© 2006 WebMD, Inc. All rights reserved.                                                      ACS Surgery: Principles and P...
© 2006 WebMD, Inc. All rights reserved.                                                           ACS Surgery: Principles ...
© 2006 WebMD, Inc. All rights reserved.                                                       ACS Surgery: Principles and ...
© 2006 WebMD, Inc. All rights reserved.                                                                             ACS Su...
© 2006 WebMD, Inc. All rights reserved.                                                                              ACS S...
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Acs0402 Cough And Hemoptysis

  1. 1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 2 COUGH AND HEMOPTYSIS — 1 2 COUGH AND HEMOPTYSIS Subroto Paul, M.D., and Raphael Bueno, M.D., F.A.C.S. CLINICAL EVALUATION An acute or chronic cough is one of the most common chief pre- senting complaints. In the United States, it accounts for approxi- An acute or self-limited cough is defined as one that resolves mately 30 to 50 million physician visits each year, and more than within 3 weeks. Usually, an acute cough is the result of minor $1 billion is spent annually on its workup and treatment.1 A cough infection or inhalation of irritant gases or particulate matter; some- can result from a wide variety of conditions, ranging from fairly times, however, it is associated with a more serious condition. non–life-threatening causes (e.g., bronchitis) to life-threatening Generally, a cough requires diagnostic attention when it persists ones (e.g., lung cancer). Hemoptysis is also a common presenting for 3 weeks or longer, at which time it is deemed chronic. Numer- complaint, with a similarly broad spectrum of possible causes. It ous conditions are capable of causing a chronic cough [see Table 1], may range in severity from mild blood streaking in sputum to mas- and the differential diagnosis of this complaint is broad. sive hemorrhage that, if left untreated, can lead to shock and rapid Careful diagnostic evaluation is required to identify potentially death from blood loss and asphyxiation. Even mild hemoptysis is life-threatening causes of chronic coughing [see Figure 1]. Such distressing to many patients and physicians and calls for prompt evaluation relies heavily on the history. Medications, tobacco use, attention and diagnosis. In cases of massive hemoptysis, expedient and occupational exposure must all be considered in the effort to evaluation and management are essential, often involving airway narrow the differential diagnosis. Associated symptoms offer control with intubation and hemodynamic resuscitation. important clues; for example, in a patient with water brash and a Because both cough and hemoptysis may be signs of urgent or chronic cough, reflux is more likely to be the cause of the cough life-threatening disease, patients who present with either or both than it would be in a patient with copious nasal secretions.5,7,8 The of these symptoms should undergo a thorough, methodical quality of the sputum is a particularly significant variable: purulent workup consisting of a detailed history, a careful physical exami- sputum may lead one to suspect infection, whereas bloody sputum nation, and appropriate diagnostic studies (usually computed may lead one to suspect malignancy, especially in a smoker. tomography of the chest and bronchoscopy). Substantial experience and acute clinical judgment are required to distinguish the relatively few patients with serious diseases from the millions of patients who present with a benign cough each Cough year. A cough is a forceful expiration that is mediated through the MANAGEMENT OF SPECIFIC CAUSES activation of a complex reflex arc.The cough reflex is triggered by the stimulation of various cough receptors, which are found not Common causes of a chronic cough include acute and chronic only in the epithelium of the respiratory tract but also in the lower bronchitis, bronchiectasis, asthma, postnasal drip, and gastro- esophagus, the stomach, and the diaphragm.2,3 These receptors esophageal reflux.4,5,9-15 Other, less common causes include drugs can be activated by mechanical, chemical, or thermal stimuli; once (e.g., angiotensin-converting enzyme [ACE] inhibitors), intersti- activated, they send signals to the medulla via the vagus nerve, the tial lung disease, congestive heart failure (CHF), bronchogenic glossopharygneal nerve, the trigeminal nerve, or the phrenic carcinoma, tracheobronchial foreign bodies, and endobronchial nerve. A center in the medulla then activates the muscles of expi- tumors (benign or malignant).7,16-18 ration by means of efferent signals transmitted via the vagus and phrenic nerves.2,3 Mechanical stimuli that can trigger the cough reflex include Table 1 Differential Diagnosis of Cough inhaled particulate matter and intrinsic and extrinsic tracheo- bronchial compression. Intrinsic compression may be caused by Acute and chronic bronchitis airway tumors, foreign bodies, granulomatous airway disease, or Bronchiectasis bronchial smooth muscle that is constricted as a result of disease Most common causes Asthma or exposure to noxious materials. Extrinsic compression may be Postnasal drip caused by aortic aneurysmal disease, a pulmonary parenchymal Gastroesophageal reflux neoplasm (e.g., lung cancer or a tumor that has metastasized to Drugs the lung), edema from pulmonary parenchymal infection (e.g., Angiotensin-converting enzyme inhibitors pneumonia or abscess), or pulmonary parenchymal fibrosis result- Interstitial lung disease ing from any of a variety of interstitial lung diseases (e.g., idio- Eosinophilic bronchitis Less common causes pathic pulmonary fibrosis or sarcoidosis). Chemical stimuli that Congestive heart failure can trigger coughing include inhaled irritant gases and aspirated Bronchogenic carcinoma gastric acid or bile. A common thermal stimulus is hot or cold Tracheobronchial foreign body Psychogenic inhaled air (or other gas).4-7
  2. 2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 2 COUGH AND HEMOPTYSIS — 2 Patient presents with chronic cough Obtain history and perform physical examination. Consider • Medications • Tobacco use • Occupational exposure to irritants • Associated symptoms Assess quality of sputum. Sputum is not purulent or bloody Sputum is purulent Sputum is bloody Common causes of cough include Cause of cough is presumed to be infectious asthma, gastroesophageal reflux (e.g., bronchitis, bronchitis with infection of disease, postnasal drip, and drugs. ectatic airway). Treat according to underlying condition. Perform diagnostic imaging with chest x-ray and chest CT. Treat infection. Patient is nonsmoker Patient is smoker Patient’s condition Patient’s condition improves does not improve Cough is isolated symptom Cough is associated with other worrisome symptom Observe patient. Figure 1 Algorithm illustrates workup Perform diagnostic imaging with chest x-ray and, of a patient with a chronic cough. if indicated, chest CT and bronchoscopy. Tracheobronchial irritation can trigger the cough reflex. Acute chronically inflamed airways.5,6 In a smoker, a chronic cough is irritation from inhaled substances (e.g., toxic fumes or cigarette not a particularly worrisome symptom; however, if the character smoke) can lead to bronchospasm and thence to coughing. In of the cough or the quality of the sputum changes, further workup addition, patients with asthma or reactive airway disease may pre- is indicated to look for a possible superimposed infection or neo- sent with a cough. Asthma, in fact, is one of the most common plasm.21 With both acute and chronic bronchitis, the diagnosis causes of cough. Although asthma is typically associated with can usually be made on the basis of the history and the physical shortness of breath and expiratory wheezing, some variants of findings (especially the sputum quality). asthma have cough as the sole presenting symptom (so-called Persistent airway inflammation from any cause (e.g., chronic cough-variant or cough-type asthma).5,15,19 Most persons with bronchitis, asthma, granulomatous airway disease, or cystic fibro- cough resulting from tracheobronchial irritation have a family his- sis) can lead to bronchiectasis, a state characterized by chronic air- tory of atopy or asthma. Diagnosis rests on a history of symptom way dilatation with cystic changes in the lower bronchial tree.The exacerbation with irritants or upper respiratory infections on the anatomic abnormalities in the dilated, cystic bronchi cause pool- associated findings of end-expiratory wheeze; it is confirmed by ing of mucus and secretions and impair clearance of secre- spirometry. tions.7,10,17 Cough, either dry or productive, is the major present- Tracheobronchial infection can also lead to a chronic cough. ing symptom of bronchiectasis. This condition is often accompa- Acute bronchitis from viral or bacterial infection (either primary nied by infection of the ectatic airway, which leads to purulent infection or superinfection) is typically signaled by thick, purulent secretion and systemic signs of illness that necessitate prompt secretions. It is usually self-limited, though in some cases, it may antibiotic therapy. In patients with cystic fibrosis, for example, have to be treated with a short course of antibiotics.20 Chronic daily postural drainage of the bronchiectatic airways is required, bronchitis is defined by the presence of a cough with sputum pro- and frequent hospitalization for intensive antibiotic therapy and duction that persists for at least 3 months and sometimes for chest physiotherapy is necessary. The diagnosis of bronchiectasis years. The sputum is clear or white, and there is no evidence of is made on the basis of the history and diagnostic imaging systemic infection. Chronic bronchitis almost always occurs in (including chest x-ray and, currently, chest CT). current smokers (or recent quitters), who almost invariably have Postnasal drip is one of the most common causes of cough. It
  3. 3. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 2 COUGH AND HEMOPTYSIS — 3 usually results from allergic rhinitis, sinusitis, or nasopharyngitis. cent structure (e.g., the esophagus, the mediastinum, or the pleu- Nasal secretions irritate the larynx and trachea, leading to the acti- ra). Such a fistula can result from cancer, surgery, trauma, aspira- vation of the cough reflex arc.7,12,14 Generally, the diagnosis is tion or swallowing of foreign objects (e.g., fish bones), radiation made on the basis of the history and the symptom complex. Often, therapy, chemotherapy, or infection. In this setting, the cough is however, the symptoms are vague, and the diagnosis is confirmed caused by secretions that enter the airway via the fistula. only when the patient responds to empirical therapy directed at In the occasional patient, a chronic cough may be of psy- the presumed underlying cause. Steroid nasal sprays and antihist- chogenic origin. amines are useful for ameliorating symptoms. In recalcitrant cases, Finally, a chronic cough can be caused by an endobronchial an otolaryngologic examination may be required to exclude sinus tumor (benign, malignant, or low-grade malignant).This is a quite disorders. rare circumstance that occasionally develops in patients who have Gastroesophageal reflux is increasingly being recognized as a no risk factors for lung cancer. Not uncommonly, a patient with a cause of cough and asthma. Several mechanisms have been pos- carcinoid tumor of the airway will have been treated with inhalers tulated for reflux-induced cough, including (1) mechanical aspira- and steroids for years because of the presumptive diagnosis of tion of gastric contents that leads to stimulation of cough recep- asthma. tors in the distal airways and (2) stimulation of cough receptors in the distal esophagus and the proximal stomach from refluxed acid or bile. The data currently available tend to support the second Hemoptysis mechanism for reflux-induced cough and bronchospasm.9,11,13 As noted (see above), hemoptysis may be a harbinger of life- Regardless of the mechanism responsible, the diagnosis is difficult threatening illness and should therefore be taken seriously in all to make if the typical symptoms of reflux and heartburn are circumstances. As a rule, the blood seen in the sputum derives absent. As awareness of reflux-induced asthma and cough grows, from either the pulmonary arteries or the bronchial arteries23,25,28; more patients are being evaluated with barium studies and only rarely does it come from the pulmonary veins. Although the esophageal pH monitoring, which often provide the correct diag- bronchial arteries provide less blood flow than the pulmonary nosis when clinical evaluation cannot.9 arteries do, they supply the bulk of the blood received by the air- Specific medications may also give rise to a cough. In particu- ways and, accordingly, are the source of the blood in most cases of lar, cough is a well-recognized complication of ACE inhibitor ther- hemoptysis. Hemoptysis can be caused by either tracheobronchial apy.3,4,7,8 Cough may also result from nonselective beta- disease or pulmonary parenchymal disease [see Table 2].23,25,28 One blocker therapy or may develop as a consequence of idiosyncratic should also consider the possibility that hemoptysis may be the reactions to a variety of drugs and herbal remedies. result of an aneurysm of the aorta (or one of its main branches) The presence of bronchogenic cancer is always a concern in a that has ruptured into the lung. smoker with a chronic cough.3,5,8,21,22 Any irritation of the airway, CLINICAL EVALUATION whether intrinsic (by airway tumors) or extrinsic (by parenchymal tumors), with or without associated inflammation, can lead to The differential diagnosis of hemoptysis, like that of cough, is coughing through mechanical or chemical stimulation of cough quite broad.The history and the physical examination play impor- receptors. In the general population as a whole, a chronic cough is tant diagnostic roles.The presence of associated signs of other dis- rarely the sole presenting symptom of developing lung cancer. In eases (e.g., interstitial lung diseases) often helps narrow the differ- smokers, the presence of a chronic cough, in and of itself, is not ential diagnosis.23,25,28 particularly worrisome, but any change in the character of the INVESTIGATIVE STUDIES cough, especially a change in sputum quality, is grounds for con- cern. Any degree of hemoptysis in a former smoker should be Any patient with significant hemoptysis should be admitted to taken seriously, especially if it is not associated with an infection; a hospital and evaluated promptly. Routine chest x-rays are insen- prompt evaluation with a chest x-ray and, if indicated, chest CT sitive. Chest CT with contrast can often identify the cause of he- and bronchoscopy is indicated.23-25 moptysis for both tracheobronchial or parenchymal lesions29,30; A chronic cough may also be a consequence of CHF (from any CT scanners capable of three-dimensional helical reconstruction cause), though this is not a common occurrence. Mild CHF with are especially useful in this regard. MRI has also been employed symptoms of orthopnea at night may be associated with coughing. to evaluate hemoptysis, but it has no clear advantages over chest The diagnosis is made on the basis of a history of orthopnea and CT in this setting. Given that infection is commonly associated associated cardiac risk factors or valvular disease, followed by car- with hemoptysis, one should probably consider administering diac echocardiography. antibiotics to most patients. Antitussives may be helpful in patients Occasionally, the presence of a small unrecognized tracheo- whose hemoptysis is exacerbated by excessive coughing. Coagu- bronchial foreign body can lead to chronic irritation of the lopathy should be considered and, if present, corrected aggres- bronchial epithelium and thence to a persistent cough; this pre- sively. Bronchoscopy is the key to the diagnosis, in that it is fre- sentation is more common in children than in adults.16 The diag- quently able to define the pathology of the preceding hemoptysis nosis is usually made by performing bronchoscopy in a patient (especially if the underlying condition is of tracheobronchial ori- who is believed to be harboring a foreign body on the basis of chest gin). It is particularly effective if performed within 48 hours of pre- imaging. sentation.23,25,28,31 Although either flexible bronchoscopy or rigid Eosinophilic bronchitis is a rare cause of chronic cough that may bronchoscopy may be used, flexible bronchoscopy is preferred be suspected in patients with no other clearly explainable diagno- because it is less traumatic to the airways and generally does not sis.26,27 Patients typically have a history of atopy, and the diagnosis require general anesthesia. is made on the basis of clinical suspicion and the results of Patients with massive hemoptysis should be promptly trans- bronchial epithelial biopsy. Steroids are the mainstay of treatment. ported to the operating room (if there is time) and selectively intu- In rare instances, a chronic cough may be the consequence of a bated with a rigid bronchoscope or special endotracheal tubes. fistula that connects some part of the airway or the lung to an adja- Balloon catheters may be placed for selective occlusion of the air-
  4. 4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 4 THORAX 2 COUGH AND HEMOPTYSIS — 4 Table 2 Differential Diagnosis of Hemoptysis (e.g., carcinoid and mucoepidermal carcinoma) that present in the bronchial tree and may be associated with hemoptysis. Acute or chronic bronchitis Tracheobronchial trauma, whether acquired or iatrogenic, is Bronchiectasis another cause of bloody sputum. Penetrating trauma to the Neoplasms bronchial tree or the pulmonary parenchyma, for example, can Tracheobronchial disease Foreign bodies lead to significant hemoptysis, especially if a major branch of the Trauma bronchial artery is involved.23,25,28,42 Particularly massive hemop- Tracheoinnominate fistula tysis may occur if a tracheoinnominate fistula develops after tra- Infection cheostomy.43-45 There are two types of tracheoinnominate fistula: Interstitial lung disease one develops at the tracheal stoma site as a consequence of erosion Parenchymal disease of the artery by the tracheostomy tube, and the other develops as Pulmonary embolism Pulmonary arteriovenous malformations a consequence of a more distal tracheal injury by a high-pressure cuff, which in turn injures the artery. Major bleeding can occur Mitral valve disease Miscellaneous conditions Coagulopathy with either type. Prompt diagnosis with bronchoscopy is required in any patient with a tracheostomy who presents with hemoptysis; an initial “sentinel” bleed can be followed by life-threatening hem- way or airways from which the hemoptysis originates, permitting orrhage.24,25,46,47 Treatment usually involves stabilization with rigid ventilation to continue through the unaffected airways. A rapid bronchoscopy and immediate sternotomy to control the artery and evaluation must then be carried out to identify and manage the resect the fistula. source of the bleeding.To this end, it may be necessary to perform Other forms of iatrogenic injury may occur in patients with tra- urgent angiographic embolization of a bronchial artery, to place a cheobronchial stents, which often irritate the mucosa and cause stent in a pulmonary artery, or to resect a portion of the lung. bleeding. In most cases, such bleeding is mild, but on occasion, the Unfortunately, the majority of patients with massive hemoptysis do stents (particularly the metallic expandable ones) erode through not survive, dying of hemorrhagic shock and suffocation.Thus, the the bronchial wall and penetrate into a major blood vessel (usual- goal of the treating physician should be to identify and treat these ly the pulmonary artery or the aorta). Hemoptysis may also occur patients before they experience their final hemoptysis. in patients who have undergone bronchial biopsies and those in whom pulmonary arterial catheters have been placed.48,49 The MANAGEMENT OF SPECIFIC CAUSES same effect may be observed in patients who have harbored foreign Tracheobronchial disease is the most common cause of hemop- bodies in the tracheobronchial tree for extended periods.24 tysis. Acute or chronic bronchitis leads to airway inflammation and Pulmonary parenchymal disease can lead to hemoptysis as well, sputum production, often associated with hemoptysis from the though less often than tracheobronchial disease does. Parenchy- bronchial artery branches found within the mucosa; the bleeding mal infection, especially from tuberculosis and aspergillosis, is a is usually minor.23,25,28 Bronchiectasis leads to bronchial artery common cause of hemoptysis.23,25,28,50 Aspergillosis, in particular, dilatation, along with cystic dilatation of the bronchial tree10,23,25,28; has a propensity for vascular invasion and thus can result in mas- the bleeding is often massive in this setting. sive hemoptysis.50 The various interstitial lung diseases (e.g., colla- Numerous types of tracheobronchial neoplasms, including var- gen vascular disorders, Goodpasture syndrome, and Wegener gran- ious benign and malignant primary epithelial and soft tissue ulomatosis) often have hemoptysis as their primary presenting tumors, have been associated with hemoptysis.32-39 The majority of symptom.51-53 Pulmonary embolism can lead to hemoptysis if it primary airway tumors are malignant, with squamous cell carcino- involves a significant portion of pulmonary parenchyma.23,25,28,54 ma and adenoid cystic carcinoma being the primary malignancies Mitral valve disease with resulting left atrial hypertension can also most frequently seen in the trachea.32-38 The majority of malignant result in hemoptysis. Any form of coagulopathy resulting from a airway tumors, however, are metastases rather than primary malig- low platelet count or a deficiency in clotting factors, therapeutic or nancies. Invasion of the tracheobronchial tree by adjacent lung, not, can lead to hemoptysis; such conditions must be corrected in thyroid, esophageal, or laryngeal tumors is not common, but it has patients who experience massive or persistent episodes. Another been described.33,34,39,40 Colon cancers, breast cancers, melano- rare cause of bloody sputum is congenital pulmonary arteriove- mas, and renal cancers have been reported to metastasize to the nous malformation, which typically is diagnosed only after chest trachea, albeit very rarely.39,41 There are also low-grade tumors imaging.55,56 References 1. Irwin RS, Boulet LP, Cloutier MM, et al: Managing anisms of acute cough. Pulm Pharmacol Ther 17: 119:977, 1993 cough as a defense mechanism and as a symptom: 389, 2004 9. 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