Cough,Cough,Haemoptysis & Haemoptysis &

Lung cancerLung cancerDr Muhammad Raza (MCPS Family medicine P.G.Trainee)

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.

Signaling PathwaysSignaling Pathways

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.

Cough HistoryCough History

(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

• Most common causesMost common causes

– Common cold (viral )

– Acute bacterial sinusitis

– Pertussis

– Exacerbation of COPD

– Allergic rhinitis

– Rhinitis secondary to environmental irritants

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(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

Tuberculosis or fungusTuberculosis or fungus

Persistent cough for weeks to months, often with blood-

tinged sputum

Interstitial fibrosis and infiltrations Interstitial fibrosis and infiltrations

Cough nonproductive, persistent

Smoking Smoking

Cough usually persistent, most marked in morning, usually

only slightly productive unless succeeded by chronic

bronchitis

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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 failure Left ventricular failure

Cough intensifies while supine, along with aggravation of

dyspnea

Pulmonary infarction Pulmonary infarction

Cough associated with hemoptysis, usually with pleural

effusion

Angiotensin-converting enzyme (ACE) inhibitors 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)

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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

Antitussives (cough centre suppressants)

Antihistamines

Bronchodilators

Pharyngeal demulcents

Expectorants, Mucokinetics & mucolytics

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Specific Treatment Approach to CoughSpecific Treatment Approach to Cough1) 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

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.

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%.

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True Hemoptysis VersusTrue Hemoptysis VersusSpurious (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

Hemoptysis Versus Hemoptysis 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 the Sputum 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 laden Sputum contains hemosedrin laden macrophagesmacrophages NoNo

Cause of HemoptysisCause of Hemoptysis

Causes of Massive HemoptysisCauses of Massive Hemoptysis1. Pulmonary tuberculosis.

2. Pulmonary infarction.

3. Bronchiectasis.

4. Cystic fibrosis

5. Lung abscess.

6. Necrotizing pneumonia.

7. Mitral stenosis.

8. Pulmonary arteriovenous malformation.

Mechanism & Sources of Mechanism & Sources of HemoptysisHemoptysis

Sources1.Bronchial circulation.

2.Pulmonary circulation.

3.Anastomosis between pulmonary & bronchial circulation.

Mechanisms

1. Vessel engorgement.

2. Erosion (or) rupture of vessels.

3. Mucosal ulceration.

4. Vascular granulation tissue.

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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)

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

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Clinical Approach for Management Clinical 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.

Management of HemoptysisManagement of HemoptysisGoalGoal

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.

Management of Minor hemoptysisManagement of Minor hemoptysisMinor 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.

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.

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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.

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

Management of Massive Management 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).

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II. Surgical

Emergency resection for bronchogenic mass.

Resection of bronchogenic mass after patient stabilization.

Surgical resection for aspergilloma.

III. Endobronchial

Identify the bleeder: determine source, Rate & to Slow (or)

Arrest bleeding.

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%).

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Recurrence may be caused by:

– Incomplete embolization of artery.

– Recanalization of previously embolized artery.

– Revascularization through collateral

circulation.

– Progression of basic lung disease.

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Complications of HemoptysisComplications of Hemoptysis

Asphyxia

Shock

Anemia

Renal failure

Atelectasis

Pulmonary infection

Prognosis Prognosis 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.

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.

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)

Clinical Presentation Clinical Presentation

S/S Incidence

Cough 75%

Hemoptysis 50%

Dyspnea 40%

Chest pain 35%

Hoarseness 5%

SVC syndrome 5%

Lung Cancer Risk Factors (2007 Lung 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

hydrocarbon)

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

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

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

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

PET scan

Brain CT scan: small cell carcinoma.

Pulmonary function tests: ability to undergo surgical resection

or withstand irradiation

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Sputum cytology: 20% to 30% sensitivity

Bronchoscopic examination: 90% positive

CT-guided Bx: 95% positive

Bx: Primary tumor lesion

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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%

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

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

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

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

Other TypesOther Types

Some other types of lung cancers are

Bronchial carcinoid tumors

Mesothelioma

Pancoast tumors

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

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N1-N3: N1: intrapulm / peribronch / hilar

N2: ipsilateral mediastinal /

subcarinal

N3: ipsilateral or contralateral

scalene / supraclavic / contralateral

mediastinal / contralateral hilar

M0 –M1: M0: No distant Mets

M1: Distant Mets

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.

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

lung cancer-Metastasis lung cancer-Metastasis

Adrenals - ~50% of cancers

Liver – 30-50%

Brain – 20%

Bone – 20%

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