Professional Documents
Culture Documents
Cough & Hemoptysis
Cough & Hemoptysis
Seminar presentation on
cough and hemoptysis
•Prepared by:
ASTAREKEW ALENE
BAMELAKU DAGNEW
BEGASHAW GETANEH
MODERATOR;DRBIRHAU
COUGH
Outline
• Definition
• Causes
• Classification
• Risk factors
• Pathophysiology
• Differential diagnosis
• Complications
• Approach to the petiant
Definition
Acute cough
Most often upper respiratory tract infection, especially:
– ƒCommon cold
– ƒAcute bacterial sinusitis
– ƒPertussis; violent cough, "the 100-day cough”
"whooping cough”(The inspiratory sound made at the end of an
episode of paroxysmal coughing)
More serious disorders, including:
– ƒPneumonia
– ƒPulmonary embolism
– Congestive heart failure
• Subacute coug
_postnasal drip following viral infection, pertussis, or
infection with Mycoplasma or Chlamydia
Chronic cough
mostly due to more than one condition
– ƒPostnasal drip
– ƒAsthma
– ƒGastro esophageal reflux disease
– ACEI(5-30%)acute or chronic
– Lung abcess
– ƒChronic obstructive lung disease
– bronchogenic carcinoma
– Bronchoectiasis
– Chronic bronchities
Post-nasal drainage
• stimulation of sensory receptors of the
cough-reflex pathway in the hypopharynx
or aspiration of draining secretions into the
trachea. Clues to this etiology include
symptoms of post-nasal drip, frequent
throat clearing, and sneezing and
rhinorrhea
• examination of the nose
excess mucoid or purulent secretions,
inflamed and edematous nasal mucosa,
and/or nasal polyps; in addition, one might
visualize secretions or a cobblestoned
appearance of the mucosa along the
posterior pharyngeal wall
COMPLICATIONS
history
• Onset, Pattern, Duration?
• Character: Productive or not,
• hemoptysis.
• Exacerbating/alleviating factors:
– Look for triggers (e.g., only at work or after mowing lawn).
– Over the counter or prescription drugs.
• Associated symptoms:
– Systemic: Fever, shaking chills, sweats,
– weight loss.
• HEENT: Sneezing, postnasal drip.
• Cardiac and pulmonary: Dyspnea, chest pain
• Gastrointestinal: Heartburn ,Retrosternal burning after
meals or on recumbency, hoarseness,throat pain
• Severity: Affecting work or sleep? Causing syncope or
incontinence?
• Relevant past medical history: Asthma, atopy, drug
allergies (always), currently taking or recently run out of
any medications, exposure to TB or other infectious
diseases?
• Relevant social history: Travel or immigration,
occupation (i.e., glue or chemical exposures), alcohol or
tobacco use?
• Relevant family history: Atopy, asthma, TB exposure,
Cough
Physical examination
• General appearance:
– How sick does patient look?
• Vital signs: BP,PR(consider pulsus
paradoxus),RR,Temp.,BMI
Pulsus paradoxsus(pericardial tamponade , massive
pulmonary embolism, hemorrhagic shock, severe
obstructive lung disease, and tension pneumothorax)
• HEENT: Examination of the auditory canals and
tympanic membranes eye conjunctiva,Nasal passage,
sinuses, throat,
• Lymphoglandular:lymphadenopathy
• Chest/lungs: inspection,palpation percussion, lung
sounds.
Auscultation
• WHEEZIG;asthma, cardiac asthma
• Rhonchi are a manifestation of obstruction
of medium-sized airways;
acute; viral or bacterial bronchitis
chronic; bronchiectasis or COPD
Crackles, or rales, are commonly a sign of
alveolar disease; Pneumonia, pul edema
and IPF(no egophony)
Other Systems
• clubbing (cystic fibrosis, IPF, and lung
cancer)
• Pedal edema(cor pulmonare,pul
embolism),jvp
• rheumatologic disease(joint and skin
examination)
investigation
• CBC,ESR
• Sputum:
– gross and microscopic examination
– Gram and acid-fast stains and cultures
– Cytology
• imaging
– CXR;mass lesion, localized pulmonary parenchymal
opacification, or diffuse interstitial or alveolar
disease,cyst, symmetric bilateral hilar adenopathy
may suggest sarcoidosis.
– High-resolution CT
Pulmonary function testing
– Forced expiratory flow rates
• ƒReversible airflow obstruction characteristic of asthma
– Bronchoprovocation testing with methacholine or cold-air
inhalation ;hyper activity of air ways
_.To diagnose asthma when flow rates normal
_Demonstrates hyperreactivity of airways to a
bronchoconstrictive stimulus
• Fiberoptic bronchoscopy
• Procedure of choice for:
– Visualization of endobronchial tumor and collecting
cytologic and histologic specimens
– Inspection of the tracheobronchial mucosa can demonstrate:
• Endobronchial granulomas often seen in sarcoidosis
• Endobronchial biopsy or transbronchial bi opsy of lung
interstitium can confirm diagnosis.
Characteristic appearance of endobronchial Kaposi’s
sarcoma in patients with AIDS
• ECG
• Echocardiography
• Organ function
– LFT
– RFT
• Urine analysis
• RVI serological test
• Serological
TRATMENT
Definitive treatment
• Dependent on determining underlying cause
• Specific considerations
– Elimination of exogenous inciting agent (cigarette smoke, ACE
inhibitor) or endogenous trigger (postnasal drip, gastroesophageal
reflux)
• ƒUsually effective if precipitant can be identified
– Treat specific respiratory tract infections.
– Bronchodilators for potentially reversible airflow obstruction
– Inhaled glucocorticoids for eosinophilic bronchitis
– Chest physiotherapy and other methods to clear secretions in
bronchiectasis
– Treatment of endobronchial tumors or interstitial lung disease if
therapy available and appropriate
– Cough-variant asthma typically responds well to inhaled glucocorticoids
and intermittent use of inhaled beta-agonist bronchodilators
• Therapy for post-nasal drainage depends
on the presumed etiology (infection,
allergy, or vasomotor rhinitis) and may
include systemic antihistamines;
antibiotics; nasal saline irrigation; and
nasal pump sprays with corticosteroids,
antihistamines, or anticholinergics
Chronic idiopathic cough is distressingly
common
• Most effective are narcotic cough
suppressants, such as codeine or
hydrocodone, which are thought to act in
the "cough center" in the brainste
• Dextromethorphan is
• Benzonatate is thought to inhibit neural
activity of sensory nerves in the cough-
reflex pathway
GERD
• Antacids, histamine type-2 (H2) receptor
antagonists, and proton-pump inhibitors
are used to neutralize or decrease
production of gastric acid
• dietary changes, elevation of the head and
torso during sleep, and medications to
improve gastric emptying are additional
therapies
• Cough productive of significant quantities
of sputum should usually not be
suppressed.
– Retention of sputum may interfere with
distribution of ventilation , alveolar aeration,
and ability of the lung to resist infection
Hemoptysis
Outline
• Definition
• Causes
• Risk factor
• Pathophysiology
• Clinical feature
• Deferential diagnosis
• Approach to patient
• Investigations
• Managements
Introduction
.Hemoptysis means coughing out blood
from the respiratory tract.
-It is the expectoration of blood, can range
from blood-streaking of sputum to the
presence of gross blood in the absence of
any accompanying sputum.
.It refers specifically to blood that comes
from the respiratory tract.
-Blood also may come from the nose, the
back of the throat, or part of the
gastrointestinal tract. When blood originates
outside of the respiratory tract, the condition
is known as "pseudohemoptysis.“
-Heamatemesis is one type of
pseudohemoptysis.
Classification
• Mild
• Massive
Mild
.If there is a small amount of blood or
sputum streaked with blood, the spitting is
considered mild hemoptysis.
.In 60% to 70% of cases, the underlying
disorder is benign and disappears on its own
without causing serious problems or
permanent damage.
.Massive
.Hemoptysis is considered massive,
or major, when there is so much blood that it
interrupts breathing (generally more than
about 100-600ml per 24 hours).
-Massive hemoptysis is a medical
emergency.
-Mortality rate can be as high as 75%.
.Most patients who die from hemoptysis
suffer from asphyxiation (lack of oxygen)
due to too much blood in the airways.
Causes
.Worldwide, tuberculosis is the commonest
cause of hemoptysis.
-In industrialized countries, the most
common causes are bronchitis,
bronchiectasis, and bronchogenic
carcinoma.
-In patients with AIDS, the most common
cause of hemoptysis is TB.
-In about 15% to 30% of cases, the
underlying problem is never found, the
hemoptysis is commonly referred to as
ETIOLOGY
• Airways diseases
– Are the most common source of hemoptysis
• Inflammatory diseases, such as bronchitis or
bronchiectasis
• Neoplasms, including primary bronchogenic
carcinoma, endobronchial metastatic carcinoma or
bronchial carcinoid
• In patients with AIDS, Kaposi's sarcoma involving
the airways and/or the pulmonary parenchyma
• Foreign body & Airway trauma
Con…
• Pulmonary vascular disorders
– Pulmonary embolism
– Pulmonary AV malformation
– Elevated pulmonary capillary pressure
• mitral stenosis
• left ventricular failure
• severe pulmonary hypertension
Con…
• Pulmonary parenchymal diseases
– Infection, especially tuberculosis, pneumonia, aspergilloma, and
lung abscess
– Inflammatory or immune disorders
• Goodpasture's syndrome, lupus pneumonitis, and Wegener's
granulomatosis
– Coagulopathy
• thrombocytopenia or use of anticoagulants
– Miscellaneous causes
Con…
• Cryptogenic
– Even after extensive evaluation, a sizable proportion
of patients (up to 30% in some series) have no
identifiable etiology for their hemoptysis
• Other causes of irritation of the airways resulting in
hemoptysis include inhalation of toxic chemicals, thermal
injury, direct trauma from suctioning of the airways
(particularly in intubated patients), and irritation from
inhalation of foreign bodies.
• All of these etiologies should be suggested by the
individual patient's history and exposures
Risk factor
• Smoking
• Chronic obstructive pulmonary disease
• Airway trauma
• Foreign body
Con…
Pulmonary parenchymal source
• Lung abscess
• Pneumonia
• Tuberculosis
• Mycetoma ("fungus ball")
• Goodpasture’s syndrome
• Wegener’s granulomatosis
• Lupus pneumonitis
• Lung contusion
Con…
Primary vascular source
• Arteriovenous malformation
• Pulmonary embolism
• Elevated pulmonary venous pressure (esp. mitral stenosis)
-rare cases
• Pulmonary endometriosis
• Systemic coagulopathy or use of anticoagulants or thrombolytic
agents
Pateint aproach
• In History Include
– age
– smoking history(current ,former,passive)
– Duration , nature , volume of the hemoptysis , specific triggers of
the bleeding and association with symptoms of acute bronchitis
or an acute exacerbation of chronic bronchitis
– history of prior lung, cardiac, or renal disease
– Has the patient had prior hemoptysis, other pulmonary
symptoms, or infectious symptoms
Con…
• family history of hemoptysis or brain aneurysms (suggesting
hereditary hemorrhagic telangiectasia)
• Is there a history of skin rash
• patient's travel history
• Working environment
• history of bleeding disorders or use of aspirin, nonsteroidal anti-
inflammatory drugs, or anticoagulants
• history of upper airway or upper gastrointestinal complaints or
diseases
Con…
• Symptoms suggestive of respiratory tract infection—
including fever, chills, and dyspnea—should be elicited.
• recent inhalation exposures or use of illicit substances as
well as risk factors for venous thromboembolism.