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Patients with respiratory illness typically present with characteristic symptoms. The most common symptoms include dyspnea (shortness of breath) and cough. Less common symptoms include hemoptysis (coughing up blood) and chest pain. Regardless of which symptoms may be present, a stepwise approach must be taken so that an underlying etiology may be determined. A proper approach always begins with a detailed history regarding the nature of present symptoms, followed by information regarding the patient’s past medical, family, and social history, on which a differential diagnosis can be entertained. A careful physical examination and appropriate diagnostic testing can help narrow the differential so that a diagnosis can be made and a plan for therapy initiated.

The anatomy and physiology of the respiratory tract is quite complex. Each anatomic segment performs in concert with the others and is accountable for a wide variety of physiological responsibilities. These responsibilities vary with rest or exercise, disease or health. Throughout this book, the reader will discover that the respiratory tract is a delicate and complicated system that can be involved in a number of disease processes. An understanding of the anatomy and physiology of the respiratory tract is critical to understanding this elaborate system to maintain respiratory health and treat respiratory diseases.

Pulmonary function tests (PFTs) refer to a panel of tests including spirometry, measurement of lung volumes, and diffusion capacity for carbon monoxide (DLCO). We first review the basic types of pulmonary disorders (obstructive versus restrictive), and then discuss the main types of PFTs. An algorithm for the use of PFTs is given at the end of this chapter.

T. L.is a 29-year-old female who presents to her primary care physician in August complaining of a stuffy, itchy nose; sneezing; intermittent headache; and daytime somnolence for the past several months. She notes that since moving to Washington, DC 3 years ago, these same symptoms seem to bother her every spring and summer. She has tried over-the-counter pseudoephedrine with mild relief of congestion. She feels her symptoms are interfering with her ability to exercise outdoors and her performance at work. Her past medical history is significant for eczema as a child. Her father has had “hay fever” for years. She lives alone in an apartment and has no pets. Physical exam is remarkable for a bilaterally indurated, erythematous nasal mucosa, a clear, watery anterior and posterior nasal discharge, an erythematous oropharynx, and bilateral tenderness over the frontal sinuses.

A 23 year-old female college student presents to her primary care clinic complaining of persistent runny nose and nasal congestion for more than 10 months a year over the past several years. She does not remember exactly when her symptoms began, and states that they occur daily regardless of her location or the time of day. She denies any fever, chills, mucopurulent drainage, cough, dyspnea, headache, ocular or nasal pruritis, or ocular symptoms. Past medical history shows no evidence of allergies, asthma, recurrent upper respiratory tract infections, chronic sinusitis, nasal or head trauma, or nasal surgery or trauma. She takes no medications except an occasional acetaminophen for headache when studying for several hours. She works as a part-time legal aid in an office building downtown. Family history and review of systems are unremarkable. Physical exam shows enlarged nasal turbinates, clear nasal discharge, moist and clear oropharynx with no erythema or exudates, clear tympanic membranes, no tenderness to palpation over the maxillary and frontal sinuses, and no cervical lymphadenopathy.

A 27-year-old female is seen at her primary care physician’s office for a second visit for re-evaluation of her symptoms. She was previously seen 2 weeks ago with symptoms of elevated temperature, rhinorrhea, and productive cough. Her symptoms improved after 3 days of treatment with first-generation anti-histamine and ibuprofen. At this time, the patient’s symptoms have worsened to include a fever, purulent cough, nasal congestion, mild facial pressure, and headache. Her past medical history is only remarkable for seasonal allergic rhinitis for which she takes an over-the-counter antihistamine as needed. Her family and social history are noncontributory.

A 40-year-old woman presents to her primary care physician complaining of fever, malaise, and sore throat for the last 3 days. The patient has a past medical history significant for hypothyroidism. She takes only levothyroxine pills and recent thyroid tests have been normal. The patient denied nausea, vomiting, diarrhea, cough, chest pain, and shortness of breath. She is a nursery school teacher who reports having taken care of multiple children with “colds” in the recent week. She drinks one glass of wine every week and denied smoking or other drug use. The patient is married and lives with her husband, who has not been sick.

A 42-year-old female jazz singer presents with a 3-day history of hoarseness. She had the onset of symptoms 3 days after a concert at a local club where she performs as a soloist in a jazz trio.Four days before her performance she complained of a cold with symptoms that included nasal congestion and sore throat. She was previously healthy with no history of systemic diseases. She occasionally drinks alcohol, but denies history of smoking.

Case 1

A 20-month-old boy is brought to his family practitioner by his mother. The boy has a 12-hour history of a loud cough, slight fever to 101°F, and a hoarse voice. The mother reports that the child had a difficult time sleeping the previous night because of the harsh cough. On examination, the boy is playful and smiling with a temperature of 99°F. It is noticed that he has a seal-like barking cough and subtle evidence of audible stridor.His chest is clear on auscultation with a normal respiratory rate.No chest wall recession is noted. The rest of the exam is unremarkable. The patient is sent home with a suspected upper respiratory infection. Later that evening, the family practitioner receives a phone call from the emergency department informing him that the patient has had worsening respiratory difficulty with visible signs of inspiratory stridor and is being admitted to the hospital for further observation.

A 6-year-old male is brought to his pediatrician by his mother for an unrelenting cough.The patient is an otherwise healthy child except for some allergies to dust and pollen that he has experienced for the past 2 to 3 years. His cough is intermittent and dry in nature. He has had no fevers, mucus production, or sore throat, and denies any other symptoms. The cough is worse at night and often keeps him up for 30 to 60 minutes before he can get back to sleep. The boy’s mother has tried over-the-counter cough suppressants but they have only shown minimal effect. He is beginning to become very sleepy during the day and is having trouble focusing in school secondary to being overly tired.