Transcript Approach to the Patient With Cough and Hemoptysis

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
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
Congenital
malformations
Patient is a smoker
Tobacco-induced
bronchitis
Purulent sputum
Pneumonia,
bronchitis
Patient is taking an ACE inhibitor
ACE inhibitorinduced cough
High risk for tuberculosis exposure
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-larynxextrathoracic 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 lifethreatening 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 preexisting lung disease.