Cough & Hemoptysis

Defining CoughTwo possible definitions of as per European Respiratory Society :

A three-phase expulsive motor act characterized by an inspiratory effort (inspiratory phase) followed by a forced expiratory effort against a closed glottis (compressive phase) and then by opening of the glottis and rapid expiratory airflow (expulsive phase)’.

Cough is a forced expulsive maneuver, usually against a closed glottis and which is associated with a characteristic sound.

Although some similarities exist, the major discrepancy between these two definitions relates to the respiratory patterns associated with cough. In particular, the preceding inspiratory phase, which constitutes the first definition, is believed to be one of a number of distinguishing features between cough and another airway defensive reflex, the expiration reflex

Signaling Pathways

Receptors in the airways are most concentrated in the larynx, diminish in density in the conducting airways, and are absent from the distal airways, enabling the pooling of secretionsin the periphery

The cough reflex may be impaired by interrupting or blunting any step in the sequence. Irritant receptors can be damaged by a local destructive process (e.g., bronchiectasis), or their sensitivity can be diminished by narcotics or anesthetics

Mechanism of CoughThe cough begins with a rapid inspiration,

followed, in rapid sequence, by closure of the glottis, contraction of the abdominal and thoracic expiratory muscles, abrupt increase in pleural and intrapulmonary pressures, sudden opening of the glottis, and expulsion of a burst of air from the mouth.

Sequence of events during a cough

The high intrathoracic pressures, which often exceed 100 to 200 mmHg, increase the velocity of airflow through the airways, hastening the propulsion of the offending particles and producing the sound of a cough by setting into vibration airway secretions, the tracheobronchial walls, and the adjacent parenchyma.

Causes & Characteristics of Cough (Acute Cough)

Sinusitis or Nasopharygnitis: Cough following an upper respiratory syndrome or sinus symptoms; sensation of a need to clear the throat; postnasal drip

Lobar pneumonia: Cough often preceded by symptoms of upper respiratory infection; cough dry, painful at first; later becomes productive

Chronic Bronchitis: Cough productive of sputum on most days for more than 3 consecutive months and for more than 2 years Sputum mucoid until acute exacerbation, when it becomes mucopurulent

Bronchiectasis: Cough copious, foul, purulent, often since childhood; forms layers upon standing

Tuberculosis or fungus: Persistent cough for weeks to months, often with blood-tinged sputum

1.upper : bubble-like, frothy, faomy (partly from saliva)2.middle : thin sero-mucus liquid3.base : pus ,necrotic tissue , cell debris

Causes & Characteristics of Cough (Chronic Cough)

Causes & Characteristics of Cough (Parenchymal Inflammatory Process) Interstitial fibrosis and infiltrations : Cough

nonproductive, persistent

Smoking : Cough usually associated with injected pharynx; persistent, most marked in morning, usually only slightly productive unless succeeded by chronic bronchitis

Gastrioesophageal reflux (GERD): Nonproductive cough often following meals or with recumbancy; may (or may not) be accompanied by other symptoms of GERD(e.g., heartburn, a bitter oral taste, belching)

Foreign body

Immediate : while still in upper airway Cough associated with progressive evidence of asphyxiation

Later : when lodged in lower airway Nonproductive cough, persistent, associated with localizing wheeze

Left ventricular failure : Cough intensifies while supine, along with aggravation of dyspnea

Pulmonary infarction : Cough associated with hemoptysis, usually with pleural effusion

Angiotensin-converting enzyme (ACE) inhibitors : Nonproductive cough, more common in women, may occur at any time (following soon after drug initiation or with years of use)

Cough Medications

Pharyngeal Demulcents: Lozenges, Cough Drops, Linctuses containing syrup, glycerine, liquorice.

Expectorants :

Bronchial Secretion Enhancers :

Na+, K+ Citrate (Salt Action), Potassium Iodide (Irritant to Bronchial Mucosa), Ammonium Chloride (Nauseating-reflexly increasing respiratory secretions),

Guaiphenesin, Vasaka, Tolu balsum are plant products which are supposed to enhance bronchial secretion and mucociliary function while being secreted by tracheobronchial glands.

Mucolytics :

Bromohexine - potent mucolytic and mucokinetic, capable of inducing thin copious bronchial secretion. It depolymerises mucopolvsaccharides directly as well as by liberating lysosomal enzymes network of fibres in tenacious sputum is broken. It is particularly useful if mucus plugs are present.

S/E – Rhinorrhea, Lacrimation

Ambroxol – Metabolite of bromohexine. Similar profile.

Acetylcystein - It opens disulfide bonds in mucoproteins present in sputum and makes it less viscid, but has to be administered directly into the respiratory tract.

Carbocystein – Liquifies viscid sputum in similar way as acetylcystein but can be administered orally.

S/E – GI Irritation & Rash

Anti-Tussives : Should be used only for dry, unproductive cough 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 – Constipation

C/I – Asthmatics and patients with diminshed respiratory reserve.

Pholcodein : Similar antitussive efficacy as codein. Longer acting -- 12hr. No analgesic or addicting property.

NON OPIOIDS:

Noscapine (Narcotine): Antitussive efficacy equal to codein, especially useful in spasmodic cough. No narcotic, analgesic or dependence. It can release histamin and cause bronchoconstriction in asthmatics.

Dextromethorphan : Synthetic Compound.

D-isomer Raises threshold of cough centre.

L-ismoer Analgesic

As 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.

Anti Histaminics : They afford relief in cough due to their sedative and anticholinergic actions, but lack selectivity for the cough centre . No expectorant property, may even reduce secretions by anticholinergic action. They have been specially promoted for cough in respiratory allergic states, though their lack of efficacy in asthma is legendary. Chlorpheniramine, Diphenhydramine and Promethazine are commonly used. Second Generations like Fexofenadine and Loratidine are ineffective.

Bronchodilators : They should be used only when an element of bronchoconstriction is present and not routinely

Aeromatic Chest Rub : shown to reduce experimentally induced cough in healthy volunteers, there is no evidence of benefit in pathological cough

Circulatory Consequences of Cough

Posttussive Syncope

HemoptysisThe coughing up of blood is termed

‘hemoptysis’

Massive hemoptysis has been variably defined according to the volume, but implies a life-threatening process requiring immediate evaluation and treatment.

Hemoptysis vs Hematemesisblood that originates in the airways is usually bright red, is mixed with frothy sputum, has an alkaline pH, and contains alveolar macrophages that are laden with hemosiderin; in contrast, blood from the stomach usually is dark, has an acid pH, contains food particles, and often occurs in patients with a long history of gastric complaints.

Blood arising from the bronchial arteries is more often the source of massive hemoptysis, owing to its higher perfusion pressure than blood from the pulmonary circulation.

Evaluation for Hemoptysis History, Physical Examination, Chest Radiograph

CBC (Degree of anemia may influence rapidity of further testing & transfusion of blood products, thrombocytopenia may be a contributing factor)

Measurement of Coagulation Times

Renal function and Urinalysis (when a systemic process which causes pulmonary-renal syndrome is a possibility)

Depending on circumstances Sputum Culture & Stains or Cytologic examination should be performed.

A high-resolution computed tomography (HRCT) of the chest is usually the next step if the patient has no history of tobacco use or if the plain chest radiograph suggests a parenchymal abnormality, such as bronchiectasis or arteriovenous malformation.

Patients with a history of tobacco use or other risk factors for a malignancy warrant fiber optic bronchoscopy

Patients with chronic bronchitis and at low risk for malignancy, or in whom the chest radiograph is normal or identifies the cause of hemoptysis (e.g., epistaxis or pneumonia) can usually be treated initially for bronchitis with follow-up appraisals to show prompt resolution of hemoptysis. However, should hemoptysis recur, further evaluation is required.

Neoplams & Hemoptysis Non-massive hemoptysis is common in bronchogenic

carcinoma; less frequently it is the cause of massive hemoptysis

Troublesome cough and vague chest pain precede and accompany the hemoptysis.

Most often the bleeding is a consequence of ulceration caused by an expanding tumor; sometimes it is due to a pneumonic process or to an abscess in the lung behind the obstructive lesion.

Hemoptysis rarely complicates metastatic tumors of the lungs, since few (primarily renal and colon carcinomas) intrude on the airways until preterminal.

Benign tumors – Bronchial Carcinoid- Bleeding that is generally difficult to arrest.

Infections & Hemoptysis It is uncommon in the usual viral or bacterial

pneumonia. Conversely, it is not uncommon in the pneumonia that complicates bronchogenic carcinoma or in the pneumonia that is caused by staphylococci, influenza virus, or Klebsiella.

Pneumococcal Lobar Pneumonia - The sputum at the onset is characteristically rusty-looking, but sometimes it is faintly or grossly bloody

Staphylococcus Pneumonia : Blood mixed with pus

Klebsiella Pneumonia : Resembling Currant Jelly

Brisk bleeding is common in lung abscess; the blood is mixed with copious amounts of foul-smelling pus

Rusty Sputum

Currant Jelly Sputum

Fungal Infections : As in tuberculosis, hemoptysis is generally a consequence of a continuing necrotizing and ulcerating inflammatory process or of bronchiectasis.

The most common fungal disorder associated with hemoptysis is a “fungus ball” that resides either in a healed tuberculous or bronchiectatic area or in a cystic residue of sarcoidosis.

Aspergillus is the usual fungal agent; less often another fungus (e.g., Mucor) is the cause

Tuberculosis : Source of hemoptysis – Active Tuberculous Cavity or Tuberculous Pneumonia (more Common).

If tuberculosis is allowed to progress to the point of extensive fibrosis and cavitation, or becomes complicated by bronchiectasis, hemoptysis can be troublesome and persistent.

Hemoptysis from a Rasmussen’s Aneurysm involves the erosion of a small or medium-sized pulmonary artery into an adjacent tuberculosis cavity

‘Right Middle Lobe Syndrome’ :

Frequently associated with hemoptysis

It is due to a partial or complete obstruction of the right middle lobe bronchus, resulting in atelectasis and/or pneumonitis in the right middle lobe. The obstruction is more often caused by scarring and/or inflammation than by physical compression of the lumen by an enlarged lymph node. The cause is usually infectious

In Amoebiasis endemic areas :

Hemoptysis follows perforation into the airways of an amebic lung abscess. The sputum resembles anchovy sauce.

Cardiovascular Diseases and Hemoptysis In chronic pulmonary congestion, secondary to

left ventricular failure or to mitral valve disease, alveolar macrophages in the sputum are often laden with hemosiderin (“heart failure cells”).

In severe congestion and edema, the sputum is often pink and frothy.

The hemoptysis of pulmonary infarction is usually associated with pleuritic pain and often with a small pleural effusion because of the peripheral location of the infarct.

Tight mitral stenosis is sometimes first manifested by a bout of brisk, bright-red hemoptysis that is difficult to control. The source of the bleeding is the sub-mucosal bronchial veins, which proliferate considerably in this disorder. Massive hemoptysis due to mitral stenosis is a medical emergency and is an indication for surgical intervention to relieve the obstruction at the mitral valve.

An extraordinary event is the communication of an arteriovenous fistula with a small airway, causing bleeding that is exceedingly difficult to arrest.

protect the airway and prevent asphyxiation

Intubation should be performed promptly, and consideration

given to selective intubation of one lung in order to protect

it from spillage of blood from the other.

place the involved side in a dependent position

bronchoscopic interventions such as the placement

of a balloon catheter to isolate the involved segment, lavage

with iced saline, or the application of topical epinephrine

(1:20,000).

Management of Massive Hemoptysis

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