1) Chest pain
2) Brreathlessness
3) Palpitation
4) Syncope
5) Edema
6) Fatigue
Blog for Respiratory-Medicine-Post-Graduates of Apollo Hospitals,Chennai,India - Diplomate National Board(DNB), started in the Year 2009 October ,by PGs & the Academic Co-Ordinator of Department - Dr.R.P.Ilangho - for enabling these Young PGs to INTER_CONNECT ideally for becoming better Pulmonologists.The word~ REMAP09 ~ was coined thus:RE= RE spiratory M=M edicine A=Apollo P= P ostGraduate 09= 2009 - thus meaning "Respiratory Medicine Apollo PostGraduate 2009 batch"
FUN is the most Sacred Word in all the religious texts put together - in Life !
1) Chest pain
2) Brreathlessness
3) Palpitation
4) Syncope
5) Edema
6) Fatigue
CAUSES OF PLEURITIC CHEST PAIN
Pleuritic chest pain is a sharp, stabbing in the chest that worsens with respiratory movements such as deep breathing, coughing, sneezing, or laughing.
CAUSES:
1. Infectious Causes: These are among the most common reasons for pleuritic chest pain.
Viral Infections
Bacterial Infections: Pneumonia, Tuberculosis
Fungal Infections: Though less common, fungal infections can also inflame the pleura, especially in individuals with weakened immune systems.
Parasitic Infections
2. Inflammatory and Autoimmune Conditions:
Pleuritis due to inflammation caused by conditions such as SLE, Rheumatoid arthritis, Sarcoidosis
Pleural Effusion
3. Cardiovascular Causes:
Pulmonary Embolism
Pericarditis
4. Neoplastic Causes (Cancers):
Lung Cancer invading or irritating the pleura.
I Mesothelioma
Pleural Metastatic Cancers
5. Traumatic Causes:
Rib Fractures or Chest Injury
Thoracic surgery or other procedures involving the chest can lead to temporary pleuritic pain.
Differential diagnosis of ILD with family history:
Process: Adhesive laminating
Risk: Isocyanate prepolymers can cause an irritation of the airways and lungs leading to occupational asthma.
Process: Digital (ink-jet) printing
Risk: Carbon present in black ink can cause lung irritation. Methyl ethyl ketone and propanol can cause abnormal heart rhythm and rate and can affect the liver and kidneys on long term exposure.
Process: UV lamps for photo processing, UV curing and high speed printing – ink misting
Risk: Acrylates and methcrylates in fumes can cause irritation of respiratory tracts with the potential for occupational asthma as well as severe headaches and nausea.
Health Effects Of Chemicals Used In Printing
Process: Etching, Engraving, Platemaking, Photographic Reproduction
Risk: Nitric, sulphuric and hydrofluoric acids can cause skin burns, eye damage and blisters.
Process: Concentrated photographic developer or fixer solutions
Risk: Acidic salt solutions and Hydroquinone can irritate eyes and even cause dermatitis
Process: UV and infra red curable inks, varnishes and lacquers
Risk: Reactive acrylates or methacrylate’s can cause corrosion of the skin, eyes and mucous membranes.
Process: Lithographic platemaking, Gravure cylinder preparation and photoengraving.
Risk: Ammonium, potassium and sodium dichromate’s are all very corrosive and can cause deep ulcers as well as a risk of cancer.
Process: Lithographic fount solution, blanket restorers, cleaning solvents, Gravure and flexographic Risk: Alcohol, Esters and Ketones can cause dermatitis, dizziness and other effects of the central nervous system.
Process: Flexographic, Dyeline Printing and Screen Inks Risk: Perchloroethylene, Ammonium hydroxide and Ketones can cause dizziness, drowsiness and other effects on the central nervous system via inhalation.
Process: Screen Cleaning chemicals
Risk: Strong alkalis such as concentrated sodium or potassium hydroxide, Oxidisers and sodium hypochlorite solvents can cause corrosion of the skin, eyes and mucous membrane as well as dizziness and drowsiness
Diagnostic Criteria for PPF:
To diagnose PPF, all three of the following must be present:
Underlying fibrosing ILD (non-IPF), with imaging or histology showing fibrosis.
Evidence of progression within the past year, based on at least one of the following:
1.Worsening respiratory symptoms, such as increasing dyspnea or cough.
2.Decline in lung function, especially:
Absolute decline in FVC ≥ 5% predicted
Decline in DLCO (diffusing capacity for carbon monoxide) ≥ 10% predicted
3.Progressive fibrosis on imaging, shown by:
Increased reticulation
New ground-glass opacities with traction bronchiectasis
Increased honeycombing
No alternative explanation (e.g., infection, heart failure, pulmonary embolism).
AGGRAVATING FACTORS OF CARDINAL SYMPTOMS- MNEMONICS
COUGH:
PDFCE
Pollution, Pollen, Posture
Drugs, Diurnal, Dry air
Food
Cold weather, Common cold
Exercise
SPUTUM
"DRIVE DUST"
D – Dust exposure
R – Respiratory infections
I – Irritants (e.g., smoke, fumes)
V – Viral infections
E – Exercise or exertion
D – Dry air
U – Upper respiratory tract conditions (e.g., postnasal drip)
S – Smoking
T – Temperature changes (cold air or sudden temperature drops)
Breathlessness:
"BREATHE HARD"
B – Body position (e.g., lying flat in orthopnea)
R – Respiratory infections
E – Exercise or exertion
A – Anxiety or emotional stress
T – Temperature extremes (cold or heat)
H – Hypoxia or high altitude
E – Environmental triggers (allergens, pollutants)
H – Heart failure or fluid overload
A – Anemia
R – Reflux (gastroesophageal reflux disease)
D – Drugs (e.g., beta-blockers,
WHEEZE:
“BREATHE WHEEZE”
B – Bronchial irritants (smoke, pollution)
R – Respiratory infections (viral or bacterial)
E – Exercise
A – Allergens (pollen, dust mites, animal dander)
T – Temperature changes (cold air)
H – Hormonal changes (pregnancy, menstruation)
E – Emotions (stress, anxiety)
W – Workplace irritants (occupational exposures)
H – Household triggers (perfumes, cleaning agents)
E – Environmental changes (high altitude)
E – Exposure to drugs (NSAIDs, beta-blockers)
Z – Zzz… sleep (nocturnal asthma triggers)
E – Eating (GERD-induced wheeze)
CHEST PAIN:
“CHEST PAINS”
C – Coughing or deep breathing (pleuritic pain)
H – Heat or cold exposure (vasospastic angina)
E – Emotion or stress (psychogenic pain, angina)
S – Swallowing (esophageal causes like GERD or spasm)
T – Trauma or movement (musculoskeletal pain, costochondritis)
P – Physical exertion (angina, cardiac ischemia)
A – Alcohol or large meals (GERD or esophageal spasm)
I – Infections (pleuritis, pericarditis, pneumonia)
N – Nighttime (GERD-related pain due to supine position)
S – Specific postures (pericarditis, GERD, musculoskeletal pain)
HEMOPTYSIS:
“COUGH BLOOD”
C – Coughing (increases airway pressure, ruptures small vessels)
O – Overexertion (exacerbates vascular stress)
U – Upper respiratory tract infections
G – GERD or vomiting (irritation of airways)
H – High altitude (pulmonary hypertension)
B – Bronchial infections (bronchitis, bronchiectasis)
L – Lung malignancy (coughing or irritation)
O – Operations (post-procedural bleeding, e.g., bronchoscopy)
O – Oral anticoagulants (worsen bleeding)
D – Deep breaths or physical strain (ruptures fragile capillaries)
The respiratory control system, broadly speaking, comprises a controller, sensors, and a plan. This hierarchical structure, in which there is central processing of afferent input, is important for coordinating respiratory movements with behaviors such as eating, speaking, and moving. The controller is a neuronal network within the central nervous system (CNS), which is responsible for generating and modulating individual breaths and the overall breathing pattern. Often referred to as the respiratory central pattern generator (rCPG), the controller comprises reciprocally connected neuronal populations in the medulla and pons. Neural output from the rCPG drives the activity of various motor neuron pools. Motor neurons in the spinal cord (e.g., phrenic and intercostal) innervate the respiratory pump muscles, while brain stem motorneurons innervate upper airway muscles. The so-called “plant” is animportant component of breathing control and includes the CO2stores, which are made up of lung stores and circulating blood volume including hemoglobin. Closed loop feedback to the controller is supplied by chemoreceptors and mechanoreceptors. The consistent cycling of the ventilatory pattern is generated spontaneously from the spatial and functional architecture of the rCPG. Intrinsic membrane properties of rhythmically active neurons within the rCPG are capable of producing automatic periodicity.4 In addition, reciprocal (excitatory and inhibitory) synaptic connections between neuronal populations in the medulla and pons are believed to be critical for the automatic generation of the respiratory rhythm.
The neural respiratory cycle comprises three phasesSLE (American College of Rheumatology criteria )
1)Malar rash
2)Discoid rash
3)Photosensitivity skin rash
4)Oral or nasopharyngeal ulceration
5)Non erosive arthritis involving ≥ 2 peripheral joints
6)Serositis (pleuritis or pericarditis)
7)Renal disorder (persistent proteinuria or cellular casts)
8)Neurologic disorder (unexplained seizures or psychosis)
9)Hematologic disorder (hemolytic anemia, leukopenia, lymphopenia,or thrombocytopenia)
10)Immunologic disorder (positive LE cell, anti-DNA antibody, anti-Sm antibody, false-positive syphilis serology)
11)Elevated antinuclear antibodies
*Minimum of 4 criteria required
SJÖGREN SYNDROME
sicca symptoms are mandatory
supportive evidence including ocular signs (positive Schirmer test testing reduced tear formation, rose bengal score > 3 for staining of conjunction and cornea)
typical histologic appearances salivary gland biopsy
antibodies to Ro (SS-A) or La (SS-B) or
reduced salivary flow.
Classification criteria for sjogren's syndrome
1) Labial salivary gland with focal lymphocytic sialadenitis and focus score of > 1 foci/4mm²
3 points
2) Anti-SS-A/Ro positive
3 points
3) Ocular Staining Score 5 (or van Bijsterveld score > 4) in at least one eye
1 point
4) Schirmer's test < 5 mm/5 minutes in at least one eye
1 point
5) Unstimulated whole saliva flow rate < 0.1 ml/minute
1 point
A score of 4 classifies a patient who meets the inclusion criteria:
⁃ ocular and/or oral dryness or suspicion of SjS according to EULAR SjS Disease Activity Index (ESSDAI)
and does not have any of the exclusion criteria:
⁃ history of head and neck radiation, active HCV infection, AIDS, sarcoidosis, amyloidosis, graft-versus-host disease, IgG4-related disease.
* ACR/EULAR classification criteria
COUGH:
PDFCE
Pollution, Pollen, Posture
Drugs, Diurnal, Dry air
Food
Cold weather, Common cold
Exercise
SPUTUM
"DRIVE DUST"
D – Dust exposure
R – Respiratory infections
I – Irritants (e.g., smoke, fumes)
V – Viral infections
E – Exercise or exertion
D – Dry air
U – Upper respiratory tract conditions (e.g., postnasal drip)
S – Smoking
T – Temperature changes (cold air or sudden temperature drops)
Breathlessness:
"BREATHE HARD"
B – Body position (e.g., lying flat in orthopnea)
R – Respiratory infections
E – Exercise or exertion
A – Anxiety or emotional stress
T – Temperature extremes (cold or heat)
H – Hypoxia or high altitude
E – Environmental triggers (allergens, pollutants)
H – Heart failure or fluid overload
A – Anemia
R – Reflux (gastroesophageal reflux disease)
D – Drugs (e.g., beta-blockers,
WHEEZE:
“BREATHE WHEEZE”
B – Bronchial irritants (smoke, pollution)
R – Respiratory infections (viral or bacterial)
E – Exercise
A – Allergens (pollen, dust mites, animal dander)
T – Temperature changes (cold air)
H – Hormonal changes (pregnancy, menstruation)
E – Emotions (stress, anxiety)
W – Workplace irritants (occupational exposures)
H – Household triggers (perfumes, cleaning agents)
E – Environmental changes (high altitude)
E – Exposure to drugs (NSAIDs, beta-blockers)
Z – Zzz… sleep (nocturnal asthma triggers)
E – Eating (GERD-induced wheeze)
CHEST PAIN:
“CHEST PAINS”
C – Coughing or deep breathing (pleuritic pain)
H – Heat or cold exposure (vasospastic angina)
E – Emotion or stress (psychogenic pain, angina)
S – Swallowing (esophageal causes like GERD or spasm)
T – Trauma or movement (musculoskeletal pain, costochondritis)
P – Physical exertion (angina, cardiac ischemia)
A – Alcohol or large meals (GERD or esophageal spasm)
I – Infections (pleuritis, pericarditis, pneumonia)
N – Nighttime (GERD-related pain due to supine position)
S – Specific postures (pericarditis, GERD, musculoskeletal pain)
HEMOPTYSIS:
“COUGH BLOOD”
C – Coughing (increases airway pressure, ruptures small vessels)
O – Overexertion (exacerbates vascular stress)
U – Upper respiratory tract infections
G – GERD or vomiting (irritation of airways)
H – High altitude (pulmonary hypertension)
B – Bronchial infections (bronchitis, bronchiectasis)
L – Lung malignancy (coughing or irritation)
O – Operations (post-procedural bleeding, e.g., bronchoscopy)
O – Oral anticoagulants (worsen bleeding)
D – Deep breaths or physical strain (ruptures fragile capillaries)
Pollution, Pollen, Posture
Drugs, Diurnal, Dry air
Cold weather, Common cold
Food, Exercise
Using cough suppressants or expectorants
Drinking warm fluids, Humidified air or steam inhalation
Avoiding triggers, Rest
Exercise,
Pollens,dust,smoke,cold air
Drugs- Aspirin,NSAIDs can aggravate breathlessness in asthmatics
Orthopnea- LV failure, large pleural effusion,massive ascites, morbid obesity and any severe lung disease.
Platypnea- ASD, patent foramen ovale, large intrapulmonary shunt,hepatopulmonary syndrome
Trepopnea- Due to large unilateral lung disease(patient prefers healthy lung down), dilated cardiomyopathy (pt prefers right side down)
Tumors compressing major airways/blood vessels
Rest or reducing physical activity
Oxygen therapy
Bronchodilators
Calm breathing techniques
Elevating the head or upper body in severe cases
Deep breathing, coughing, sneezing (if pleuritic)
Physical exertion (if cardiac in nature)
Stress or anxiety
Movement or pressure on the chest area
acid reflux
Rest
Pain medication
Positioning (e.g., lying on one side for pleuritic pain)
Relaxation or stress-reduction techniques
Oxygen therapy
Aggravating and relieving factors for pedal edema
Aggravating factor
Prolonged immobility
Dietary- excess fluid
Reliving factor
Compression
Limb elevation
Diet- fluid and sodium restriction
Reference: Hutchison and macleod
CAUSES OF ORTHOPNEA :
1. Left ventricular failure.
2. Asthma
3. COPD
4. Bilateral diaphragmatic paralysis in the absence of heart disease.
Ref : Fraser 4th edition page no. 388
Breathlessness aggravated by exercise - exercise induced asthma
Aggravated by Pollens,dust,smoke,cold air, drugs, animals - Asthma
Drugs- Aspirin,NSAIDs can aggravate breathlessness in asthmatics
Aggravated by lying down- orthopnea(relieved by sitting)- LV failure, large pleural effusion,massive ascites, morbid obesity and any severe lung disease.
Aggravated by sitting up- platypnea (relieved by lying down)- ASD, patent foramen ovale, large intrapulmonary shunt,hepatopulmonary syndrome
Aggravated by lying on oneside - trepopnea
Due to large unilateral lung disease(patient prefers healthy lung down), dilated cardiomyopathy (pt prefers right side down)
Tumors compressing major airways/blood vessels
Referrence - Macleod's 13 th edition
Respiratory system page no-142
Monkey pox
Etiology :Poxviruses are a family of double-stranded DNA viruses whose genomic structure is generally conserved across subfamilies, genera, and species.
Most poxviruses that infect humans are spread through contact, not by respiratory route
Patient usually presents with nodular or vesicopustular lesions ,fever ,followed by rash,centrifugal distributionprominet in palms and soles
Treatment :mainly supportive and prevent secondary bacterial infection
Recently u.s FDA approved the anti viral drug Tecovirmat (Tpoxx) has been used.
Brincidofovir (tembexa)also approved by FDA
Ref : Harrison principal of internal medicine
Indications of AEROBIKA
COPD
Cystic fibrosis
Bronchiectasis
Bronchial asthma
Bronchiolitis obliterans
Relative contraindications to Aerobika
Untreated pneumothorax
Intracranial pressure > 20mm Hg
Active haemoptysis
Recent trauma or surgery to skull, face, mouth, or oesophagus
Patient with acute asthma attack or acute worsening of Chronic Obstructive Pulmonary Disease (COPD) unable to tolerate increased work of breathing
Acute sinusitis or epistaxis
Tympanic membrane rupture or other known or suspected inner ear pathology
Nausea
Source- aerobika user guide
https://www.aerobika.us/wp-content/uploads/2018/10/patient-user-guide-en.pdf? 1
Chromogranin A (CgA) is a constituent of neuroendocrine vesicles and catecholamine storage vesicles . Neuroendocrine cancer , like small cell carcinoma of lung has been found to have CgA secretion and hence used as a tumor marker . It has been used as a marker for disease progression and can also be demonstrated in immunohistochemistry of Neuroendocrine tumors .
Indications for Noninvasive Mechanical Ventilation (NIV) in COPD
At least one of the following:
1) Respiratory acidosis (PaCO2 > 6.0 kPa or 45mmHg and arterial pH < 7.35)
2) Severe dyspnea with clinical signs suggestive of respiratory muscle fatigue, increased work of
breathing, or both, such as use of respiratory accessory muscles, paradoxical motion of the
abdomen, or retraction of the intercostal spaces
3) Persistent hypoxemia despite supplemental oxygen therapy
Reference : GOLD 2024
MECHANISM OF NORMAL BREATH SOUNDS
Normal breath sounds originate from the larynx. When the sound leaves the larynx it travels down the trachea and then divides when the airway divides. Some sound must be transmitted through the lung parenchyma but most travels down the airway. Eventually the sound travels along airways of different lengths and therefore becomes out of phase. Next it arrives in the respiratory bronchioles and alveoli and then gets transmitted through the chest wall to your stethoscope. The fat layer filters out much of the high frequency sound (above 4 kHz). The resulting sounds are much softer (because the sound has effectively been diluted throughout the whole of the lungs). There is no gap between inspiration and expiration (because all of the sound has become out of phase and therefore filled in the gap. Finally, the first third of expiration is now the only part that is audible because the latter two-thirds are much quieter.
REFERENCE : CHAMBERLAIN'S symptoms and signs of clinical medicine, 13th edition
ILO CLASSIFICATION TO DESCRIBE PNEUMOCONIOTIC OPACITIES
ILO TERM OPACITY WIDTH OPACITY TYPE
P < 1.5mm Small rounded
Q 1.5 - 3 mm Small rounded
R > 3 - 10 mm Small rounded
S < 1.5mm Linear/ Irregular
T 1.5 - 3 mm Linear/ Irregular
U > 3 - 10 mm Linear/ Irregular
A > 10 - 50 mm Large
B > 50 mm - RUZ Large
C > RUZ Large
1. COUGH
Aggravating factors:
Pollution, Pollen, Posture
Drugs, Diurnal, Dry air
Food
Cold weather, Common cold
Exercise
Relieving Factors:
Using cough suppressants or expectorants
Drinking warm fluids
Humidified air or steam inhalation
Avoiding triggers
Rest
2. SPUTUM
Aggravating Factors:
Respiratory infections (e.g., bronchitis, pneumonia)
Exposure to cold air or smoke
Allergic reactions
COPD, asthma
Physical activity
Relieving Factors:
Hydration
Expectorants
steam inhalation
Deep breathing exercises
3. HEMOPTYSIS
Aggravating Factors:
Trauma or injury to the respiratory tract
Relieving Factors:
Treating the underlying condition
Cough suppressants
Oxygen therapy
Positioning the person to reduce coughing or to prevent aspiration
4. CHEST PAIN
Aggravating Factors:
Deep breathing, coughing, sneezing (if pleuritic)
Physical exertion (if cardiac in nature)
Stress or anxiety
Movement or pressure on the chest area
acid reflux
Relieving Factors:
Rest
Pain medication
Positioning (e.g., lying on one side for pleuritic pain)
Relaxation or stress-reduction techniques
Oxygen therapy
5. BREATHLESSNESS
Aggravating Factors:
Physical exertion or exercise
Exposure to cold air or allergens
Respiratory infections
Anxiety or panic attacks
Relieving Factors:
Rest or reducing physical activity
Oxygen therapy
Bronchodilators
Calm breathing techniques
Elevating the head or upper body in severe cases
6. WHEEZE
Aggravating Factors:
Exposure to allergens or irritants (e.g., smoke, dust, pollen)
Respiratory infections
Exercise or physical activity
Cold air or sudden weather changes
Anxiety or panic attacks
Relieving Factors:
Bronchodilators
Avoidance of triggers
Breathing exercises
Inhaling steam
Rest and calm environment