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Subject: Medicine Topic: Cough and Hemoptysis Lecturer: Date of Lecture: August 31, 2011 Transcriptionist: Madame and

the Super Minion Pages: 11

COUGH An explosive expiration that acts to protect lungs from aspiration to propel secretions and other materials upward through the airways. Its is a protective mechanism of our body to expel foreign material or infection or secretions. It provides a normal protective mechanism for clearing the tracheobronchial tree of secretions and foreign materials. When excessive, it is also one of the most common symptoms for which patients seek medical attention. Reasons for this include discomfort from the cough itself, interference with normal lifestyle and concern for the cause of the cough, especially fear of cancer. MECHANISM Cough may be voluntary or reflexive Defensive reflex: both afferent pathways are activated Afferent limb: Receptors within sensory distribution of trigeminal, glossopharyngeal, superior laryngeal, and vagus nerves are triggered. Efferent limb: Recurrent laryngeal nerve and spinal nerves are activated to cause muscle contraction.

COUGH: What? How? Why? How do we cough? The glottis covering the trachea closes. The diaphragm pushes up in a relaxed position Intrathoracic pressure builds up to 300mgHg, causing alveoli to squeeze down, pushing air out with expiratory velocities approaching 500mph. The glottis opens allowing forceful expulsion of air and/or secretions. MECHANISM: Irritant triggers Exogenous source e.g. smoke, dust, fumes, foreign bodies Endogenous origin such as upper airway secretions, gastric contents, may go unrecognized Cough can be persistent or inflammation of airway from prolonged exposure can precipitate cough and sensitize airway to other irritants. Gastroesophageal reflux disease (GERD) Irritant of upper airways receptors or aspiration of gastric contents, vagally mediated reflex mechanism secondary to acid in distal esophagus SIGNS AND SYMPTOMS History Valuable clues for etiology -acute or chronic? -Symptoms of respiratory infection at onset? -Seasonal?Wheezing? -Symptoms of postnasal drip? (Nasal discharge, Frequent throat clearing, Tickle in the throat) -Symptoms of gastroesophageal reflux? -Heartburn or sensation of regurgitation? -Fever or sputum?If sputum is present , what is its volume, character? -Hemoptysis? -Associated diseases or risk fators? -Cigarrete smoking? -HIV? -Enviromental exposures (e.g. asbestos) -Angiotensin-converting enzyme (ACE) inhibitor?

PHYSICAL EXAMINATION Signs of postnasal drip may be present ( Oropharyngeal muscus or erythema, Cobblestone appearance to mucosa

Auscultation of the chest may demonstrate: -Inspiratory stridor (upper airway disease) -Rhonchi or expiratory wheezing (lower airway disease) -Inspiratory crackles (process involving pulmonary parenchyma e.g., insterstitial lung disease, pneumonia, or pulmonary edema) Temperature -Fever suggests infection (bronchitis, pneumonia) Check for systemic or nonpulmonary causes -Heart failure -Primary nonpulmonary neoplasm -AIDS

DIFFERENTIAL DIAGNOSIS ACUTE COUGH (<3 weeks) Most often upper respiratory infection: -Common cold -Acute bacterial sinusitis -Pertussis More serious disorders maybe indicated by cough: -Pneumonia -Pumonary embolism -Congestive Heart Failure CHRONIC COUGH (>3 weeks) Often due to more than one condition. In a nonsmoker (where normal chest radiograph; no ACE inhibitor) most common causes are: -Postnasal drip -Asthma -Gastroesophageal reflux disease While in a smoker, suspect: -Chronic obstructive lung disease -Bronchogenic carcinoma Eosinophilic bronchitis in absence of asthma REMEMBER:

ACUTE COUGH- lasting < 3 weeks SUBACUTE COUGH- lasting between 3 and 8 weeks CHRONIC COUGH- lasting > 8 weeks
3 most common causes of chronic cough identified were: - upper airway cough syndrome (UACS) or Post-nasal drip syndrome - Asthma - GERD

CONDITIONS ASSOCIATED WITH COUGH Airway infections, including Viral bronchitis (cough may last weeks), Pertussis infection Brochientasis, Lung abscess Asthma: cough masy occur in absence of wheezing or dsypnea ( cough variant asthma) Neoplasm infiltrating the airway wall including Bronchogenic carcinoma and Carcinoid tumor Airway filtration with granulomas including Endobronchial sarcoidosis and Tuberculosis Compression of airways from extrinsic masses including Lymph nodes, Mediastinal tumors, Aortic aneurysms Parenchymal lung disease including Interstitial lung disease, Pneumonia, Lung abscess CHF ACE inhibitors which occurs in 5-20% of patients receiving these drugs. Onset usually within 1 week and can be delayed up to 6 months

LABORATORY TESTS SPUTUM: gross and microscopic examination PURULENT SPUTUM- suggests Chronic Bronchitis, Pneumonia, Bronchiectasis, Lung abscess BLOOD IN SPUTUM- also seen in above disorders but also with Endobronchial tumor >3% EOSINOPHILS ON STAINING OF INDUCED SPUTUM IN PATIENTS WITHOUT ASTHMA- suggests Eosinophilic bronchitis GRAM AND ACID-FAST STAINS AND CULTURES- are used to identify infectious pathogen CYTOLOGY- it can provide diagnosis or high suspicions of pulmonary malignancy


PULMONARY FUNCTION TESTING To assess functional abnormalities: -Forced expiratory flow rates - reversible airflow obstruction characteristic of asthma -Lung volumes and diffusing capacity - Restrictive pattern seen with diffuse interstitial lung disease

BRONCHOPROVOCATION TESTING With methacholine or cold-air inhalation To diagnose asthma when flow rates are normal Demonstrates hyperreactivity of airways to a bronchoconstrictive stimulus SPIROMETRY Measures lung volumes and airflow parameters Procedure: 1. Inhale maximally to TLC 2. Exhale forcefully to RV for 6 seconds

BRONCOSCOPY Types: 1. Flexible Video Bronchoscope 2. Rigid Bronchoscope

TREATMENT APPROACH Definitive treatment: dependent on determining underlying cause ---Specific considerations: -Elimination of exogenous inciting agent (cigarette smoking, ACE inhibitor), or endogenous trigger (postnasal drip, gastroesophageal reflux) -Usually effective if precipitant can be identified - Treat specific respiratory tract infections -Bronchodilators for potentially reversible airflow obstruction -Inhaled glucocorticoids for eosinophilic bronchitis -Chest physiotherapy and other methods to clear secretions in bronchiectasis - Treatment of endobronchial tumors or interstitial lung disease if therapy available and appropriate Specific treatments: Symptomatic or nonspecific therapy --- Consider when: -Cause not known or specific treatment not possible and cough performs no useful function or causes marked discomfort ---Treat irritative, nonproductive cough with antitussive agents -Codeine (15mg QID) or nonnarcotics such as Dextromethorphan (15mg QID), increases latency or threshold of cough center; and provides symptomatic relief; interrupts prolonged self-perpetuating paroxysms -Ipratropium bromide (2-4 puffs QID)- lacks proof of efficacy; possibly inhibits efferent limb of cough reflex --- Cough productive of significant quantities of sputum should usually not be suppressed -retention of sputum may interfere with distribution of ventilation, alveolar aeration and ability of the lung to resist infection

MONITORING Referral to a pulmonologist may be warranted after: 1. No identifiable cause is found in history, physical exam and chest x-ray 2. Patient does not respond to sequential or concurrent treatment for postnasal drip, asthma, and GERD 3. Specialized tests such as high-resolution CT scan, modified barium esophagography, bronchoscopy, and cardiac studies are negative.

COMPLICATIONS Exhaustions Cough syncope- due to markedly positive intrathoracic and alveolar pressures, diminished venous return, and decreased cardiac output. It is occasionally precipitated by paroxysms of coughing Chest and abdominal wall soreness Urinary incontinence Cough fractures of ribs- may occur in otherwise normal patients. Should raise the possibility of pathologic fractures, seen in Multiple myeloma, Osteoporosis, Osteolytic metastases

It comes from the Greek words: haima- blood ptysis- spitting

Hemoptysis- expectoration of blood or bloody sputum from the lungs or tracheobronchial tree

DIFFERENTIATING FEATURES OF HEMOPTYSIS AND HEMATEMESIS HEMOPTYSIS HISTORY -absence of nausea and vomiting -lung disease -asphyxia possible SPUTUM EXAMINATION -frothy -liquid or clotted appearance -bright red or pink LABORATORY -alkaline pH -mixed with macrophages and neutrophils -acidic pH -mixed with food particles -rarely frothy -coffe ground appearance -brown to black -presence of nausea and vomiting -gastric or hepatic disease -asphyxia unusual HEMATEMESIS

CLASSIFICATION Massive Hemoptysis- 200-600 mL/ 24 hours blood loss Mild or minimal hemoptysis- usually refers to specks of blood or a few small clots in sputum Moderate hemoptysis- is everything from specks to 200 mL in 24 hours

PRINCIPAL SOURCES OF BLEEDING INTO THE LUNGS Brochial arteries Pulmonary arteries Pulmonary capillaries and veins Systemic fistulas ( rare ) ANATOMICAL ORIGINS OF HEMOTYSIS TRACHEOBROCHIAL SOURCE Neoplasm (bronchogenic carcinoma, endobronchial metastatic tumor, Karposi sarcoma, bronchial carcinoid) Bronchitis (acute or chronic) Bronchiectasis Broncholithiasis Airway trauma Foreign body

PULMONARY PARENCHYMAL SOURCE Lung abscess Pneumonia TB Mycetoma (fungus ball) Goodpastures syndrome Idiopathic pulmonary hemosiderosis Wegeners granulomatosis Lupus pneumonitis Lung contusion

DIAGNOSTIC CLUES IN HEMOPTYSIS: PHYSICAL HISTORY CLINICAL CLUES Anticoagulant use Association with menses Dyspnea on exertion, fatigue, orthopnea, paroxysmal nocturnal dyspnea, frothy pink sputum Fever, productive cough SUGGESTED DIAGNOSIS Medication effect, coagulation disorder Catamenial hemoptysis CHF, left ventricular dysfunction, mitral valve stenosis Upper respiratory infection, acute sinusitis, acute bronchitis, pneumonia. Lung abscess Endobronchial metastatic disease of lungs Bronchiectasis, lung abscess

History of breast, colon, or renal cancers History of chronic lung disease, recurrent lower respiratory track infection, cough with copious purulent sputum HIV, immunocompression

Neoplasia, TB, Kaposis sarcoma

Always ask about: Medications taken Travel history Weight loss Tobacco use/ smoking Alcoholism (esophageal varices) Nausea/ vomiting/ melena Occupational history/ exposure to chemicals

HISTORY Important points in the history: -Hx of prior lung, cardiac or renal disease -Hx of smoking -Hx of prior hemoptysis, pulmonary symptoms or infectious symptoms -Family hx of hemoptysis or aneurysms -Skin rash -Hx of exposure to organic chemicals -Hx of exposure to asbestos -Travel hx -Hx of bleeding disorders, use of aspirin or NSAIDS, or anticoagulants -Upper airways of upper GI symptoms

PHYSICAL EXAMINATIONS Physical examination points of interest -many telengectasia -skin rash -splinter hemorrhage and needle cracks -clubbing -chest bruit or chest murmur -augmented P2, Tricuspid regurge, Pulmonary insufficiency, Parasternal heave -signs of deep vein thrombosis DIAGNOSTICS CBC, Platelet count PT, PTT, International Normalized Ratio Arterial blood gases D-dimer Sputum Gram stain, culture Acid-fast bacillus smear and culture Sputum cytology HIV test Erythrocyte sedimentation rate Consider chest CT scan and bronchoscopy where: -hemoptysis last longer than 2 weeks -recurrent episodes of hemoptysis -volume of hemoptysis is >30 mL/ day -patient is a smoker and >40 y.o -suspected brochiectasis



*Sorry for the poor quality of this picture but you can refer to the book for clearer diagram MASSIVE HEMOPTYSIS Patients with massive hemoptysis need rapid establishment of airway patency, prevention of suffocation and control bleeding The secondary goal is to determine the site of bleeding and cause. INITIAL MANAGEMENT: If the bleeding site is known, the patient should be put in lateral decubitus position with the bleeding side down to protect the other lung from spillage and drowning. If oxygenation is compromised or bleeding continues, the patient should be intubated and mechanically ventilated. OTHER OPTIONS IN MANAGEMENT OF MASSIVE HEMOPTYSIS: Use of double-lumen endotracheal tube Insert a balloon catheter through bronchoscope Laser phototherapy Electrocautery Embolotherapy Surgical resection -END11