Chapter 034. Cough and Hemoptysis (Part 3) Complications Common complications of coughing include chest and abdominal wall soreness, urinary incontinence, and exhaustion. On occasion, paroxysms of coughing may precipitate syncope (cough syncope; Chap. 21), consequent to markedly positive intrathoracic and alveolar pressures, diminished venous return, and decreased cardiac output. Although cough fractures of the ribs may occur in otherwise normal patients, their occurrence should at least raise the possibility of pathologic fractures, which are seen with multiple myeloma, osteoporosis, and osteolytic metastases. Cough: Treatment Definitive treatment of cough depends on determining the underlying cause and then initiating specific therapy. Elimination of an exogenous inciting agent (cigarette smoke, ACE inhibitors) or an endogenous trigger (postnasal drip, gastroesophageal reflux) is usually effective when such a precipitant can be identified. Other important management considerations are treatment of specific respiratory tract infections, bronchodilators for potentially reversible airflow obstruction, inhaled glucocorticoids for eosinophilic bronchitis, chest physiotherapy and other methods to enhance clearance of secretions in patients with bronchiectasis, and treatment of endobronchial tumors or interstitial lung disease when such therapy is available and appropriate. In patients with chronic, unexplained cough, an empirical approach to treatment is often used for both diagnostic and therapeutic purposes, starting with an antihistamine-decongestant combination, nasal glucocorticoids, or nasal ipratropium spray to treat unrecognized postnasal drip. If ineffective, this may be followed sequentially by empirical treatment for asthma, nonasthmatic eosinophilic bronchitis, and gastroesophageal reflux. Symptomatic or nonspecific therapy of cough should be considered when: (1) the cause of the cough is not known or specific treatment is not possible, and (2) the cough performs no useful function or causes marked discomfort or sleep disturbance. An irritative, nonproductive cough may be suppressed by an antitussive agent, which increases the latency or threshold of the cough center. Such agents include codeine (15 mg qid) or nonnarcotics such as dextromethorphan (15 mg qid). These drugs provide symptomatic relief by interrupting prolonged, self-perpetuating paroxysms. However, a cough productive of significant quantities of sputum should usually not be suppressed, since retention of sputum in the tracheobronchial tree may interfere with the distribution of alveolar ventilation and the ability of the lung to resist infection. HEMOPTYSIS Hemoptysis is defined as the expectoration of blood from the respiratory tract, a spectrum that varies from blood-streaking of sputum to coughing up large amounts of pure blood. Massive hemoptysis is variably defined as the expectoration of >100–600 mL over a 24-h period, although the patient's estimation of the amount of blood is notoriously unreliable. Expectoration of even relatively small amounts of blood is a frightening symptom and may be a marker for potentially serious disease, such as bronchogenic carcinoma. Massive hemoptysis, on the other hand, can represent an acutely life-threatening problem. Blood can fill the airways and the alveolar spaces, not only seriously disturbing gas exchange but potentially causing asphyxiation. Etiology Because blood originating from the nasopharynx or the gastrointestinal tract can mimic blood coming from the lower respiratory tract, it is important to determine initially that the blood is not coming from one of these alternative sites. Clues that the blood is originating from the gastrointestinal tract include a dark red appearance and an acidic pH, in contrast to the typical bright red appearance and alkaline pH of true hemoptysis. An etiologic classification of hemoptysis can be based on the site of origin within the lungs (Table 34-1). The most common site of bleeding is the tracheobronchial tree, which can be affected by inflammation (acute or chronic bronchitis, bronchiectasis) or by neoplasm (bronchogenic carcinoma, endobronchial metastatic carcinoma, or bronchial carcinoid tumor). The bronchial arteries, which originate either from the aorta or from intercostal arteries and are therefore part of the high-pressure systemic circulation, are the source of bleeding in bronchitis or bronchiectasis or with endobronchial tumors. Blood originating from the pulmonary parenchyma can be either from a localized source, such as an infection (pneumonia, lung abscess, tuberculosis), or from a process diffusely affecting the parenchyma (as with a coagulopathy or with an autoimmune process such as Goodpasture's syndrome). Disorders primarily affecting the pulmonary vasculature include pulmonary embolic disease and those conditions associated with elevated pulmonary venous and capillary pressures, such as mitral stenosis or left ventricular failure. . Chapter 034. Cough and Hemoptysis (Part 3) Complications Common complications of coughing include chest and abdominal wall soreness, urinary incontinence, and exhaustion occasion, paroxysms of coughing may precipitate syncope (cough syncope; Chap. 21), consequent to markedly positive intrathoracic and alveolar pressures, diminished venous return, and decreased cardiac. with multiple myeloma, osteoporosis, and osteolytic metastases. Cough: Treatment Definitive treatment of cough depends on determining the underlying cause and then initiating specific therapy.