Chronic Cough & Hemoptysis - Johns Flashcards
What is the definition of chronic cough?
Defined as a cough persisting for three weeks or longer
What is the physiology of cough?
Reflex arc Nose/sinuses => Trigeminal Nerve Posterior pharynx => Glossopharyngeal Pericardium Diaphragm => Phrenic nerve Ear/Trachea/Bronchi => Vagus
What are the three most common etiologies for cough?
- Postnasal drip
- Asthma
- GI reflux
What drug causes coughing as a major side effect?
ACE inhibitors
What is treatment of cough due to postnasal drip?
Ipratropium nasal spray
What is the best way to diagnose cough due to asthma?
Demonstrate improvement with one week of inhaled beta-agonist therapy
(spirometry not always helpful)
How does gastroesophageal reflux cause cough?
Receptors stimulated in larynx, lower respiratory tract and distal esophagus
How do you diagnose cough due to gastroesophageal reflux?
24 hour esophageal pH monitoring
What is the treatment of cough due to gastroesophageal reflux?
- dietary changes (smaller meals, no evening snacks)
- elevation of head of bed
- proton pump inhibitor
May need 6-12 months of Rx.
What are the common centrally acting cough medications?
Codeine & Dextromethorphan
What is the overall treatment plan for a chronic cough?
- Try to establish etiology
- If no cause found then try dextromethorphan and inhaled ipratropium or inhaled corticosteroid.
- Can try PPI if suspecting GI etiology
What is the typical presentation of hemoptysis?
- Can be pure blood or mixed with sputum
- Rarely massive (over 300 cc in 6 hours)
What are the vascular origins of hemoptysis?
Bronchial arteries – supply airways, hilar lymph nodes, visceral pleura
- Are at systemic pressure unlike the pulmonary arteries
- Can cause massive bleeding
What is the DDx for Hemoptysis?
- 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)
What is the evaluation for Hemoptysis?
- History and physical
- Chest x-ray
- CBC, UA, creatinine, coags (plts, INR, PTT)
- Bronchoscopy?
When should you do bronchoscopy in patients with hemoptysis?
-Patients with abnormal CXR (Tumor found
Should you order bronchoscopy vs. CT with patient who has hemoptysis with normal CXR and increased risk factors?
Yes, both.
Probably best to do bronchoscopy first.
Where do PE’s come from?
- 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
What are the risk factors for PE?
- 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
What are causes of pulmonary emboli without risk factors?
-Factor V Leiden mutation in up to 40% of these cases
-High concentrations of factor VIII
-Occult malignancy – up to 17%
pancreatic, prostate
What are the typical symptoms of PE?
Absent symptoms in 26% of patients Dyspnea – 73% Pleuritic pain – 66% Cough – 36% Hemoptysis- 13%
What are the typical signs (on physical exam) of PE?
Tachypnea – 70% Crackles– 51% Tachycardia – 50% Loud P2 – 23% Fever – 14% Many of the above are nonspecific!
A loud P2 means:
- Congestive heart failure
- Mitral stenosis
- Pulmonary hypertension
- Pulmonary stenosis
- Pulmonary hypertension
cause pulmonary valve to close louder due to increased pressure
What is the clinical work up for PE?
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)
How helpful is a VQ scan in diagnosing PE?
Normal scan excludes PE
High probability scan not very sensitive
Many scans are intermediate or low probability – not diagnostic
How helpful is a CT scan in diagnosing PE?
Sensitivity of 70-87%
Specificity of 90%
Can’t detect small emboli beyond segmental arteries
Problem – too many normal scans are ordered!
What is the treatment for PE?
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.
What is the most common source of PE?
A. Calf veins
B. Superficial thigh veins
C. Ileo-femoral veins
D. Right ventricular clots
C. Ileo-femoral veins
