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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 thrombosis 의 risk 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 blood-

stained 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 ,

DrugBronchiectasis- β-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 syndromePCWP

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 FurosemideMorphine vasodilators

acute respiratory distress syndrome

Severe, acute lung injury involving diffuse alveolar damage, increased microvascular permeability and

non cardiogenic pulmonary edema acute refractoryhypoxemia

diagnosis

Acute onset

Oxygenation Pao2/Flo2<200 mmHg

Chest RadiographBilateral 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 injurya) 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 Radiographradiological 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

Treatmentpostural drainage

DrugPenicillin

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 en-larged

lymph

second - both lesions( upper) , Fibrosis, calcification

tuberculosis’mass,

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 ,

Sjögren'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

Surgerybronchial artery embolization