Cough and Hemoptysis Flashcards
1
Q
Forced expulsive maneuver usually against a closed glottis, whih is associated sound
A
cough
2
Q
Cough pellets
A
Broncholiths
3
Q
Initiation of cough
A
Voluntary cough -cortex
Reflexive cough - vagus nerve and its branches
4
Q
Most sensitive sites for initiating cough
A
larynx and tracheobronhial tree, esp. carina and branching points
5
Q
Phases of cough Production
A
- Inspiratory
- Compressive/ Glottic Closure
- Expulsive (Expiratory or explosive)
- recovery
6
Q
Inspiratory phase of coughing
A
1st phase
2.5 L
negative flow rate
7
Q
Compressive/ Glottic cllosure
A
2nd phase of production
Zero flow rate
Pressure builds up, to as high as 300 mmHg
Positive intrathoracic pressure
8
Q
Expulsive (Expiratory or explosive)
A
3rd Phase 1st cough sound heard Growing, constant, decreasing sub-phases Positive flow rate Pressure is highest 120 to 160kph large pressure differential
9
Q
Recovery
A
4th phase of coughing
Restorative inspiration
10
Q
Which phase is not critical to effective coughing?
A
Glottic clossure
11
Q
Initiation of cough
A
- Inflammatory or mechanical changes in the airways
- Polymodal Sensosy nerve receptros
- Rapid and large changes in lung volumes
- Psychological factors
12
Q
Exaggerated response to harmless or mildly irritating stimuli
A
Cough sensor plasticity
13
Q
Which nerves are involved in both the efferent and afferent limbs of the cough reflex?
A
Phrenic and Vagus
14
Q
Medullary cough pattern generatory
A
Nucleus tractus solitarius
15
Q
Dual primary sensory neuron model of cough induction
A
C fibers - chemical irritants
Mechanoreceptors - sense punctate mechanical forces
16
Q
Compose most of the bronchopulmonary vagal afferent nerves, with terminals in and around the mucosa surface of the airways
A
Unmyelinated C-fiber nociceptors
17
Q
Sensitive to bradykinin and activators of the ion channels
A
Unmyelinated C fibers
18
Q
TRPV1
A
Capsaicin, protons
19
Q
TRPVA1
A
Ozone, spices, mustard, wasabi-allyl isothiocyanate
20
Q
Mechanically sensitive “cough receptors”
A
beneath the epithelium in the large airways
Relative insensitive to most chemical mediators
Include Widdicombe cough receptors and lung stretch receptors
21
Q
Include Widdicombe cough receptors and lung stretch receptors -
A
Rapidly adapting receptors (RARs) and slowly adapting receptors (SARs)
22
Q
The major afferent pathway
A
Vagus nerve
23
Q
Stimuli triggering the vagus nerve
A
Ear, pharynx, larynx, trachea, carina, large intrapulmonary bronchi, heart, pericardium, esophagus
24
Q
Involuntary cough appears to be initiated only from
A
vagal innervation of the airways
25
Airway afferent nerve fibers originate in the ________-
nodose and jugular ganglia
26
Airway afferents are stimulated by irritants or inflammatory mediators via _______?
activation of G protein coupled receptors
27
Factors contibuting to cough Inefficiency
1. Altered cough mechanics
2. altered mucous rheology
3. altered mucociliary function
28
Altered cough mechanics
1. Expiratory muscle weakness
2. Inspiratory muscle weakness
3. Abdominal wall muscle weakness
29
Altered mucous rheology
Adhesiveness
| Cohesiveness
30
Composition of Normal Mucus
95% water
3% mucin
1% lipids
<0.3% DNA
31
Confers viscosity and elasticity
Mucin
32
Liquid-like propertythat resists flow -stickness
Viscosity
33
Solid-like capacity to store energy that moves or deforms the fluid - stringiness
Elasticity
34
MUC genes
20 human MUC genes
| 9 expressed in the human respiratory tract
35
membrane tethered Mucin
MUC 1, MCU 4, MUC 16
36
Only 3 are classic gel-forming mucins
MUC 2 , MUC 5AC, MUC5B
37
MUC produced mostly at proximal airways by goblet cells
MUC5AC
38
MUC produced by goblet cells throughout airways and by submucosal glands
MUC5B
39
Mucin
Cysteine-richsecretory mucins stabilized by multiple disulfide bonds _> entangled in a mesh
40
Airway inflammation ->Mucus hypersecretory phenotype
* Decreased mucociliary clearance
* Increaed luminal mucus
* Submucosal gland hypertrophy
41
Decreasd mucociliary clearance
Goblet cell hyperplasia/mucus metaplasia
| Increased plasma exudation
42
Increased luminal mucus
Increased mucus synthesis and secretion
| Reduced mucin degradation within the airways
43
Submucosal gland hypertrophy
Secretion of inflammatory mediators
44
Cystic fibrosis
Increased (+++++) inflammatory cells, DNA, Actin, Bacteria
45
Asthma
Increased (+++++) mucin
46
Major symptom in chronic bronchitic phenotype II
Mucus hypersecretion of COPD (Myeloperoxidase)
| myeloperoxidase
47
Sequelae of mucus
```
Increased Viscosity of mucus
decreased ciliary effectiveness
increased Mucus plugs
Increased Airway Resistance
increased infections
Obstructed bronchioles lead to atelectasis
```
48
Cough reflex sensitization
Viral infection ->Cough reflex becomes hyperreactive-> cough subsides after 2-3 weeks
49
Duration of Cough
Acute <3 weeks
Sub-acute : 3-8 weeks
Chronic ->8 weeks
50
Several nerves that are involved in the afferent limb
Trigeminal, glossopharungeal, phrenic, and vagus
51
Systematic evaluation of the afferent limb of the cough reflex
Anatomic diagnostic protocol
52
drug induced cough
ACEI (Captopril, enalapril for HTN)
| - accumulation of bradykinin
53
Formerly known as Postnasal drip syndrome
Chronic Upper Airway Cough syndrome
54
Complications of cough
```
Soreness
Syncope
Fractures
Pneumothorax
Exhaustion
Tracheobronchial trauma
Insomnia
Lifestyle change
```
55
Examples of Non-Specific Cough therapy
1. Antitussive or cough supressant
| 2. Protrussive
56
Drugs than increase the latency or threshold of the cough center. Affects the afferent Limb of the cough reflex
Antitussive or cough supressant
| Levodropropizine
57
a cough productive of significant quantities of sputum should usually not be suppressed, since retention of the sputum in the tracheobronchial tree may interfere with distribution of alveolar ventilation and the ability of the lung to resist infection
ptrotrussive
- indicated in cystic fibrosis, bronchiectasis, pneumonia, and post operative atelectasis
58
Controlling Mucus Hypersecretion
Increase depth of the sol layer
Alter the consistency of the gel layer
Improve ciliary activity
59
Mucoactive agents
Expectorants
Mucoregulators
Mucolytics
Mucokinetics
60
Increase secretion of mucin, Increase the depth f the sol layer and hydration until it can be coughed out
Expectorants
| hypertonic saline, guaifenesin
61
Decrease neurogenic/airway iflammation
Mucoregulators
| Anticholinergics, steroids, and macrolides
62
Compounds with sulfhydryl groups that are able to dissociate disulphide bonds -> reduce mucus viscosity
"free" sulfhydryl groups -> N-acetylcysteine
"Blocked" sulfhydryl groups _> carbocysteine, erdosteine
Proteolytic enzymes and rhDNAse also breaks up mucus
63
Increase the transportability of mucus through cough
improve mucociliary transport
| Bronchodilators, surfactants, ambroxol, certain mucolytics
64
Tickle in the throat, throat clearing, hoarseness, nasal congestion
Chronic upper airway syndrome
65
Secretions from nose/sinuses stimulate upper airway cough receptors; inflammation increases receptor sensitivity
Chronic Upper Airway Cough Syndrome
66
Reversible airflow obstruction in spirometry (FEV1/FVC <75% at least 12% and 200 mL increase in FEV1 or FVC after 2 puffs of SABA)
Low peak flow and at least 15% increase after SABA
Cough-variant asthma
67
Cough that worsens when lying supine
GERD/LPR
68
Laryngoscopy findings
Edema, Erythema, Ventricular obliteration, pseduosulcus, postcricoid hyperplasia
69
Eosinophilic airway inflammation without variable airflow obstruction or airway hyperresponsiveness
Non-asthmatic eosinophilic bronchitis (NAEB)
70
Diagnostic tests for NAEB
Induced sputum (>3% eosinophils)
71
Diagnostic/therapeutic trial
inhaled corticosteroid for >4 weeks
72
Cough that has been present for at last 3-8 weeks following flu-like symptoms, includes tansient post viral BHR, pertussis, cough due to atypical organisms. Consider other diagnoses if cough >8weeks
Post infectious cough
73
Likely due to extensive inflammation and disruption of upper and/or lower airway epithelial integrity
Post-infectious cough
74
Accumulation of protrussive mediators such as bradykinins and substance P in the respiratory tract with ACEI; bradykinins stimulate production of prostaglandins
ACEI- induced cough
75
DDX for dry cough, scratchy throat, feeling of throat obstruction
ACEI-Induced cough
76
cough resolves within 1-4 weeks (ave 26 days) If its due to ACE-I intake
ACEI-Induced cough
77
Afferent nerve carried by the auricular branch of the vagus nerve innervate the external auditory meatus
Arnold reflex
78
Most common cause of mortality in hemoptysis
Asphyxiation
79
Massive hemoptysis
200-600ml
unquantified amount but with the hemodynamic instability or anemia requiring transfusion
Medical Emergency
80
dark red or brown in clumps, mixed with food, acidic pH, stomachache, abdominal discomfort, nausea, retching
hematemesis
81
Why is hemoptysis common>
Dual circulation of the lung
82
Most common source of hemoptysis
Bronchial arteries (high pressure)
83
Most common etiology of hemoptysis
Tracheobronchial disorders
- diffuse alveolar damage
- diffuse bleeding in the alveolar space
84
Destruction of cartilaginous support, bronchial artery hypertrophy, expansion of peribronchial and submucosal bronchial arterial apparatus, augmented anastomoses
Bronchiectasis
85
Hemoptysis in TB mechanism
Bronchial ulceration with necrosis
| Rupture of Rasmussen;s aneurysm
86
Pulmonary artery erosion pseudoaneurysm., An aneurysm created by the erosion of a vessel by disease in the lung. Can be simultaneously perfused by teh pulmonary and the systemic circulation. Can be multiple, Diagnosed by spiral CT or pulmonary angiography
Ramussen's aneurysm
87
Primary Pulmonary vascular Disorders
Arteriovenous malformmation
Pulmonary embolism
Elevated pulmonary venous pressure
Iatrogenic
88
Miscellaneous/Rare Causes of hemoptysis
Cocaine-induced pulmonary hemorrhage
Catamenial hemoptysis
Leptospirosis
Paragonimiasis
89
Seen in free base cocaine users. Associated with diffuse alveolar hemorrhage
Cocaine-induced pulmonary hemorrhage
90
Recurrent and coincident with menses, Cause: intrathoracic endometriosis
Catamenial hemoptysis
91
TOP main cause of Massive hemoptysis
TB, bronchiectasis, Pneumoconiosis, Aspergilloma, Bronchial CA
'BattleCamp"
92
Putrid smell to the sputum
Anaerobic organism
93
Highest value in a patient with hemoptysis + normal or non localizing the bleeding site
Bronchoscopy
94
Acute management of Massive Hemoptysis
```
ABCs
Stop the bleeding
Treat underlying cause
Protect the non bleeding lung
Bronchoscopy
Bronchial artery embolization
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