consultant Neonatologist and Paediatrician Respiratory Disease Dr Amal Damrah consultant Neonatologist and Paediatrician

Signs and Symptoms of Respiratory Diseases Cardinal Symptoms Cough Sputum Hemoptysis Dyspnea Wheezes Chest pain

Signs and Symptoms of Respiratory Diseases Other presenting symptoms Apnea Hoarseness Stridor Snoring Fever Night sweating Weight loss

Cough Acute cough Chronic cough (>2 weeks) Bronchial asthma Acute bronchitis Pneumonia Pulmonary Embolism Chronic cough (>2 weeks) Bronchial asthma Chronic bronchitis Pulmonary fibrosis Lung cancer Bronchiectasis

Sputum Bronchiectasis (yellow, green, large amount, more in the morning) Lung abscess ( Foul smelling) Pneumonia ( yellowish, streaks of blood) Pulmonary edema ( Pink frothy)

Hemoptysis Massive >200 ml/episode Frank (fresh, bright red, no sputum) Causes Lung cancer ( clots) Tuberculosis, Bronchiectasis ( brisk & brief) Pulmonary infarction Pneumonia A/V malformation

Dyspnea Acute dyspnea (hours to days) Bronchial asthma Pneumonia Massive pleural effusion Pulmonary edema (LVF, MS) Chronic dyspnea (months to Years) Chronic bronchitis Emphysema Pulmonary fibrosis

Wheezes –Bronchial asthma –COPD –Pulmonary embolism –Lung cancer –Bronchiectasis –LVF

Chest pain –Pulmonary infarction –Pneumonia –Acute pleurisy –Trauma –MI

Differences Between Obstructive and Restrictive Lung Diseases One of the first steps in diagnosing lung diseases is differentiating between obstructive lung disease and restrictive lung disease. While both types can cause shortness of breath, obstructive lung diseases (such as asthma and COPD) cause more difficulty with exhaling air and restrictive lung diseases (such as pulmonary fibrosis) can cause problems by restricting a person's ability to inhale air.

Obstructive Obstructive lung diseases are characterized by obstruction in the air passages, with obstruction defined by exhalation that is slower and shallower than in someone without the disease. Obstruction can occur when inflammation and swelling cause the airways to become narrowed or blocked, making it difficult to expel air from the lungs. This results in an abnormally high volume of air being left in the lungs (increased residual volume). Increased residual volume, in turn, leads to both the trapping of air and hyperinflation of the lungs—changes that contribute to a worsening of respiratory symptoms.

Restrictive Restriction is defined by inhalation that fills the lungs far less than would be expected in a healthy person. Restrictive lung diseases are characterized by a reduced total lung capacity. This occurs because of difficulty filling the lungs completely in the first place, and can be due to intrinsic factors (e.g. stiff lungs); extrinsic factors, such as when pressure from an enlarged abdomen limits the expansion of the lungs; or neurological factors, such as muscular dystrophy, where damage to the nervous system interferes with movements necessary to draw air into the lungs.

Symptoms With obstruction, a person may have difficulty expelling all of the air from lungs. This often worsens with activity, since when respiratory rate increases, it becomes challenging to blow out all of the air in the lungs before taking the next breath. Narrowing of the airways may cause signs such as wheezing, and many of the conditions that fall under the category of obstructive lung disease are associated with increased sputum production as well.

With restrictive lung disease, a person may feel like it hard to take a full breath, and this can cause considerable anxiety at times. With extrinsic lung disease, a person may change positions trying to find a position that makes it easier to breathe.

Both Shortness of breath, is common with both obstructive and restrictive lung diseases. Early on in the course of these diseases, dyspnea may occur primarily with activity, with symptoms at rest occurring in the more advanced stages. persistent cough (though this is more common in conditions such as bronchitis and pneumonia. tachypnea unintentional weight loss (due to the increased energy needed to breathe). • • •

Conditions Obstructive Lung Diseases: Chronic obstructive pulmonary disease (COPD) Chronic bronchitis Asthma Bronchiectasis Bronchiolitis Cystic fibrosis •

Restrictive Lung Diseases (Intrinsic) Intrinsic restrictive disorders are those that occur due to restriction in the lungs (often a "stiffening") and include: Pneumonia Pneumoconioses Adult respiratory distress syndrome (ARDS) Eosinophilic pneumonia Tuberculosis Sarcoidosis Interstitial lung diseases due to a known cause (such as pulmonary fibrosis) and idiopathic pulmonary fibrosis Lobectomy and pneumonectomy (lung cancer surgery) • • •

Restrictive Lung Diseases (Extrinsic) Extrinsic restrictive disorders refer to those that originate outside of the lungs. These include impairment caused by: • Scoliosis Obesity hypoventilation syndrome Pleural effusion Ascites (abdominal swelling caused by cirrhosis or liver cancer) Pleurisy Rib fractures

Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease) Restrictive Lung Diseases (Neurological) Neurological restrictive disorders are those caused by disorders of the central nervous system that prevent the lungs from working properly. Among the most common causes: • Paralysis of the diaphragm Guillain-Barré syndrome Myasthenia gravis Muscular dystrophy Amyotrophic lateral sclerosis (ALS or Lou Gehrig's Disease)

Diagnosis Pulmonary Function Tests Spirometry is a common office test used to evaluate lungs function by measuring how much air you inhale, and how much and how quickly you exhale. It can be very helpful in differentiating obstructive and restrictive lung diseases, as well as determining the severity of these diseases. This test can determine the following:

Forced vital capacity (FVC): Forced vital capacity measures the amount of air a person can breathe out forcefully after taking as deep a breath as possible. Because lung capacity is reduced in both obstructive and restrictive diseases, the FVC alone cannot diagnose either disorder. Forced expiratory volume in one second (FEV1): Forced expiratory volume in one second measures the total amount of air that can be forcibly exhaled in the first second of the FVC test. Healthy people generally expel around 75 percent to 85 percent in this time. The FEV1 is decreased in obstructive lung diseases and normal to minimally decreased in restrictive lung diseases.

FEV1/FVC ratio: The ratio of FEV1 to FVC measures the amount of air a person can forcefully exhale in one second relative to the total amount of air he or she can exhale. This ratio is decreased in obstructive lung disorders and normal in restrictive lung disorders. In an adult, a normal FEV1/FVC ratio is 70 percent to 80 percent, and in a child, a normal ratio is 85 percent or greater. The FEV1FVC ratio can also be used to figure out the severity of obstructive lung disease. Total lung capacity (TLC): Total lung capacity (TLC) is calculated by adding the volume of air left in the lungs after exhalation (the residual volume) with the FVC. TLC is normal or increased in obstructive defects and decreased in restrictive ones. In obstructive lung diseases, air is left in the lungs (air trapping or hyperinflation), causing the increase.

Spirometry Interpretation: Obstructive vs. Restrictive Defect Obstructive Disorders Characterized by a limitation of expiratory airflow so that airways cannot empty as rapidly compared to normal (such as through narrowed airways from bronchospasm, inflammation, etc.) Examples: Asthma Emphysema Cystic Fibrosis Restrictive Disorders Characterized by reduced lung volumes/decreased lung compliance Examples: Interstitial Fibrosis Scoliosis Obesity Lung Resection Neuromuscular diseases Cystic Fibrosis

Spirometry Interpretation: Obstructive vs. Restrictive Defect

Severity of any spirometric abnormalities based on the FEV1 Degree of severity FEV1 % predicted Mild Moderate Mod severe Severe Very Severe >70 60-69 50-59 35-49 < 35

Laboratory Tests Lab tests may give an indication of the severity of lung disease, but are not very helpful in determining if it is obstructive or restrictive in nature. Oximetry, a measure of the oxygen content in the blood, may be low in both types of diseases. Arterial blood gases may also reveal a low oxygen level and, sometimes, an elevated carbon dioxide level (hypercapnia). With chronic lung disease, hemoglobin levels are often elevated in an attempt to carry more oxygen to the cells of the body. • •

Imaging Studies Tests such as chest X-ray or chest computed tomography (CT) scan may give clues as to whether a lung disease is obstructive or restrictive if the underlying condition (such as pneumonia or a rib fracture). Bronchoscopy is a test in which a lighted tube with a camera is threaded through the mouth and down into the large airways. Like imaging studies, it can sometimes diagnose the underlying condition.

Treatments The treatment options are significantly different for obstructive and restrictive lung diseases. obstructive lung diseases such as COPD and asthma, medications that dilate the airways (bronchodilators) can be very helpful. Inhaled or oral steroids are also frequently used to reduce inflammation. restrictive lung disease treatment of the underlying cause, such as a pleural effusion or ascites, may result in improvement. Supportive treatment can be helpful for both types of lung diseases and may include supplemental oxygen, noninvasive ventilation (such as CPAP or BiPAP), or mechanical ventilation. When severe, lung transplantation is also sometimes an option.

Questions?