1. C OUGH AND H EMOPTYSIS Levy Liran, M.D. Institute of Pulmonology Hadassah-Hebrew University Medical Center Jerusalem, Israel

2. D EFINITION ‘Explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree free of secretions and foreign material.’

3. C OMPLICATIONS OF COUGH Chest and abdominal wall soreness Exhaustion Urinary incontinence Cough syncope Hernias, Uterine prolapse Cough fractures

4. C OUGH R EFLEX

5. E TIOLOGY Post nasal drip Laryngitis, tumor, whooping cough, croup Tracheitis Bronchitis, COPD, Asthma, Bronchial Carcinoma TB, Pneumonia, Bronchiectasis, Pulmonary Oedema, Interstitial Fibrosis

6. D IFFERENTIAL DIAGNOSIS Acute- < 3 weeks URTI- common cold, sinusitis, pertussis Aspiration Inhalation of chemical/smoke Subacute- 3 to 8 weeks Post infectious (pertussis, post viral) Chronic- > 8 weeks Metabolic/Mulad Inflammatory asthma, eosinophilic bronchitis, COPD, bronchiectasis, PND, ILD, pneumoconiosis Infectious TB, mycobacteria, fungus, atypical bacteria Neoplastic mass involving tracheo-bronchial tree Drugs ACE inhibitors Vascullar pulmonary congestion, PE Toxin/Chemical GERD, smoking

7. A PPROACH 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

8. A PPROACH TO CHRONIC COUGH Physical Examonation Full cardio-pulmonary examination:Inspection Palpation Percussion Auscultation Investigations: Chest X Ray Sputum cytology & microbiology Pumonary Function Tests (PFT) High Resolution CT (HRCT) Fibreoptic bronchoscopy Echo PH metria Swallow study Sinus imaging

9. M ANAGEMENT OF COUGH > 8 WEEKS Cough > 8 weeks ACEISmoking Stop Cough persists CXR Normal Post nasal drip Asthma Eosinophilic bronchitis GERD Abnormal Evaluate with: HRCT Sputum testing Bronchoscopy Echo PH metria Swallow study Sinus imaging

10. T REATMENT Acute- < 3 weeks or Subacute- 3 to 8 weeks TreatmentDiagnosis If CXR normal target most common causes and treat empircally stopACE inhibitors Anti acids / PPI / Life styleICS GERD antihistamine, steroidal nasal spray PND / bronchodilatorsAsthma / Eeosinophilic bronchitis /COPD TreatmentDiagnosis 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 TreatmentDiagnosis antibiotic / anti fungal / anti Tb Infectious anti-coagulationPE airway hygiene, antibiotics Bronchiectasis symptomatic / systemis steroids ILD / Pneumoconiosis radiotherapy / chemotherapy Cancer treat CHFPulmonary congestion Fail to respond merits further investigation Chronic- > 8 weeks

11. H EMOPTYSIS Expectoration of blood from the respiratory tract Massive hemoptysis- 100-600ml per day

12. E TIOLOGY Tracheo bronchial Pulmonary parenchyma Primary Vascular Miscellaneous

13. A NATOMY Bronchial artery Pulmonary artery Pulmonary vein

14. D IFFERENTIAL DIAGNOSIS

15. A PROACH TO PATIENT WITH HEMOPTYSIS

16. T REATMENT Blood streaking or small amounts of blood Establish the diagnosis Follow up Massive Hemoptysis *Proper positioning *Endotracheal intubation (single lung) *Balloon Catheter *Bronchoscopy with laser phototherapy/ electrocautery *Bronchial artery embolization *Surgery