检体诊断学：Cough and Expectoration

Cough and ExpectorationThe common respiratory symptomso Cough and expectorationo Hemoptysiso Dyspneao Chest paino Cyanosis（紫绀）Cough and expectorationo The most common respiratory symptomo Initiated by varied stimulation or by voluntary exertiono Severe cough indicates a serious clinical problemo Severe cough may lead to pneumothorax or hemoptysis Definitiono A protective reflex act.o Coughing is an essential defense mechanism Protects airway from foreign substance Clears the excretion of respiratory tract.Mechanism of coughoCough receptors Ear,and upper airway(nose,throat,pharynx)Lower airway(trachea,bronchi,carina)Pleura Few or no receptor in lung parenchymaoAfferent limb Internal laryngeal nerve(vagus laryngeal branch)oCough center:medulla cough centeroEfferent limb:recurrent laryngeal and spinal nervesoEffector organs:diaphragm,expiratory muscle Mechanism of coughCough receptorMedulla cough centerCough Internal laryngeal neverRecurrent laryngeal never and spine neverMechanism of coughCough-three phases Short inspiration-airway opens load the lungs with gas Compression-Glottis close to build up of pressure(Abdominal and expiratory muscles contract)Exhalation-Sudden opening of glottis with explosive exhalation of gas Cough-three phasesEtiologyo Respiratory diseaseso Pleural diseaseso Cardiovascular diseaseso Central nerve system factorsRespiratory diseaseso Stimulator-extra and interthoracic-from nose oropharynx-bronchi-cough reflex such asInflammation of respiratory tract(bacterial infection,viral infection,and allergy)Inhalation of foreign materialBleeding of respiratory tractTumor of respiratory tract p Most common causes-respiratory infection(influenza,bronchitis,pneumonia,tuberculosis)Pleural diseasesSuch as Pleurisy,thoracic effusion,pneumothorax Pleural biopsy or thoracentesisCardiovascular diseaseso Mitral stenosis-left heart failure-pulmonary edema-transudate or exudate-stimulates intra-thoracic-cough receptor-cougho Pulmonary embolism-elevates pulmonary venous pressure-pulmonary edema-transudae or exudate-stimulate intra-thoracic-cough receptor-coughCentral nerve systemo Inflammatory of CNS can cause coughingo Such as:encephalitis(脑炎）and meningitis（脑膜炎）Expectorationo Is a pathological phenomenon that human being removes the pathological secretion from respiratory system by means of coughingExpectorationo The daily quantity of bronchial secretions produced by a normal person is unknown,but it is sufficiently small to be removed by mucociliary action aloneo Cough and expectoration are not requiredExpectorationo Excessive productiono Altered physical propertieso Deficient clearance Those factors lead to the secretions accumulate in the tracheobronchial system and cause expectorationExpectoration Mechanical,chemical,physical and allergic factors can cause respiratory mucosa edema,congestion and cause transudade or exudate.Then,cough and expectoration appears.ExpectorationSuch as Inflammation including virus,bacteria,and fungus infection can cause coughing and expectoration.Acute left heart failure can cause pulmonary edema and pink foamy sputumManifestationo Character of cougho The duration and pattern of cougho The tone quality of cougho The character and volume of sputumCharacter of cougho Cough without sputum-Unproductive or dry cough mainly in the patient of acute pharyngitis,early stage of bronchitis,pleurisy and TBo Cough with sputum-Productive cough It is caused by pnemonia,chronic bronchitis,bronchiectasis,lung abscess,and cavitious TBDuration and pattern of cougho Acute cough:present less than 3 weeks occur sudden-caused by acute respiratory infectiono Subacute cough:present between 3 to 8 weeks postinfectious Duration and pattern of cougho Chronic cough:last more than 8 weeks X-ray exam exclude COPD,TB,lung cancer,bronchiectasis asthma,postnasal drip,gastroesophageal reflux are common reason Duration and pattern of cougho Cough initiated suddenly-acute upper airway infection,foreign body,asthmao Chronic cough with sputum-Chronic bronchitis,bronchiectasis,and TBo Paroxysmal cough-whooping cough,bronchi compressed by tumor and TBDuration and pattern of cougho Periodic cough-chronic bronchitis,bronchiectasis related to the change of bodily positiono Nocturnal cough-asthma,chronic heart failure-associated with the vagal excitation at nightThe character and volume of sputumo Clear,white,gray sputum-chronic bronchitiso Foul-smelling purulent sputum-bronchiectasis,lung abscesso Sputum with calcific particles-bronchothoptysisThe tone quality of cougho It means the change of the sound and may suggest the location of pathologyo“breaking”cough-epiglottal diseaseo“brassy”cough-tracheal airwayo“hacking”or“cleaning of throat”-postnasal dischargeo“darking”or“croupy”-laryngeal diseaseThe tone quality of cougho Hoarseness with cough-function of recurrent laryngeal nerve impairment,aneurysm of the aorta,left atrial enlargement,mediastinal malignancyo Inspiratory stridor-upper airway obstructiono Cough with hemoptysis also raises the possibility of a malignant process-bronchiectasis,lung abscess,lung cancerThe associated clinical featureso Cough with fever-acute respiratory infection including measles,pneumonia,influenza,lung abscess,TB,pleurisyo Cough with chest pain-plural cavity involve,heart disease,pneumonia,pleurisy,bronchogenic carcinoma.o Cough with dyspnea-edema of larynx,larynx tumor,COPD,severe pneumonia,massive pleural effusion,pneumothorax,and pulmonary edemaThe associated clinical featureso Cough with quantitative purulent sputum-bronchiectasis,lung abscess,bronchi-fistula(瘘）o Cough with hemoptysis-bronchiectasis,TB,lung cancer,lung abscess mitral stenosiso Cough with clubbed fingers-bronchiectasis,lung abscess,lung cancero Cough with wheeze-bronchial asthma,cardiac asthma,foreign body in trachea and bronchi