3CoughA cough is a sudden, forceful, noisy expulsion of air from the lungs.It is a protective reflex ，but excessive coughing is harmful to human’s body.
4Mechanism of cough from Stimuli vagus nerve larynx, trachea, bronchi, pleura and external acoustic meatusfromStimulivagus nerveafferent nerve fibercoughing centre （in oblongata）efferent nerve fiberlaryngeal nerve diaphragmatic nerve spinal nervesCough is a protective action，but excessive coughing is harmful to human’s body (pharyngeal muscle） （diaphragmatic muscle）（respiratory muscle）deep breathglottal closureintrathoracic pressure increasesudden glottal openingoutward blast of air
12Expectoration The attributes of sputum Bloody Sputum (Hemoptysis,next class )Bloody gelatinous sputumRusty SputumPurulent SputumStringy Mucoid SputumFrothy SputumBroncholiths
13Bloody gelatinous sputum （Currant-jelly sputum ） Copious quantities of tenacious ,bloody sputum are almost pathognomonic for pneumonia caused by klebsiella pneumoniae or streptococcus pneumoniae
14Rusty Sputum ( Prune-juice Sputum) Purulent sputum containing changed blood pigment is typical of pneumococcal pneumonia but it is frequently preceded by small amounts of frank blood.Stringy Mucoid SputumIncreased mucous production and formation of mucous plugs occur in asthma; during resolution of an acute attack, retained mucous is mobilized.Frothy Sputum ( Pulmonary Edema)Fluid from the pulmonary capillaries enters the alveoli and is expectorated. A thin secretion containing air bubbles, frequently colored with hemoglobin , is typical of pulmonary edema. Both acute lung injury and left ventricular failure produce this sign.
15Purulent SputumInflammatory cells, predominately polymorphonuclear leukocytes, enter the airways and alveoli in response to lower airway infection.Colour:yellow (general bacterial), green (aeruginosus Bacillus), or Grey or black (dust inhalation).Amounts:Small amounts ：acute bronchitis, pneumonia during resolution, small tuberculous cavities or lung abscess. Copious purulent sputum suggests lung abscess, bronchiectasis, or bronchopleural fistula communicating with an empyema. Many lung abscesses do not yield much sputum because their bronchial communications are inadequate for complete drainageOdor :Fetid sputum suggests anaerobic infection and/or lung abscess.Bronchiectasis:200 to 500 ml/d. On standing, bronchiectatic sputum typically separates into three layers,with mucus on top separated by clear fluid from pus on the bottom. (or upper: frothy, middle: serofluid or serofluid pus,lower: necrosis substance)bronchopleural fistula :Copious sputum from a patient with signs of pleural effusion suggests
16BroncholithsOccasionally, calcified particles are found in the sputum either by the patient or the physician. These are usually broncholiths, derived from calcified lymph nodes eroding the bronchi or from calcareous granulomas in silicosis, tuberculosis, or histoplasmosis. Their discovery may explain the source of pulmonary hemorrhage
18Hemoptysis Definition: Spitting or coughing of blood is hemoptysis. The blooding region: anywhere from the nose to the lungs .The amount varies from blood-strained sputum to several hundreds ml pure bloodMild: 100ml/dModerate: ml/dSevere: >500ml/d, or /time
19Hemoptysis Differential diagnosis Bleeding from upper respiratory tractExpectorated blood usually comes from the upper respiratory tract while blood in the bronchial tree induces coughing. However, the patient may not be able to distinguish which of the two is occurring, so both upper and lower respiratory tract disorders must be considered.Hematemesis
20Distinguished hemoptysis from hematemesis CausesPulmo or cardiacdigestive systemPrevious symptomsCough, chest tightnessNausea, vomitingSpit upCough upVomitedColorBright redDark redMixtureSputum, frothyGastric contentspHalkalinityacidityTarry stoolsNegative/ positivepositivePost-bleedingSputum with bloodNo sputum
25Bloody SputumBlood in the sputum usually impresses patients enough to bring them to the physician. The first problem is to identify the anatomic site of hemorrhage.Blood-Streaked Sputum is usually caused by inflammation in the nose, nasopharynx, gums, larynx, or bronchi. Sometimes it occurs only after severe paroxysms of coughing and may be attributed to trauma.Pink Sputum usually results from blood mixing with secretions in the alveoli or smaller bronchioles; it most frequently occurs in pneumonia or pulmonary edema.
26Massive bleeding occurs with erosion of a bronchial artery by cavitary pulmonary tuberculosis, aspergilloma, lung abscess, bronchiectasis, pulmonary infarction, pulmonary embolism, bronchogenic carcinoma or a broncholith.Goodpasture syndrome Alveolar Hemorrhage, does not produce bloody sputum in all cases.mitral stenosis. Not infrequently,frank bleeding from the lungs occurs in
302.Bronchial Tree bronchiectasis, bronchial carcinoma, acute and chronic bronchitis,trauma from coughing,broncholiths,foreign body aspiration,erosion by aortic aneurysms.bronchiectasisChicken bonebroncholithscarcinomaforeign body