COUGH AND HEMOPTYSISLevy Liran, M.D.Institute of PulmonologyHadassah-Hebrew University Medical CenterJerusalem, Israel
DEFINITION
‘Explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree free of secretions and foreign material.’
COMPLICATIONS OF COUGH
Chest and abdominal wall soreness
Exhaustion
Urinary incontinence
Cough syncope
Hernias, Uterine prolapse
Cough fractures
COUGH REFLEX
ETIOLOGYPost nasal drip
Laryngitis, tumor, whooping cough, croup
Tracheitis
Bronchitis, COPD, Asthma, Bronchial Carcinoma
TB, Pneumonia, Bronchiectasis, Pulmonary Oedema, Interstitial Fibrosis
DIFFERENTIAL DIAGNOSIS
Acute- < 3 weeksURTI- common cold, sinusitis, pertussisAspirationInhalation of chemical/smoke
Subacute- 3 to 8 weeks Post infectious (pertussis, post viral)
Chronic- > 8 weeksMetabolic/MuladInflammatory asthma, eosinophilic bronchitis, COPD, bronchiectasis,
PND, ILD, pneumoconiosisInfectious TB, mycobacteria, fungus, atypical bacteriaNeoplastic mass involving tracheo-bronchial treeDrugs ACE inhibitors Vascullar pulmonary congestion, PEToxin/Chemical GERD, smoking
APPROACH TO CHRONIC COUGH
History
• Circumstances surrounding onset of cough• Sputum – color, smell• Type• Hemoptysis • Duration• Variation- posture, time• Precipitating factors & what makes it better• Associated symptoms
APPROACH TO CHRONIC COUGH
Physical Examonation
Full cardio-pulmonary examination: InspectionPalpationPercussionAuscultation
Investigations:
Chest X RaySputum cytology & microbiologyPumonary Function Tests (PFT)High Resolution CT (HRCT)Fibreoptic bronchoscopyEchoPH metriaSwallow studySinus imaging
MANAGEMENT OF COUGH > 8 WEEKSCough > 8 weeks
ACEI Smoking
Stop
Cough persists
CXR
Normal
Post nasal drip
Asthma
Eosinophilic bronchitis
GERD
Abnormal
Evaluate with: HRCTSputum testingBronchoscopyEchoPH metriaSwallow studySinus imaging
TREATMENT Acute- < 3 weeks
or Subacute- 3 to 8
weeks
Treatment Diagnosis
If CXR normal target most common causes and treat empircally
stop ACE inhibitors
Anti acids / PPI / Life styleICS
GERD
antihistamine, steroidal nasal spray
PND
/ bronchodilators Asthma / Eeosinophilic bronchitis /COPD
Treatment Diagnosis
Cough suppression:• Narcotics (codeine or
hydrocodone)• Not to be used in productive
cough
Infectious / aspiration / inhalation
90% of diagnoses
of chronic cough
with normal CXR
Treatment Diagnosis
antibiotic / anti fungal / anti Tb
Infectious
anti-coagulation PE
airway hygiene, antibiotics
Bronchiectasis
symptomatic / systemis steroids
ILD / Pneumoconiosis
radiotherapy / chemotherapy
Cancer
treat CHF Pulmonary congestion
Fail to respond merits further investigation
Chronic- > 8 weeks
HEMOPTYSIS
Expectoration of blood from the respiratory tract
Massive hemoptysis- 100-600ml per day
ETIOLOGY
Tracheo bronchial
Pulmonary parenchyma
Primary Vascular
Miscellaneous
ANATOMYBronchial artery
Pulmonary artery
Pulmonary vein
DIFFERENTIAL DIAGNOSISMost common cause is infection of
medium-sized airways:• Western world viral/bacterial
• World wide TB
APROACH TO PATIENT WITH HEMOPTYSIS
TREATMENT
Blood streaking or small amounts of bloodEstablish the diagnosisFollow up
Massive Hemoptysis *Proper positioning
*Endotracheal intubation (single lung) *Balloon Catheter
*Bronchoscopy with laser phototherapy/ electrocautery *Bronchial artery embolization *Surgery
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