c ough and h emoptysis levy liran, m.d. institute of pulmonology hadassah-hebrew university medical...

COUGH AND HEMOPTYSISLevy Liran, M.D.Institute of PulmonologyHadassah-Hebrew University Medical CenterJerusalem, Israel

DEFINITION

‘Explosive expiration that provides a normal protective mechanism for clearing the tracheobronchial tree free of secretions and foreign material.’

COMPLICATIONS OF COUGH

Chest and abdominal wall soreness

Exhaustion

Urinary incontinence

Cough syncope

Hernias, Uterine prolapse

Cough fractures

COUGH REFLEX

ETIOLOGYPost nasal drip

Laryngitis, tumor, whooping cough, croup

Tracheitis

Bronchitis, COPD, Asthma, Bronchial Carcinoma

TB, Pneumonia, Bronchiectasis, Pulmonary Oedema, Interstitial Fibrosis

DIFFERENTIAL DIAGNOSIS

Acute- < 3 weeksURTI- common cold, sinusitis, pertussisAspirationInhalation of chemical/smoke

Subacute- 3 to 8 weeks Post infectious (pertussis, post viral)

Chronic- > 8 weeksMetabolic/MuladInflammatory asthma, eosinophilic bronchitis, COPD, bronchiectasis,

PND, ILD, pneumoconiosisInfectious TB, mycobacteria, fungus, atypical bacteriaNeoplastic mass involving tracheo-bronchial treeDrugs ACE inhibitors Vascullar pulmonary congestion, PEToxin/Chemical GERD, smoking

APPROACH TO CHRONIC COUGH

History

• Circumstances surrounding onset of cough• Sputum – color, smell• Type• Hemoptysis • Duration• Variation- posture, time• Precipitating factors & what makes it better• Associated symptoms

APPROACH TO CHRONIC COUGH

Physical Examonation

Full cardio-pulmonary examination: InspectionPalpationPercussionAuscultation

Investigations:

Chest X RaySputum cytology & microbiologyPumonary Function Tests (PFT)High Resolution CT (HRCT)Fibreoptic bronchoscopyEchoPH metriaSwallow studySinus imaging

MANAGEMENT OF COUGH > 8 WEEKSCough > 8 weeks

ACEI Smoking

Stop

Cough persists

CXR

Normal

Post nasal drip

Asthma

Eosinophilic bronchitis

GERD

Abnormal

Evaluate with: HRCTSputum testingBronchoscopyEchoPH metriaSwallow studySinus imaging

TREATMENT Acute- < 3 weeks

or Subacute- 3 to 8

weeks

Treatment Diagnosis

If CXR normal target most common causes and treat empircally

stop ACE inhibitors

Anti acids / PPI / Life styleICS

GERD

antihistamine, steroidal nasal spray

PND

/ bronchodilators Asthma / Eeosinophilic bronchitis /COPD

Treatment Diagnosis

Cough suppression:• Narcotics (codeine or

hydrocodone)• Not to be used in productive

cough

Infectious / aspiration / inhalation

90% of diagnoses

of chronic cough

with normal CXR

Treatment Diagnosis

antibiotic / anti fungal / anti Tb

Infectious

anti-coagulation PE

airway hygiene, antibiotics

Bronchiectasis

symptomatic / systemis steroids

ILD / Pneumoconiosis

radiotherapy / chemotherapy

Cancer

treat CHF Pulmonary congestion

Fail to respond merits further investigation

Chronic- > 8 weeks

HEMOPTYSIS

Expectoration of blood from the respiratory tract

Massive hemoptysis- 100-600ml per day

ETIOLOGY

Tracheo bronchial

Pulmonary parenchyma

Primary Vascular

Miscellaneous

ANATOMYBronchial artery

Pulmonary artery

Pulmonary vein

DIFFERENTIAL DIAGNOSISMost common cause is infection of

medium-sized airways:• Western world viral/bacterial

• World wide TB

APROACH TO PATIENT WITH HEMOPTYSIS

TREATMENT

Blood streaking or small amounts of bloodEstablish the diagnosisFollow up

Massive Hemoptysis *Proper positioning

*Endotracheal intubation (single lung) *Balloon Catheter

*Bronchoscopy with laser phototherapy/ electrocautery *Bronchial artery embolization *Surgery