Cough & Hemoptysis

  • View

  • Download

Embed Size (px)


Presentation of two of the cardinal symptoms of pulmonary medicine, cough and hemoptysis.

Text of Cough & Hemoptysis

  • 1. Cough & Hemoptysis

2. Defining CoughTwo possible definitions of as per European RespiratorySociety : A three-phase expulsive motor act characterized byan inspiratory effort (inspiratory phase) followed by aforced expiratory effort against a closed glottis(compressive phase) and then by opening of theglottis and rapid expiratory airflow (expulsivephase).Cough is a forced expulsive maneuver, usuallyagainst a closed glottis and which is associated witha characteristic sound.Although some similarities exist, the major discrepancybetween these two definitions relates to the respiratorypatterns associated with cough. In particular, the precedinginspiratory phase, which constitutes the first definition, isbelieved to be one of a number of distinguishing featuresbetween cough and another airway defensive reflex, theexpiration reflex 3. Signaling PathwaysReceptors in the airways are most concentratedin the larynx, diminish in density in theconducting airways, and are absent from thedistal airways, enabling the pooling of secretionsin the periphery 4. The cough reflex may be impaired by interruptingor blunting any step in the sequence. Irritantreceptors can be damaged by a localdestructive process (e.g., bronchiectasis), or theirsensitivity can be diminished by narcotics oranesthetics 5. Mechanism of Cough The cough begins with a rapid inspiration,followed, in rapid sequence, by closure of theglottis, contraction of the abdominal andthoracic expiratory muscles, abrupt increase inpleural and intrapulmonary pressures, suddenopening of the glottis, and expulsion of a burst ofair from the mouth. 6. Sequence of events duringa cough 7. The high intrathoracic pressures, which oftenexceed 100 to 200 mmHg, increase the velocityof airflow through the airways, hastening thepropulsion of the offending particles andproducing the sound of a cough by setting intovibration airway secretions, the tracheobronchialwalls, and the adjacent parenchyma. 8. Causes & Characteristics ofCough (Acute Cough) Sinusitis or Nasopharygnitis: Cough following anupper respiratory syndrome or sinus symptoms;sensation of a need to clear the throat; postnasaldrip Lobar pneumonia: Cough often preceded bysymptoms of upper respiratory infection; coughdry, painful at first; later becomes productive Chronic Bronchitis: Cough productive of sputumon most days for more than 3 consecutivemonths and for more than 2 years Sputummucoid until acute exacerbation, when itbecomes mucopurulent 9. Causes & Characteristics ofCough (Chronic Cough) Bronchiectasis: Cough copious, foul, purulent, oftensince childhood; forms layers upon standing1.upper : bubble-like, frothy, faomy(partly from saliva)2.middle : thin sero-mucus liquid3.base : pus ,necrotic tissue , cell debris Tuberculosis or fungus: Persistent cough for weeks tomonths, often with blood-tinged sputum 10. Causes & Characteristics ofCough (ParenchymalInflammatory Process) Interstitial fibrosis and infiltrations : Coughnonproductive, persistent Smoking : Cough usually associated with injectedpharynx; persistent, most marked in morning,usually only slightly productive unless succeededby chronic bronchitis 11. Gastrioesophageal reflux (GERD): Nonproductivecough often following meals or with recumbancy;may (or may not) be accompanied by othersymptoms of GERD(e.g., heartburn, a bitter oraltaste, belching) Foreign body Immediate : while still in upper airway Coughassociated with progressive evidence ofasphyxiation Later : when lodged in lower airway Nonproductivecough, persistent, associated with localizingwheeze 12. Left ventricular failure : Cough intensifies whilesupine, along with aggravation of dyspnea Pulmonary infarction : Cough associated withhemoptysis, usually with pleural effusion Angiotensin-converting enzyme (ACE) inhibitors :Nonproductive cough, more common in women,may occur at any time (following soon after druginitiation or with years of use) 13. Cough Medications Pharyngeal Demulcents: Lozenges, Cough Drops,Linctuses containing syrup, glycerine, liquorice. Expectorants :Bronchial Secretion Enhancers :Na+, K+ Citrate (Salt Action), Potassium Iodide (Irritantto Bronchial Mucosa), Ammonium Chloride(Nauseating-reflexly increasing respiratorysecretions),Guaiphenesin, Vasaka, Tolu balsum are plantproducts which are supposed to enhance bronchialsecretion and mucociliary function while beingsecreted by tracheobronchial glands. 14. Mucolytics :Bromohexine - potent mucolytic and mucokinetic, capable of inducing thincopious bronchial secretion. It depolymerises mucopolvsaccharides directly aswell as by liberating lysosomal enzymes network of fibres in tenacious sputum isbroken. It is particularly useful if mucus plugs are present.S/E Rhinorrhea, LacrimationAmbroxol Metabolite of bromohexine. Similar profile.Acetylcystein - It opens disulfide bonds in mucoproteins present in sputum andmakes it less viscid, but has to be administered directly into the respiratorytract.Carbocystein Liquifies viscid sputum in similar way as acetylcystein but canbe administered orally.S/E GI Irritation & Rash 15. Anti-Tussives : Should be used only for dry, unproductivecough or if cough is unduly tiring, disturbs sleep or is hazardus(hernia, piles, cardiac disease, ocular surgery)OPIOIDS:Codein : Opium alkaloid more selective for cough centre.Abuse liability is low.Supresses cough for about 6hr.S/E ConstipationC/I Asthmatics and patients with diminshed respiratory reserve.Pholcodein : Similar antitussive efficacy as codein. Longeracting -- 12hr. No analgesic or addicting property. 16. NON OPIOIDS:Noscapine (Narcotine): Antitussive efficacy equal to codein, especiallyuseful in spasmodic cough. No narcotic, analgesic or dependence. Itcan release histamin and cause bronchoconstriction in asthmatics.Dextromethorphan : Synthetic Compound.D-isomer Raises threshold of cough centre.L-ismoer AnalgesicAs effective as codein, devoid of constipation and addicting action.Action ~ 6 hrs.S/E Dizziness,Nausea, Drowsiness, Ataxia.Clophedianol : Slow onset and longer duration of action. 17. Anti Histaminics : They afford relief in cough due to theirsedative and anticholinergic actions, but lack selectivityfor the cough centre . No expectorant property, mayeven reduce secretions by anticholinergic action. Theyhave been specially promoted for cough in respiratoryallergic states, though their lack of efficacy in asthma islegendary. Chlorpheniramine, Diphenhydramine andPromethazine are commonly used. Second Generationslike Fexofenadine and Loratidine are ineffective. Bronchodilators : They should be used only when anelement of bronchoconstriction is present and notroutinely Aeromatic Chest Rub : shown to reduce experimentallyinduced cough in healthy volunteers, there is no evidenceof benefit in pathological cough 18. Circulatory Consequencesof Cough 19. Posttussive Syncope 20. Hemoptysis The coughing up of blood is termed hemoptysis Massive hemoptysis has been variably definedaccording to the volume, but implies a life-threateningprocess requiring immediateevaluation and treatment. 21. Hemoptysis vs Hematemesisblood that originates in the airways is usually brightred, is mixed with frothy sputum, has an alkaline pH,and contains alveolar macrophages that areladen with hemosiderin; in contrast, blood from thestomach usually is dark, has an acid pH, containsfood particles, and often occurs in patients with along history of gastric complaints. 22. Blood arising from the bronchial arteries is moreoften the source of massive hemoptysis, owing toits higher perfusion pressure than blood from thepulmonary circulation. 23. Evaluation for Hemoptysis History, Physical Examination, Chest Radiograph CBC (Degree of anemia may influence rapidity offurther testing & transfusion of blood products,thrombocytopenia may be a contributing factor) Measurement of Coagulation Times Renal function and Urinalysis (when a systemicprocess which causes pulmonary-renal syndrome isa possibility) Depending on circumstances Sputum Culture &Stains or Cytologic examination should beperformed. 24. A high-resolution computed tomography (HRCT) of thechest is usually the next step if the patient has no history oftobacco use or if the plain chest radiograph suggests aparenchymal abnormality, such as bronchiectasis orarteriovenous malformation. Patients with a history of tobacco use or other risk factorsfor a malignancy warrant fiber optic bronchoscopy Patients with chronic bronchitis and at low risk formalignancy, or in whom the chest radiograph is normal oridentifies the cause of hemoptysis (e.g., epistaxis orpneumonia) can usually be treated initially for bronchitiswith follow-up appraisals to show prompt resolution ofhemoptysis. However, should hemoptysis recur, furtherevaluation is required. 25. Neoplams & Hemoptysis Non-massive hemoptysis is common in bronchogeniccarcinoma; less frequently it is the cause of massivehemoptysis Troublesome cough and vague chest pain precede andaccompany the hemoptysis. Most often the bleeding is a consequence of ulcerationcaused by an expanding tumor; sometimes it is due to apneumonic process or to an abscess in the lung behindthe obstructive lesion. Hemoptysis rarely complicates metastatic tumors of thelungs, since few (primarily renal and colon carcinomas)intrude on the airways until preterminal. Benign tumors Bronchial Carcinoid- Bleeding that isgenerally difficult to arrest. 26. Infections & Hemoptysis It is uncommon in the usual viral or bacterialpneumonia. Conversely, it is not uncommon inthe pneumonia that complicates bronchogeniccarcinoma or in the pneumonia that is causedby staphylococci, influenza virus, or Klebsiella. Pneumococcal Lobar Pneumonia - The sputumat the onset is characteristically rusty-looking, butsometimes it is faintly or grossly bloody Staphylococcus Pneumonia : Blood mixed withpus Kle