Symptoms and Signs of

Respiratory Diseases

Meyer Balter MD, FRCPC, FCCP

University of Toronto

© 2014 American College of Chest Physicians

Disclosure Statements

In  the  past  2  years:  

I have served on advisory boards for:
Almirall, AstraZeneca, Boehringer-Ingelheim, GlaxoSmithKline, Novartis

I have received honoraria for speaking from:

Almirall, AstraZeneca, Boehringer-Ingelheim, Merck, Novartis, Takeda

I have no financial interests in any pharmaceutical company

None of this has any relationship to this talk

© 2014 American College of Chest Physicians

Objectives
After this session, you will be able to:
•  Discuss the most common presenting signs and symptoms of respiratory
diseases
•  Cough
•  Hemoptysis
•  Dyspnea
•  Chest pain
•  Clubbing
•  Discuss the differential diagnosis of these signs and symptoms
•  Briefly describe an approach to working up the most common symptoms

© 2014 American College of Chest Physicians

A 34 yo previously healthy woman complains of a non-
productive cough that started two weeks previously
following two days of myalgias, coryza, and one day of low
grade fever. She has had no recent travel or infectious
symptoms. Physical examination is unremarkable. Which of
the following would you suggest?
A.  Trial of a brompheniramine/pseudoephedrine combination
B.  Trial of loratidine
C.  Trial of albuterol
D.  Trial of inhaled fluticasone

© 2014 American College of Chest Physicians

Acute Cough
•  Maximum duration is < 3 weeks
•  URTI (viral etiology) most common
•  Bacterial bronchitis/tracheobronchitis possible
•  Aspiration
•  Pulmonary embolus (unusual presentation)
•  Pulmonary edema
•  Early manifestation of chronic cough
•  No way of predicting duration or persistence
•  Benign neglect is usually best approach
•  Avoid imaging if no focal findings/persistent fever

© 2014 American College of Chest Physicians

Acute Cough: Therapy
•  First generation antihistamines/long acting
decongesants (brompheniramine/pseudoepedrine) can
be helpful
•  Newer generation antihistamines are not useful
•  Inhaled ipratropium may be helpful
•  Inhaled albuterol may be helpful ONLY if audible
wheezing is detected
•  Avoid OTC products in children

© 2014 American College of Chest Physicians

A 42 y.o. man with underlying hypertension developed
cough with a URI four weeks ago. All other URI symptoms
have resolved except for the dry cough. His only
medication is amlodipine. Examination of the oropharynx
and neck are unremarkable and no wheezes are heard.
The next best step is:
1. Test for B. pertussis antibodies
2. Test for B. pertussis PCR
3. Trial of anti-tussives
4. Empiric treatment with sulfamethoxazole / trimethoprim

© 2014 American College of Chest Physicians

Sub-Acute Cough
•  Sub-acute cough lasts 3-8 weeks and B. pertussis may play a
significant role
•  Without significant co-morbidities, symptom relief is probably the key
step
•  Evidence supporting use of codeine not convincing
•  Peripheral cough suppressants may be helpful
•  levodropropizine
•  moguistine
•  Testing for B. pertussis is best reserved for epidemiologic purposes
•  Ask about vaccination status/infectious contacts
•  Treatment of B. pertussis includes macrolides and SMX/TMP if within
1-2 weeks of symptom onset

© 2014 American College of Chest Physicians

 A 36 yo man comes for evaluation of a cough that started
insidiously 6 months ago. He is a lifelong non-smoker, has
no other medical problems and is on no medications.
Physical exam, spirometry, and a CXR are normal.
What would you suggest next?

1.  A chest CT scan

2.  24 hour pH monitoring with esophageal manometry
3.  A trial of nasal ICS and an older generation antihistamine
4.  A 2 week trial of prednisone at a dose of 30 mg daily

© 2014 American College of Chest Physicians

Chronic Cough
•  Most common causes in non-smokers include:
•  Asthma
•  Upper Airway Cough Syndrome
•  GERD
•  Secondary to ACE inhibitor use
•  Nonasthmatic eosinophilic bronchitis
•  A response to a specific therapy is probably the best diagnostic
strategy
•  Treatment should include avoidance of any known / identifiable
triggers
•  More than one underlying condition may be contributing to chronic
cough in about a third of of patients

© 2014 American College of Chest Physicians

Cough Variant Asthma
•  Methacholine challenge test suggested for confirmation
•  Initial therapy should be inhaled corticosteroid
•  In patients refractory to ICS AND who have been adherent to
medication therapy and removal of offending irritants/allergens:
•  a trial of LTRA therapy is reasonable
•  an assessment of airway inflammation is suggested
•  If cough refractory to ICS, trial of 1-2 weeks of OCS warranted

© 2014 American College of Chest Physicians

Upper Airway Cough Syndrome (includes post nasal drip)

•  No pathognomonic findings
•  Allergic, infectious, and vasomotor etiologies are most common
•  An empiric trial of therapy for UACS warranted in idiopathic chronic cough
•  First line therapy includes a first generation antihistamine/decongestant
•  Nasal corticosteroids are widely used
•  unclear if specific subsets of UACS benefit
•  If there is a history of atopy a non-sedating antihistamine should be
substituted
•  Consider imaging of sinuses if strong suspicion of sinus etiology and no
response to trial of empiric therapy

© 2014 American College of Chest Physicians

Gastroesophageal Reflux
•  High likelihood that this is source of idiopathic cough if GERD symptoms
•  Frequently coexists with other causes of cough
•  Role for 24 hour pH monitoring contentious
•  Non acid reflux may be important
•  ? role for esophageal impedance studies
•  Subjects should be off reflux therapy before study
•  Expensive- trial of therapy warranted first
•  Medical anti reflux surgery includes:
•  Dietary and lifestyle modifications
•  Acid suppression therapy (H2 blocker or PPI)
•  Addition of a prokinetic agent
•  In patients with cough due to reflux unresponsive to maximal medical therapy
fundoplication may be warranted

© 2014 American College of Chest Physicians

Non-Asthmatic Eosinophilic Bronchitis
•  Eosinophilic airway inflammation without BHR
•  Spirometry, CXR also normal
•  Can exist with other causes of cough
•  consider occupation-related cause
•  ICS are first line therapy
•  Consider OCS trial if no response to ICS
•  Response to ICS/OCS alone does NOT differentiate NAEB from asthma
•  Must demonstrate airway eosinophilia
•  Induced sputum preferred
•  Bronchoscopy not routinely warranted

© 2014 American College of Chest Physicians

Angiotensin Converting Enzyme Inhibitor Cough

•  Can occur in approximately 10% (5-35%) of treated patients

•  Temporal relationship not always clear
•  Therefore trial of cessation always warranted
•  First line therapy is cessation of ACE-I
•  Usually resolves in 1-4 weeks
•  Can replace with ARB
•  If ACE-I cannot be stopped
•  Sodium cromoglycate, theophyline, sulindac, indomethacin, amlodipine,
nifedipine, ferrous sulfate have all been tried with variable sucess

© 2014 American College of Chest Physicians

Approach to chronic cough when the H&P suggest
no clear cause
•  Stop any smoking and ACE-Is
•  ARB’s cause no more chronic cough than diuretics
•  Methacholine challenge testing recommended
•  CTs (chest/sinus) are rarely helpful
•  Begin empiric therapy before extensive testing
•  24-hour esophageal pH probes have limitations
•  Cause of cough not identified more frequently than suggested by guidelines

© 2014 American College of Chest Physicians

Less Common Causes of Chronic Cough
•  Bronchiectasis
•  Malignancy
•  Benign airway tumors
•  Foreign bodies
•  External otitis / impaction (irritation of the auricular branch of the vagus nerve)
•  ILD
•  Aspiration
•  Chronic infection
•  Cardiac

© 2014 American College of Chest Physicians

Cough Patterns and Pearls:
Mucus Characteristics
Pink, frothy
Pulmonary edema
Copious, frothy, saliva-like
Mucinous form of adenocarcinoma
Thick, mucoid, with casts
Asthma (APBA)
Malodorous
Anaerobic infections
Yellow/green
Infection (except in asthma-marker of airway eosinophilia)

© 2014 American College of Chest Physicians

Cough Patterns and Pearls:
Mucus Characteristics
Rust-colored
Pneumococcus
Brownish (chocolate/anchovy paste)
Amoebic lung abscess
Caseous (cheese-like)
Tuberculosis
Purulent, intermittent blood, and influenced by posture
Bronchiectasis
Currant Jelly Sputum
Blood, mucous, debris from infection
(classically Klebsiella pneumonia)

© 2014 American College of Chest Physicians

Cough Patterns and Pearls:
Other Characteristics
Temporal
Early morning
•  Smoking, chronic bronchitis
Nocturnal
•  Asthma, pulmonary edema
Sound
“whooping” sound during inspiration that precedes cough
•  Pertussis
“Barking” sound during cough
•  Laryngotracheal infections: viral, diptheria, pertussis
© 2014 American College of Chest Physicians
A 65 yo male smoker with a 40 pack year history
comes to the ED stating that he has coughed up
small amounts of blood mixed with sputum most
days over the past week. He is otherwise well, there
was no infectious prodrome and he has had no
recent travel. Physical exam is unremarkable. A CXR
reveals hyperinflation alone. CBC, PT/PTT, U/A and
creatinine are all normal. What would you do next?
1.  Arrange urgent rigid bronchoscopy
2.  Arrange urgent flexible fiberoptic bronchoscopy
3.  Organize a chest CT scan
4.  Perform a bronchial angiogram with planned embolization

© 2014 American College of Chest Physicians

Hemoptysis
•  Infection is the most common cause of non-massive hemoptysis
•  Bronchitis, bronchiectasis, necrotizing pneumonia, TB
•  Lung cancer is most common non infectious cause
•  Only minority of bronchogenic CA presents this way
•  Confirm that bleeding is coming from the lung
•  Nose, oropharynx, GI tract
•  Important points on history/physical exam
•  Anticoagulant use
•  Association with menses
•  History of immunosuppresion, cigarette use, rash, hematuria, CTD, travel
•  Look for signs of AVM, CHF, CTD, clubbing, murmurs

© 2014 American College of Chest Physicians

Hemoptysis
•  No nausea vomiting
•  History of lung disease
•  Frothy sputum
•  Liquid/clotted appearance
•  Bright red/pink
•  Alkaline pH
•  Mixed with AM/pmns
Hematemesis
•  Presence of nausea/vomiting
•  History of gastric/hepatic disease
•  Rarely frothy
•  Coffee ground appearance
•  Brown to black
•  Acidic pH
•  Mixed with food particles
© 2014 American College of Chest Physicians
Hemoptysis: Differential Diagnosis
•  Bronchitis/Bronchiectasis
•  Aspergilloma
•  TB
•  Tumor
•  Lung abscess
•  Emboli
•  Coagulopathy
•  AVM, Alveolar hemorrhage, autoimmune disease
•  Mitral stenosis (CHF, pulmonary hypertension)
•  Pneumonia

© 2014 American College of Chest Physicians

Hemoptysis: General Principles
•  Make sure patients is hemodynamically stable (ABCs)
•  Rule out coagulopathy and check urine
•  If patient actively bleeding
•  Immediate bronchoscopy increases yield
•  If bleeding has stopped
•  CT scan first to look for area where BAL may be directed
•  If no source is found follow patient
•  Idiopathic usually have good prognosis
•  Some studies have shown increased risk of malignancy

© 2014 American College of Chest Physicians

Massive Hemoptysis
•  Variable definitions-most use > 500-600 ml/24 hours
•  Bronchiectasis
•  Cancer
•  Airway maintenance is vital
•  Early ICU admission +/- intubation
•  If bleeding source known-place patient with bleeding lung down
•  Contrast enhanced CT is probably best procedure if patient is stable
•  Rigid bronchoscopy preferred
•  Bronchial artery embolization has mostly supplanted urgent surgery

© 2014 American College of Chest Physicians

A 52 yo man comes to the ED for evaluation of acute onset
chest pain. He describes the pain as pressure like with no
radiation and no associated symptoms. He has a history of
hypertension for which he is on a beta-blocker. He had
taken a tablet of sildenafil earlier that evening. His physical
exam is normal aside from a pulse of 108/min. You would
suggest each of the following EXCEPT:

1.  Start a large bore iv

2.  Give ASA
3.  Give sublingual NTG
4.  Provide supplemental oxygen by nasal prongs

© 2014 American College of Chest Physicians

Differential Diagnosis of Acute Chest Pain
•  Cardiac
•  ACS
•  Aortic dissection
•  Pericardial disease
•  Respiratory
•  Pulmonary embolus
•  Pneumothorax
•  Pneumonia
•  Gastrointestinal
•  Pancreatitis, cholecystitis, splenic rupture, GERD
•  Anxiety
•  Miscellaneous
•  Costochondritis, herpes zoster, trauma

Familiarize  yourself  with  predic9on  rules    

© 2014 American College of Chest Physicians
Causes of non-cardiac chest pain:
Pearls and patterns
Pleuritic with some hemoptysis
Pulmonary embolism with infarct
Point tenderness of cartilaginous portion of ribs
Trauma and relapsing polychondritis
Pain followed by rash
Zoster
Present in tall, thin, young males
Spontaneous pneumothorax
Mid-back and “stabbing”
Aortic dissection

© 2014 American College of Chest Physicians

A 76 yo woman with advanced COPD (FEV1 =34%
predicted) complains of intractable progressive
dyspnea that interferes with her daily activities. She
is on maximal bronchodilator therapy. Her CXR
merely shows hyperinflation and her ABG reveals
pH=7.42, pCO2=38, pO2=68 and sat=93%.
Which of the following would you recommend?
1.  Begin therapy with low dose benzodiazepines
2.  Start therapy with oxygen 2LPM by nasal prongs
3.  Recommend acupuncture and relaxation therapy
4.  Start low dose therapy with oral morphine

© 2014 American College of Chest Physicians

Chronic Dyspnea
•  FIT
•  Deconditioning (e.g. post operatively in elderly)
•  Respiratory
•  Obstruction
•  Restriction
•  Vascular
•  Cardiac
•  Ischemic, pump, arrhythmia
•  Muscle and Metabolic
•  Anemia, thyroid
•  Guillain-Barre, myasthenia
•  Psychiatric

© 2014 American College of Chest Physicians

A 72 y.o. man with HTN, DM, CAD and former
smoker presents with dyspnea, productive
cough, and finger clubbing. All of the
following are possible explanations for the
finger clubbing except:
A.  Advanced COPD with hypoxia
B.  Bronchogenic lung cancer
C.  Bronchiectasis
D.  Familial
E.  IPF

© 2014 American College of Chest Physicians

 Clubbing: Major causes
•  Pulmonary
•  Suppurative infections (abscess, bronchiectasis, CF)
•  Bronchogenic carcinoma
•  IPF (UIP)
•  Congenital heart disease (esp. R->L shunt)
•  SBE
•  Advanced liver disease (particularly PBC)
•  Inflammatory bowel disease (Crohn’s > UC)
•  Thalassemia
•  Familial
•  Pachydermoperiostosis

Hypoxia  and  COPD  are  not  independently  associated  with  clubbing  

  © 2014 American College of Chest Physicians
Summary
•  Read about cough
•  The big three: asthma, UACS, GERD
•  Remember: smoking, ACE-I, NAEB
•  Hemoptysis
•  Chronic Dyspnea
•  FIT RCMP
•  Chest pain
•  Don’t miss ACS or pulmonary emboli
•  Clubbing
•  NOT caused by COPD/hypoxemia alone

© 2014 American College of Chest Physicians