Respiratory System



Respiratory System





11-A. Cough


Acute

Viral upper respiratory infection



  • Pharyngitis


  • Rhinitis


  • Tracheobronchitis


  • Bronchiolitis

Gastroesophageal reflux

Bacterial and other infections



  • Pneumonia


  • Sinusitis, especially maxillary


  • Lung abscess


  • Bordetella pertussis

Asthma

Inhalation of irritants (environmental, occupational)



  • Smoke/smog


  • Noxious fumes


  • Extremely hot or cold air

Pulmonary edema

Pulmonary embolism

Aspiration pneumonia

Foreign body inhalation

Laryngeal inflammation


External or middle ear disease

Acute pleural, pericardial, mediastinal, or diaphragmatic inflammation


Chronic

(May have more than one etiology)

Postnasal drip syndrome



  • Perennial or seasonal allergic rhinitis


  • Vasomotor rhinitis


  • Chronic bacterial sinusitis


  • Allergic fungal sinusitis (e.g., Aspergillus spp.)


  • Nonallergic rhinitis



    • Medication abuse (legal or illegal)


    • Pregnancy


    • Environmental irritants

Asthma

Gastroesophageal reflux

Bronchiectasis

Neoplasms (especially endobronchial or laryngeal), malignant or benign

Lung abscess

Interstitial lung disease

Recurrent aspiration (hiatal hernia or achalasia)

Drug induced



  • Angiotensin-converting enzyme (ACE) inhibitors


  • Beta-blockers, selective and nonselective


  • Amiodarone

Chronic pulmonary edema

Mitral stenosis

Psychogenic/habit cough

Chronic laryngeal inflammation or tumor

Chronic pneumonia, especially tuberculosis and fungal

Cystic fibrosis

External and middle ear disease, chronic

Bronchogenic/mediastinal cyst

Zenker diverticulum

Aortic aneurysm

Irritation of vagal afferent nerve

Osteophytes

Pacemaker wires

Chronic pleural, pericardial, mediastinal, or diaphragmatic inflammation




References

1. Tilles S. See Bibliography, 1.

2. Irwin RS. Diagnosis and management of cough. Chest. 2006;129:25S-27S.

3. Prakash U. Uncommon causes of cough. Chest. 2006;129:206S-219S.


11-B. Dyspnea


Acute

Pleuropulmonary causes



  • Obstructive lung disease [chronic obstructive pulmonary disease (COPD) and asthma]


  • Acute tracheobronchitis


  • Pneumonitis


  • Pulmonary edema and congestion


  • Pulmonary thromboembolism/vasculitis


  • Pneumothorax


  • Pleurisy and/or pleural effusion


  • Gastric or other fluid aspiration


  • Noxious gas inhalation (including carbon monoxide)


  • Upper airway obstruction/foreign body aspiration


  • Collapse of lung segment(s)


  • Angioedema


  • Chest trauma-pulmonary contusion, rib fractures

Nonpulmonary causes



  • Psychogenic causes (e.g., anxiety)


  • Acute neuromuscular dysfunction


  • Decreased inspired oxygen tension (e.g., at high altitude)


  • Shock


  • Fever


  • Acute anemia


  • Increased intracranial pressure


  • Metabolic acidosis


  • Cardiac tamponade


  • Thoracic burn with eschar formation


Chronic

Pleuropulmonary causes



  • Chronic obstructive diseases—emphysema, asthma


  • Chronic bronchitis


  • Cystic fibrosis


Pulmonary edema (see 11-L)

Interstitial fibrosis (any cause)

Chronic pneumonia

Pulmonary vascular disease



  • Recurrent pulmonary emboli


  • Pulmonary hypertension


  • Arteriovenous malformation

Malignancy—primary lung tumors or metastatic disease to the lung

Respiratory muscle disease



  • Phrenic nerve dysfunction


  • Neuromuscular disease



    • Guillain-Barré syndrome


    • Myasthenia gravis


    • Muscular dystrophy


    • Poliomyelitis

Chest wall abnormalities



  • Pectus excavatum


  • Kyphoscoliosis

Pleural disease



  • Effusion


  • Fibrothorax


  • Pulmonary or metastatic neoplasm

Bronchiectasis

Alveolar filling disease



  • Lipoid pneumonia


  • Pulmonary alveolar proteinosis

Lung resection

Upper airway obstruction

Nonpulmonary causes



  • Anemia, abnormal hemoglobins


  • Obesity


  • Psychogenic disorders


  • Abdominal mass (e.g., tumor, pregnancy)


  • Ascites


  • Metabolic acidosis


  • Thyroid disease


  • Arteriovenous shunt


  • Congenital heart disease



References

1. Shiber J, Santana J. Dyspnea. Med Clin North Am. 2006;90:453-479.


2. Sarkar S, Amelung P. Evaluation of the dyspneic patient in the office. Prim Care Clin Office Pract. 2006;33:643-657.


11-C. Wheezing


Asthma

Allergic sensitization, viral trigger

Exercise or cold induced

Drug induced



  • Aspirin, indomethacin


  • Beta-blockers


  • Sulfites, tartrazine


  • Acetylcysteine


Other Etiologies

Anaphylaxis

Upper airway/tracheal obstruction



  • Extrinsic



    • Thyroid enlargement, tumor, hemorrhage


    • Lymphoma


    • Edema of, or hemorrhage into, subcutaneous tissues of the neck


    • Retropharyngeal edema, hemorrhage, abscess


    • Mediastinal tumor or hemorrhage


    • Esophageal cancer


    • Vascular compression (aortic aneurysm, congenital anomalies)


  • Intrinsic



    • Epiglottitis


    • Foreign body


    • Tracheal fracture, stricture, tumor, or tracheomalacia


    • Laryngeal tumor, trauma, edema, spasm


    • Vocal cord dysfunction or paralysis


    • Amyloidosis


  • Functional



    • Laryngeal dyskinesia

Peripheral airway obstruction



  • Bronchitis, acute or chronic


  • Bronchiolitis


  • Bronchiectasis


  • Cystic fibrosis


  • Pneumonia

Pulmonary embolism


Pulmonary edema (cardiogenic or noncardiogenic)

Aspiration of foreign body or gastric contents

Irritant inhalants (e.g., toluene, sulfur dioxide)

Pulmonary infiltrate with eosinophilia



  • Löffler syndrome


  • Tropical eosinophilia


  • Chronic eosinophilic pneumonia


  • Bronchopulmonary aspergillosis


  • Polyarteritis nodosa

Angioedema



  • Idiopathic


  • Hereditary angioneurotic edema

Carcinoid syndrome



References

1. Tilles S. See Bibliography, 1.

2. Nowak R, Tokarski G. Chapter 27. See Bibliography, 2.

3. Mathur SK, Busse WW. Asthma: diagnosis and management. Med Clin North Am. 2006;90:39-60.


11-D. Hemoptysis1


Pseudohemoptysis

Blood of upper gastrointestinal origin

Upper airway lesions

Epistaxis

Gingival bleeding

Oropharyngeal carcinoma

Laryngeal carcinoma or other lesions

Hereditary hemorrhagic telangiectasia

Airway trauma


Tracheobronchial Sources

Bronchitis, acute or chronic

Bronchiectasis

Bronchogenic carcinoma

Bronchial adenoma

Foreign body

Endobronchial metastatic neoplasm

Bronchial trauma

Cystic fibrosis

Bronchiolithiasis

Amyloidosis



Pulmonary Parenchymal Sources

Pneumonia (bacterial, tuberculosis)

Pulmonary embolism/infarction

Neoplasm

Lung abscess

Fungal infections (especially aspergilloma)

Lung contusion or laceration

Goodpasture syndrome

Wegener granulomatosis

Idiopathic pulmonary hemosiderosis

Inhalation injury (toxic or heated gases)

Sequestration

Bronchogenic cyst

Parasitic infestation (e.g., Paragonimus westermani)

Pulmonary endometriosis

Pulmonary Kaposi sarcoma


Cardiac or Vascular Disorders

Pulmonary edema

Severe mitral stenosis

Aortic aneurysm

Primary pulmonary hypertension

Arteriovenous malformation

Eisenmenger syndrome

Pulmonary vasculitis

Collagen vascular diseases (lupus)

Behçet syndrome

Pulmonary veno-occlusive disease

Pulmonary telangiectasia


Hematologic Disorders

Coagulopathy, congenital or acquired (anticoagulant therapy)

Thrombocytopenia



References

1. Bidwell J, Pachner R. Hemoptysis: diagnosis and management. Am Fam Physician. 2005;72:1253-1260.

2. Hanley ME, Welsh CH. Hemoptysis. In: Current Diagnosis and Treatment in Pulmonary Medicine. New York: McGraw-Hill; 2003.



11-E. Cyanosis1


Central Cyanosis

Arterial desaturation



  • Decreased inspired oxygen tension, high altitude


  • Pulmonary disease



    • Alveolar hypoventilation


    • Ventilation-perfusion mismatch


    • Impaired oxygen diffusion


  • Anatomic (right to left) shunt



    • Congenital heart disease


    • Pulmonary arteriovenous fistulas


    • Other intrapulmonary shunts


  • Hemoglobin abnormalities



    • Carbon monoxide intoxication


    • Cyanide toxicity


    • Sulfhemoglobinemia


    • Methemoglobinemia



      • Drug induced (e.g., lidocaine, dapsone, sulfonamides, benzocaine)


    • Hemoglobin with low affinity for oxygen (e.g., hemoglobin Kansas)


    • Hemoglobin M


Pseudocyanosis

Polycythemia vera

Argyria

Hemochromatosis


Peripheral Cyanosis

Reduced cardiac output, shock

Cold exposure (including Raynaud phenomenon)

Arterial obstruction

Venous stasis and/or obstruction



References

1. Bocock J, Kolodizwk J. Chapter 30. See Bibliography, 2.

2. Kasper D, et al. Hypoxia and cyanosis. In: Harrison’s Principles of Internal Medicine. 16th ed. New York: McGraw-Hill; 2005.

3. Lichtman MA, et al. Methemoglobin and other causes of cyanosis. In: Williams Hematology. 7th ed. New York: McGraw-Hill; 2006.



11-F. Pleuritic Pain1


Chest Wall Disease

Bony thorax



  • Costochondritis (Tietze syndrome)


  • Rib fracture or tumor


  • Fractured cartilage


  • Periostitis or periosteal hematoma


  • Xiphoidalgia


  • Thoracic spondylitis due to arthritis, infection

Soft tissues



  • Infection


  • Muscle spasm (intercostals or pectoral)


  • Myositis or fibromyositis

Neural structures



  • Intercostal neuritis


  • Herpes zoster


  • Neurofibromatosis


Pleuropulmonary Disease2

Infectious pleuritis, especially viral

Pulmonary embolism and infarction

Pneumonia

Pneumothorax

Trauma

Neoplasm (primary or metastatic)

Immune-mediated disease



  • Systemic lupus erythematosus


  • Post-cardiac injury syndrome


  • Rheumatoid disease


  • Vasculitis


  • Drug induced

Diaphragmatic irritation



  • Pancreatitis


  • Abscess (subphrenic, splenic, and hepatic)

Asbestosis

Uremic pleuritis, renal capsular hematoma

Radiation pleuritis

Familial polyserositis

Middle lobe syndrome



Mediastinal Disease

Pneumomediastinum

Mediastinitis

Esophageal perforation

Esophageal variceal sclerotherapy

Pericarditis

Tumor, primary or metastatic



References

1. English J, Leslie K. See Bibliography, 3.

2. Kass S, Williams PM, Reamy BV. Pleurisy. Am Fam Physician. 2007;75:1357-1364.

3. Butler K, Swencki S. Chest pain: a clinical assessment. Radiol Clin North Am. 2006;44:165-179.


11-G. Pleural Effusion: Exudate

Infection



  • Bacterial



    • Empyema (see 11-J)


    • Parapneumonic effusion


  • Tuberculosis


  • Viral


  • Fungal


  • Parasitic (amebiasis, echinococcosis, paragonimiasis)


  • Mycoplasma, actinomycosis, nocardiosis


  • Rickettsiae (Q-fever)

Neoplasm



  • Lung1


  • Breast1


  • Lymphoma, leukemia1


  • Ovarian neoplasm (Meigs syndrome)


  • Metastasis (sarcoma, melanoma)


  • Kaposi sarcoma


  • Primary pleural malignancy (mesothelioma)

Thromboembolic disease



  • Pulmonary embolism


  • Pulmonary infarction


Immune-mediated diseases



  • Rheumatoid arthritis


  • Systemic lupus erythematosus


  • Churg-Strauss syndrome


  • Drug-induced lupus


  • Wegener granulomatosis


  • Sarcoidosis


  • Post-cardiac injury syndrome


  • Sjögren syndrome


  • Familial Mediterranean fever

Intra-abdominal disorders



  • Pancreatitis


  • Esophageal perforation


  • Intra-abdominal abscesses (e.g., hepatic, splenic, subphrenic)


  • Esophageal variceal sclerotherapy


  • Post-abdominal surgery, postpartum state

Drug-induced pleural disease



  • Nitrofurantoin


  • Amiodarone


  • Methotrexate


  • Interleukin-2


  • Ovarian hyperstimulation syndrome

Inhalation of inorganic dusts (asbestosis)


Hemothorax

Traumatic



  • Penetrating or nonpenetrating trauma


  • Iatrogenic

Nontraumatic



  • Malignancy, especially metastatic


  • Anticoagulant therapy for pulmonary emboli


  • Spontaneous



    • Secondary to bleeding disorder (hemophilia, thrombocytopenia)


    • Rupture of intrathoracic vessel or aneurysm


    • Ruptured pancreatic pseudocyst


    • Thoracic endometriosis


    • Idiopathic


  • Pulmonary emboli

Yellow nail syndrome

Uremic pleuritis

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Jun 19, 2016 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Respiratory System

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