PATHOPHYSIOLOGY OF RESPIRATORY SYMPTOM:

COUGH, HEMOPTYSIS, DYSPNEA, CHEST PAIN

Pulmonology and Respiratory Medicine

Medical Faculty of Brawijaya University/ Saiful Anwar Hospital Malang

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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.

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Mechanism Of Cough
Cough

 Normal reflex
 Protective mechanism
 Stimulation of cough receptor
 Clear secretions and foreign material from respiratory tree.
 COUGH REFLEX
Cough Receptor
(Laring, Trachea, Bronchus, Ear , Pleura, Gaster, Nose,
Sinus Paranasalis, Pharing, Pericard, Diafragma)

Afferent Nerve
(Vagus,Trigeminus,Glossopharingeus, Phrenicus nerve)

Cough Centre
(Medulla oblongata)

Efferent Nerve
(Vagus, Phrenicus, Intercostal and Lumbar, trigeminus,
Facialis, Hipoglossus Nerves)

Effectors
(Laring, Trakea, Bronchus, Diafragma, Intercostal Muscles)
Pathways at various levels involved in the control of coughing. (Modified
from Eccles R: Codeine, cough, and upper respiratory infection. Pulm
6 Pharmacol 9:293–298, 1996.)
Stimulators Of Cough
 Excess mucous production
 Environment irritants (cigarette smoke, noxious gases, dust,
allergens)
 Aspiration
 Inflammation (secondary to microbial invasion)
 Thermal factors (hot or cold air)
 Pressure or extrinsic tension (tumor, adenopathy, aortic aneurysm)
 COMMON CAUSES of COUGH
Acute Infection Tracheobronchitis Parenchymal Chronic Tumors Bronchogenic Ca
Brochopneumonia Disease Interstitial Lung Alveolar Wall Ca
Viral Pneumonia Fibrosis Benign Airway
Exacerbation of Emphysema tumors
COPD/ Bronchitis Sarcoidosis Mediastinal
Pertussis tumors
Chronic Infection Bronchietasis Chronic Infection Bronchietasis Cardiovascular Left Ventricular
Tuberculosis Tuberculosis Diseases Failure
Cystic Fibrosis Cystic Fibrosis Pulmonary
Infarction
Aortic aneurism
(thoracic)
Airway Disease Asthma Airway Disease Asthma Other Diseases Reflux Esophagitis
Chronic Chronic Recurrent
Bronchitis Bronchitis Aspiration
Chronic Postnasal Chronic Postnasal Endobronchial
drip drip sutures

Drugs Angiotensin- Foreign Bodies Middle Ear

converting Patholoogy
enzyme inhibitors
EXCESSIVE COUGH
 Respiratory Complications
 Cardiovascular Complications
 CN System Complications
 Musculoskeletal Complications
 Gastrointestinal Complications
 Others
Potential Complications from Excessive Cough
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
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 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 3–8

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 7–14 days

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 DIFFERENTIAL DIAGNOSIS

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

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A simplified overview of the assessment and management of the common causes of acute cough (< 3 weeks)
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A simplified overview of the assessment and management of prolonged acute cough (3–8 weeks)
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 A simplified overview of the
assessment and
management of the
common causes of chronic
cough (> 8 weeks)

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 Definition
 Hemoptysis: Expectoration of blood from the respiratory tract

 It can range from blood-streaking of sputum to the presence of gross

blood in the absence of any accompanying sputum

 Massive hemoptysis is variably defined as the expectoration of >100 to

>600 mL over a 24-hour period,
Massive hemoptysis can result in suffocation, risk for large aspiration,
airway obstruction, or hypotension

 “Exsanguinating” hemoptysis is enough bleeding to threaten life by

blood loss itself
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HEMOPTOE/ HEMOPTYSIS
 Haima= blood; ptysis= expectorate
 Derived from the lungs or bronchial tubes.
 Scant, the appearance of streaks of bright red blood in the sputum,
profuse, with expectoration of a large volume of blood.
 3 to 10% of all patients with hemoptysis.

Stage of Hemoptoe (PURSEL)

1. Blood streak
2. 1-30 cc
3. >30-150 cc
4. >150-500 cc
5. Massive : >500-1000 cc or >500 cc
Anatomy
Blood Circulation in the lungs :
2 Components

Low pressure High pressure

Pulmonary Circulation Bronchial Circulation
SBP = 15-20 mmHg = systemic pressures
DBP = 5-10 mmHg
Patients with normal PAP Bronchial arteries & collaterals
(no PAH) rarely bleed: only originate from the aorta
5% of massive hemoptysis The source of bleeding in most
cases
 Pathophysiology (1)
 The bronchial arteries → chief source of blood for the airways (from
mainstem bronchi to terminal bronchioles).

 Support framework of the lung → pleura, intrapulmonary lymphoid

tissue, & 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.

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Pathophysiology (2)

 Bronchopulmonary arterial & venous anastomoses, occur in the

proximity of the junction of the terminal & respiratory bronchioles →
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.

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 Pathophysiology (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.

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PATHOPHYSIOLOGY
1. Mucosal inflammation
In acute or chronic tracheobronchitis, the mucosal with rich blood vessel is
fragile, so even a mild trauma can cause bloody cough
2. Lung infarction
Commonly caused by lung embolism or microorganisme invassion such as
coccus, viral, or fungal infection
3. Rupture of vein or capiler vessel
Blood vessel distension due to increase of intraluminar blood pressure in acute
left heart decompensation and mitral stenotic
4. Disorder of alveocapillary membrane
Due to antibody reaction to the membrane, such in Goodpasture’s syndrome
 PATHOPHYSIOLOGY
5. Bleeding of TB cavity
Rupture of blood vessel in wall of TB cavity, known as Rasmussen
aneurism. Bloody cough in bronchiectasis caused by dilatation of
branch of bronchial blood vessel. It’s caused by anastomose of
bronchial and pulmonal blood vessel. Rupture of pulmonal blood vessel
can cause massive hemoptisis)
6. Chest injury
Because of injury on chest wall, transudation of lung parenchym to the
alveol will occur and induce bloody cough.
7. Malignant tumor invasion
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Etiology

 Infectious
 Malignancy
 Trauma
 Cardiac/pulmonary vascular
 Factitious
 Cryptogenic

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Etiology: Classification By Site
Tracheobronchial source Pulmonary Parenchymal
Bronchitis Source
Bronchiactasis Lung abscess
Neoplasm Pneumonia
Broncholithiasis TB
Airway trauma Mycetoma (Fungus Ball)
Foreign body GPS
Idiopathic pulmonary hemosederosis
Pulmonary Vascular WG
source Lupus pneumonitis
Pulmonary embolism Lung contusion
Arteriovenous malformations
Pulmonary arterial hypertension Miscellaneous/rare causes
Pulmonary venous hypertension Pulmonary endometriosis
(Mitral stenosis) Systemic coagulopathy
Pulmonary artery rupture Use of anticoagulants or
thrombolytics
Etiology
Tuberculosis Rasmussen aneurysm vs bronchial hypervascularisation
Bronchogenic Ca Erotion/ necrose; abruption of small blood vessels; invasion to pulmonary
vessels
Bronchiectasis Infection → trauma
Anastomose
Blood vessels abruption of granulation
Chronic bronchitis Inflammation
Lung abcess Thick cavity which is difficult to close
Mitral stenosis ang Left Mild : perdiapedesis because of the pressure of pulmonal vein
Heart Failure Ferguson : varices of bronchus mucosa
Anastomose pulmonary and bronchial vein
Infarct of the lung Arterial closure causes anastomose
Spasm reflex
Good Pasture Syndrome Abnormality of basal membran capillary alveol (GBM Ab)- collagen type IV
Mycosis Friction of mycetoma movement
Anticoagulant
Proteolitic enzyme
Excessive cough
 DIAGNOSIS OF HEMOPTYSIS
 The diagnostic work-up of hemoptysis involves:
 History, Physical examination, Complete blood count, Coagulation
studies , Electrocardiogram, Chest radiograph, ± Bronchoscopy
 Anamnese of previous or coexisting illness
 Renal disease (Goodpasture’s syndrome, Wegener’s granulomatosis)
 SLE (lupus pneumonitis with pulmonary hemorrhage)
 Previous malignancy
 AIDS (Kaposi’s sarcoma)
 Risk factors for cancer
 Smoking
 Asbestos exposure
 Bleeding disorders, use of anticoagulant or drugs associated with cytopenia
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DIAGNOSTIC PROCEDURE
 Anamnese of previous or coexisting illness
 Renal disease (Goodpasture’s syndrome, Wegener’s
granulomatosis)
 SLE (lupus pneumonitis with pulmonary hemorrhage)
 Previous malignancy
 AIDS (Kaposi’s sarcoma)
 Risk factors for cancer
 Smoking
 Asbestos exposure
 Bleeding disorders, use of anticoagulant or drugs associated with
cytopenia
 Diagnostic Procedure Cont…..

 Physical Examination
 Pleural friction rub
 Localized or diffuse crackles (parenchymal process)
 Evidence of airflow obstruction (chronic bronchitis)
 Prominent rhonchi (bronchiectasis)
 Cardiac exam (pulmonary arterial hypertension, MS, CHF)
 SLE

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 Diagnostic Procedure Cont…..

 Diagnostic evaluation
 Chest x-ray and chest CT scan
 Complete blood count
 Coagulation profile
 Assessment for renal disease
 Sputum examination
 Bronchoscopy
 Localization
 Treatment

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Radiologic studies
CXR
 Normal in up to 30 %
 Abnormality may not reflect the exact site of bleeding
Why?
CT Scan : higher yield
 HRCT in certain Dx (Bronchiectasis) 82-97% (compared with 37%
in CXR)
 The advantage of CT :
 Suggest one of several diagnoses (such as bronchiectasis, lung abscess,
and mass lesions, including cancer, mycetomas, and AVM’S)
 Help in the acute setting to guide arteriography or bronchoscopy to the
regions of highest yield
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Role of FOB
 Identify the site of bleeding; make a pathologic diagnosis

 Ability to identify the site of bleeding is dependent on the rate of

bleeding

 FOB done early (within 48 hrs) more likely to identify the site (34 vs
11%)

 Diagnostic yield higher when an abnormality present on CXR

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 Laboratory Examination
 CBC
 Faal hemostasis
 Urinalysis
 RFT
 Sputum AFB
 Sputum gram, culture, sensitivity test
 Cytoplasmic anti-neutrophylic cytoplasmic antibody (Susp. Wegener’s
granulomatosis)
 Anti gromerular basement membrane antibodies (Susp. Goodpasture’s
syndrome)
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 Differential Diagnose
Make sure it is Hemoptysis
DDx:
 Hematemesis
 Epitasis
 Other nasopharyngeal bleeding
 Before assuming a lower respiratory source of the bleeding, it is
important to consider whether the blood may be coming from a non-
pulmonary source, such as the upper airway or the gastrointestinal
tract
 Alkaline pH, foaminess, or the presence of pus may sometimes suggest
the lungs as the primary source of bleeding rather than the stomach.
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 Session Hemoptoe Hematemesis

1. Prodromal Discomfort of throat Nausea, discomfort abdomen

2. Onset Cough of blood, can Blood is vomited, can
accompanied by cough accompanied by cough
3. Blood performance Foaminess No Foam
4. Colour Bright Red Dark Red
5. Content Leucocyte, microorganism, Wasting food
macrophag, hemosiderin
6. Reaction Alkaline (high pH) Acid (low pH)
7. Hystorical desease Abnormality in lung Liver and gastric disturbance
8. Anemi Rarely Frequently
9. Faces Normal colour Dark colour
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Definition
 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.

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 PATHOPHYSIOLOGY OF DYSPNEA
 There are multiple stimuli, receptors, nerves, and neural pathways that
mediate the sensation 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.

 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.
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DIFFERENTIAL DIAGNOSIS OF DYSPNEA

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
Pulmonary COPD; Asthma
Restrictive lung disorders; Hereditary lung disorders
Pneumothorax
Mixed cardiac or COPD with pulmonary hypertension and Cor pulmonale
pulmonary Deconditioning
Chronic pulmonary emboli
Trauma
Noncardiac or Metabolic conditions (e.g., acidosis)
nonpulmonary Pain
Neuromuscular disorders
Otorhinolaryngeal disorders
Functional
- Anxiety
- Panic disorders
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- 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)

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 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
3. Pulmonary function testing
4. Noninvasive cardiac studies to include ECG, echocardiography, and
stress testing
5. Chest CT scan
6. Other more invasive test such as cardiac catheterization and lung
biopsy
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GUIDELINES FOR EVALUATING
DYSPNEA(3)
 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.

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Thoracic Pain
 First thoughts : Myocardial ischemia
 Characteristic radiation: to the left arm, shoulder, or neck
Lack relation to breathing
Deep, oppressive substernal pain

 Extracardiac painful sensation : from pleura, lungs, chest wall,

referred to the thorax as a result oh GERD

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Pleuritic Pain
 Originates in the parietal pleura & endothoracic fascia. The visceral
pleura is insensitive to pain.
 Close to the thoracic cage, abrupt onset, unilateral.
 Tachypnea & shallow tidal volumes
 Inspiratory pain → stretching of inflamed parietal pleura during
movement of the thorax, coughing, or laughing.
 The pain is ussually local, sometimes spreads along the course of the
intercostals nerves that supply the affected area.

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 Pleuritic Pain Cont…

 Irritation of the diaphragmatic pleura by an inflammatory process

(below or above the diaphragm)→ ipsilateral shoulder pain
 Pleural pain is part of a syndrome of pleural inflammation that
includes malaise and fever.
 Important exception to this generalization is the pleural pain of
pulmonary infarction, unassociated with any premonitory signs
 Inflamation & malignant etiologies → pleuritic pain occurs with
pneumothorax

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Pulmonary Pain
 Searing sensation and most pronounced after cough.
 Associated with upper respiratory infection → tracheitis or
tracheobronchitis
 Uncommon type of chest pain  pulmonary hypertension, absent in
rest & appears during exertion.
 Substernal, associated with dyspnea. Often mistaken for left heart
angina. May be due to right ventricular strain & ischemia

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Chest Wall Pain
 Musculoskeletal pain → aggravated by breathing, confused with
pleuritic pain
 Often bilateral, intensified by changes in body position or flexing the
thorax.
 The affected muscles are often tender to gentle pressure, fractured
rib is often identified → history of a fall, injury or trauma.
 Horner’s syndrome, local destruction of bone by the tumor & atrophy
of hand muscles. Destruction of one or more of upper three ribs
posteriorly

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Cardiac Pain
 Another type of cardiac pain → pericarditis
 Pericardial pain → agrravated by deep breathing, telltale rub that is
synchronous with the heartbeat. Discomfort may be relieve by leaning
forward.
 Postpericardiotomy syndr → chest pain that develops within a few
days to weeks after cardiac or percardiotomy . Sudden in onset &
substernal, radiation to the left side of the neck, aggravated by deep
breathing.

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Miscelaneous Pain
 Other structures in the mediastinum → source of chest pain
 Arising from the esophagus (peptic esophagitis) & dissection of the
aorta
 Esophageal disease → burning pain, after eating. Acid reflux may
worsen with recumbency
 Aortic dissection → sharp, tearing sensation, acute onset, radiation
to the shoulder. Signs of impending cardiovascular collapse.

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 Miscelaneous Pain Cont…
 Arthritis of cervical spine → thoracic pain
 Quite clear → characteristic distribution
cervical spondylosis → severe pain in the chest & arms. Mimic
myocardial infarction pain
 Metastatic tumor to the thoracic spine → bilateral symmetric pain.
Discomfort to palpation over the affected area. Unilateral →
distribution of of an intercostal nerve
 Anxiety → produce or intensify chest pain. Accompanied by dyspnea
& hyperventilasi, vasomotor instability ( excessive palmar sweating,
flushing & tachycardia.

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