Chronic Cough & Hemoptysis - Johns

Question 1

What is the definition of chronic cough?

Answer 1

Defined as a cough persisting for three weeks or longer

Question 2

What is the physiology of cough?

Answer 2

Reflex arc
Nose/sinuses => Trigeminal Nerve
Posterior pharynx => Glossopharyngeal
Pericardium Diaphragm => Phrenic nerve
Ear/Trachea/Bronchi => Vagus

Question 3

What are the three most common etiologies for cough?

Answer 3

1. Postnasal drip
2. Asthma
3. GI reflux

Question 4

What drug causes coughing as a major side effect?

Answer 4

ACE inhibitors

Question 5

What is treatment of cough due to postnasal drip?

Answer 5

Ipratropium nasal spray

Question 6

What is the best way to diagnose cough due to asthma?

Answer 6

Demonstrate improvement with one week of inhaled beta-agonist therapy
(spirometry not always helpful)

Question 7

How does gastroesophageal reflux cause cough?

Answer 7

Receptors stimulated in larynx, lower respiratory tract and distal esophagus

Question 8

How do you diagnose cough due to gastroesophageal reflux?

Answer 8

24 hour esophageal pH monitoring

Question 9

What is the treatment of cough due to gastroesophageal reflux?

Answer 9

• dietary changes (smaller meals, no evening snacks)
• elevation of head of bed
• proton pump inhibitor

May need 6-12 months of Rx.

Question 10

What are the common centrally acting cough medications?

Answer 10

Codeine & Dextromethorphan

Question 11

What is the overall treatment plan for a chronic cough?

Answer 11

• Try to establish etiology
• If no cause found then try dextromethorphan and inhaled ipratropium or inhaled corticosteroid.
• Can try PPI if suspecting GI etiology

Question 12

What is the typical presentation of hemoptysis?

Answer 12

• Can be pure blood or mixed with sputum

- Rarely massive (over 300 cc in 6 hours)

Question 13

What are the vascular origins of hemoptysis?

Answer 13

Bronchial arteries – supply airways, hilar lymph nodes, visceral pleura

• Are at systemic pressure unlike the pulmonary arteries
• Can cause massive bleeding

Question 14

What is the DDx for Hemoptysis?

Answer 14

• Airway diseases (acute/chronic bronchitis, neoplasms, foreign bodies)
• Pulmonary parenchymal diseases (infection, immune diseases)
• Pulmonary vascular disorders (pulmonary thromboembolisms, left atrial HTN)
• Miscellaneous (cocaine, coagulopathy, iatrogenic)

Question 15

What is the evaluation for Hemoptysis?

Answer 15

• History and physical
• Chest x-ray
• CBC, UA, creatinine, coags (plts, INR, PTT)
• Bronchoscopy?

Question 16

When should you do bronchoscopy in patients with hemoptysis?

Answer 16

-Patients with abnormal CXR (Tumor found

Question 17

Should you order bronchoscopy vs. CT with patient who has hemoptysis with normal CXR and increased risk factors?

Answer 17

Yes, both.

Probably best to do bronchoscopy first.

Question 18

Where do PE’s come from?

Answer 18

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

Question 19

What are the risk factors for PE?

Answer 19

• 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

Question 20

What are causes of pulmonary emboli without risk factors?

Answer 20

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

Question 21

What are the typical symptoms of PE?

Answer 21

Absent symptoms in 26% of patients
Dyspnea – 73%
Pleuritic pain – 66%
Cough – 36%
Hemoptysis- 13%

Question 22

What are the typical signs (on physical exam) of PE?

Answer 22

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

Question 23

A loud P2 means:

1. Congestive heart failure
2. Mitral stenosis
3. Pulmonary hypertension
4. Pulmonary stenosis

Answer 23

3. Pulmonary hypertension

cause pulmonary valve to close louder due to increased pressure

Question 24

What is the clinical work up for PE?

Answer 24

ABG’s – usually have decreased pO2, pCO2 and respiratory alkalosis. May be normal in 20% of PE’s
ECG’s – insensitive
CXR – may show atelectasis or pleural effusion, many are normal
D-dimer – low specificity, high sensitivity
(Negative predictive value is high in patients with a low pretest probability of PE)

Question 25

How helpful is a VQ scan in diagnosing PE?

Answer 25

Normal scan excludes PE
High probability scan not very sensitive
Many scans are intermediate or low probability – not diagnostic

Question 26

How helpful is a CT scan in diagnosing PE?

Answer 26

Sensitivity of 70-87%
Specificity of 90%
Can’t detect small emboli beyond segmental arteries
Problem – too many normal scans are ordered!

Question 27

What is the treatment for PE?

Answer 27

Heparin - unfractionated vs. low molecular weight
Heparin is overlapped with warfarin for at least 5 days
Warfarin for 6 months
Other treatments
Thrombolytics – use in massive PE’s
with hypotension
Inferior vena caval filter – use in patients
with PE and contraindication for anti-
coagulation or recurrent PE despite
anti-coagulation.

Question 28

What is the most common source of PE?

A. Calf veins
B. Superficial thigh veins
C. Ileo-femoral veins
D. Right ventricular clots

Answer 28

C. Ileo-femoral veins