Approach to cough and

hemoptysis
By Chirag , 3434
Preceptor – Dr. Ananthu Narayan
Cough
• Protective airway reflex

• Reflex arc –
Afferent – Vagus and superior laryngeal nerves with receptors in
pharynx, larynx, tracheobronchial tree, external auditory meatus and
esophagus.
Integrating center – Nucleus tractus solitarius, cough center
Efferent – Recurrent laryngeal nerve and phrenic nerves
Mechanism of cough
Approach to cough
Approach to cough

1. Duration – Acute (<3 wks), subacute(3-8 wks) & chronic (>8 wks)
2. Variability- (Daytime, nocturnal, morning, seasonal)
long-time cigarette smoker, an early-morning, productive cough-
Chronic Bronchitis
3. Precipitating factors (dust, fumes, allergens, lying down, sideways
turning)
4. Expectoration – colour , amount , odour
Hemoptysis
Approach To Cough
5. Associated symptoms – postnasal drip, GERD, wheeze, dyspnea, chest pain, fever
• Cough , wheezing, shortness of breath, and chest tightness after exposure to dust ,
exercise in cold air or other sources of allergen – Asthma
• Onset of cough to exposure to typical triggers for asthma and
the resolution of cough to discontinuation of exposure and absence of shortness of
breath, wheezing , chest tightness – Cough Variant Asthma
• Postnasal drip, frequent throat clearing, sneezing and rhinorrhea – Postnasal
Drainage
• Retrosternal burning after meals or on recumbency, frequent
belching, hoarseness, and throat pain - GERD

6. Drug intake – ACE inhibitors (Accumulated Bradykinin)

Acute vs chronic cough
Which system – cardiovascular or respiratory

CARDIAC RESPIRATORY

Night time Early morning/ seasonal / no variation

Orthopnea, PND, palpitations may be seen Orthopnea may be present

JVP raised, pedal edema seen None

Crepitation in dependent lung areas Crepitation according to the lobe affected

Types of cough
1. Dry cough – Pleuritis, ILD, acute tracheobronchitis, asthma, GERD
2. Productive – Pneumonias (infective), bronchiectasis, lung abscess
3. Whooping cough
4. Barking cough – epiglottitis
5. Croupy cough – Laryngotrachebronchitis
Sputum – color of sputum
Type Appearance Cause

Serous Frothy , pink Acute Pulmonary Oedema

Clear , watery Alveolar Cell Cancer
Mucoid Clear , grey Chronic Bronchitis /COPD
White , viscid Asthma
Purulent Yellow Acute bronchopulmonary
infection
Asthma

Green Longer standing infection

Pneumonia
Bronchiectasis
Cystic Fibrosis
Lung Abscess

Rusty Rusty red Pneumococcal pneumonia

Relevant history

1. Past history – TB, Asthma, COPD, HTN

2. Personal history – Smoking, Chulha exposure, food habits
3. Treatment history – MDI use, ACE inhibitors
4. Family history – Atopy, asthma in family, CA lung
5. Socioeconomic history – overcrowding
Relevant examination
1. GPE – clubbing (CA lung, bronchiectasis, lung abscess), cyanosis,
pedal edema (RHD, ADHF, CHD), Tympanic membrane and Auditory
Canal (Arnold’s nerve), nasal passageways (rhinitis or polyps)
2. Respiratory examination – wheeze/ crepitations, bronchial
breathing, dull note on percussion
Hemoptysis
Expectoration of blood from respiratory tract
Physiology
• Lung has dual blood supply – Pulmonary (low pressure system
essential for gas exchange at alveolar level) and Bronchial (high
pressure system originating from the aorta)

• Bronchial arteries supply the airways and can neovascularize tumors

and dilate airways of bronchiectasis, and cavitary lesions.
• Most common artery of bleed is bronchial artery.

• Massive hemoptysis – 400 mL in 24 hrs or 100-150 mL at a single time

Common Causes of Hemoptyis
Ascertain whether the bleeding is coming from the respiratory tree or
instead originating from the nasal cavities (i.e., epistaxis) or the gastrointestinal
tract (i.e., hematemesis)

• Infectious
• Vascular
• Malignancy
Hemoptysis vs hematemesis

HEMOPTYSIS HEMATEMESIS
Blood mixed with sputum Blood mixed with food particles
Bright red in color Coffee brown in color
Alkaline Acidic
Melena absent Melena may be present
Pulmonary symptoms GI symptoms
Infectious causes
1. Viral Bronchitis - Most blood-tinged sputum and small-
volume hemoptysis is due to viral bronchitis.
2. Bronchiectasis
3. Pulmonary TB - In patients with tuberculosis, development of cavitary
disease is frequently the source of bleeding but rarer complications
such as the erosion of a pulmonary artery aneurysm into a preexisting
cavity (i.e., Rasmussen’s aneurysm) can also be the source.
4. Patients if Chronic Bronchitis with bacterial superinfection
5. Pneumonia – Pulmonary abscesses and necrotizing pneumonia can
cause bleeding by devitalizing lung parenchyma.
Vascular Causes
• From Pul. Edema due to elevated end diastolic left ventricular pressure
Classic sputum – Pink frothy
Sometimes – Frank blood
• Pulmonary Embolism with parenchymal infarction
• Diffuse alveolar hemorrhage (DAH), despite causing significant bleeding
into the lung parenchyma, uncommonly results in hemoptysis.
• Rarely – rupture of aortobronchial fistulae – massive bleeding and
sudden death
Malignant Causes
• Bronchogenic Carcinoma
• Pulmonary metastases from
distant tumors (e.g., melanoma, sarcoma, adenocarcinomas of the
breast and colon) can also cause bleeding .
Mechanical & Other Causes
• Pulmonary endometriosis causes cyclical bleeding known as
catamenial hemoptysis.
• Foreign body aspiration
• Diagnostic and therapeutic procedures -
- pulmonary vein stenosis can result from left atrial procedures
- pulmonary artery catheters can lead to rupture of the
pulmonary artery if the distal balloon is kept inflated
• Thrombocytopenia, coagulopathy, anticoagulation, or
antiplatelet therapy
Relevant history – hemoptysis
1. HOPI – Amount, hematemesis vs hemoptysis
2. Past history – Prior TB, COPD
3. Personal history – Smoking
4. Family history – CA lung, TB
5. Treatment history – anticoagulant, aspirin
Examination
1. GPE – nasal & oral cavities, clubbing, pallor, vitals, signs of bleeding
diathesis
2. Respiratory and cardiovascular examination
Thank you