Dyspnea & Hemoptesis

Dyspnea
Dyspnea is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the
level of exertion. commonly results from cardiac or pulmonary disease.
Ask Have you had any difficulty breathing? Find out when the symptom occurs, at rest or
with exercise, and how much effort produces onset.
Because of variations in age, body weight, and physical fitness, there is no absolute scale for
quantifying dyspnea.
Instead, make every effort to determine its severity based on the patients daily activities.
How many steps or flights of stairs can the patient climb before pausing for breath?
What about work such as carrying bags of groceries, mopping the floor, or making the bed?
Has dyspnea altered the patients lifestyle and daily activities? How?

Carefully elicit the timing and setting of dyspnea, any associated symptoms, and relieving or
aggravating factors.

Anxious patients with dyspnea
They may describe difficulty taking a deep enough
breath
Smothering sensation with inability to get enough air,
along with paresthesias, or sensations of tingling or
pins and needles around the lips or in the
extremities.
Anxious patients may have episodic dyspnea during
both rest and exercise, and hyperventilation, or rapid,
shallow breathing.
At other times they may have frequent sighs.
Left-Sided Heart Failure

Setting: History of heart disease or its predisposing factors
Process Elevated pressure in pulmonary capillary bed with
transudation of fluid into interstitial spaces and alveoli, decreased
compliance (increased stiffness) of the lungs, increased work of
breathing
Timing Dyspnea may progress slowly, or suddenly as in acute
pulmonary edema.
Factors That Aggravate Exertion, lying down
Factors That Relieve Rest, sitting up, though dyspnea may become
persistent Often cough, orthopnea, paroxysmal nocturnal dyspnea;
Associated Symptoms sometimes wheezing



Chronic Bronchitis
Setting : History of smoking, air pollutants, recurrent respiratory
infections
Process Excessive mucus production in bronchi, followed by
chronic obstruction of airways
Timing Chronic productive cough followed by slowly progressive
dyspnea
Factors That Aggravate Exertion, inhaled irritants, respiratory
infections
Factors That Relieve Expectoration; rest, though dyspnea may
become persistent
Associated Symptoms Chronic productive cough, recurrent
respiratory infections; wheezing may develop
Chronic Obstructive Pulmonary
Disease

Setting: History of smoking, air pollutants, sometimes a familial
deficiency in alpha1-antitrypsin
Process Overdistention of air spaces distal to terminal bronchioles,
with destruction of alveolar septa and chronic obstruction of the
airways
Timing Slowly progressive dyspnea; relatively mild cough later
Factors That Aggravate Exertion
Factors That Relieve Rest, though dyspnea may become persistent
Associated Symptoms Cough, with scant mucoid sputum
Asthma

Setting ; Environmental and emotional conditions
Process Bronchial hyper responsiveness involving release of
inflammatory mediators, increased airway secretions, and
bronchoconstriction
Timing Acute episodes, separated by symptom-free periods.
Nocturnal episodes are common.
Factors That Aggravate Variable, including allergens, irritants,
respiratory infections, exercise, and emotion
Factors That Relieve Separation from aggravating factors
Associated Symptoms Wheezing, cough, tightness in chest
Diffuse Interstitial Lung Diseases
Setting: Varied. Exposure to one of many substances may be
causative.
sarcoidosis, widespread neoplasms, asbestosis, and idiopathic
pulmonary fibrosis
Process Abnormal and widespread infiltration of cells, fluid, and
collagen into interstitial spaces between alveoli.
Timing Many causes Progressive dyspnea, which varies in its rate
of development with the cause
Factors That Aggravate Exertion
Factors That Relieve Rest, though dyspnea may become persistent
Associated Symptoms Often weakness, fatigue. Cough less
common than in other lung diseases
Pneumonia

Process Inflammation of lung parenchyma from the
respiratory bronchioles to the alveoli
Timing An acute illness, timing varies with the
causative agent
Associated Symptoms Pleuritic pain, cough, sputum,
fever, though not necessarily present Varied
Spontaneous Pneumothorax
Process Leakage of air into pleural space through
blebs on visceral pleura, with resulting partial or
complete collapse of the lung
Timing Sudden onset of dyspnea
Associated Symptoms Pleuritic pain, cough Often a
previously healthy young adult
Acute Pulmonary Embolism
Setting: Postpartum or postoperative periods; prolonged bed rest;
congestive heart failure, chronic lung disease, and fractures of hip
or leg;
Deep venous thrombosis (often not clinically apparent)
Process Sudden occlusion of all or part of pulmonary arterial tree
by a blood clot that usually originates in deep veins of legs or pelvis
Timing Sudden onset of dyspnea
Associated Symptoms Often none. Retrosternal oppressive pain if
the occlusion is massive. Pleuritic pain, cough, and hemoptysis may
follow an embolism if pulmonary infarction ensues.
Anxiety With Hyperventilation
Process Overbreathing, with resultant respiratory alkalosis and fall
in the partial pressure of carbon dioxide in the blood
Timing Episodic, often recurrent
Factors That Aggravate More often occurs at rest than after
exercise. An upsetting event may not be evident.
Factors That Relieve: Breathing in and out of a paper or plastic
bag sometimes helps
Associated symptoms. Sighing, lightheadedness, numbness or
tingling of the hands and feet, palpitations, chest pain
Other manifestations of anxiety may be present.
Cough
Cough is a reflex response to stimuli that irritate receptors in the larynx,
trachea, or large bronchi.
These stimuli include mucus, pus, and blood, as well as external agents
such as dusts, foreign bodies, or even extremely hot or cold air.
Other causes include inflammation of the respiratory mucosa and pressure
or tension in the air passages from a tumor or enlarged peribronchial
lymph nodes.
Ask whether the cough is dry or produces sputum, or phlegm.
Ask the patient to describe the volume of any sputum and its color, odor,
and consistency.
Although cough typically signals a problem in the respiratory tract, it
may also be cardiovascular in origin.
Cough is an important symptom of left-sided heart failure.
Hemoptysis
Hemoptysis is the coughing up of blood from the lungs
it may vary from blood-streaked phlegm to frank blood.
assess the volume of blood produced as well as the other sputum attributes;
ask about the related setting and activity and any associated symptoms.

Try to confirm the source of the bleeding by both history and physical examination.
Blood or blood-streaked material may originate in the mouth, pharynx, or
gastrointestinal tract and is easily mislabeled.
Occasionally, however, blood from the nasopharynx or the gastrointestinal tract is
aspirated and then coughed out.

When vomited, it probably originates in the gastrointestinal tract.
Blood originating in the stomach is usually darker than blood from the respiratory
tract and may be mixed with food particles.

Cough and Hemoptysis
acute infections
Problem Cough and Sputum Associated Symptoms
Laryngitis

Dry cough (without sputum),
may become
productive of variable
amounts of sputum
An acute, fairly minor illness
with hoarseness.
Often associated with viral
nasopharyngitis
Tracheobronchitis

Dry cough, may become
productive
An acute, often viral illness,
with burning
retrosternal discomfort
Mycoplasma and Viral
Pneumonias
Dry hacking cough, often
becoming
productive of mucoid sputum
An acute febrile illness, often
with malaise,
headache, and possibly
dyspnea
Bacterial Pneumonias



Pneumococcal: sputum
mucoid or
purulent; may be blood-
streaked, diffusely
pinkish, or rusty
An acute illness with chills,
high fever,
dyspnea, and chest pain.
Often is preceded by
acute upper respiratory
infection.
Chronic Inflammation

Problem Cough and Sputum Associated Symptoms and
Setting
Postnasal Drip

Chronic cough; sputum
mucoid or
mucopurulent
Repeated attempts to clear
the throat.
Postnasal discharge may be
sensed by patient
or seen in posterior pharynx.
Associated with
chronic rhinitis, with or
without sinusitis
Chronic Bronchitis
.

Chronic cough; sputum
mucoid to
purulent, may be blood-
streaked or even
bloody
Often longstanding cigarette
smoking.
Recurrent superimposed
infections. Wheezing
and dyspnea may develop
Bronchiectasis

Chronic cough; sputum
purulent, often
copious and foul-smelling;
may be bloodstreaked
or bloody

Recurrent bronchopulmonary
infections
common; sinusitis may
coexist

Chronic Inflammation

Pulmonary Tuberculosis


Cough dry or sputum that is
mucoid or purulent; may be
blood-streaked or bloody

Early, no symptoms. Later,
anorexia, weight loss, fatigue,
fever, and night sweats
Lung Abscess

Sputum purulent and foul-
smelling; may be bloody
A febrile illness.
Often poor dental hygiene
and a prior episode of
impaired consciousness
Asthma
Often a history of allergy

Cough, with thick mucoid
sputum,
especially near end of an
attack
Episodic wheezing and
dyspnea, but cough
may occur alone.
Gastroesophageal Reflux


Chronic cough, especially
at night or early
in the morning
Wheezing, especially at
night (often mistaken
for asthma), early
morning hoarseness, and
repeated attempts to clear
the throat.
Neoplasm
Cancer of the Lung
Usually a long history of cigarette smoking.
Cough dry to productive; sputum may be blood-
streaked or bloody
Associated manifestations are numerous.
Cardiovascular Disorders

Left Ventricular Failure or Mitral Stenosis
Often dry, especially on exertion or at night;
may progress to the pink frothy sputum of pulmonary
edema or to frank hemoptysis
Dyspnea, orthopnea, paroxysmal nocturnal dyspnea
Pulmonary Emboli

factors that predispose to deep venous thrombosis
Dry to productive; may be dark, bright red, or mixed
with blood
Dyspnea, anxiety, chest pain, fever;

Health Promotion and Counseling
More than 27% of Americans age 12 and older still smoke.
All who smoke should be counseled regularly to stop smoking.
Smoking has been definitively linked to significant CVS,RS, and
neoplastic disease
Accounts for one out of every five deaths in the United States.
It is considered the leading cause of preventable death.
Nonsmokers exposed to smoke are also at increased risk for diseases
related to smoking.
Nicotine is an addictive drug.
Tobacco cessation
Be especially alert to smoking by teenagers, the age group when tobacco use often
begins, and by pregnant women, who may continue smoking during pregnancy.
The disease risks of smoking drop significantly within a year of smoking cessation.

Effective interventions
Targeted messages by clinicians
Group counseling
Use of nicotine-replacement therapies.

Clinicians to adopt the four As:
Ask about smoking at each visit.
Advise patients regularly to stop smoking in a clear personalized message.
Assist patients to set stop dates and provide educational materials for self help.
Arrange for follow-up visits to monitor and support progress.