The symptoms of Respiratory

disease

Department of Respiratory Medicine,

Affiliated Hospital, Jiangsu University

Dr. Zheng Jinxu

jxuzh135@163.com
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Respiratory symptoms
v Cough
v Expectoration (productive Cough)

v Hemoptysis

v Chest pain

v Dyspnea (short of breath)

 1、Cough
v Coughing is an essential defense
mechanism that it prevents the airways
from the foreign substance and clear the
excretion of respiratory tract.
v Coughing is a reflex.

v permanent and frequent coughing

indicates an abnormality.
 Mechanism
v Extrathoracic cough receptors located in
nose oropharynx larynx and upper trachea
(cricoid cartilage and glottis )
v intrathoracic cough receptors located in
low trachea and large central bronchi
v Afferent vague , trigeminal , superior
laryngeal , glosso-pharyngeal nerves
v Efferent recurrent laryngeal nerve ---
closure of glottis, corticospinal tract and
peripheral nerves ---contraction of thoracic
and abdominal musculature
 The cough reflex

A deep breath---glottic closure---relaxation

of diaphragm, contraction of expiratory
muscle---positive thoracic pressure--
suddenly release of glottis open---thoracic
positive pressure airflow out--- cough reflex
 Etiology

v Respiratory disease
v pleural disease

v cardiovascular disease

v central nerve system factor

 Respiratory disease
Stimulator --- extra and intrathoracic --- from
nose,oropharynx --- bronchi --- cough reflex.
such as:
1.inhalation of foreign material
2.inflammation of respiratory tract
3.bleeding of respiratory tract
4.tumor of respiratory tract
 Pleural Disease
Such as:

v pleurisy, thoracic effusion

v pleural biopsy or pleuracentesis

 Cardiovascular Disease
v Mitral stenosis --- left heart failure ---
pulmonary edema --- stimulates intra-
thoracic-cough receptor --- cough

v Embolism of pulmonary can cause

pulmonary venous pressure elevate ---
pulmonary edema --- stimulates intra
thoracic cough receptor ---cough
 Central nerve system

v Inflammatory of CNS can cause

coughing

v such as: encephalitis and meningitis

2、Expectoration

Expectoration is a pathological
phenomenon that human being remove
the pathological secretion from respiratory
system by means of coughing
v The daily quantity of bronchial secretions
produced by a normal person is unknown.
But it is sufficiently small to be removed
by mucocillary action alone.

v Cough and expectoration are not required

v Excessive production
v Altered physical properties

v Deficient clearance

These factors cause the secretions

accumulate in the tracheobronchial
system and cause expectoration.
 Expectoration appears

Mechanical, chemical, physical and

allergic factors can cause respiratory
mucosa edema, congestion and cause
transudate or exudate then cough and
expectoration appears
Such as:
1) Inflammation include virus, bacteria,
fungus can cause coughing and
expectoration.
2)Acute left heart failure can cause
pulmonary edema and pink foamy
sputum.
 Manifestation

v Character of cough
v The duration and pattern of cough

v The tone quality of cough

v The character and volume of sputum

 Character of cough
v Cough without sputum---unproductive or
dry cough mainly in the patient of acute
pharyngitis, early stage of bronchitis,
pleurisy and TB.
v Cough with sputum is called productive .

It is caused by pneumonia, chronic

bronchitis, bronchiectasis, lung abscess
and cavitious TB
 The character and volume of sputum

v clear ,white ,gray sputum--chronic bronchitis

v tenacious sticky mucoid sputum -----
asthmatics(occasionally with bronchial cast)
v foul-smelling purulent sputum--bronchiectasis
v sputum with calcific particles -----
broncholithoptysis
The duration and pattern of cough

v Cough initiated suddenly --- acute upper

airway infection
v Chronic cough --- chronic bronchitis,
bronchial asthma and TB
v Paroxysmal cough --- whooping cough,
bronchi compressed by tumor and TB
v Periodic cough --- chronic bronchitis
bronchiectasis related to the change of
body position.

v Nocturnal cough---asthma, TB,chronic

heart failure--associated with the vagal
excitation at night.
 The tone quality of cough
v It means the change of the sound and may
suggest the the location of pathology.
v “breaking” cough --- epiglottal disease
v “brassy” cough --- tracheal airways
v “hacking” or “cleaning of throat”--postnasal
discharge
v “barking”or “croupy”--laryngeal disease.
v Hoarseness with cough --- larynto-tracheal
bronchitis or impaired the function of recurrent
laryngeal.
v Inspiratory stridor --- upper airway obstruction
v Cough with hemoptysis also raises the
possibility of a malignant process,
bronchiectasis, lung abscess, chronic
bronchitis.
The associated clinical features
v cough with fever --- acute respiratory
infection including measles, pneumonia,
influenza, lung abscess, TB, pleurisy.

v cough with chest pain --- plural cavity

involve, heart disease, pneumonia,
pleurisy, bronchogenic carcinoma.
v cough with dyspnea -------- edema of
larynx, larynx tumor, chronic obstructive
pulmonary disease, sever pneumonia, TB,
massive pleural effusion, pulmonary
congestion,pneumothorax and pulmonary
edema.
v cough with quantitative purulent sputum ---
bronchiectasis, lung abscess.
v Cough with hemoptysis --- bronchiectasis,
TB, lung tumor, lung abscess, mitral
stenosis.
v cough with clubbed fingers ---
bronchiectasis, TB, lung
abscess ,carcinoma of lung, thoracic
empyema, interstitial lung dsease.
v Cough with wheeze --- bronchial asthma,
cardiac asthma, foreign body in trachea
and bronchi.
 Any change in character
or pattern of a chronic
cough warrants immediate
diagnostic evaluation, with
special attention directed
towards the detection of
bronchogenic carcinoma.
 3、Hemoptysis
v Hemoptysis is the
expectoration of blood from
airway blow larynx.

v Hemoptysis patients
should be examined the
nose, mouth and upper
respiratory tract to be found
the hemorrhagic spot.
v The quantity of blood may vary from streaks
and flecks in the sputum to massive
hemorrhage.
v Minimal bleeding may be an early indicator

of the presence of serious bronchopulmonary

disease.
v Hemorrhages of even moderate degree may

life threatening.
v About 50 percent of the chest films of the
hemoptysis patient show no abnormalities
or only minimal nonspecific change.
v Hemoptysis may be the initial or the sole

symptom of bronchopulmonary disease.

These factors sometimes cause the

dignostic problem.
 Etiology

1.Bronchial disease
2.lung disease
3.cardiovascular disease
4.constitutional disease
 Investigation
Ø whether coughed out or vomitted out
Ø Volume: how much
Ø Time duration
Ø Any accompanied appearances
 1.Bronchial disease

v hemoptysis occur in bronchiectasis,chronic

bronchitis, endobronchial tuberculosis and
bronchogenic carcinoma.
v Also occur in the benign bronchogenic
tumor, foreign body, bronchogenic
nonspecific ulceration.
 1.Bronchial disease

v The inflammatory process lead to the increase

the permeability of capillary and rapture of
vessels in bronchial mucosa and then induce
hemoptysis.
v blood-streaked sputum occasionally occur in

the course of acute bronchitis.

 2.Lung disease
v The sputum of pneumococcal pneumonia
is described as “rusty” in appearance.
v Pulmonary TB is the common cause of
the hemoptysis.
v Cavitious TB may cause the expectora-
tion of frank blood from pulmonary cavity.
 2.Lung disease
v Lung abscess may be related to putrid
smelling sputum and expectoration of
blood.
v hemoptysis occur in 25 percent of the
patient of pulmonary embolism and
infarction.
v pulmonary fungi and parasite infection
may also serve as the sources of
hemoptysis.
 3.Cardiovascular disease
v Pink frothy sputum --- acute pulmonary
edema
v blood streaked sputum--acute pulmonary
congestion
blood comes from pulmonary capillaries
which ruptured under high intravascular
pressure.
 3.Cardiovascular disease

v Hemoptysis due to mitral stenosis is

frequently induced by physical exercise or
excitement.
v Many pulmonary emboli do not lead to
pulmonary infarction, when they do, frank
hemoptysis occurs in the minority of
instance.
v Hemoptysis is also associated with congenital
cardiac disease and aortic aneurysms
 4.Constitutional disease

v Blood spitting may also occur in the

patients suffering from certain blood
dyscrasias, such as hemophilia, leukemia
and infectious disease, connective tissue
disease.
 Clinical manifestation
1.the patient’s age.

2.the amount of coughing up blood.

3.color and character.

 1.The patient’s age
v Hemoptysis is often seen in pulmonary TB,
bronchiectasis and rheumatic heart disease
(mitral stenosis) for most youth.
v Cancer is now the disease that patients
think of when they expectorate blood, just
as it was TB 50 years ago.
 1.The patient’s age

v Elder patient with bloody sputum or

streaked of bloody sputum, especially in
the males with long history of smoking.
cancer should be taken into account.
v Patients close contact with TB suffer,TB
should be considered.
2.The amount of coughing up blood

v Hemoptysis can be classified into three

groups according to the amount of
coughing blood.
Massive: expectoration > 500ml/24hr.
Moderate: 500ml> expectoration
>100ml/24hr
minimal: expectoration <100ml/24hr
2.The amount of coughing up blood

massive hemoptysis often occurs

in pulmonary TB cavity,chronic lung
abscess and bronchiectasis.
 3.Color and character.

v To a hemoptysis patient,it is necessary to

ascertain the exact nature of the sputum,
the sputum must be examined both grossly
and microscopically.
 3.Color and character
It is useful to determine whether the material
that is coughed up contains large amount of
liquid blood, which is indicates brisk bleeding,
or whether it contains small amount of dark or
clotted blood,which would indicate slow bleeding
from low-pressure vessels or subsiding bleeding.
 3.Color and character

v Brisk bleeding is commonly associated with

specific focal ulceration of the bronchus,such
as bronchogenic carcinoma, a foreign body,
bronchiectasis or a bleeding aortic aneurysm.
v Slow bleeding strongly suggests venous bleeding
which is more likely to be the result of increased
in blood flow through the bronchial venous system
such as may occur as a result of mitral stenosis.
 Accompanying symptom

v Hemoptysis with fever: pulmonary tuber-

culosis, pneumonia, lung abscess,
epidemic hemorrhagic fever,bronchogenic
carcinoma.
v Hemoptysis with chest pain: lobar pneu-
monia ,pulmonary infarction,pulmonary
TB,lung cancer.
 Accompanying symptom
v Hemoptysis with putrid sputum:lung
abscess,cavitious TB, bronchiectasis.
v Hemoptysis with irritating cough:
bronchogenic carcinoma,mycoplasma
pneumonia.
 Accompanying symptom
v Hemoptysis with skin and mucosa
bleeding: hematological disease,
epidemic hemorrhagic fever,
rheumatism.
v Hemoptysis with undice: leptospirosis,
lobar pneumonia,pulmonary infarction.
 The distinction between
hemoptysis and hematemesis
Hemoptysis Hematemesis
Causes Pulmo or cardiac digestive system
Previous symptoms Cough, chest Nausea, vomiting
tightness
Spit up Cough up Vomited
Color Bright red Dark red
Mixture Sputum, frothy Gastric contents
pH alkality acidity
Tarry stools - or + +

Post-bleeding Sputum with blood No sputum

 Differentiating from upper
airway bleeding by intenssive
investigation and examination

Post nasal bleeding

Mouth and pharynx membrane bleeding

 4、Chest pain

u Causes

u Character

u Degree

u Location

u Reflection
 Common causes

v Cardiovascular & pulmonary vascular

(ischemic)
v Pleural
v Chest wall
v Mediastinal
v Emanating pains of neighboring
abnormalities
 Cardiovascular
v Location blured press like discomfort
v Eradiation

v Angina pectoris, myocardial infarction,

aortic stenosis (ischemic),
v Myocarditis, pericarditis, (inflamation)
 Pleural
v Pleural disorders (Pleuritis),
v pneumothorax,
v carcinoma

Chest wall
•Injury(rib fracture)
•Inflamation(herpes zoster)
•Costal Neuritis
Mediastinal
•Mediastinitis,
•mediastinal emphysema,
•mediastinal tumor

Other diseases causing

chest pain
v esophageal carcinoma,
v liver abscess,
v subdiaphragmatic abscess,
v hiatal hernia
 Characteristics
v Location
v Referred pain
v Level or feature
›Burning pain, pressing pain, bursting
pain, pricking pain
v Duration
v Influential factors
›Exertional, respiration, foodintake
 Accompany signs
v Cough, sputum and/or fever
› Respiratory disease
v Dyspnea
› Severe pneumonia, pneumothorax, pleurisy, pulmo
embolism
v Hemoptysis
› Carcinoma, pulmo embolism
v Shock
› myocardial infarction, dissecting aneurysm
(rupture ), large area pulmo embolism
v Dysphagia
› Esophageal disease
 5、Dyspnea

u Dyspnea is defined as an awareness of

difficulty in breathing.
u Most patients suffer from actual difficulty,
some patients just taste an awareness of
hyperventilation
 Causes
v Respiratory system
› Obstruction: asthma, COPD, tumor
› Pulmo Diseases: pneumonia, interstitial lung disease,
› Chest wall or pleura: pleurisy, pneumothorax, trauma
› neuro-muscles: poliomyelitis，myasthenia gravis
› Diaphragma movement disorder: obviously elevated
pressure in abdominal cavity
v Cardiovascular system
›Heart failure
›Pulmo embolism
v Poisoning
›ketoacidosis
v Central nervous system
›cerebral tumor , trauma, abscess,
hemorrhage, encephalitis, meningitis
v hematological system
›Severe anemia
u Normal person may experience the
physiologic dyspnea during heavy
exercise
u Environment short of oxygen
 Respiratory Dyspnea
v Inspiratory dyspnea：obstruction in large
airway
›Three depression sign
v depression in suprasternal fossa,
supraclavicular fossa, intercostal
space
v Expiratory dyspnea：obstruction in small
airway or alveolar elasticity decreased
›Prolonged expiratory time
›Expiratory rhonchi
v Mixed dyspnea：deficient gas exchange
Clinical characteristics: breathing is difficult
during both inspiration and expiration.
›Respiratory rate increased

›Shallow breathing
 Accompany signs
v Rhonchi
› Asthma
› Acute left heart failure (cardiac asthma)
› Foreign body in large airway
› Acute laryngeal edema
v Chest pain
› Infection
› Pneumothorax
› Pulmo embolism
› Lung cancer
› Acute myocardial infarct
 Accompany signs
v Fever
› Infection
v Cough and sputum
› COPD
› Infection
› Left heart failure
v Unconsciousness
› CNS disorder
› Uremia
› diabetic ketoacidosis
 Functional classification
v Class Ⅰ– no limitation: Ordinary physical activity
does
v Class Ⅱ– slight limitation of physical activity
v Class Ⅲ– Marked limitation of physical activity
v Class Ⅳ– inability to carry on any physical activity
without discomfort
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