Aggravating factors of cough

PDFCE 

Pollution, Pollen, Posture

Drugs, Diurnal, Dry air

Food

Cold weather, Common cold

Exercise

Normal cortisol levels, diurnal variation and it's significance in respiratory system

Serum cortisol levels

Normal levels

Morning -8am- 5-23 mcg/dL

Evening -4pm- 3-13 mcg/dl

Diurnal variation is maintained by suprachiasmatic nucleus of the hypothalamus.

Cortisol levels peak during early morning and gradually decline throughout the day reaching lowest point around midnight 

Effects on the respiratory system

Increased Inflammatory response when the levels of cortisol reach lowest at around midnight. 

Low cortisol levels at midnight lead to airway hyper responsiveness leading to morning dip in Peak expiratory flow rate.

During cortisol trough at around late night, eosinophil counts rise leading to influx of inflammatory cells into the airway mucosa, exacerbating conditions like Eosinophilic Bronchitis or severe asthma.

Cortisol is essential for surfactant production in fetus. It stimulates the maturation of Type II pneumocytes, which is why exogenous glucocorticoids are administered in cases of threatened preterm labor to prevent Respiratory Distress Syndrome (RDS).

Stridor vs wheeze

 Stridor – Definition

A harsh, high-pitched, monophonic sound produced by turbulent airflow through a narrowed upper airway (larynx or trachea), typically heard best over the neck.

 Wheeze – Definition

A continuous, musical, high-pitched sound caused by airflow through narrowed lower airways (bronchi/bronchioles), typically heard over the chest.

Stridor vs Wheeze – Key Differences

Anatomical site

Upper airway (larynx, trachea) -stridor 

Lower airway (bronchi, bronchioles) - wheeze 

Sound quality

Harsh, loud, non-musical -stridor

Musical, whistling - wheeze

Best heard over

Neck -stridor

Chest (lung fields) - wheeze

Mechanism

Extrathoracic airway narrowing -stridor

Intrathoracic airway narrowing - wheeze

Common causes

Croup, epiglottitis, foreign body (upper airway), laryngeal edema -stridor

Asthma, COPD, bronchiolitis - wheeze

Clinical significance

Often emergency (airway compromise) -stridor

Suggests airflow limitation, not always immediately life-threatening - wheeze

causes of bronchial breath sounds

Primary Causes

Pneumonia (consolidation from bacterial, viral, or fungal infection)

Lung abscess or cavitary lesions (e.g., necrotic tumor, tuberculosis cavity)

Bronchiectasis (dilated airways with chronic inflammation)

Pleural effusion (over compressed underlying lung)

Atelectasis or lung collapse (obstructive or compressive)

Secondary Causes

Pulmonary fibrosis (scarring stiffens parenchyma)

Pulmonary edema (fluid overload in alveoli)

Large tumors compressing airways

Sinusitis symptoms

 Major symptoms 

1.purulent anterior nasal discharge 

2.purulent or discolored posterior nasal discharge 

3.Nasal congestion or obstruction 

4.Facial congestion or fullness

5.Facial pain or pressure

6.Hyposmia or anosmia 

7.Fever

Minor symptoms 

1.Headache

2.Halitosis

3.Ear pain, pressure or fullness

4.Dental pain

5.Cough

6.Fever

7.Fatigue

Presence of atleast 2 major or 1 major and 2 minor criteria -diagnosis of Sinusitis is made.

Reference - IDSA 2012

Causes of dry cough with hemoptysis

 Causes of dry cough with hemoptysis 

Malignancy

Bronchiectasis sicca

Pulmonary embolism

Use of anticoagulants

Pulmonary vasculitis

Mitral stenosis

Dynamic auscultation in Respiratory System

 Dynamic auscultation is listening to breath sounds while the patient performs specific maneuvers (like deep breathing, coughing, forced expiration, or posture change) to reveal abnormal findings not heard during quiet breathing.

1. Forced expiratory auscultation

• Ask patient to blow out forcefully

         Example: Wheeze appears → Asthma, COPD

2. Post-tussive auscultation (after cough)

• Ask patient to cough, then listen again

         Example: Crackles disappear/change → secretions (Bronchiectasis)

Persistent crackles → Pneumonia

3. Deep inspiration auscultation

• Ask patient to take slow deep breaths

Example: Late inspiratory crackles → Pulmonary fibrosis

4.Mouth open vs closed breathing

• Compare breathing with mouth open vs closed

Example: Sound changes/stridor → upper airway obstruction

5.Postural (position) change auscultation

• Listen in sitting vs lying position

Example: Shifting findings → Pleural effusion

spurious and pseudo hemoptysis

Spurious hemoptysis

Spurious hemoptysis means there is real blood in the sputum, but it comes from the upper respiratory tract (above the larynx), such as from an upper‑airway infection, epistaxis, or gingival bleeding, rather than from the lungs or bronchi.

The blood is genuinely present under the microscope, but the source is not the lower respiratory tract (below the glottis).

Pseudo‑hemoptysis

Pseudo‑hemoptysis (or pseudohemoptysis) refers to blood‑like sputum that may look like blood but sometimes does not actually contain blood cells; for example, red pigment (prodigiosin) from Serratia marcescens infection can stain sputum red without true bleeding.

It can also include situations where blood is aspirated from the upper aerodigestive or gastrointestinal tract (e.g., hematemesis aspirated into the lungs) and then expectorated, so the bleeding source is extrapulmonary

kilip classification

Heart failure and predict mortality in patients with acute myocardial infarction (AMI), especially in the first 24–48 hours. 

Killip classes (I–IV)

Class I: No clinical evidence of heart failure.

Vital signs and physical exam are normal; no pulmonary rales, no S₃, no jugular venous distension. 

Class II: Mild to moderate left‑ventricular (LV) failure.

Rales/crackles in the lungs, S₃ gallop, elevated jugular venous pressure, or combination

Class III: Severe LV failure – acute pulmonary edema.

Frank pulmonary edema with marked dyspnea, frothy sputum, diffuse rales; oxygenation is impaired. 

Class IV: Cardiogenic shock.

Hypotension (systolic BP ≤90 mmHg), tachycardia, cold clammy skin, oliguria, and evidence of peripheral hypoperfusion; often with pulmonary edema. 

Higher the class , there increased risk or short term mortality 

Post TB sequelae

 -Airway-related

Bronchiectasis

Bronchial stenosis / stricture

Tracheobronchomalacia

-Parenchymal (lung tissue)

Fibrosis (fibro-cavitary disease)

Destroyed lung

Residual cavities

-Pleural

Pleural thickening

Fibrothorax

-Vascular

Pulmonary hypertension

Rasmussen aneurysm (pulmonary artery aneurysm in cavity wall)

-Infective / colonization

Aspergilloma (fungal ball)

Functional consequence

Chronic respiratory failure / COPD-like picture