Dyspnea

uncomfortable awareness of breathing, and as the experience of breathlessness

acute dyspnea cause Cardiovascular disease : acute myocardial ischemia, congestive heart failure,

cardiac tamponade

Respiratory disease : bronchospasm, pulmonary embolism, pneumothorax,

pulmonary infection (bronchitis, pneumonia),

upper airway obstruction

chronic dyspnea cause Obstructive lung disease : asthma, COPD

Restrictive lung disease :

interstitial lung disease, kyphoscoliosis

Nonpumonary cause :
congestive heart failure, ischemic heart disease, anemia, obesity

substernal chest pain- cardiac ischemia,

fever , cough, sputum-respiratory infection, Urticaria- anaphylxasis, Wheezing- bronchospasm, Stridor- upper airway obstruction

Trepopnea Dyspnea in one lateral position but not in the other cause Unilateral lung diseases, Unilateral pleural effusion, Unilateral obstruction of the airway, Chronic obstructive pulmonary disease , Congestive heart failure

Orthopnea Dyspnea in the recumbent position Cause

Left ventricular failure , Mitral stenosis , Obstructive airway disease, Respiratory muscle weakness, Diaphragmatic paralysis,

Platypnea Dyspnea in the upright position and relieved by recumbency Cause

Atrial septal defects , Liver cirrhosis, Pulmonary arterial-venous malformation, Hypovolemia, Neuromuscular diseases

physical examination, Chest X-ray, EKG , ABGA, Spirometry

Chest X-ray : pneumonia, pneumothorax, pleural effusion, congestive heart failure

Chest X-ray normal

pulmonary embolism deep vein thrombosisrisk factors

plasma D-dimer, perfusion lung scan

Arterial Blood Gas Analysis :

acid-base balance,

PaO2
Spirometry : asthma, COPD, DILD, chest wall abnormality, lung resection

Hemoptysis
haemoptysis is the expectoration of blood or of bloodstained sputum from the bronchi, larynx, trachea, or lungs

massive hemoptysis : 24 hours 100~600 cc

Cause Tuberculsosis, Bronchiectasis,

cause Neoplasm ,

Bronchiectasis ,
Infections,

Vascular Pulmonary infarct and embolism , Mitral stenosis, Iatrogenic rupture of pulmonary artery, Arteriobronchial fistula , Ruptured thoracic aneurysm

AV malformation,
Vasculitis

etc. Anticoagulation therapy ,

coagulopathy,
Trauma

most common causes of hemoptysis : bronchitis. bronchogenic carcinoma most comnon causes of massive hemoptysis :

tuberculosis.
bronchiectasis

Tracheobronchial Disorders
sputum test (TB, parasites, fungi, cytology) bronchoscopy, HRCT High Resolution - CT

Localized Parenchymal Diseases

sputum test (TB, parasites, fungi, cytology) Chest CT , Lung biosy with special stains

Diffuse Parenchymal Diseases sputum test (cytology)

laboratory test (BUN, ANA, RF, ANCA Anti neutrophil cytopasmic Ab )

Lung or kidney biopsy with special stains , HRCT

Cardiovascular Disorders
echocardiography, ABGA , Pulmonary arteriogram CT

Hematologic Disorders
Coagulation studies , Bone marrow biopsy

treatment bed rest, Transfusion, oxygen therapy , endotracheal intubation , Drug Bronchiectasis- -adrenergic agonist, theophylline

Chronic bronchitis- mucociliary escalator,

Nonsmoking, artery angiography+bronchial artery embolization

pulmonary edema
Pulmonary edema is a condition characterized by fluid accumulation in the lungs caused by back pressure in the Lung veins. Lung/pulmonary congestion , Lung water

cause A) cardiogenic : rise of pulmonary hydrostatic (1) LA outflow impairment , (2) LV systolic or diastolic dysfunction , (3) LV volume overload , (4) LV outflow obstruction

B) noncardiogenic: pulmonary capillary permeability blood pulmonary capillary pressure is normal

acute respiratory distress syndrome

pathophysiology Cardiogenic pulmonary edema, left ventricular dysfunction, pulmonary capillary permeability pulmonary capillary wedge pressure : PCWP

non cardiogenic acute respiratory distress syndrome PCWP

non cardiogenic rare type

(1) altitude pulmonary edema (2)neurogenic pulmonary edema (3) Surgery (4) toxic gases : Nitrogen dioxide, CO, Smoke

Symptoms
Extreme shortness of breath, severe difficult breathing , Feeling of "air hunger" , Inability to lie down ,

Rales ,
Wheezing

Anxiety ,
Cough , Excessive sweating , Pale skin , Coughing up blood ,

diagnosis
1) Chest PA

2) EKG : T wave inversion, QT

3) Swan-Ganz catheterization

4) Plasma brain natriuretic peptide (BNP) 20pg/ml

treatment
Hospitalization ,

Oxygen is given ,
Medications Furosemide Morphine vasodilators

acute respiratory distress syndrome

Severe, acute lung injury involving diffuse alveolar damage, increased microvascular permeability and non cardiogenic pulmonary edema acute refractory hypoxemia

diagnosis
Acute onset Oxygenation Pao2/Flo2<200 mmHg Chest Radiograph Bilateral infiltrates seen on frontal chest radiograph Pulmonary Artery Wedge Pressure

CAUSE Direct Lung Injury: a) pneumonitis b) pulmonary contusion, penetrating lung injury c) fat emboli d) drowning

e) inhalation injury
f) lung transplant

Indirect lung injury a) sepsis b) severe trauma c) drug over dose d) acute pancreatitis e) transfusion of multp blood products

phase
1. Exudative (acute) phase - 0- 4 days 2. Proliferative phase - 4- 8 days 3. Fibrotic phase - >8 days 4. Recovery

pneumonia
Pneumonia is an infection of one or both lungs which is

usually caused by bacteria, viruses, or fungi.

(1)community-acquired pneumonia :
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumoniae

(2)hospital-acquired pneumonia :
Klebsiella pneumoniae, Escheichia coli, Pseudomonas aeruginosa, Staphylococcus aureus

symptoms: fever, chills ,

(cough, sputum, shortness of breath, Hemoptysis, chest pain)

acute and purulent sputum- Bacterial pneumonia subacute and not sputum - atypical pneumonia hospital-acquired pneumonia

diagnosis
Laboratory

leukocytosis ,
Chest Radiograph radiological infiltration: infiltration Gram stain and microbiological culture

treatment drugs

beta-lactam, macrolide, quinolone, tetracy-cline

lung abscess
A localized area of destruction of lung parenchyma in which infection by pyogenic organisms results in tissue necrosis & suppuration

Primary = abscess in previously healthy patient or in a patient at risk for aspiration

Secondary = associated bronchogenic neoplasm or immunocompromised patient.

cause
Peptostreptococcus, F. nucleatum, P. melaninogenica, Klebsiella pneumoniae, Staphylococcus aureus, Haemophilus influenzae

diagnosis
cough, purulent sputum, hemoptysis, chest pain , increase of white blood cell count

Treatment postural drainage Drug Penicillin Surgery

tuberculosis TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs. It is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease

Mycobacterium
Nontuberculous mycobacteriosis (Mycobacterium avium, Mycobacterium kansasii)

Symptoms (usually) lungs lymph nodes , bones, joints, other organs fever , leukocytosis , anemia, cough, hemoptysis , dyspnoea

diagnosis Chest Radiograph

primary - middle lobe , lower lobe, ipsilateral enlarged lymph

second - both lesions( upper) , Fibrosis, calcification

tuberculosismass,
bronchiectasis, airway obstruction, pulmonary embolism, pleural effusion,

Sputum examination There are direct smear and culture Direct smear examination is only positive when large numbers of bacilli begin to be excreted A negative smear by no means excludes tuberculosis A negative smear in the presence of extensive disease and cavitation makes the diagnosis less likely. Particularly if the negatives are frequently repeated

Tuberculin testing
A positive tuberculin test although it is of great use in children, but it has limited diagnostic significance in older age groups less than 5 mm (-) 5-9 mm is considered positive (+) 10-19 mm is considered positive (++) more than 20 mm is considered positive (+++)

treatment drugs isoniazid, rifampicin, ethambutol, pyrazina-mide, streptomycin

bronchiectasis Bronchiectasis is a term that describes damage to the walls of the large airways, or bronchial tubes, of the lung. Inflammation due to infection or other causes destroys the smooth muscles that allow the bronchial tubes to be elastic and prevents secretions that are normally made by lung tissue to be cleared

cause Infectious causes A) Virus Infection: Adenovirus, Influenza virus B) Bacterial infection: Staphylococcus aureus, Klebsiella, C) Tuberculosis

decrease of the host defense mechanism Localized impairment

Generalized impairment: (1) panhypogammaglobulinemia, (2) primary ciliary dyskinesia, (3) cystic fibrosis

other cause ammonia , allergic bronchopulmonary aspergillosis(ABPA) ulcerative colitis , rheumatoid arthritis , Sjgren's syndrome,

symptoms Continuous or recurrent cough, purulent sputum , hemoptysis,

dyspnoea ,
wheezing

Diagnosis The radiological findings Chest radiograph plate-like atelectasis, dilated and thickened airways, tram-track or parallel lines,

impaction of mucopurulent plugs, signet ring sign ,

cluster of cysts,
string of cysts, air-fluid level within cysts

bronchoscopy:
foreign bodies, tumors, structural deformity, extrinsic compression by lymph nodes

pulmonary function tests:

spirometry obstructive dysfunction (obstructive impairment) FVC normal or decreased, FEV1 and FEV1/FVC

treatment remove secretions (vibration),(percussion) ,(postural drainage) drugs antibiotics drugs ( Ampicillin, Amoxicillin ,Trimethoprim -sulfamethoxazole) Respiratory Relaxants Surgery bronchial artery embolization