This presentation cover cough haemoptysis and lung cancer. Made by Dr Muhammad Raza,PG Trainee Family Medicine at FMH Lhr

1. Cough,Cough,Haemoptysis &Haemoptysis &
Lung cancerLung cancer
Dr Muhammad Raza (MCPS Family medicine P.G.Trainee)

2. Defining CoughDefining Cough
Two possible definitions of cough as per European Respiratory Society :
A three-phase expulsive motor act characterized by an inspiratory effort
(inspiratory phase) followed by a forced expiratory effort against a closed
glottis (compressive phase) and then by opening of the glottis and rapid
expiratory airflow (expulsive phase)’.
Cough is a forced expulsive maneuver, usually against a closed glottis and
which is associated with a characteristic sound.

3. Signaling PathwaysSignaling Pathways

4. Mechanism of CoughMechanism of Cough
 The cough begins with a rapid inspiration, followed, in rapid
sequence, by closure of the glottis, contraction of the
abdominal and thoracic expiratory muscles, abrupt increase
in pleural and intrapulmonary pressures, sudden opening of
the glottis, and expulsion of a burst of air from the mouth.

5. Cough HistoryCough History

6. (Acute Cough)(Acute Cough)
Causes & Characteristics of CoughCauses & Characteristics of Cough
 Sinusitis or NasopharygnitisSinusitis or Nasopharygnitis
Cough following an upper respiratory syndrome or sinus
symptoms; sensation of a need to clear the throat; postnasal
drip
 Lobar pneumoniaLobar pneumonia
Cough often preceded by symptoms of upper respiratory
infection; cough dry, painful at first; later becomes productive

7. • Most common causesMost common causes
– Common cold (viral )
– Acute bacterial sinusitis
– Pertussis
– Exacerbation of COPD
– Allergic rhinitis
– Rhinitis secondary to environmental irritants
Conti…Conti…

8. (Chronic Cough)(Chronic Cough)
Causes & Characteristics of CoughCauses & Characteristics of Cough
BronchiectasisBronchiectasis
Cough copious, foul, purulent, often since childhood; forms
layers upon standing
1.upper : bubble-like, frothy, faomy
(partly from saliva)
2.middle : thin sero-mucus liquid
3.base : pus ,necrotic tissue , cell debris

9.  Tuberculosis or fungusTuberculosis or fungus
Persistent cough for weeks to months, often with blood-
tinged sputum
 Interstitial fibrosis and infiltrationsInterstitial fibrosis and infiltrations
Cough nonproductive, persistent
 SmokingSmoking
Cough usually persistent, most marked in morning, usually
only slightly productive unless succeeded by chronic
bronchitis
Conti…Conti…

10. Conti…Conti…
 Gastroesophageal reflux (GERD)Gastroesophageal reflux (GERD)
Nonproductive cough often following meals ; may (or may not)
be accompanied by other symptoms of GERD(e.g., heartburn,
a bitter oral taste, belching)
 Left ventricular failureLeft ventricular failure
Cough intensifies while supine, along with aggravation of
dyspnea

11.  Pulmonary infarctionPulmonary infarction
Cough associated with hemoptysis, usually with pleural
effusion
 Angiotensin-converting enzyme (ACE) inhibitorsAngiotensin-converting enzyme (ACE) inhibitors
Nonproductive cough, more common in women, may occur
at any time (following soon after drug initiation or with
years of use)
Conti…Conti…

12. Treatment of CoughTreatment of Cough
 Cough is useful physiological mechanism that serves to clear
the respiratory passages of foreign material and excess
secretions
– It should not be suppressed indiscriminately
There are however, many situations in which cough does not
serve any useful purpose
– Instead it only annoys the patient or prevents rest and sleep

13. Antitussives (cough centre suppressants)
Antihistamines
Bronchodilators
Pharyngeal demulcents
Expectorants, Mucokinetics & mucolytics
Conti…Conti…

14. Specific Treatment Approach to CoughSpecific Treatment Approach to Cough
1) Upper / Lower respiratory
– Appropriate antibiotics tract infections
2) Smoking / Chronic bronchitis
– Cessation of smoking
3) Pulmonary Tuberculosis
– Antibiotics
4) Asthmatic cough
– Inhaled ᵦ2 agnostics / ipratropium / corticosteroid
5) Postnasal drip (sinusitis)
– Antibiotics, nasal decongestants, antihistamines

15. HemoptysisHemoptysis
 Hemoptysis is defined as coughing of blood originating from
below the vocal cords.
 The word "hemoptysis" comes from the Greek "haima"
meaning "blood“ & "ptysis" which means "a spitting".
 Hemoptysis can range from blood-streaking of sputum to the
presence of gross blood in the absence of any accompanying
sputum.

16. Life threatening (or) Massive hemoptysis is defined as
coughing of blood > 150 ml/time (or) > 600 ml/24 hours.
Only 5% of hemoptysis is massive but mortality is 80%.
Conti…Conti…

17. True Hemoptysis VersusTrue Hemoptysis Versus
Spurious (False) HemoptysisSpurious (False) Hemoptysis
True hemoptysisTrue hemoptysis False hemoptysisFalse hemoptysis
Below vocal cords Above vocal cords
Persists as blood tinged sputum Sputum is free of blood
Blood may be mixed with sputum Not mixed with sputum
History of cardiopulmonary disease Obvious by ENT examination
CXR may be abnormal Normal CXR

18. Hemoptysis VersusHemoptysis Versus
HematemesisHematemesis
HemoptysisHemoptysis HematemesisHematemesis
Coughing of bloodCoughing of blood Vomiting of bloodVomiting of blood
History of cardiopulmonary diseaseHistory of cardiopulmonary disease History of GIT diseaseHistory of GIT disease
Blood bright red in colorBlood bright red in color Dark brown in colorDark brown in color
Sputum remains blood stained after theSputum remains blood stained after the
attack for few daysattack for few days
Usually followed by melenaUsually followed by melena
Mixed with sputumMixed with sputum Mixed with gastric contentsMixed with gastric contents
Blood is frothyBlood is frothy AirlessAirless
AlkalineAlkaline AcidicAcidic
Sputum contains hemosedrin ladenSputum contains hemosedrin laden
macrophagesmacrophages
NoNo

20. Cause of HemoptysisCause of Hemoptysis

21. Causes of Massive HemoptysisCauses of Massive Hemoptysis
1. Pulmonary tuberculosis.
2. Pulmonary infarction.
3. Bronchiectasis.
4. Cystic fibrosis
5. Lung abscess.
6. Necrotizing pneumonia.
7. Mitral stenosis.
8. Pulmonary arteriovenous malformation.

22. Mechanism & Sources ofMechanism & Sources of
HemoptysisHemoptysis
Sources
1.Bronchial circulation.
2.Pulmonary circulation.
3.Anastomosis between pulmonary & bronchial circulation.

23. Mechanisms
1. Vessel engorgement.
2. Erosion (or) rupture of vessels.
3. Mucosal ulceration.
4. Vascular granulation tissue.
Conti…Conti…

24. Evaluation for HemoptysisEvaluation for Hemoptysis
 History, Physical Examination, Chest Radiograph
 CBC (Degree of anemia which may influence rapidity of
further testing & transfusion of blood products,
thrombocytopenia may be a contributing factor)
 Measurement of Coagulation Times
 Renal function and Urinalysis (when a systemic process which
causes pulmonary-renal syndrome is a possibility)

25.  Depending on circumstances Sputum Culture & Stains or
Cytologic examination should be performed.
 A high-resolution computed tomography (HRCT) of the
chest is usually the next step if the patient has no history of
tobacco use or if the plain chest radiograph suggests a
parenchymal abnormality, such as bronchiectasis or
arteriovenous malformation.
 Patients with a history of tobacco use or other risk factors for
a malignancy warrant fiber optic bronchoscopy
Conti…Conti…

26. Clinical Approach for ManagementClinical Approach for Management
of Hemoptysisof Hemoptysis
 Make sure that this is True Hemoptysis.
 Identify the Severity of hemoptysis.
 Clinical clues in History & Examination.
 Diagnostic Investigations.
 Appropriate Treatment.

27. Management of HemoptysisManagement of Hemoptysis
GoalGoal
1.Evaluate the severity of hemoptysis.
2.Airway protection & patency.
3.Identify the site of bleeding.
4.Protect the contralateral un involved lung.
5.Stop the bleeding.
6.Treatment of the cause of bleeding.

28. Management of Minor hemoptysisManagement of Minor hemoptysis
Minor hemoptysisMinor hemoptysis
 Effort should be concentrated on determining the origin of
the hemoptysis, providing specific treatment where available
and excluding serious underlying pathology.
 Normal CXR, history consistent with bronchitis - oral
antibiotic, advise smoking cessation and follow-up in a few
weeks.

29.  Consider chest CT scan and bronchoscopy where:
– Haemoptysis lasts longer than 2 weeks.
– There are recurrent episodes of haemoptysis.
– The volume of haemoptysis is >30 ml per day.
– The patient is a smoker and >40 years old.
– There is suspected bronchiectasis.
Conti…Conti…

30. Moderate haemoptysis
 Moderate hemoptysis (30-50 ml in the previous 24 hours)
requires hospitalization for observation, due to increased risk
of further heavy bleeding.
 Nurse in the semi-sitting position when awake and with
abnormal lung down when lying in bed.
 Consider cough suppression with codeine but avoid over
sedation.
 Await bronchoscopy - diagnostic yield is often highest when
performed a few days after bleeding has stopped.

31. Major haemoptysisMajor haemoptysis
 ≥500 mL of expectorated blood over a 24 hour period or
bleeding at a rate ≥100 mL/hour,
 This is a medical emergency which require immediate
hospital admission
• Treatment categories into > Medical > Surgical >
Endobronchial > Endovascular

32. Management of MassiveManagement of Massive
HemoptysisHemoptysis
I. Medical
 Endotracheal tube (single wide bore (or) double lumen).
 Position of the patient sitting (or) bleeding side down
 Large bore IV line fluids, blood transfusion .
 Supplemental Oxygen/ Mechanical ventilation.
 Avoid cough suppressants (if necessary Benzodiazepine).
 Pitressin (Vasopressin) 0.2-0.4 units/min. IV.
 Oral tranexamic acid has been used long term in recurrent bleeders with some
success. Dose is 15-25 mg/kg TDS (max 1.5 g/dose).

33. Conti..Conti..
II. Surgical
Emergency resection for bronchogenic mass.
Resection of bronchogenic mass after patient stabilization.
Surgical resection for aspergilloma.

34. III. Endobronchial
Identify the bleeder: determine source, Rate & to Slow (or)
Arrest bleeding.

35. IV. Endovascular:
 First results of embolization were published in 1973.
 In most patients the bleeding originates from bronchial
arteries rather than pulmonary arteries.
 Trans catheter embolization is effective in immediate
control of massive hemoptysis (73% - 98%).
Conti..Conti..

36. Recurrence may be caused by:
– Incomplete embolization of artery.
– Recanalization of previously embolized artery.
– Revascularization through collateral
circulation.
– Progression of basic lung disease.
Conti..Conti..

37. Complications of HemoptysisComplications of Hemoptysis
 Asphyxia
 Shock
 Anemia
 Renal failure
 Atelectasis
 Pulmonary infection

38. PrognosisPrognosis
 Haemoptysis may be a mild, self-limiting symptom or may
herald serious underlying disease.
 Massive haemoptysis can directly cause death and has a bad
prognosis, worse in some groups such as those with an
underlying cancer.

39. Lung CancerLung Cancer
 Lung cancer has been the most common cancer in the world
for several decades.
 Lung cancer usually starts in the lining of bronchi , but can
also begin in other area of respiratory system , including the
trachea , broncheoles , or alveoli.
 Lung cancers are believed to develop over a periods of many
years.

40. Cancer is a leading cause of death worldwide,
accounting for 8.8 million deaths in 2015.
 The most common causes of cancer death are cancers of:
 Lung (1.69 million deaths)19.4% of total.
 Liver (788 000 deaths)
 Colorectal (774 000 deaths)
 Stomach (754 000 deaths)
 Breast (571 000 deaths)

41. Clinical PresentationClinical Presentation
S/S Incidence
Cough 75%
Hemoptysis 50%
Dyspnea 40%
Chest pain 35%
Hoarseness 5%
SVC syndrome 5%

42. Lung Cancer Risk Factors (2007Lung Cancer Risk Factors (2007
American Cancer Society Data)American Cancer Society Data)
 Gender
 Smoking history
 Older age
 Presence of airflow obstruction
 Genetic predisposition
 Occupational
exposures(Arsenic,Asbestos,Chromium,Mustard
gas,Nickel,Silica,Vinyl chloride and polycyclic aromatic

43. Lung Cancer and GenderLung Cancer and Gender
(2007 American Cancer Society Data)(2007 American Cancer Society Data)
 Male predilection, but changing rapidly
 Increase in women smokers
– 55% Men
– 45% Women

44. LUNG CANCERLUNG CANCER
(2007 American Cancer Society Data)(2007 American Cancer Society Data)
Tobacco Percent
Active 85-87
Passive 3-5
Etiology
Relationship to Smoking

45. Lung Cancer and SmokingLung Cancer and Smoking
(2007 American Cancer Society Data)(2007 American Cancer Society Data)
 ~90% of lung cancers attributed to smoking
 However, only 20% smokers will develop lung cancer in their
lifetime.
 Risk decreases when stop smoking
 Yet, 50% of new cases are former smokers

46. DIAGNOSTIC WORKUPDIAGNOSTIC WORKUP
 History: metastasis symptoms
 P/E: H & N lymph nodes
 Chest X-ray
 CT: the most valuable radiologic study for evaluation,
staging, and therapeutic planning of lung cancer
 MRI: mediastinum or paravertebral region
 Bone scans: stage III before curative therapy

47.  PET scan
 Brain CT scan: small cell carcinoma.
 Pulmonary function tests: ability to undergo surgical resection
or withstand irradiation
Conti..Conti..

48.  Sputum cytology: 20% to 30% sensitivity
 Bronchoscopic examination: 90% positive
 CT-guided Bx: 95% positive
 Bx: Primary tumor lesion
Conti..Conti..

49. Types of lung cancerTypes of lung cancer
Non small cell carcinoma(NSCC) 85%
– Adenocarcinoma 40%
– Squamous cell carcinoma(epidermoid)30%
– Large cell carcinoma 15%
Small cell carcinoma 15%

50. Adenocarcinoma 40%Adenocarcinoma 40%
 Location: Peripheral
 Characteristics: Most common lung cancer in non smokers
and overall,associated with hypertrophic
osteoarthopathy(clubbing)
 CXR often shows hazzy infiltrates similar pneumonia
 Prognosis is excellent
 Histology:Thickening of alveolar walls

51. Squamous cell carcinoma 30%Squamous cell carcinoma 30%
 location: Central
 Characteristics: Hilar mass arising from bronchus; Cavitation;
Cigarettes; hyperCalcemia; This type of lung cancer most
often stays within the lung, spreads to lymph nodes, and
grows quite large, forming a cavity
 Histology: Keratin pearls and intracellular bridges

52. Large cell carcinoma 15%Large cell carcinoma 15%
 Location: peripheral
 Characteristics: Highly anaplastic, This type of cancer has a
high tendency to spread to the lymph nodes and distant sites
 Pronosis: Very poor,less responsive to chemotherapy
 Histology: Pleomorphic giant cells

53. Small cell carcinoma 15%Small cell carcinoma 15%
 Location: Central
 Characteristics: Undifferentiated, very aggressive , may
produce ACTH,ADH. SCLC is strongly related to
cigarette smoking. It metastasize rapidly to many sites within
the body and are most often discovered after they have
spread extensively.
 Prognosis: Inoperable,Treat with chemotherapy
 Histology: Neoplasm of neuroendocrine cells

54. Other TypesOther Types
Some other types of lung cancers are
Bronchial carcinoid tumors
Mesothelioma
Pancoast tumors

55. TNM categories in lung cancerTNM categories in lung cancer
T1-T4: T1: < 3cm, surr by lung
T2: > 3cm / main bronchus /
visceral pleura
T3: any size / invades chest wall / diaph
mediast pleura / parietal pericard
T4: any size / invades
mediastinum /malignant effusion

56. Conti…Conti…
N1-N3: N1: intrapulm / peribronch / hilar
N2: ipsilateral mediastinal /
subcarinal
N3: ipsilateral or contralateral
scalene / supraclavic / contralateral
mediastinal / contralateral hilar

57. M0 –M1: M0: No distant Mets
M1: Distant Mets
Conti…Conti…

58. .
Management: ACCP guidelines(5)Management: ACCP guidelines(5)
CT Screening
• Only to smokers age
55-74, with > 30
pack/year of smoking
• Not to pts. with
severe comorbidities
Stages I & II
• VATS with
systematic lymph
node sampling
preferred
• Better outcomes
with specialty-
trained surgeons &
at high-volume
centers
Stage III
• Chemo + radiation
therapy for most
N2,3 pts
• Trimodal approach
for toxicity mgmt.
• Tailor treatment
depending on
mediastinal
involvement
Stage IV
• EGFR+ pts: targeted
therapy (TKRIs >
Gefitinib) is 1st
line of
treatment
• Appropriate
maintenance
chemotherapy
• VEGF inhibitors safe
& useful
• Doublet
chemotherapy in
selected cases
ACCP, American College of Chest Physicians; chemo, chemotherapy; mgmt., management; NLST, National Lung Cancer Screening Trial; pts., patients;
VATS, video-assisted thoracic surgery; VEGF, Vascular endothelial growth factor.Cisplatin+carboplatin(doublet therapy)
5. Detterbeck FC, Lewis SZ, Diekemper R, Addrizzo-Harris D, Alberts WM. Executive Summary: Diagnosis and management of lung cancer, 3rd ed:
American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):7s-37s.
Advances in treatment for different stages

59. lung cancer-Metastasislung cancer-Metastasis
 Adrenals - ~50% of cancers
 Liver – 30-50%
 Brain – 20%
 Bone – 20%

61. Thank YouThank You 