- •Table of Contents
- •Copyright
- •Dedication
- •Introduction to the eighth edition
- •Online contents
- •List of Illustrations
- •List of Tables
- •1. Pulmonary anatomy and physiology: The basics
- •Anatomy
- •Physiology
- •Abnormalities in gas exchange
- •Suggested readings
- •2. Presentation of the patient with pulmonary disease
- •Dyspnea
- •Cough
- •Hemoptysis
- •Chest pain
- •Suggested readings
- •3. Evaluation of the patient with pulmonary disease
- •Evaluation on a macroscopic level
- •Evaluation on a microscopic level
- •Assessment on a functional level
- •Suggested readings
- •4. Anatomic and physiologic aspects of airways
- •Structure
- •Function
- •Suggested readings
- •5. Asthma
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Treatment
- •Suggested readings
- •6. Chronic obstructive pulmonary disease
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach and assessment
- •Treatment
- •Suggested readings
- •7. Miscellaneous airway diseases
- •Bronchiectasis
- •Cystic fibrosis
- •Upper airway disease
- •Suggested readings
- •8. Anatomic and physiologic aspects of the pulmonary parenchyma
- •Anatomy
- •Physiology
- •Suggested readings
- •9. Overview of diffuse parenchymal lung diseases
- •Pathology
- •Pathogenesis
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Suggested readings
- •10. Diffuse parenchymal lung diseases associated with known etiologic agents
- •Diseases caused by inhaled inorganic dusts
- •Hypersensitivity pneumonitis
- •Drug-induced parenchymal lung disease
- •Radiation-induced lung disease
- •Suggested readings
- •11. Diffuse parenchymal lung diseases of unknown etiology
- •Idiopathic pulmonary fibrosis
- •Other idiopathic interstitial pneumonias
- •Pulmonary parenchymal involvement complicating systemic rheumatic disease
- •Sarcoidosis
- •Miscellaneous disorders involving the pulmonary parenchyma
- •Suggested readings
- •12. Anatomic and physiologic aspects of the pulmonary vasculature
- •Anatomy
- •Physiology
- •Suggested readings
- •13. Pulmonary embolism
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic evaluation
- •Treatment
- •Suggested readings
- •14. Pulmonary hypertension
- •Pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic features
- •Specific disorders associated with pulmonary hypertension
- •Suggested readings
- •15. Pleural disease
- •Anatomy
- •Physiology
- •Pleural effusion
- •Pneumothorax
- •Malignant mesothelioma
- •Suggested readings
- •16. Mediastinal disease
- •Anatomic features
- •Mediastinal masses
- •Pneumomediastinum
- •Suggested readings
- •17. Anatomic and physiologic aspects of neural, muscular, and chest wall interactions with the lungs
- •Respiratory control
- •Respiratory muscles
- •Suggested readings
- •18. Disorders of ventilatory control
- •Primary neurologic disease
- •Cheyne-stokes breathing
- •Control abnormalities secondary to lung disease
- •Sleep apnea syndrome
- •Suggested readings
- •19. Disorders of the respiratory pump
- •Neuromuscular disease affecting the muscles of respiration
- •Diaphragmatic disease
- •Disorders affecting the chest wall
- •Suggested readings
- •20. Lung cancer: Etiologic and pathologic aspects
- •Etiology and pathogenesis
- •Pathology
- •Suggested readings
- •21. Lung cancer: Clinical aspects
- •Clinical features
- •Diagnostic approach
- •Principles of therapy
- •Bronchial carcinoid tumors
- •Solitary pulmonary nodule
- •Suggested readings
- •22. Lung defense mechanisms
- •Physical or anatomic factors
- •Antimicrobial peptides
- •Phagocytic and inflammatory cells
- •Adaptive immune responses
- •Failure of respiratory defense mechanisms
- •Augmentation of respiratory defense mechanisms
- •Suggested readings
- •23. Pneumonia
- •Etiology and pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features and initial diagnosis
- •Therapeutic approach: General principles and antibiotic susceptibility
- •Initial management strategies based on clinical setting of pneumonia
- •Suggested readings
- •24. Bacterial and viral organisms causing pneumonia
- •Bacteria
- •Viruses
- •Intrathoracic complications of pneumonia
- •Respiratory infections associated with bioterrorism
- •Suggested readings
- •25. Tuberculosis and nontuberculous mycobacteria
- •Etiology and pathogenesis
- •Definitions
- •Pathology
- •Pathophysiology
- •Clinical manifestations
- •Diagnostic approach
- •Principles of therapy
- •Nontuberculous mycobacteria
- •Suggested readings
- •26. Miscellaneous infections caused by fungi, including Pneumocystis
- •Fungal infections
- •Pneumocystis infection
- •Suggested readings
- •27. Pulmonary complications in the immunocompromised host
- •Acquired immunodeficiency syndrome
- •Pulmonary complications in non–HIV immunocompromised patients
- •Suggested readings
- •28. Classification and pathophysiologic aspects of respiratory failure
- •Definition of respiratory failure
- •Classification of acute respiratory failure
- •Presentation of gas exchange failure
- •Pathogenesis of gas exchange abnormalities
- •Clinical and therapeutic aspects of hypercapnic/hypoxemic respiratory failure
- •Suggested readings
- •29. Acute respiratory distress syndrome
- •Physiology of fluid movement in alveolar interstitium
- •Etiology
- •Pathogenesis
- •Pathology
- •Pathophysiology
- •Clinical features
- •Diagnostic approach
- •Treatment
- •Suggested readings
- •30. Management of respiratory failure
- •Goals and principles underlying supportive therapy
- •Mechanical ventilation
- •Selected aspects of therapy for chronic respiratory failure
- •Suggested readings
- •Index
however, the clinician must keep in mind the broader differential diagnosis of cough outlined in Table 2.2, recognizing that cough may be a marker and the initial presenting symptom of a more serious disease, such as tuberculosis or carcinoma of the lung.
Evaluation and management of cough
When cough is acute, accompanied by other symptoms of an upper respiratory tract infection, and not associated with other concerning findings (e.g., high fever, chills, or hemoptysis), further evaluation is not needed. A mild cough often needs no treatment, but if it is particularly bothersome, an over-the-counter antitussive (cough suppressant) can be used. In many cases of a lingering, subacute cough after an upper respiratory tract infection, the cough can be particularly bothersome but will ultimately resolve. The possibility of persistent cough from Bordetella pertussis (whooping cough) can also be considered in these cases suggestive of a postinfectious cough. If the patient is on an ACE inhibitor, the patient should ideally be switched to a medication acting by another mechanism.
When cough extends beyond 8 weeks and becomes chronic, further evaluation and/or management may be indicated. The patient’s history and physical examination may provide clues to an etiology, particularly if there is a suggestion or evidence of underlying pulmonary disease. In the absence of a likely cause of the subacute or chronic cough, a chest radiograph is typically indicated to look for underlying intrathoracic disease (pulmonary or cardiac) to explain the cough. If the chest radiograph does not show pathology that could be responsible for the cough, then the patient may be tried sequentially on therapy to address the three most common causes of chronic cough—upper airway cough syndrome (postnasal drip), asthma, and gastroesophageal reflux disease (GERD). Empiric therapy for any of these common diagnoses serves not only as a therapeutic trial but also as a diagnostic trial that can potentially clinch the diagnosis. Other diagnostic tests that can be applied to look for specific diagnoses include pulmonary function testing (for asthma), chest CT (for bronchiectasis), and esophageal pH monitoring (for GERD).
When no etiology of cough is found and empiric therapeutic trials have failed, a centrally acting neuromodulatory drug used for neuropathic pain (gabapentin or pregabalin) is sometimes tried, though often limited by side effects. With recognition of the cough hypersensitivity syndrome as an explanation for unexplained, persistent cough in some patients, there is now interest in developing a therapeutic approach targeting a variety of chemical mediators (e.g., P2X3 and TRPV-1) involved in activation of sensory nerves leading to cough.
Hemoptysis
Hemoptysis refers to coughing up blood derived from airways or the lung itself. When the patient complains of coughing or spitting up blood, whether the blood actually originated from the respiratory system is not always apparent. Other sources of blood include the nasopharynx (particularly from the common nosebleed), mouth (even lip or tongue biting can be mistaken for hemoptysis), and upper gastrointestinal tract (esophagus, stomach, and duodenum). The patient often can distinguish some of these causes of pseudohemoptysis, but the physician also should search by examination for an oral or nasopharyngeal source.
The major causes of hemoptysis can be divided into three categories based on location: airways, pulmonary parenchyma, and vasculature (Table 2.3). Airway disease is the most common cause, with bronchitis, bronchiectasis, and bronchogenic carcinoma leading the list. Bronchial carcinoid tumor (formerly called bronchial adenoma), a less common neoplasm with variable malignant potential, also originates in the airway and may cause hemoptysis. In patients with advanced acquired immunodeficiency syndrome (AIDS), hemoptysis may be due to endobronchial (and/or pulmonary parenchymal) involvement
with Kaposi sarcoma.
TABLE 2.3
Differential Diagnosis of Hemoptysis
Airway Disease
Acute or chronic bronchitis
Bronchiectasis
Bronchogenic carcinoma
Bronchial carcinoid tumor (bronchial adenoma)
Other endobronchial tumors (Kaposi sarcoma and metastatic carcinoma)
Parenchymal Disease
Tuberculosis
Lung abscess
Pneumonia
Mycetoma (“fungus ball”)
Miscellaneous
Goodpasture syndrome
Idiopathic pulmonary hemosiderosis
Granulomatosis with polyangiitis (Wegener granulomatosis)
Vascular Disease
Pulmonary embolism
Elevated pulmonary venous pressure
Left ventricular failure
Mitral stenosis
Vascular malformation
Miscellaneous/Rare Causes
Impaired coagulation
Pulmonary endometriosis
Diseases of the airways (e.g., bronchitis) are the most common causes of hemoptysis.
Parenchymal causes of hemoptysis frequently are infectious in nature: tuberculosis, lung abscess, pneumonia, and localized fungal infection (generally attributable to Aspergillus organisms), termed
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
mycetoma (“fungus ball”) or aspergilloma. Rarer causes of parenchymal hemorrhage, some of which are discussed in Chapter 11, are Goodpasture syndrome, idiopathic pulmonary hemosiderosis, and granulomatosis with polyangiitis (formerly called Wegener granulomatosis).
Vascular lesions resulting in hemoptysis are generally related to problems with the pulmonary circulation. Pulmonary embolism, with either frank infarction or transient bleeding without infarction, is often a cause of hemoptysis. Elevated pressure in the pulmonary venous and capillary bed may also be associated with hemoptysis. Acutely elevated pressure, such as in pulmonary edema, may have associated low-grade hemoptysis, commonly seen as pinkor red-tinged frothy sputum. Chronically elevated pulmonary venous pressure results from mitral stenosis, but this valvular lesion is a relatively infrequent cause of significant hemoptysis in developed countries. Vascular anomalies, such as arteriovenous malformations, may also be associated with coughing of blood.
Other miscellaneous etiologic factors in hemoptysis should be considered. Some of these belong in more than one of the aforementioned categories; others are included here because of their rarity. Cystic fibrosis affects both airways and pulmonary parenchyma. Although either component theoretically can cause hemoptysis, bronchiectasis (a common complication of cystic fibrosis) is most frequently responsible. Patients with impaired coagulation, either from disease or from anticoagulant therapy, rarely may have pulmonary hemorrhage in the absence of other obvious causes of hemoptysis. An interesting but rare disorder is pulmonary endometriosis, in which implants of endometrial tissue in the lung can bleed coincident with the time of the menstrual cycle. Other causes are even more rare, and discussion of them is beyond the scope of this chapter.
Chest pain
Chest pain as a reflection of respiratory system disease does not originate in the lung itself, which is free of sensory pain fibers. When chest pain does occur in this setting, its origin usually is the parietal pleura (lining the inside of the chest wall), diaphragm, or mediastinum, each of which has extensive innervation by nerve fibers capable of pain sensation. Although cardiac disease is of course an extremely important cause of chest pain, it will not be included in this discussion.
Chest pain can be associated with pleural, diaphragmatic, or mediastinal disease.
For the parietal pleura or the diaphragm, an inflammatory or infiltrating malignant process generally produces the pain. When the diaphragm is involved, the pain commonly is referred to the shoulder. In contrast, pain from the parietal pleura usually is relatively well localized over the area of involvement. Pain involving the pleura or diaphragm is often worsened on inspiration; in fact, chest pain that is particularly pronounced on inspiration is described as pleuritic.
Inflammation of the parietal pleura producing pain is often secondary to pulmonary embolism or to pneumonia extending to the pleural surface. A pneumothorax may result in the acute onset of pleuritic pain, although the mechanism is not clear because an acute inflammatory process is unlikely to be involved. Some diseases, particularly connective tissue disorders such as lupus, may result in episodes of pleuritic chest pain from a primary inflammatory process involving the pleura. Inflammation of the parietal pleura as a result of a viral infection (e.g., viral pleurisy) is a common cause of pleuritic chest pain in otherwise healthy individuals.
Infiltrating tumor can produce chest pain by affecting the parietal pleura or adjacent soft tissue, bones, or nerves. In the case of malignant mesothelioma, the tumor arises from the pleura itself. In other circumstances, such as lung cancer, the tumor may extend directly to the pleural surface or involve the pleura after bloodborne (hematogenous) metastasis from a distant site.
A variety of disorders originating in the mediastinum may result in pain, but they may or may not be associated with additional problems in the lung itself. These disorders of the mediastinum are discussed in Chapter 16.
Suggested readings
Dyspnea
Burki N.K. & Lee L.Y. Mechanisms of dyspnea Chest 2010;138: 1196-1201.
Harver A, Mahler D.A, Schwartzstein R.M. & Baird J.C. Descriptors of breathlessness in healthy individuals: Distinct and separable constructs Chest 2000;118: 679-690.
Heinicke K, Taivassalo T, Wyrick P, Wood H, Babb T.G. & Haller R.G. Exertional dyspnea in mitochondrial myopathy: Clinical features and physiological mechanisms American Journal of Physiology. Regulatory, Integrative and Comparative Physiology 2011;301:
R873-R874.
Laviolette L, Laveneziana P, ERS & Research Seminar Faculty. Dyspnoea: A multidimensional and multidisciplinary approach European Respiratory Journal 2014;43: 1750-1762.
Mahler D.A. & O’Donnell D.E. Recent advances in dyspnea Chest 2015;147: 232-241. Mahler D.A, Selecky P.A, Harrod C.G, Benditt J.O, Carrieri-Kohlman V, Curtis J.R., et al.
American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease Chest 2010;137: 674-691.
O’Donnell D.E, Ora J, Webb K.A, Laveneziana P. & Jensen D. Mechanisms of activityrelated dyspnea in pulmonary diseases Respiratory Physiology & Neurobiology 2009;167: 116-132.
Parshall M.B, Schwartzstein R.M, Adams L, Banzett R.B, Manning H.L, Bourbeau J., et al. An official American Thoracic Society statement: Update on the mechanisms, assessment, and management of dyspnea American Journal of Respiratory and Critical Care Medicine 2012;185: 435-452.
Cough
Canning B.J, Chang A.B, Bolser D.C, Smith J.A, Mazzone S.B. & McGarvey L. Anatomy and neurophysiology of cough. CHEST guideline and expert panel report Chest 2014;146: 1633-1648.
Gibson P.G, Fujimara M. & Niimi A. Eosinophilic bronchitis: Clinical manifestations and implications for treatment Thorax 2002;57: 178-182.
Gibson P, Wang G, McGarvey L, Vertigan A.E, Altman K.W. & Birring S.S. Treatment of unexplained chronic cough. CHEST guideline and expert panel report Chest 2016;149: 27-44.
Kahrilas P.J, Altman K.W, Chang A.B, Field S.K, Harding S.M, Lane A.P., et al. Chronic cough due to gastroesophageal reflux in adults. CHEST guideline and expert panel report Chest 2016;150: 1341-1360.
Kwon N.H, Oh M.J, Min T.H, Lee B.J. & Choi D.C. Causes and clinical features of subacute cough Chest 2006;129: 1142-1147.
Lee K.K, Davenport P.W, Smith J.A, Irwin R.S, McGarvey L, Mazzone S.B., et al. Global
physiology and pathophysiology of cough. Part 1: Cough phenomenology – CHEST
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
guideline and expert panel report Chest 2021;159: 282-293.
Mazzone S.B, Chung K.F. & McGarvey L. The heterogeneity of chronic cough: A case for endotypes of cough hypersensitivity Lancet. Respiratory Medicine 2018;6: 636-646.
Mazzone S.B, McGovern A.E, Cole L.J. & Farrell M.J. Central nervous system control of cough: Pharmacological implications Current Opinion in Pharmacology 2011;11: 265271.
McGarvey L, Rubin B.K, Ebihara S, Hegland K, Rivet A, Irwin R.S., et al. Global physiology and pathophysiology of cough. Part 2. Demographic and clinical considerations: CHEST expert panel report Chest 2021;160: 1413-1423.
Moore A, Harnden A, Grant C.C, Patel S. & Irwin R.S. Clinically diagnosing pertussisassociated cough in adults and children Chest 2019;155: 147-154.
Morice A.H, Millqvist E, Bieksiene K, Birring S.S, Dicpinigaitis P, Domingo Ribas C., et al.
ERS guidelines on the diagnosis and treatment of chronic cough in adults and children
European Respiratory Journal 2020;55: 1901136.
Muroi Y. & Undem B.J. Targeting peripheral afferent nerve terminals for cough and dyspnea Current Opinion in Pharmacology 2011;11: 254-264.
Smith J.A. & Woodcock A. Chronic cough New England Journal of Medicine 2016;375: 1544-1551.
Smith J.A, Abdulqawi R. & Houghton L.A. GERD-related cough: Pathophysiology and diagnostic approach Current Gastroenterology Reports 2011;13: 247-256.
Hemoptysis
Chun J.Y, Morgan R. & Belli A.M. Radiological management of hemoptysis: A comprehensive review of diagnostic imaging and bronchial arterial embolization
Cardiovascular and Interventional Radiology 2010;33: 240-250.
Davidson K. & Shojaee S. Managing massive hemoptysis Chest 2020;157: 77-88. Dudha M, Lehrman S, Aronow W.S. & Rosa J. Hemoptysis: Diagnosis and treatment
Comprehensive Therapy 2009;35: 139-149.
Larici A.R, Franchi P, Occhipinti M, Contegiacomo A, del Ciello A, Calandriello L., et al. Diagnosis and management of hemoptysis Diagnostic and Interventional Radiology (Ankara, Turkey) 2014;20: 299-309.
Sakr L. & Dutau H. Massive hemoptysis: An update on the role of bronchoscopy in diagnosis and management Respiration 2010;80: 38-58.
Savale L, Parrot A, Khalil A, Antoine M, Théodore J, Carette M.F., et al. Cryptogenic hemoptysis: From a benign to a life-threatening pathologic vascular condition American Journal of Respiratory and Critical Care Medicine 2007;175: 1181-1185.
Simon D.R, Aronoff S.C. & Del Vecchio M.T. Etiologies of hemoptysis in children: A systematic review of 171 patients Pediatric Pulmonology 2017;52: 255-259.
Chest pain
Brims F.J, Davies H.E. & Lee Y.C. Respiratory chest pain: Diagnosis and treatment Medical Clinics of North America 2010;94: 217-232.
Brown A.F, Cullen L. & Than M. Future developments in chest pain diagnosis and management Medical Clinics of North America 2010;94: 375-400.
Ebell M.H. Evaluation of chest pain in primary care patients American Family Physician
2011;83: 603-605.
Goldberg A. & Litt H.I. Evaluation of the patient with acute chest pain Radiologic Clinics of North America 2010;48: 745-755.
Lee T.H. & Goldman L. Evaluation of the patient with acute chest pain New England Journal of Medicine 2000;342: 1187-1195.
Lenfant C. Chest pain of cardiac and noncardiac origin Metabolism Suppl. 1, 2010;59: S41S46.
Winters M.E. & Katzen S.M. Identifying chest pain emergencies in the primary care setting
Primary Care 2006;33: 625-642.
Yelland M, Cayley W.E,Jr. & Vach W. An algorithm for the diagnosis and management of chest pain in primary care Medical Clinics of North America 2010;94: 349-374.
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/