1. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 2 COUGH AND HEMOPTYSIS — 1
2 COUGH AND HEMOPTYSIS
Subroto Paul, M.D., and Raphael Bueno, M.D., F.A.C.S.
CLINICAL EVALUATION
An acute or chronic cough is one of the most common chief pre-
senting complaints. In the United States, it accounts for approxi- An acute or self-limited cough is defined as one that resolves
mately 30 to 50 million physician visits each year, and more than within 3 weeks. Usually, an acute cough is the result of minor
$1 billion is spent annually on its workup and treatment.1 A cough infection or inhalation of irritant gases or particulate matter; some-
can result from a wide variety of conditions, ranging from fairly times, however, it is associated with a more serious condition.
non–life-threatening causes (e.g., bronchitis) to life-threatening Generally, a cough requires diagnostic attention when it persists
ones (e.g., lung cancer). Hemoptysis is also a common presenting for 3 weeks or longer, at which time it is deemed chronic. Numer-
complaint, with a similarly broad spectrum of possible causes. It ous conditions are capable of causing a chronic cough [see Table 1],
may range in severity from mild blood streaking in sputum to mas- and the differential diagnosis of this complaint is broad.
sive hemorrhage that, if left untreated, can lead to shock and rapid Careful diagnostic evaluation is required to identify potentially
death from blood loss and asphyxiation. Even mild hemoptysis is life-threatening causes of chronic coughing [see Figure 1]. Such
distressing to many patients and physicians and calls for prompt evaluation relies heavily on the history. Medications, tobacco use,
attention and diagnosis. In cases of massive hemoptysis, expedient and occupational exposure must all be considered in the effort to
evaluation and management are essential, often involving airway narrow the differential diagnosis. Associated symptoms offer
control with intubation and hemodynamic resuscitation. important clues; for example, in a patient with water brash and a
Because both cough and hemoptysis may be signs of urgent or chronic cough, reflux is more likely to be the cause of the cough
life-threatening disease, patients who present with either or both than it would be in a patient with copious nasal secretions.5,7,8 The
of these symptoms should undergo a thorough, methodical quality of the sputum is a particularly significant variable: purulent
workup consisting of a detailed history, a careful physical exami- sputum may lead one to suspect infection, whereas bloody sputum
nation, and appropriate diagnostic studies (usually computed may lead one to suspect malignancy, especially in a smoker.
tomography of the chest and bronchoscopy). Substantial experience and acute clinical judgment are required to
distinguish the relatively few patients with serious diseases from
the millions of patients who present with a benign cough each
Cough year.
A cough is a forceful expiration that is mediated through the
MANAGEMENT OF SPECIFIC CAUSES
activation of a complex reflex arc.The cough reflex is triggered by
the stimulation of various cough receptors, which are found not Common causes of a chronic cough include acute and chronic
only in the epithelium of the respiratory tract but also in the lower bronchitis, bronchiectasis, asthma, postnasal drip, and gastro-
esophagus, the stomach, and the diaphragm.2,3 These receptors esophageal reflux.4,5,9-15 Other, less common causes include drugs
can be activated by mechanical, chemical, or thermal stimuli; once (e.g., angiotensin-converting enzyme [ACE] inhibitors), intersti-
activated, they send signals to the medulla via the vagus nerve, the tial lung disease, congestive heart failure (CHF), bronchogenic
glossopharygneal nerve, the trigeminal nerve, or the phrenic carcinoma, tracheobronchial foreign bodies, and endobronchial
nerve. A center in the medulla then activates the muscles of expi- tumors (benign or malignant).7,16-18
ration by means of efferent signals transmitted via the vagus and
phrenic nerves.2,3
Mechanical stimuli that can trigger the cough reflex include Table 1 Differential Diagnosis of Cough
inhaled particulate matter and intrinsic and extrinsic tracheo-
bronchial compression. Intrinsic compression may be caused by Acute and chronic bronchitis
airway tumors, foreign bodies, granulomatous airway disease, or Bronchiectasis
bronchial smooth muscle that is constricted as a result of disease Most common causes Asthma
or exposure to noxious materials. Extrinsic compression may be Postnasal drip
caused by aortic aneurysmal disease, a pulmonary parenchymal Gastroesophageal reflux
neoplasm (e.g., lung cancer or a tumor that has metastasized to Drugs
the lung), edema from pulmonary parenchymal infection (e.g., Angiotensin-converting enzyme inhibitors
pneumonia or abscess), or pulmonary parenchymal fibrosis result- Interstitial lung disease
ing from any of a variety of interstitial lung diseases (e.g., idio- Eosinophilic bronchitis
Less common causes
pathic pulmonary fibrosis or sarcoidosis). Chemical stimuli that Congestive heart failure
can trigger coughing include inhaled irritant gases and aspirated Bronchogenic carcinoma
gastric acid or bile. A common thermal stimulus is hot or cold Tracheobronchial foreign body
Psychogenic
inhaled air (or other gas).4-7

2. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 2 COUGH AND HEMOPTYSIS — 2
Patient presents with chronic cough
Obtain history and perform physical examination.
Consider
• Medications
• Tobacco use
• Occupational exposure to irritants
• Associated symptoms
Assess quality of sputum.
Sputum is not purulent or bloody Sputum is purulent Sputum is bloody
Common causes of cough include Cause of cough is presumed to be infectious
asthma, gastroesophageal reflux (e.g., bronchitis, bronchitis with infection of
disease, postnasal drip, and drugs. ectatic airway).
Treat according to underlying condition. Perform diagnostic imaging with chest x-ray
and chest CT.
Treat infection.
Patient is nonsmoker Patient is smoker
Patient’s condition Patient’s condition
improves does not improve
Cough is isolated symptom Cough is associated with
other worrisome symptom
Observe patient.
Figure 1 Algorithm illustrates workup Perform diagnostic imaging with chest x-ray and,
of a patient with a chronic cough. if indicated, chest CT and bronchoscopy.
Tracheobronchial irritation can trigger the cough reflex. Acute chronically inflamed airways.5,6 In a smoker, a chronic cough is
irritation from inhaled substances (e.g., toxic fumes or cigarette not a particularly worrisome symptom; however, if the character
smoke) can lead to bronchospasm and thence to coughing. In of the cough or the quality of the sputum changes, further workup
addition, patients with asthma or reactive airway disease may pre- is indicated to look for a possible superimposed infection or neo-
sent with a cough. Asthma, in fact, is one of the most common plasm.21 With both acute and chronic bronchitis, the diagnosis
causes of cough. Although asthma is typically associated with can usually be made on the basis of the history and the physical
shortness of breath and expiratory wheezing, some variants of findings (especially the sputum quality).
asthma have cough as the sole presenting symptom (so-called Persistent airway inflammation from any cause (e.g., chronic
cough-variant or cough-type asthma).5,15,19 Most persons with bronchitis, asthma, granulomatous airway disease, or cystic fibro-
cough resulting from tracheobronchial irritation have a family his- sis) can lead to bronchiectasis, a state characterized by chronic air-
tory of atopy or asthma. Diagnosis rests on a history of symptom way dilatation with cystic changes in the lower bronchial tree.The
exacerbation with irritants or upper respiratory infections on the anatomic abnormalities in the dilated, cystic bronchi cause pool-
associated findings of end-expiratory wheeze; it is confirmed by ing of mucus and secretions and impair clearance of secre-
spirometry. tions.7,10,17 Cough, either dry or productive, is the major present-
Tracheobronchial infection can also lead to a chronic cough. ing symptom of bronchiectasis. This condition is often accompa-
Acute bronchitis from viral or bacterial infection (either primary nied by infection of the ectatic airway, which leads to purulent
infection or superinfection) is typically signaled by thick, purulent secretion and systemic signs of illness that necessitate prompt
secretions. It is usually self-limited, though in some cases, it may antibiotic therapy. In patients with cystic fibrosis, for example,
have to be treated with a short course of antibiotics.20 Chronic daily postural drainage of the bronchiectatic airways is required,
bronchitis is defined by the presence of a cough with sputum pro- and frequent hospitalization for intensive antibiotic therapy and
duction that persists for at least 3 months and sometimes for chest physiotherapy is necessary. The diagnosis of bronchiectasis
years. The sputum is clear or white, and there is no evidence of is made on the basis of the history and diagnostic imaging
systemic infection. Chronic bronchitis almost always occurs in (including chest x-ray and, currently, chest CT).
current smokers (or recent quitters), who almost invariably have Postnasal drip is one of the most common causes of cough. It

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4 THORAX 2 COUGH AND HEMOPTYSIS — 3
usually results from allergic rhinitis, sinusitis, or nasopharyngitis. cent structure (e.g., the esophagus, the mediastinum, or the pleu-
Nasal secretions irritate the larynx and trachea, leading to the acti- ra). Such a fistula can result from cancer, surgery, trauma, aspira-
vation of the cough reflex arc.7,12,14 Generally, the diagnosis is tion or swallowing of foreign objects (e.g., fish bones), radiation
made on the basis of the history and the symptom complex. Often, therapy, chemotherapy, or infection. In this setting, the cough is
however, the symptoms are vague, and the diagnosis is confirmed caused by secretions that enter the airway via the fistula.
only when the patient responds to empirical therapy directed at In the occasional patient, a chronic cough may be of psy-
the presumed underlying cause. Steroid nasal sprays and antihist- chogenic origin.
amines are useful for ameliorating symptoms. In recalcitrant cases, Finally, a chronic cough can be caused by an endobronchial
an otolaryngologic examination may be required to exclude sinus tumor (benign, malignant, or low-grade malignant).This is a quite
disorders. rare circumstance that occasionally develops in patients who have
Gastroesophageal reflux is increasingly being recognized as a no risk factors for lung cancer. Not uncommonly, a patient with a
cause of cough and asthma. Several mechanisms have been pos- carcinoid tumor of the airway will have been treated with inhalers
tulated for reflux-induced cough, including (1) mechanical aspira- and steroids for years because of the presumptive diagnosis of
tion of gastric contents that leads to stimulation of cough recep- asthma.
tors in the distal airways and (2) stimulation of cough receptors in
the distal esophagus and the proximal stomach from refluxed acid
or bile. The data currently available tend to support the second Hemoptysis
mechanism for reflux-induced cough and bronchospasm.9,11,13 As noted (see above), hemoptysis may be a harbinger of life-
Regardless of the mechanism responsible, the diagnosis is difficult threatening illness and should therefore be taken seriously in all
to make if the typical symptoms of reflux and heartburn are circumstances. As a rule, the blood seen in the sputum derives
absent. As awareness of reflux-induced asthma and cough grows, from either the pulmonary arteries or the bronchial arteries23,25,28;
more patients are being evaluated with barium studies and only rarely does it come from the pulmonary veins. Although the
esophageal pH monitoring, which often provide the correct diag- bronchial arteries provide less blood flow than the pulmonary
nosis when clinical evaluation cannot.9 arteries do, they supply the bulk of the blood received by the air-
Specific medications may also give rise to a cough. In particu- ways and, accordingly, are the source of the blood in most cases of
lar, cough is a well-recognized complication of ACE inhibitor ther- hemoptysis. Hemoptysis can be caused by either tracheobronchial
apy.3,4,7,8 Cough may also result from nonselective beta- disease or pulmonary parenchymal disease [see Table 2].23,25,28 One
blocker therapy or may develop as a consequence of idiosyncratic should also consider the possibility that hemoptysis may be the
reactions to a variety of drugs and herbal remedies. result of an aneurysm of the aorta (or one of its main branches)
The presence of bronchogenic cancer is always a concern in a that has ruptured into the lung.
smoker with a chronic cough.3,5,8,21,22 Any irritation of the airway,
CLINICAL EVALUATION
whether intrinsic (by airway tumors) or extrinsic (by parenchymal
tumors), with or without associated inflammation, can lead to The differential diagnosis of hemoptysis, like that of cough, is
coughing through mechanical or chemical stimulation of cough quite broad.The history and the physical examination play impor-
receptors. In the general population as a whole, a chronic cough is tant diagnostic roles.The presence of associated signs of other dis-
rarely the sole presenting symptom of developing lung cancer. In eases (e.g., interstitial lung diseases) often helps narrow the differ-
smokers, the presence of a chronic cough, in and of itself, is not ential diagnosis.23,25,28
particularly worrisome, but any change in the character of the
INVESTIGATIVE STUDIES
cough, especially a change in sputum quality, is grounds for con-
cern. Any degree of hemoptysis in a former smoker should be Any patient with significant hemoptysis should be admitted to
taken seriously, especially if it is not associated with an infection; a hospital and evaluated promptly. Routine chest x-rays are insen-
prompt evaluation with a chest x-ray and, if indicated, chest CT sitive. Chest CT with contrast can often identify the cause of he-
and bronchoscopy is indicated.23-25 moptysis for both tracheobronchial or parenchymal lesions29,30;
A chronic cough may also be a consequence of CHF (from any CT scanners capable of three-dimensional helical reconstruction
cause), though this is not a common occurrence. Mild CHF with are especially useful in this regard. MRI has also been employed
symptoms of orthopnea at night may be associated with coughing. to evaluate hemoptysis, but it has no clear advantages over chest
The diagnosis is made on the basis of a history of orthopnea and CT in this setting. Given that infection is commonly associated
associated cardiac risk factors or valvular disease, followed by car- with hemoptysis, one should probably consider administering
diac echocardiography. antibiotics to most patients. Antitussives may be helpful in patients
Occasionally, the presence of a small unrecognized tracheo- whose hemoptysis is exacerbated by excessive coughing. Coagu-
bronchial foreign body can lead to chronic irritation of the lopathy should be considered and, if present, corrected aggres-
bronchial epithelium and thence to a persistent cough; this pre- sively. Bronchoscopy is the key to the diagnosis, in that it is fre-
sentation is more common in children than in adults.16 The diag- quently able to define the pathology of the preceding hemoptysis
nosis is usually made by performing bronchoscopy in a patient (especially if the underlying condition is of tracheobronchial ori-
who is believed to be harboring a foreign body on the basis of chest gin). It is particularly effective if performed within 48 hours of pre-
imaging. sentation.23,25,28,31 Although either flexible bronchoscopy or rigid
Eosinophilic bronchitis is a rare cause of chronic cough that may bronchoscopy may be used, flexible bronchoscopy is preferred
be suspected in patients with no other clearly explainable diagno- because it is less traumatic to the airways and generally does not
sis.26,27 Patients typically have a history of atopy, and the diagnosis require general anesthesia.
is made on the basis of clinical suspicion and the results of Patients with massive hemoptysis should be promptly trans-
bronchial epithelial biopsy. Steroids are the mainstay of treatment. ported to the operating room (if there is time) and selectively intu-
In rare instances, a chronic cough may be the consequence of a bated with a rigid bronchoscope or special endotracheal tubes.
fistula that connects some part of the airway or the lung to an adja- Balloon catheters may be placed for selective occlusion of the air-

4. © 2006 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
4 THORAX 2 COUGH AND HEMOPTYSIS — 4
Table 2 Differential Diagnosis of Hemoptysis (e.g., carcinoid and mucoepidermal carcinoma) that present in the
bronchial tree and may be associated with hemoptysis.
Acute or chronic bronchitis Tracheobronchial trauma, whether acquired or iatrogenic, is
Bronchiectasis another cause of bloody sputum. Penetrating trauma to the
Neoplasms bronchial tree or the pulmonary parenchyma, for example, can
Tracheobronchial disease
Foreign bodies lead to significant hemoptysis, especially if a major branch of the
Trauma bronchial artery is involved.23,25,28,42 Particularly massive hemop-
Tracheoinnominate fistula tysis may occur if a tracheoinnominate fistula develops after tra-
Infection cheostomy.43-45 There are two types of tracheoinnominate fistula:
Interstitial lung disease one develops at the tracheal stoma site as a consequence of erosion
Parenchymal disease of the artery by the tracheostomy tube, and the other develops as
Pulmonary embolism
Pulmonary arteriovenous malformations a consequence of a more distal tracheal injury by a high-pressure
cuff, which in turn injures the artery. Major bleeding can occur
Mitral valve disease
Miscellaneous conditions
Coagulopathy
with either type. Prompt diagnosis with bronchoscopy is required
in any patient with a tracheostomy who presents with hemoptysis;
an initial “sentinel” bleed can be followed by life-threatening hem-
way or airways from which the hemoptysis originates, permitting orrhage.24,25,46,47 Treatment usually involves stabilization with rigid
ventilation to continue through the unaffected airways. A rapid bronchoscopy and immediate sternotomy to control the artery and
evaluation must then be carried out to identify and manage the resect the fistula.
source of the bleeding.To this end, it may be necessary to perform Other forms of iatrogenic injury may occur in patients with tra-
urgent angiographic embolization of a bronchial artery, to place a cheobronchial stents, which often irritate the mucosa and cause
stent in a pulmonary artery, or to resect a portion of the lung. bleeding. In most cases, such bleeding is mild, but on occasion, the
Unfortunately, the majority of patients with massive hemoptysis do stents (particularly the metallic expandable ones) erode through
not survive, dying of hemorrhagic shock and suffocation.Thus, the the bronchial wall and penetrate into a major blood vessel (usual-
goal of the treating physician should be to identify and treat these ly the pulmonary artery or the aorta). Hemoptysis may also occur
patients before they experience their final hemoptysis. in patients who have undergone bronchial biopsies and those in
whom pulmonary arterial catheters have been placed.48,49 The
MANAGEMENT OF SPECIFIC CAUSES
same effect may be observed in patients who have harbored foreign
Tracheobronchial disease is the most common cause of hemop- bodies in the tracheobronchial tree for extended periods.24
tysis. Acute or chronic bronchitis leads to airway inflammation and Pulmonary parenchymal disease can lead to hemoptysis as well,
sputum production, often associated with hemoptysis from the though less often than tracheobronchial disease does. Parenchy-
bronchial artery branches found within the mucosa; the bleeding mal infection, especially from tuberculosis and aspergillosis, is a
is usually minor.23,25,28 Bronchiectasis leads to bronchial artery common cause of hemoptysis.23,25,28,50 Aspergillosis, in particular,
dilatation, along with cystic dilatation of the bronchial tree10,23,25,28; has a propensity for vascular invasion and thus can result in mas-
the bleeding is often massive in this setting. sive hemoptysis.50 The various interstitial lung diseases (e.g., colla-
Numerous types of tracheobronchial neoplasms, including var- gen vascular disorders, Goodpasture syndrome, and Wegener gran-
ious benign and malignant primary epithelial and soft tissue ulomatosis) often have hemoptysis as their primary presenting
tumors, have been associated with hemoptysis.32-39 The majority of symptom.51-53 Pulmonary embolism can lead to hemoptysis if it
primary airway tumors are malignant, with squamous cell carcino- involves a significant portion of pulmonary parenchyma.23,25,28,54
ma and adenoid cystic carcinoma being the primary malignancies Mitral valve disease with resulting left atrial hypertension can also
most frequently seen in the trachea.32-38 The majority of malignant result in hemoptysis. Any form of coagulopathy resulting from a
airway tumors, however, are metastases rather than primary malig- low platelet count or a deficiency in clotting factors, therapeutic or
nancies. Invasion of the tracheobronchial tree by adjacent lung, not, can lead to hemoptysis; such conditions must be corrected in
thyroid, esophageal, or laryngeal tumors is not common, but it has patients who experience massive or persistent episodes. Another
been described.33,34,39,40 Colon cancers, breast cancers, melano- rare cause of bloody sputum is congenital pulmonary arteriove-
mas, and renal cancers have been reported to metastasize to the nous malformation, which typically is diagnosed only after chest
trachea, albeit very rarely.39,41 There are also low-grade tumors imaging.55,56
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