1. Cough and expectoration zhengcuixia

2. Concept A protective reflex act clean excessive secretion & foreign material Initiated by miscellaneous stimuli or by voluntary exertion. The most common respiratory symptom. Severe cough is a serious clinical problem.

3. Cough reflex Afferent inform.from: larynx, trachea, bifurcation of the bronchi Irritant type: mechanical, chemical, inflammation Afferent fibers are in the vague nerve cough center.

4. Cough reflex Efferent signals larynx, muscles of diaphragm, chest wall, abdomen A coordinated series of movement complete the cough. Deep inspiration – expiration effort with glottis closed- glottis open abruptly – high volocity of airflow brings out screations from airways.

5. Influencing factors Suppressed afferent or efferent nerve function Failed glottis function (laryngopharynx dis) Diminished muscle force Obstructed airway seen in severe COPD Trachea intubation Chest or abdominal pain limit cough movement

6. Causes Airway stimulation by chemicals & foreign material (smoker & occupational exposure) Airway infection & inflammation Lung parenchyma disorders Pleural & chest wall disorders Cardiovascular abnormalities Other causes Psychiatric cough

7. classify Non production ( dry cough ) Production (with sputum) Acute Chronic or acute on chronic

8. Clinical appearance in common diseases Acute respiratory infection or excesobation of chronic infectious illnesss Neoplasms Pleural disease Cardiovascular diseases General disease affecting the respiratory system Chronic cough: postualnasal drip syndrom, cough type asthma, smoker, occupational exposure

9. Accompanied abnormalities Fever Chest pain Dyspnea & wheeze Sputum production

10. Accompanied CXF abnormalities Neoplasm Efussional interstinal Mediastinum Cardiovascular Pleural or chest wall

11. complication Cough syncope syndrom Fatigue Fractures due to severe persistent cough Pneumomediastinum, pneumothorax, and subcutaneous emphysema due to high intrathoracic pressure during cough.

12. Investigation General condition of the patient Time specialties Voice specialties Productive or not In relation with posture Accompany with chest pain; with dyspnea, or other complications

13. Sputum production (expectoration)

14. Characters: mucoid, tenasious, purulent, blood stained, with special odor, rusty, serous Volume: Accompanied manifestation

15. Laboratory examination Rutine Microbiologic test ( including culture ) Cellular

16. hemoptysis Bleeding below the level of the larynx that being coughed out Degrees: from blood-tinged sputum to massive gross blood, even leading to airway occlusion (apnea ) & shock. The latter is much less seen.

17. Common causes Infectious respiratory disease: TB, bronchiactesis, bronchitis Neoplasm: Cardiovascular disease: MS, PE, PAH, deformity of blood vessle Other less seen disease leading to hemoptysis.

18. Clacification Small Moderate Massive

19. Differentiating from hematemesis hemoptysishematemesis Coughed up & frothyVomited without frothy Preceded by stimulating cough Preceded nausea, vomiting Bright redDark red or brown alkalineacid History of coughingGastric, liver disease Blood-tinged sputumTar stool Mixed with sputumMixed with food Anemia variableBlood loss common

20. Differentiating from upper airway bleeding Post nasal bleeding Mouth and farynxil membrane bleeding by intenssive investigation and examination

21. Investigation If coughed out or vomitted out Volume: how much Time duration Any accompanied appearances