Runny, blocked nose and sneezing
Nasal symptoms are extremely common. The differentiation between the common cold or allergic rhinitis as a cause of ‘runny nose’ (rhinorrhoea), nasal blockage and attacks of sneezing is difficult. In allergic rhinitis, symptoms may be seasonal, following contact with grass pollen, or perennial, when the house-dust mite is the important allergen. Colds are frequent during the winter but, if more than three occur, the patient is probably suffering from perennial rhinitis rather than from infection due to a virus. Patients may be able to identify the cause of their symptoms if, for example, they sneeze whilst walking in the park in summer or after making beds.
Nasal secretions are usually thin and runny in rhinitis but thicker and yellow-green in the common cold. Nose bleeds and blood-stained nasal discharge are common occurrences and are not as serious as haemoptysis. Nevertheless, a blood-stained nasal discharge associated with nasal obstruction and pain may be the presenting feature of a nasal tumour. Total nasal blockage with loss of smell is often a feature of nasal polyps.
Cough is the commonest manifestation of lower respiratory tract disease. Smokers often have a morning cough with little sputum. Cough is the cardinal feature of chronic bronchitis, while sputum production and coughing, particularly at night, can be symptoms of asthma. Cough also occurs in asthmatics after mild exertion or following a forced expiration. A cough can also occur for psychological reasons.
A worsening cough is the commonest presenting symptom of a bronchial carcinoma. The explosive character of a normal cough is lost when laryngeal paralysis is present- a bovine cough-usually resulting from carcinoma of the bronchus infiltrating the left recurrent laryngeal nerve. Cough may be accompanied by stridor in whooping cough and in the presence of laryngeal or tracheal obstruction.
Despite the popularity of cough mixtures, the correct treatment of this symptom is to identify and treat the underlying cause. Cough may persist in some individuals for many weeks following a respiratory tract infection, perhaps as the result of persisting bronchial inflammation and increased airway responsiveness, a process that may settle with inhaled corticosteroid treatment.
Approximately 100 rnl of mucus is produced daily in a healthy, non-smoking individual. This flows at a regular pace up the airways, through the larynx, and is swallowed Excess mucus is expectorated as sputum. The most common cause of excess mucus production is cigarette smoking.
Mucoid sputum is clear and white but can contain black specks resulting from the inhalation of carbon. Yellow or green sputum is due to the presence of cellular material, including bronchial epithelial cells, or neutrophil or eosinophil granulocytes. Yellow sputum is not necessarily due to infection, as eosinophils in the sputum, as seen in asthma, can give the same appearance. The production of large quantities of yellow or green sputum is characteristic of bronchiectasis. Blood-stained sputum (haemoptysis) varies from small streaks of blood to massive bleeding. It requires thorough investigation. The following should be borne in mind.
• The commonest cause of haemoptysis is acute infection, particularly in exacerbations of chronic bronchitis and emphysema, but it should not be attributed to this without investigation.
• Other common causes are pulmonary infarction, bronchial carcinoma and tuberculosis.
• In lobar pneumonia, the sputum is rusty in appearance when blood is present.
• Pink, frothy sputum is seen in pulmonary oedema.
• In bronchiectasis, the blood is often mixed with purulent sputum.
• Massive haemoptyses (>200 rnl of blood in 24 hours) are usually due to bronchiectasis or tuberculosis.
• Uncommon causes of haemoptyses are idiopathic pulmonary haemosiderosis, Goodpasture’s syndrome, microscopic polyarteritis, trauma, blood disorders and benign tumours.
Haemoptysis should always be investigated. Often, the diagnosis can be made from a chest X-ray. Firm plugs of sputum may be coughed up by patients suffering from an exacerbation of allergic bronchopulmonary aspergillosis; sometimes such sputum may appear as firm threads representing casts from inflamed bronchi.
Breathlessness should be assessed in relation to the patient’s life-style. For example, a moderate degree of breathlessness may be totally disabling if the patient has to climb many flights of stairs to reach home. A grading for breathlessness is given The term dyspnoea should be used to describe a sense of awareness of increased respiratory effort that is unpleasant and that is recognized by the patient as being inappropriate. It is highly unlikely that this term will be used by the patient. Patients may complain of tightness in the chest; this must be differentiated from angina. Orthopnoea is breathlessness on lying down and is partly due to the weight of the abdominal contents pushing the diaphragm further into the thorax. Such patients are also made uncomfortable by bending over. The terms tachypnoea and hyperpnoea refer, respectively, to an increased rate of breathing and an increased level of ventilation, which may be appropriate to the situation (e.g. during exercise). Hyperventilation is overbreathing and results in a lowering of the alveolar and arterial Pco2.
Paroxysmal nocturnal dyspnoea is described
Respiratory diseases can cause breathlessness within minutes or hours or else more slowly over days, weeks or months. The typical causes of breathlessness over differing time periods are:
(a) Inhaled foreign body
(c) Pulmonary embolism
2 Over a few hours
(c) Pulmonary oedema
(d) Extrinsic allergic alveoli tis
(b) Pulmonary oedema
4 Over days
(a) Pleural effusions
(b) Carcinoma of the bronchus/trachea
5 Over months or years
(a) Chronic bronchitis and emphysema
(b) Cryptogenic fibrosing alveoli tis
(c) Occupational fibrotic lung disease
(d) Non-respiratory causes-anaemia, hyperthyroidism
Wheezing is a common complaint and is the result of airflow limitation due to any cause. The symptom of wheezing is not diagnostic of asthma; it may be absent in the early stages of this disease, and may also occur in patients with chronic bronchitis and emphysema.
The commonest type of chest pain encountered in respiratory disease is a localized sharp pain, often referred to as pleuritic. It is made worse by deep breathing or coughing and can be precisely localized by the patient. Localized anterior chest pain may be accompanied by tenderness of a costochondrial junction due to costochondritis. Pain in the shoulder tips suggests irritation of the diaphragmatic pleura, whereas central chest pain radiating to the neck and arms is typically of cardiac origin. Retrosternal soreness may occur in patients with tracheitis, and a constant, severe, dull pain may be the result of invasion of the thoracic wall by carcinoma.