Respiratory Symptoms – When and whether to treat?

Almost one-fourth of patients in a general hospital or a medical clinic present with symptoms pertaining to the respiratory system which primarily consist of cough, sputum production, running nose and/or nasal blockade and sneezing. Other important complaints include breathlessness and wheezing; chest pain and occasionally blood in the sputum (hemoptysis). Not infrequently, there are associated general symptoms of fatigue, malaise, headaches, muscle aches, sore-throat and fever. Besides being troublesome and debilitating, they are also responsible for absence from work and studies or other essential activities.  There is hardly any doubt that they need to be controlled and cured.

Respiratory symptoms may be caused by routine upper respiratory catarrh such as allergic rhinitis, common cold or viral infections, but may also point to the presence of a chronic respiratory disease (such as asthma, chronic bronchitis, bronchiectasis). A host of diseases can present with similar complaints. Some of these symptoms can also point to a cardiac disease or other systemic illnesses. In elderly people and smokers, respiratory cancers cannot be altogether forgotten.

Treatment of any symptom can be classified as symptomatic or curative. People are likely to try one or more forms of treatment for symptom-relief before they see a doctor. There are a large number of remedies which are variously used at home. Several combinations of drugs and herbs are also available as on-the –counter treatments in the market. Misuse of some drugs (such as the antibiotics) which is highly undesirable is also common. Symptoms of recent onset or of short duration do sometimes abate either on their own or with such symptomatic treatments. It is also likely that the underlying disease responsible for the presence of these symptoms remains undiagnosed and progresses unhindered. Precious time may be lost before one can hope to institute correct treatment.

While it is important to manage the troublesome complaints with symptomatic treatment, it is also critical to recognize the seriousness of the symptom/s rather than waiting. There are certain ‘red-flag signs’ which should help a patient to seek curative treatment from a specialist physician. Presence of hemoptysis, breathlessness, high fever, loss of weight and other systemic symptoms qualify for more investigations to look for the underlying cause. Persistence and recurrence of symptoms may also point to the presence of an underlying cause than a simple respiratory catarrh. It is better to seek consultation with your best chest physician in the town in all such situations.

The answer to our question in the title is therefore simple: Symptomatic treatment for respiratory symptoms is important and must be provided at all stages. It is important to understand the conditions when one cannot rely only on symptomatic treatment and look for the underlying disease responsible for those symptoms.

Chest Pain

Chest pain is a pain in any area of chest; may spread to other areas, including down to the arms, neck or jaw. The most important issue is to decide whether the pain is a mere symptom of an illness or a disease in itself. It is sometimes difficult for a common man to distinguish between a symptom and a disease. Normally, a patient is always concerned with the symptom which is troublesome. On the other hand, it is the duty of the physician to find the cause of the symptom i.e. the disease responsible for the symptom.

Chest pain has a wide spectrum of quality, intensity, duration & location. It could be vaguely or definitely located in some part of the chest; sharp or dull in intensity and of variable character.  A patient may feel tightness, achiness, or a feeling that the chest is being crushed or squeezed. Sometimes, it is expressed as sharp and stabbing pain while it is dull in other conditions. Duration of chest pain usually depends upon the duration of the illness; it can last for a few minutes or hours in some diseases while it can last for months or longer in other conditions.

Patient’s perception about gravity of chest pain may vary. To some, it is a warning of potential life-threatening illness and they may seek repeated consultations even when the symptom is trivial. Others, including those with serious illnesses, may tend to ignore. It is however important for a physician never to discard the symptom without exploring its cause. Chest pain may arise due to diseases of chest wall and spine, lungs, heart, great vessels, esophagus and sub diaphragmatic structures and many other organs.

Common lung/respiratory system diseases causing chest pain: Laryngo-tracheobronchitis, Pneumonias, Pneumothorax (collapsed lung), causes a sudden onset of chest pain, Pleurisy & Pleural Effusion, Pulmonary Thrombo-embolism, Bronchospasm: Asthma, COPD

Cardio-vascular diseases: Coronary Artery (Ischaemic) Disease: Angina, Myocardial Infarction, Peri carditis & Pericardial effusion, Myo carditis, Cardio myopathies, Aortic Dissection

Gastrointestinal causes: Heartburn & Acid Reflux, Swallowing problems related to esophagus, Gallbladder & Pancreatic causes

Muscle- or bone-related: Sore muscles from exertion or chronic pain syndromes, Bruised, broken ribs, Compression fractures (Spine)

Miscellaneous causes: Shingles; Anxiety and Panic attacks

To make a diagnosis, we need to look into history of duration, location, radiation to other areas and character, i.e. heaviness, tearing, burning, stabbing, sharp needle like, urge to eructate or merely a discomfort (dull ache or boring). Precipitating factors of chest pain include physical or psychological stress, respiratory efforts, coughing or swallowing, and relieving factors (such as leaning forward). Other associated symptoms such as ough, dyspnea, palpitation, syncope, diaphoresis, nausea, vomiting, fever and chills, weakness, malaise and weight loss are also important.

Pain due to heart attacks can be life-threatening.  Other signs of a heart attack include:

•         Sweating, Nausea or vomiting, Shortness of breath, Light-headedness or fainting

•         A rapid or irregular heartbeat, Pain in the back, jaw, neck, upper abdomen, arm or shoulder

Leg pain and swelling may point to deep vein thrombosis and pulmonary thromboembolism.

Almost any lung disease can cause soreness around the chest and muscle aches

Further tests will depends upon clinical suspicion. It is best to follow the advice of you physician of the best chest centre in the town. 

Apart from good clinical history, your physician will initially like to do Chest X-ray and Electrocardiogram. Pulmonary evaluation includes Spirometry & other lung function tests. Sometimes, CT Chest: CECT, CT Pulmonary Angiography may be required. Cardiac Evaluation may include blood biochemistry, Echocardiogram, Stress test, Angiography

It is important to manage health conditions such as high blood pressure, high cholesterol and diabetes. One should also take care to avoid risk factors (not using tobacco products;  limiting the amount of alcohol); lifestyle changes such as healthy diet and exercising.  

Snoring during sleep - Symptom of a Disease state

Snore is the sound produced due to vibration in the throat when the air is inhaled during breathing. This is more likely produced when there is partial obstruction to the air passage in the throat especially while lying down such as during sleep when the muscle tone is poor.  During sleep, the tissues in the throat get relaxed, partially block the airway and vibrate with breathing air. It is more common in obese people who are likely to have bulky throat tissue, as well as in people with a long soft palate or uvula. People who are heavy smokers and regularly drink alcohol are more likely to snore and develop other problems. Snoring also increases with age and body weight.

It is common for people to snore especially at night when sleeping. It is normal to have less than 5 snoring events per hour but more than 30 events per hour indicate a disease state. Snoring is not normal if chronic, frequent and troublesome or associated with sleep disturbance when it may point to a bigger problem.  It is wrong to believe that snoring is a sign of sound sleep. On the contrary, it indicates the presence of restless sleep. It is a sign that the air does not move freely through the nose and the throat due to some amount of obstruction in the respiratory pathways.

Snoring can have serious implications on health and can itself be a symptom of a disease like obstructive sleep apnea (OSA) especially when frequent or loud or accompanied with waking up through the night because of difficulty in breathing. Patients with OSA are excessively sleepy and drowsy during the day which can sometimes result in accidents while driving. This may also be accompanied with recurrent and transient cessation of breathing altogether (apnea episodes). Transient but significant falls in oxygen saturation (and rise in carbon-di-oxide) occur during each such episode.

OSA leads to several serious and chronic medical diseases such as diabetes, obesity, hypertension, stroke, heart attack and other cardiovascular problems. It also causes memory loss, cognitive and other intelligence disturbances. Snoring is frequently associated with respiratory symptoms such as breathlessness, chest congestion, wheezing and chronic bronchitis. Individuals with both sleep disordered breathing and chronic respiratory diseases have poorer sleep quality and overall quality of life. Other associated symptoms may include dryness of mouth, frequency of urination and sleep disturbances. Morning drowsiness and headaches are common. OSA can occasionally result in complete collapse and obstruction of upper airways. It is an important cause of sudden death during sleep.

OSA must be recognized in time and managed appropriately before the complications develop. It is common for people to ignore this important symptom as ‘normal’ or inconsequential.  Unfortunately, it is not so. Consult your best chest physician in case you or your partner has such a problem. Get general evaluation and ‘full sleep-study’ done for treatment advice.

 Other general health measures include the following:

i.   Regular exercise helps to reduce snoring, by toning various muscles in the body (arms, legs, and abdominals) as well as the muscles in the neck and throat.

ii.    Lose weight in case of obesity with exercise and diet-regulation.

iii.   Quit smoking and restrict use of alcohol and sedatives.

iv.   Sleep measures: try to sleep on one side; raise the head end of your bed.

v.    Treat nasal congestion or obstruction if present.

As of now, there is no drug therapy which can be used to manage OSA. The most successful method is the use of positive pressure breathing administered through the night with a CPAP or BIPAP machine and a tight fitting face mask (as per doctor’s prescription). It is always advisable to get the sleep-study done at your best chest centre, before instituting the treatment. Relief from various symptoms is highly rewarding