《中医学》咳嗽咳血

1、Cough and expectoration HemoptysisDyspnea咳痰咯血Outline(cough and hemoptysis) Introduction/DefinitionEtiology /PathogenesisKey Points of InquiryDepartment of Respiratory Medicine Third Xiangya Hospital of Central South UniversityLIU CHUN咳嗽、咳痰Cough and ExpectorationIntroductionA common complaintA protec

2、tive reflexa symptom of a disease or of a problem Complications of cough：cough syncope（咳嗽性晕厥） , insomnia（失眠症）, cough-induced vomiting(呕吐), spontaneous pneumothorax（气胸） Pathogenesisa protective reflex afferent nervecoughing center (medulla of the brain )efferent nerveeffectorscoughsensory neurons Pro

3、cess of coughan inhalationa forced exhalation against a closed glottis(声门)glottis suddenly opens, there is an explosive rush of air that clears the air passages（气道）. Expectoration Expectoration ：Mucus(黏液) and other fluids formed in the airways, and expelled by coughing Sputum(痰) may contain cellular

4、 debris（碎片）, mucus, blood, pus, or microorganisms（微生物）.EtiologyRespiratory diseasesPleural diseasesCardiovascular diseaseCentral nervous system factorOtherGastroesophageal reflux disease（胃食管返流病） ACE inhibitors carinaKey points of inquiryCharacteristics of cough Duration and pattern of cough Tone of

5、coughAmount, consistency, color, and smell of sputum Accompanied symptomsothers Characteristics of coughDry cough (non-sputum): acute pharyngitis(咽炎), early stage of acute bronchitis, pleurisy（胸膜炎）, and mild tuberculosis （结核）Wet cough (sputum): pneumonia, chronic bronchitis, bronchiectasis（支扩）, lung

6、 abscess（肺脓肿）Duration and pattern of coughAcute(8 weeks): chronic bronchitis, lung cancer, bronchiectasis, tuberculosis, CVA, PNDS/UACS, GERD, EB, medicationsMorning: chronic bronchitis, bronchiectasisNocturnal: asthma, left heart failure Paroxysmal: whooping cough, the bronchi impressed by tumor, a

7、sthmaSeasonal: chronic bronchitis, asthmaTone of coughHoarsenessHigh pitchBrassyWeak whooping coughSputum: consistencyMucoid sputum(粘液痰)Bronchitis (without bacterial infection)AsthmaEarly stage of pneumoniaSerous sputum（浆液痰）Pulmonary edemaAlveolar cell carcinomaPus sputumAny bacterial infection Bloo

8、dy sputumBronchiectasis, tumor, tuberculosis, pneumoniaSputum: amountLarge amount of serofluid sputumAlveolar cell carcinomaLarge amount of pus sputumBronchiectasisLung abscessSputum: colorWhite (mucoid or serofluid sputum)Asthma, tumors, tuberculosis, COPD, pneumoniaYellow pusGeneral bacterial infe

9、ctionGreen pusPseudomonas aeruginosa(绿脓杆菌) infectionGrey or black Dust inhalation, smokerRusty Lobar pneumonia Pink Cardiac edemaRed currant jelly klebsiella pneumoniae（肺炎克雷伯） infection Red (bloody sputum)Bronchiectasis, tumor, tuberculosis, pneumonia, cardiac diseaseSputum: foul odoranaerobic bacte

10、rium infectionAccompanied symptomsFever (infection)Chest pain (infection, tumor, pleurisy, pneumothorax, pulmonary embolism)Dyspnea (COPD, asthma, pulmonary edema) Hemoptysis (bronchiectasis, tuberculosis, tumor)Bulk pus sputum (bronchiectasis, lung abscess)Accompanied symptomsWheezing (asthma, COPD

11、, foreign body)Clubbing fingers (bronchiectasis, lung cancer, chronic lung abscess, empyema) Weight lose (lung cancer, tuberculosis)age of onsetpast medical history whooping cough？asthma？ heart disease？ Gastroesophageal reflux disease ？drug history？dust, parasite and poison contact history？history o

12、f atopy？reaction of treatmentOther contents of inquiry 咯 血Hemoptysis DefinitionHemoptysis is the expectoration of blood from lower respiratory tract.Etiology Respiratory diseaseBronchial disorders (Bronchiectasis, Bronchogenic carcinoma, endobronchial TB, Chronic bronchitis)Pulmo Disorders (Pulmo tu

13、berculosis, Pneumonia, Lung abscess, Pulmo embolism)Etiology Cardiovascular disordersAcute left heart failure Mitral stenosis （二尖瓣狭窄） OthersHematologic disease, leptospirosis （钩端螺旋体病），epidemic hemorrhagic fever(流行性出血热)，endometriosis （子宫内膜异位症）To determine the authenticity of hemoptysis -To rule out t

14、he possibility of blood from upper respiratory tract and gastrointestinal tractKey points of inquiryDistinction between hemoptysis and hematemsisHemoptysis Hematemesis History Pulmo or cardiacdigestive system PresymptomCough, chest tightnessNausea, vomiting, abdominal discomfortMode of expectoration

15、Coughing upVomiting Color Bright red Dark brown or blackMixture Frothy, sputumGastric contents pH alkalineacidTarry stools no or occasionally swallowedYes, may continue for several daysPost-bleedingSputum with bloodNo sputumKey points of inquiryAgeAmountColor Accompanied symptomsManifestationageAgey

16、oung and middle-aged : tuberculosis, bronchiectasis, mitral stenosisAge40 years (smoker): lung cancerChild (with hypochrosis) : idiopathic hemosiderosis（特发性含铁血黄素沉着病）ManifestationamountThe amount varies from blood-stained sputum to several hundreds ml pure bloodBlood-stained sputum Bloody sputumMild:

17、 100ml/dModerate: 100-500ml/dSevere: 500 ml/d, or 100-500 ml/timeManifestation colorBright red Active bleedingPulmo TB, Lung abscess, BronchiectasisDark red Old bloodRusty Lobar pneumonia Brick redKlebsiella pneumoniaPink cardiac edemaAccompanied symptomsFeverInfection or carcinomaChest painInfectio

18、n，Pulmo Embolism，CarcinomaPus sputumBronchiectasis，Lung abscessClubbing fingersBronchiectasis，Lung abscess，CarcinomaHemorrhagic spotsHematologic disease, leptospirosis, epidemic hemorrhagic fever Accompanied symptomsjaundiceLeptospirosis, Pulmo Embolism, Pneumococcal（肺炎球菌的） pneumoniabuckingMycoplasm

19、al（支原体的） pneumonia, CarcinomaOther content of inquirypast medical historyWhooping cough，measles(麻疹) in childhood，accompanied chronic cough and pus sputum - bronchiectasisPersonal historyMenstrual history - Endometriosis（子宫内膜异位症）Diet of uncooked food（crab，crawdad）- lung fluke disease（肺吸虫病）Smoking his

20、tory lung cancer呼吸困难DyspneadefinitionDyspnea is defined as an awareness of difficulty in breathing.Dilatation of nares(鼻翼扇动), cyanosis(紫绀), use of accessory muscles of respirationAbnormalities of respiratory rate, depth or rhythmEtiologyRespiratory disease（呼吸系统疾病）Cardiovascular disease（心血管系统疾病）Toxic

21、（中毒）Haematological disease（血液病）Neuropsychiatric disease（神经精神因素）classification肺源性呼吸困难（ Respiratory dyspnea ）心源性呼吸困难（ Cardiac dyspnea ）中毒性呼吸困难（ Toxic dyspnea ）中枢-精神性呼吸困难（ Neuropsychiatric dyspnea ）血液病所致呼吸困难（ Haematological dyspnea ）Respiratory dyspneaInspiratory dyspnea-obstruction in large airway Thr

22、ee depression sign -depression in suprasternal fossa, supraclavicular fossa, intercostal spaceExpiratory dyspnea-obstruction in small airway or alveolar elasticity decreased Prolonged expirationExpiratory rhonchi Mixed dyspnea-deficient gas exchange Respiratory rate increasedShallow breathing（浅快呼吸）L

23、eft heart failure： Mechanism: Pulmo edema gas diffusion function Alveolar tension excitation of vagus nerve Alveolar elasticity lung capacity pressure of pulmonary circulation respiratory center Cardiac dyspneaCardiac dyspneaLeft heart failure（ Distinguished left heart failure from respiratory dyspn

24、ea ） feature： the basic disease of leading left heart failure Mixed dyspnea and position related dyspnea Moist crackles or rhonchi in both lungs Relief of symptoms after digitalis（洋地黄）, diuretic（利尿剂）, vasodilator （血管扩张剂） used nocturnal paroxysmal dyspnea cardiac asthmaRight heart failure： 机制：右心房和上腔静脉压 呼吸中枢 血氧含量 酸性代谢产物 呼吸中枢 肝肿大、胸腹水 呼吸运动受限Cardiac dyspnea肺受压 肺呼吸面积Cardiac dyspneaRight heart failure 特点：呼吸困难伴有体循环淤血表现 临床上主要见于慢性肺源性心脏病、 某些先天性心脏病、心包积液、心 包缩窄Accompanied symptomsParoxysmal dyspnea with wheezing ：asthma，cardiac asthmaParoxysmal severe