8 Chronic unexplained coughs are most commonly related to one or a combination of : chronic post-nasal drip; gastroesophageal reflux; cough-variant asthma; drugs (angiotensin converting enzyme inhibitors)
12 Expectoration Bloody Sputum (Hemoptysis,next class ) Bloody gelatinous sputum Rusty Sputum Purulent Sputum Stringy Mucoid Sputum Frothy Sputum Broncholiths The attributes of sputum
13 Bloody gelatinous sputum （ Currant-jelly sputum ） Copious quantities of tenacious,bloody sputum are almost pathognomonic for pneumonia caused by klebsiella pneumoniae or streptococcus pneumoniae
14 Rusty 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 Sputum Increased 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.
15 Purulent Sputum Inflammatory 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 drainage Odor :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
16 Broncholiths Occasionally, 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
18 Hemoptysis 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 blood –Mild: 100ml/d –Moderate: 100-500ml/d –Severe: >500ml/d, or 100-500/time
19 Hemoptysis Differential diagnosis –Bleeding from upper respiratory tract Expectorated 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
20 Distinguished hemoptysis from hematemesis HemoptysisHematemesis CausesPulmo or cardiacdigestive system Previous symptomsCough, chest tightnessNausea, vomiting Spit upCough upVomited ColorBright redDark red MixtureSputum, frothy Gastric contents pHalkalinityacidity Tarry stools Negative/ positivepositive Post-bleedingSputum with bloodNo sputum
25 Bloody Sputum Blood 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.
26 Massive 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
30 bronchiectasis, bronchial carcinoma, acute and chronic bronchitis, trauma from coughing, broncholiths, foreign body aspiration, erosion by aortic aneurysms. 2.Bronchial Tree foreign body broncholiths bronchiectasis carcinoma