COUGH, SPUTUM,

HEMOPTYSIS
Prof. Dr. Bilun Gemiciolu

COUGH
A cough is an action your body takes to get rid of
substances that are irritating to your air passages,
which carry the air you breathe in from the nose and
mouth to the lungs.
A cough occurs when special cells along the air
passages get irritated and trigger a chain of events. The
result? Air in your lungs is forced out under high
pressure; an explosive expiration
You can choose to cough (a voluntary process), or your
body may cough on its own (an involuntary process).

Anatomic causes of cough

Extra-thoracic

ntra-thoracic
Upper GIS

CNS

Head and neck

Mediastinum

Stomac
Lower airways
diseases

Pleura
Lung Parenchyma
Cardiovascular

Diaphragm

Cough receptors and related

nerves
Regions
Paranasal

Afferent nerves
Trigeminal (V)

Pharynx

Glossofaringeus (IX)

Larynx/tracheobronchial sys.
External ear way/ thympanic
membrane
Eusophagus, stomac, pleura
Diaphragm, pericard

Vagus (X)
Vagus (X)
Vagus (X)
Phrenic nerve

Simpson CB. et al. OtolaryngologyHead Neck Surg 2006; 134: 693-700

Anamnesis: History
While ?
When ?
Characteria ?
Productive/non productive
Additional symptoms?
Risk factors: tabacco smoke
additional diseases or use of drugs ?

Anamnesis: While
Shorter then 3 weeks
3 to 8 weeks

acute cough

subacute cough

Longer then 8 weeks

chronic cough

Irwin RS et al. Chest 1998, 114:2 suppl

Causes of acute cough

Respiratory Causes:
Inhaled gases or particule
Mucus secretion
Inflammatory exudate
Foreing body
Endobronchial lesion
Bronchial boosts

Other causes of acute cough

-acute heart failure
-acute rhinosinusitis
-Eusephageal reflux
-Middle ear patologies and infections
-Diaphragm, pleura and pericardium
irritations

Chronic cough causes in adult

PNDS

Allergic rhinitis
chronic sinusitis

GER
cough-variant asthma
ACE Inhibitors
tabacco smoke
Whoopping
Neurogenic
Travmatic vagal injury
After upper respiratory tract infection

Psychogenic
chronic aspiration
Zenker diverticule

Foreign body

Tracheobronchial tree
Laryngopharingeal
Sinonasal
External ear way

Chronic bronchitis, COPD

Bronchiectasis
Lung Cancer
Subglottic stenosis
Tracheomalasia
Tracheosephageal fistula
Tuberculosis
Sarkoidosis
Congestive heart disease

Simpson CB. et al. OtolaryngologyHead Neck Surg 2006; 134: 693-700

Chung KF, Pavord ID Lancet 2008; 371: 1364-1374

Patogenic Triad

Irwin RS et al. Chest 1998, 114:2 suppl

Palombini BC et al. Chest 1999, 116:2,279-284

Anamnesis: When
Morning
Bed time; night
After meal
After irritant
Only waking
Talking
Stress

Anamnesis: Characteria
Like barking
Metalic cough
Cow cough
Vomitig cough
Smoking cough
Irrtative cough

Larynx tm, inf.

Trachea, brochies.
V.Chord paralisis
Whoopping cough
tabacco smoke
URTI

Anamnesis: Characteria

In prospective adult studies time and

character of the coughing cannot guide the
diagnosis.

Mello CG et al. Arch Intern Med 1996,156; 997-1003

Anamnesis:
Productive/Nonproductive
Productive
Non productive

Airway diseases
Pleura, pericardium,
Ear, GIS, heart,
ACEI usage, diaphragm,
mediastinum, thyroid

Irwin RS et al. Chest 1998, 114:2 suppl

Anamnesis: Additional symptoms

Specific
pyrosis,

Dyspnea, wheezing,
retronasal discharge..

sputum,

Non specific
Eshaustion, insomnia,
sweating, muscular pain, urine
incontinence, headache, loss of appetite, axiety

Anamnesis:

Specific additional

symptoms

PNDS

post nasal drip, throat clearing

runny nose, nasalcongestion,
sputum

Asthma

Dispnea, thightness of breath,

wheezing

GER

Burning, regurgitation,
sputum, effort dispnea
Sputum
Effort dispnea, tachycardia, edema

COPD
Bronchiectasia
Heart failure

Anamnesis: Risk factors

Smoking cases

Lung cancer, COPD,

asthma, irritation

Additional diseases

AIDS, cancer, viral URI

Drug usage

ACEI, Nitrofurantoin,
Immunosupresives
Irwin RS et al. Chest 1998, 114:2 suppl

Physical Examination
Head and neck
Thorax
Upper GIS
Heart
ENT

Laboratory
Chest X Ray
Pulmonary function tests
Paranasal sinus X-Ray
Blood analysis
Sputum examination
Bronchoscopy
ECG, ECO
Thorax CT, HRCT
Rhinoscopy
Barium eseuphagography
Allergy prick tests

Treatment of cough
NON SPECIFIC
ANTITUSSVE

SPECIFIC

PROTUSSIVE

TARGET
THERAPY

Codein

Hipertonic saline

Dekstrometorfan

Erdostein

Difenhidramin

Amilorid

Pseudoephedrine

N acetylcysteine

Dekstrobromfeniramin

Terbutaline

pratropium Bromid

Phisiotherapy

Naproxen

Postural drenage
Irwin RS et al. Chest 1998, 114:2

SPUTUM
Mucus glands and goblet cells of lower
respiratory tract secrete 10ml mucus every
day
Exess of lower respiratory track expectoration
is called sputum

General causes of sputum

Exess of mucus production
Changement in the quality of mucus
Lacking activity of mucociliar clearance

Sputum:Anamnesis:
Quantity of sputum
Quality of sputum; density, calour
Odor of sputum
Time of expectoration

Sputum: Anamnesis
Sputum Quality
Purulent; yellow-green mucoid

Suspect diseases
Pneumonia, asthma with
eosinophilia

Rusty
Cherry
Melanopthisis (black-grey)
Rock water vomic

Pneumonia (pneumoccocus)
Pneumonia (klebsiella)
Air pollution, coal worker
Eccinoccocus cystes

Chocolate
Putrefactive; faol smelling

Amibe abscess
Lung abscess (anaerobic
infections)

< 600cc/day, morning expect.

Bronchiectsasis

Sputum: Diagnosis
Physical examination of the lungs
Chest X-ray, CT, HRCT
Sputum analysis
Blood analysis
Bronchoscopy

Sputum: Treatment
Treat the causative disease
Postural dranage
Mucolytics
Decongestant

HEMOPTYSIS
Lower respiratory track bleeding below
epiglottis
Differential diagnosis with ENT ve GIS
must be evaluated before saying
hemoptysis

Causes of hemoptysis:
Chest X Ray: Anormal
I.Infections:

-Pneumonia
-Tbc
-Lung abcess
-Bronchiectasis
-Fungal infections
II.Lung tumours: -Bronchial Cancers
-Metastatic cancers
-B.adenoma

Causes of hemoptysis:
III. Alveolar hemorrhage: -Vasculitis
-Goodpastures syndrome
-Wegener granulomatosis
-Behet Disease
-SLE
-Drugs (penicillamine)
IV.Other -Thorax trauma
-A-V malformations
-P.E
-Disorders of coagulation

Causes of hemoptysis
Normal X-Ray
-Chronic bronchitis
-Pulmonary Embolism
-Bronchiectasis
-Lung cancer
-Mitral stenosis
-Endometriosis

Massive hemoptysis
Hemoptysis > 600 mL /24 h
Cause is % 90 bronchial arteries
causes:1-Tbc
2-Bronchiectasis
3-Malignity
4.Behet disease

Hemoptysis: Physical
examination

-Vital signs
-Telengiectasia (Osler-Weber-rendu Syndrome)
-Clubbing
-Deep venous thrombosis
-ENT (URT haemorrhage)
-Oral ulcer =>Behet ?
-Chest exanination
-Cardiovascular system examination (mitral
stenosis)

Hemoptysis: Diagnosis
Radiology:
PA, Lat chest X-ray,
BT, HRCT if needed
PA Chest Xray and CT: normal => Angiography

Hemoptysis: Diagnosis
Laboratory:
-Blood analysis, blood goup
-Electrolytes, liver and kidney
function tests
-PFT, ABG
-PT, aPTT
-ECG, Urine analysis
- Bronchoscopy

Masif hemoptysis: Tedavi

Prensipleri
1-Block asphyxia
2-Stop bleeding
3-Treat primary disaese