chapter 3 cardiopulmonary symptoms mosby items and derived items © 2014, 2010, 2005, 2000, 1995,...

Chapter 3Chapter 3

Cardiopulmonary SymptomsCardiopulmonary Symptoms

Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc.

Cardiopulmonary SymptomsCardiopulmonary Symptoms

As a Respiratory Therapist you will encounter As a Respiratory Therapist you will encounter patients with a variety of symptoms.patients with a variety of symptoms.

It is necessary to become familiar with these It is necessary to become familiar with these symptoms and their characteristics in order to symptoms and their characteristics in order to ask relevant questions and provide optimal ask relevant questions and provide optimal care.care.

Always assess your patients fully and Always assess your patients fully and thoroughly before rushing to judgment, use thoroughly before rushing to judgment, use critical thinking skills!critical thinking skills!

Learning ObjectivesLearning Objectives

After reading this chapter you will be able to:After reading this chapter you will be able to:1.1. Know causes and common characteristics of the Know causes and common characteristics of the

following symptoms:following symptoms: CoughCough Sputum productionSputum production HemoptysisHemoptysis DyspneaDyspnea Chest painChest pain Dizziness and faintingDizziness and fainting

Mosby items and derived items © 2014, 2010, 2005, 2000, 1995, 1990, 1985 by Mosby, Inc., an imprint of Elsevier Inc. 3

Learning Objectives (Cont.)Learning Objectives (Cont.)

Swelling of the anklesSwelling of the ankles Fever, chills, and night sweatsFever, chills, and night sweats Headache, altered mental status, and personality changesHeadache, altered mental status, and personality changes SnoringSnoring Gastroesophageal refluxGastroesophageal reflux Daytime somnolence (sleepiness)Daytime somnolence (sleepiness)


Signs and SymptomsSigns and Symptoms

SignsSigns SubjectiveSubjective Patient descriptionPatient description Measured by patient Measured by patient

perceptionperception Ex: Pain, shortness Ex: Pain, shortness

of breath, coughof breath, cough

SymptomsSymptoms ObjectiveObjective MeasureableMeasureable Assessed valuesAssessed values Ex: Heart rate, blood Ex: Heart rate, blood

pressure, respiratory pressure, respiratory raterate


OverviewOverview

Assess symptoms to determine: Assess symptoms to determine: Seriousness of problemSeriousness of problem Potential underlying cause of problemPotential underlying cause of problem Effectiveness of treatmentEffectiveness of treatment

Primary symptoms of cardiopulmonary disordersPrimary symptoms of cardiopulmonary disorders CoughCough Sputum productionSputum production HemoptysisHemoptysis Shortness of breath (dyspnea)Shortness of breath (dyspnea) Chest painChest pain


Overview (Cont.)Overview (Cont.)

Definition of terms associated with symptomsDefinition of terms associated with symptoms Discuss etiology and differential diagnosisDiscuss etiology and differential diagnosis Familiarity with these symptoms in order Familiarity with these symptoms in order

to ask relevant questions and provide to ask relevant questions and provide optimal careoptimal care


CoughCough Protective reflex Protective reflex Stimulation of receptors Stimulation of receptors

Pharynx, larynx, trachea, large bronchi, lung and Pharynx, larynx, trachea, large bronchi, lung and visceral pleuravisceral pleura

Caused by inflammatory, mechanical, chemical, Caused by inflammatory, mechanical, chemical, or thermal stimulation of cough receptors or thermal stimulation of cough receptors

Key to determine etiology is careful history, Key to determine etiology is careful history, physical exam, and CXRphysical exam, and CXR


Cough (Cont.)Cough (Cont.) Afferent pathway (to brain)Afferent pathway (to brain)

Vagus, phrenic, glossopharyngeal, trigeminal nervesVagus, phrenic, glossopharyngeal, trigeminal nerves Efferent pathway (from brain)Efferent pathway (from brain)

Smooth muscles of larynx and tracheobronchial tree Smooth muscles of larynx and tracheobronchial tree via phrenic, spinal nervesvia phrenic, spinal nerves

PhasesPhases InspiratoryInspiratory CompressionCompression ExpiratoryExpiratory


Cough (Cont.)Cough (Cont.) Reduced effectiveness of coughReduced effectiveness of cough

Weakness of inspiratory or expiratory muscles Weakness of inspiratory or expiratory muscles (neuromuscular disease/ atrophy / age)(neuromuscular disease/ atrophy / age)

Inability of the glottis to open or close correctly Inability of the glottis to open or close correctly (stroke)(stroke)

Obstruction, collapsibility, or alteration in shape or Obstruction, collapsibility, or alteration in shape or contours of the airwayscontours of the airways

Decrease in lung recoil (e.g., emphysema)Decrease in lung recoil (e.g., emphysema) Abnormal quantity or quality of mucus production Abnormal quantity or quality of mucus production

(e.g., thick sputum) (cystic fibrosis/pneumonia)(e.g., thick sputum) (cystic fibrosis/pneumonia) Decreased consciousness/sedation= no cough Decreased consciousness/sedation= no cough


Effectiveness of a CoughEffectiveness of a Cough

Effectiveness is determined by:Effectiveness is determined by: The depth of inspirationThe depth of inspiration Amount of pressure that can be generated in the Amount of pressure that can be generated in the

airwaysairways Effectiveness is reduces when:Effectiveness is reduces when:

Weakness of either the inspiratory or expiratory Weakness of either the inspiratory or expiratory musclesmuscles

Inability of the glottis to open or closeInability of the glottis to open or close Obstruction, collapsibility or alteration in shape or Obstruction, collapsibility or alteration in shape or

contours of the airwaycontours of the airway Decrease in lung recoil (emphysema)Decrease in lung recoil (emphysema) Abnormal quantity or quality of mucus productionAbnormal quantity or quality of mucus production

Causes and Clinical PresentationCauses and Clinical Presentation

AcuteAcute Sudden onsetSudden onset Severe, short courseSevere, short course Self-limitingSelf-limiting

• Viral infectionViral infection

ChronicChronic PersistentPersistent Last >3 weeksLast >3 weeks Causes: Causes:

• Postnasal drip, Postnasal drip, asthma, COPD asthma, COPD exacerbation, allergic exacerbation, allergic rhinitis, GERD, rhinitis, GERD, chronic bronchitis, chronic bronchitis, bronchiectasis, left bronchiectasis, left heart failureheart failure


Causes and Clinical Presentation (Cont.)Causes and Clinical Presentation (Cont.)

ParoxysmalParoxysmal PeriodicPeriodic Prolonged, forceful episodesProlonged, forceful episodes

Paroxysm:Paroxysm: In medicine, a paroxysm is a violent In medicine, a paroxysm is a violent attack. It may be due to the sudden occurrence of attack. It may be due to the sudden occurrence of symptoms or the acute exacerbation (the abrupt symptoms or the acute exacerbation (the abrupt worsening) of preexisting symptoms. worsening) of preexisting symptoms.

You may have "a paroxysm of coughing" as opposed, You may have "a paroxysm of coughing" as opposed, for example, to "a lingering cough." for example, to "a lingering cough."


Associated Symptoms of CoughAssociated Symptoms of Cough

WheezingWheezing StridorStridor Chest painChest pain DyspneaDyspnea

*In pediatrics with asthma, sometimes coughing is *In pediatrics with asthma, sometimes coughing is the only sign of attack/wheezes are often not the only sign of attack/wheezes are often not heardheard


Complications of Cough Complications of Cough

Torn chest muscleTorn chest muscle Rib fracturesRib fractures Disruption of surgical woundsDisruption of surgical wounds Pneumothorax or pneumomediastinumPneumothorax or pneumomediastinum SyncopeSyncope Arrhythmia Arrhythmia Esophageal ruptureEsophageal rupture Urinary incontinenceUrinary incontinence

*Death/Code Blue: I have see this happen!*Death/Code Blue: I have see this happen!


Sputum ProductionSputum Production SputumSputum

Secretions from tracheobronchial tree, pharynx, Secretions from tracheobronchial tree, pharynx, mouth, sinuses, nosemouth, sinuses, nose

PhlegmPhlegm Secretions from lungs and tracheobronchial treeSecretions from lungs and tracheobronchial tree


Sputum Production (Cont.)Sputum Production (Cont.)

ComponentsComponents Mucus, cellular debris, microorganisms, blood, Mucus, cellular debris, microorganisms, blood,

pus, foreign particlespus, foreign particles Most mucus however is water (held together by Most mucus however is water (held together by

mucoproteins)/ this is the basis of most mucoproteins)/ this is the basis of most mucolytics, if you break the bond you liquefy the mucolytics, if you break the bond you liquefy the mucus (STAY HYDRATED)mucus (STAY HYDRATED)

Normal sputum 100 mL/dayNormal sputum 100 mL/day Upward displacement via wavelike motion of cilia Upward displacement via wavelike motion of cilia

until swalloweduntil swallowed https://www.youtube.com/watch?v=NSXbb5KZl_I


https://www.youtube.com/watch?v=NSXbb5KZl_I

Abnormal Sputum ProductionAbnormal Sputum Production Excessive production by inflamed glandsExcessive production by inflamed glands

Caused by: Infection, cigarette smoking, allergiesCaused by: Infection, cigarette smoking, allergies Describe:Describe:

ColorColor QuantityQuantity ConsistencyConsistency OdorOdor Time of dayTime of day Presence of bloodPresence of blood


HemoptysisHemoptysis Expectoration of sputum containing bloodExpectoration of sputum containing blood

From streaking to frank bleedingFrom streaking to frank bleeding CausesCauses

BronchopulmonaryBronchopulmonary CardiovascularCardiovascular Hematologic Hematologic Systemic disordersSystemic disorders Tuberculosis or fungal infectionsTuberculosis or fungal infections Cancer/tumorsCancer/tumors Excessive coughingExcessive coughing


Description of Hemoptysis Description of Hemoptysis

AmountAmount Massive hemoptysis: 400 ml/3h or 600 ml/24hMassive hemoptysis: 400 ml/3h or 600 ml/24h

• Emergency conditionEmergency condition

• Cancer, tuberculosis, bronchiectasis, traumaCancer, tuberculosis, bronchiectasis, trauma

Streaky: pulmonary infection, lung cancer, Streaky: pulmonary infection, lung cancer, thromboembolithromboemboli

OdorOdor ColorColor AcutenessAcuteness


Hemoptysis vs. HematemesisHemoptysis vs. Hematemesis

Hematemesis: Vomited bloodHematemesis: Vomited blood Determine sourceDetermine source

OropharynxOropharynx• Swallowed from respiratory tractSwallowed from respiratory tract

Esophagus or stomach Esophagus or stomach • Alcoholism or cirrhosis of liverAlcoholism or cirrhosis of liver


Shortness of Breath (SOB)Shortness of Breath (SOB) Most distressing symptom of respiratory diseaseMost distressing symptom of respiratory disease

Single most important factor limiting ability to functionSingle most important factor limiting ability to function SOB is SUBJECTIVE however, so use your clinical SOB is SUBJECTIVE however, so use your clinical

judgmentjudgment Cardinal symptom of cardiac diseaseCardinal symptom of cardiac disease

SOB product of either:SOB product of either:• Heart/perfusionHeart/perfusion

• V/Q mismatchV/Q mismatch

• PsychologicalPsychological

• Assess when SOB occursAssess when SOB occurs

• Sitting/excertion/laying flat… Sitting/excertion/laying flat…


DyspneaDyspnea

Subjective experience of breathing discomfortSubjective experience of breathing discomfort ComponentsComponents

Sensory input to cerebral cortexSensory input to cerebral cortex Perception of the sensationPerception of the sensation

• ““Breathless,” “short-winded,” “feeling of suffocation”Breathless,” “short-winded,” “feeling of suffocation”


Dyspnea Scoring SystemsDyspnea Scoring Systems Scale of 0 (no SOB) to 10 (max SOB)Scale of 0 (no SOB) to 10 (max SOB) Visual analog scalesVisual analog scales Modified Borg scaleModified Borg scale ATS SOB ScaleATS SOB Scale UCSD SOB QuestionnaireUCSD SOB Questionnaire


Causes, Types, and Clinical Causes, Types, and Clinical Presentation of DyspneaPresentation of Dyspnea

WOB abnormally high for the given level of WOB abnormally high for the given level of exertionexertion Asthma and pneumoniaAsthma and pneumonia

Ventilatory capacity is reducedVentilatory capacity is reduced Neuromuscular diseaseNeuromuscular disease

Drive to breathe is elevated Drive to breathe is elevated Hypoxemia, acidosis, exerciseHypoxemia, acidosis, exercise


Dyspnea is most often related to pulmonary or cardiac disease, Dyspnea is most often related to pulmonary or cardiac disease, but it is also seen with hematologic, metabolic, chemical, but it is also seen with hematologic, metabolic, chemical, neurologic, psychogenic, and mechanical disorders. neurologic, psychogenic, and mechanical disorders.

Attempts to understand the physiologic bases of dyspnea have Attempts to understand the physiologic bases of dyspnea have evolved around several separate concepts, including mechanics evolved around several separate concepts, including mechanics of breathing, ventilatory performance, work and efficiency of of breathing, ventilatory performance, work and efficiency of breathing, oxygen cost, length-tension inappropriateness, breathing, oxygen cost, length-tension inappropriateness, chemoreception, and exercise testing. chemoreception, and exercise testing.

it is helpful to remember that patients with respiratory disorders it is helpful to remember that patients with respiratory disorders will complain of dyspnea when any of the following are present will complain of dyspnea when any of the following are present alone or in combination:alone or in combination:

1. The work of breathing is abnormally high for the given level of 1. The work of breathing is abnormally high for the given level of exertion. This is common with narrowed airways as in asthma exertion. This is common with narrowed airways as in asthma and when the lung is stiff as in pneumonia.and when the lung is stiff as in pneumonia.

2. The ventilatory capacity is reduced. This is common when the 2. The ventilatory capacity is reduced. This is common when the vital capacity is abnormally low as seen patients with vital capacity is abnormally low as seen patients with neuromuscular disease.neuromuscular disease.

3. The drive to breathe is elevated beyond normal (e.g., 3. The drive to breathe is elevated beyond normal (e.g., hypoxemia, acidosis, exercise).hypoxemia, acidosis, exercise).


Clinical Types of DyspneaClinical Types of Dyspnea

Cardiac and Circulatory Cardiac and Circulatory Inadequate supply of oxygen to tissuesInadequate supply of oxygen to tissues Primarily during exercisePrimarily during exercise

PsychogenicPsychogenic Panic disorder Panic disorder Not related to exertionNot related to exertion

Hyperventilation Hyperventilation Rate, depth exceeds body’s metabolic needRate, depth exceeds body’s metabolic need Results in hypocapnia and decreased cerebral Results in hypocapnia and decreased cerebral

blood flowblood flow


Acute and Chronic DyspneaAcute and Chronic Dyspnea(see Table 3-10)(see Table 3-10)

Acute or RecurrentAcute or Recurrent Children:Children:

• Asthma, bronchiolitis, Asthma, bronchiolitis, croup, epiglottitiscroup, epiglottitis

Adults: Adults: • Pulmonary embolismPulmonary embolism

• AsthmaAsthma

• PneumoniaPneumonia

• PneumothoraxPneumothorax

• Pulmonary edemaPulmonary edema

• HyperventilationHyperventilation

• Panic disorderPanic disorder

ChronicChronic Most common causes: Most common causes:

• COPD COPD

• CHFCHF


Description of DyspneaDescription of Dyspnea

Paroxysmal Nocturnal Dyspnea (PND)Paroxysmal Nocturnal Dyspnea (PND) Sudden dyspnea when sleeping in recumbent Sudden dyspnea when sleeping in recumbent

positionposition Associated with coughingAssociated with coughing Sign of left heart failureSign of left heart failure

OrthopneaOrthopnea Dyspnea when lying downDyspnea when lying down Associated with left heart failureAssociated with left heart failure


Description of Dyspnea (Cont.)Description of Dyspnea (Cont.)

TrepopneaTrepopnea Dyspnea when lying on one sideDyspnea when lying on one side Unilateral lung disease, pleural effusionUnilateral lung disease, pleural effusion

Platypnea Platypnea Dyspnea in upright positionDyspnea in upright position


Description of Dyspnea (Cont.)Description of Dyspnea (Cont.)

Orthodeoxia Orthodeoxia Hypoxemia in upright position, relieved by Hypoxemia in upright position, relieved by

returning to a recumbent positionreturning to a recumbent position Platypnea and orthodeoxia seen in patients Platypnea and orthodeoxia seen in patients

with right-to-left intracardiac shunts or with right-to-left intracardiac shunts or venoarterial shuntsvenoarterial shunts


Chest PainChest Pain

CausesCauses Cardiac ischemiaCardiac ischemia Inflammatory disorders of thorax, abdomenInflammatory disorders of thorax, abdomen Musculoskeletal disorders, trauma, anxietyMusculoskeletal disorders, trauma, anxiety Referred pain from indigestion, dissecting aortic Referred pain from indigestion, dissecting aortic

aneurysmaneurysm Cardinal symptom of heart diseaseCardinal symptom of heart disease

AnginaAngina Quickly assess if pain is an emergent conditionQuickly assess if pain is an emergent condition See Table 3-11See Table 3-11


Pulmonary Causes of Chest PainPulmonary Causes of Chest Pain

Involvement of chest wall or parietal pleuraInvolvement of chest wall or parietal pleura Pleuritic painPleuritic pain

Inspiratory, sharp, and abrupt in onsetInspiratory, sharp, and abrupt in onset Worsens with inspiration, cough, sneeze, hiccup, Worsens with inspiration, cough, sneeze, hiccup,

or laughteror laughter Increases with pressure and movementIncreases with pressure and movement

Chest wall painChest wall pain Intercostal and pectoral musclesIntercostal and pectoral muscles Well localizedWell localized


Dizziness and Fainting (Syncope)Dizziness and Fainting (Syncope)

Temporary loss of consciousnessTemporary loss of consciousness Resulting from reduced cerebral blood flow and Resulting from reduced cerebral blood flow and

oxygenoxygen CausesCauses

Thrombosis, embolism, atherosclerotic obstructionThrombosis, embolism, atherosclerotic obstruction Pulmonary: embolism, bouts of coughing, hypoxia, Pulmonary: embolism, bouts of coughing, hypoxia,

hypocapniahypocapnia Vasovagal: most common type of syncope Vasovagal: most common type of syncope

Loss of peripheral venous toneLoss of peripheral venous tone


Dizziness and Fainting (Syncope) (Cont.)Dizziness and Fainting (Syncope) (Cont.)

Orthostatic hypotensionOrthostatic hypotension Sudden drop in blood pressure when a person Sudden drop in blood pressure when a person

stands upstands up Dizziness, blurred vision, weakness, syncopeDizziness, blurred vision, weakness, syncope Elderly, vasodilator use, dehydrationElderly, vasodilator use, dehydration


Dizziness and Fainting (Syncope) (Cont.)Dizziness and Fainting (Syncope) (Cont.)

Carotid sinus syncopeCarotid sinus syncope Hypersensitive carotid sinusHypersensitive carotid sinus Slows pulse rate, decreases blood pressure, Slows pulse rate, decreases blood pressure,

syncopesyncope Tussive syncopeTussive syncope

Syncope caused by strong coughingSyncope caused by strong coughing Seen most often in men with COPD, obesity, a Seen most often in men with COPD, obesity, a

positive smoking history, and frequent use of positive smoking history, and frequent use of alcoholalcohol


Dependent EdemaDependent Edema

Edema is soft tissue swelling from abnormal Edema is soft tissue swelling from abnormal accumulation of fluidaccumulation of fluid

Bilateral peripheral edemaBilateral peripheral edema Most often occurs in ankles and lower legsMost often occurs in ankles and lower legs Most often caused by right or left heart failureMost often caused by right or left heart failure Right heart failure often caused by cor pulmonaleRight heart failure often caused by cor pulmonale


Fever, Chills, and Night SweatsFever, Chills, and Night Sweats

EuthermiaEuthermia 97° to 99.5° F 97° to 99.5° F 36° to 37.5° C36° to 37.5° C

Fever (Hyperthermia, Pyrexia)Fever (Hyperthermia, Pyrexia) SustainedSustained RemittentRemittent IntermittentIntermittent Relapsing Relapsing


Causes for FeverCauses for Fever

Hot environmentHot environment Dehydration Dehydration Reaction to chemicals Reaction to chemicals DrugsDrugs Hypothalamic damageHypothalamic damage InfectionInfection MalignancyMalignancy


Fever with Pulmonary DiseaseFever with Pulmonary Disease

Pulmonary InfectionsPulmonary Infections Lung abscess, empyema, tuberculosis, pneumoniaLung abscess, empyema, tuberculosis, pneumonia Remittent fever in mycoplasma pneumonia, Remittent fever in mycoplasma pneumonia,

Legionnaire’s disease, acute viral infectionsLegionnaire’s disease, acute viral infections Infections with No FeverInfections with No Fever

High-dose corticosteroidsHigh-dose corticosteroids ImmunosuppressantsImmunosuppressants Immunocompromised (leukemia, AIDS)Immunocompromised (leukemia, AIDS)


Headache, Altered Mental Status, Headache, Altered Mental Status, and Personality Changesand Personality Changes

Headache as a manifestation of cerebral Headache as a manifestation of cerebral hypoxia and hypercapniahypoxia and hypercapnia Lung disease, high altitudeLung disease, high altitude

Altered mental status in hypercapniaAltered mental status in hypercapnia From affected alertness to comaFrom affected alertness to coma

Personality changes in advanced pulmonary Personality changes in advanced pulmonary disordersdisorders Forgetfulness, inability to concentrate, anxiety, Forgetfulness, inability to concentrate, anxiety,

irritabilityirritability


SnoringSnoring

Serious concern when associated with apneaSerious concern when associated with apnea Evaluation for OSAEvaluation for OSA

Incidence and causesIncidence and causes 10% to 12% of children10% to 12% of children 10% to 30% of adults10% to 30% of adults Peak at age 50 to 59 (male), 60 to 64 (female)Peak at age 50 to 59 (male), 60 to 64 (female) Obesity is one of the most common causes Obesity is one of the most common causes


Snoring Clinical PresentationSnoring Clinical Presentation

FatigueFatigue Excessive daytime sleepiness (daytime Excessive daytime sleepiness (daytime

somnolence)somnolence) Occupational accidentsOccupational accidents Motor vehicle accidentsMotor vehicle accidents Loss of employmentLoss of employment Social dysfunctionSocial dysfunction


Gastroesophageal Reflux (GERD)Gastroesophageal Reflux (GERD)

Heartburn and regurgitationHeartburn and regurgitation Extraesophageal manifestationsExtraesophageal manifestations

Laryngitis, asthma, chronic and nocturnal dry Laryngitis, asthma, chronic and nocturnal dry cough, chest pain, dental erosioncough, chest pain, dental erosion

GER more than twice a week = GERDGER more than twice a week = GERD Risk factorsRisk factors

Obesity, cigarette smoking, pregnancyObesity, cigarette smoking, pregnancy


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