1. Respiratory Symptoms GuoYing
The respiratory department of the first affiliated hospital of liaoning medical college

2. Common symptoms Cough Expectoration Hemoptysis Chest pain Dyspnea
Cyanosis

3. Cough
A cough is a sudden, forceful, noisy expulsion of air from the lungs.
It is a protective reflex ，but excessive coughing is harmful to human’s body.

4. Mechanism of cough from Stimuli vagus nerve
larynx, trachea, bronchi, pleura and external acoustic meatus
from
Stimuli
vagus nerve
afferent nerve fiber
coughing centre （in oblongata）
efferent nerve fiber
laryngeal nerve diaphragmatic nerve spinal nerves
Cough is a protective action，but excessive coughing is harmful to human’s body (pharyngeal muscle） （diaphragmatic muscle）（respiratory muscle）
deep breath
glottal closure
intrathoracic pressure increase
sudden glottal opening
outward blast of air

5. Cough : manifestations
Characteristics
Unproductive /Dry cough (non-sputum: non-infectious)
Productive cough (sputum: infectious, edema)
Attack
Time (single/paroxysmal /nocturnal)
Season (chronic)
motivation
Tone
Hoarseness
High pitch/brassy cough
Weak

6. Cough : Clinical Occurrence
Respiratory diseases___ the most common causes
Airway agents
Bronchitis, bronchiectasis, asthma, endobronchial tuberculosis, tumor, pharyngitis， tracheoesophageal fistula，foreign bodys
Lung agents
Infection, edema, fibrosis, tumor
Pleural agents
Pleurisy, pneumothorax, mesothelioma of pleura

7. Cardiovascular diseases Cardiogenesis edema/ congestive heart failure,
pulmonary embolism and infarction
_vasculitis : Wegener, Churg-Straus syndrome ,
Goodpasture syndrome.
_aortic aneurysm, pulmonary hemorrhage.
Central nervous system agents
Initiative cough, encephalitis, meningitis

8. Chronic unexplained coughs are most commonly
related to one or a combination of :
chronic post-nasal drip;
gastroesophageal reflux;
cough-variant asthma;
drugs (angiotensin converting enzyme inhibitors)

10. Cough: accompany signs
Fever (infection)
Chest pain (infection, tumor, pleurisy,
pneumothorax, pulmo embolism)
Hemoptysis (bronchiectasis, tuberculosis, tumor)
Bulk pus sputum (bronchiectasis, lung abscess)
Wheezing (asthma, foreign body)
Clubbing fingers (bronchiectasis, lung cancer, chronic lung abscess)

11. Common symptoms Expectoration Cough Chest pain Hemoptysis Dyspnea
Cyanosis

12. Expectoration The attributes of sputum
Bloody Sputum (Hemoptysis,next class )
Bloody gelatinous sputum
Rusty Sputum
Purulent Sputum
Stringy Mucoid Sputum
Frothy Sputum
Broncholiths

13. Bloody gelatinous sputum （Currant-jelly sputum ）
Copious quantities of tenacious ,bloody sputum are almost pathognomonic for pneumonia caused by klebsiella pneumoniae or streptococcus pneumoniae

14. Rusty Sputum ( Prune-juice Sputum)
Purulent sputum containing changed blood pigment is typical of pneumococcal pneumonia but it is frequently preceded by small amounts of frank blood.
Stringy Mucoid Sputum
Increased mucous production and formation of mucous plugs occur in asthma; during resolution of an acute attack, retained mucous is mobilized.
Frothy Sputum ( Pulmonary Edema)
Fluid from the pulmonary capillaries enters the alveoli and is expectorated. A thin secretion containing air bubbles, frequently colored with hemoglobin , is typical of pulmonary edema. Both acute lung injury and left ventricular failure produce this sign.

15. Purulent Sputum
Inflammatory cells, predominately polymorphonuclear leukocytes, enter the airways and alveoli in response to lower airway infection.
Colour:yellow (general bacterial), green (aeruginosus Bacillus), or Grey or black (dust inhalation).
Amounts:Small amounts ：acute bronchitis, pneumonia during resolution, small tuberculous cavities or lung abscess. Copious purulent sputum suggests lung abscess, bronchiectasis, or bronchopleural fistula communicating with an empyema. Many lung abscesses do not yield much sputum because their bronchial communications are inadequate for complete drainage
Odor :Fetid sputum suggests anaerobic infection and/or lung abscess.
Bronchiectasis:200 to 500 ml/d. On standing, bronchiectatic sputum typically separates into three layers,with mucus on top separated by clear fluid from pus on the bottom. (or upper: frothy, middle: serofluid or serofluid pus,lower: necrosis substance)
bronchopleural fistula :Copious sputum from a patient with signs of pleural effusion suggests

16. Broncholiths
Occasionally, calcified particles are found in the sputum either by the patient or the physician. These are usually broncholiths, derived from calcified lymph nodes eroding the bronchi or from calcareous granulomas in silicosis, tuberculosis, or histoplasmosis. Their discovery may explain the source of pulmonary hemorrhage

17. Common symptoms Hemoptysis Cough Expectoration Chest pain Dyspnea
Cyanosis

18. Hemoptysis Definition: Spitting or coughing of blood is hemoptysis.
The blooding region: anywhere from the nose to the lungs .
The amount varies from blood-strained sputum to several hundreds ml pure blood
Mild: 100ml/d
Moderate: ml/d
Severe: >500ml/d, or /time

19. Hemoptysis Differential diagnosis
Bleeding from upper respiratory tract
Expectorated blood usually comes from the upper respiratory tract while blood in the bronchial tree induces coughing. However, the patient may not be able to distinguish which of the two is occurring, so both upper and lower respiratory tract disorders must be considered.
Hematemesis

20. Distinguished hemoptysis from hematemesis
Causes
Pulmo or cardiac
digestive system
Previous symptoms
Cough, chest tightness
Nausea, vomiting
Spit up
Cough up
Vomited
Color
Bright red
Dark red
Mixture
Sputum, frothy
Gastric contents pH
alkalinity
acidity
Tarry stools
Negative/ positive
positive
Post-bleeding
Sputum with blood
No sputum

21. Hemoptysis: causes Bronchial disorders Bronchiectasis
Bronchogenic carcinoma
endobronchial TB
Chronic bronchitis

22. Hemoptysis: causes Pulmo Disorders Pulmo TB Pneumonia Lung abscess
Pulmo embolism

23. Hemoptysis: causes Cardiovascular disorders Acute left heart failure
Mitral stenosis

24. Hemoptysis: causes Others
Hematologic disease, leptospirosis （钩端螺旋体病），epidemic hemorrhagic fever，endometriosis （子宫内膜异位症）

25. Bloody Sputum
Blood in the sputum usually impresses patients enough to bring them to the physician. The first problem is to identify the anatomic site of hemorrhage.
Blood-Streaked Sputum is usually caused by inflammation in the nose, nasopharynx, gums, larynx, or bronchi. Sometimes it occurs only after severe paroxysms of coughing and may be attributed to trauma.
Pink Sputum usually results from blood mixing with secretions in the alveoli or smaller bronchioles; it most frequently occurs in pneumonia or pulmonary edema.

26. Massive bleeding occurs with erosion of a bronchial artery by cavitary pulmonary tuberculosis, aspergilloma, lung abscess, bronchiectasis, pulmonary infarction, pulmonary embolism, bronchogenic carcinoma or a broncholith.
Goodpasture syndrome Alveolar Hemorrhage, does not produce bloody sputum in all cases.
mitral stenosis. Not infrequently,frank bleeding from the lungs occurs in

27. Hemoptysis: accompany symptoms
Fever
Infection or carcinoma
Chest pain
Infection， Pulmo Embolism，Carcinoma
Pus sputum
Bronchiectasis，Lung abscess
Clubbing fingers
Bronchiectasis，Lung abscess，Carcinoma
Hemorrhagic spots
Hematologic disease, leptospirosis, epidemic hemorrhagic fever

28. Clubbing fingers

29. Clinical occurrence 1.Upper Respiratory Tract bleeding from :
nasopharynx,
oropharynx,
gums,
laryngitis,
laryngeal carcinoma,
hereditary hemorrhagic telangiectasia.
.laryngopharynx喉咽oropharynx nasopharynx epistaxis鼻衄 破裂rupture break cricoid cartilage环状软骨

30. 2.Bronchial Tree bronchiectasis, bronchial carcinoma,
acute and chronic bronchitis,
trauma from coughing,
broncholiths,
foreign body aspiration,
erosion by aortic aneurysms.
bronchiectasis
Chicken bone
broncholiths
carcinoma
foreign body

31. 4 Cardiovascular diseases
3 Lungs
infections ( pneumonia, especially caused by Klebsiella, lung abscess, tuberculosis,fungal infections, amebiasis, hydatid cyst) , pulmonary embolism with infarction, trauma, pulmonary hemorrhage ( vasculitis especially Wegener, Goodpasture syndrome ) , idiopathic pulmonary hemo-siderosis, lipoid pneumonia.
4 Cardiovascular diseases
Mitral stenosis, congestive heart failure, arteriovenous fistula, anomalous pulmonary artery, hypertension.
5 Hematologic diseases
thrombocytopenia, leukemia, hemophilia
二尖瓣mitral valve anomalous异常的,反常的
肺出血肾炎综合症pulmonary hemorrhage nephritis syndrome

32. Lung abscess lobar pneumonia Pulmo TB
气液平面air fluid level 大叶性肺炎 空洞型肺结核cavity
Lung abscess
Pulmo TB