About Asthma Terms
The three most common chronic obstructive pulmonary diseases—emphysema, chronic bronchitis, and asthma—all present a confusingly similar symptom scenarios. Dyspnea, difficulty in moving air through the airways, chest tightness, and wheezing are common with all three. Coughing is a basic symptom of chronic bronchitis, and frequent with the other two. The airway hyperactivity of asthma often appears when chronic bronchitis temporarily worsens.
These similarities muddied the diagnostic waters for a very long time. Back in 1794, the distinguished 18th-century Edinburgh physician William Cullen complained that:
The term asthma has been commonly applied even by many specialists to every case of difficulty in breathing. By not distinguishing it with sufficient accuracy from other cases of Dyspnea, they have introduced a great deal of confusion into their treatises on this subject.
” The road leading to accurate diagnosis of the COPD entities opened up when the French physician Laennec developed the stethoscope early in the nineteenth century.”
The principles of treatment for each COPD entity are also very similar. Therapy is aimed primarily at decreasing or reversing the airflow obstruction created by abundant mucus secretion, and/or hyperinflation, and/or airway muscle contraction, and/or other inflammatory processes.
If the goal of therapy is the same regardless of the diagnosis, then why is there any real need to distinguish between these three respiratory diseases? Because current and future plans for coping with the disease’s overall impact on your life are very different depending on which disease you have.
The history’s overall purpose is to establish the nature and time frame of your current symptoms. Most physicians also find that taking a careful medical history is an invaluable diagnostic aid and helps evaluate your disease’s severity and its impact on your life. And just from talking, information about factors that aggravate your symptoms may well come to light.
A clear understanding of symptoms can also disclose a disability or discomfort that may require rehabilitation therapy. Finally, the conversational give-and-take of the history-taking process provides an excellent opportunity for you and your physician to establish a mutually trusting relationship.
There are five traditional categories of questions that your doctor asks. They concern: social history, family history, past medical history, present complaints, and a review of the different organ systems (neurological, digestive, etc.). Each category begins with general questions and proceeds to more specific ones. Above all, be honest in your answers. (You won’t help yourself by hiding, for example, the recreational use of drugs.)
When all questions have been asked, if you think that your doctor has missed possibly important information it is your responsibility to tell him. (Before your appointment, you might consider writing down everything that you see as relevant to your symptoms.)
First, your doctor will ask you about your past. Did you have asthma as a child? Have you had pneumonia several times? Do you have recurrent sinusitis? The doctor will also want to know your smoking history: do/did you, how much, and for how long. There will be questions about your occupation and whether it might be exposing you to respiratory irritants. Your doctor will also inquire about your family’s relevant history. Do/did any family members have emphysema, asthma, or chronic bronchitis, or a vulnerability to sinusitis or pneumonia?
If answers to his general questions suggest COPD, your doctor’s remaining questions will help clarify his understanding of where you stand in relation to the three major symptoms of respiratory disease: cough, sputum production, and dyspnea.
Although a persistent cough is the most easily noticeable of these symptoms, it is usually people other than patients who are aware of it. Patients themselves often deny anything unusual, chalking it up to “smoker’s cough” or “a lingering cold,” and so haven’t thought much about it. Yet any persistent cough indicates something abnormal, and its characteristics can help characterize the disease causing it.
A long-term “productive” cough—one that regularly brings up mucus—is the primary early symptom of chronic bronchitis. In fact, one of the criteria defining chronic bronchitis is the presence of a productive morning cough for three consecutive months of the year, two years in a row.
The typical chronic bronchitic’s cough is a paroxysm. The uncontrollable response is caused by anything (laughter, exercise, excitement, etc.) that makes him breathe more deeply. Some patients even faint during particularly violent coughing fits. The cough is often worse in the morning because mucus accumulates in the airways during sleep (although these patients are rarely awakened at night by coughing).
When the patient coughs, people in earshot often hear prodigious amounts of mucus rumbling in his airways. Yet these coughing fits do not always bring much up. Patients typically complain that their cough does a poor job of clearing congestion.
Regular coughing—especially a productive cough—is not a hallmark of the patient suffering primarily from emphysema. Some of these patients do cough regularly, some just occasionally, and some cough only if their condition worsens substantially—and when a cough exists, it is usually a dry one.
Noticeable mucus production is also abnormal. Healthy people produce no more than two teaspoons worth of sputum each day, and swallow most of it unawares. Patients with chronic bronchitis predominating produce substantially more, although the amount varies with the patient: a large soup spoon of mucus at the small end of the continuum, with a cupful at the other.
Equally important to diagnosis are how your mucus looks and feels. Is it thin and watery (“serous”) and therefore easy to bring up, or is it thick and slippery (“mucoid”)? Patients with especially thick mucus may need special treatment to help them clear their airways. Is it clear (which is normal), or shaded white to gray from particulate matter, for example, dust or air pollution residues? Mucus that is yellow or green reflects an inflammation of some sort—most likely a respiratory infection or an allergic response.
A putrid odor—which indicates infection—is another diagnostic aid. In addition, your doctor will ask if your mucus has recently changed color. Any recent appearance of blood in your sputum should also be mentioned. This usually indicates either an infection or particularly violent coughing fits. But it can also be a symptom of more serious lung diseases.
Dyspnea is the uncomfortable, sometimes frightening, sensation that “I am not getting enough air to breathe.” This highly subjective experience cannot be measured, and exactly what causes it remains a mystery. Neurological, muscular, biochemical, and physical processes all combine to control our breathing. How each of these factors does—or doesn’t—contribute to creating the sense of breathlessness is still unsolved.
We do know that the symptom of dyspnea is not limited to respiratory diseases. So for each patient complaining of dyspnea, the physician needs to determine whether the cause is respiratory or non-respiratory.
Although dyspnea may be an important symptom even in the early phases of emphysema, the patient usually remains unaware of it for quite some time. Its onset is insidious, progressing slowly and ever so gradually, happening with less and less—the decreases almost unnoticeable—exertion. When chronic bronchitis is the primary disease, shortness of breath is usually not a problem until the disease is in its advanced stages. Then it becomes severe.