Understanding Cough, Sputum, and Hemoptysis

Cough

• Cough is a reflex that can last for less than 3 weeks (acute), 3-8 weeks (subacute), or more than 8 weeks (chronic)
• Acute cough is often caused by upper or lower respiratory tract infections, acute exacerbation of chronic pulmonary diseases, or pulmonary embolism
• Subacute cough is often caused by post-infection of upper or lower respiratory tract or by angiotensin converting enzyme inhibitors (ACEIs)
• Chronic cough is often caused by upper airway cough syndrome, bronchial asthma, or gastroesophageal reflux disease

Sputum

• Normal sputum is clear and white, less than 100 ml per day, and not smelly
• Large amounts of purulent sputum may indicate bronchiectasis (chronic) or lobar pneumonia (acute)
• Foul-smelling purulent sputum may indicate a lung abscess with anaerobic infection
• Pink frothy secretions occur in pulmonary edema

Hemoptysis

• Hemoptysis is blood-stained sputum
• The amount of blood can range from streaks to massive bleeding (over 100-600 ml in 24 hours)
• The most common cause is an acute infection, such as an exacerbation of COPD, but other serious causes should be ruled out
• Other causes include pulmonary embolism, bronchogenic cancer, pulmonary tuberculosis, bronchiectasis, lung abscess, pulmonary hemorrhage, and non-respiratory causes like severe mitral stenosis and acute left ventricular failure

Dyspnea

• Dyspnea is the experience of discomfort in breathing or awareness of respiratory distress
• Onset can be instantaneous (pneumothorax, PE), minutes to hours (airway disease, parenchymal disease, pulmonary vascular disease, cardiac disease, metabolic acidosis, hyperventilation syndrome), subacute (days, many causes of acute dyspnea plus pleural effusion, lobar collapse, acute interstitial pneumonia, superior vena cava obstruction, pulmonary vasculitis), or chronic (months to years, COPD & BA, diffuse parenchymal disease, hypoventilation, anemia, thyrotoxicosis)
• Dyspnea can be graded from I-IV based on the NYHA classification

Chest Pain

• Pulmonary causes of chest pain include pulmonary vasculature (acute PE, pulmonary hypertension, cor pulmonale), lung parenchyma (pneumonia, cancer, sarcoidosis, pleuritis and serositis), pleura and pleural spaces (pneumothorax, pleural effusion), and psychogenic/psychosomatic

Wheezing

• Wheezing is a continuous whistling sound that is not diagnostic for asthma and can occur in other respiratory diseases such as COPD

Other Symptoms

• Runny, blocked nose and sneezing can occur in both common cold and allergic rhinitis
• Nocturnal fever may accompany TB, pneumonia, and mesothelioma
• Nocturnal sweating can occur in TB, lymphoma, and lung abscess
• Hoarseness may be secondary to laryngitis, vocal cord tumor, and recurrent laryngeal nerve palsy in apical lung cancer
• Symptoms of cor pulmonale include abdominal and ankle swelling, etc.

History

• Details should be collected about the onset, duration, character, radiation, severity, frequency, aggravating and relieving factors, and associated symptoms of respiratory system symptoms.
• Previous medical history of respiratory disease, smoking history, drug history (including IV drug abuse and alcohol consumption), occupational history, pets history

Clinical Examination

• General Appearance: look for respiratory distress (tachypnea, hyperapnea, accessory muscle use), coughing, sputum, abnormal sounds (stridor, wheezing), abnormal voice (hoarseness), and surroundings
• General System Examination:
  • Hands: clubbing, tar staining, weakness of hand’s small muscles
  • Wrist: pulse (rate and character), flapping tremors (asterixis), blood pressure (pulsus paradoxus, hypotension)
  • Neck: jugular venous pressure (elevated in cor pulmonale and SVC obstruction but not pulsatile), lymph nodes (enlargement in bronchogenic cancer or metastases)
  • Face: eyes (Horner’s syndrome in bronchogenic cancer), tongue (central cyanosis), SVC obstruction (plethoric and cyanosed, periorbital edema, injected conjunctivae, positive Pemberton’s sign)
• Chest Examination:
  • Inspection: shape (barrel-chest, pectus excavatum, pectus carinatum, kyphoscoliosis), symmetry (assessment of upper and lower lobes should be done posteriorly looking for decreased or delayed chest movement during moderate respiration), scars, prominent veins (in case of SVC obstruction)
  • Palpation:
    • trachea (normally central, slight right displacement could be, check for gross displacement, tracheal tug means the distance between sternal notch and cricoid cartilage is less than 3-4-finger breadths and occurs in chest over expansion as COPD)
    • apex beat and mediastinum (check for displacement)
    • chest expansion (expansion ≥ 5 cm)
    • tactile vocal fremitus (TVF) can be done with the palm of one hand
  • Percussion: done symmetrically (left compared with right), posteriorly (the back), anteriorly (the front), and laterally (the sides), supraclavicular area, then clavicles should be percussed directly to evaluate the upper lobes, liver dullness (of the upper edge starting at the 6th rib MCL, resonant note below this area indicates hyper-inflation (COPD, severe asthma), cardiac dullness (may be decreased in a hyperinflated chest)
  • Auscultation:
    • Breath Sounds:
      • intensity (normal, decreased as in consolidation, collapse, pleural effusion, pneumothorax, lung fibrosis), quality (vesicular or bronchial in consolidation
      • Differentiation between vesicular and bronchial:
      • Vesicular breath sounds are louder and longer on inspiration than the expiratory phase and have no gap between the two phases.
      • Bronchial breath sounds are louder and longer on the expiratory phase and have a gap between the two phases.
    • Added Sounds:
      • type (wheezes, crackles, friction rub)
      • timing (inspiratory or expiratory)
      • Wheezes: continuous musical polyphonic sounds, heard louder on expiration and can be heard on inspiration (may imply severe airway narrowing), high-pitched wheezes are found in asthma due to acute/chronic airflow limitation and low-pitched in COPD, localized monophonic wheeze due to fixed airway obstruction in bronchogenic cancer
      • Crackles: interrupted, non-musical inspiratory sounds, may be early, late, or pan-inspiratory and fine, medium, or coarse, late/pan-inspiratory coarse crackles in bronchiectasis, late/pan-inspiratory medium crackles in pulmonary edema, late/pan-inspiratory fine crackles in pulmonary fibrosis
      • Friction rub: due to thickened or roughened pleural surfaces rubbing together as lungs expand and contract and give off a continuous or intermittent grating sound, indicates pleurisy and may be heard in pneumonia or pulmonary infarction.
    • Vocal Resonance: It’s the ability to transmit sounds.

This quiz explores the classifications and causes of cough, sputum characteristics, and hemoptysis. You'll learn about acute, subacute, and chronic cough, as well as what different types of sputum can indicate about respiratory health. Test your knowledge on these essential respiratory symptoms.