Respiratory Diseases

Upper respiratory tract infections constitute one of the frequently encountered problems in practice. Depending on the organ predilection and immune response it will take different forms and may be acute or enter into a recurrent chronic trouble. The site of infection and its manifestations are given below.

1. Nose – Congestion manifested by nose block. Nasal catarrh with sneezing. Infection may extend to throat, Eustachian tube with ear blocking or ear infection. Repeated attacks may lead to deviated nasal septum (DNS).
2. Pharyngitis, laryngitis – Sore throat, hoarseness of voice, cough, stridor in children with oedematous inflammation.
3. Sinusitis – Pain over frontal or maxillary sinuses, fever, and discharge may be purulent, postnasal drip with throat irritation and cough.
4. Tracheobronchitis – Generally follows acute coryza. Dry cough with retrosternal discomfort. If bronchitis develops, breathlessness and wheezing may appear. Expectoration scanty or profuse.
5. Epiglottis – Sore throat, oedematous swelling of epiglottis can be seen.

Rarely acute laryngo-tracheo-bronchitis results with sudden cough, stridor and breathlessness.

In children, if severe, it leads to death from asphyxia.

Cough and Breathlessness

These are most important symptoms in respiratory disorders.

Cough

Most of the time it results from acute upper respiratory tract infection or nasopharyngeal allergic response. It responds to homoeopathic treatment.

If the response does not occur in expected period or if there are certain other diagnostic possibilities like fever, auscultatory findings indicating pneumonia etc., then another group of diseases is to be considered. Amongst these pneumonia, bronchial asthma, bronchitis, chronic obstructive pulmonary disease (COPD), tuberculosis, bronchiectasis and rarely interstitial lung disease are to be considered.

Breathlessness

Breathlessness can result from pulmonary diseases like any inflammatory process (pneumonia), effusion in pleural cavity, lung collapse etc. It can also result from respiratory muscle overload as in asthma, emphysema and pulmonary fibrosis. Cardiac causes should be kept in mind like cardiac hypertrophy, cardiac failure with pulmonary congestion leading to breathlessness. History and requisite investigations are necessary to rule out cardiac cause.

Obstructive vs restrictive airway disease

Once the cardiac causes of breathlessness are ruled out, respiratory function tests are useful in differentiating obstructive versus restrictive airway disease. These are not essential if diagnosis is obvious. Obstructive diseases result from narrowing of airway for ex. Asthma, bronchitis, and emphysema. In restrictive category, loss of lung volume leads to breathlessness. For example, Pneumonia, pulmonary fibrosis etc.

Obstructive Pulmonary diseases

Asthma

Asthma denotes increased hyper responsiveness of airway and most of the time associated with airway inflammation. It is manifested as wheeze due to bronchospasm, cough and dyspnoea for variable period of time and which is reversible with treatment. In few cases chronicity occurs resulting in fibrosis of airway wall and these cases do not respond satisfactorily to the treatment. Many cases will have atopy (hypersensitivity) and elevated serum IgE. In such individuals, asthma may alternate with skin allergy.

The triggering factors inducing an asthma are allergies like house dust mite, pets in the house, pollens in the air, infection etc. Exercise can induce or aggravate attack possibly due to water loss from respiratory mucous membrane which triggers mediator release leading to bronchospasms.

The diagnosis of asthma is clinical. A patient presents with cough, wheezing and dyspnoea either as isolated symptom or in combination. Generally, the attack is worse in the morning. The attack may be preceded by upper respiratory tract infection especially coryza or sinusitis. Severe attack of asthma is recognised by respiratory rate > 25 min, heart rate > 110/min and inability to talk even a sentence.

Chronic obstructive pulmonary disease (COPD)

Typically, COPD includes emphysema, and chronic bronchitis.

Chronic bronchitis is defined as persistent cough with sputum production for more than 3 months and which occurs for at least 2 consecutive years. Typically occurring in smokers, its prevalence is increasing with pollution especially in city areas. As the disease progresses, goblet cells of small airway increase in number along with submucosal glands hypertrophy. Infection exaggerate the process. Clinically it is recognised by persistent productive cough, breathlessness and changes in pulmonary function test.

Emphysema denotes irreversible enlargement of air spaces distal to the terminal bronchiole associated with destruction of their wall. It is more common in smokers. The destruction is believed to be caused by inflammation leading to release of mediators and imbalance between oxidant and antioxidant radicals.

Clinically dyspnoea is the predominant symptom which appears when at least 1/3 of functioning lung parenchyma is destroyed. Sometimes it is associated with cough and wheezing. As the disease progresses weight loss occurs. Typically, patient is breathless with barrel shaped chest; prolonged expiration is noted.

Asthma is different from chronic bronchitis and emphysema because bronchospasm is reversible. Few cases of asthma may develop irreversible component. Therefore, there is lot of overlapping between COPD and asthma.

As COPD progresses O2 content of blood reduces (hypoxemia) while Co2 increases (hypercapnia) and mild cyanosis occurs (blue bloaters). In patient with severe emphysema overdistention of pulmonary air spaces is severe, diffusion capacity is low and blood gases are relatively normal (Pink puffers). Cor pulmonale develops due to pulmonary vascular hypertension. Congestive cardiac failure slowly develops.

Bronchiectasis

Bronchiectasis is a distinct entity characterised by permanent dilatation of bronchioles and bronchi due to destruction of elastic tissue of the wall. It results from various conditions like necrotizing pneumonia, bronchial obstruction due to tumour, mucus impaction and may be associated with other diseases like R.A., S.L.E. etc. In short obstruction and infection contribute to it.

Patient has severe persistent cough with purulent, foul smelling sometimes bloody sputum. Dyspnoea and later on orthopnoea (i.e. patient can breathe only on sitting or standing) develop.

Pneumonia

Pneumonia can be defined as infection of lung parenchyma. It results

1. When local defence mechanisms are lowered for e.g. Loss of cough reflex due to coma or neuromuscular disorder, interference with phagocytic action of alveolar macrophages due to tobacco etc.
2. Poor general resistance as in diabetes, immune mediated disorders etc.

Most of the time the infection is viral or bacterial. The entry of the organism is through respiratory tract. Occasionally hematogenous spread can occur.

In bacterial pneumonia alveoli are filled with inflammatory exudates causing consolidation (solidification) of lung tissue. A patient presents with high fever, chill, cough which becomes productive later on and occasionally haemoptysis can occur. If pleuritis is associated with it, patient complains of severe chest pain. During the stage of consolidation one can notice dull note on percussion and bronchial breathing on auscultation. As pneumonia resolves rales are heard. Radiologically whole lobe is opaque in lobar pneumonia, focal opacities are seen in bronchopneumonia. Rarely, in neglected cases complications like meningitis, lung abscess can develop.

Viral or atypical pneumonia is characterised by mild fever, mild to moderate cough and most of the time no physical findings. Patchy inflammatory changes occur in pulmonary interstitium. Radiologist reports it as pneumonitis. Clinical course is variable. Most of the cases improve in 3 weeks. Secondary bacterial infection can occur.

Pleural effusion

Pleural effusion can be inflammatory or non-inflammatory. Non inflammatory effusion may be due to congestive cardiac failure, nephritic syndrome etc.

Common inflammatory causes of pleural effusion are tuberculosis and pneumonia.

Severe chest pain even on inspiration and coughing is the predominant symptom. Pleural rub often develops. Depending on the amount of pleural fluid, breathlessness can occur. Aspiration of pleural fluid for examination is necessary if tuberculosis is suspected.

Pulmonary Tuberculosis

Tuberculosis is caused by infection with mycobacterium tuberculosis. The infection generally occurs by inhalation. In the alveoli, protective immune response occurs through macrophages and lymphocytes. It may be effective in controlling infection with minimal changes in the tissue. Hypersensitivity or preexposure to bacilli may lead to heightened response with tissue destruction with formation of granuloma and caseous necrosis and cavitation.

Clinically, unexplained cough from more than 3 weeks, nonresponsive to treatment may be the presenting trouble. Typically, mild evening fever, weakness, loss of weight, anorexia may be present. Chest X-ray may reveal typical lesion. However, sputum examination and culture are advisable in all the cases. Skin test (Mantoux test) is hypersensitivity reaction and need not necessarily indicate active lesion.