5.11 Evaluation of Cough, Dyspnea, Hemoptysis & the Solitary Pulmonary Nodule

1. Chronic Cough

Cough lasting more than eight weeks is chronic. In a non-smoker with a normal chest radiograph who is not taking an ACE inhibitor, three conditions account for the overwhelming majority of cases, and they frequently coexist:

1. Upper airway cough syndrome (formerly postnasal drip) — the single most common cause. Throat clearing, cobblestoning of the posterior pharynx, a sensation of drainage. Diagnosed by response to an empiric first-generation antihistamine-decongestant.
2. Asthma, including cough-variant asthma — cough may be the only symptom, without wheeze. Spirometry with bronchodilator response, or bronchoprovocation testing if spirometry is normal.
3. Gastroesophageal reflux disease — may occur without heartburn. Cough worse when supine or after meals.

Before any of this, do two things:

• Stop the ACE inhibitor. Cough occurs in roughly 10 to 20% of users, is not dose-related, and may begin weeks to months after initiation — patients and clinicians often dismiss the drug because it was started long ago. It resolves within one to four weeks of withdrawal, occasionally taking up to three months. Angiotensin receptor blockers do not cause it.
• Obtain a chest radiograph. An abnormal film redirects the entire workup.

Red flags requiring imaging and often bronchoscopy: hemoptysis, weight loss, fever, a substantial smoking history, hoarseness, or an abnormal radiograph.

Non-asthmatic eosinophilic bronchitis is worth knowing as the diagnosis in a patient with chronic cough, sputum eosinophilia, and normal spirometry with a negative bronchoprovocation test; it responds to inhaled corticosteroids.

2. Dyspnea

The exam task is separating cardiac, pulmonary, hematologic, metabolic and deconditioning causes efficiently.

Initial evaluation: history and examination, pulse oximetry at rest and with ambulation, chest radiograph, ECG, complete blood count and, when the cause is unclear, B-type natriuretic peptide and spirometry.

Ambulatory oximetry is the single highest-yield underused test. A resting saturation of 96% that falls to 87% after walking reframes the entire differential.

Platypnea-orthodeoxia — dyspnea and desaturation that are worse upright and better supine — is the reverse of orthopnea and indicates a right-to-left shunt, classically hepatopulmonary syndrome (an enumerated blueprint topic) or a patent foramen ovale. Hepatopulmonary syndrome is the triad of liver disease, an elevated alveolar-arterial gradient and intrapulmonary vascular dilatation demonstrated by contrast-enhanced echocardiography with delayed left-sided opacification. Liver transplantation is the only definitive therapy.

3. Hemoptysis

First, confirm the source. Hematemesis and nasopharyngeal bleeding are frequent mimics. Blood from the airway is frothy, bright red and alkaline; blood from the stomach is dark, may contain food particles and is acidic.

Causes: bronchitis (the most common overall), bronchiectasis, lung cancer, tuberculosis and other infection, pulmonary embolism with infarction, mitral stenosis, and diffuse alveolar hemorrhage from vasculitis or anti-glomerular basement membrane disease.

Diffuse alveolar hemorrhage deserves particular attention because the presentation can be deceptively bland: falling hemoglobin, diffuse alveolar infiltrates and hypoxemia — with hemoptysis absent in up to a third of cases. Bronchoalveolar lavage showing progressively bloodier aliquots, or hemosiderin-laden macrophages, establishes it. In this setting an increased DLCO is the counterintuitive clue, because intra-alveolar blood binds carbon monoxide.

Massive hemoptysis is a mechanical emergency — patients asphyxiate rather than exsanguinate, since the anatomic dead space is small. Management:

1. Position the bleeding side down to protect the unaffected lung.
2. Secure the airway, using a large-bore endotracheal tube to permit bronchoscopy.
3. Reverse coagulopathy.
4. Bronchial artery embolization — the definitive intervention, because roughly 90% of massive hemoptysis arises from the high-pressure bronchial circulation rather than the pulmonary arteries.
5. Surgery for refractory bleeding.

4. The Solitary Pulmonary Nodule

A solitary pulmonary nodule is a single, well-circumscribed opacity 3 cm or smaller surrounded by aerated lung. A lesion larger than 3 cm is a mass and is presumed malignant until proven otherwise.

Step 1: Find prior imaging

The most valuable next step, and the cheapest, is comparison with old films. Documented stability over two years for a solid nodule strongly suggests benignity and generally ends the workup. Note that this rule does not apply to subsolid and ground-glass nodules, which grow slowly and require longer surveillance.

Step 2: Assess morphology

Popcorn calcification indicates a hamartoma. Central or laminated calcification indicates prior granulomatous infection.

Step 3: Assess patient risk

Age, cigarette smoking (current and pack-years), prior malignancy, family history, and exposures such as asbestos, radon or endemic fungi. Upper lobe location modestly increases malignancy risk.

Step 4: Choose a strategy

PET/CT limitations are heavily tested. False negatives occur in lesions under about 8 mm (below spatial resolution), in carcinoid tumors, and in adenocarcinoma in situ / lepidic-predominant lesions, all of which are metabolically indolent. False positives occur with active infection, granulomatous disease including sarcoidosis and histoplasmosis, and rheumatoid nodules. PET is therefore not useful for a 5 mm nodule and not reassuring in a ground-glass lesion.

Ground-glass and part-solid nodules behave differently from solid nodules: they are more often malignant when persistent, grow much more slowly, and require longer surveillance. A part-solid nodule whose solid component enlarges is the highest-risk pattern.

Incidental nodules versus screening

Do not confuse the two pathways. Lung cancer screening with annual low-dose CT applies to asymptomatic adults meeting age and smoking-history criteria and uses a structured reporting system. An incidentally discovered nodule is managed by the risk-based algorithm above.

5. Miscellaneous Pulmonary Disorders: Indications for Spirometry

The blueprint explicitly names indications for spirometry. Order it to:

• Diagnose obstructive or restrictive disease in a patient with dyspnea, chronic cough or wheeze
• Confirm COPD — the diagnosis cannot be made without post-bronchodilator spirometry
• Assess severity and monitor progression in asthma, COPD, interstitial and neuromuscular disease
• Evaluate preoperative risk before lung resection
• Monitor occupational exposure and drug toxicity

Screening spirometry in asymptomatic adults is not recommended, even in smokers, because it does not improve outcomes independent of cessation counseling.

Flow-volume loop patterns identify upper airway obstruction, which is otherwise easily missed: