Dyspnoea the subjective sensation of shortness of breath, often exacerbated by exertion.

Try to quantify exercise tolerance (eg dressing, distance walked, climbing stairs, NYHA classification-p121). May be due to:

Cardiac- g mitral stenosis, ischaemic heart disease or left ventricular failure (LVF) of any cause. LVF is associated with orthopnoea (dyspnoea worse on lying; ow many pillows?) and paroxysmal nocturnal dyspnoea (PND; dyspnoea waking one up). Other features include ankle oedema, lung crepitations and JVP. Lung oth airway and interstitial disease. It may be hard to separate from cardiac causes; asthma may also wake the patient, as well as cause early morning dyspnoea and wheeze. Focus on the circumstances in which dyspnoea occurs (eg on exposure to an occupational allergen). Anatomical g diseases of the chest wall, muscles, pleura. Ascites can cause breathlessness by splinting on the diaphragm, restricting its movement. Others Any patient who is shocked may also be dyspnoeic (p581) nd this may be shock's presenting feature. Other causes: anaemia or metabolic acidosis causing respiratory compensation eg ketoacidosis, aspirin poisoning. Look for other clues yspnoea at rest unassociated with exertion may be psychogenic: prolonged hyperventilation causes respiratory alkalosis. This causes a fall in ionised calcium leading to an apparent hypocalcaemia. Symptoms and signs include peripheral and perioral paraesthesiae, carpopedal spasm.

The speed of onset helps diagnosis: Acute Subacute Chronic Foreign body Asthma COPD and chronic Pneumothorax (p735, fig 1)Parenchymal diseaseparenchymal diseases Acute asthma eg alveolitis Non-respiratory causes Pulmonary embolus effusion eg cardiac failure Acute pulmonary oedema pneumonia anaemia

Cough
Commonshow all
Upper airway cough syndrome (postnasal drip) Asthma Gastro-oesophageal reflux disease (GORD) Non-asthmatic eosinophilic bronchitis (NAEB) Chronic bronchitis Angiotensin-converting enzyme inhibitor (ACE inhibitor) Pneumonia Post-infectious cough Bordetella pertussis infection

Uncommonshow all
Lung cancer Bronchiectasis and chronic suppurative lung disease Interstitial pulmonary fibrosis Sarcoidosis Tuberculosis Foreign body Hypersensitivity pneumonitis Bronchiolitis Recurrent aspiration Psychogenic cough

Wheeze

Wheezing may be caused by respiratory disorders including: Acute bronchitis Asthma or allergies Bronchiectasis (destruction and widening of the large airways) Bronchiolitis (inflammation of the smallest airways within the lungs) Chronic obstructive pulmonary disease (COPD), including emphysema and chronic bronchitis Epiglottitis (life-threatening inflammation and swelling of the epiglottis, a tissue flap between the tongue and windpipe) Foreign object in the airway Lung cancer Pneumonia Anaphylaxis (life-threatening allergic reaction) Congestive heart failure (deterioration of the hearts ability to pump blood) Gastroesophageal reflux disease (GERD) Pulmonary edema (fluid buildup in the lungs) Smoking

Haemoptysis Commonshow all

Acute/chronic bronchitis Pulmonary tuberculosis Lung abscess Pneumonia Primary lung cancer Lung metastasis Anticoagulants, thrombolytic agents Toxic inhalation Bronchiectasis Pulmonary thromboembolism Mitral valve stenosis Left ventricular failure Coagulopathy Thrombocytopenia Disseminated intravascular coagulation

Causes of pleurisy

A number of different conditions may cause pleurisy including: Asbestosis Bacterial infections Cancers

Pancreatitis (inflammation of the pancreas) Pneumonia Pulmonary embolism associated with deep vein thrombosis Rheumatic disease such as rheumatoid arthritis Systemic lupus erythematosus (disorder in which the body attacks its own healthy cells and tissues) Trauma or injury to the chest such as a rib fracture Viral infection such as the flu

Coughing is a relatively nonspecific symptom, resulting from irritation anywhere from the pharynx to the lungs. The character of a patient's cough may, however, give some clues as to the underlying cause:

Loud, brassy coughing suggests pressure on the trachea eg by a tumour. Hollow, bovine coughing is associated with recurrent laryngeal nerve palsy. Barking coughs occur in acute epiglottitis. Chronic cough: Think of pertussis, TB, foreign body, asthma (eg nocturnal). Dry, chronic coughing may occur following acid irritation of the lungs in oesophageal reflux, and as a side-effect of ACE inhibitors.

Clubbing Finger nails ( toenails) have exaggerated curvature in all directions. There is a loss of the angle between nail and nail-fold, and the nail-fold feels boggy. There are changes in local blood flow, but the exact mechanism is unclear. Thoracic causes:

Bronchial carcinoma (usually not small cell) Chronic lung suppuration o empyema, abscess o bronchiectasis o cystic fibrosis Fibrosing alveolitis Mesothelioma

GI causes:

Inflammatory bowel disease (especially Crohn's) Cirrhosis GI lymphoma Malabsorption, eg coeliac

Rare:

Familial Thyroid acropachy (p546) Unilateral clubbing, from: o axillary artery aneurysm o brachial arteriovenous malformations

Cardiac causes:

Cyanotic congenital heart disease Endocarditis Atrial myxoma

s/s of poorly controlled asthma

Tachypnoea; audible wheeze; hyperinflated chest; hyperresonant percussion note; diminished air entry; widespread, polyphonic wheeze. Severe attack: inability to complete sentences; pulse >110bpm; respiratory rate >25/min; PEF 33-50% of predicted. Life-threatening attack: silent chest; cyanosis; bradycardia; exhaustion; PEF <33% of predicted; confusion; feeble respiratory effort.

Investigate asthma
Acute attack: PEF, sputum culture, FBC, U&E, CRP, blood cultures. ABG analysis usually shows a normal or slightly reduced PaO2 and low PaCO2 (hyperventilation). If PaO2 normal but the patient is hyperventilating, watch carefully and repeat the ABG a little later. If PaCO2 is raised, transfer to high dependency unit or ITU for ventilation, as this signifies failing respiratory effort. CXR (to exclude infection or pneumothorax). Chronic asthma: PEF monitoring (p148): a diurnal variation of >20% on >3d a wk for 2wks. Spirometry: obstructive defect (decrease FEV1/FVC, increase RV p148); usually 15% improvement in FEV1 following 2 agonists or steroid trial. CXR: hyperinflation. Skin-prick tests may help to identify allergens. Histamine or methacholine challenge. Aspergillus serology.

RX asthma
Drugs B2-adrenoceptor agonists relax bronchial smooth muscle ( increase cAMP), acting within minutes. Salbutamol is best given by inhalation (aerosol, powder, nebulizer), but may also be given PO or IV. SE: tachyarrhythmias, decrease K+, tremor, anxiety. Long-acting inhaled B2-agonist (eg salmeterol, formoterol) can help nocturnal symptoms and reduce morning dips. They may be an alternative to reduce steroid dose when symptoms are uncontrolled. SE: as salbutamol, paradoxical bronchospasm (salmeterol). Also: tolerance and arrhythmias may be a problem. Corticosteroids are best inhaled to minimize systemic effects, eg beclometasone via spacer (or powder), but may be given PO or IV. They act over days to decrease bronchial mucosal inflammation. Rinse mouth after inhaled steroids to prevent oral candidiasis. Oral steroids are used acutely (high-dose, short courses, eg prednisolone 40mg/24h PO for 7d) and longer term in lower dose (eg 5-10mg/24h) if control is not optimal on inhalers. Warn about SEs: Side effects of steroid use

System: Gastrointestinal

Musculoskeletal

Endocrine CNS Eye Immune

Adverse reactions: Pancreatitis Candidiasis Oesophageal ulceration Peptic ulceration Myopathy Osteoporosis Fractures Growth suppression Adrenal suppression Cushing's syndrome Aggravated epilepsy Depression; psychosis Cataracts; glaucoma Papilloedema Increased susceptibility to, and severity of infections, especially chicken pox.
91

Steroids can also cause fever and leucocytosis; steroids only rarely cause leucopenia. in terms that patients understand: document this in the notes.

Explain side effects

Aminophylline (metabolized to theophylline) may act by inhibiting phosphodiesterase, thus decrease bronchoconstriction by increase cAMP levels. Try as prophylaxis, at night, PO, to prevent morning dipping. Stick with one brand name (bioavailability variable). It is also useful as an adjunct if inhaled therapy is inadequate. In acute severe asthma, it may be given IVI. It has a narrow therapeutic ratio, causing arrhythmias, GI upset, and fits in the toxic range. Check theophylline levels (p739), and do ECG monitoring and check plasma levels after 24h if IV therapy is used. Anticholinergics (eg ipratropium, tiotropium) may decre muscle spasm synergistically with B2-agonists but are not recommended in current guidelines for asthma. They may be of more benefit in COPD. Cromoglicate May be used as prophylaxis in mild and exercise-induced asthma (always inhaled), especially in children. It may precipitate asthma. Leukotriene receptor antagonists (eg montelukast, zafirlukast) block the effects of cysteinyl leukotrienes in the airways. Anti-IgE monoclonal antibody Omalizumab be of use in highly selected patients with persistent allergic asthma.

Mx of asthma
British Thoracic Society guidelines 27 Start at the step most appropriate to severity; moving up if needed, or down if control is good for >3 months. Rescue courses of prednisolone may be used at any time. Step 1 Occasional short-acting inhaled B2-agonist as required for symptom relief. If used more than once daily, or night-time symptoms, go to Step 2. Step 2

Add standard-dose inhaled steroid: eg beclometasone 200mg/12h or fluticasone 50-250 g/12h. Titrate to lowest dose needed for effective control. Step 3 Add long-acting B2-agonist (eg salmeterol 50ug/12h or formoterol 12ug/12h). If benefit but still inadequate control-continue and incre dose of beclometasone to 400ug/12h. If no effect of long acting B2-agonist stop it. Step 4 Consider trials of: beclometasone up to 1000Ug/12h; modified-release oral theophylline; modified-release oral B2-agonist; or oral leukotriene receptor antagonist (see below), in conjunction with previous therapy. Step 5 Add regular oral prednisolone (1 dose daily, at the lowest possible dose). Refer to asthma clinic.