Cough Lecture

Course Period : 3rd Semester

Course Content : Syndromatology & SymptomatologyCourse Topic : Cough, Hemoptysis & Dyspneu

CLINICAL COMPETENCE

• Be able to recognize and place the clinical pictures of the most common diseases related to Cough, Hemoptysis, Dyspneu syndrome and symptoms and know how to acquire more information on it

OBJECTIVES• To address the symptoms of respiratory diseases• To review the anatomy & pathophysiology,

differential diagnosis, pathogenesis, complication, guidelines for evaluating chronic cough

• To review the etiology, pathogenesis, differential diagnosis, diagnosis of hemoptysis

• To review the pathophysiology, differential diagnosis and guidelines for evaluating dyspneu

Definitions

• A deep inspiration followed by a strong expiration against a closed glottis, which then opens with an expulsive flow of air, followed by a restorative inspiration; these are the inspiratory, compressive, expulsive, and recovery phases of cough.

Basic term

• Acute cough: a recent onset of cough lasting < 3 weeks

• Chronic cough: a cough lasting > 8 weeks• Prolonged acute cough: cough may be slowly

resolving over a 3–8-week period• Recurrent cough: A recurrent cough without a cold is

taken as repeated (>2/year) cough episodes, apart from those associated with head colds, that each last more than 7–14 days

Pathways at various levels involved in the control of coughing. (Modified from Eccles R: Codeine, cough, and upper respiratory infection. Pulm Pharmacol 9:293–298, 1996.)

Acute cough : Chronic cough :Common cold SinusitisPertusis Allergic RhinitisExacerbation of COPD Vasomotor RhinitisAsthma Lung TuberculosisPneumonia Chronic BronchitisCongestive Heart Failure BronchiectasisAspiration Syndrome Bronchogenic CarcinomaPulmonary Embolism

Differential diagnosis

A simplified overview of the assessment and management of thecommon causes of acute cough (< 3 weeks)

A simplified overview of the assessment and management ofprolonged acute cough (3–8 weeks)

A simplified overview of the assessment and management of thecommon causes of chronic cough(> 8 weeks)

Respiratory ComplicationsPneumothorax

Subcutaneous emphysema

Pneumomediastinum

Pneumoperitoneum

Laryngeal damage

Cardiovascular ComplicationsCardiac dysrhythmias

Loss of consciousness

Subconjunctival hemorrhage

Central Nervous System ComplicationsSyncope

Headaches

Cerebral air embolism

Potential Complications from Excessive Cough

• Hemoptysis is the blood derived from the lungs or bronchial tubes.

• Hemoptysis may be scant, the appearance of streaks of bright red blood in the sputum, profuse, with expectoration of a large volume of blood.

• Massive hemoptysis is defined as the expectoration of 600 mL of blood within 24 to 48 hours.

• May occur in 3 to 10% of all patients with hemoptysis.

ETIOLOGY OF HEMOPTYSIS(1)

• Cardiovascular – Arteriobronchial fistula– Congestive heart failure– Pulmonary arteriovenous fistula

• Diffuse intrapulmonary hemorrhage• Diffuse parenchymal disease


• Iatrogenic–Malposition of chest tube – Pulmonary artery rupture– Tracheoartery fistula

• Infections– Aspergilloma - Cystic Fibrosis– Bronchiectasis - Lung abscess– Bronchitis - Tuberculosis


• Malignancies– Bronchogenic carcinoma – Leukemia– Metastatic cancer

PATHOGENESIS OF HEMOPTYSIS(1)

• The bronchial arteries are the chief source of blood for the airways (from mainstem bronchi to terminal bronchioles),

• Support framework of the lung that includes the pleura, intrapulmonary lymphoid tissue, and the large branches of the pulmonary vessels, the nerves in the hilar regions.

• The pulmonary arteries supply the pulmonary parenchymal tissue, including the respiratory bronchioles.


• Communications between these two blood supplies, bronchopulmonary arterial and venous anastomoses, occur in the proximity of the junction of the terminal and respiratory bronchioles.

• These anastomoses allow the two blood supplies to complement each other.

• If flow through one system is increased or decreased, a reciprocal change occurs in the amount of blood supplied by the other system.


• The pathogenesis of hemoptysis depends on the type and location of the disease.

• Endobronchial lesion, the bleeding is from the bronchial circulation

• Parenchymal lesion, the bleeding is from the pulmonary circulation.

• Chronic diseases, repetitive episodes are most likely due to increased vascularity in the involved area.

DIFFERENTIAL DIAGNOSIS OF HEMOPTYSIS• In evaluating patients with hemoptysis, it is

necessary to rule out the causes of pseudohemoptysis.

• Unless the cause of pseudohemoptysis is definitively determined, the spitting up of blood must be assumed to be true hemoptysis.

• An upper airway lession must not be assumed to be the cause of the bleeding unless it is seen bleeding actively at the time of examination.

DIAGNOSIS OF HEMOPTYSIS

• The diagnostic work-up of hemoptysis involves:– History, Physical examination, Complete blood

count, Coagulation studies , Electrocardiogram, Chest radiograph, ± Bronchoscopy

• Dyspnea is a distressing sensation of difficult, labored, or unpleasant breathing.

• The word distressing is very important to this definition since labored or difficult breathing may be encountered by healthy individuals while exercising.

• It does not qualify as dyspnea because it may not be perceived as distressing.

• The sensation is often poorly or vaguely described by patients.

PATHOPHYSIOLOGY OF DYSPNEA(1)

• There are multiple stimuli, receptors, nerves, and neural pathways that mediate the sensation of dyspnea.

• The multiple neural pathways model of dyspnea suggests that dyspnea may arise due to abnormalities in the afferent pathways, the efferent pathways, or the central control centers of the respiratory system.

PATHOPHYSIOLOGY OF DYSPNEA(2)

• Since afferent pathways feed back to the central nervous system from virtually all levels of the efferent pathways, afferent dyspneic information from virtually all thoracic and upper abdominal organs.

• Including the pharynx, larynx, airways, lung parenchyma, esophagus, heart, and stomach may potentially impact the sensation.

DIFFERENTIAL DIAGNOSIS OF DYSPNEA(1)

• Cardiac Congestive heart failure (right, left or biventricular) Coronary artery disease Myocardial infarction (recent or past history) Cardiomyopathy Valvular dysfunction Left ventricular hypertrophy Asymmetric septal hypertrophy Pericarditis Arrhythmias


• Pulmonary COPD Asthma Restrictive lung disorders Hereditary lung disorders Pneumothorax


• Mixed cardiac or pulmonary COPD with pulmonary hypertension and Cor pulmonale Deconditioning Chronic pulmonary emboli Trauma


• Noncardiac or nonpulmonary Metabolic conditions (e.g., acidosis) Pain Neuromuscular disorders Otorhinolaryngeal disorders Functional - Anxiety - Panic disorders - Hyperventilation

GUIDELINES FOR EVALUATING DYSPNEA(1)• Acute dyspnea

- A clinical approach is recommended for evaluating acute dyspnea. - It consists of performing history and physical examination and performing laboratory test. - Considering potensial life-threatening conditions first (eg,acute asthma, pulmonary embolism, pulmonary oedema states, pneumonia)

GUIDELINES FOR EVALUATING DYSPNEA(2)

• CHRONIC DYSPNEACOPD, asthma, interstitial lung disease, cardiomyopathy, GERD, other respiratory diseases, and the hyperventilation syndrome.

1. Clinical features 2. Chest radiograph in nearly all

patients


3. Pulmonary function testingNoninvasive cardiac studies to include ECG, echocardiography, and stress testingChest CT scanComprehensive ETTOther more invasive test such as cardiac catheterization and lung biopsy


• Final determination of the cause of dyspnea is made by observing which specific therapy eliminates dyspnea as a complaint.

• Dyspnea may be simultaneously due to more than one condition

• Do not stop therapy that appears to be partially successful; rather, sequentially add to it.

Documents

Cough Lecture