Respiratory Diseases: Bronchitis and Emphysema

Bronchitis

• Inflammation of the trachea, bronchi, and bronchioles.
• Lasts 3-6 weeks.
• Cigarette smoking can increase the severity and frequency of acute bronchitis.
• Cough is the primary symptom and can last longer than 10-14 days.
• Cough may progress from dry to productive with yellow, green, or clear sputum.
• Other symptoms include low-grade fever, fatigue, malaise, occasional dyspnea or wheezing, headache, and substernal chest discomfort or burning pain.
• Chest x-ray will be normal.
• Treatment includes rest, fluids, cough suppressants, and inhaled medications such as albuterol.

Emphysema

• Progressive airflow limitations, gas exchange abnormalities, and hypersecretion of mucous, often caused by exposure to noxious particles or gases.
• Permanent abnormal enlargement and destruction of air spaces distal to the terminal bronchioles, including alveolar ducts, alveolar sac, and alveoli.
• Chronic and progressive dyspnea, cough, wheezing, chest tightness, and recurrent lower respiratory tract infections are common symptoms.
• Physiologic changes associated with airflow remodeling may not be physically observable until lung function is significantly impaired.
• Physical signs include increased AP diameter, weight loss, accessory muscle use, and tachypnea.
• Spirometry is the most reliable method for measuring airflow limitation.
• Diagnosis of COPD is based on FEV1/FVC ratio.

Bronchitis

• Inflammation of the trachea, bronchi, and bronchioles.
• Typically lasts 3-6 weeks.
• Cigarette smoking can worsen symptoms and increase frequency.
• Subjective findings:
  • Persistent cough lasting over 10-14 days, often the only symptom.
  • Cough initially dry, progressing to productive with yellow, green, or clear sputum.
  • Low-grade fever (<101°F).
  • Fatigue, malaise.
  • Occasional dyspnea or wheezing.
  • Headache.
  • Substernal chest discomfort or burning pain.
• Objective findings:
  • Clear and resonant lung sounds.
  • Afebrile.
  • Occasional wheezing.
  • Crackles that clear with coughing.
• Diagnosis: Based on clinical presentation, primarily viral. Chest X-ray will be normal in acute bronchitis.
• Treatment:
  • Rest.
  • Plenty of fluids.
  • Mucus looseners.
  • Cough suppressants.
  • Inhaled medications like albuterol.

Emphysema

• Progressive airflow limitation, gas exchange abnormalities, and mucous hypersecretion.
• Typically caused by significant exposure to harmful particles or gases.
• Symptoms may not fully resolve after treatment.
• Permanent: Abnormal enlargement and destruction of air spaces distal to terminal bronchioles, including alveolar ducts, sacs, and alveoli.
• Symptoms:
  • Chronic and progressive dyspnea.
  • Cough.
  • Wheezing.
  • Chest tightness.
  • Recurrent lower respiratory tract infections.
• Physical signs:
  • Increased anteroposterior (AP) diameter.
  • Weight loss.
  • Accessory muscle use.
  • Tachypnea (rapid breathing).
  • These physical signs may not appear until lung function is significantly impaired.
• Spirometry: The most reliable and objective method to assess airflow limitation.
• Diagnosis of COPD: Based on FEV1/FVC ratio.

Bronchitis

• Inflammation of the trachea, bronchi, and bronchioles, lasting 3-6 weeks.
• Cigarette smoking exacerbates the severity and frequency.
• Key Symptom: Persistent cough lasting over 10-14 days.
• Cough transitions from dry to productive, producing yellow, green, or clear sputum.
• Other symptoms: low-grade fever (<101°F), fatigue, malaise, occasional dyspnea or wheezing, headache, substernal chest discomfort.
• Objective findings: Clear and resonant lungs, afebrile, occasional wheezing, crackles that clear with coughing.
• Diagnosis is based on clinical presentation, often viral in origin.
• Chest x-ray will be NORMAL in cases of acute bronchitis.
• Treatment: Rest, hydration, mucus thinning agents, cough suppressants, inhaled medications (e.g., albuterol).

Emphysema

• Progressive airflow limitation with gas exchange abnormalities and mucus hypersecretion, often triggered by exposure to noxious particles/gases.
• Symptoms may persist despite treatment.
• Key characteristic: Permanent destruction and enlargement of air spaces distal to the terminal bronchioles, including alveolar ducts, sacs, and alveoli.
• Symptoms: Chronic and progressive dyspnea, cough, wheezing, chest tightness, recurrent lower respiratory infections.
• Physiological changes associated with airflow remodeling are often undetectable until significant lung function impairment occurs.
• Physical signs: Increased anteroposterior (AP) diameter, weight loss, accessory muscle use, tachypnea.
• Diagnosis: Spirometry is crucial for assessing airflow limitation.
• COPD Diagnosis: FEV1/FVC ratio is used.

Giant Cell Arteritis (GCA)

• GCA is an inflammatory condition affecting the temporal artery, often causing headaches, scalp tenderness, jaw pain, and visual disturbances.
• GCA typically affects individuals over 50 years of age.
• Diagnostic tests include elevated ESR and C-reactive protein levels, temporal artery biopsy, Doppler ultrasound, and MRI.
• Treatment involves corticosteroids, starting with high doses (60 mg prednisolone) and gradually tapering down.
• For patients with visual symptoms or other vascular complications, intravenous methylprednisolone is administered.
• Monitoring includes regular blood tests, imaging, and symptom assessment.

Delirium

• Delirium is an acute and fluctuating disturbance of consciousness and cognition, characterized by impaired attention and awareness.
• Risk factors include dementia, hospitalization, and certain medications.
• Symptoms may include confusion, disorientation, hallucinations, and agitation.
• Differential diagnosis is important to distinguish delirium from dementia, depression, and psychosis.
• Diagnostic evaluations may include blood work, urine analysis, and drug screens.
• Interventions focus on correcting underlying causes, managing symptoms, and providing a safe and supportive environment for the patient.

Dementia

• Dementia is a progressive decline in cognitive function, affecting memory, thinking, language, and behavior.
• Causes can be due to Alzheimer's disease, vascular dementia, Lewy body dementia, or other conditions.
• Diagnosis is made through history, physical exam, cognitive testing, neuroimaging, and blood work.
• Treatment aims to manage symptoms and slow down the progression of the disease, utilizing medications such as cholinesterase inhibitors and memantine.

Acute Stroke

• Acute stroke is a medical emergency characterized by sudden neurological deficits, including weakness, speech difficulties, visual disturbances, balance issues, and headache.
• Types: Ischemic stroke (blocked artery) and hemorrhagic stroke (bleeding).
• Prompt diagnosis and treatment are crucial to minimize brain damage and improve outcomes.

Bacterial Meningitis

• Bacterial meningitis is a serious infection of the meninges, the protective coverings of the brain and spinal cord.
• Symptoms include fever, headache, stiff neck, and altered mental status.
• Diagnosis is based on clinical presentation, lumbar puncture, and cerebrospinal fluid analysis.
• Treatment with intravenous antibiotics is critical to prevent life-threatening complications.

Parkinson's Disease (PD)

• PD is a neurodegenerative disorder characterized by tremors, slowness, rigidity, and gait disturbance.
• Early features often include resting tremors, slowness in movements, and stiffness.
• Diagnosis is typically made based on clinical features, as there are no definitive diagnostic tests.
• Treatment involves medications such as levodopa, dopamine agonists, anticholinergics, and amantadine.
• Surgical interventions, such as deep brain stimulation, are available for severe cases.

Aortic Stenosis

• Aortic stenosis is a narrowing of the aortic valve, limiting blood flow from the left ventricle to the aorta.
• Symptoms include chest pain, fatigue, shortness of breath, and decreased ability to exercise.
• Treatment may involve medication, surgery, or valve replacement.

Aortic Regurgitation

• Aortic regurgitation, also known as aortic insufficiency, is a condition where the aortic valve doesn't close properly, allowing blood to leak backward into the left ventricle.
• Symptoms include chest pain, shortness of breath, fatigue, and irregular heartbeat.
• Treatment options include surgery, medication, and blood pressure management.

Mitral Valve Prolapse

• Mitral valve prolapse (MVP) occurs when the mitral valve's flaps become floppy, causing them to not close properly and allowing blood to leak backward into the left atrium.
• Symptoms include palpitations, chest pain, dizziness, and fatigue.
• Treatment is often not necessary, but some may need medication for symptoms.

Mitral Valve Regurgitation

• Mitral valve regurgitation (MR) is a heart condition where the mitral valve doesn't close properly, causing blood to leak backward into the left atrium.
• Symptoms include shortness of breath, fatigue, and irregular heartbeat.
• Treatment may involve medication or surgery, depending on the severity of the regurgitation.

Cranial Nerves

• Twelve paired nerves that stem from the brain
• Transmit electrical signals between the brain and parts of the head, face, neck, and torso
• Functions include:
  • Vision
  • Smell
  • Taste
  • Hearing
  • Facial muscle movement, including expressions and speech

### Cranial Nerve Pairs

• Two pairs, olfactory and optic, begin in the cerebrum and branch out to target tissues
• Ten pairs begin in the brainstem and branch out
• Each pair splits to serve the two sides of the brain and body
• Longest cranial nerve is the vagus nerve, extending from the brain to the large intestine

Cranial Nerve Damage

• Can cause specific movement or sensory issues depending on the nerve's function
• Conditions affecting functioning:
  • Trauma to the head or face
  • Infections
  • Tumors
  • Stroke
  • Multiple sclerosis (MS)
  • Guillain-Barré syndrome
  • Diabetes

Cranial Nerve Conditions

• Palsy: Muscle weakness and movement issues when a cranial nerve with motor function is damaged
• Trigeminal neuralgia: Episodes of intense facial pain caused by blood vessel pressure on the trigeminal nerve
• Other conditions:
  • Glaucoma and optic neuritis can affect the optic nerve
  • Gastroparesis and vasovagal syncope (fainting) can result from vagus nerve dysfunction

Cranial Nerve Mnemonic

• Olfactory: Smell
• Optic: Sight
• Oculomotor: Eye movement
• Troclear: Eye movement
• Trigeminal: Sensation of face, chewing
• Abducens: Eye movement
• Facial: Facial expressions, taste
• Acoustic: Hearing, balance
• Glossopharyngeal: Taste, swallowing
• Vagus: Parasympathetic nervous system, heart, lungs, digestive tract
• Accessory: Neck and shoulder movement
• Hypoglossa: Tongue movement

Importance of Cranial Nerves

• Essential for interacting with the world through senses and movement
• Problems with senses or facial functions may be caused by a cranial nerve issue
• See a healthcare provider if any issues arise

Cranial Nerves

• Olfactory Nerve (I): responsible for smell sensation
• Optic Nerve (II): transmits visual information from retina
• Oculomotor Nerve (III): controls most eye movements, pupillary constriction, and accommodation for near vision
• Trochlear Nerve (IV): controls superior oblique muscle movement, which helps rotate the eye downwards and outwards
• Trigeminal Nerve (V): responsible for facial sensation (pain, touch, temperature) and controls chewing muscles
• Abducens Nerve (VI): controls lateral rectus muscle, responsible for outward eye movement
• Facial Nerve (VII): controls facial expressions, taste sensation from anterior tongue, and stimulates salivary and lacrimal glands
• Vestibulocochlear Nerve (VIII): responsible for hearing and balance
• Glossopharyngeal Nerve (IX): carries taste sensation from posterior tongue, contributes to swallowing and salivation from parotid gland
• Vagus Nerve (X): regulates heart, lungs, and digestive system, also responsible for sensory functions from throat, larynx, and abdomen, and helps control swallowing and speech
• Accessory Nerve (XI): controls neck and shoulder muscles, specifically the sternocleidomastoid and trapezius muscles
• Hypoglossal Nerve (XII): controls tongue movements

Murmur Types

• Systolic Murmurs: Occur between the closure of the AV valves and closure of the semilunar valves. Common in conditions like aortic stenosis (narrowing of the aortic valve) and mitral regurgitation (backflow of blood through the mitral valve).
• Diastolic Murmurs: Occur between closure of the semilunar valves and closure of the AV valves. Associated with conditions like aortic regurgitation (backflow of blood through the aortic valve) and mitral stenosis (narrowing of the mitral valve).
• Continuous Murmurs: Last throughout the entire cardiac cycle. Indicative of conditions like a patent ductus arteriosus (an open connection between the aorta and pulmonary artery).

Murmur Quality

• Blowing: Often indicative of regurgitant flow (backward flow of blood).
• Harsh: Associated with turbulent flow (chaotic or turbulent blood flow).
• Musical or Vibratory: Suggests an innocent or functional murmur (a murmur caused by normal physiological variations).

Murmur Grading

• Levine Scale: A common scale for grading murmurs:
  • Grade I: Very faint, heard only with focused listening.
  • Grade II: Faint but immediately audible.
  • Grade III: Moderately loud, easy to hear.
  • Grade IV: Loud, associated with a palpable thrill (vibration felt on the chest).
  • Grade V: Very loud, heard with one edge of the stethoscope off the chest, also associated with a thrill.
  • Grade VI: Extremely loud, heard without a stethoscope, also associated with a thrill.

Murmur Significance

• Innocent Murmurs: Common in children, generally harmless. Often caused by increased blood flow or normal anatomical variations.
• Pathological Murmurs: Indicative of heart disease or structural abnormalities. Require further evaluation through echocardiography (ultrasound of the heart) or other diagnostic tests.

Assessing Murmurs

• Location, timing, and radiation of the murmur help in diagnosis.
• Clinical history and physical examination are crucial for determining the significance of a murmur.

Referral and Follow-Up

• Patients with suspicious murmurs (e.g., new, loud, associated with symptoms) should be referred for cardiology evaluation.
• Regular monitoring may be necessary for patients with known heart conditions or those with significant murmurs.