COUGH & HEMOPTYSIS

Dr: Amr El Meligi

Prof. Internal Medicine
Cairo University
COUGH:

Cough is a deep expiratory

effort against a closed glottis
which opens suddenly
expelling out a jet of air /
secretions
Cough Reflex
Stimuli :
External agents:
Dust, foreign bodies and extremely hot or cold
air.
Irritant gases, fumes or cigarette smoke

Inflammation of the respiratory mucosa

(mucus, pus, blood).

Pressure on the airways:

a tumor or
enlarged peri-bronchial lymph node.
Causes of cough:
1- Respiratory diseases:
Cough is the most common respiratory symptom

It is in almost all chest diseases:

Inflammation: (Larynx lung) laryngitis, tracheitis,
bronchitis (acute /chronic), pneumonia, suppurative
syndromes & pulmonary tuberculosis.

Bronchial asthma

Pleural Causes: pleurisy, pleural effusion, pneumothorax

, tumors.

Bronchial tumors:
2- Non-respiratory causes:
Cardiovascular:
Pulmonary congestion
Cardiomegaly compressing the tracheal bifurcation
Pulmonary embolism

Drugs as angiotensin converting enzyme inhibitors

Pharyngitis, Postnasal Discharge

Gastroesophageal reflux disease

According to the presence or absence of sputum cough
may be:

Dry: no sputum.

Productive: cough brings sputum.

In respiratory infections cough starts dry then it

becomes productive.

Description of sputum should include:

volume, color, consistency, odor, relation to posture.
Mucoid sputum is translucent
(viral infections, early chronic
bronchitis, bronchial asthma)

Mucopurulent
has components of both

Purulent sputum is yellow or

green

A common sign in infection

but can be seen in bronchial
asthma due to increased
sputum eosinophils).
Frothy, pink in cardiac asthma

Foul smelling in anaerobic infections.

Large amount (>200cc/d) in suppurative syndrome (lung

abscess & bronchiectasis).
Characteristics of common causes of cough:
Acute viral laryngitis:
Early, cough is dry, painful and associated with
hoarseness of voice, stridor in infants then it becomes
productive (mucoid)
Tracheitis & Tracheobronchitis:
Early, cough is dry, associated with retrosternal
soreness then becomes mucoid or mucopurulent

Pneumonia:
Early, cough is dry (associated with
fever and dyspnea), then it becomes
productive, rusty or mucopurulent.
Chronic bronchitis:

Productive cough for 3 successive months for at least 2

successive years.

Cough, mucoid or mucopurulent sputum especially in

winter when the patient arises or smokes his 1st
cigarette

, later on cough becomes throughout the day and

throughout the year.
Suppurative syndrome:

Long history of productive cough of purulent sputum

Large amount > 200 cc/day, of fowl odor (anaerobic

bacteria)

Related to posture.
Bronchial asthma:

During acute attacks : Cough is dry with expectoration

of thick mucus pellets at the end of the attack.

Dry cough may occur at night

Dry cough may be the presenting symptom in bronchial

asthma
Dry cough:

Enlarged left atrium compressing the tracheal

bifurcation (carina)

Lymph node compressing a bronchus.

Pulmonary congestion:

Dry , especially on exertion.

Frothy & pink in cardiac asthma.

Bronchial carcinoma:

Worsening cough is the most common presenting

symptom of bronchial carcinoma.

It may dry or productive +/- hemoptysis.

Vocal cord paralysis due to malignant infiltration of the

left recurrent laryngeal nerve results in loss of the
explosive character of cough (bovine cough).
 Hemoptysis

Coughing up blood from structures below the level of the larynx

Pseudohemoptysis: Upper airway (nasopharyngeal, sinuses)

 HEMOPTYSIS

Blood tinged

Blood streaked sputum

Frank hemoptysis
 Pulmonary causes
1- Common Causes of hemoptysis:

Infection (60-70% of Hemoptysis)

Acute Bronchitis (26%)
Pneumonia (10% of ) (Staphylococcus aureus & Pseudomonas
aeruginosa)
Tuberculosis (8%)
Fungal organisms (e.g. Aspergillosis)
Primary Lung tumors:

Lung Cancer (23%) mucosal invasion, vascular erosion or highly

vascular tumor.

Bronchial adenoma hemoptysis is common but adenoma itself is

rare

Hemoptysis is rare with metastases (breast, colonic and renal).

2- Less common causes:
1- Bronchiectasis, lung abcess
2- Trauma or foreign body (esp. children)
3- Autoimmune diseases: Lupus pneumonitis.)
Cardiovascular causes
1.Pulmonary venous Hypertension
1.Congestive Heart Failure
2.Severe Mitral Stenosis
2.Pulmonary Embolism
3.Arteriovenous malformation heridatary
hemorrhagic telangectasia (rare)

Systemic coagulopathy, Use of anticoagulants or

thrombolytic agents
Pulmonary apoplexy (ruptured dilated bronchial
veins due to the high venous pressure in pulmonary
veins transmitted to the bronchial veins in severe
mitral stenosis
IDIOPATHIC: (7 to 34%)

No identifiable cause after careful evaluation

Prognosis usually is good

In most patients resolution of bleeding occurs within 6 months.

One study found an increasing incidence of lung cancer in

smokers older than 40 years and suggested that these patients
may need close follow up.
 Differential Diagnosis of Hemoptysis

Exclude

1) Pseudohemoptysis:

Acute upper respiratory infection, acute sinusitis: Fever, facial

tenderness, muco-purulent nasal /postnasal
discharge
2) Hematemesis: Upper Gastrointestinal bleeding
Nasopharyngeal cancer
 Hemoptysis Hematemesis

Coughing up blood Vomiting of blood

Physical Bright red or pink Dark coffee ground
appearance (oxyHb) (acid hematin)
of sputum Frothy (mixed with
air) Food particles
History & Ex No nausea, no Nausea, vomiting,
vomiting, no melena followed by melena

Hepatic, pepetic
Lung disease ulcer, NSAI
Sputum ex Alkaline PH Acidic PH
WBC, macrophages
 Fever & productive cough: (INFECTION) Upper
respiratory infection, acute
sinusitis, acute bronchitis,
pneumonia, lung abscess.

Recurrent pulmonary infection, (SUPPURATIVE):

cough with copious purulent Bronchiectasis, lung abscess
sputum

Dyspnea on effort, orthopnea, Left ventricular failure & MS.

PND, frothy pink sputum:

Pleuritic chest pain, tender calf: Pulmonary embolism/infarction.

Tobacco use: COPD, lung cancer,

Weight loss: lung cancer, tuberculosis,

bronchiectasis, lung abscess
Anticoagulant use

DM, HIV, Immunosuppression: tuberculosis

Cachexia, voice hoarseness, Horners syndrome, Cushings syndrome,
hyperpigmentation:
Bronchial carcinoma
Clubbing:
bronchogenic carcinoma, bronchiectasis, lung abscess, severe COPD.

Dullness to percussion, fever, unilateral rales:

Pneumonia

Fever, tachypnea, barrel chest, intercostal retractions, rhonchi, hyper-

resonance on percussion, distant heart sounds:
Acute exacerbation of chronic bronchitis, primary lung cancer.

Signs of CHF cardiac murmurs, gallop, bilateral basal fine end inspiratory
rales:
CHF due to MS or Left ventricular dysfunction

Tachycardia, tachypnea, pleural rub, tender swollen calf:

Pulmonary thromboembolic disease
1) A chest radiograph:

If a diagnosis remains unclear:

2) Chest computed tomography (CT) or

3) Direct visualization with bronchoscopy.

In high-risk patients of lung cancer with a normal chest

radiograph, fiberoptic bronchoscopy should be considered to rule
out malignancy.

Risk factors:
Male sex
> 40 years
A smoking history > 40 pack-years
Duration of hemoptysis > one week
 Bronchoscopy

Fiberoptic bronchoscopy:

Direct visualization of the bleeding site

Diagnostic:
Tumors (central endobronchial disease)

Tissue biopsy

Bronchial lavage

Brushings for pathologic diagnosis.

Direct therapy in cases of continued bleeding.

Leucocytosis with shift to the left: respiratory tract infection

ESR elevated: TB, Autoimmune disorders , Cancer

Prolonged PT, PTT: Anticoagulants or coagulation disorder

D-dimer elevated in: pulmonary embolism

Sputum: Gram stain, culture & AFB smear , culture: Pneumonia,

lung abscess, TB

Tuberculin test +ve: increases risk for tuberculosis

 NON-MASSIVE HEMOPTYSIS: < 200 cc

Objectives of management:
Bleeding cessation

Aspiration prevention, care of airways

Treatment of the underlying cause.

 NON-MASSIVE

Exclude Pseudo hemoptysis and Hematemesis

CXR

Nl CXR

No risk for No risk for High risk for

cancer cancer cancer
No evidence of Evidence of
lower resp lower resp
infection infection
Bronchoscopy
Close follow / CT
up, consider Antibiotic
Bronchoscopy brochoscopy if
if persistant or persistant
recurrent
 NON-MASSIVE

CXR

Mass Other
abnormalities

Bronchoscopy
CT
/ CT
No suggested diagosis
bronchoscopy

Or
Suggested Lab
investigations focused
on the suspected cause
MASSIVE HEMOPTYSIS:

Mortality depends on the rate of bleeding and the cause

The mortality in massive hemoptysis (> 1000 cc/d) in a

patient with bronchial cancer is 80%:

Emergency, ICU: Death usually as a result of

asphyxiation and not exsanguination:

Diagnostic steps and therapy are simultaneously.

Maintaining air ways, Oxygen
IV fluid resuscitation
Cardiothoracic surgical consultation because
emergency surgical intervention may be needed
THANK YOU
Mucoid sputum is translucent
(viral infections, early chronic
bronchitis, bronchial asthma)

Mucopurulent
has components of both

Purulent sputum is yellow or

green

A common sign in infection

but can be seen in bronchial
asthma due to increased
sputum eosinophils).
 HEMOPTYSIS

Blood tinged

Blood streaked sputum

Frank hemoptysis
Pulmonary apoplexy (ruptured dilated bronchial
veins due to the high venous pressure in pulmonary
veins transmitted to the bronchial veins in severe
mitral stenosis
Characteristics of common causes of cough:
Acute viral laryngitis:
Early, cough is dry, painful and associated with
hoarseness of voice, stridor in infants then it becomes
productive (mucoid)
Tracheitis & Tracheobronchitis:
Early, cough is dry, associated with retrosternal
soreness then becomes mucoid or mucopurulent

Pneumonia:
Early, cough is dry (associated with
fever and dyspnea), then it becomes
productive, rusty or mucopurulent.