Thursday, September 23, 2010

6.23 Cough, Short of Breath, Wheezing,Cough Blood, Chest Xray

Physician's Notebooks 6  - - See Homepage

23. Some Important Respiratory Symptoms - Update 17 December 2018 The following descending list of headings is useful to locate by scroll down or search & find. 
 Shortness of Breath (SOB or dyspnea)
Wheezing and Asthma
Swelling along the lower respiratory tract
Causes of Bronchial Asthma
What to do if child develops asthma?
Coughing Blood
Routine chest X-ray
 Cough: Divides into either “itchy dry at embarrassing moment” or “painful with sputum", or as dry vs. wet cough. Dry is the more common, less serious and is typically experienced a few days after catching a cold and then the cold symptoms leave, but the cough stays. This cough originates high in throat; a deep-throat itch stimulates it. It's an embarrassment that gets bad just when you do not want to hear it. It is not serious and will leave with time but it can be bothersome. A so-called cough suppressant like dextromethorphan pill, I have found not to be useful. For temporary relief, a codeine-based cough syrup is best. If the cough lingers, look into your environment for air irritant or allergen like pet fur or powder soap you use to clean in kitchen.
   Such a dry cough could be caused or worsened by aspirin or NSAIDs or by the ACE Inhibitor pill you take every day for your high blood pressure. Replace the aspirin by acetaminophen (Tylenol) and temporarily stop the ACE-I for the few days it takes the cough to go away. Also you’ll note the dry cough is brought on by eating and drinking, exercise and cold temp. It usually disappears during sleep or when you get very interested in something. Sometimes it can be due to a viral infection in which case it will run its course over several weeks.
   Cough may, in its first days, start dry but become productive or wet. A wet cough is due to respiratory tract infection and should be checked. A cough that is bloody, foul smelling or shows weird color sputum or in a smoker, should get a chest x-ray. 
Coughs with loss of voice (temporary) and/or episodes of strangling (like croup) locate the anatomy of the cough to the larynx (voice box), which starts the upper airway from deep throat. If it lasts, see nose & throat specialist in University HMO.
Coughs at night coming on constantly (chronic) in bed are suspicious of coming from lung cavity (TB or cancer) or bronchiectasis (dilatation of bronchi from chronic infection). Blood coughed up at night in bed is always serious and demands chest x-ray and often needs bronchoscopy. Similarly, a cough worst in erect body position that is relieved by lying down also suggests a localized lung lesion. In either case, if the cough persists more than several days, a chest x-ray should be done.
   When cough is symptom of developing heart failure; other signs or symptoms and risk factors for heart failure should be present. It worsens with increased activity.
Finally, attacks of coughing that come on after eating and that are related to position, are usually due to inadvertent gastro-intestinal reflux aspiration and should not be treated with cough medication. 
Shortness of Breath (SOB) is a feeling of not getting enough breath, a need to breathe-in deeper or faster; it is not the feeling of resistance to breathing-out that you get with asthma. When sudden it should suggest lack of oxygen in the air you breathe or toxic gas like carbon monoxide that blocks tissue access to oxygen or else it may be due to pulmonary embolus from leg vein clot to lung. Lack of oxygen will be relieved by breathing pure oxygen or by getting out of where you currently are, at once, and finding source of good, fresh air.
Pulmonary embolus when not catastrophic shows chest pain on taking a breath. It causes immediate SOB not related to body position or other factors. When SOB is gradual, developing over weeks, month, year, or related to effort, it may be heart failure and you should get an echocardiogram and heart consult. If without other sign of heart failure, think of losing lung tissue as we see in pulmonary fibrosis disease from breathing asbestos or other toxic substance or from lung cancer, and after surgery that removes part of lung. A simple do-it-yourself vital capacity estimation (see just-previous chapter) will show a reduction but if VC is normal then a lung diffusion test may show decreased diffusion of gases from breathed air to pulmonary artery blood.
   If SOB starts suddenly after cough, suspect pneumothorax. It means rupture of bleb on surface of lung.
   As implied earlier, SOB due to sudden change in surrounding atmosphere (like driving in car up to 8000 or more feet high into the Rocky Mountains) is relieved immediately by breathing pure oxygen or after minutes by reclined rest. It is why a person at risk best have an oxygen can safely stored.
Wheezing and Asthma: The respiratory tract from trachea to small bronchi is made of tubes with cartilage rings and smooth muscle to control its widening and narrowing. From smaller bronchi to start of tiny bronchioles the tubes are lined by smooth muscle without cartilage. The sympathetic nervous system and its main neurotransmitter epinephrine relaxes the smooth muscle and causes widening of respiratory tract, which helps breathing by providing low resistance to inhaled air flow. Non selective beta blockers like Inderal oppose the broncho-dilation and worsen wheezing. Also the parasympathetic nervous system and its drugs favor bronchus constriction; so parasympathetic blocker drug like atropine (in tincture of belladonna) is good against wheezing. 
Swelling along the lower respiratory tract: the lining of the tract swells inward, narrowing the tubes. Viral bronchial infection and other inflammation and allergy cause wheezing by this effect. This explains why adrenal corticosteroid is good due to its anti-inflammatory effect that reduces the swelling. Also helped by breathing warm, moist air.
   Wheezing can come from acute obstruction in one part of the respiratory tract due to a foreign body from swallowing a lump of food the wrong way and small enough to get down to partially block bronchus or from narrowing due to local tumor.
   I gave the causes of wheezing/asthma before its effect. What is wheezing? It is the high-pitched (whistle-like) sound of labored partly obstructed exhalation caused by general increased airway resistance or partial obstruction. “Partial” is the key: if complete obstruction at trachea or major bronchus level, no wheezing and no sound at all; but death from asphyxiation if not relieved. Wheezing is not only a sound it is a feeling of resistance to breathing-out that is uncomfortable and associated with wheezing, coughing and sputum. Asthma is a general diagnosis of wheezing not localized to one part of Respiratory Tract.
   Asthma implies acute attacks that come on at particular time (more at night in cold weather or with bad air pollution), that last hours to days and that are stopped by medicine or other treatments. Bronchial asthma rarely results in sudden death but is not good for healthy longevity.
   The diagnosis of asthma is divided into cardiac asthma due to (and always with other symptom of) heart failure and bronchial asthma due to all other causes.
   Bronchial asthma is more common in children than in adults and its incidence has increased during the last 50 years with air pollution. Most childhood asthma improves or disappears as adult because the bronchial tubes of the child's respiratory tract get wider with growth and give less resistance to airflow in adult. So your child will probably grow out of his or her asthma but still it can be bad. 
Causes of Bronchial Asthma: Foremost is allergy or hypersensitivity to air pollutant. But the kind of allergy that causes asthma is not helped much by desensitization shot or anti-histamine. It seems a combination of allergy and genetic hyper-reacting to airborne irritant. Concerning inhalant steroid treatment of asthma, when other drugs fail, one may experiment with steroid inhalant but try to keep low dose and use sparingly. 
   Overview advice: “What to do if child develops asthma?” and “What would I do if I had asthma as adult?”  First, a home remedy to relieve a bad acute asthma attack (includes croup in a child); The remedy is to moisturize the upper respiratory tract: You do this by turning on a shower to hottest level (Not while you are in it) and breathing-in the steam fumes (or boil a pot of hot water and breathe-in the steam). Then after you have moisturized the respiratory tract (takes a minute or two), turn the shower to coldest setting and step into the shockingly cold shower. This will put a big dose of natural adrenaline into your system. 
Once bronchial asthma is diagnosed – in child or adult – it is best to travel to top asthma center (eg, Asthma Center in Denver Co) and get tested by team of specialists to rule out cardiac cause and find if allergen or air pollutant is cause. This would include respiratory function and allergy profile.
   Assuming it turned out the usual bronchial asthma (ie, no definite, specific single cause) my response would differ depending on whether child or adult. Since the outlook for child asthma is to get better with age, I would treat a child by paying attention to the purity of the breathed air; making sure the child understands the dangers of pollutant and irritant from marijuana and tobacco and passive smoking; and I would treat any acute attack with epinephrine (adrenaline); and try to arrange maximally healthful, non-stress environment and breathing air for the child and family.
   I would relocate to least polluted air area (the southwest that includes Colorado, Nevada and Arizona), and to most reasonable place for me or family to live. In deciding, I would take into account the opinion of asthma experts and those who have experienced years of asthma, and consider the effects of high and low humidity, of altitude, of clean air, of body weight, and of dietary approach, and even global warming with its sudden extreme of temperature. Finally before relocation I would experiment by seeing the affect of the local atmosphere during vacations to the area. 
Asthmatics, smokers and chronic lung infections like TB should always be aware of high risk, with aging, of chronic obstructive pulmonary disease (COPD) and seek expert preventive care.
Coughing Blood: Cough up more than occasional spot of blood and everyone correctly goes to emergency! But if you caught a cold last week and it settled in throat and is giving you a painful noisy bronchitis with sputum, and after one bad cough you see a mucous of blood, it’s not a reason to get excited; the cause is irritation from the coughing and cure will be a cough suppressant. Risk factors for lung cancer count much: A chronic smoker who sees even a little blood ought to get chest x-ray.

Routine chest X-ray: It used to be everyone got one, a holdover from the days that Tuberculosis ran rampant. Today you ought to get chest X-ray when you have Short Of Breath, lung cancer fear, TB or COPD symptoms. The chest x-ray done after age 50 is also a screen for heart disease by showing size and shape of heart and can pick up abnormal calcification of coronary or aortic disease. Otherwise be cautious about to many chest x-rays.
  End of Chapter. To read next now, click 6.24 Control Your Blood Pressure & Heart Rate

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