Cough and Hemoptysis

COUGH

Produced by inflammatory,mechanical, chemical, and thermal stimulation of

cough receptors.

ETIOLOGY

• Inflammatory—edema and hyperemia of airways and alveoli due to laryngitis,

tracheitis, bronchitis,bronchiolitis, pneumonitis,lung abscess.

• Mechanical—inhalation of particulates (dust) or compression of airways

(pulmonary neoplasms,foreign bodies, granulomas, bronchospasm).

Chemical—inhalation of irritant fumes,including cigarette smoke.

• Thermal—inhalation of cold or very hot air.

Sputum quantity and character—change in sputum character,color, or volume

in a smoker with “smoker’s cough” necessitates investigation.

• Temporal or seasonal pattern—seasonal cough may indicate “cough

asthma.”

• Risk factors for underlying disease—environmental exposures may suggest

occupational asthma or interstitial lung disease.

• Past medical history—past history of recurrent pneumonias may indicate

bronchiectasis,particularly if associated with purulent or copious sputum production.

A change in the character of chronic cigarette cough raises suspicion

of bronchogenic carcinoma. Chronic CHF causes cough.

• Drugs—is pt. on ACE inhibitor? Causes chronic cough in 5–20%

Short duration with associated fever suggests acute viral or bacterial infection.

Persistent cough after viral illness suggests postinflammatory cough. Postnasal

drip is common cause of chronic cough. Nocturnal cough may indicate

chronic sinus drainage or esophageal reflux.

Physical exam should assess upper and lower airways and lung parenchyma.

• Stridor suggests upper airway obstruction; wheezing suggests bronchospasm

as the cause of cough.

• Midinspiratory crackles indicate airways disease (e.g.,chronic bronchitis).

• Fine end-inspiratory crackles occur in interstitial fibrosis and heart failure.

• CXR may show neoplasm, infection,interstitial disease,or the hilar adenopathy

of sarcoidosis.

• High-resolution computed tomography (HRCT) helpful in unexplained

chronic cough.

• PFTs may reveal obstruction or restriction.

• Sputum exam can indicate malignancy or infection.

• Fiberoptic bronchoscopy helpful in defining endobronchial causes.

COMPLICATIONS (1) Syncope,due to transient decrease in venous return;

(2) rupture of an emphysematous bleb with pneumothorax; (3) rib fractures—

may occur in otherwise normal individuals.

TREATMENT

• When possible,therapy of cough is that of underlying disease. Eliminate

ACE inhibitors and cigarette smoking.

• If no cause can be found,a trial of an inhaled anticholinergic agent (e.g.,

ipratropium 2–4 puffs qid),an inhaled _ agonist (e.g.,albuterol) or an inhaled

steroid (e.g.,triamcinolone) can be attempted. Inhaled steroids may take 7–

10 days to be effective when used for an irritative cough.

• Cough productive of significant volumes of sputum should generally not

be suppressed. Sputum clearance can be facilitated with adequate hydration,

expectorants,and mechanical devices. Iodinated glycerol (30 mg qid) may be

useful in asthma or chronic bronchitis.

• When symptoms from an irritative cough are severe,the cough may be

suppressed with a narcotic antitussive agent such as codeine,15 –30 mg up

to qid,or a nonnarcotic such as dextromethorphan (15 mg qid).

HEMOPTYSIS

Includes both streaked sputum and coughing up of gross blood.

ETIOLOGY (Table 45-1) Bronchitis and pneumonia are common

causes. Neoplasm may be the cause,particularly in smokers and when hemoptysis

is persistent. Hemoptysis rare in metastatic neoplasm to lung. Pulmonary thromboembolism and infection are other causes. Diffuse hemoptysis may occur

with vasculitis involving the lung. Five to 15% of cases with hemoptysis remain

undiagnosed.

Differential Diagnosis of Hemoptysis

Source other than the lower respiratory tract

Upper airway (nasopharyngeal) bleeding

Gastrointestinal bleeding

Tracheobronchial source

Neoplasm (bronchogenic carcinoma,endobronchial metastatic tumor,

Kaposi’s sarcoma,bronchial carcinoid)

Bronchitis (acute or chronic)

Bronchiectasis

Broncholithiasis

Airway trauma

Foreign body

Pulmonary parenchymal source

Lung abscess

Pneumonia

Tuberculosis

Mycetoma (“fungus ball”)

Goodpasture’s syndrome

Idiopathic pulmonary hemosiderosis

Wegener’s granulomatosis

Lupus pneumonitis

Lung contusion

Primary vascular source

Arteriovenous malformation

Pulmonary embolism

Elevated pulmonary venous pressure (esp. mitral stenosis)

Pulmonary artery rupture secondary to balloon-tip pulmonary artery catheter

manipulation

Miscellaneous/rare causes

Pulmonary endometriosis

Systemic coagulopathy or use of anticoagulants or thrombolytic agents

Approach to the Patient

Diagnosis (Fig. 45-2) Essential to determine that blood is coming from

respiratory tract. Often frothy,may be preceded by a desire to cough.

• History may suggest diagnosis: chronic hemoptysis in otherwise asymptomatic

young woman suggests bronchial adenoma.

• Hemoptysis,weight loss, and anorexia in a smoker suggest carcinoma.

• Hemoptysis with acute pleuritic pain suggests infarction; fever or chills with

blood streaked sputum suggests pneumonia.

Physical exam may also suggest diagnosis: pleural friction rub raises possibility

of pulmonary embolism or some other pleural-based lesion (lung abscess,

coccidioidomycosis cavity, vasculitis); diastolic rumbling murmur suggests

mitral stenosis; localized wheeze suggests bronchogenic carcinoma.

Initial evaluation includes CXR. A normal CXR does not exclude tumor or

bronchiectasis as a source of bleeding. The CXR may show an air-fluid level

suggesting an abscess or atelectasis distal to an obstructing carcinoma. Follow

with chest CT.

Most pts should be assessed by fiberoptic bronchoscopy. Rigid bronchoscopy

helpful when bleeding is massive or from proximal airway lesion and when

endotracheal intubation is contemplated.

TREATMENT

• Treat the underlying condition

• Mainstays are bed rest and cough suppression with an opiate (codeine,

15–30 mg,or hydrocodone, 5 mg q4–6h).

• Pts with massive hemoptysis (_600 mL/d) and pts with respiratory compromise

due to aspiration of blood should be monitored intensively with suction

and intubation equipment close by so that selective intubation to isolate

the bleeding lung can be accomplished. In massive hemoptysis,highest priority

is to maintain gas exchange,and this may require intubation with doublelumen

endotracheal tubes

Choice of medical or surgical therapy often relates to the anatomic site of

hemorrhage and the pt’s baseline pulmonary function.

• Localized peripheral bleeding sites may be tamponaded by bronchoscopic

placement of a balloon catheter in a lobar or segmental airway. Central bleeding

sites may be managed with laser coagulation. Pts with severely compromised

pulmonary function may be candidates for bronchial artery catherization

and embolization.