Symptoms: Sputum Production – Lung Disease

00:00 Moving on to sputum production: This is evidence of active inflammation of the lower airways in general. Clearly, viral infections and respiratory tract infections often lead to a bit of sputum production, but again, that's a short-lived problem that will last for a few days, then go away. Chronic sputum production is quite unusual, and that suggests either the patient is a smoker with some degree of chronic bronchitis, or has smoking-related lung diseases such as COPD, or has bronchiectasis.

00:30 And occasionally, patients with asthma will produce some phlegm as well. And interstitial lung disease: Although that normally causes breathlessness, it can cause cough, and that cough can be productive of some phlegm. There are several different descriptions of phlegm, but essentially, you either describe the phlegm as mucoid, which is clear, white phlegm—and that doesn't normally suggest they have a bacterial infection—or it's purulent, in which case the phlegm is green, it's thick, and it's tenacious. And that is likely to be due to an active bacterial infection. And there's something which is in between, mucopurulent, where it's slightly purulent but with a mixture of mucoid as well. Patients with asthma do often describe coughing up yellow phlegm, and that's due to eosinophils, probably, present in the sputum that's being produced. Hemoptysis is when you cough up blood, and I'll describe that in a little bit more detail shortly.

01:26 So sputum production occurs when people have exacerbations of chronic lung disease due to the underlying infection. So patients with COPD often cough up a little bit of gray–white phlegm most days due to their chronic bronchitis, but when they get an infective exacerbation, that phlegm becomes green, thick, and larger in quantity, suggesting an active bacterial problem. In bronchiectasis, the hallmark of bronchiectasis would be daily production chronically (i.e. every day) of purulent phlegm, so green or discolored, thick phlegm being produced each day. And with patients with severe disease, this can be produced in very high quantities.

02:04 A cup a day is not uncommon in patients with very severe bronchiectasis. Patients with less severe bronchiectasis may not cough up purulent phlegm each day; it might be relatively clear and only become purulent during exacerbations. Hemoptysis is blood in the sputum, and minor hemoptysis—a little bit of blood in the sputum—is relatively common. New minor hemoptysis in a smoker: You need to think about lung cancer. So this is a sign that could indicate that they have a lung cancer. In most cases, it does not, but in a smoker coughing up blood for the first time, you must investigate to make sure they don't have lung cancer. In fact, chronic mild hemoptysis—a little bit of blood being produced every now and then over months or years—is not uncommon in some respiratory diseases such as bronchiectasis, but it is not of any real consequence. It has no physiological consequence for the patient and is just a reflection of the underlying lung disease.

03:06 The situations which might suggest an important cause of hemoptysis is if it's pure, fresh blood rather than just a few flecks or a few streaks mixed in with phlegm. If the patient actually hasn't got an abs… actually hasn't got an active infection at the time, that would make me more worried about the cause of the blood. And clearly, a short history, as we already mentioned, would concern you. If they've had a long history of minor hemoptysis, that's not a major problem. Somebody who'd never had hemoptysis, is now coughing up blood every few days: I would be concerned as to why that may be happening. Acutely, if you cough up blood associated with pleuritic chest pain, that would suggest they have an infection or pulmonary embolism as an active problem. But that should be detectable by other symptoms and signs as well. Major hemoptysis is quite different to minor hemoptysis in that it is actually a serious problem. It can be life-threatening, and the patient should be admitted to hospital and investigated urgently to identify what's happening.

04:12 A major hemoptysis is defined as 100 to 200 ml (half to a full cup) of fresh blood produced in one day. That sort of rate of blood production puts you at risk of either drowning in your own blood production down the bronchial tree or significant volume loss of circulating blood. So the list of causes of minor hemoptysis is very large, but the common causes will be chronic bronchitis: Patients with a bit of COPD are coughing a lot and they get a little bit of blood in their phlegm as a consequence of having burst a small blood vessel. But there's a situation there that they could have lung cancer, so you do need to take that very seriously and investigate if somebody presents with new hemoptysis. Bronchiectasis is a very common cause of hemoptysis. And then acute lung infections (pneumonia, bronchitis) may cause hemoptysis. Tuberculosis in high-risk countries and high-risk populations must be considered in somebody presenting, especially if it's quite frank hemoptysis. And pulmonary emboli we've already discussed.

05:17 An important point is that many people presenting with minor hemoptysis, we don't really know why it happens. It's called cryptogenic hemoptysis. That's about 40% of cases. And there's a range of other causes. Pulmonary edema classically causes a frothy pink phlegm due to a mixture of white phlegm with just a low amount of blood in it, making it pink in color. And then you need to think about mycetomas: fungal balls which are colonizing cavities in the lung which have been created by previous tuberculosis, for example, etc., etc.

05:49 Major hemoptysis: There's a relatively limited number of causes which will cause a massive blood loss: 1. Lung cancer 2. Bronchiectasis 3. Mycetomas (the fungal walls in preexisting cavities) 4. Tuberculosis And then occasionally, that you can get lung abscesses, severe fungal infections. And there's arteriovenous malformations, an occasional fistula between circulating arteries in the bronchial tree, which can rarely cause major hemoptysis. But the major problems are cancer, bronchiectasis, tuberculosis, and mycetomas that you need to consider in somebody presenting with a lot of fresh blood being produced. We've discussed respiratory symptoms, but actually, one area of very great importance when taking a history is to work out whether the patient has systemic symptoms. Now, these are symptoms suggestive of a systemic problem of inflammatory or neoplastic nature, and they're very simple. Does the patient feel unwell? Have they lost their appetite? Are they losing weight? Do they feel very fatigued? And that's different to being breathless. So patients with COPD will say, "I feel fine when I'm sitting down, but as soon as I try and walk 200 yards, I get breathless." That's quite different from feeling ill and fatigued if somebody has a cancer, for example.

07:13 And weight loss clearly is a very important sign. Patients don't normally lose weight without active dieting—and even with active dieting—unless they've got a severe underlying physiological problem such as an infection or a cancer. And fevers and night sweats, again, would reflect active inflammatory problem. So this is important. You need to identify the patients with systemic symptoms, because that certainly puts them in a category of patients who may have problems such as lung cancer, active infection such as tuberculosis, and some of the more rare inflammatory causes of lung disease as opposed to the less systematic… less inflammatory problems, such as COPD or asthma.

08:00 So acutely, the main causes of systemic upset would be pneumonia, but they could also have other infections such as empyema. And inflammatory diseases such as hypersensitivity pneumonitis is also potentially possible. And chronically, it’s a lung cancer, other malignancies, tuberculosis, connective tissue diseases that you need to think about.

08:20 There are other symptoms which are not related directly to the respiratory tract which are relevant for respiratory disease. These are relatively limited number, but the important ones are bilateral ankle edema. So ankle edema equals somebody who's got some problem with their cardiac function in general. And that could be right heart failure—cor pulmonale—so that's a consequence of chronic lung disease. Or it could be pulmonary hypertension independent of chronic lung disease. So you need to consider bilateral ankle edema as a respiratory symptom.

08:50 Clearly, it could also reflect congestive cardiac failure, which is a differential diagnosis for patients presenting with breathlessness. Unilateral leg swelling suggests there may be a deep vein thrombosis: a clot in one of the veins in that… in the swollen leg which is indicating that the patient might be presenting due to P... with respiratory problems because of pulmonary embolus. So unilateral leg swelling indicates somebody who might have a DVT and therefore could have a PE. Hay fever and eczema, in combination, identify somebody who has atopy, which is a general allergic sensibility and means they quite likely, or more commonly, will have asthma than the nonatopic individual. We've already discussed that upper respiratory tract symptoms is a cause of chronic cough in some people due to a postnasal drip. But upper respiratory tract symptoms also are closely associated with some patients with asthma and bronchiectasis, due to some causes of bronchiectasis. For example, idiopathic bronchiectasis frequently have upper respiratory tract infection as does cystic fibrosis and primary ciliary dyskinesia. Bone pain, neurological symptoms, other symptoms might suggest that the patient… of new onset can occur in patients who've got lung cancer metastases outside the respiratory system and are relevant in those circumstances where you think that cancer might be the diagnosis.