Cough Physiology, mechanism. Approach to cough. Acute vs chronic cough. Types of cough. Sputum Color, History and Examination. Hemoptysis Physiology, common causes. Hemoptysis vs Hematemesis. Case scenarios. Cardiac vs Respiratory cause of cough

1. APPROACH TO COUGH
AND HEMOPTYSIS

2. COUGH
1. Protective airway reflex
2. Reflex arc –
Afferent – Vagus and superior laryngeal nerves with receptors in
pharynx, larynx, tracheobronchial tree, external auditory meatus
and esophagus.
Integrating center – Nucleus tractus solitarius, cough center
Efferent – Recurrent laryngeal nerve and phrenic nerves

3. MECHANISM OF COUGH

4. APPROACH TO COUGH

5. CASE SCENARIO – WHAT WILL YOU
WANT TO KNOW ?
42 yr old male presents with history of cough for 2 weeks…..

6. BEDSIDE ASSESSMENT OF COUGH
1. Duration – Acute (<3 wk), subacute, chronic (>8 wk)
2. Variability (Daytime, nocturnal, morning)
3. Precipitating factors (dust, fumes, allergans, lying down, sideways
turning)
4. Expectoration
5. Hemoptysis
6. Associated symptoms – postnasal drip, GERD, wheeze, dyspnea,
chest pain, fever
7. Drug intake – ACE inhibitors

7. ACUTE VS CHRONIC COUGH

8. WHICH SYSTEM –
CARDIOVASCULAR OR
RESPIRATORY
CARDIAC RESPIRATORY
Night time Early morning/ seasonal / no variation
Orthopnea, PND, palpitations may be seen Orthopnea may be present
JVP raised, pedal edema seen None
Crepitation in dependent lung areas Crepitation according to the lobe affected

9. TYPES OF COUGH
1. Dry cough – Pleuritis, ILD, acute tracheobronchitis, asthama, GERD
2. Productive – Pneumonias (infective), bronchiectasis, lung abscess
3. Whooping cough
4. Barking cough – epiglottitis
5. Croupy cough - Laryngotrachebronchitis

10. SPUTUM – COLOR OF SPUTUM

11. RELEVANT HISTORY - COUGH
1. HOPI – As discussed
2. Past history – TB, Asthma, COPD, HTN
3. Personal history – Smoking, Chulha exposure, food habits
4. Treatment history – MDI use, ACE inhibitors
5. Family history – Atopy, asthma in family, CA lung
6. Socioeconomic history – overcrowding

12. RELEVANT EXAMINATION
1. GPE – clubbing (CA lung, bronchiectasis, lung abscess), cyanosis,
pedal edema (RHD, ADHF, CHD), Tympanic membrane (Arnold’s
nerve),
2. Respiratory examination – wheeze/ crepitations, bronchial
breathing, dull note on percussion
3. Cardiovascular examination – S3, parasternal heave, down and out
apex

13. HEMOPTYSIS

14. PHYSIOLOGY
Lung has dual blood supply – Pulmonary (low pressure system) and
Bronchial (high pressure system)
Bronchial arteries neovascularize tumors and bronchiectasis areas
and cavities. Most common artery of bleed is bronchial artery.
In TB pulmonary artery are dilated and Rasmussen aneurysm may
form leading to bleeding.
Massive hemoptysis – 400 mL in 24 hrs or 100-150 mL at a single
time

15. COMMON CAUSES
1. Bronchiectasis
2. Pulmonary TB
3. Bronchitis - Viral
4. Bronchogenic CA
5. Pneumonia
6. Mitral stenosis

16. HEMOPTYSIS VS HEMATEMESIS
HEMOPTYSIS HEMATEMESIS
Blood mixed with sputum Blood mixed with food particles
Bright red in color Coffee brown in color
Alkaline Acidic
Melena absent Melena may be present
Pulmonary symptoms GI symptoms

17. RELEVANT HISTORY – HEMOPTYSIS
1. HOPI – Amount, hematemesis vs hemoptysis
2. Past history – Prior TB, COPD
3. Personal history – Smoking
4. Family history – CA lung, TB
5. Treatment history – anticoagulant, aspirin

18. EXAMINATION
1. GPE – clubbing, pallor, vitals
2. Respiratory and cardiovascular examination

19. CASE SCENARIO

20. CASE 1
A 21-year-old man presents to his doctor with a cough that has been
bothering him and asks to speak to the pharmacist.
History ? ? ?
The patient explains that he has had a cough for two days and it is dry in
nature with no sputum, but he is coughing frequently and it is keeping him
up at night with a headache. He is currently a student, a non-smoker and
drinks occasionally. He has no relevant medical history and has not taken
any medicines or OTC treatments.
Diagnosis ? ? ?
Since the patient has no comorbidities or symptoms to indicate a more
serious condition, it is likely that he has an acute viral upper respiratory tract
infection (e.g. a cold) that will resolve itself in three to four weeks without
antibiotics

21. CASE 2
A 42-year-old woman presents to the doctor with an ongoing cough
that is causing her problems and would like to buy some cough
medicine.
The patient explains that she is an office worker, has been smoking
20 cigarettes per day since the age of 15 years and has had a cough
for the past three months. She has not wanted to bother her GP as
the cough is persistent throughout the whole day and is mildly
expectorant in nature. She has been having pain in her ribs, but she
feels this is only owing to her coughing constantly. She has noticed
recently that she has been feeling more breathless and is unable to
walk up the hill to her house without stopping, like she did
previously. She has also noticed that, in the past couple of
weeks, there have been red blood spots on her tissue when she
coughs. She also complains of severe loss of appetite and weight.
Likely CA lung

22. CASE 3
A 43 year old male presents with complains of fever for 4 months and
hemoptysis for 3 months.
The patient tells that he has been having fever for 4 months which
was evening rise and low grade. It was associated with significant loss
of weight around 10 kgs in the last 3 months. He also feels like not
wanting to eat anything. He is also having cough for 3 months which
is associated with blood streaking around 30-40 mL per day. The
cough is more at night and associated with occasional wheezing. He
is a chronic smoker and smokes around 12 bidi/day for the last 20
yrs. He has a prior history of tuberculosis 15 yrs back for which he
received treatment for 6 months. He lives in a single room with his
family of his wife and 4 children and is a rickshaw puller.

23. LONG CASE - HISTORY
A 45 year old male presents with 3 days of fever and cough. He was
previously well without prior hospitalizations or known chronic illnesses,
working as a school teacher and farmer, always monogamous since
marriage, and the father of 5 healthy children 10 to 25 years old. Three days
ago he returned early from the fields feeling weak, “hot and cold”, with
intermittent chills. He slept uncomfortably, and the next morning was
nauseated, vomited twice and had 2 loose bowel movements that then
turned watery (without blood) with his 3rd episode. He was too weak to
work. The next day he developed a mild dry cough that later became
productive of scant white-yellow sputum with streaks of blood. On the day
of admission, he awoke confused, talked non-sense to his wife, couldn’t get
out of bed, complained of abdominal pain and some shortness of breath,
and was incontinent of diarrhea. He had no chest pain. His wife became
alarmed and called the village health worker who arranged for transport to
the hospital. He never had similar symptoms before, hadn’t had unusual
problems with abdominal pain, cough or wheezing in the past, doesn’t
smoke, drinks socially1-2 times/week without becoming drunk, and hasn’t
lost consciousness, weight, or appetite recently.

24. DIFFERENTIALS ?

25. LONG CASE - EXAMINATION
Sitting up in bed in moderate respiratory distress, occasionally
speaking incoherently BP 78/40 without orthostatic change; HR 156,
regular; Temperature, 103.2 axillary; RR 36; pulse oximetry, 88% sat.
Skin: normal, without rash or herpes zoster scar Eyes: conjunctiva
without icterus or pallor; Mouth: dry mucous membranes; no thrush
ENT: no pharyngeal exudates/erythema; no nasal discharge or sinus
tenderness; Neck: no lymphadenopathy, thyroid palpable/normal; no
JVP except when lying flat; Lungs: dull to percussion and increased
tubular breath sounds with, egophony, and scant crackles over the
right lower lung field; Abdomen: mildly distended, normal bowel
sounds, no guarding/rigidity/tenderness or masses noted to
superficial or deep palpation; liver span 10 cm to percussion with
percussion tenderness noted in RUQ, no edge palpated; spleen non-
palpable. Neuro: disoriented to place and time, incoherent, unable to
assess attention span; grossly nonfocal and moving all extremities;

26. CHEST X RAY

27. DIFFERENTIALS ?

28. QUIZ

29. MATCH THE COLUMN
Column 1 Column 2
Acute cough > 8 weeks
Subacute cough < 2 weeks
Chronic cough 3-8 weeks
< 3 weeks

30. FILL IN THE BLANKS
Orthopnea and PND are suggestive of ___________ etiology of cough

31. MCQ
Barking cough is seen in ?
A. Pneumonia
B. Pleural effusion
C. Laryngotracheobronchitis
D. Epiglottitis

32. PICTURE QUIZ
Pink frothy sputum

33. PICTURE QUIZ
Purulent

34. PICTURE QUIZ
Rusty sputum

35. PICTURE QUIZ
Anchovy sauce

36. MCQ
Volume of massive hemoptysis –
A. ~ 200 mL at a single time
B. 100-600 mL over 24 hrs
C. 150 mL at a single time.
D. > 400 mL over 24 hrs

37. WHAT IS THE SYSTEM INVOLVED?
42 yr old male, chronic smoker and alcoholic came with complains of
throwing of large amounts of blood with cough and retching. He has
around 3-4 cup full of bloody sputum which was coffee ground in
color for past 3 days. There is history of passage of dark taary
colored stools for last 2 days.

38. WHAT SYSTEM IS INVOLVED
72 yr old male, k/c/o T2DM presents with cough which is exertional
and more in early morning. It is associated with expectoration which
is pink frothy in nature and it worsens on lying down. Sometimes he
wakes up in night suddenly and goes to the window gasping for air
and coughing.

39. THANK YOU