WELCOME!!!

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

• Cough is an explosive expiration that provides a normal

protective mechanism for clearing the tracheobronchial
tree of secretions and foreign material.
• It is a sudden and often repetitively occurring reflex
which helps to clear the large breathing passages from
secretions, irritants, foreign particles and microbes.
• Frequent coughing usually indicates the presence of a
disease. It is the most frequent symptom of respiratory
disease, but rarely it can be symptom in diseases of the
pleura, the diaphragm, or the pericardium.
• In rare cases it is due to an irritation of the ear drum by
hairs in the external ear channel.
 ETIOLOGY
Common causes of cough are
 Common cold, which is a frequent cause of acute cough
 Sucking materials into the breathing tubes from mouth.
 More severe illnesses, such as pneumonia, acute heart
failure or pulmonary embolism
 Smoking, which often causes chronic cough (smoker's lung).
 Asthma - particularly in children who may only cough and show no
wheezing(Cough-variant asthma )
 GERD
 medicines ACE inhibitors.
 Bacterial or viral infections ,e.g. acute bronchitis, pneumonia
…..e
The triggering agents can also be classified into four.
• 1.mechanical
• Dust inhalation
• Pressure on the air way(tumour)
• Foreign body
• Aortic aneurysm and
• traction on the lung parenchyma due to a tissue-
contracting process (fibrosis, atelectasis)
• 2.Chemical
• various gases (ammonia, tear gas)
• tobacco smoke.
• ACE inhibitors(bradykinin and other tachykinins, such as
substance P)
3.Thermal
• hot /dry air
• cold air
4. Inflammatory
• Mostly due to airway infections
 Risk Factors
• The main risk factor for cough is being exposed to
irritants, such as:
– Smoke
– Noxious fumes
– Allergens such as pollen and dust
– Smog and other environmental pollutants
• Exposure to viral and bacterial infections affecting the
respiratory tract also increases the risk of cough.
 Mechanism
• Afferent nerve endings richly innervate the pharynx,
larynx, and airways to the level of terminal bronchioles
and into the lung parenchyma. They may also be found
in the external auditory meatus (the auricular branch of
the vagus nerve, called the Arnold nerve) and in the
esophagus.
• Sensory signals travel via the vagus and superior
laryngeal nerves to a region of the brainstem in the
nucleus tractus solitarius.
Mechanism of cough
 Signs & Symptoms
• More serious symptoms that may require medical
attention include coughs accompanied by:
• Large amounts of thick sputum
• Blood
• Chest pain
• High fever
• Shortness of breath
• Unintentional weight loss
• Many acute coughs do not require medical attention
unless they fail to resolve or become progressively
worse. A chronic cough, however, is a sign that you
should seek medical care.
 Classification of cough

• A cough can be classified by its duration, character,

quality, and timing.
• Based on duration can be
– acute <3 weeks,
– sub acute 3_8weeks and
– Chronic >8weeks
• Based on character
– non-productive (dry) or
– productive (when sputum is coughed up).
• The composition the sputum reflects inflammatory and
neoplastic processes of the respiratory tract.
– Normal sputum is usually clear.
• Based on timing
– nocturnal cough,(HF)
– day time,
– day and night time
– Morning cough ( bronchiectasis and chronic bronchitis)
– During or after meal(GERD)
• Based on quality
– Barking cough implies involvement of the epiglottis or larynx.
– Staccato(disconnected cough ( chlamydia pneumonia.)
– Brassy(loud);(Pressure on the trachea)
– Hollow/Bovine (Laryngeal nerve palsy causing vocal cord dysfunction)
– whooping cough( typical of pertussis.)
 Differential diagnosis

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

• Common complications of coughing include

– chest and abdominal wall soreness,
– urinary incontinence,
– Stiuational syncope( paroxysms of coughing ),
consequent to increased intrathoracic and alveolar
pressures, diminished venous return, and decreased
cardiac output.
– fractures of the ribs may
– Exhaustion
– Hernias, Uterine prolapse
 Causes of Impaired Cough
• Decreased expiratory-muscle strength
• Decreased inspiratory-muscle strength
• Chest-wall deformity
• Impaired glottic closure or tracheostomy
Tracheomalacia
• Abnormal airway secretions
• Central respiratory depression (e.g.,
anesthesia, sedation, or coma
 Approach to the patient

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

• environmental exposures ( such as, exposure to: nickel

and chromium
• Genetic
 pathophysiology
• Specific pathogenesis depends on etiology and location
of disease.
• Blood traversing the lungs can arrive from
– pulmonary arteries, or
– bronchial arteries
• Virtually the entire cardiac output courses through the
low-pressure pulmonary arteries and arterioles enroute
to being oxygenated in the pulmonary capillary bed
 Con…
• In contrast, the bronchial arteries are under much higher
systemic pressure but carry only a small portion of the
cardiac output.
• Despite the quantitatively smaller contribution of the
bronchial circulation to pulmonary blood flow, the
bronchial arteries are generally a more important source
of hemoptysis than the pulmonary circulation
• In addition to being perfused at a higher pressure, they
also supply blood to the airways and to lesions within the
airways
 Clinical feature
The patient may notice other symptoms including the
following:
– Chest pain
– Dyspnea (shortness of breath, even at rest)
– Fever
– Nausea
– Tachypnea (rapid breathing)
 DIFFERENTIAL DIAGNOSIS OF
HEMOPTYSIS
Source other than the lower respiratory tract
– Upper airway (nasopharyngeal) bleeding
– Gastrointestinal bleeding
Tracheobronchial source
• Neoplasm (bronchogenic carcinoma, endobronchial metastatic
tumor, Kaposi’s sarcoma, bronchial carcinoid)
• Bronchitis (acute or chronic)
• Bronchiectasis

• 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.

• Past medical history of malignancy or treatment of

rheumatologic disease, vascular disease, or underlying
lung disease.
• Because many of the causes of DAH can be part of a
pulmonary-renal syndrome, specific inquiry into a history
of renal insufficiency also is important.
 Physical examination
• Generalappearance;dyspnea,respiratorydistress,anxiety,diaphor
esis,pallor.Note whether the patient looks well,ill,or malnourished
• assessment of vital signs and oxygen saturation to
gauge whether there is evidence of life-threatening
bleeding.
• Tachycardia, hypotension(consider orthostatic),
and decreased oxygen saturation should dictate a
more expedited evaluation of hemoptysis.
• Temp.,BMI
 Con…
• HEENT: eye:conjunctiva
Nosse:close inspection of the nasal mucosa,nose
deformity
–Mouth and Throat:inspect oral
mucosa,toungue,oropharynx for lesions
• LGS:accesible lymph nodes.
• Respiratory system:cyanosis,clubbing
» inspection,palpation,pecusion,auscultation
Should done respectively

• Cardiovascular system :arterial,veinous examination

pericordial examination(inspection,palpation,auscultation)
 Con…
• Gastrointestinalexamination:inspection,auscultation,pal
pation&percusion.to chuck whether there is mass,liver
nodules,tenderness.
•Integumentary system:
May see multiple telangiectasias suggest HHT
Palpable purpura suggest vaculitis
Malar rash is sometimes present in SLE
•Muskuloskeletal system:hot,tender,erythematous
joints&edema.
 Investigation
• laboratory
– CBC (hematocrit&platlate count,WBC with
differential), coagulation studies.
– Liver function test(pt,ptt,coagulating factors)
– Renal function and urinalysis and studies
(ANCA ,anti-GBM, and ANA), should be
considered.
– If a patient is producing sputum( Gram and
acid-fast stains ,culture)
 Con…
• Imaging
– CXR and then CT scan: look for mass lesion,
bronchiactasis, focal or diffuse parenchyma
disorder.
– ECG,Echocardiography
• Endoscopy
– If all of these studies are unrevealing,
(bronchoscopy)
• Cytology
 Treatment
• Mild hemoptysis:
– Treat the the underlying causes.
– Mainstays are bed rest and cough suppre-
ssion with an opiate(codiene,hydrocodiene).
• Severe hemoptysis: Is a medical
emergency
– The first step is to establish a patent airway
usually by endotracheal intubation and
subsequent mechanical ventilation
 Con…
• Protection of the nonbleeding lung
– If the location or side of bleeding is known, placing
the bleeding lung in a dependent position may
prevent blood spillage into the nonbleeding lung
– An alternative strategy involves placement of a
typical, single lumen endotracheal tube into either the
right or left mainstem bronchus
– A third alternative is the placement of a double lumen
endotracheal tube specially designed for selective
intubation of the right or left mainstem bronchi
 Con…
• Pts with massive hemoptysis and pts with
respiratory compromise due to aspiration
of blood should be monitored intensively
with suction and intubation equipment.
• Choice of medical or surgical therapy
often relates to the anatomic site of
hemorrhage and the pt’s baseline
pulmonary function.
 Angiographic embolization of the culprit bronchial artery.(risk of
unintentional spinal-artery embolization and consequent paraplegia
with this procedure)
Bronchoscopically directed interventions, including cauterization
and laser therapy.
In extreme conditions, surgical resection of the affected region of
lung is considered.
• Most cases of hemoptysis will resolve with treatment of the infection
or inflammatory process or with removal of the offending stimulus.
 Con…
• Localized peripheral bleeding sites may be
tamponaded by bronchoscopic placement of a
balloon catheter in a lobar or segmental airway.
Central bleeding sites may be man aged with laser
coagulati.Pts with severely compromised pulmonary
function may be candidates for bronchial artery
catherization and embolization.
 References
• Harrison 17th,18th editon
• Harrison’s manual of medicine, 17th edition
• Internet(wikpedia,www.lungcenter.com)
END