BREATHE EASY

Symptoms and Signs of Lung Disease

WHAT ARE THE SIGNS AND SYMPTOMS OF LUNG DISEASE?

First I should clarify the difference between signs and symptoms. Symptoms are what bother the patient; they are whatever abnormalities the patient notices, such as chest pain, shortness of breath, or cough. Signs are what the physician sees or observes about the patient, such as blue nailbeds, fast breathing, abnormal sounds heard with the stethoscope, or a temperature of 103°. Signs may also include abnormal chest x­rays and other laboratory findings. We can think of symptoms as the subjective aspect of illness and signs as the objective aspect. Both are important in diagnosing and treating any illness, especially lung disease.

The most common symptoms of lung disease are:

The most common signs of lung disease are:

DO THESE SIGNS AND SYMPTOMS ALWAYS MEAN LUNG DISEASE?

Definitely not. These signs and symptoms are non­specific; they may indicate lung disease, disease in other organs, or no disease. For example, shortness of breath may occur due to anemia (low blood count), heart disease, or even pregnancy, to name a few non­respiratory causes. Cough could be due to a simple cold and be of no consequence, or could be the first symptom of lung cancer. Hemoptysis, always a frightening symptom, could be from a bleeding nose or tooth; more commonly it is due to lung disease, but patients with some types of heart disease can also cough up blood. Chest pain could of course be cardiac in origin, but many times chest pain is due to indigestion or even muscle spasm of the chest cage.

Signs are also non­specific. Tachypnea and hyperpnea are present in every healthy person who exercises vigorously. When present in a resting individual they may be related to heart or lung disease, or less commonly to disease elsewhere. Finally, an abnormal chest x­ray (a spot or mass in the lung; fluid in or around the lungs) could be from a benign condition or from something serious, such as lung cancer.

Because of this non­specificity of signs and symptoms, each patient must be evaluated in view of the entire clinical picture. Given the presence of a bothersome symptom or abnormal sign, there is simply no substitute for a good clinical evaluation by an interested, competent physician.

WHEN SHOULD I BE WORRIED ABOUT SYMPTOMS OF RESPIRATORY DISEASE?

Most symptoms of benign respiratory disease are self­limiting, that is, they last no more than a few days and then go away. (See also Section K on flu and the common cold.)

Symptoms lasting longer than a few days should probably be investigated, especially if they limit you in any way. Certain symptoms should be investigated immediately. These include:

WHAT CAUSES COUGH?

We all cough at times. It is a natural and normal protective mechanism to clear our airways of particulate matter that doesn't belong there. Cough is due to irritation of the airway lining by something, usually mucus, dust, secretions, or blood. The underlying condition may range from a simple cold or a mild asthma attack to heart failure or lung cancer.

When a cough lasts only a few minutes we think no more about it. However, many times, particularly after a cold or virus infection, the cough persists. Because it is so commonly associated with colds and upper respiratory infections, coughing is one of the most frequent respiratory complaints. Whenever a cough is associated with high fever, shortness of breath, production of foul smelling sputum, or severe chest pain, it should be evaluated by a physician. These all point to potentially serious but treatable causes. Beyond these associated symptoms, it is convenient to discuss the symptom of cough based on its time span.

Acute Cough: Lasts only a few minutes; it is a universal experience and is a normal protective mechanism.

Cough of Short Duration: This is a self­limited cough lasting less than three weeks, usually due to colds or upper respiratory infections. It may also be due to asthma, bacterial infections, or limited exposure to noxious material.

Chronic Cough: Lasts longer than three weeks; this is a time beyond which a cough can no longer be simply attributed to colds or viral infections.

MOST COMMON CAUSES OF A CHRONIC COUGH

Cigarette smoking
Chronic bronchitis
Emphysema
Asthma
Lung Cancer
Chronic post­nasal drip due to sinusitis or allergy
Tuberculosis
Chronic viral infection of the airways

WHAT IS HEMOPTYSIS?

Hemoptysis is the coughing up of blood. Many physicians distinguish between blood streaking and gross hemoptysis. In the former a few streaks of blood can be seen in a sea of otherwise whitish or grayish mucus; it is a common (but not to be ignored) finding in chronic bronchitis and in protracted coughs from any reason. Gross hemoptysis is when the majority of what is coughed up is blood. Although this may also be found in patients with chronic bronchitis, it usually demands a thorough evaluation for lung cancer or other serious illnesses.

MAJOR CAUSES OF HEMOPTYSIS

Bronchiectasis (chronic infection of the airways that leads to weak and dilated bronchial tubes)
Tuberculosis
Lung cancer
Pulmonary embolism
Pneumonia

Some forms of heart disease
Blood arising from anywhere in the mouth or nose
Chronic bronchitis (chronic inflammation of the airways associated with chronic cough)

WHAT IS THE BEST TREATMENT FOR A COUGH?

For a cough of short duration the best treatment is no treatment. Most cough medicines are really expectorants, designed to help you mobilize secretions, not prevent the cough. Although many times it may be helpful to give an expectorant, this cannot be considered "treating the cough." True cough suppressants, such as codeine, are related to narcotics and potentially harmful if they suppress the coughing of mucus or other irritating material. If a cough is truly non­productive of mucus and suppression is desired, one of the many codeine­containing compounds may be tried for a short period of time.

When a cough is due to a limited condition such as a cold, it will disappear when the patient improves. A chronic cough demands investigation for the underlying cause that, if found and treated, will also do away with the cough. If a thorough investigation does not reveal a specific cause, a trial of bronchodilators and/or corticosteroids may be helpful (see Section E). However, it cannot be overemphasized that treatment of a chronic cough is not the same as treating the underlying condition. Cough is a symptom and not a disease: treating only the symptom may miss the disease.

WHAT CAUSES SHORTNESS OF BREATH?

"Shortness of breath" is perhaps the most common respiratory complaint. Other phrases used by patients to explain the sensation are: "I can't catch my breath"; "my chest is tight"; "I can't get all the air in (or out.)" The medical term used for all such cases is dyspnea, which means difficult breathing.

Dyspnea may occur at rest or with exertion, the latter being more common. Dyspnea at rest is a serious symptom, deserving full evaluation. Such patients are usually incapacitated with the slightest exertion.

The most common causes of dyspnea are heart and respiratory disease. Because dyspnea is a symptom and therefore subjective (what the patient feels), it is difficult to predict which patients will have dyspnea even though their disease is well characterized. For example, two patients the same age and with identical respiratory impairment can have varying complaints of dyspnea. This may be because of different degrees of body conditioning, body weight, lifestyles (one sedentary, one active), amount of blood cells, and a host of other factors.

Another common cause of dyspnea is psychological. So­called psychogenic dyspnea is present when a patient has a consistent complaint of dyspnea but careful testing and examination reveal no physical reason. Such patients often breathe with frequent, deep sighs. Another clue to the diagnosis of psychogenic dyspnea is its presence only on rest and disappearance on exercise. This confirms the lack of significant heart or lung disease.

WHAT IS THE HYPERVENTILATION SYNDROME?

This is a condition of "over­breathing" due to psychological or anxiety­related factors. Patients with hyperventilation frequently (but not necessarily complain of dyspnea. They also report numbness and tingling around the mouth, in the fingers and toes. This sensation is due to "blowing off" excess carbon dioxide (CO2), making the blood too alkaline.

In severe, acute situations the excess alkali in the blood can lead to tetany, a drawing up of the hands and feet. Acute hyperventilation syndrome can be treated by having the patient re­breathe from a paper bag placed over the face. This allows re­breathing of exhaled CO2 and helps establish normal acidity to the blood.

Hyperventilation syndrome is most commonly found in young people, both men and women. Reproducing the symptoms by having the patient take deep breaths helps establish the diagnosis. Psychotherapy may occasionally be indicated for recurring episodes or when the problem interferes with normal lifestyle.

WHAT CAUSES CHEST PAIN?

After coughing and dyspnea, chest pain is the next most common symptom of respiratory disease. Since chest pain is also the most common complaint of patients with coronary artery disease (hardening of the arteries supplying blood to the heart, the cause of most heart attacks), the symptom is frequently a serious diagnostic challenge. Certain characteristics of the pain may help separate a respiratory from a cardiac condition or point to some other cause.

Crushing chest pain is sometimes also described as the squeezing of the chest, as if it were in a vise, or as if an elephant were standing on the chest. This type of pain is usually cardiac in origin, often the first symptom of a heart attack, and demands immediate evaluation.

Sharp chest pain made worse on inspiration is called pleuritic chest pain and is usually respiratory in origin since it arises from inflammation of the pleural membranes surrounding the lungs. Many conditions can cause this including pneumonia, pulmonary embolism (blood clots in the lungs), and pleurodynia (viral infection of the pleural membranes).

Chest pain that occurs with eating may be cardiac or gastrointestinal in origin; pain that occurs mainly on recumbency is usually related to the stomach and digestive system; this type of pain represents a form of indigestion.

Pain and tenderness to touch of some area of the chest is usually due to inflammation of the bones, joints or muscles of the chest wall and not to lung or heart disease.

There may be many atypical manifestations of chest pain as well as overlap of symptoms when more than one condition is present. Although diagnosing the cause of pain usually requires some laboratory tests, these may be no more complicated than a chest X­ray and electrocardiogram. Chest pain should be investigated if it is severe enough to limit your activities or to cause apprehension and worry.

WHAT ARE UPPER RESPIRATORY SYMPTOMS?

These are symptoms usually found in patients with infection of the upper respiratory system. From a practical standpoint respiratory infections can be divided into those predominantly affecting either the upper respiratory or lower respiratory tract. The upper respiratory tract includes the trachea (windpipe in the neck) and all respiratory passages above; the lower respiratory tract includes all respiratory passages below the trachea, i.e. airways within both lungs.

Upper respiratory infection (URI) symptoms can usually be distinguished from lower respiratory ones. URI symptoms include one or more of the following: cough, runny nose, runny eyes, sore throat, laryngitis, headache, sinus tenderness, and post­nasal drip. Most URI's are viral in origin and therefore self­limiting. Any sputum (phlegm) expectorated in these infections is usually white and not foul smelling.

In contrast, lower respiratory tract infections – the most common of which are bronchitis and pneumonia – may be manifested by cough, chest pain, shortness of breath, and expectoration of dark and/or foul smelling sputum, occasionally blood­tinged. Lower tract infections may also be viral in origin but are commonly caused by bacteria and therefore amenable to antibiotic treatment.

WHAT ARE SOME COMMON SIGNS OF RESPIRATORY DISEASE?

Physicians usually have no trouble recognizing patients in respiratory distress. This is because certain signs point to difficult breathing, although they may not reveal the specific cause. Tachypnea (rapid breathing) and breathing with the aid of one's neck muscles are the most frequently observed signs of dyspnea.

Other signs that patients indicate may be in respiratory distress include sweating, blue discoloration to the skin, nails, and/or lips (cyanosis), and mental changes such as confusion. Patients with severe asthma or bronchitis may breathe so nosily they can be heard from across the room. Of course with a stethoscope physicians can hear many abnormal breath sounds not otherwise audible.

WHAT IS FLUID IN THE LUNGS?

"Fluid in (or around) the lungs" is a frequently used explanation given to patients manifesting a variety of different respiratory conditions. This fluid can be seen on chest x­ray, and may be within the lung alveoli or surrounding the lungs (in which case it is actually outside the lungs, between them and the chest wall). Some patients may have fluid in both places.

When fluid builds up in the alveolar spaces it is called pulmonary edema (see Section M). When it builds up around the lungs it is called a pleural effusion, because the pleura are the thin membranes surrounding the lungs (see Section M).

The most common cause for fluid in (pulmonary edema) or around (pleural effusion) the lungs is congestive heart failure (CHF). Congestive is a good term, because that is just what the lungs become–congested, or backed up with fluid. The cause is a weak and therefore failing heart. Treatment with medication to remove the fluid (diuretics, digitalis) is often beneficial and can relieve the accompanying dyspnea. Another sign of congestive heart failure is swollen ankles and legs (but not all swollen feet are due to CHF).

There are many other causes for fluid in or around the lungs, some of which are discussed in other parts of this site.

WHAT IS A SPOT IN THE LUNGS?

A spot in the lung usually refers to a small, discrete, rounded nodule visible on a routine chest x­ray. Spots may range in size from that of a dime to a silver dollar; because their shape is rounded they are often referred to as coin nodules. Coin nodules are never a normal finding, although they may be benign or malignant.

Benign lesions (another word for abnormal spots or coin nodules) are usually due to old infections that have healed to form a scar. Malignant lesions are usually due to lung cancer or cancer that has spread from elsewhere in the body to the lungs. Utilizing only the routine chest x­ray it is seldom possible to differentiate between benign and malignant lesions. This difference is critical since a malignancy (cancer) may be in its early stages and amenable to surgery. Conversely, a benign lesion usually warrants no treatment and will not affect the patient's life. What to do after finding a coin nodule on chest x­ray depends on the patient's age, smoking history, availability of old x­rays, and a host of other factors.

A lung infiltrate is an abnormality on chest x­ray larger than a coin lesion or spot. It is also non­specific and may be due to a variety of causes: pneumonia, partial lung collapse, cancer, tuberculosis, and pulmonary blood clots are common examples. The x­ray appearance of these terms is shown in Section I.

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