Breathing and respiratory complaints are very common and a frequent reason people seek medical attention. In the emergency department especially, we see all the varieties, from colds to life-threatening lung conditions. Here’s the rundown, starting at the top.
With every breath, we breathe in air and God-knows-what else. So the mouth, the nose and sinuses, and the lungs themselves, have several levels of defense built in, and put up an impressive performance generally over a very long time in fighting off these “insults”. The tissues tend to heal their injuries and fight off infections.
Sinus problems: The sinuses generate a layer of mucous that coats the back or the nose and throat area, and this layer migrates back as a “layer” to the top of the esophagus, where it is swallowed and recycled. Irritation with pollens, pollutants, molds, funguses, and viruses stimulate them to generate more stuff, and the congestion becomes noticeable. We have called this “sinusitis”, and the new preferred name is “rhinosinusitis”, getting that nose word rhino in there.
The kick-up of the sinus activity will run a while and cool it, and that should be that, Decongestants, and maybe an antihistamine, usually manage the problem. But if it goes on for two or three weeks or more you begin to wonder. Sinus infection with the big germs like bacteria, where an antibiotic would be useful, I have considered unlikely, and while it depends on what you read a little, I generally favor treating the possibility with antibiotics when I see people with these symptoms. Remember, America love two things, the automobile and the antibiotic.
True sinus infection most often involves the sinuses in the cheeks, the maxillary sinuses, and also the sinuses along the sides of the nasal bridge, the ehtmoids. Did you know you had sinuses there? Generally, local pain and tenderness over these areas suggest infection, and with the maxillaries, the pain often feels like a toothache, and people go to the dentist only to find that the sinus above the tooth is infected and hurting. And the eyeball above the infected side will feel like it is popping out when you bend over. And as far as that stuff you’re blowing out of your nose is concerned, is it stretchy and thick like mucous, or runny and discolored, like pus? Infections like this are obviously common, but most can be expected to get better without significant medical intervention.
Having said that, people seek relief from these conditions, and it’s a big industry.
There is the word “pharynx (FAY-rinks, say it right please), a word that means “sucker”. Like the mouth of the shark, it’s what grabs food and shoves it into the digestive system. Not surprisingly, it is often under attack by germs. When the immune system has to become involved, there is swelling and pain, and the throat gets sore and makes it painful to swallow. The term is “pharyngitis”.
You guessed it, there are two kinds of throat infection generally, viruses, and the big germs, bacteria, like strep. Most are viral, and when there is cough associated with it it’s definitely viral. But what about strep? Can you tell by looking back there?
Answer: not really. But bacterial illness is usually a more serious illness. So more than just throat soreness, when the big germs are working on you, you get “sicker”. There might be fever, and chills and laying on the couch. Headache. Stomach ache. This is an illness that’s more like strep throat.
Can you tell anything by looking back there? Here are the classics: When the uvula is red and swollen, and the soft palate is also real red, and there are dots of red on the palate above the throat (the “sunrise appearance”), and the voice is a little muffled, and the lymph nodes in front of the neck muscles are swollen and tender, then that has a good shot at being a bacterial situation (strep throat).
The Epstein-Barr virus is the germ that causes the infamous illness of acute infectious mononucleosis. It is a bug that likes humans very much, and pretty much infects all of them, gaining hold in the sinuses and upper respiratory structures. At any given time 15% of the population is shedding the virus in their respiratory secretions and saliva.
Most people get mono when they’re 2 or 3 years old, as a long fever illness with vague symptoms often generally indistinguishable from other childhood febrile illnesses. But that’s when you want to get it, as a little kid. In fact, as many as a third of people arrive in adulthood having not gotten it, and they are often stuck with a run of weeks or months of relapsing sinus and throat congestion as they mount an immune reaction to subdue the invasion, and this can take months in some people. Some get hepatitis. Eventually, the immune system wins out. A key finding with these sore throats, besides the often huge, pus-filled tonsils, is the swelling of the lymph nodes behind that muscle that forms the neck and makes football players look like they do (the sternocleidomastoid muscle). In strep throat, it’s the ones in front of the muscle swell up and get tender.
A very important class of medicine for managing all of these allergic and respiratory conditions is what you call steroids. Part of the body’s biology anyway, their effect is to tame the immune reaction. Often it’s this response itself that’s the problem, either because of long term irritation or hardcore acute invasion with germs like the flu. They really work and are prescribed a lot. It’s like managing friendly fire, the good guys shooting at you. Typical outcome of an armed anything, right? I love steroids, the anti-inflammatory variety, that is, and I would say in my career I’ve prescribed more of them than anything else by a long shot.
Like sinuses and sore throats, viral infection of the lungs is much more common than bacterial invasion. When the latter is happening down in the lungs, that’s technically what you think of as pneumonia. But infact viruses can also cause infection down inside the lungs, but much more commonly they attach to and injure the respiratory “tree”, involving the sinuses, the throat, and the bronchial tubes. Since the Good Lord put the cough reflexes in the bronchial tubes, when you get “bronchitis”, you’re basically coughing your head off, especially at night. These are dry, non-productive coughs, and with enough trauma, you can even cough up a little blood. And some people really traumatize their bronchial apparatus with forceful coughing, maybe trying desperately to “cough something out”, and instead are prolonging their problem. It is not unusual for people to go a month with a cough in this circumstance. In smokers it can last even longer.
But then there’s pneumonia. Remember, bacteria are the big germs, and they are trying to eat you. They generate pus and recruit large amounts of the inflammatory system to react and infiltrate the area, and this accounts for the more significant, whole body symptoms. There is fever, often in high spikes followed by the traditional sweaty cool-down. There may be vomiting. In big infections breathing may be short, but this is unusual. And if the germs are overflowing into the blood stream, there is a giant chill and shake lasting half-an-hour or so, as the immune system is stoked by this real-deal threat. This chill they used to call “rigors”.
With bacterial pneumonia, you get sick quick and are getting sicker. There may be prostration and even confusion. An ambulance might be called by someone who loves you. And diagnostically, we can usually tell. People look and act sick, you can often hear the gurgling sounds in the area of infected lung with the stethoscope, and x-ray studies usually show the cloudiness of the area of infection. Antibiotics and fluids and supportive care, even hospitalization, is in order. We hope for and expect rapid improvement.
Kids get pneumonias and get over them quickly. Middle aged people can get them, and for me this has usually been during flu season. In fact, the “weakening” of a person caused by the flu often is the forerunner to bacterial complication of pneumonia, and this is why the flu can be so dangerous. Other conditions like lung cancer and look like pneumonia at first, but when there is no improvement, further testing may reveal a tumor under it all.
Influenza is a lung virus, and causes an upper respiratory infection involving the sinuses and throat, and a really bad cough, and high fever to boot. Influenza is in the top ten causes of death every year in the US, usually from bacterial infection that follows it as pneumonia. The flu shot reduces you chance of getting it something like 60%. So if you have smoker’s lung and emphysema or COPD, or medical problems, or a lot of mileage, get the shot. It’s real safe, and not getting it can be disastrous.
In my career we have seen mostly Influenza B, which I think is a worse germ. You tend to see it around Christmas, and the later it comes, the less severe the epidemic. The Influenza A’s we’ve seen are sporadic, might come in the fall or spring, and because it is less common, it seems to be harder on younger people, who have less acquired immunity. We saw this with the H1N1 scare around 2008 or so.
In smokers, the lungs are populated with an increased amount of immune tissue, and the mucous glands get bigger and pour out more stuff. Over years, gradually the situation plugs up more and more of the smaller airways that make up lung tissue, and eventually air movement and breathing is affected. If I gave you a stethoscope and had you listen to the lungs of smokers and non-smokers, you’d be able to tell who the smoker is. That is, if you couldn’t already tell by the bad teeth, bad skin, irritable disposition, and the fact that they look older than people their age.
At 40 or 50, or 60, it all adds up to trapped area and the inability to move enough in and out with each breath that shortness of breath results. It is harder to ventilate off the CO2 than to oxygenate yourself, but either way it breathlessness to some degree until the grave.
Thus a “chronic” condition, it is always there and will be made worse by conditions like upper respiratory viral infection, allergies and pollens, and especially, cold weather. Treatment with steroids to reduce the swelling of the airways, antibiotics (rarely helpful because bacterial infection is usually not the case), inhalers that relax airway muscle, and mucous reducers like guaifenesin (present in almost all the over-the-counter preps) is the approach. If you end up hospitalized, that is not exactly a good sign, and if this is starting to be required every several months, the end is in sight.
And for what exactly? A million tranquilized moments, that’s what. Quitting the habit is obviously very difficult. And smokers, well, they’re of an ilk. They all remind me of each other. Their main addiction is to taking breaks. I always say that “all the fun people smoke”, which is being kind. So do all the drunks and drug addicts, and the schizophrenics and most of the psychiatry patients. Hence the impression that nicotine is the “nonspecific tonic for the troubled mine. Glad I never did it.