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

2. 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.

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

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

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

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

7. 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

8. 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

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

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

11. 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.

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

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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.

19. 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

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

21. 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

22. 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

23. *** 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

24. 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

25. 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

26. 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

27. 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)

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

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

30. 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.

31. 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.

32. 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.

33. 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.

34. THANK YOU