The Chest

Cough

The most common symptom of lung disease is the cough. Coughing is so common that it is frequently regarded as a trivial complaint. The cough reflex is a normal defense mechanism of the lungs that protects them from foreign bodies and excessive secretions. Infections of the upper respiratory tract are associated with coughing that usually improves in 2 to 3 weeks. A persistent cough necessitates further investigation.

Coughing is a coordinated, forced expiration, interrupted by repeated closure of the glottis. The expiratory muscles contract against the partially closed glottis, creating high pressure within the lungs. When the glottis suddenly opens, there is an explosive rush of air that clears the air passages. When a patient complains of coughing, ask these questions:

• “Can you describe your cough?”

• “How long have you had a cough?”

• “Was there a sudden onset of coughing?”

• “Do you smoke?” If so , “What do you smoke? How much, and for how long?”

• “Does your cough produce sputum?” If so, “Can you estimate the amount of your expectorations? What is the color of the sputum? Does the sputum have a foul odor?”

• “Does the cough occur for prolonged periods?”

• “Does the cough occur after eating?”

• “Is the coughing worse in any position?”

• “What relieves the cough?”

• “Are there any other symptoms associated with the cough? Fever? Headaches? Night sweats? Chest pain? Runny nose? Shortness of breath? Weight loss? Hoarseness? Loss of consciousness?”

• “Do you have any birds as pets? Do you feed pigeons?”

• “Have you ever been exposed to anyone with tuberculosis?”

Coughing may be voluntary or involuntary, productive or nonproductive. In a productive cough, mucus or other materials are expelled. A dry cough does not produce any secretions.

Smoking is probably the most common cause of the chronic cough. Smoker ' s cough results from inhalation of irritants in tobacco and is most marked in the morning. Coughing is normally decreased during sleep. When the smoker awakens, productive coughing increases and tends to clear the respiratory passages. In patients who stop smoking, the cough decreases and may disappear.

Coughing may also be psychogenic. This nonproductive cough occurs in individuals with emotional stress. When attention is drawn to it, the cough occurs more often. During sleep, or when the patient is distracted, the coughing stops. Psychogenic coughing is a diagnosis of exclusion: Only after all other causes have been eliminated can this diagnosis be made.

There are many terms used by patients and physicians to describe a cough. Table 13.1 provides a list of some of the more common descriptors and their possible causes.

Sputum Production

Sputum is the substance expelled by coughing. Approximately 75 to 100 mL of sputum is secreted daily by the bronchi. By ciliary action, it is brought up to the throat and then swallowed unconsciously with the saliva. An increase in the quantity of sputum production is the earliest manifestation of bronchitis. Sputum may contain cellular debris, mucus, blood, pus, or microorganisms.

Sputum should be described according to color, consistency, quantity, the number of times it is brought up during the day and night, and the presence or absence of blood. An adequate description may indicate a cause of the disease process. Uninfected sputum is odorless, transparent, and whitish-gray, resembling mucus; it is termed mucoid . Infected sputum contains pus and is termed purulent ; the sputum may be yellow, greenish, or red. Table 13.2 lists the appearances of sputum and their possible causes.

Hemoptysis

Hemoptysis is the coughing up of blood. Few symptoms produce as much alarm in patients as does hemoptysis. Careful description of the hemoptysis is crucial because what is produced can include clots of blood, as well as blood-tinged sputum. The implications of each are very different. Coughing up clots of blood is a symptom of extreme importance because it often heralds a serious illness. Clots of blood are usually indicative of a cavitary lung lesion, a tumor of the lung, certain cardiac diseases, or pulmonary embolism. Blood-tinged sputum is usually associated with smoking or minor infections, but it can be seen with tumors and more serious diseases as well. When a patient complains of coughing up blood, the examiner should ask the following questions:

• “Do you smoke?” If yes, “What do you smoke? How much, and for how long?”

• “Did the coughing up of blood occur suddenly?”

• “Have there been recurrent episodes of coughing up blood?”

• “Is the sputum blood-tinged, or are there actual clots of blood?”

• “How long have you noticed the blood?”

• “What seems to bring on the coughing up of blood? Vomiting? Coughing? Nausea?”

• “Have you ever had tuberculosis?”

• “Is there a family history of coughing up blood?”

• “Have you had recent surgery?”

• “Do you take any ‘blood thinners’?”

• “Are you aware of any bleeding tendency?”

• “Have you had any recent travel on airplanes?”

• “Have you had night sweats? Shortness of breath? Palpitations? Irregular heartbeats? Hoarseness? Weight loss? Swelling or pain in your legs?”

• “Have you felt any unusual sensation in your chest after coughing up blood?” If so, “Where?”

• (For a woman with hemoptysis) “Do you use oral contraceptives?”

Any suppurative (associated with the production of pus) process of the airways or lungs can produce hemoptysis. Bronchitis is probably the most common cause of hemoptysis. Bronchiectasis and bronchogenic carcinoma are also major causes. Hemoptysis results from mucosal invasion, tumor necrosis, and pneumonia distal to bronchial obstruction by tumor. Pneumococcal pneumonia characteristically produces rust-colored sputum. Pink and frothy sputum can result from pulmonary edema.

On occasion, patients have a warm sensation in the chest at the location from which the hemoptysis originated. Therefore, it is useful to ask patients with recent hemoptysis whether they experienced such a sensation. This information may lead to a more careful review of the physical examination and x-ray films of that area.

Patients who have undergone recent surgery or have traveled for long periods on airplanes are at risk for deep vein thrombophlebitis with pulmonary embolism. Women taking oral contraceptives are likewise at risk for pulmonary embolic disease. Hemoptysis occurs when pulmonary emboli result in infarction, with necrosis of the pulmonary parenchyma.

Recurrent episodes of hemoptysis may result from bronchiectasis, tuberculosis, or mitral stenosis. Atrial fibrillation is a common cause of “irregular heartbeats” and embolic phenomena.

Sometimes it is difficult to ascertain whether the patient coughed up or vomited blood. Most patients can provide a sufficiently clear history. Table 13.3 lists characteristics that help distinguish hemoptysis from hematemesis (vomiting of blood).

Dyspnea

The subjective sensation of “shortness of breath” is dyspnea. Dyspnea is an important manifestation of cardiopulmonary disease, although it is found in other states such as neurologic, metabolic, and psychologic conditions. It is important to differentiate dyspnea from the objective finding of tachypnea, or rapid breathing. A patient may be observed to be breathing rapidly while stating that he or she is not short of breath. The converse is also true: a patient may be breathing slowly but have dyspnea. Never assume that a patient with a rapid respiratory rate is dyspneic.

It is important for the examiner to inquire when dyspnea occurs and in which position. Paroxysmal nocturnal dyspnea is the sudden onset of shortness of breath occurring at night during sleep. Patients are suddenly seized with an intense strangling sensation. They frantically sit up and, classically, run to the window for “air.” As soon as they assume an upright position, the dyspnea usually improves. Orthopnea is difficulty breathing while lying flat. Patients require two or more pillows to breathe comfortably. Platypnea is a rare symptom of difficulty breathing while sitting up and is relieved by a recumbent position. Trepopnea is a condition in which patients are more comfortable breathing while lying on one side. (Some of the more common causes of positional dyspnea are listed in Table 13.4 .) For any patient complaining of dyspnea, ask the following questions:

• “How long have you had shortness of breath?”

• “Did the shortness of breath occur suddenly?”

• “Is the shortness of breath constant?”

• “Does the shortness of breath occur with exertion? At rest? Lying flat? Sitting up?”

• “What makes the shortness of breath worse? What relieves it?”

• “How many level blocks can you walk without becoming short of breath?”

• “How many level blocks could you walk 6 months ago?”

• “Is the shortness of breath accompanied by wheezing? Fever? Cough? Coughing up blood? Chest pain? Palpitations? Hoarseness?”

• “Do you smoke?” If so, “How much? For how long?”

• “Have you had any exposure to asbestos? Sandblasting? Pigeon breeding?”

• “Have you had any exposure to individuals with tuberculosis?”

• “Have you ever lived near the San Joaquin Valley? Midwestern or southeastern United States?”

It is essential to try to quantify the dyspnea. Questions such as “How many level blocks can you walk?” provide a framework for exercise tolerance. For example, if the patient answers, “two blocks,” the patient is said to have two-block dyspnea on exertion . The interviewer can then ask, “How many level blocks were you able to walk 6 months ago?” and thus assess approximately the progression of the disease or the efficacy of therapy.

Careful questioning regarding industrial exposure is paramount for any patient with unexplained dyspnea. Examples of further questions regarding occupational and environmental history are discussed in Chapter 1 , The Interviewer's Questions. Exposure to pigeons may result in psittacosis. Outbreaks of coccidioidomycosis have occurred in individuals living in the southwestern United States. Living in the midwestern and southeastern United States has been linked to outbreaks of histoplasmosis.

Wheezing

Wheezing is an abnormally high-pitched noise resulting from a partially obstructed airway. It is usually present during expiration when slight bronchoconstriction occurs. Bronchospasm, mucosal edema, loss of elastic support, and tortuosity of the airways are the usual causes. Asthma causes bronchospasm, which results in the wheezing associated with this condition. Obstruction by intraluminal material, such as aspirated foreign bodies or secretions, is another important cause of wheezing. A well-localized wheeze, unchanged by coughing, may indicate that a bronchus is partially obstructed by a foreign body or tumor. When a patient complains of wheezing, the examiner must determine the following:

• “At what age did the wheezing begin?”

• “How often does it occur?”

• “Are there any precipitating factors, such as foods, odors, emotions, animals, and so forth?”

• “What usually stops the attack?”

• “Have the symptoms worsened over the years?”

• “Are there any associated symptoms?”

• “Is there a history of nasal polyps?”

• “Do you smoke?” If so, “What do you smoke? How much, and for how long?”

• “Is there a history of heart disease?”

An important axiom to remember is that asthma is associated with wheezing, but not all wheezing is asthma.

Do not equate wheezing only with asthma. Although congestive heart failure is usually associated with abnormal breath sounds called crackles (discussed later in this chapter), sometimes there is such severe bronchospasm in heart failure that the main physical finding is a wheeze rather than a crackle.

A decrease in wheezing may result from either an opening of the airway or a progressive closing off of the air passage. A “silent” chest in a patient with an acute asthmatic attack is usually an ominous sign: It indicates worsening of the obstruction.

Cyanosis

Cyanosis is commonly detected by a family member or friend. The subtle bluish discoloration may go completely unnoticed by the patient. Central cyanosis occurs with inadequate gas exchange in the lungs that results in a significant reduction in arterial oxygenation. Primary pulmonary problems or diseases that cause mixed venous blood to bypass the lungs (e.g., intracardiac shunt) are frequently the causative factors. The bluish discoloration is best seen in the mucous membranes of the mouth (e.g., the frenulum) and lips. Peripheral cyanosis results from an excessive extraction of oxygen at the periphery. It is limited to the extremities (e.g., the fingers, toes, nose). Ask the following questions:

• “Where is the cyanosis present?”

• “How long has the cyanosis been present?”

• “Are you aware of any lung problem? Heart problem? Blood problem?”

• “What makes the cyanosis worse?”

• “Is there associated shortness of breath? Cough? Bleeding?”

• “What types of work have you performed?”

• “Is there anyone else in your family who has cyanosis?”

Cyanosis from birth is associated with congenital heart lesions. The acute development of cyanosis can occur in severe respiratory disease, especially acute airway obstruction. Peripheral cyanosis results from increased oxygen extraction in states of low cardiac output and is seen in cooler areas of the body such as the nail beds and the outer surfaces of the lips. Peripheral cyanosis disappears as the area is warmed. Cyanosis of the nails and warmth in the hands suggest that the cyanosis is central. Central cyanosis occurs only after the oxygen saturation has fallen to less than 80%. Central cyanosis diffusely involves the skin and mucous membranes and does not disappear with warming of the area. At least 2 to 3 g of unsaturated hemoglobin per 100 mL of blood must be present for the patient to manifest central cyanosis. Exercise worsens central cyanosis because the exercising muscles require an increased extraction of oxygen from the blood. In patients with severe anemia, in whom hemoglobin levels are markedly decreased, cyanosis may not be seen. Clubbing of the nails is seen in association with central cyanosis and significant cardiopulmonary disorders. See Fig. 8.12 .

Some industrial workers, such as arc welders, inhale toxic levels of nitrous gases that can produce cyanosis by methemoglobinemia. Hereditary methemoglobinemia is a primary hemoglobin abnormality causing congenital cyanosis.

Chest Pain

Chest pain related to pulmonary disease usually results from involvement of the chest wall or parietal pleura. Nerve fibers are abundant in this area. Pleuritic pain is a common symptom of inflammation of the parietal pleura. It is described as a sharp, stabbing pain that is usually felt during inspiration. It may be localized to one side, and the patient may splint ⁴

4 Splinting means making the chest muscles rigid to avoid motion of that part of the chest.

to avoid the pain. Chapter 14 , The Heart, summarizes the important questions to ask a patient complaining of chest pain.

Acute dilatation of the main pulmonary artery may also produce a sensation of dull pressure, often indistinguishable from angina pectoris. This results from nerve endings responding to the stretch on the main pulmonary artery.

Although chest pain occurs in pulmonary disease, chest pain is the cardinal symptom of cardiac disease and is discussed more completely in Chapter 14 , The Heart.

Snoring

Snoring is a common complaint. An important problem often associated with heavy snoring is obstructive sleep apnea. Many affected patients are overweight and have a history of excessive daytime sleepiness. A bed partner may describe the patient as at first sleeping quietly; then a transition occurs to louder snoring, followed by a period of cessation of snoring, during which time the patient becomes restless, has gasping motions, and appears to be struggling for breath. This period is terminated by a loud snort, and the sequence may begin again. It is common for patients with sleep apnea to have many of these episodes each night. Refer to Chapter 12 , The Oral Cavity and Pharynx, for more information on snoring and sleep apnea and sleep disordered breathing.

Other Symptoms

In addition to the main symptoms of pulmonary disease, there are other, less common symptoms. These include the following:

• Stridor (noisy, harsh breathing)

• Voice changes

• Swelling of the ankles (dependent edema)

Stridor is an abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, or trachea. Stridor is not in and of itself a diagnosis, but rather is a symptom or sign that points to a specific airway disorder. Some of the causes are infectious diseases, while others are problems with the anatomical structure of a child's airway; or foreign bodies, such as a peanut or unchewed food, in the trachea or bronchi. Stridor is considered a medical emergency. Urgent care may be required. The timing and the sound of stridor can provide clues to the type of airway disorder: Inspiratory stridor occurs when the individual breathes in; it generally indicates a collapse of tissue at the level of the supraglottis or glottis. Inspiratory stridor often occurs in children with croup. It may be indicative of serious airway obstruction from severe conditions such as epiglottitis, a foreign body lodged in the airway, or a laryngeal tumor. Expiratory stridor occurs when the individual exhales; it generally indicates a problem in the subglottic area, lower trachea, or bronchus. Biphasic stridor occurs when the individual breathes in and out; it generally indicates an obstruction at the subglottic area, or upper trachea.

Voice changes can occur with inflammation of the vocal cords or interference with the recurrent laryngeal nerve. Swelling of the ankles is a manifestation of dependent edema, which is associated with right-sided heart failure, renal disease, liver disease, and obstruction of venous flow. As the condition worsens, abnormal accumulations of fluid produce generalized edema of the entire body, known as anasarca.