Cough and haemoptysis

Question 1

Cough

Answer 1

Cough is a non-specific reaction to irritation anywhere in the respiratory tract from the pharynx to the alveol

Question 2

Acute vs chronic cough

Answer 2

• ‘Acute cough’ is defined as cough of 8 weeks it becomes a ‘chronic cough’ and subacute if somewhere in between.
• As most viral upper respiratory tract infections will have resolved within 3 weeks, any cough lasting >8 weeks or >3 weeks with other symptoms warrants systematic investigation

Question 3

Most common cause of acute cough

Answer 3

infections such as common cold or chest infections which usually clear within 3 weeks

Question 4

Most common causes of chronic cough

Answer 4

Smoking 
ACE inhibitors - dry cough
Acid reflux 
Asthma
COPD
Cancer - Lung cancer, mesothilioma, secondary metastases, lymphoma
Atopy
Postnasal drip 
Environmental pollution, especially PM10 particulates (particles of 10 micrometres or fewer).

Question 5

Features of smoking-related cough

Answer 5

Cigarette smoke is irritant to the lining of the airways, so being a smoker, or being around other people smoking (being a passive smoker) is a common cause of cough. Smoking-related coughs are usually dry - in other words you don’t cough anything up - and tend to be worst in the mornings

Question 6

GORD cough

Answer 6

Heartburn (but may have no gastrointestinal symptoms).
Cough worse at night.
Cough when eating/talking.
Hoarseness.
Sour taste.

Question 7

Asthma cough

Answer 7

History of atopy.
Nocturnal cough.
Wheeze.
Peak flow rate variable by >20% or reversible changes on spirometry (these ‘rule in’ asthma but their absence does not rule it out).

Question 8

COPD cough

Answer 8

The cough of COPD usually comes with gradually worsening breathlessness when you do anything.

Colds often progress to coughs which turn into chest infections and linger. It is usually caused by many years of smoking.

Question 9

Less common causes of chronic cough - cardiovascular

Answer 9

left ventricular failure, pulmonary emboli, aortic aneurysm

Question 10

Cases where cause of cough is not found

Answer 10

• Idiopathic cough. (Idiopathic means there is no cause to be found.)
• Chronic refractory cough.
• Cough hypersensitivity syndrome.
• Neurogenic or psychogenic cough.

Question 11

Cough reflex

Answer 11

The cough reflex is triggered by mechanical or inflammatory changes or irritants in the airways. The afferent pathway is via the vagus nerve to respiratory neurons termed the ‘cough centre’ in the brain stem. Higher cortical centres also control the cough.

Chronic cough tends to be inhibited during sleep.

Chronic cough is often associated with bronchial hyper-reactivity (bronchial hyper-responsiveness), which can persist in the absence of the initiating cough event.

Bronchial hyper-responsiveness is defined as a state of increased sensitivity to a wide variety of airway-narrowing stimuli - eg, exercise, dry or cold air and hypertonic or hypotonic aerosols. It occurs in asthma and chronic obstructive pulmonary disease (COPD) but also can occur in the absence of lung disease.

Question 12

Less common causes of cough - chronic infections

Answer 12

• Bronchiectasis, tuberculosis, cystic fibrosis, lung abscess.

Question 13

Postinfectious cough

Answer 13

• May be more likely following infection with Mycoplasma pneumoniae, chlamydial pneumonia and whooping cough.

Question 14

Parenchymal lung diseases

Answer 14

• interstitial lung fibrosis, emphysema, sarcoidosis.

Question 15

Cancers that can cause cough

Answer 15

Lung cancer, metastatic carcinoma, lymphoma, mediastinal tumours, benign tumours

Question 16

Upper airway causes of cough

Answer 16

chronic tonsil enlargement, obstructive sleep apnoea, chronic snoring, irritation of external auditory meatus.

Laryngeal problems are increasingly recognised as being part of chronic cough

Question 17

Foriegn body obstruction - cough causes

Answer 17

• recurrent aspiration, inhaled foreign body, endobronchial sutures.

Question 18

Can cardiac arrhythmias cause cough

Answer 18

Yes but rarely

Question 19

Cough only when supine indication

Answer 19

• may be due to collapse of large airways

Question 20

Red flag symptoms in chronic cough

Answer 20

Copious sputum production (bronchiectasis).

Systemic symptoms - fever, sweats, weight loss (tuberculosis, lymphoma, bronchial carcinoma).

Haemoptysis (tuberculosis, bronchial carcinoma).

Significant dyspnoea (heart failure, COPD, fibrotic lung disease).

Question 21

Postnasal drip syndrome

Answer 21

Subjective symptoms - postnasal drip, having a recurrent need to clear the throat.

Persistent nasal blockage.

Persistent nasal discharge.

Question 22

Green sputum

Answer 22

Indicative of longstanding respiratory infection (green from degenerative changes in cell debris) as in pneumonia, ruptured lung abscess, chronic infectious bronchitis, and infected bronchiectasis or cystic fibrosis.

Question 23

Rust coloured sputum

Answer 23

Usually caused by pneumococcal bacteria (in pneumonia), pulmonary embolism, lung cancer or pulmonary tuberculosis.

Question 24

Brown sputum

Answer 24

chronic bronchitis (greenish/yellowish/brown); chronic pneumonia (whitish-brown); tuberculosis; lung cancer.

Question 25

Yellow sputum

Answer 25

containing pus. “The sputum color of patients with acute cough and no underlying chronic lung disease does not imply therapeutic consequences such as prescription of antibiotics.”
The color can provide hints as to effective treatment in chronic bronchitis patients:
A yellow-greenish (mucopurulent) color suggests that treatment with antibiotics can reduce symptoms. The green color is caused by degenerating neutrophil verdoperoxidase.

Question 26

Foamy white sputum

Answer 26

• May come from earlier-phase pulmonary edema.

Question 27

Frothy pink sputum

Answer 27

• May indicate more severe pulmonary edema. Antibiotics may not be necessary at this time.

Question 28

Clear sputum

Answer 28

• Pulmonary embolism (clear to frothy); COPD chronic obstructive pulmonary disease (clear to gray); viral respiratory infection (clear to whitish and sometimes a hint of yellow); asthma (thick and white to yellowish).

Question 29

Initial investigation and management for smokers with cough

Answer 29

For smokers, initial investigations are CXR and spirometry, with advice to stop smoking.

If smoking is the cause, cough should improve within eight weeks of smoking cessation.

Question 30

Initial investigation and management for non-smokers with cough

Answer 30

For non-smokers, if taking an ACE inhibitor, trial of stopping/replacing this drug.

ACE inhibitor-induced cough should improve within four weeks of stopping the drug.

Then consider CXR and spirometry (or serial peak flow measurements, if spirometry is unavailable).

Question 31

GORD management

Answer 31

Trial of high-dose proton pump inhibitors (may require up to 12 weeks for improvement).

Question 32

Postnasal drip syndrome management

Answer 32

Trial of antihistamines or nasal steroids.

Question 33

What is postnasal drip syndrome

Answer 33

Post-nasal drip (PND) occurs when excessive mucus is produced by the nasal mucosa.

The excess mucus accumulates in the back of the nose and eventually the throat once it drips down the back of the throat.

It can be caused by rhinitis, sinusitis, gastroesophageal reflux disease (GERD / GORD), or by a disorder of swallowing (such as an esophageal motility disorder).

Other causes can be allergy, cold, flu, and side effects from medications

Question 34

Cough - blood tests

Answer 34

FBC (infection, eosinophilia), ESR/CRP (infection, malignancy, connective tissue disorders)

Question 35

Cough - contributing factors

Answer 35

reflux disease, rhinitis, occupation (there may be more than one factor causing chronic cough). Try treating these (or removing the cause, if occupational) for a limited period to observe response

Question 36

Cough - imaging investigations besides cxr

Answer 36

Bronchial provocation testing (methacholine or histamine)

• positive result supports diagnosis of asthma but cough may be steroid-responsive even if negative.
• Assess for eosinophilic airway inflammation - by induced sputum analysis or trial of steroids (prednisolone 30 mg daily for two weeks).
• Bronchoscopy - if inhalation of a foreign body is suspected, or where common causes have been excluded.
• Echocardiogram or other cardiac investigations - if a cardiac cause is suspected clinically.
• 24-hour ambulatory oesophageal pH testing and/or oesophageal manometry.
• Radiology of sinuses - eg, CT or MRI scanning.
• High-resolution CT scan of thorax - however, there is low diagnostic yield in this scenario.

Question 37

Assessment of cough

Answer 37

May use a cough assessment tool such as the cough visual analogue scale or the Leicester Cough Questionnaire

Question 38

Cough management

Answer 38

Treat the underlying cause(s), if possible

A ‘trial of treatment’ strategy is often appropriate, ensuring that each treatment is used for a sufficient time - eg, eight weeks for inhaled steroids, 12 weeks for anti-reflux treatment

Smoking cessation; avoid exposure to irritants.
If initial management is unsuccessful, referral to secondary care may be required.

This may involve a chest physician, ENT specialist and/or gastroenterologist, depending on the individual context

Question 39

Codeine in cough management

Answer 39

Codeine may be effective but can cause dependence. Dextromethorphan and pholcodine have fewer side-effects.

Question 40

Sedating antihistamines in cough management

Answer 40

Sedating antihistamines are used as the cough suppressant component of many compound cough preparations on sale to the public

Question 41

Usage of morphine in cough management

Answer 41

Morphine or diamorphine at higher doses may be used for severe, distressing cough in palliative care.

Question 42

Mucolytics in cough management

Answer 42

Mucolytics (eg, carbocisteine or erdosteine) are prescribed to facilitate expectoration by reducing sputum viscosity.

In some patients with COPD and a chronic productive cough, mucolytics can reduce exacerbations. Mucolytic therapy should be stopped if there is no benefit after a four-week trial.

Steam inhalation with postural drainage is effective in bronchiectasis and in some cases of chronic bronchitis.

Question 43

Demulcent substances in cough management

Answer 43

Demulcent cough preparations contain soothing substances such as syrup or glycerol and may be used to relieve a dry irritating cough.

Preparations such as simple linctus have the advantage of being harmless and inexpensive.

Question 44

What is pseudohaemoptysis

Answer 44

Where a cough reflex is stimulated by blood not derived from the lungs or bronchial tubes.

This may be from the oral cavity or nasopharynx (eg, following an epistaxis) or following aspiration of haematemesis into the lungs.

Question 45

Causes of haemoptysis - trachea or bronchus

Answer 45

Malignancy:

Bronchogenic carcinoma.
Endobronchial metastatic tumour.
Kaposi’s sarcoma.
Carcinoid tumour.

Bronchitis.
Bronchiectasis.
Airway trauma.
Foreign body.

Question 46

Causes of haemoptysis - lung parenchyma

Answer 46

Lung abscess.
Pneumonia - bacterial (eg, Staphylococcus aureus, Pseudomonas aeruginosa) or viral (eg, influenza).
Tuberculosis (TB).
Fungal infection and mycetoma.
Hydatid cysts.
Goodpasture's syndrome.
Pulmonary haemosiderosis.
Wegener's granulomatosis.
Behçet disease.
Lupus pneumonitis.
Lung contusion.
'Crack' lung.

Question 47

Vascular causes of haemoptysis

Answer 47

Arteriovenous malformation.
Aortic aneurysm.
Pulmonary embolism (PE).
Mitral stenosis.
Other cause of pulmonary venous hypertension - eg, left ventricular failure (LVF).
Trauma.
Iatrogenic (eg, chest drain malposition, secondary to pulmonary artery catheter manipulation).

Question 48

Other causes of haemoptysis

Answer 48

Pulmonary endometriosis.
Congenital or acquired systemic coagulopathy - eg, leukaemia.
Anticoagulant or thrombolytic agents.
Factitious haemoptysis.

Question 49

Most common cause of haemoptysis

Answer 49

Haemoptysis is rare in children and often only presents where bleeding is substantial, as children tend to swallow rather than expectorate their sputum.

Respiratory tract infection is the most common cause.

Foreign body inhalation is the second most common cause (particularly with younger children) and congenital heart disease and bronchiectasis secondary to cystic fibrosis are other important causes.

Question 50

Features of haemoptysis

Answer 50

No nausea or vomiting
Concurrent lung disease	
Sputum is frothy	
Sputum has a liquid or clotted appearance	
Haemoptysis is bright red or pink	
Alkaline pH	
Mixed with macrophages and neutrophils

Question 51

Associated symptoms - haemoptysis

Answer 51

Abrupt-onset cough, fever with bloody and purulent sputum - suggestive of acute pneumonia or bronchitis.
Chronic productive cough - suggestive of chronic bronchitis or bronchiectasis.
Fevers, night sweats and weight loss - consider TB and other infections or malignancy.
Anorexia, weight loss and changing cough - think of possible bronchogenic carcinoma.
Dyspnoea, fatigue, orthopnoea, paroxysmal nocturnal dyspnoea, frothy pink sputum - suggestive of congestive heart failure.
Dyspnoea and pleuritic chest pain - consider a PE.

Question 52

Nasal cavity + oropharynx - Haemoptysis signs

Answer 52

Extrapulmonary causes (pseudohaemoptysis).
Signs of vasculitis.
Gingival thickening, mulberry gingivitis, saddle nose, and nasal perforation suggest Wegener’s granulomatosis.

Question 53

Cardiovascular examination signs - haemoptysis

Answer 53

The diastolic murmur of mitral stenosis.
Signs of LVF.
Tachypnoea, tachycardia, fixed split S2, pleural rub, and unilateral leg pain or swelling which may indicate thromboembolic disease.

Question 54

Resp examination signs - haemoptysis

Answer 54

Fine inspiratory rales (associated with alveolar blood).
Inspiratory and expiratory rhonchi (associated with airway secretions and blood).

Look for evidence of an exacerbation of chronic obstructive pulmonary disease or lower respiratory tract infection.

Unilateral wheeze and distal consolidation raise the suspicion of endobronchial tumour. Unilateral wheeze or stridor may also indicate the presence of a foreign body.

With apical dullness and cachexia, TB should be considered.

Digital clubbing can reflect chronic lung disease (lung cancer, bronchiectasis, lung abscess).

Supraclavicular lymphadenopathy, cachexia, hoarse voice, Cushing’s syndrome, hyperpigmentation, and Horner’s syndrome may be associated with malignancy.

Question 55

Haemoptysis investigations

Answer 55

Bronchoscopy combined with imaging technology usually identifies the bleeding site in the lungs.

Imaging - CXR +/- CT scan. About 30% of patients with haemoptysis have normal CXRs. A negative CXR warrants other investigations, usually including a bronchoscopy.

A CT scan is more sensitive than a CXR.

Computed tomography angiography (CTA) can play a crucial role in assessing the cause and origin of the haemoptysis and directing the interventional radiologist prior to treatment.

Fibreoptic bronchoscopy enables direct visualisation and is required where there is a mass on CXR, there are risk factors for cancer despite normal CXR, or where diagnosis remains open, particularly in instances of recurrent haemoptysis.

ECG +/- echocardiogram (ECHO) - if a cardiac cause or PE is suspected.

Other tests are dependent on the clinical setting but may include FBC, ESR, U&Es, coagulation studies, urinalysis, arterial blood gases, sputum cytology and culture, acid-fast bacillus (AFB) smear and culture, D-dimer testing, and HIV test.

Question 56

Management of minor haemoptysis

Answer 56

Effort should be concentrated on determining the origin of the haemoptysis, 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 two 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.

All smokers or ex-smokers aged >40 years with persistent haemoptysis should urgently be referred to a chest physician under the two-week wait rules.

Question 57

Management of moderate haemoptysis

Answer 57

Moderate haemoptysis (30-50 ml in the previous 24 hours) requires hospitalisation for observation, due to increased risk of further heavy bleeding.

Question 58

Management of severe haemoptysis

Answer 58

This is a medical emergency with a high mortality rate. However, there are few large, good-quality, controlled trials looking at best management to guide practice - particularly in the medical versus surgical dilemma.

Resuscitate according to ‘ABC’ principles. Intubate where there are signs of acute respiratory failure. Selective intubation of the right or left main bronchus with a large single-lumen endotracheal tube or, alternatively, the use of a double lumen tube should be considered. Maintain oxygenation saturations with high flow oxygen and suction. Obtain IV access and give fluids/blood transfusion as appropriate. Correct any clotting abnormalities. The patient will require admission to intensive care.

Localisation of the bleeding site via radiology and early bronchoscopy. CXR and even CT scanning may not be helpful (due to the presence of aspirated blood). The use of rigid or flexible fibreoptic bronchoscopy remains controversial and tends to depend on local preference and expertise.

Question 59

Specific therapies to control bleeding in haemoptysis

Answer 59

Specific therapies to control bleeding:

Angiography and embolisation - endovascular embolisation is the most effective and minimally invasive technique for managing massive and recurrent haemoptysis.

Bronchoscopic therapy:
Iced saline lavage.
Topical agents - eg, use of thrombin or fibrinogen-thrombin glue.
Endobronchial balloon catheter tamponade.
Laser photocoagulation.
Surgical resection:
Segmentectomy.
Lobectomy.
Pneumonectomy.
Under emergency conditions, surgery is difficult, has a high risk of septic complications and a significant mortality rate. Surgery is usually only the treatment of choice in selected cases, such as chest trauma and iatrogenic pulmonary artery rupture. Emergency surgery should therefore be reserved for patients with persistent life-threatening haemoptysis.

Radiotherapy - may be used to treat aspergillomas and vascular tumours.

Antifibrinolytic therapy - although there is currently insufficient evidence to determine whether antifibrinolytics can be used to treat haemoptysis from any cause, there is limited evidence to suggest they may reduce the duration of bleeding

Question 60

Palliative care in haemoptysis

Answer 60

Given the bleak prognosis of a massive haemoptysis, active resuscitation may not be desired or appropriate. Under these circumstances, the emphasis should be on the relief of pain and of fear in the patient and supporting witnesses and family:

Nurse the patient lying on the side of the tumour.
Administer parenteral opioid and fast-acting benzodiazepine.
Mask blood with red or green towels.
In some, the likelihood of such a bleed can be predicted (based on the tumour site, earlier bleeds, etc) and it may be appropriate to discuss and plan for such an eventuality with the patient and their family.

Where active treatment is desired, management of a major bleed is as above. With more minor haemoptysis, additional palliative care measures may include:

Oral haemostatics - eg, tranexamic acid.
Cough suppression.
Anticoagulation (where PE).
Antibiotics (where infection).
Radiotherapy or laser treatment of the tumour site.
Therapeutic bronchoscopy with balloon tamponade and infusion of vasoactive agents such as adrenaline (epinephrine) may be successful. Bronchial angiography with bronchial artery embolisation can sometimes control haemoptysis.

Question 61

Haemoptysis prognosis

Answer 61

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.