Dyspnea and Coughing

Thomas R. Bodette, D.C., CCSP

Dyspnea

History questions:

1) Pain on full inspiration?

Direct trauma (pneumothorax, rib fracture) Muscle strain

2) Chest tightness/pressure?
Radiation to jaw/left arm? (A: Cardiac related) Headache, dizziness, multiple joint pains? (A: Depression)

3) With exertion? (CHF, exerciseinduced asthma) 4) Position related (orthostatic)?

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Dyspnea

Asthma

Asthma

A) Extrinsic
Childhood onset, family Hx of allergies Testing with spirometry, allergen challenge Monitor with peak flow meter Distinguish from hyperactive airway

B) Intrinsic
Usually an adult over the age of 40 years Secondary to URI, smoking, occupational exposure to toxins No relationship to allergies Patients get progressively worse

Dyspnea

Asthma

C) Acute-phase medications:
Epinephrine Beta-agonists (ie: ventolincan actually give you a chronic cough, along with ACE inhibitors ) Methyl-xanthines (theophyline)

D) Prophylactic medications:
Cromolyn sodium (Intal) Leukotriene receptor antagonists (block cytokine formation pathwaysantiinflammatory) Beta-2-agonists (ie: Salmeterol) Oral and aerosol corticosteroids (antiinflammatory)

Coughing

Chronic, non-productive cough seen in:

Post-nasal drip (longer than three weeks duration, worse at night) Hyperactive airway disease (coughvariant asthma) Gastroesophageal reflux (may stimulate lower part of cough receptors) Chronic bronchitis (in smokers)

Wheezes = obstruction (mucus or narrowed airway)

Coughing

Chronic Obstructive Pulmonary Disease (COPD):

Chronic Restrictive Pulmonary Disease (CRPD):

Exhalation most affected Due to mucus or bronchial constriction Decrease in FEV1 (forced expiratory volume) Increased residual volume Wheezes and rhonchi (upon auscultation) Examples: asthma, chronic bronchitis, emphysema, bronchiectasis

Affects all aspects of respiration Sources are extrapulmonary

Neuromuscular (Myasthenia gravis, Guillain-Barr) Skeletal deformity (kyphosis, obesity, etc.) Pleural

Rales more prevalent on auscultation Examples: asbestosis, sarcoidosis, eosinophilia

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Coughing

Blue Bloater:

Pink Puffer:

Centrilobular (respiratory bronchiole expanded) Blockage of distal bronchioles Decreased CNS sensitivity to CO2, leads to cyanosis Not in apparent distress Chronic cough (smoker)

Panacinar (respiratory bronchiole AND alveoli expanded) Destruction of distal alveoli (no blockagetotally destroyed) 25% of total body energy needed to breathe Thin, frail, flushed (breathes through pursed lips to normalize pressure) Barrel-chest appearance
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Other conditions

Pulmonary embolism:

Chest pain, dyspnea, coughing, diaphoresis Thrombi in lower extremity travels to lungs (results in vascular blockage or infarction) Physical exam: tachycardia, tachypnea, accentuated S2 at pulmonic location Treatment: antithrombolytic therapy (tissue plasminogen activator, heparin, warfarin)
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Other conditions

Congestive heart failure:

Dyspnea upon exertion and/or lying supine at night (orthopnea) Increased venous pressure (blood doesnt get back to the heart as fast as it should) Ascites, bilateral leg edema, rales upon auscultation Increased chance of mortality with high Na diet and overweight Treatment: diuretics, strict low-fat diet, gradual supervised exercise