COUGH, SPUTUM, COUGH, SPUTUM, HEMOPTYSISHEMOPTYSIS

Prof. Dr. Bilun Gemicioğlu

COUGHCOUGH

A cough is an action your body takes to get rid of substances that are irritating to your air passages, which carry the air you breathe in from the nose and mouth to the lungs.

A cough occurs when special cells along the air passages get irritated and trigger a chain of events. The result? Air in your lungs is forced out under high pressure; an explosive expiration

You can choose to cough (a voluntary process), or your body may cough on its own (an involuntary process).

Anatomic causes of coughAnatomic causes of cough

Extra-thoracicExtra-thoracic İntra-thoracicİntra-thoracic

CNSCNS Head and neckHead and neck

Lower airways Lower airways diseasesdiseases

Lung ParenchymaLung Parenchyma

MediastinumMediastinum

CardiovascularCardiovascular

Upper GISUpper GIS

PleuraPleura

DiaphragmDiaphragm

StomacStomac

Cough receptors and related nervesCough receptors and related nerves

Regions Afferent nerves

Paranasal Trigeminal (V)

Pharynx Glossofaringeus (IX)

Larynx/tracheobronchial sys. Vagus (X)

External ear way/ thympanic membrane

Vagus (X)

Eusophagus, stomac, pleura Vagus (X)

Diaphragm, pericard Phrenic nerve

Simpson CB. et al. Otolaryngology–Head Neck Surg 2006; 134: 693-700Simpson CB. et al. Otolaryngology–Head Neck Surg 2006; 134: 693-700

Anamnesis: History

While ? When ?Characteria ?Productive/non productiveAdditional symptoms?Risk factors: tabacco smoke

additional diseases or use of drugs ?

Anamnesis: While

Shorter then 3 weeks acute cough

3 to 8 weeks subacute cough

Longer then 8 weeks chronic cough

Irwin RS et al. Chest 1998, 114:2 supplIrwin RS et al. Chest 1998, 114:2 suppl

Causes of acute cough

Respiratory Causes:

Inhaled gases or particuleMucus secretionInflammatory exudate Foreing bodyEndobronchial lesionBronchial boosts

Other causes of acute cough

-acute heart failure

-acute rhinosinusitis

-Eusephageal reflux

-Middle ear patologies and infections

-Diaphragm, pleura and pericardium irritations

Chronic cough causes in adultChronic cough causes in adult

PNDS Allergic rhinitis chronic sinusitis

GER cough-variant asthma ACE Inhibitors tabacco smoke Whoopping Neurogenic

Travmatic vagal injury After upper respiratory tract infection

Psychogenic chronic aspiration Zenker diverticule

Foreign body Tracheobronchial tree Laryngopharingeal Sinonasal External ear way

Chronic bronchitis, COPD Bronchiectasis Lung Cancer Subglottic stenosis Tracheomalasia Tracheosephageal fistula Tuberculosis Sarkoidosis Congestive heart disease

Simpson CB. et al. Otolaryngology–Head Neck Surg 2006; 134: 693-700Simpson CB. et al. Otolaryngology–Head Neck Surg 2006; 134: 693-700Chung KF, Pavord ID Lancet 2008; 371: 1364-1374Chung KF, Pavord ID Lancet 2008; 371: 1364-1374

Patogenic TriadPatogenic Triad

Irwin RS et al. Chest 1998, 114:2 supplIrwin RS et al. Chest 1998, 114:2 suppl

Palombini BC et al. Chest 1999, 116:2,279-284Palombini BC et al. Chest 1999, 116:2,279-284

Anamnesis: When

MorningBed time; nightAfter mealAfter irritant Only wakingTalkingStress

Anamnesis: Characteria

Like barking Larynx tm, inf. Metalic cough Trachea, brochies.

Cow cough V.Chord paralisis

Vomitig cough Whoopping cough

Smoking cough tabacco smoke

Irrıtative cough URTI

Anamnesis: Characteria

In prospective adult studies time and character of the coughing cannot guide the diagnosis.

Mello CG et al. Arch Intern Med 1996,156; 997-1003Mello CG et al. Arch Intern Med 1996,156; 997-1003

Anamnesis: Productive/Nonproductive

Productive Airway diseases

Non productive Pleura, pericardium, Ear, GIS, heart, ACEI usage, diaphragm, mediastinum, thyroid…

Irwin RS et al. Chest 1998, 114:2 supplIrwin RS et al. Chest 1998, 114:2 suppl

Anamnesis: Additional symptoms

Specific Dyspnea, wheezing, sputum, pyrosis, retronasal discharge…..

Non specific Eshaustion, insomnia, sweating, muscular pain, urine incontinence, headache, loss of appetite, axiety

Anamnesis: Specific additional symptoms

PNDS post nasal drip, throat clearing runny nose, nasalcongestion, sputum

Asthma Dispnea, thightness of breath, wheezing

GER Burning, regurgitation,COPD sputum, effort dispneaBronchiectasia SputumHeart failure Effort dispnea, tachycardia,

edema

Anamnesis: Risk factors

Smoking cases Lung cancer, COPD, asthma, irritation

Irwin RS et al. Chest 1998, 114:2 supplIrwin RS et al. Chest 1998, 114:2 suppl

Additional diseases AIDS, cancer, viral URI

Drug usage ACEI, Nitrofurantoin, Immunosupresives

Physical ExaminationPhysical Examination

Head and neck

Thorax

Upper GIS

Heart

ENT

LaboratoryLaboratory

Chest X Ray Pulmonary function tests Paranasal sinus X-Ray Blood analysis Sputum examination Bronchoscopy ECG, ECO Thorax CT, HRCT Rhinoscopy Barium eseuphagography Allergy prick tests

Treatment of cough

NON SPECIFICNON SPECIFIC SPECIFICSPECIFIC

ANTITUSSİVEANTITUSSİVE PROTUSSIVEPROTUSSIVE TARGET TARGET THERAPYTHERAPY

CodeinCodein

DekstrometorfanDekstrometorfan

DifenhidraminDifenhidramin

PseudoephedrinePseudoephedrine

DekstrobromfeniraminDekstrobromfeniramin

İpratropium Bromidİpratropium Bromid

NaproxenNaproxen

Hipertonic salineHipertonic saline

ErdosteinErdostein

AmiloridAmilorid

N acetylcysteineN acetylcysteine

TerbutalineTerbutaline

PhisiotherapyPhisiotherapy

Postural drenagePostural drenageIrwin RS et al. Chest 1998, 114:2Irwin RS et al. Chest 1998, 114:2

SPUTUM

Mucus glands and goblet cells of lower respiratory tract secrete 10ml mucus every day

Exess of lower respiratory track expectoration is called sputum

General causes of sputum

Exess of mucus production

Changement in the quality of mucus

Lacking activity of mucociliar clearance

Sputum:Anamnesis:

Quantity of sputum

Quality of sputum; density, calour

Odor of sputum

Time of expectoration

Sputum: Anamnesis

Sputum Quality Suspect diseases

Purulent; yellow-green mucoid Pneumonia, asthma with eosinophilia

Rusty Pneumonia (pneumoccocus)

Cherry Pneumonia (klebsiella)

Melanopthisis (black-grey) Air pollution, coal worker

Rock water vomic Eccinoccocus cystes

Chocolate Amibe abscess

Putrefactive; faol smelling Lung abscess (anaerobic infections)

< 600cc/day, morning expect. Bronchiectsasis

Sputum: Diagnosis

Physical examination of the lungs

Chest X-ray, CT, HRCT

Sputum analysis

Blood analysis

Bronchoscopy

Sputum: Treatment

Treat the causative disease

Postural dranage

Mucolytics

Decongestant

HEMOPTYSIS

Lower respiratory track bleeding below epiglottis

Differential diagnosis with ENT ve GIS must be evaluated before saying hemoptysis

Causes of hemoptysis:

Chest X Ray: Anormal

I.Infections: -Pneumonia -Tbc -Lung abcess -Bronchiectasis -Fungal infections

II.Lung tumours: -Bronchial Cancers

-Metastatic cancers

-B.adenoma

Causes of hemoptysis:

III. Alveolar hemorrhage: -Vasculitis -Goodpasture’s syndrome -Wegener granulomatosis -Behçet Disease -SLE -Drugs (penicillamine)

IV.Other -Thorax trauma

-A-V malformations

-P.E

-Disorders of coagulation

Causes of hemoptysis

Normal X-Ray

-Chronic bronchitis-Pulmonary Embolism-Bronchiectasis-Lung cancer-Mitral stenosis-Endometriosis

Massive hemoptysis

Hemoptysis > 600 mL /24 h Cause is % 90 bronchial arteries

causes:1-Tbc 2-Bronchiectasis 3-Malignity

4.Behçet disease

Hemoptysis: Physical examination

-Vital signs -Telengiectasia (Osler-Weber-rendu Syndrome) -Clubbing -Deep venous thrombosis -ENT (URT haemorrhage) -Oral ulcer =>Behçet ? -Chest exanination -Cardiovascular system examination (mitral

stenosis)

Hemoptysis: Diagnosis

Radiology:PA, Lat chest X-ray,

BT, HRCT if needed

PA Chest Xray and CT: normal => Angiography

Hemoptysis: Diagnosis

Laboratory: -Blood analysis, blood goup -Electrolytes, liver and kidney

function tests -PFT, ABG -PT, aPTT -ECG, Urine analysis

- Bronchoscopy

Masif hemoptysis: Tedavi Prensipleri

1-Block asphyxia

2-Stop bleeding

3-Treat primary disaese