musculoskeletal chest
pain, and this is a little bit like pleuritic
chest pain in that it's a localized pain that's
often made worse by taking a deep breath or
by coughing, but it's not as sharp. It doesn't
stop them from breathing; it's just there
when they breathe. It's not so localized as
a pleuritic chest pain, and it often moves
around the chest. And of course, it's made
worse by twisting and turning as well, whereas
pleurisy itself should not be. And this sort
of pain is very common in anybody who's been
coughing a lot because of the straining of
cough… pulls onto the… as it pulls on
the chest wall. And it's common in patients
with pleural disease, pleural thickening,
or due to bronchiectasis. Any other chronic
lung disease, it's quite common for someone
to have musculoskeletal chest pain. And the
important thing here is that it moves around.
It's worse on moving, twisting the body as
well as inspiration. Then we can be fairly
relaxed about the pain and that it's not likely
to be pleurisy or another serious cause.
Cough is probably one of the commonest of
respiratory symptoms. There are many causes
of cough. We all know that getting a respiratory
tract infection—a viral infection of the
throat or the trachea—will cause a cough.
04:22
And that only lasts for a few days, and that
must be, by far, the commonest cause across
the globe. But the important thing about that
is that it's a cough that comes on with other
symptoms suggestive of a respiratory tract
infection, and it's not going to last. It
only lasts for a few days—maybe two, three
weeks if you're unlucky.
04:39
A persistent cough is a different situation.
So there are such… there are particular
things that we need to think about with somebody
presenting with a new persistent cough. If
they smoke cigarettes and they're over 50
years of age, a persistent cough which has…
of a new onset, you really need to think that
lung cancer might be present, because lung
cancer is… the commonest symptom is a cough.
And that patient will require a chest x-ray
to be sure that there are no new masses.
Somebody's got a persistent cough and other
respiratory symptoms—mainly breathlessness
is the commonest one—then that does suggest
they could have a chronic lung disease such
as COPD or interstitial lung disease. And
it's quite likely they'll have [Inaudible
00:16:50] from examination, and x-ray will
be abnormal as will their lung function tests.
And that requires further investigation for
whatever the underlying lung disease might
be. If they have a persistent cough with sputum
production, that does suggest that they either
have been smoking, with a smoker's cough (chronic
bronchitis); COPD, which is a smoker's plus
airways obstruction; or bronchiectasis. And
occasionally, patients with asthma also do
have some sputum production as well.
05:51
So this slide lists some of the causes of
cough, and it's quite an extensive list, as
you can see. Acute cough is largely an infective
problem: bronchitis, upper respiratory tract
infection, pneumonia, or exacerbations of
chronic lung disease such as COPD or asthma,
which are usually infective in origin. In
addition, you can inhale foreign bodies. The
things that we often see are teeth which are
knocked out during somebody's general anesthetic
can end up in the lung, or people can swallow…
can be eating food and chicken bones, etc.,
can end up being inhaled by mistake, and that
will cause a sudden onset of cough, which
is fairly obvious as to why the patient is
presenting with cough.
06:33
Chronic cough, persistent over several weeks:
Then the main issues are whether they have
asthma, COPD, whether it's just due to smoking
cigarettes, or whether the patient may have
lung cancer. There's another condition, postinfective
bronchial hyper-reactivity, which is persistent
cough that occurs after a viral tract infection,
which I'll describe in the lectures on airways
disease. But there are myriad level causes
of chronic cough, gastroesophageal reflux
being quite a common one, where the acid coming
up from the stomach into the esophagus stimulates
a cough reflex in the patient. Chronic upper
respiratory tract disease such as sinusitis
and rhinitis: The inflammation forms the droplets
which form down the back of the throat and
get inhaled into the lung. That's called a
postnasal drip. And that will cause a chronic
cough as well. But there are several other
causes which need to be considered.
07:28
So if you've got somebody presenting with
cough but has no evidence for other lung disease—their
lung function's normal; the x-ray's normal;
the examination doesn't really identify any
abnormalities (when you listen to the chest,
for example)—then what sort of things do
you need to think about? Well, there are three
main causes of cough in this situation. One
is asthma. The other is gastroesophageal reflux.
And the other is a postnasal drip.
07:53
If somebody has asthma, the cough tends to
have a diurnal variation: It's worse in the
morning, and in fact, during bad periods,
it will wake the patient in the middle of
the night. It's also worse by various stimuli:
cold air, viral infections, inhaling dust
and smoke: These all would suggest the patient
may have asthma if they make the cough worse.
08:15
And with asthma, because it's a variable disease,
you have periods where the cough is either
better or gone completely, and then it returns—perhaps
after a respiratory tract infection, for example.
08:27
Gastroesophageal reflux: That's a problem
that is made worse by eating lots of food
and spicy foods and lying down immediately
afterwards. And postnasal drip: The patient
will describe symptoms of upper respiratory
tract disease. They'll have a rhinitis with
a snotty nose, maybe a runny nose. They might
even feel the postnasal drip of the inflammatory
material dripping down the back of their throat.
If somebody has a cough productive of daily
purulent phlegm, that might suggest they have
bronchiectasis, and that would require further
investigation.