Presentation of two of the cardinal symptoms of pulmonary medicine, cough and hemoptysis.

1. Cough & Hemoptysis

2. Defining Cough
Two possible definitions of 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.
Although some similarities exist, the major discrepancy
between these two definitions relates to the respiratory
patterns associated with cough. In particular, the preceding
inspiratory phase, which constitutes the first definition, is
believed to be one of a number of distinguishing features
between cough and another airway defensive reflex, the
expiration reflex

3. Signaling Pathways
Receptors in the airways are most concentrated
in the larynx, diminish in density in the
conducting airways, and are absent from the
distal airways, enabling the pooling of secretions
in the periphery

4.  The cough reflex may be impaired by interrupting
or blunting any step in the sequence. Irritant
receptors can be damaged by a local
destructive process (e.g., bronchiectasis), or their
sensitivity can be diminished by narcotics or
anesthetics

5. Mechanism 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.

6. Sequence of events during
a cough

8.  The high intrathoracic pressures, which often
exceed 100 to 200 mmHg, increase the velocity
of airflow through the airways, hastening the
propulsion of the offending particles and
producing the sound of a cough by setting into
vibration airway secretions, the tracheobronchial
walls, and the adjacent parenchyma.

9. Causes & Characteristics of
Cough (Acute Cough)
 Sinusitis or Nasopharygnitis: Cough following an
upper respiratory syndrome or sinus symptoms;
sensation of a need to clear the throat; postnasal
drip
 Lobar pneumonia: Cough often preceded by
symptoms of upper respiratory infection; cough
dry, painful at first; later becomes productive
 Chronic Bronchitis: Cough productive of sputum
on most days for more than 3 consecutive
months and for more than 2 years Sputum
mucoid until acute exacerbation, when it
becomes mucopurulent

10. Causes & Characteristics of
Cough (Chronic Cough)
 Bronchiectasis: 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
 Tuberculosis or fungus: Persistent cough for weeks to
months, often with blood-tinged sputum

11. Causes & Characteristics of
Cough (Parenchymal
Inflammatory Process)
 Interstitial fibrosis and infiltrations : Cough
nonproductive, persistent
 Smoking : Cough usually associated with injected
pharynx; persistent, most marked in morning,
usually only slightly productive unless succeeded
by chronic bronchitis

12.  Gastrioesophageal reflux (GERD): Nonproductive
cough often following meals or with recumbancy;
may (or may not) be accompanied by other
symptoms of GERD(e.g., heartburn, a bitter oral
taste, belching)
 Foreign body
 Immediate : while still in upper airway Cough
associated with progressive evidence of
asphyxiation
 Later : when lodged in lower airway Nonproductive
cough, persistent, associated with localizing
wheeze

13.  Left ventricular failure : Cough intensifies while
supine, along with aggravation of dyspnea
 Pulmonary infarction : Cough associated with
hemoptysis, usually with pleural effusion
 Angiotensin-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)

15. Cough Medications
 Pharyngeal Demulcents: Lozenges, Cough Drops,
Linctuses containing syrup, glycerine, liquorice.
 Expectorants :
Bronchial Secretion Enhancers :
Na+, K+ Citrate (Salt Action), Potassium Iodide (Irritant
to Bronchial Mucosa), Ammonium Chloride
(Nauseating-reflexly increasing respiratory
secretions),
Guaiphenesin, Vasaka, Tolu balsum are plant
products which are supposed to enhance bronchial
secretion and mucociliary function while being
secreted by tracheobronchial glands.

16. Mucolytics :
Bromohexine - potent mucolytic and mucokinetic, capable of inducing thin
copious bronchial secretion. It depolymerises mucopolvsaccharides directly as
well as by liberating lysosomal enzymes network of fibres in tenacious sputum is
broken. It is particularly useful if mucus plugs are present.
S/E – Rhinorrhea, Lacrimation
Ambroxol – Metabolite of bromohexine. Similar profile.
Acetylcystein - It opens disulfide bonds in mucoproteins present in sputum and
makes it less viscid, but has to be administered directly into the respiratory
tract.
Carbocystein – Liquifies viscid sputum in similar way as acetylcystein but can
be administered orally.
S/E – GI Irritation & Rash

17.  Anti-Tussives : Should be used only for dry, unproductive
cough or if cough is unduly tiring, disturbs sleep or is hazardus
(hernia, piles, cardiac disease, ocular surgery)
OPIOIDS:
Codein : Opium alkaloid more selective for cough centre.
Abuse liability is low.
Supresses cough for about 6hr.
S/E – Constipation
C/I – Asthmatics and patients with diminshed respiratory reserve.
Pholcodein : Similar antitussive efficacy as codein. Longer
acting -- 12hr. No analgesic or addicting property.

18. NON OPIOIDS:
Noscapine (Narcotine): Antitussive efficacy equal to codein, especially
useful in spasmodic cough. No narcotic, analgesic or dependence. It
can release histamin and cause bronchoconstriction in asthmatics.
Dextromethorphan : Synthetic Compound.
D-isomer  Raises threshold of cough centre.
L-ismoer  Analgesic
As effective as codein, devoid of constipation and addicting action.
Action ~ 6 hrs.
S/E – Dizziness,Nausea, Drowsiness, Ataxia.
Clophedianol : Slow onset and longer duration of action.

19.  Anti Histaminics : They afford relief in cough due to their
sedative and anticholinergic actions, but lack selectivity
for the cough centre . No expectorant property, may
even reduce secretions by anticholinergic action. They
have been specially promoted for cough in respiratory
allergic states, though their lack of efficacy in asthma is
legendary. Chlorpheniramine, Diphenhydramine and
Promethazine are commonly used. Second Generations
like Fexofenadine and Loratidine are ineffective.
 Bronchodilators : They should be used only when an
element of bronchoconstriction is present and not
routinely
 Aeromatic Chest Rub : shown to reduce experimentally
induced cough in healthy volunteers, there is no evidence
of benefit in pathological cough

20. Circulatory Consequences
of Cough

21. Posttussive Syncope

22. Hemoptysis
 The coughing up of blood is termed ‘hemoptysis’
 Massive hemoptysis has been variably defined
according to the volume, but implies a life-threatening
process requiring immediate
evaluation and treatment.

23. Hemoptysis vs Hematemesis
blood that originates in the airways is usually bright
red, is mixed with frothy sputum, has an alkaline pH,
and contains alveolar macrophages that are
laden with hemosiderin; in contrast, blood from the
stomach usually is dark, has an acid pH, contains
food particles, and often occurs in patients with a
long history of gastric complaints.

24.  Blood arising from the bronchial arteries is more
often the source of massive hemoptysis, owing to
its higher perfusion pressure than blood from the
pulmonary circulation.

26. Evaluation for Hemoptysis
 History, Physical Examination, Chest Radiograph
 CBC (Degree of anemia 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)
 Depending on circumstances Sputum Culture &
Stains or Cytologic examination should be
performed.

27.  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
 Patients with chronic bronchitis and at low risk for
malignancy, or in whom the chest radiograph is normal or
identifies the cause of hemoptysis (e.g., epistaxis or
pneumonia) can usually be treated initially for bronchitis
with follow-up appraisals to show prompt resolution of
hemoptysis. However, should hemoptysis recur, further
evaluation is required.

28. Neoplams & Hemoptysis
 Non-massive hemoptysis is common in bronchogenic
carcinoma; less frequently it is the cause of massive
hemoptysis
 Troublesome cough and vague chest pain precede and
accompany the hemoptysis.
 Most often the bleeding is a consequence of ulceration
caused by an expanding tumor; sometimes it is due to a
pneumonic process or to an abscess in the lung behind
the obstructive lesion.
 Hemoptysis rarely complicates metastatic tumors of the
lungs, since few (primarily renal and colon carcinomas)
intrude on the airways until preterminal.
 Benign tumors – Bronchial Carcinoid- Bleeding that is
generally difficult to arrest.

29. Infections & Hemoptysis
 It is uncommon in the usual viral or bacterial
pneumonia. Conversely, it is not uncommon in
the pneumonia that complicates bronchogenic
carcinoma or in the pneumonia that is caused
by staphylococci, influenza virus, or Klebsiella.
 Pneumococcal Lobar Pneumonia - The sputum
at the onset is characteristically rusty-looking, but
sometimes it is faintly or grossly bloody
 Staphylococcus Pneumonia : Blood mixed with
pus
 Klebsiella Pneumonia : Resembling Currant Jelly
 Brisk bleeding is common in lung abscess; the
blood is mixed with copious amounts of foul-smelling
pus
Rusty Sputum
Currant Jelly Sputum

30.  Fungal Infections : As in tuberculosis, hemoptysis is
generally a consequence of a continuing
necrotizing and ulcerating inflammatory process
or of bronchiectasis.
The most common fungal disorder associated with
hemoptysis is a “fungus ball” that resides either in a
healed tuberculous or bronchiectatic area or in a
cystic residue of sarcoidosis.
Aspergillus is the usual fungal agent; less often
another fungus (e.g., Mucor) is the cause

31.  Tuberculosis : Source of hemoptysis – Active
Tuberculous Cavity or Tuberculous Pneumonia
(more Common).
If tuberculosis is allowed to progress to the point of
extensive fibrosis and cavitation, or becomes
complicated by bronchiectasis, hemoptysis can be
troublesome and persistent.
Hemoptysis from a Rasmussen’s Aneurysm involves
the erosion of a small or medium-sized pulmonary
artery into an adjacent tuberculosis cavity

32.  ‘Right Middle Lobe Syndrome’ :
Frequently associated with hemoptysis
It is due to a partial or complete obstruction of the
right middle lobe bronchus, resulting in atelectasis
and/or pneumonitis in the right middle lobe. The
obstruction is more often caused by scarring
and/or inflammation than by physical compression
of the lumen by an enlarged lymph node. The
cause is usually infectious

33.  In Amoebiasis endemic areas :
Hemoptysis follows perforation into the airways of
an amebic lung abscess. The sputum resembles
anchovy sauce.

34. Cardiovascular Diseases
and Hemoptysis
 In chronic pulmonary congestion, secondary to
left ventricular failure or to mitral valve disease,
alveolar macrophages in the sputum are often
laden with hemosiderin (“heart failure cells”).
 In severe congestion and edema, the sputum is
often pink and frothy.
 The hemoptysis of pulmonary infarction is usually
associated with pleuritic pain and often with a
small pleural effusion because of the peripheral
location of the infarct.

35.  Tight mitral stenosis is sometimes first manifested
by a bout of brisk, bright-red hemoptysis that is
difficult to control. The source of the bleeding is
the sub-mucosal bronchial veins, which
proliferate considerably in this disorder. Massive
hemoptysis due to mitral stenosis is a medical
emergency and is an indication for surgical
intervention to relieve the obstruction at the
mitral valve.
 An extraordinary event is the communication of
an arteriovenous fistula with a small airway,
causing bleeding that is exceedingly difficult to
arrest.

36. Management of Massive Hemoptysis
protect the airway and prevent asphyxiation
place the involved side in a dependent
Intubation should be performed promptly,
and consideration
given to selective intubation of one lung in
order to protect
it from spillage of blood from the other.
position
bronchoscopic interventions such as the
placement
of a balloon catheter to isolate the involved
segment, lavage
with iced saline, or the application of topical
epinephrine
(1:20,000).