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however, the clinician must keep in mind the broader differential diagnosis of cough outlined in Table 2.2, recognizing that cough may be a marker and the initial presenting symptom of a more serious disease, such as tuberculosis or carcinoma of the lung.

Evaluation and management of cough

When cough is acute, accompanied by other symptoms of an upper respiratory tract infection, and not associated with other concerning findings (e.g., high fever, chills, or hemoptysis), further evaluation is not needed. A mild cough often needs no treatment, but if it is particularly bothersome, an over-the-counter antitussive (cough suppressant) can be used. In many cases of a lingering, subacute cough after an upper respiratory tract infection, the cough can be particularly bothersome but will ultimately resolve. The possibility of persistent cough from Bordetella pertussis (whooping cough) can also be considered in these cases suggestive of a postinfectious cough. If the patient is on an ACE inhibitor, the patient should ideally be switched to a medication acting by another mechanism.

When cough extends beyond 8 weeks and becomes chronic, further evaluation and/or management may be indicated. The patient’s history and physical examination may provide clues to an etiology, particularly if there is a suggestion or evidence of underlying pulmonary disease. In the absence of a likely cause of the subacute or chronic cough, a chest radiograph is typically indicated to look for underlying intrathoracic disease (pulmonary or cardiac) to explain the cough. If the chest radiograph does not show pathology that could be responsible for the cough, then the patient may be tried sequentially on therapy to address the three most common causes of chronic cough—upper airway cough syndrome (postnasal drip), asthma, and gastroesophageal reflux disease (GERD). Empiric therapy for any of these common diagnoses serves not only as a therapeutic trial but also as a diagnostic trial that can potentially clinch the diagnosis. Other diagnostic tests that can be applied to look for specific diagnoses include pulmonary function testing (for asthma), chest CT (for bronchiectasis), and esophageal pH monitoring (for GERD).

When no etiology of cough is found and empiric therapeutic trials have failed, a centrally acting neuromodulatory drug used for neuropathic pain (gabapentin or pregabalin) is sometimes tried, though often limited by side effects. With recognition of the cough hypersensitivity syndrome as an explanation for unexplained, persistent cough in some patients, there is now interest in developing a therapeutic approach targeting a variety of chemical mediators (e.g., P2X3 and TRPV-1) involved in activation of sensory nerves leading to cough.

Hemoptysis

Hemoptysis refers to coughing up blood derived from airways or the lung itself. When the patient complains of coughing or spitting up blood, whether the blood actually originated from the respiratory system is not always apparent. Other sources of blood include the nasopharynx (particularly from the common nosebleed), mouth (even lip or tongue biting can be mistaken for hemoptysis), and upper gastrointestinal tract (esophagus, stomach, and duodenum). The patient often can distinguish some of these causes of pseudohemoptysis, but the physician also should search by examination for an oral or nasopharyngeal source.

The major causes of hemoptysis can be divided into three categories based on location: airways, pulmonary parenchyma, and vasculature (Table 2.3). Airway disease is the most common cause, with bronchitis, bronchiectasis, and bronchogenic carcinoma leading the list. Bronchial carcinoid tumor (formerly called bronchial adenoma), a less common neoplasm with variable malignant potential, also originates in the airway and may cause hemoptysis. In patients with advanced acquired immunodeficiency syndrome (AIDS), hemoptysis may be due to endobronchial (and/or pulmonary parenchymal) involvement

with Kaposi sarcoma.

TABLE 2.3

Differential Diagnosis of Hemoptysis

Airway Disease

Acute or chronic bronchitis

Bronchiectasis

Bronchogenic carcinoma

Bronchial carcinoid tumor (bronchial adenoma)

Other endobronchial tumors (Kaposi sarcoma and metastatic carcinoma)

Parenchymal Disease

Tuberculosis

Lung abscess

Pneumonia

Mycetoma (“fungus ball”)

Miscellaneous

Goodpasture syndrome

Idiopathic pulmonary hemosiderosis

Granulomatosis with polyangiitis (Wegener granulomatosis)

Vascular Disease

Pulmonary embolism

Elevated pulmonary venous pressure

Left ventricular failure

Mitral stenosis

Vascular malformation

Miscellaneous/Rare Causes

Impaired coagulation

Pulmonary endometriosis

Diseases of the airways (e.g., bronchitis) are the most common causes of hemoptysis.

Parenchymal causes of hemoptysis frequently are infectious in nature: tuberculosis, lung abscess, pneumonia, and localized fungal infection (generally attributable to Aspergillus organisms), termed

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mycetoma (“fungus ball”) or aspergilloma. Rarer causes of parenchymal hemorrhage, some of which are discussed in Chapter 11, are Goodpasture syndrome, idiopathic pulmonary hemosiderosis, and granulomatosis with polyangiitis (formerly called Wegener granulomatosis).

Vascular lesions resulting in hemoptysis are generally related to problems with the pulmonary circulation. Pulmonary embolism, with either frank infarction or transient bleeding without infarction, is often a cause of hemoptysis. Elevated pressure in the pulmonary venous and capillary bed may also be associated with hemoptysis. Acutely elevated pressure, such as in pulmonary edema, may have associated low-grade hemoptysis, commonly seen as pinkor red-tinged frothy sputum. Chronically elevated pulmonary venous pressure results from mitral stenosis, but this valvular lesion is a relatively infrequent cause of significant hemoptysis in developed countries. Vascular anomalies, such as arteriovenous malformations, may also be associated with coughing of blood.

Other miscellaneous etiologic factors in hemoptysis should be considered. Some of these belong in more than one of the aforementioned categories; others are included here because of their rarity. Cystic fibrosis affects both airways and pulmonary parenchyma. Although either component theoretically can cause hemoptysis, bronchiectasis (a common complication of cystic fibrosis) is most frequently responsible. Patients with impaired coagulation, either from disease or from anticoagulant therapy, rarely may have pulmonary hemorrhage in the absence of other obvious causes of hemoptysis. An interesting but rare disorder is pulmonary endometriosis, in which implants of endometrial tissue in the lung can bleed coincident with the time of the menstrual cycle. Other causes are even more rare, and discussion of them is beyond the scope of this chapter.

Chest pain

Chest pain as a reflection of respiratory system disease does not originate in the lung itself, which is free of sensory pain fibers. When chest pain does occur in this setting, its origin usually is the parietal pleura (lining the inside of the chest wall), diaphragm, or mediastinum, each of which has extensive innervation by nerve fibers capable of pain sensation. Although cardiac disease is of course an extremely important cause of chest pain, it will not be included in this discussion.

Chest pain can be associated with pleural, diaphragmatic, or mediastinal disease.

For the parietal pleura or the diaphragm, an inflammatory or infiltrating malignant process generally produces the pain. When the diaphragm is involved, the pain commonly is referred to the shoulder. In contrast, pain from the parietal pleura usually is relatively well localized over the area of involvement. Pain involving the pleura or diaphragm is often worsened on inspiration; in fact, chest pain that is particularly pronounced on inspiration is described as pleuritic.

Inflammation of the parietal pleura producing pain is often secondary to pulmonary embolism or to pneumonia extending to the pleural surface. A pneumothorax may result in the acute onset of pleuritic pain, although the mechanism is not clear because an acute inflammatory process is unlikely to be involved. Some diseases, particularly connective tissue disorders such as lupus, may result in episodes of pleuritic chest pain from a primary inflammatory process involving the pleura. Inflammation of the parietal pleura as a result of a viral infection (e.g., viral pleurisy) is a common cause of pleuritic chest pain in otherwise healthy individuals.

Infiltrating tumor can produce chest pain by affecting the parietal pleura or adjacent soft tissue, bones, or nerves. In the case of malignant mesothelioma, the tumor arises from the pleura itself. In other circumstances, such as lung cancer, the tumor may extend directly to the pleural surface or involve the pleura after bloodborne (hematogenous) metastasis from a distant site.

A variety of disorders originating in the mediastinum may result in pain, but they may or may not be associated with additional problems in the lung itself. These disorders of the mediastinum are discussed in Chapter 16.

Hemoptysis

Chest pain

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