1. Cough
Explosive expiration to clear
tracheobronchial tree

2. Mechanism
 Voluntary or reflexive
 Phases-
 Deep inspiration
 Glottic closure & muscle contraction
 Glottis opens causing forced exhalation
 Stimuli-
 Inflammatory- infection, postnasal drip, GERD
 Mechanical- dust, tumors, edema, interstitial fibrosis
 Chemical- smoke, fumes
 Thermal- cold/hot air

3. Evaluation of cough
 Acute <3 wks. or Chronic >8 wks.
Ac.- RTI; Ch.- postnasal drip, asthma, GERD
 Fever- present or absent
 Dry or productive; character of sputum
 Hemoptysis +/-
 Postural or diurnal or seasonal variation
 Associated symptoms- SOB/DOE, heartburn
 Past history of episodes of cough
 Personal history- smoking etc.

4. Evaluation- contd.
 Examination- oral cavity, larynx,
rhonchi or crepts
 Investigation- need based
 Eosinophilia
 Sputum exam. ± culture, ± cytology
 CxR
 Spirometry
 CT scan
 Bronchoscopy

5. Investigation mandatory
 Hemoptysis
 Recurrent cough
 Rhonchi or crepts
 Any change in ‘smoker’s cough’

6. Complications of cough
 Syncope
 Insomnia
 Vomiting
 Subconjunctival hemorrhage
 Costochondritis
 Rib fracture
 Pneumothorax
 Hernia/Prolapse

7. Treatment
 Etiology based
 Stop ACEI
 Antacids/H2RB/PPI
 Antibiotics- bacterial infection
 Inhaled bronchodilators/steroids
 Symptomatic- dry cough only
 Cough suppressant- codeine/dextromethorphan
 Humidification & expectorants

8. Hemoptysis
Blood in sputum
streaking or gross

9. Hemoptysis- causes
 RTI- commonest
 TB
 Lung cancer
 Bronchiectasis
 Lung abscess
 Mitral stenosis
 Heart failure
 Pulmonary
embolism
 Foreign body
 Trauma
 Wegener’s
 Goodpasture’s syn.
 Bleeding diathesis

10. Hemoptysis- evaluation
 A.B.C.- massive hemoptysis
 History
 Examination
 CxR- AP & lateral
 CT scan ± HRCT
 Bronchoscopy
 Echocardiography

11. Treatment
 Majority stops spontaneously
 Cough suppressants, if required
 Treat underlying pathology
 If massive or unresolving
 Angiography  arterial embolization
 Bronchoscopy  Surgery

12. Cyanosis
Bluish color of skin/mucous
membranes, due to
>5 gm./dl. deoxygenated Hb.

13. Cyanosis- types
 Central
 Skin & mucous
membranes
 Caused by decreased
arterial oxygen sat. or
abnormal hemoglobin
 Exposed areas warm
 Clubbing may be
present
 Peripheral
 Peripheral exposed skin
only
 Caused by
vasoconstriction or
decreased blood flow
 Exposed areas cold,
massage/warming helps
 No clubbing

14. Cyanosis- causes
 Central-
 High altitude- decreased atmospheric pressure
 Bronchospasm, hypoventilation
 Congenital heart disease- TOF
 Intrapulmonary fistula/shunts
 Met/Sulf-hemoglobinemia
 Peripheral-
 low cardiac output
 cold exposure
 arterial/venous obstruction

15. Cyanosis- treatment
Oxygen
Etiology based

16. Clubbing
Drumstick finger
Cause- vasodilation, PDGF,
PGE2

17. Stages of clubbing
 1- nail bed fluctuation
 2- loss of angle between nailbed & fold
 3- increased convexity of nail fold
 4- thickened distal phalanx
 5- hypertrophic osteoarthropathy
Schamroth’s window test

18. Clubbing- causes
 Lung
 Cancer
 ILD
 TB
 Abscess
 Bronchiectasis
 Empyema
 Mesothelioma
 Cyanotic heart dis.
 SABE
 Atrial myxoma
 IBD
 PBC
 Hyperthyroidism
 Idiopathic

19. Management
 History
 Examination
 Investigation
 CxR
 CT scan
 ECHO
 Treatment- of underlying etiology