Course Period : 3

rd
Semester
Course Content : Syndromatology & Symptomatology
Course Topic : Cough, Hemoptysis & Dyspneu
CLINICAL COMPETENCE
Be able to recognize and place the clinical
pictures of the most common diseases related
to Cough, Hemoptysis, Dyspneu syndrome and
symptoms and know how to acquire more
information on it
OBJECTIVES
To address the symptoms of respiratory diseases
To review the anatomy & pathophysiology,
differential diagnosis, pathogenesis, complication,
guidelines for evaluating chronic cough
To review the etiology, pathogenesis, differential
diagnosis, diagnosis of hemoptysis
To review the pathophysiology, differential diagnosis
and guidelines for evaluating dyspneu
Definitions
A deep inspiration followed by a strong
expiration against a closed glottis, which then
opens with an expulsive flow of air, followed
by a restorative inspiration; these are the
inspiratory, compressive, expulsive, and
recovery phases of cough.
Basic term
Acute cough: a recent onset of cough lasting < 3
weeks
Chronic cough: a cough lasting > 8 weeks
Prolonged acute cough: cough may be slowly
resolving over a 38-week period
Recurrent cough: A recurrent cough without a cold is
taken as repeated (>2/year) cough episodes, apart
from those associated with head colds, that each last
more than 714 days

Pathways at various levels involved in the
control of coughing. (Modified from Eccles
R: Codeine, cough, and upper respiratory
infection. Pulm Pharmacol 9:293298,
1996.)
Acute cough : Chronic cough :
Common cold Sinusitis
Pertusis Allergic Rhinitis
Exacerbation of COPD Vasomotor Rhinitis
Asthma Lung Tuberculosis
Pneumonia Chronic Bronchitis
Congestive Heart Failure Bronchiectasis
Aspiration Syndrome Bronchogenic
Carcinoma
Pulmonary Embolism
Differential diagnosis
A simplified overview of the assessment and management of the
common causes of acute cough (< 3 weeks)
A simplified overview of the assessment and management of
prolonged acute cough (38 weeks)
A simplified overview of
the assessment and
management of the
common causes of
chronic cough
(> 8 weeks)
Respiratory Complications
Pneumothorax
Subcutaneous emphysema
Pneumomediastinum
Pneumoperitoneum
Laryngeal damage
Cardiovascular Complications
Cardiac dysrhythmias
Loss of consciousness
Subconjunctival hemorrhage
Central Nervous System Complications
Syncope
Headaches
Cerebral air embolism
Potential Complications from Excessive Cough
Hemoptysis is the blood derived from the
lungs or bronchial tubes.
Hemoptysis may be scant, the appearance of
streaks of bright red blood in the sputum,
profuse, with expectoration of a large volume
of blood.
Massive hemoptysis is defined as the
expectoration of 600 mL of blood within 24 to
48 hours.
May occur in 3 to 10% of all patients with
hemoptysis.

ETIOLOGY OF HEMOPTYSIS
(1)
Cardiovascular
Arteriobronchial fistula
Congestive heart failure
Pulmonary arteriovenous fistula
Diffuse intrapulmonary hemorrhage
Diffuse parenchymal disease
ETIOLOGY OF HEMOPTYSIS
(2)
Iatrogenic
Malposition of chest tube
Pulmonary artery rupture
Tracheoartery fistula

Infections
Aspergilloma - Cystic Fibrosis
Bronchiectasis - Lung abscess
Bronchitis - Tuberculosis
ETIOLOGY OF HEMOPTYSIS
(3)
Malignancies
Bronchogenic carcinoma
Leukemia
Metastatic cancer

PATHOGENESIS OF
HEMOPTYSIS
(1)
The bronchial arteries are the chief source of
blood for the airways (from mainstem bronchi
to terminal bronchioles),
Support framework of the lung that includes
the pleura, intrapulmonary lymphoid tissue,
and the large branches of the pulmonary
vessels, the nerves in the hilar regions.
The pulmonary arteries supply the pulmonary
parenchymal tissue, including the respiratory
bronchioles.
PATHOGENESIS OF
HEMOPTYSIS
(2)

Communications between these two blood
supplies, bronchopulmonary arterial and venous
anastomoses, occur in the proximity of the
junction of the terminal and respiratory
bronchioles.
These anastomoses allow the two blood supplies
to complement each other.
If flow through one system is increased or
decreased, a reciprocal change occurs in the
amount of blood supplied by the other system.
PATHOGENESIS OF
HEMOPTYSIS
(3)

The pathogenesis of hemoptysis depends on
the type and location of the disease.
Endobronchial lesion, the bleeding is from the
bronchial circulation
Parenchymal lesion, the bleeding is from the
pulmonary circulation.
Chronic diseases, repetitive episodes are most
likely due to increased vascularity in the
involved area.

DIFFERENTIAL DIAGNOSIS OF
HEMOPTYSIS
In evaluating patients with hemoptysis, it is
necessary to rule out the causes of
pseudohemoptysis.
Unless the cause of pseudohemoptysis is
definitively determined, the spitting up of
blood must be assumed to be true
hemoptysis.
An upper airway lession must not be assumed
to be the cause of the bleeding unless it is
seen bleeding actively at the time of
examination.

DIAGNOSIS OF HEMOPTYSIS
The diagnostic work-up of hemoptysis
involves:
History, Physical examination, Complete blood
count, Coagulation studies , Electrocardiogram,
Chest radiograph, Bronchoscopy

Dyspnea is a distressing sensation of difficult,
labored, or unpleasant breathing.
The word distressing is very important to this
definition since labored or difficult breathing
may be encountered by healthy individuals
while exercising.
It does not qualify as dyspnea because it may
not be perceived as distressing.
The sensation is often poorly or vaguely
described by patients.

PATHOPHYSIOLOGY OF
DYSPNEA
(1)
There are multiple stimuli, receptors, nerves,
and neural pathways that mediate the
sensation of dyspnea.
The multiple neural pathways model of
dyspnea suggests that dyspnea may arise due
to abnormalities in the afferent pathways, the
efferent pathways, or the central control
centers of the respiratory system.
PATHOPHYSIOLOGY OF
DYSPNEA
(2)

Since afferent pathways feed back to the
central nervous system from virtually all levels
of the efferent pathways, afferent dyspneic
information from virtually all thoracic and
upper abdominal organs.
Including the pharynx, larynx, airways, lung
parenchyma, esophagus, heart, and stomach
may potentially impact the sensation.

DIFFERENTIAL DIAGNOSIS
OF DYSPNEA
(1)
Cardiac
Congestive heart failure (right, left or
biventricular)
Coronary artery disease
Myocardial infarction (recent or past history)
Cardiomyopathy
Valvular dysfunction
Left ventricular hypertrophy
Asymmetric septal hypertrophy
Pericarditis
Arrhythmias

DIFFERENTIAL DIAGNOSIS
OF DYSPNEA
(2)

Pulmonary
COPD
Asthma
Restrictive lung disorders
Hereditary lung disorders
Pneumothorax
DIFFERENTIAL DIAGNOSIS
OF DYSPNEA
(3)

Mixed cardiac or pulmonary
COPD with pulmonary hypertension and Cor
pulmonale
Deconditioning
Chronic pulmonary emboli
Trauma

DIFFERENTIAL DIAGNOSIS
OF DYSPNEA
(4)

Noncardiac or nonpulmonary
Metabolic conditions (e.g., acidosis)
Pain
Neuromuscular disorders
Otorhinolaryngeal disorders
Functional
- Anxiety
- Panic disorders
- Hyperventilation
GUIDELINES FOR
EVALUATING DYSPNEA
(1)
Acute dyspnea
- A clinical approach is recommended for
evaluating acute dyspnea.
- It consists of performing history and
physical examination and performing
laboratory test.
- Considering potensial life-threatening
conditions first (eg,acute asthma,
pulmonary embolism, pulmonary
oedema states, pneumonia)

GUIDELINES FOR
EVALUATING DYSPNEA
(2)

CHRONIC DYSPNEA
COPD, asthma, interstitial lung disease,
cardiomyopathy, GERD, other respiratory diseases,
and the hyperventilation syndrome.
1. Clinical features
2. Chest radiograph in nearly all
patients




GUIDELINES FOR
EVALUATING DYSPNEA
(3)

3. Pulmonary function testing
Noninvasive cardiac studies to include ECG,
echocardiography, and stress testing
Chest CT scan
Comprehensive ETT
Other more invasive test such as cardiac
catheterization and lung biopsy

GUIDELINES FOR
EVALUATING DYSPNEA
(4)


Final determination of the cause of dyspnea is
made by observing which specific therapy
eliminates dyspnea as a complaint.
Dyspnea may be simultaneously due to more
than one condition
Do not stop therapy that appears to be
partially successful; rather, sequentially add to
it.