Approach to the Patient With Cough and Hemoptysis Asisst. Prof. Dr. Özlem Tanrıöver University of Yeditepe College of Medicine Dept. Of Family Practice

Objectives Understand the function and physiological mechanisms of cough. Classify cough according to its duration. List the most common causes of acute cough in adults. Describe the symptoms, signs, and empiric treatment for the 4 most common causes of chronic cough in adults.

Cough Mechanism: Deep Inhalation Glottic closure Relaxation of the diaphragm Contraction of the expiratory muscles

Cough Coughing is an essential defence mechanism It protects the airways from the adverse effects of inhaled noxious substances It clears retained secretions

Medical History Present Illness: The three cardinal symptoms of lung disease are dyspnea, cough, chest pain; other common manifestations are hemoptysis and wheezing.

A man presents to you with coughing What would you like to know?

Cough Diagnostic approach: History 1-acute or chronic? 2-productive or non productive? 3-character 4- time relationships 5-type and quantity of the sputum 6-associated features

Definitions lasting < 3 weeks lasting between 3 and 8 weeks 1 . Acute Cough : lasting < 3 weeks 2. Subacute Cough : lasting between 3 and 8 weeks 3. Chronic Cough : lasting > 8 weeks

Acute Cough Usually non-life-threatening diagnosis Infectious Exacerbation of pre-existing conditions

Environmental/Occupational Occasionally life-threatening diagnosis Pneumonia Heart failure COPD/Asthma exacerbation

Case #1 A 22 year-old medical student presents to student health center with a 2 day history of nasal stuffiness, headaches, general malaise, sore throat, and a cough. There are no fevers, chest pain, or shortness of breath. Her roommates have also had similar symptoms.

Case #1 (continued) What is the likely diagnosis? What therapy should be provided for her cough?

Case #1 (continued) What is the likely diagnosis? Common cold most common infectious disease of humankind US Adults: 2-4 colds/year Over 200 viruses have been identified thought to be a viral related post-nasal drip and inflammatory mediators which increase cough sensitivity

Case #1 (continued) What therapy should be provided for her cough? first generation antihistamine/decongestant addresses the rhinitis and post nasal drip second generation antihistamines are not effective for cough related to the common cold naproxen addresses the inflammatory component of the cough as well as the malaise, headaches, and sore throat

Chronic Cough Assess if the patient is a smoker smoking cessation will generally result in resolution of the cough within 4 weeks Assess if the patient is on an angiotensin converting enzyme inhibitor (ACEI) stopping the ACEI will generally result in cough cessation within 4 weeks

Chronic Cough All patients with a chronic cough should have a CXR If a specific cause of cough is found on the CXR then that diagnosis should be pursued lung mass (cancer) mediastinal adenopathy/mass pulmonary fibrosis

Medical History Present Illness: It is equally important to ask questions about associated systemic features, such as fever, sweats, weight loss, weakness, and fatigue, which are important for chronic disease, especially infection and malignancy.

Medical History Present Illness: No evaluation of pulmonary symptoms is complete without a detailed history of smoking habits. If the patient says “no” when asked “do you smoke?” the next question must be “did you ever smoke? ” Exposure to cigarettes is customarily quantified as the number of “pack-years,” which is calculated by multiplying the average number of packages of cigarettes smoked daily by the number of years they were consumed.

Cough Chronic bronchitis and bronchogenic carcinoma coexist being a complication of CIGARETTE SMOKING ***Any change in the character or pattern of a chronic cough warrants immediate diagnostic evaluation, with special attention directed toward the detection of bronchogenic carcinoma

Cough Productive cough Underlying inflammatory process Often infectious Non productive cough Mechanical or other irritative stimulus

Character Paroxysmal coughing with ‘whoops’ is characteristic of pertussis ‘Barking’ or ‘croupy cough’ occurs in laryngeal disease Coughing at night may accompany congestive cardiac failure Cough occuring at meals suggests esophagogastric disease (hiatal hernia, diverticulum) Worse upon awakening in severe bronchitis or bronchiectasis

A description of the secretions produced in association with cough is diagnostically useful: *** Foul-smelling sputum indicates anaerobic infection (lung abscess or necrotizing pneumonia) Abundant frothy saliva-like sputum symptom of bronchoalveolar carcinoma Pink foamy sputum indicates pulmonary edema Rust-colored or prune juice colored sputum may be observed in pneumococcal pneumonia Chronic production of copious purulent sputum with intermittent blood streaking clue for bronchiectasis

*** Clues to Common Causes of Cough That May Be Apparent by History Infant with cough Patient is a smoker Purulent sputum Patient is taking an ACE inhibitor High risk for tuberculosis exposure Congenital malformations Tobacco-induced bronchitis Pneumonia, bronchitis ACE inhibitor­induced cough Tuberculosis

Clues to Common Causes of Cough That May Be Apparent by History Wheezing Nocturnal wheezing Cough is worse at work Cough following upper respiratory infection or exposure to allergen Sensation of postnasal drip Facial pain, tooth pain Heartburn or sour taste in mouth History of weight loss Asthma Asthma, congestive heart failure Occupational environment cause Postnasal drip Postnasal drip, asthma Sinusitis Gastroesophageal reflux disease Cancer, tuberculosis

Cough Associated features: Wheezing– a disorder with obstruction to air flow such as asthma Stridor– involvement of the pharynx-larynx-extrathoracic trachea Fever and chills– acute infection Weakness and weight loss—tuberculosis or other chronic infection or malignancy Recurrent pneumonias—bronchiectasis, foreign body or obstructing tumor

Treatment: The ideal treatment of cough is the elimination of its underlying cause In bronchopulmonary infections –suitable antimicrobial treatment of the responsible microorganism Cessation of cigarette smoking in chronic bronchitis Productive cough should not be suppressed because retention of secretions impairs the distribution of inspired air which worsens gas exchange and promotes the development of atelectasis and secondary infection Adequate hydration Respiratory physical therapy with postural drainage and percussion may be helpful

Hemoptysis Sources The first step in the evaluation of hemoptysis is to decide if it is really hemoptysis—that is, is the blood coming from the bronchial tree or lungs or from some other site? In most cases, history will suggest that blood is actually being coughed up from the airways or lungs, but it may be difficult at times to distinguish blood being coughed up from the lower respiratory system from blood coming from two other sites: 1. bleeding in the upper respiratory tract, in the nasopharynx or sinuses, 2. or blood originating in the gastrointestinal tract that was regurgitated or vomited . (hematemesis)

Hemoptysis The most common causes are: bronchitis, lung cancer, pneumonia, lung abscess tuberculosis, bronchiectasis, pulmonary thromboembolism.

Evaluation of Hemoptysis The initial evaluation in all patients: a careful history, physical examination, and upright postero-anterior and lateral chest x-rays.

The history : any acute or chronic pulmonary symptoms, including cough, sputum production, shortness of breath or wheezing, and any previous history of lung disease. Systemic symptoms such as: fever, sweats, weight loss, and malaise may reflect ongoing inflammation or reflect a catabolic process related to cancer or chronic infection.

Evaluation of Hemoptysis A complete blood count and coagulation studies should be ordered. A posteroanterior and lateral chest x-ray should be routinely obtained. The chest x-ray may be very helpful in suggesting a source of the hemoptysis, such as pulmonary inflammatory disease or cancer. If the chest x-ray is abnormal, it will often suggest subsequent steps in the work-up. Sputum cytology on expectorated sputum should be obtained in any patient at significant risk for lung cancer based on epidemiologic considerations, whether or not the chest x-ray is suspicious for cancer.

Hemoptysis summary There are several important steps in evaluation of the patient with hemoptysis. 1. it should be determined whether the bleeding represents true hemoptysis or whether the source of bleeding is in the upper airway or in the gastrointestinal tract. 2. the significance of the bleeding should be evaluated, specifically ascertaining whether life-threatening bleeding is present. 3. a differential diagnosis based on the initial history should be developed; this will help focus subsequent questioning, physical examination, and laboratory studies on likely sources of bleeding for the specific clinical situation.

Hemoptysis A chest x-ray should be obtained. If history, physical examination, and a chest x-ray do not reveal the source of bleeding, then a chest CT should be considered. Patients who are candidates for bronchoscopy include those with bleeding of more than 30 ml per day, hemoptysis which has been persistent for one week, and patients at high risk for lung cancer, particularly cigarette smokers older than forty years of age. Massive or life-threatening hemoptysis (bleeding at a rate of greater than 200 ml per day) constitutes an emergency with the major diagnostic objective being localizing the source of the bleeding so that emergent surgery to remove the bleeding site can be carried out. Bronchial arteriography and embolization should be considered in patients with poor pulmonary reserve due to pre-existing lung disease.

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