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CRRAB II Week 7 > Chronic Cough & Hemoptysis > Flashcards

Chronic Cough & Hemoptysis Flashcards

1
Q

Definition of a Chronic Cough:

A

Defined as a cough persisting for three weeks or longer.

  • Fifth most common outpatient symptom
  • Over 1 billion dollars per year
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2
Q

What is the physiology of chronic cough?

A
  • During cough, intrathoracic pressures may reach 300 mmHg
  • Expiratory velocities approach 500 mph
  • Complex reflex arc: mechanical and chemical receptors
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3
Q

What nerves are involved in the cough reflex?

A

Trigeminal, Glossopharyngeal, Phrenic, Vagus, Spinal motor

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4
Q

What feeds into the medullary cough center?

A
  1. Nose and sinuses through —> Trigeminal nerve
  2. Posterior pharynx through —> Glossopharyngeal nerve
  3. Pericardium, diaphragm through —> Phrenic nerve
  4. Ear canals and ear drums, Trachea, Bronchi, Esophagus, Stomach, Pleura through —> Vagus nerve
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5
Q

What are the outputs of the medullary cough center?

A
  1. Spinal motor nerve —> Expiratory muscles
  2. Phrenic nerve —> Diaphragm
  3. Vagus nerve —> Larynx, Trachea, Bronchi
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6
Q

What etiologies are associated with chronic cough (3 most common!)?

A

Most common:

  1. Postnasal drip
  2. Asthma
  3. GI reflux
    - Many patients have more than one cause
    - Also consider URI’s, side effect of ACE inhibitors
    - 25% of smokers have a chronic cough
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7
Q

Major causes of chronic cough:

A
  • Postnasal drip
  • Asthma
  • Gastroesophageal reflux
  • Chronic bronchitis
  • Bronchieotasis
  • Miscellaneous
  • Angiotensin-converting enzyme inhibitors
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8
Q

Less common causes of chronic cough:

A
  • Bronchiectasis
  • Eosinophilic bronchitis
  • Bronchogenic carcinoma
  • Interstitial lung disease
  • Occult pulmonary infection
  • Occult congestive heart failure
  • Occult aspiration
  • Tracheobronchial foreign body or mass (other than bronchogenic carcinoma)
  • Occupational asthma
  • Nasal polyps
  • Disorders of external auditory ear canals, pharynx, larynx, diaphragm, pleura pericardium, esophagus, stomach, or thyroid
  • Psychogenic
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9
Q

What is the most common cause of chronic cough?

A

Post-nasal drip

  • Can be allergic, vasomotor rhinitis, sinusitis
  • May be “silent drip”
  • No definite criteria for diagnosis
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10
Q

What treatment is recommended for post-nasal drip chronic coughs?

A
  • Treatment may be empiric before large workup is done

- Ipratropium nasal spray, nasal corticosteroids, antibiotics (if sinusitis is present) (consider but try to stay away)

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11
Q

What is the second most common cause of chronic cough?

A

Asthma!

  • Can be associated with wheezing but may have “cough variant type”
  • Best way to confirm diagnosis is demonstrate improvement with one week of inhaled beta-agonist therapy
  • Spirometry not always helpful
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12
Q

What is the best treatment for asthma?

A

Inhaled bronchodilators and/or inhaled corticosteroids. Consider short course of prednisone.

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13
Q

What is another common cause of chronic cough?

A

Gastroesophageal Reflux!

  • Most common cause in recent study
  • Many patients have reflux symptoms but 40% may not have symptoms
  • Receptors stimulated in larynx, lower respiratory tract and distal esophagus
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14
Q

What workup should you do for Gastroesophageal Reflux?

A

24 hr. esophageal pH monitoring

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15
Q

What is the recommended treatment for Gastroesophageal Reflux?

A 
Dietary changes (smaller meals, no evening snacks), elevation of head of bed, proton pump inhibitor. 
-May need 6-12 months of Rx
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16
Q

What are less likely causes of chronic cough?

A
  • Lung cancer - less than 2% of chronic coughs. Neoplasms in large airways.
  • Bronchiectasis - chronic purulent sputum
  • Eosinophilic bronchitis - atopic tendencies, elevated serum eosinophils, respond to inhaled steroids
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17
Q

What are centrally acting cough medications?

A
  • Codeine vs. Dextromethorphan
  • One study indicated equal effectiveness
  • Both superior to placebo
18
Q

What is the overall treatment plan for chronic cough?

A
  • Establish etiology

- If no cause found, try dextromethorphan and inhaled ipratopium or inhaled corticosteroid

19
Q

Most Common Causes of Cough:

A

Asthma, GERD, post-nasal drip

20
Q

Describe hemoptysis:

A
  • Can be pure blood or mixed with sputum

- Rarely massive (over 300 cc in 6 hours)

21
Q

What are vascular origins of hemoptysis?

A
  • Bronchial arteries - supply airways, hilar lymph nodes, visceral pleura
  • Are at systemic pressure unlike the pulmonary arteries]
  • Can cause massive bleeding
22
Q

What approaches should you use to evaluate hemoptysis?

A

H and P, CXR, CBC, UA, Creatinine, Coags (plts, INR, PTT), Bronchoscopy

23
Q

In what patients should bronchoscopy used in?

A

Patients with hemoptysis and normal CXR.

  • Tumor found in less than 5%
  • Increased risk factors:
  • -Male sex
  • -Older than age 40
  • -Smoking history over 40 pack years
  • -Hemoptysis greater than one week
24
Q

What should be used in assessing hemoptysis (Bronchoscopy or CT)?

A
  • One study: In 91 patients with hemoptysis, CT found all the tumors seen by bronchoscopy plus several others
  • However, CT can’t detect bronchitis and small mucosal lesions
  • Therefore, they are complimentary
  • Probably best to do bronchoscopy first
25
Q

What pathophysiology is associated with Pulmonary Embolism?

A
  • Iliofemoral thrombi source of most PE’s
  • Calf vein thrombi do not commonly embolus
  • Also consider pelvic veins as a source
  • Less likely - right heart, renal veins, upper extremities
26
Q

What are facts about Pulmonary Embolism?

A
  • 500,000 patients diagnosed per year
  • 50,000 deaths
  • Estimated another 600,000 are undiagnosed
  • Untreated mortality of 30%
  • Treated mortality of 2-8%
27
Q

What is the differential for Hemoptysis?

A
  • Acute/chronic bronchitis
  • Bronchiectasis
  • Neoplasms
  • Foreign bodies
  • Airway trauma
  • Bronchovascular fistula
  • Infection
  • Immune distorders (Wegner’s, Goodpasture’s, idiopathic pulmonary hemosiderosis)
  • Pulmonary thromboembolism
  • Pulmonary arteriovenous malformations
  • Left trail hypertension
  • Coagulopathy
  • Cocaine use
  • Catamenial hemoptysis
  • Iatrogenic
  • Cryptogenic
28
Q

What are the Risk Factors for Pulmonary Embolism?

A
  • Immobilization
  • Surgery within three months
  • Stroke
  • History of thromboembolism
  • Malignancy
  • In women - obesity, heavy smoking, hypertension, birth control pills, pregnancy
  • Air travel - over 3000 miles
29
Q

What can cause Pulmonary Emboli without risk factors?

A
  • Factor V Leiden mutation in up to 40% of these cases
  • High concentrations of factor VIII
  • Occult malignancy - up to 17% pancreatic, prostate
30
Q

What are the clinical manifestations of Pulmonary Embolism?

A
  • Absent symptoms in 26% of patients
  • Dyspnea - 73%
  • Pleuritic pain - 66%
  • Cough - 36%
  • Hemoptysis - 13%
31
Q

What are the clinical signs of Pulmonary Embolism?

A

-Tachypnea - 70%
-Crackles - 51%
-Tachycardia - 50%
-Loud P2 - 23%
-Fever - 14%
Many of the above are nonspecific

32
Q

What does a loud P2 indicate?

A

Pulmonary hypertension

33
Q

What scores on the Modified Wells Criteria indicate high, moderate and low probability of Pulmonary Embolism?

A 
High = greater than 6.0
Moderate = 2.0 to 6.0 
Low = less than 2.0
34
Q

What scores are associated with the seven Modified Wells Criteria?

A
  • Clinical symptoms of DVT - 3.0
  • Other diagnosis less likely than pulmonary embolism - 3.0
  • Heart rate >100 - 1.5
  • Immobilization or surgery in the previous four weeks - 1.5
  • Previous DVT/PE - 1.5
  • Hemoptysis - 1.0
  • Malignancy - 1.0
35
Q

What is the Modified Wells Criteria used for?

A

Clinical Assessment for Pulmonary Embolism

36
Q

What do the arterial blood gases show in pulmonary embolism?

A

Usually have decreased pO2, pCO2 and respiratory alkalosis

-May be normal in 20% of PEs however

37
Q

What do ECGs show in Pulmonary Embolism?

A

Insensitive

38
Q

What does CXR show in Pulmonary Embolism?

A

May show atelectasis (complete or partial collapse of part of lung) or pleural effusion, many are normal

39
Q

What does D-dimer show in Pulmonary Embolism?

A

Low specificity, high sensitivity

-Negative predictive value is high in patients with a low pretest probability of PE

40
Q

What do Ventilation-Perfusion Lung Scans tell us?

A
  • Normal scan excludes PE
  • High probability scan not very sensitive
  • Many scans are intermediate or low probability - not diagnostic
41
Q

What is the sensitivity and specificity of CT for Pulmonary Embolism?

A

Sensitivity - 70-87%

Specificity - 90%

42
Q

What are the limitations of the CT scan in detecting PE?

A
  • Can’t detect small emboli beyond segmental arteries

- Problem: too many normal scans are ordered!

CRRAB II Week 7 (8 decks)

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